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Cell surface molecules in basal cell carcinomas

Mon, 06/02/2014 - 3:05pm

BACKGROUND: The factors determining a basal cell carcinoma's (BCC's) growth pattern and invasive potential are not known. In other tumors it has been shown recently that the expression of cellular adhesion molecules may determine a tumor's invasive and metastatic potential. Integrins, cell surface molecules important in cell stroma interactions, are present on BCCs and may help regulate the tumor's growth pattern.

OBJECTIVE: We compared the expression of cellular adhesion molecules alpha 2 integrin, beta 1 integrin, intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), leukocyte function antigen 1a (LFA-1a), and E-selectin in different histological subtypes of basal cell carcinomas.

METHODS: BCCs were obtained from patients undergoing Mohs surgery. The BCCs were classified as nodular, micronodular, mixed, infiltrative, and basosquamous types and stained using an avidin-biotin-immunoperoxidase technique with antibodies against alpha 2 integrin, beta 1 integrin, ICAM, LFA-1a, VCAM-1, and E-selectin.

RESULTS: BCCs expressed alpha 2 and beta 1 integrin, but no significant differences in the amount or pattern of expression was seen in the different histologic subtypes.

CONCLUSION: The expression of integrins by BCCs by binding to the surrounding stroma may limit BCC's growth; however, their expression does not appear to correlate with their histological pattern.

Trichilemmal carcinoma

Mon, 06/02/2014 - 3:05pm

Trichilemmal carcinoma is an uncommon cutaneous neoplasm that occurs in sun-exposed areas of older persons. It is thought to be related to the external root sheath of the hair follicle and to be the malignant counterpart of a trichilemmoma. We describe a case of trichilemmal carcinoma treated with Mohs micrographic surgery.

Microcystic adnexal carcinoma. Case report and review of the literature

Mon, 06/02/2014 - 3:05pm

Microcystic adnexal carcinoma is an aggressive, locally destructive cutaneous neoplasm with a high rate of recurrence. This tumor is often misdiagnosed clinically and histologically. It usually occurs in middle-aged to older adults. We describe a 44-year-old man with a large microcystic adnexal carcinoma that was present for more than 20 years. The tumor invaded the perichondrium, muscle, nerve, and blood vessel adventitia. A review of the literature suggests that these tumors are often histologically misdiagnosed because the biopsy specimens may be too small to reveal all the characteristic histologic features. The clinical presence of marked induration, a smooth surface, and, possibly, sensory changes should alert the clinician to the possibility of this neoplasm. The initial biopsy specimen must be large enough to demonstrate the identifying histologic features. Mohs surgery is currently the treatment of choice for microcystic adnexal carcinoma, as it often spreads far beyond clinically evident tumor.

Arsenic in Dermatology

Mon, 06/02/2014 - 3:05pm

BACKGROUND: Arsenic is a chemical carcinogen that exists naturally and in the workplace.

OBJECTIVES: Review exposure, clinical signs of arsenic exposure, and the carcinogenic potential.

METHOD: Review of literature.

RESULTS: Arsenic is a known carcinogen that occurs both naturally and in the workplace. It causes cutaneous malignancies, hyperpigmentation, palmer and plantar keratosis, and internal malignancies, especially of the lung and bladder.

CONCLUSION: Exposure risks need to be well publicized. Those people with known exposure need regular full skin exams as well as close follow-up by their primary care physician.

Stump the experts. Apocrine hidrocystoma

Mon, 06/02/2014 - 3:05pm

Malignant melanoma with clinical and histologic features of Merkel cell carcinoma

Mon, 06/02/2014 - 3:05pm

We describe a patient with malignant melanoma that resembled a Merkel cell carcinoma both clinically and histologically. Immunohistochemical studies showed focally positive staining with S-100 protein and strongly positive staining with HMB-45. Ultrastructural study confirmed the diagnosis by demonstrating premelanosomes and melanosomes. Although the tumor appeared to be clinically unimpressive, it was a deep melanoma with a Breslow level of 3.8 mm that necessitated aggressive treatment. Small cell melanoma must be considered in the differential diagnosis of small cell tumors, which also includes lymphoma, eccrine carcinoma, squamous cell carcinoma, and Merkel cell carcinoma. The diagnosis of amelanotic melanoma, including the small cell variant, may require electron microscopic studies.

Management of a hidradenoma with Mohs micrographic surgery

Mon, 06/02/2014 - 3:05pm

BACKGROUND: Hidradenomas are adnexal tumors that may grow to be very large and frequently recur after excision. Malignant transformation and metastatic spread can occur and histologic distinction of benign from malignant hidradenomas can be very difficult. Some tumors with bland histology have demonstrated aggressive behavior.

OBJECTIVE: To decide the benefits of management with Mohs micrographic surgery of large hidradenomas.

METHODS: The literature was reviewed, including both the clinical course of the tumor and histologic features. The case of our report was interpreted in light of the review.

RESULTS: Three stages of Mohs surgery were required for complete removal of the hidradenoma. The patient remains free of recurrence.

CONCLUSION: This report highlights the difficulties in distinguishing benign from malignant hidradenomas and emphasizes the benefits of Mohs surgery for large or recurrent tumors.

Frequency of postoperative allergic contact dermatitis to topical antibiotics

Mon, 06/02/2014 - 3:05pm

BACKGROUND AND DESIGN: Topical antibiotics are one of the most common causes of allergic contact dermatitis and are frequently used in postoperative wound care. We prospectively followed up patients having cutaneous surgery to determine the frequency of allergic contact dermatitis to topical antibiotics used on postoperative wound care.

RESULTS: Nine (4.2%) of 215 patients who had undergone surgery who were using a topical antibiotic had an eruption develop postoperatively that was consistent with an allergic contact dermatitis from the topical antibiotic. Seven of the nine patients agreed to patch testing with the standard tray and selected topical antibiotics. Five patients had a positive patch test to neomycin sulfate and four had a positive patch test to bacitracin. The frequency of allergic contact dermatitis proved by patch testing to neomycin and bacitracin is five (5.3%) of 94 and four (2%) of 198, respectively, in the patients who used these antibiotics. All proved sensitivities to bacitracin occurred in patients using a topical antibiotic that also contained neomycin and were patch tested positive to the neomycin. No patients using only pure bacitracin had allergic contact dermatitis.

CONCLUSIONS: Allergic contact dermatitis to a topical antibiotic, especially neomycin, should be considered in any patient who has development of a dermatitis after cutaneous surgery. Because of the frequency of allergic contact dermatitis, neomycin-containing antibiotics should be avoided in postoperative wound care.

Pigmented basal cell carcinoma: investigation of 70 cases

Mon, 06/02/2014 - 3:05pm

BACKGROUND: Pigmented basal cell carcinoma (PBCC) is a clinical and histologic variant of BCC.

OBJECTIVE: Our purpose was to identify the histologic subtypes of BCC that were most often associated with pigment and to determine whether this correlated with outcome after excision.

METHODS: A series of PBCC was identified and the histologic subtype noted. Margins of all excisions were examined for residual tumor. These results were then compared with a series of nonpigmented BCCs.

RESULTS: In a series of 1039 consecutive BCCs, 70 (6.7%) contained pigment. The histologic growth pattern most frequently associated with pigment was the nodular/micronodular pattern (12.4%) followed by the nodular (7.7%), superficial (7.2%), micronodular (4.0%), and the nodular/micronodular/infiltrative (3.4%) patterns. Margins were examined for evidence of residual tumor in the 40 cases that were excised. In only one case (2.5%) was the margin positive for tumor. This was statistically significant (p less than 0.05) compared with 388 excisions of nonpigmented BCCs with comparable growth patterns in which 69 (17.7%) showed positive margins.

CONCLUSION: PBCC, as a clinical variant, is more frequently excised with adequate margins than are tumors of comparable histologic subtypes that do not contain pigment.

Cytomegalovirus diaper dermatitis

Mon, 06/02/2014 - 3:05pm

Cytomegalovirus inclusions have been reported in perineal ulcers from immunosuppressed adults. The importance of this finding is unknown. We report the first pediatric case of cutaneous cytomegalovirus infection in an infant with congenital human immunodeficiency virus infection, presenting as a diaper dermatitis. Cytomegalovirus was cultured from the skin biopsy specimen, and characteristic inclusions were seen on hematoxylin-eosin-stained sections. Results of this biopsy specimen analysis prompted further investigation revealing disseminated cytomegalovirus infection, including retinitis. Aggressive pursuit of a pathogen in common conditions such as diaper dermatitis is strongly recommended in immunosuppressed pediatric patients.

Histologic pattern analysis of basal cell carcinoma. Study of a series of 1039 consecutive neoplasms

Mon, 06/02/2014 - 3:05pm

This study attempts to define histologic patterns in 1039 consecutive cases of basal cell carcinoma and to correlate these patterns with adequacy of margins of surgical excision. Five major histologic patterns were identified: nodular, 218 cases (21%); superficial, 181 cases (17%); micronodular, 151 cases (15%); infiltrative, 77 cases (7%); and morpheic, 11 cases (1%). A mixed pattern (two or more major histologic patterns) was present in 401 cases (38.5%). Our study indicates that nodular and superficial basal cell carcinomas can be completely removed by simple surgical excision in a high percentage of cases (93.6% and 96.4%, respectively) whereas the micronodular, infiltrative, and morpheic basal cell carcinomas have a higher incidence of positive tumor margins (18.6%, 26.5%, and 33.3%, respectively) after excision. Mixed patterns that consisted of combinations of the nodular, micronodular, or infiltrative types exhibited a behavior similar to the pattern that resulted in a greater chance of incomplete surgical removal.

Pruritic urticarial papules and plaques of pregnancy and its relationship to maternal-fetal weight gain and twin pregnancy

Mon, 06/02/2014 - 3:05pm

Thirty women who were seen at our institution between 1984 and 1988 for pruritic urticarial papules and plaques of pregnancy (PUPPP) were retrospectively evaluated and interviewed. We found a significantly increased maternal weight gain and newborn birth weight in patients with PUPPP, compared with age and parity-matched controls. The average weight gain during pregnancy was 18.1 +/- 0.9 (SEM) kg for the patients with PUPPP (excluding twin gestations) and 14.6 +/- 1.0 kg for the controls. The mean newborn birth weight was 3.6 +/- 0.09 kg for the PUPPP group and 3.3 +/- 0.08 kg for the control group. There were three twin pregnancies (10%), compared with the twin gestation rate at our institution of 1.6%. Therefore, based on our findings of an increased maternal weight gain and neonatal birth weight, an increased twin rate, and an abdominal eruption that occurs in primigravidas in their third trimester of pregnancy, we suggest that abdominal distention or a reaction to it may play a role in the development of PUPPP.

Lipids in the pathogenesis of ichthyosis: topical cholesterol sulfate-induced scaling in hairless mice

Mon, 06/02/2014 - 3:05pm

Although several abnormalities of lipid metabolism have been associated with abnormal cornification in humans, evidence that these lipids directly provoke abnormal scale is lacking. One recently described example of a lipid abnormality in ichthyosis is absence of the enzyme steroid sulfatase in recessive X-linked ichthyosis (RXLI). This enzyme normally desulfates cholesterol sulfate (CS) and sulfated steroid hormones, including dehydroepiandrosterone sulfate (DHEAS). As a result of this enzyme deficiency, patients with RXLI accumulate CS in their blood and skin. To determine whether sulfated sterols are the specific cause of increased scale, we applied CS, DHEAS, cholesterol, or vehicle alone to the backs of hairless mice. In animals treated with CS, but not with DHEAS or with vehicle, visible scale without erythema appeared after 1 week, peaked at 2 weeks, and then diminished. When the dose of CS was doubled, abnormal scale reappeared and then decreased again. CS-induced scale was reversible, clearing within 3 days of discontinuation of treatment. Because there was no acanthosis, dermal inflammation, abnormal transepidermal water loss, or increased labeling index, it appears that the 3-fold increase in thickness of the stratum corneum in CS-treated animals is due to a direct effect on this layer.

Febrile ulceronecrotic Mucha-Habermann's disease

Mon, 06/02/2014 - 3:05pm

A patient with febrile ulceronecrotic Mucha-Habermann's disease manifested the characteristic features of this entity. These include a polymorphous eruption with histopathologic findings of Mucha-Habermann's disease, large ulceronecrotic skin lesions, intermittent high fever, and constitutional symptoms. The patient was unique in that he also had malabsorption and eosinophilia. This disease may represent a hypersensitivity reaction. To our knowledge, there are five previous cases of febrile ulceronecrotic Mucha-Habermann's disease reported in the world literature.

An easy method for removal of syringoma

Mon, 06/02/2014 - 3:05pm

Syringomas pose a cosmetic problem in some patients. In the past, surgical removal of large portions of the lower lid or electrodesiccation have been the usual methods of removal. This report describes a technique for individual excision of these tumors that is easily performed as an office procedure using a pair of fine ophthalmologic spring-action scissors and gives excellent cosmetic results.