Shyamala C. Huilgol

The ophthalmic side-effects of imiquimod therapy in the management of periocular skin lesions

Aim To describe the ophthalmic side-effects of topical imiquimod for periocular actinic keratoses, squamous cell carcinoma in situ and basal cell carcinoma. Method A retrospective study was carried out in two centres of all patients who underwent topical imiquimod therapy between January 2004 and January 2009. Imiquimod was applied three times weekly for 4–6u2005weeks. Diagnosis of the lesions, complications, clinical resolution and long-term ophthalmic side-effects was recorded. Patients on therapy were reviewed fortnightly and then every 6u2005weeks following completion of treatment. Results 47 patients were identified; the mean age was 74u2005years. 37 patients had actinic keratoses, seven patients had Bowen disease, and three patients had BCC. The lower lid was the commonest site involved (68%). Application site erythema occurred in all patients. Conjunctivitis occurred in 15 patients, and six patients complained of ocular stinging on application of imiquimod. One patient had a staphylococcal keratitis, which responded to topical antibiotic and steroid therapy. Two patients required oral antibiotics for preseptal cellulitis. Three patients had delayed conjunctivitis at a mean of 2.3u2005weeks. Nine patients discontinued imiquimod due to ocular irritation and conjunctivitis, of whom four patients recommenced and finished the treatment after a rest period. At a mean follow-up of 16u2005weeks, 34 patients had clinical resolution of the periocular lesions and no patient had any residual ophthalmic side-effects from imiquimod. Conclusion Conjunctivitis and ocular stinging were the commonest ophthalmic side-effects encountered with the application of imiquimod for periocular skin lesions. These effects were temporary and resolved on terminating the imiquimod therapy.

Eccrine porocarcinoma of the upper eyelid.

Eccrine porocarcinoma is an unusual, locally aggressive tumor with a significant risk of metastasis and recurrence after surgical excision. Eyelid involvement is rare. We describe a 70-year-old man who was examined for right upper eyelid eccrine porocarcinoma that was treated with Mohs surgery. Eccrine porocarcinoma should be considered in the differential diagnosis of malignant eyelid tumors.

Treatment of actinic cheilitis with the Er:YAG laser

BACKGROUNDnActinic cheilitis is a common condition with the potential to develop into squamous cell carcinoma. Current treatments have varying cure rates and complications. The role of the erbium:yttrium-aluminum-garnet (Er:YAG) laser in the treatment of actinic cheilitis has not been widely published, despite offering theoretical advantages over current treatment modalities.nnnOBJECTIVEnTo evaluate the outcome of a series of patients treated with the Er:YAG laser for actinic cheilitis.nnnMETHODSnThis was a retrospective, interventional, nonrandomized, sequential case series set in a tertiary referral, dermatologic surgery unit. Ninety-nine consecutive patients with actinic cheilitis treated with the Er:YAG laser between January 2001 and June 2008 underwent a case note review, of which 77 went on to a structured telephone interview. The main outcome measures were a subjective improvement in lip symptoms related to actinic cheilitis and objective improvement in the lips at routine follow-up.nnnRESULTSnMean time to interview follow-up was 65.7 months. Of those interviewed, 92.2% believed there had been an improvement in the cosmetic appearance of their lips; one hundred percent believed the function of their lips had improved or remained unchanged; and 84.8% remained completely disease free at the time of follow-up. The majority of patients (93.5%) were satisfied with the laser treatment. Scarring as a direct result of the laser occurred in 5.1% of patients.nnnLIMITATIONSnRetrospective nature of data collection; inability to interview all patients who underwent treatment.nnnCONCLUSIONnThe Er:YAG laser is a successful modality for the treatment of actinic cheilitis with good functional and cosmetic results and only a small risk of long-term scarring. It should be considered as a first-line treatment for the disease.

Accuracy of Biopsy in Subtyping Periocular Basal Cell Carcinoma.

Purpose: To determine the accuracy of initial biopsy in the diagnosis of basal cell carcinoma (BCC) histologic subtype. Methods: Retrospective histopathologic review of patients with a diagnosis of primary periocular BCC from 2006 to 2013 inclusive. Results: A total of 174 primary BCCs were identified. BCCs were classified as nodular, superficial, or aggressive (including mixed cases with an aggressive component). Punch biopsies were used in 41% of cases, while the remaining patients underwent shave or incision biopsies. The final histologic subtypes at excision were nodular (59%), superficial (7%), nodular and superficial (7%), and aggressive (51%). The overall concordance between the BCC subtype identified in the biopsy specimen and the subsequent excision specimen was 54%. In total, there were 51 cases (29%) of BCC, which included aggressive subtypes, of which 52% of initial biopsies failed to detect an aggressive component. There were 45 cases (26%) of mixed BCC, and an aggressive histologic subtype was present in 73% of these cases. Conclusions: The accuracy of initial biopsy for BCC histologic subtype at excision is highest for nodular BCC. For aggressive BCC, biopsy was able to detect the aggressive component in only 48% of cases. This may have implications for choice of treatment modality.

Management of periorbital basal cell carcinoma with orbital invasion

Basal cell carcinoma (BCC) is the most common eyelid malignancy; however, orbital invasion by periocular BCC is rare, and management remains challenging. Established risk factors for orbital invasion by BCC include male gender, advanced age, medial canthal location, previous recurrences, large tumor size, aggressive histologic subtype and perineural invasion. Management requires a multidisciplinary approach with orbital exenteration remaining the treatment of choice. Globe-sparing treatment may be appropriate in selected patients and radiotherapy and chemotherapy are often used as adjuvant therapies for advanced or inoperable cases, although the evidence remains limited. We aim to summarize the presentation and treatment of BCC with orbital invasion to better guide the management of this complex condition.

Scalp Basal Cell Carcinoma: Review of 2,202 Cases.

BACKGROUND Increases in the incidence of basal cell carcinoma (BCC) in women, younger age groups and in aggressive scalp subtypes in younger women have been reported. OBJECTIVE To describe lesion and patient characteristics in scalp BCC. MATERIALS AND METHODS Retrospective audit of scalp BCCs from 3 pathology laboratories in Adelaide, South Australia, January 2009–December 2013. RESULTS Scalp BCC was 2.6% of all BCC. Of 2,202 patients with scalp BCC, 62% were male and 78% were >60 years. Histologic subtypes included nodular (55%), mixed (30%), and superficial (8%). The concordance between biopsy and excision was 83% for division into nonaggressive and aggressive subtypes. The incomplete excision rate was 16%. Aggressive subtypes were larger and had perineural invasion (PNI) in 8.5% and incomplete excision in 26%. CONCLUSION Basal cell carcinoma on the scalp was less common. Men and the elderly had the majority of cases, with no predilection for women, including aggressive histologic subtypes in younger women. Aggressive subtypes were associated with increased size, incomplete excision, and PNI. A preliminary biopsy assisted division into aggressive and nonaggressive histologic subtypes. Incomplete excision rates were higher and increased in aggressive histologic subtypes and PNI. Mohs surgery or wider margins are suggested in these cases.

Orbital Varix Thrombosis and Review of Orbital Vascular Anomalies in Blue Rubber Bleb Nevus Syndrome.

A 57-year-old woman with cutaneous manifestations of (BRBNS) presented with acute left proptosis and venous congestion secondary to thrombosis within a superior ophthalmic vein varix. Multiple phleboliths were noted in the contralateral right orbit, and an incidental right middle cerebral artery aneurysm. Her symptoms spontaneously resolved within a few days. An English literature review found 7 reported cases of orbital vascular lesions in association with BRBNS from 1950 to 2012. All lesions showed contrast enhancement on CT or MRI: 4 had small orbital calcifications and 3 were distensible with raised venous pressure. The occurrence of a thrombosed orbital varix or cerebral artery aneurysm in BRBNS, to the best of the authors’ knowledge, has not been previously reported. Although orbital vascular lesions in BRBNS have been described as hemangiomas, the biologic behavior and histology of most of the reported orbital lesions are most compatible with venous malformations.

Perineural Invasion of the Orbit by Neurotropic Nondesmoplastic Melanoma.

The authors report a case of neurotropic nondesmoplastic melanoma involving the ophthalmic division of the trigeminal nerve and the cavernous sinus in a patient with recurrent scalp melanoma. This case highlights the importance of earlier diagnosis of local recurrence of melanoma and the rare association of neurotropic melanoma and orbital metastasis.

Infundibulocystic basal cell carcinoma of the eyelid

regarded as a personal clinical experience with its own intrinsic value. Firstly, it is not stated whether the patients were under a correct, continuous corticosteroid regimen or had temporarily discontinued it. As is very often observed, in the former condition VLS can be identified as recalcitrant to steroids, while in the latter it is more likely a recurrent condition secondary to treatment discontinuation. In our opinion, what appears particularly arguable is the absence of objective data on the effects of the fractional laser on vulvar tissue. Apart from figures of two of the five reported cases (one of which is of a patient treated with laser ablation and therefore to be excluded from the reported series), only generic subjective data are reported. We believe that at the least a visual analogue scale report of symptoms before and after treatment should have been used. Moreover, figure 3, the second image of case 3 (the only one available after CO2 fractional laser treatment) was taken 6 months after the treatment, during clobetasol propionate applications: how can the authors clearly split the relative effects of the two therapies? This observation can also be made for the remaining three cases. In fact all the patients received corticosteroid treatment immediately after laser treatment. In addition, regarding case 4, the authors state that this patient was asymptomatic before treatment. It is unclear why she was included in the laser treatment protocol, as perineal lichen sclerosus is less likely to determine severe clinical implications other than itching. As a final consideration, we firmly believe that before introducing and promoting novel technologies in clinical practice an adequate pre-clinical evaluation based upon research and experimental studies is always advisable.

Pigmented squamous cell carcinoma in situ of the eyelid

include arsenic exposure, genetic susceptibility, chronic interstitial pneumonitis, ionizing radiation, atmospheric pollution and asbestos exposure. Our patient was living in a highly polluted industrial area in South China. Cutaneous metastases from lung cancer represent a poor prognostic indicator. The average survival rate ranges from 3 to 5 months, which is significantly lower than other malignancies including melanoma and breast cancer. Due to multi-organ metastases, our patient died before implementing further treatment. In this condition early diagnosis remains a challenge.