The role of dermabrasion and chemical peels in the treatment of patients with xeroderma pigmentosum

Xeroderma Pigmentosum: General Aspects and Management

Xeroderma Pigmentosum (XP) is a rare genetic syndrome with a defective DNA nucleotide excision repair. It is characterized by (i) an extreme sensitivity to ultraviolet (UV)-induced damages in the skin and eyes; (ii) high risk to develop multiple skin tumours; and (iii) neurologic alterations in the most severe form. To date, the management of XP patients consists of (i) early diagnosis; (ii) a long-life protection from ultraviolet radiation, including avoidance of unnecessary UV exposure, wearing UV blocking clothing, and use of topical sunscreens; and (iii) surgical resections of skin cancers. No curative treatment is available at present. Thus, in the last decade, in order to prevent or delay the progression of the clinical signs of XP, numerous strategies have been proposed and tested, in some cases, with adverse effects. The present review provides an overview of the molecular mechanisms featuring the development of XP and highlights both advantages and disadvantages of the clinical approaches developed throughout the years. The intention of the authors is to sensitize scientists to the crucial aspects of the pathology that could be differently targeted. In this context, the exploration of the process underlining the conception of liposomal nanocarriers is reported to focus the attention on the potentialities of liposomal technology to optimize the administration of chemoprotective agents in XP patients.

Current Therapeutic Strategies of Xeroderma Pigmentosum

Xeroderma pigmentosum (XP) is an autosomal recessive genetic disease caused by a defect in the DNA repair system, exhibiting skin cancer on sun exposure. As it is an incurable disease, therapeutic strategies of this disease are critical. This review article takes an attempt to explore the current therapeutic advancements in XP. Different approaches including sun avoidance; surgical removal of cancerous lesions; laser and photodynamic therapy; use of retinoid, 5-fluorouracil, imiquimod, photolyase, and antioxidant; interferon therapy and gene therapy are chosen by doctors and patients to lessen the adverse effects of this disease. Among these options, sun avoidance, use of 5-fluorouracil and imiquimod, and interferon therapy are effective. However, some approaches including laser and photodynamic therapy, and the use of retinoids are effective against skin cancer having severe side effects. Furthermore, surgical removal of cancerous lesions and use of antioxidants are considered to be effective against this disease; however, efficacies of these are not experimentally determined. In addition, some approaches including oral vismodegib, immunotherapy, nicotinamide, acetohexamide, glimepiride-restricted diet are found to be effective to minimize the complications secondary to defects in the nucleotide excision repair (NER) system and also enhance the NER, which are under experimental level yet. Besides these, gene therapy, including the introduction of missing genes and genome edition, may be a promising approach to combat this disease, which is also not well established now. In the near future, these approaches may be effective tools to manage XP.

Systematic review of Mohs micrographic surgery in children: Identifying challenges and practical considerations for successful application

BACKGROUND

Few data exist to guide the application of Mohs micrographic surgery (MMS) in the pediatric population.

OBJECTIVE

We sought to summarize the clinical characteristics of children undergoing MMS, identify challenges that limit the use of MMS in this population, and examine how these challenges can be overcome.

METHODS

A systematic review of PubMed and EMBASE, from inception of databases to November 2, 2019, identified all cases of pediatric skin lesions treated with MMS.

RESULTS

A total of 111 patients were included. The median patient age was 11 years (range 6 weeks to 17 years). The most commonly treated tumor was dermatofibrosarcoma protuberans (n = 62), followed by basal cell carcinoma (n = 30). The most common location was the head and neck (n = 34), followed by the trunk (n = 28) and the extremities (n = 23). The most commonly cited challenges in the application of MMS in children included patient cooperation, concerns for the safety of prolonged general anesthesia, availability of a MMS service in the pediatric setting, and access to a histopathology laboratory experienced in MMS sectioning.

LIMITATIONS

Many articles did not report specific patient characteristics.

CONCLUSION

Multiple obstacles limit the application of MMS in pediatric patients. This review describes practical methods to circumvent these obstacles to facilitate the appropriate use of MMS in children.

De Sanctis-Cacchione syndrome in a female infant--case report

The De Sanctis-Cacchione Syndrome is the rarest and most severe kind of xeroderma pigmentosum, characterized by microcephaly, hypogonadism, neurological disorders, mental and growth retardation, with very few cases published. The clinical findings compatible with De Sanctis-Cacchione Syndrome and the therapeutic approach used to treat a one year and nine months old child, with previous diagnosis of xeroderma pigmentosum, are reported.

Chemical peels in aesthetic dermatology: an update 2009

BACKGROUND/OBJECTIVES

Peelings are among the oldest and most widespread aesthetic procedures used in aesthetic dermatology worldwide. More than 50 commercial peelings are currently available on the European market.

MATERIALS AND METHODS

In the present review, we summarise the current knowledge on chemical peels.

RESULTS/CONCLUSIONS

A state-of-the-art peeling procedure will take into account the depth of the targeted structure and the skin condition of the patient to choose carefully among the variables such as chemical class of the peeling agent, concentration, frequency and pressure of the application. The usual classification of chemical peels comprises superficial, medium and deep peels. For superficial peels alpha-hydroxy-acids and most recently lipo-hydroxy acid are used to induce an exfoliation of the epidermis. Medium-depth agents such as trichloroacetic acid (<50%) cause an epidermal to papillary dermal peel and regeneration. Deep peels using trichloroacetic acid (>50%) or phenol based formulations reach the reticular dermis to induce dermal regeneration. The success of any peel is crucially dependent on the physicians understanding of the chemical and biological processes, as well as of indications, clinical effectiveness and side effects of the procedures.

Basal cell carcinoma in childhood: case report and literature review

Childhood onset basal cell carcinoma is uncommon. In addition to occurring in children with albinism, Bazex syndrome, basal cell carcinoma nevus syndrome, nevus sebaceus, radiotherapy-treated cancers, solid organ transplants, and xeroderma pigmentosum, childhood onset basal cell carcinoma has also occurred, albeit less commonly, de novo. We describe a boy with idiopathic childhood onset basal cell carcinoma. Previously published children with de novo basal cell carcinoma were collected from computerized medical literature search (PubMed) and citations from earlier reports. To our knowledge, childhood onset idiopathic basal cell carcinoma has been observed in a total of 107 children, including our patient. Tumors were most commonly located on the head (90%). The tumors are most frequently nodular in appearance (52%) and in histology (at least 17%); however, aggressive histologic variants were observed in 20% of tumors. Basal cell carcinoma in children may be associated with prior sun exposure. The most common treatment is excision, with or without using the Mohs technique. However, 15 of 85 children, nearly 20%, developed recurrent tumors during a follow-up period ranging from 4 months to 20 years.

Excellent response of basal cell carcinomas and pigmentary changes in xeroderma pigmentosum to imiquimod 5% cream

Xeroderma pigmentosum (XP) is an autosomal recessive disease in which patients have a 1000-fold increased risk of developing cutaneous neoplasms. Management of patients with XP is a difficult therapeutic challenge as they usually present with many cutaneous malignancies and continue to form skin tumours at a high rate. We describe a 19-year-old woman with XP who had been previously treated with many different therapeutic approaches. She had an excellent clinical response of her multiple small pigmented basal cell carcinomas and pigmentary changes using imiquimod 5% cream with only minor side-effects.

Skin cancer in organ transplant recipients: Epidemiology, pathogenesis, and management

In the United States more than 100,000 people are living with solid organ transplants. The intense immunosuppressive regimens necessary for prolonged survival of allografts significantly increase the rates of both internal and cutaneous malignancies in recipients of solid organ transplants. Skin cancer is the most common cancer in patients after transplantation. Because of the early onset and high tumor burden in transplant recipients, dermatologists have significant challenges in managing the treatment of these patients. This article describes the epidemiology and clinical presentation of skin cancer during posttransplantation immunosuppression, discusses pathogenic cofactors, and reviews the optimal management for mild and severe skin cancer in transplant recipients.

Formulation of trichloroacetic acid peeling solution: a bibliometric analysis

Since the beginning of this century, trichloroacetic acid solutions of various concentrations have been used for chemical exfoliation. These solutions have been prepared by using four different formulas. To prepare a 50% solution, for instance, water may be added to 50 g of trichloroacetic acid crystals until 100 ml of solution is obtained (weight-to-volume solution). Alternatively, 50 g of water may be added to 50 g of trichloroacetic acid crystals (weight-to-weight solution), or 50 g of trichloroacetic acid crystals may be solved in 100 ml of water (weight-plus-volume solution). Finally, a saturated trichloroacetic acid solution (or "100% solution") may be diluted by an equal volume of water (dilution). Depending on the method used, these so-called 50% solutions contain 40 to 71 weight-to-volume percentages of trichloroacetic acid. From a review of 120 publications on trichloroacetic acid peeling that have appeared since 1926, it was concluded that the authors of 87 of these publications (73 percent) did not report their formula for the trichloroacetic acid solution. Any one of the four methods was reported to have been used by the 33 authors who did report their formula. Eight of 10 internationally reputed pharmacopeias were found not to include the formula of a trichloroacetic acid solution. Proper evaluation of results and prevention of complications of trichloroacetic acid chemexfoliation is only feasible if both the concentration and the formula of trichloroacetic acid solution are reported by the author. Practitioners who use a trichloroacetic acid solution need to establish that the concentration of the solution they apply corresponds with that of the solution reported in the literature.

Cutaneous laser resurfacing

Cutaneous resurfacing with the new generation of carbon dioxide and erbium lasers has recently come into favor for the treatment of facial rhytides, photodamage, and scarring. The precise control of these resurfacing lasers over the extent of tissue vaporization minimizes thermal damage to the skin while maximizing therapeutic efficacy. Proper use of resurfacing lasers is contingent upon a complete understanding of their clinical, histologic, and ultrastructural effects, as well as an appreciation of the principles of laser safety. An organized approach to the preoperative, intraoperative, and postoperative management of the patient undergoing laser resurfacing will be provided, including a discussion of prevention and treatment of postoperative side effects and complications. (J Am Acad Dermatol 1999;41:365-89.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical, histologic, and ultrastructural effects of resurfacing lasers and be able to discuss the preoperative, intraoperative, and postoperative management of patients undergoing laser resurfacing.

A case report of laser resurfacing as a skin cancer prophylaxis

BACKGROUND

Many patients suffer from multiple nonmelanoma skin cancers. We recently encountered two such patients who requested some form of prophylaxis against future skin cancers.

OBJECTIVE

To highlight the potential utility of laser resurfacing as a skin cancer prophylaxis.

METHODS

Two patients with histories of multiple facial skin cancers were treated with CO2 laser resurfacing for the purpose of skin cancer prophylaxis.

RESULTS

During a follow-up period of 33 and 52 months, both patients have remained free of skin cancers in the main treatment field while developing new tumors outside of this area.

CONCLUSION

Laser resurfacing should be considered as a potential method of achieving skin cancer prophylaxis in selected patients.

The actinic keratosis. A perspective and update

BACKGROUND

Actinic keratosis (AK) is a common sun-induced precancerous neoplasm confined to the epidermis. It is the initial manifestation of a continuum of clinical and histologic abnormalities that progresses to invasive squamous cell carcinoma (SCC), a disorder that accounts for thousands of preventable deaths in America each year.

OBJECTIVE

The purpose of this work is to describe the actinic keratosis.

METHODS

This effort was performed by a literature review and analysis.

RESULTS

Like SCCs, the vast majority of AKs are asymptomatic. Although some actinic keratoses may become clinically inapparent, possibly either due to immune rejection or simply having their external surface unknowingly scraped off, an untreated AK represents a potentially curable fatal cancer.

CONCLUSIONS

Each AK should be treated before it progresses to invasive squamous cell carcinoma. Destructive modalities such as cryosurgery using liquid nitrogen and electrodesiccation and curettage are the mainstays of therapy. Each case must be individualized.

LEARNING OBJECTIVES

After studying this article, participant should be able to: 1. Understand the concept of an actinic keratosis. 2. Learn how to recognize its clinical manifestations. 3. Be aware of the danger it poses as an easily curable papulonodule that may become a fatal cancer.

Dermabrasion in xeroderma pigmentosum

BACKGROUND

Dermabrasion is one choice of treatment for patients with severe actinic damage.

OBJECTIVE

To report the youngest xeroderma pigmentosum patient ot have received the benefits of this procedure.

METHODS

The dermabrasion was performed under general anesthesia using an acrotorque hand engine.

RESULTS

New tumor formation was reduced for several months after the treatment.

CONCLUSION

Dermabrasion can be considered as another therapeutic choice for young xeroderma pigmentosum patients with severe actinic damage.