Steven Kossard

Skin cancer in Australian heart transplant recipients

BACKGROUND Cutaneous malignancy is a major cause of morbidity in organ transplant recipients. OBJECTIVE Our purpose was to report on skin cancer in Australian heart transplant recipients with analysis of HLA factors. METHODS We reviewed histologically proven skin cancers in the first 455 patients undergoing organ transplantation in Sydney, Australia. RESULTS The cumulative incidence of skin cancer was 31% at 5 years and 43% at 10 years with a squamous cell carcinoma/basal cell carcinoma ratio of 3:1. Caucasian origin, increasing age at transplantation, and duration of follow-up were significantly associated with skin cancer. Skin cancer accounted for 27% of 41 deaths occurring after the fourth year. Recipient HLA-DR homozygosity was associated with skin cancer overall, whereas HLA-DR7 was a protective factor in skin cancer overall, squamous cell carcinoma, and Bowens disease. HLA-A1 and HLA-A11 were significant protective factors in Bowens disease. CONCLUSION Skin cancer is a major cause of morbidity and long-term mortality in heart transplant patients.

Postmenopausal frontal fibrosing alopecia : A frontal variant of lichen planopilaris

BACKGROUND Lichen planopilaris usually produces multifocal areas of scarring alopecia. Recently, a condition in postmenopausal women characterized by progressive frontal hairline recession associated with scarring has been described. OBJECTIVE Our purpose was to study the clinical and histopathologic features and results of treatment in a group of women with the frontal variant of lichen planopilaris and to compare the immunohistochemical profile of scalp biopsy specimens from this subset with that found in the multifocal variant of lichen planopilaris. METHOD The clinical data as well as the histopathologic findings in 16 women with frontal fibrosing alopecia were collated. The immunohistochemical profile of six scalp biopsy specimens from the frontal hairline were compared with six specimens from women with multifocal lichen planopilaris. RESULTS In addition to the progressive frontal fibrosing alopecia in all 16 women, total loss or a marked decrease of the eyebrows was observed in 13. No evidence of lichen planus was observed at other sites. In one patient multifocal areas of lichen planopilaris developed in the scalp. The frontal fibrosing alopecia was slowly progressive but has stabilized in five patients. Biopsy specimens from the frontal hairline showed histologic changes identical to lichen planopilaris. Immunophenotyping failed to reveal any significant differences between the frontal and multifocal variants. No effective treatments emerged although oral steroids and antimalarials may temporarily slow the course. Hormone replacement therapy did not appear to influence the course of the alopecia. CONCLUSION Progressive frontal fibrosing alopecia is a clinically distinct variant of lichen planopilaris that affects in particular elderly women and frequently involves the eyebrows. The basis for this lichenoid tissue reaction targeting frontal scalp follicles and eyebrows is unknown.

Necrobiotic xanthogranuloma with paraproteinemia

Eight patients had multiple xanthomatous plaques and subcutaneous nodules that had a predilection for the periorbital area, flexures, and trunk and that tended to ulcerate. Skin biopsy specimens showed a combination of xanthogranulomatous nodules with necrobiosis. All patients had an accompanying dysproteinemia, which was a monoclonal IgG paraprotein in six. Hyperlipidemia, low serum complement, and cryoglobulinemia were variable features. Five patients had leukopenia. Bone marrow examination showed myeloma in two patients, a lymphoproliferative process in one, and some atypical plasma cells in two. Cutaneous necrobiotic xanthogranuloma is a distinctive histologic pattern most frequently related to plasma cell dyscrasias, and it should be distinguished from normolipemic plane xanthoma and other necrobiotic granulomas.

Cutaneous Bowen's disease: An analysis of 1001 cases according to age, sex, and site

BACKGROUND There are no large studies of Bowens disease that have analyzed its distribution according to age, sex, and site. OBJECTIVE This study was performed primarily to determine whether there were significant sex and site differences in the distribution of Bowens disease. METHODS One thousand one skin biopsy specimens of Bowens disease were analyzed according to age, sex, and site of origin. RESULTS This study revealed that the most common site of Bowens disease was the head and neck (440 lesions), whereas specimens from the lower limbs (298 lesions) and upper limbs (198 lesions) outnumbered specimens from the torso (65 lesions). Of 298 specimens from the lower limbs, 72.1% were from women; 79.3% of the 87 specimens from the scalp and ears were from men. Eighty percent of the 85 specimens of Bowens disease from the cheeks were from women. CONCLUSION These results indicate that cutaneous Bowens disease occurs mainly on sun-exposed sites. This is also supported by the predominance of Bowens disease on the lower limbs in women and on the scalp and ears in men. The basis for the female predominance on the cheeks is unknown, but may reflect the increased vulnerability to sun damage of superficial vellus hair follicles that predominate on the cheeks in women. This finding may provide indirect support for the hypothesis that some forms of Bowens disease have a follicular histogenesis.

Epidermolysis bullosa acquisita: A heterogeneous disease

The question of whether epidermolysis bullosa acquisita (EBA) is a distinct entity prompted a review of the Mayo Clinic experience. Twelve patients with this diagnosis were seen from 1955 through 1979, and their records were reviewed. Particular attention was directed to immunofluorescence microscopy (IF), which had been performed in seven patients. Direct IF was positive in seven patients, and indirect IF was positive in four patients. Although many cases of EBA may remain distinct, we believe that the morphologic appearance known as EBA may represent a final common pathway of disease expression in a heterogeneous group of patients with a variety of more specific diseases and that trauma serves as a localizing factor. Our findings indicate that cicatricial pemphigoid probably is the most common specific diagnosis but that all cases of EBA are not represented by this diagnosis. Furthermore, we conclude that when IF is performed, exclusion of other bullous diseases, which is a key criterion for the diagnosis of EBA, is more difficult than previously recognized.

Keratoacanthoma and Infundibulocystic Squamous Cell Carcinoma

One of the major controversies in dermatopathology is the relationship of keratoacanthoma to squamous cell carcinoma. Leaders in the field remain polarized in their views. Carcinomas with distinct follicular pattern of differentiation have been described in reference to the isthmus as trichilemmal carcinomas, to the follicular bulb as pilomatricomal carcinomas, and to the stem cell or rapidly amplifying cell compartment as basal cell carcinomas (trichoblastic carcinomas). We have employed the term infundibulocystic or infundibular squamous cell carcinoma to identify a subset of squamous cell carcinomas that demonstrate this pattern of differentiation. The recognition of infundibular squamous cell carcinoma is important in that well-differentiated examples are likely to have been diagnosed as keratoacanthoma, whereas moderately or poorly differentiated tumors would be more often reported as squamous cell carcinomas, leading to underrecognition of these infundibular variants of squamous cell carcinoma. The descriptive term infundibulocystic or infundibular squamous cell carcinoma may help to better define an alternative follicular-based pathway to squamous cell carcinoma distinct from the more common evolution from solar keratoses and also refine the classification of keratoacanthoma.

Photodynamic therapy with methyl aminolevulinate for primary nodular basal cell carcinoma: results of two randomized studies

Background  Data suggest that photodynamic therapy using topical methyl aminolevulinate (MAL PDT) may be a noninvasive alternative to excisional surgery for nodular basal cell carcinoma (BCC). In the studies described here, we investigated the histologic response, tolerability, and cosmetic outcome with MAL PDT for primary nodular BCC (≤ 5 mm in depth).

Acquired scalp alopecia. Part II: A review.

The neutrophil‐associated and infiltrative scarring alopecias are reviewed including folliculitis decalvans, tufted folliculitis, dissecting cellulitis of the scalp, acne keloidalis and follicular degeneration syndrome. The management of acquired scalp alopecia is also reviewed including newer, promising therapies. More specific agents targeting components of the androgen system will make the treatment of androgenetic alopecia more rewarding. Similarly new immunomodulatory therapies show great promise for the lymphocyte‐associated alopecias and include a new generation of macrolide immunosuppressives (tacrolimus, SDZ ASM 981, and SDZ 281‐240), some of which appear to have good transcutaneous absorption.

Frontal fibrosing alopecia developing after hair transplantation for androgenetic alopecia

A 75-year-old man developed progressive recession of his frontal hairline associated with loss of follicular orifices and development of telangiectasia over an 18-month period (Fig. 1a). The fibrosing alopecia was confined to the frontal scalp and there were no multifocal areas present over the sides, vertex or occiput. There were no lesions of lichen planus on general skin examination. He had received hair transplants for progressive male pattern alopecia (Hamilton type III progressing to early type IV), involving the frontal hairline between 1971 and 1994. There had been seven procedures using plugs till 1988 and then mini or micro transplants till 1994, with an excellent result 5 years before the onset of the frontal fibrosing alopecia (Fig. 1b). He had a history of prostate cancer in 1988 that had been treated with radiotherapy and brachotherapy. His only medications were prazosin hydrochloride and celecoxib. Multiple scalp biopsies were analyzed. Removal of a transplant plug with intact hairs at the frontal edge of the hairline revealed 16 terminal follicles and three fibrous tracts. Ten of the follicles were associated with perifollicular fibrosis and lichenoid inflammation concentrated around the infundibulum and isthmus regions in a pattern typical of lichen planopilaris (Fig. 2). A transplant plug devoid of hairs from the frontal area showed three remaining terminal follicles with lichenoid inflammation and 12 fibrous tracts. A biopsy from the central scalp with hair thinning showed 10 terminal hair follicles and 24 fibrous tracts with miniaturized follicles in a pattern of androgenetic alopecia. A biopsy from the temporoparietal zone of clinically normal hairs showed 32 follicles and five fibrous tracts but no perifollicular fibrosis, perifollicular inflammation or significant miniaturization. Discussion

Spotted cicatricial alopecia in dark skin. A dermoscopic clue to fibrous tracts.

Study of areas of cicatricial alopecia in a 42 year old black woman by dermoscopy with oil revealed uniform pale dots associated with a radiating pigment network. Scalp biopsy showed a cicatricial alopecia with lichen planopilaris and multiple fibrous tracts. The pale dots appear to correspond to focal decrease in epidermal melanin pigment overlying the site of the fibrous tracts and may provide a dermoscopic clue in analysing the cicatricial alopecias.