Intralesional methotrexate treatment for keratoacanthoma tumors: a retrospective study and review of the literature

Geriatric dermatologic surgery part I: Frailty assessment and palliative treatments in the geriatric dermatology population

Longer life expectancy and increasing keratinocyte carcinoma incidence contribute to an increase in geriatric patients presenting for dermatologic surgery. Unique considerations accompany geriatric patients including goals of care, physiologic changes in medication metabolism, cognitive decline, and frailty. Limited geriatric training in dermatology residency has created a knowledge gap and dermatologic surgeons should be familiar with challenges facing older patients to provide interventions more congruent with goals and avoid overtreatment. Frailty assessments including the Geriatric 8 and Karnofsky Performance Scale are efficient tools to identify patients who are at risk for poor outcomes and complications. When frail patients are identified, goals of care discussions can be aided using structured palliative care frameworks including the 4Ms (what matters, medications, mentation, and mobility), REMAP (reframing, expecting emotion, mapping patient goals, aligning patient goals, and proposing a plan), and Serious Illness Conversation Guide. Most geriatric patients will tolerate standard of care treatments including invasive modalities like Mohs surgery and excision. However, for frail patients, nonstandard treatments including topicals, energy-based devices, and intralesional chemotherapy may be appropriate options to limit patient morbidity while offering reasonable disease control.

Intralesional Methotrexate Injection for the Treatment of Epithelial Crateriform Tumor

BACKGROUND

Intralesional methotrexate injection (IL-MTX) is an appropriate strategy for treating epithelial crateriform tumors (ECTs) when surgical excision can result in functional or cosmetic defects; however, not all ECTs are responsive to this treatment.

OBJECTIVE

This study aimed to evaluate the effectiveness of IL-MTX for ECTs and to determine the differences in clinical response according to the pathological features.

METHODS

The medical records of patients treated with IL-MTX for their ECTs were retrospectively reviewed. Effectiveness was evaluated in terms of size reduction and flattening.

RESULTS

Twenty-five cases of ECTs with biopsy were included in this study. Eight cases of keratoacanthoma (KA) and 15 cases of squamous cell carcinoma (SCC) were identified, but 2 cases could not be clearly distinguished. Seventeen patients (68%) showed a response after injection, and response rate in KA and SCC were 75% (6/8) and 60% (9/15), respectively. Nine patients showed complete resolution with IL-MTX. Patients received 3 injections, and regression was observed in 7.56 weeks after the first injection. According to histopathological results, patients with KA and SCC received 2 and 3.33 injections, respectively, and complete resolution was observed after 7 and 7.67 weeks, respectively.

CONCLUSION

IL-MTX is safe and effective, and could be considered as a useful non-surgical treatment option for ECTs. Both KA and crateriform SCC showed good response; However, KA showed a better response.

Intralesional methotrexate versus 5-flurouracil in the treatment of keratoacanthoma

BACKGROUND

Keratoacanthoma (KA) is a benign neoplasm that affects mainly photodamaged skin. It is locally destructive and may rarely spread. Surgery is not always suitable and usually disfiguring. Thus, non-operative modalities represent good alternatives.

OBJECTIVE

To assess and compare the efficacy of intralesional methotrexate (MTX) and 5-flurouracil (5-FU) in the treatment of KA.

PATIENTS AND METHODS

Randomized controlled trial included 20 patients with biopsy proven KA divided into 2 equal groups; group (A) received intralesional MTX, 25 mg/ml and group (B) received intralesional 5-FU, 50 mg/ml every 2 weeks till complete clearance or for a maximum 5 sessions.

RESULTS

In the MTX group, complete clearance was observed in 7 patients (70%) compared to 8 patients (80%) in the 5- FU group with no statistically significant difference. However, the median number of injections needed to achieve complete response in the MTX group was 3 sessions versus only 2 sessions in the 5-FU group.

LIMITATIONS

the small sample size due to the relatively low incidence of KAs in our population.

CONCLUSION

Intralesional therapy is a good alternative to surgery in selected cases of KA. Both drugs showed comparable efficacy, but 5-FU may give faster results, hence increasing patient satisfaction and compliance.

Multiple Eruptive Keratoacanthomas Secondary to Nivolumab Immunotherapy

Immune checkpoint inhibitors are increasingly being utilized for the treatment of advanced neoplastic disease and have been associated with wide-ranging cutaneous adverse effects. Though exceedingly rare, eruptive keratoacanthomas have been associated with the use of immune checkpoint inhibitors such as pembrolizumab and nivolumab, whose molecular target is the programmed cell death protein 1. Herein, we detail a case of numerous eruptive keratoacanthomas arising in a patient one month after initiation of nivolumab for recurrent metastatic oropharyngeal squamous cell carcinoma. Treatment with multiple rounds of intralesional corticosteroids and a several-month course of oral acitretin resulted in partial improvement. Subsequent treatment with intralesional 5-fluorouracil demonstrated near-complete resolution of the keratoacanthomas without discontinuation of nivolumab. Although eruptive keratoacanthomas secondary to immune checkpoint inhibitors are exceptionally rare, physicians should be aware of this cutaneous adverse effect as their use becomes more widespread.

Intralesional methotrexate as non-surgical therapy for giant keratoacanthoma on the nose

Keratoacanthoma is an epithelial tumour derived from hair follicles. Clinical and histopathological features of keratoacanthoma can resemble that of squamous cell carcinoma. Different treatment alternatives have been described over the years including intralesional methotrexate injection. We present an interesting case of treatment of solitary keratoacanthoma lesion on the nose with intralesional methotrexate as non-surgical therapy.

Intralesional Treatments for Invasive Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is the second most frequent cancer in humans and has the potential to progress locally, metastasize, and cause death in a subset of patients. cSCC is especially common in the elderly, and it will probably represent a major health concern in the near future. Surgery is the standard treatment for cSCC, but intralesional therapies can sometimes be considered for certain patients and under certain circumstances. The choice of intralesional treatment depends on the patient's characteristics and the clinician's previous experience and expertise. Here we are reviewing intralesional treatments for cSCC and keratoacanthoma (KA). We have started with some classic drugs, such as methotrexate and 5-fluorouracil, bleomycin, interferon, and cryosurgery, but also comment on electrochemotherapy. Finally, we have focused on novel therapies, some of which are under development, and future perspectives, including intralesional immunotherapy and oncolytic viruses.

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma: Part 2. Treatment-Update 2023

In order to update recommendations on treatment, supportive care, education, and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV), and the European Organisation of Research and Treatment of Cancer (EORTC) was formed. Recommendations were based on an evidence-based literature review, guidelines, and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable), and distant metastatic cSCC. For common primary cSCC, the first-line treatment is surgical excision with postoperative margin assessment or micrographically controlled surgery. Achieving clear surgical margins is the most important treatment consideration for patients with cSCCs amenable to surgery. Regarding adjuvant radiotherapy for patients with high-risk localised cSCC with clear surgical margins, current evidence has not shown significant benefit for those with at least one high-risk factor. Radiotherapy should be considered as the primary treatment for non-surgical candidates/tumours. For cSCC with cytologically or histologically confirmed regional nodal metastasis, lymph node dissection is recommended. For patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drugs Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC, include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiotherapy. Multidisciplinary board decisions are mandatory for all patients with advanced cSCC, considering the risks of toxicity, the age and frailty of patients, and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with the best supportive care to improve symptom management and quality of life. The frequency of follow-up visits and investigations for subsequent new cSCC depends on underlying risk characteristics.

Advances in Cutaneous Squamous Cell Carcinoma Management

Simple Summary

Cutaneous squamous cell carcinoma (cSCC) is an increasingly prevalent and morbid cancer worldwide. Management of this cancer has changed significantly in the last decade through improved risk stratification and new therapies offering patients with locally advanced and metastatic disease more effective, less toxic, and more durable treatment options. Ongoing clinical trials are assessing new therapeutic options as well as optimizing existing regimens in efforts to better manage this cancer. The recent developments highlight the need for multidisciplinary care, especially for those with locally advanced and metastatic disease.

Abstract

cSCC is increasing in prevalence due to increased lifespans and improvements in survival for conditions that increase the risk of cSCC. The absolute mortality of cSCC exceeds melanoma in the United States and approaches that of melanoma worldwide. This review presents significant changes in the management of cSCC, focusing on improvements in risk stratification, new treatment options, optimization of existing treatments, and prevention strategies. One major breakthrough in cSCC treatment is the advent of immune checkpoint inhibitors (ICIs) targeting programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1), which have ushered in a renaissance in the treatment of patients with locally advanced and metastatic disease. These agents have offered patients with advanced disease decreased therapeutic toxicity compared to traditional chemotherapy agents, a more durable response after discontinuation, and improved survival. cSCC is an active field of research, and this review will highlight some of the novel and more developed clinical trials that are likely to impact cSCC management in the near future.

Management of pre-malignant and malignant non-melanoma skin cancers: A study from a Tertiary Care Hospital of North India

Introduction:

The incidence of non-melanoma skin cancers (NMSCs) is increasing over the last few decades. This necessitates an early diagnosis which is nowadays aided by dermoscopy. Once diagnosed early, the treatment armamentarium is diverse and includes both topical and surgical modalities.

Objective:

Our aim was to diagnose pre-malignant and malignant NMSCs at an early stage and treat them as per the standard protocol.

Materials and Materials:

Out of 136 patients of pre-malignant and malignant tumors enrolled, 100 were taken up for treatment. These were then classified into various subtypes on the basis of clinical examination and dermoscopy. The selected patients were subjected to topical treatment or surgical modalities, wide local excision or flap excision, based on the type of tumor and its size.

Results:

The pre-malignant group included actinic keratoses, Bowen’s disease, and keratoacanthoma, whereas the malignant group included undifferentiated squamous cell carcinoma (SCC), differentiated SCC, pigmented basal cell carcinoma (BCC), nodulo-ulcerative BCC, and superficial BCC. Actinic keratoses, superficial BCCs, and five cases of keratoacanthoma were treated with topical therapies with a resolution of 90% in 86.8% cases. All the remaining cases (62 in number) were treated with conventional and flap surgery with 88% and 89.1% clearance rates, respectively, with complications in only 7 patients.

Conclusion:

A prompt identification of NMSCs can enable selection of the appropriate treatment modality for a specific lesion and thus reduce their associated morbidity and mortality.

Intralesional Agents in Dermatology: Pros and Cons

Since introduced in 1961, intralesional (IL) agent has become an essential part of the dermatological practice. The term IL referred to the direct delivery of agent percutaneously into skin lesions. This therapeutic approach is relatively safe, easy to perform and applicable for a broad range of dermatological conditions. On the other hand, immediate side effects, including pain during administration, bleeding, high risk of infection and allergic reaction, and subsequent side effects involving skin changes such as atrophy, telangiectasia, pigmentary changes, and striae are usually associated with this modality. This review paper highlights the pros and cons of IL agents in modern dermatology practice.

Effectiveness of neoadjuvant intralesional methotrexate in cutaneous squamous cell carcinoma: A prospective cohorts study

Intralesional methotrexate (il-MTX) has been used in cutaneous squamous cell carcinoma (cSCC) achieving important reductions in tumor size. However, there is a lack of controlled studies on this regard. The primary objective was to analyze the effect of il-MTX on tumor size in cSCC. As a secondary objective, we evaluated its impact on the surgical approach. We conducted a prospective cohorts study that included 200 patients with histologically confirmed cSCC. Patients in Group 1 (Cases) received neoadjuvant treatment with il-MTX prior to surgery. Patients in Group 2 (Controls) underwent scheduled surgery without prior neoadjuvant therapy. Clinical measurements of lesions were made at the time of inclusion in the study and before surgery. No intergroup statistical differences were found between the assessed variables. In Group 1, tumor size reduction occurred in 93% of the patients after il-MTX therapy. Tumor surface was reduced by 54%. Complex reconstructions were needed in 15% of these patients. In Group 2, tumor surface increased by 33.1% and complex reconstructions were needed in 40% of patients. Intergroup differences were statistically significant (p < 0.001). Neoadjuvant Il-MTX therapy achieves very important tumor size reduction and significantly simplifies surgical treatment.

A clinical and biological review of keratoacanthoma

Keratoacanthoma (KA) is a common skin tumour that remains controversial regarding classification, epidemiology, diagnosis, prognosis and management. Classically, a KA manifests as a rapidly growing, well-differentiated, squamoid lesion with a predilection for sun-exposed sites in elderly people and a tendency to spontaneously regress. Historically, KAs have been considered a variant of cutaneous squamous cell carcinoma (cSCC) and are often reported as KA-type cSCC. However, the penchant for regression has led many to categorize KAs as biologically benign tumours with distinct pathophysiological mechanisms from malignant cSCC. The clinical and histopathological similarities between KA and cSCC, particularly the well-differentiated variant of cSCC, have made definitive differentiation difficult or impossible in many cases. The ambiguity between entities has led to the general recommendation for surgical excision of KAs to ensure a potentially malignant cSCC is not left untreated. This current standard creates unnecessary surgical morbidity and financial strain for patients, especially the at-risk elderly population. There have been no reports of death from a definitive KA to date, while cSCC has an approximate mortality rate of 1·5%. Reliably distinguishing cSCC from KA would shift management strategies for KAs towards less-invasive treatment modalities, prevent unnecessary surgical morbidity, and likely reduce associated healthcare costs. Herein, we review the pathophysiology and clinical characteristics of KA, and conclude on the balance of current evidence that KA is a benign lesion and distinct from cSCC.

Case Report: Combined Intra-Lesional IL-2 and Topical Imiquimod Safely and Effectively Clears Multi-Focal, High Grade Cutaneous Squamous Cell Cancer in a Combined Liver and Kidney Transplant Patient

Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer worldwide, with ever increasing incidence and mortality. While most patients can be treated successfully with surgical excision, cryotherapy, or radiation therapy, there exist a subset of patients with aggressive cSCC who lack adequate therapies. Among these patients are solid organ transplant recipients who due to their immunosuppression, develop cSCC at a dramatically increased rate compared to the normal population. The enhanced ability of the tumor to effectively undergo immune escape in these patients leads to more aggressive tumors with a propensity to recur and metastasize. Herein, we present a case of aggressive, multi-focal cSCC in a double organ transplant recipient to frame our discussion and current understanding of the immunobiology of cSCC. We consider factors that contribute to the significantly increased incidence of cSCC in the context of immunosuppression in this patient population. Finally, we briefly review current literature describing experience with localized therapies for cSCC and present a strong argument and rationale for consideration of an IL-2 based intra-lesional treatment strategy for cSCC, particularly in this immunosuppressed patient population.

Neoadjuvant Therapy for Non-melanoma Skin Cancer: Updated Therapeutic Approaches for Basal, Squamous, and Merkel Cell Carcinoma

OPINION STATEMENT

Recently introduced systemic therapies for locally advanced and metastatic non-melanoma skin cancers (NMSCs) are paving the way for neoadjuvant approach. Although none of the therapeutic options has currently gained indication in this setting, neoadjuvant approach for NMSCs is an open field and we are likely to see huge developments in the near future. Targeted therapy with sonic hedgehog pathway inhibitors is very effective in locally advanced or multiple basal cell carcinomas while immunotherapy with immune checkpoint inhibitors appears to be promising for advanced cutaneous squamous cell carcinoma and Merkel cell carcinoma. To date, targeted therapy and immunotherapy represent the frontiers in NMSC therapeutic management and, according to recent studies, good results can be achieved.

Intralesional methotrexate in dermatology: Diverse indications and practical considerations

Intralesional methotrexate (IL-MTX) is a long-established treatment, which is arguably underutilized by dermatologists. We describe the underlying evidence base and practical considerations for its broad range of cutaneous indications, including in cutaneous oncology (keratoacanthomas, squamous cell carcinomas, lymphomas), inflammatory dermatology (nail psoriasis, plaque psoriasis, pyoderma gangrenosum, cutaneous Crohn's disease, amyloidosis), cutaneous infections (viral warts) and for treatment of filler complications. In certain circumstances, IL-MTX can be more efficacious and less invasive than other treatments, with fewer adverse effects. Dermatologists should consider using IL-MTX for a range of recalcitrant cutaneous conditions, particularly for those patients not amenable to surgery or systemic therapy.

Resolution of Keratoacanthoma Type Squamous Cell Carcinoma Following Intralesional Therapy With Methotrexate

Keratoacanthoma is considered a variant of squamous cell carcinoma prone to spontaneous involution, but it may also rapidly grow and invade surrounding tissues. Herein, we report a case of keratoacanthoma-type squamous cell carcinoma that resolved after intralesional therapy with methotrexate.

Efficacy of intralesional methotrexate in the treatment of plantar warts

Warts are tumors or growths caused by infection with human papilloma virus (HPV). Currently, over 170 HPV types have been identified. This study aimed to evaluate the efficacy and safety of intralesional injection of methotrexate (MTX) for the treatment of plantar warts. Sixty patients presented with plantar warts were divided into two groups. Group A patients were injected with intralesional MTX (2 mg/ml). Group B patients were injected with intralesional saline as a placebo. The injections were repeated every week for a maximum of six sessions or until complete clearance, whichever was earlier. The patients were followed up for 6 months after the last injection. In the intralesional MTX group, 2 patients (6.7%) showed complete improvement, 8 patients (26.7%) showed partial improvement, and 20 patients (66.7%) showed no improvement. In the intralesional saline group, 3 patients (10%) showed complete improvement, 4 patients (13.3%) showed partial improvement, and 23 patients (76.7%) showed no improvement. Reported adverse events were local reactions in the form of swelling, pain, and infection in both groups. There was no statistically significant difference between the therapeutic responses to intralesional MTX injection and saline.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2. Treatment

In order to update recommendations on treatment, supportive care, education and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Dermatology Forum, the European Association of Dermato-Oncology and the European Organization of Research and Treatment of Cancer was formed. Recommendations were based on evidence-based literature review, guidelines and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable) and distant metastatic cSCC. For common primary cSCC (the most frequent cSCC type), first-line treatment is surgical excision with postoperative margin assessment or microscopically controlled sugery. Safety margins containing clinical normal-appearing tissue around the tumour during surgical excision and negative margins as reported in the pathology report are necessary to minimise the risk of local recurrence and metastasis. In case of positive margins, a re-excision shall be done, for operable cases. Lymph node dissection is recommended for cSCC with cytologically or histologically confirmed regional nodal involvement. Radiotherapy should be considered as curative treatment for inoperable cSCC, or for non-surgical candidates. Anti-PD-1 antibodies are the first-line systemic treatment for patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiation, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drug Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiation therapy. Multidisciplinary board decisions are mandatory for all patients with advanced disease who require more than surgery. Patients should be engaged with informed decisions on management and be provided with best supportive care to optimise symptom management and improve quality of life. Frequency of follow-up visits and investigations for subsequent new cSCC depend on underlying risk characteristics.

Cryosurgery, Intralesional Methotrexate and Imiquimod for Keratoacanthoma: Tuning the Combination

Keratoacanthomas (KA) are self-regressing, destructively expanding keratinocyte skin neoplasms typically characterized by sudden onset of explosive growth followed by complete involution. Cryosurgery, intralesional methotrexate and imiquimod have been used alone or in combination of two for the treatment of KA. Presently 3 patients (49, 60, and 65 years old; two females, one suspected with Ferguson-Smith syndrome), with 5 KA (6–24 mm maximal diameter) were treated with the combination of cryosurgery (liquid N₂, open spray, 2 cycles of 15 sec each) and intralesional methotrexate (2.5–30 mg cumulative dose) and subsequent daily application of imiquimod (14–35 days). Starting with 4 cryosurgery/intralesional methotrexate sessions and 5 weeks daily imiquimod, to document feasibility and efficacy we progressively reduced the intensity of the treatment to one cryosurgery/intralesional methotrexate (total dose: 5 mg) session and 14 days of daily imiquimod without compromising efficacy. KA stopped growing promptly with sustained clearance after 6–24 months follow up, implicating a huge potential of therapeutic synergy of the employed modalities in the management of KA. We suggest that, optimized, the present three modalities combination (one session mild cryosurgery/low dose, 5 mg intralesional methotrexate and 2 weeks once daily imiquimod) is a promising treatment for KA that merits evaluation in further studies.

Relative Efficacy of Nonoperative Treatment of Keratoacanthomas

Background

Keratoacanthomas (KAs) are neoplasms of squamous epithelium which exhibit rapid growth and are often difficult to distinguish clinically from squamous cell carcinoma. Excision is the most common treatment, but in refractory cases or for KAs in cosmetically sensitive areas, nonoperative modalities may be better suited.

Objective

To compare efficacies of topical and intralesional therapies for the treatment of KAs.

Methods

A systematic literature review was performed using Medline, Ovid, and Embase. Studies looking at the efficacy of topical or intralesional treatments for KAs were included. To compare efficacy, 2-tailed t-tests were performed, with P < .05 considered statistically significant.

Results

Forty-one studies were identified across 5 modalities. Both topical and intralesional treatments had high KA eradication rates (92%-100%). Intralesional 5-fluorouracil led to faster KA healing times when compared to intralesional methotrexate (3.7 vs 4.6 weeks, P = .017). Similarly, topical 5-fluorouracil led to faster time to heal than topical imiquimod (3.8 vs 7.6 weeks with imiquimod, P < .0001).

Conclusion

For nonoperative treatment of KAs, strong evidence currently exists for both topical and intralesional therapies. Decisions on which modality to use should be made on a case-by-case basis.

Evolving Role of Systemic Therapies in Non-melanoma Skin Cancer

Keratinocyte cancers - basal and cutaneous squamous cell carcinoma (BCC, cSCC) - are the most common forms of non-melanoma skin cancer (NMSC) and there has been a significant increase in their incidence globally in recent decades. Although the majority of BCC and cSCC are cured with conventional surgery or radiotherapy, certain tumour or patient-determined factors may result in these modalities being inadequate or inappropriate, for example, locally advanced or metastatic disease, high tumour multiplicity, patient comorbidities and patient preferences. In these clinical circumstances, systemic treatment may be indicated, and over the past 10 years a number of new systemic agents have been approved. Nonetheless, effective systemic therapy for keratinocyte cancers remains an area of significant unmet clinical need. Improved understanding of the molecular and immune pathogenesis underlying tumour growth and development is critical for driving future advances and is a research priority. The aim of this review is to provide clinicians with an overview of systemic treatments for BCC and cSCC and will focus on current evidence for conventional chemotherapy, targeted therapies, immunotherapy, adjuvant and neoadjuvant therapy, chemoprevention and future prospects for novel systemic treatment approaches.

Efficacy of methotrexate as anti-inflammatory and anti-proliferative drug in dermatology: Three case reports

Methotrexate (MTX) is a folic acid analog with anti-proliferative (anti-neoplastic, cytotoxic), immunosuppressive and anti-inflammatory properties, which has been used in the treatment of various cutaneous disorders, such as psoriasis, keratoacanthoma, pityriasis rubra pilaris, atopic dermatitis, mycosis fungoides, bullous skin diseases, systemic sclerosis, morphea, lupus erythematosus, dermatomyositis and crusted scabies. Inhibition of cell proliferation is explained through its role in blocking DNA/RNA synthesis, by inhibiting dihydrofolate reductase, necessary for the production of pyrimidine and purine nucleotides. An anticancer effect can be related to α-oxoaldehyde metabolism (MTX increases methylglyoxal levels). Its anti-inflammatory property is based on the inhibition of 5-aminoimidazole-4-carboxamide ribonucleotide transformylase, thus increasing intracellular and extracellular adenosine, a purine nucleoside with anti-inflammatory effect. This drug can limit inflammation by scavenging free radicals and decreasing malondialdehyde-acetaldehyde protein-adduct production. Moreover, the anti-proliferative and anti-inflammatory effects can also be related to inhibition of the DNA methylation pathway, thus inhibiting methionine formation. The aim of the present study was to report various dermatological cases from our daily practice that demonstrate the efficacy of MTX in the treatment of cutaneous diseases, highlighting different mechanisms of action: its anti-inflammatory effect in psoriasis and its anti-proliferative, and anti-neoplastic effect in well-differentiated squamous cell carcinoma or in keratoacanthoma. Moreover, different administration pathways and doses are addressed. Assessment of the treatment plan, clinical improvement of cutaneous lesions, biologic evaluation, final aesthetic result, quality of life, as well as potential adverse effects and drug tolerance related to each case mentioned.

Efficacy of methotrexate as anti-inflammatory and anti-proliferative drug in dermatology: Three case reports

Methotrexate (MTX) is a folic acid analog with anti-proliferative (anti-neoplastic, cytotoxic), immunosuppressive and anti-inflammatory properties, which has been used in the treatment of various cutaneous disorders, such as psoriasis, keratoacanthoma, pityriasis rubra pilaris, atopic dermatitis, mycosis fungoides, bullous skin diseases, systemic sclerosis, morphea, lupus erythematosus, dermatomyositis and crusted scabies. Inhibition of cell proliferation is explained through its role in blocking DNA/RNA synthesis, by inhibiting dihydrofolate reductase, necessary for the production of pyrimidine and purine nucleotides. An anticancer effect can be related to α-oxoaldehyde metabolism (MTX increases methylglyoxal levels). Its anti-inflammatory property is based on the inhibition of 5-aminoimidazole-4-carboxamide ribonucleotide transformylase, thus increasing intracellular and extracellular adenosine, a purine nucleoside with anti-inflammatory effect. This drug can limit inflammation by scavenging free radicals and decreasing malondialdehyde-acetaldehyde protein-adduct production. Moreover, the anti-proliferative and anti-inflammatory effects can also be related to inhibition of the DNA methylation pathway, thus inhibiting methionine formation. The aim of the present study was to report various dermatological cases from our daily practice that demonstrate the efficacy of MTX in the treatment of cutaneous diseases, highlighting different mechanisms of action: its anti-inflammatory effect in psoriasis and its anti-proliferative, and anti-neoplastic effect in well-differentiated squamous cell carcinoma or in keratoacanthoma. Moreover, different administration pathways and doses are addressed. Assessment of the treatment plan, clinical improvement of cutaneous lesions, biologic evaluation, final aesthetic result, quality of life, as well as potential adverse effects and drug tolerance related to each case mentioned.

Intralesional Methotrexate for the Treatment of Keratoacanthoma: The Neapolitan Experience

Introduction

Keratoacanthomas are cutaneous neoplasms known for their rapid growth and spontaneous regression over a long time period. Their treatment can be difficult because of the potentially large field size and number of lesions. Intralesional methotrexate constitutes an effective, nonsurgical treatment of keratoacanthomas, as proven by our experience.

Methods

We treated 11 elderly patients affected by keratoacanthoma with intralesional methotrexate. The injections were performed weekly, followed by 10 mg of folic acid to be taken 24 h later.

Results

All our patients underwent complete resolution of the lesions after 4–8 injections, without side effects.

Conclusion

Intralesional methotrexate seems to be an effective and safe nonoperative treatment modality for keratoacanthoma, especially when it arises in anatomic areas difficult to treat with surgery, in elderly debilitated patients, and in those refusing surgery.

Efficacy and Safety of Intralesional Methotrexate in the Treatment of a Large Keratoacanthoma of the Dorsal Hand in a 99-Year-Old Woman

Several case reports and retrospective studies have demonstrated that intralesional methotrexate (MTX) could be a very effective and safe alternative treatment of keratoacanthoma (KA). Here, we report a rapid clinical efficacy of two intralesional MTX injections (total dose 40 mg) that were performed 1 week apart in the treatment of a large KA lesion of the dorsal hand in a 99-year-old woman. The lesion, with a 3-cm major axis diameter and a thickness of 2 cm with a central ulceration had rapidly appeared on the right dorsal hand. A 3-mm punch biopsy confirmed the diagnosis of a well-differentiated KA-type spinous cellular carcinoma. Due to the presence of comorbidities (arterial hypertension and atrial fibrillation) and chronic treatment with antihypertensive and oral anticoagulant drugs, treatment with intralesional MTX was proposed to the patient. Two intralesional MTX injections of 20 mg each were performed 1 week apart. A very fast resolution of the lesion was observed after the first injection. A week after the second injection a full resolution of the skin lesion was observed, with a nearly complete resolution of the central ulceration. The treatment was very well tolerated. No local or systemic side effects were observed. This case report confirms that intralesional MTX could be considered an effective and safe treatment of KA also in very old subjects.

Resistance of Nonmelanoma Skin Cancer to Nonsurgical Treatments. Part II: Photodynamic Therapy, Vismodegib, Cetuximab, Intralesional Methotrexate, and Radiotherapy

A wide range of treatments is now available for nonmelanoma skin cancer, including 5-fluorouracil, ingenol mebutate, imiquimod, diclofenac, photodynamic therapy, methotrexate, cetuximab, vismodegib, and radiotherapy. All are associated with high clinical and histologic response rates. However, some tumors do not respond due to resistance, which may be primary or acquired. Study of the resistance processes is a broad area of research that aims to increase our understanding of the nature of each tumor and the biologic features that make it resistant, as well as to facilitate the design of new therapies directed against these tumors. In this second article, having covered the topical treatments of nonmelanoma skin cancer, we review resistance to other nonsurgical treatments, such as monoclonal antibodies against basal and squamous cell carcinomas, intralesional chemotherapy, photodynamic therapy, and radiotherapy.

Fractional laser-assisted drug delivery: Laser channel depth influences biodistribution and skin deposition of methotrexate

BACKGROUND AND OBJECTIVE

Ablative fractional laser (AFXL) facilitates delivery of topical methotrexate (MTX). This study investigates impact of laser-channel depth on topical MTX-delivery.

MATERIALS AND METHODS

MTX (1% [w/v]) diffused for 21 hours through AFXL-exposed porcine skin in in vitro Franz Cells (n = 120). A 2,940 nm AFXL generated microscopic ablation zones (MAZs) into epidermis (11 mJ/channel, MAZ-E), superficial-dermis (26 mJ/channel, MAZ-DS), and mid-dermis (256 mJ/channel, MAZ-DM). High performance liquid chromatography (HPLC) was used to quantify MTX deposition in full-thickness skin, biodistribution profiles at specific skin levels, and transdermal permeation. Fluorescence microscopy was used to visualize UVC-activated MTX-fluorescence (254 nm) and semi-quantify MTX distribution in skin.

RESULTS

AFXL increased topical MTX-delivery (P < 0.001). Without laser exposure, MTX-concentration in full-thickness skin was 0.07 mg/cm(2) , increasing sixfold (MAZ-E), ninefold (MAZ-DS), and 11-fold (MAZ-DM) after AFXL (P < 0.001). Deeper MAZs increased MTX-concentrations in all skin layers (P < 0.038) and favored maximum accumulation in deeper skin layers (MAZ-E: 1.85 mg/cm(3) at 500 μm skin-level vs.

MAZ-DM

3.75 mg/cm(3) at 800 μm, P = 0.002). Ratio of skin deposition versus transdermal permeation remained constant, regardless of MAZ depth (P = 0.172). Fluorescence intensities confirmed MTX biodistribution through coagulation zones and into surrounding skin, regardless of thickness of coagulation zones (6-47 μm, P ≥ 0.438).

CONCLUSION

AFXL greatly increases topical MTX-delivery. Deeper MAZs deliver higher MTX-concentrations than superficial MAZs, which indicates that laser channel depth may be important for topical delivery of hydrophilic molecules. Lasers Surg. Med. 48:519-529, 2016. © 2016 Wiley Periodicals, Inc.

Keratoacanthoma (KA): An update and review

Keratoacanthoma (KA) is a common but underreported tumor of the skin. Two striking features of KA are its clinical behavior with spontaneous regression after rapid growth and its nosological position on the border between benignity and malignancy. We review current knowledge on the clinical, histopathological, and dermoscopic features of KA to ensure a proper diagnosis and describe its variants, including different types of multiple KAs. We highlight current concepts of KA ethiopathogenesis with special emphasis on the genetic background of multiple familial KA, the role of Wnt signaling pathway, and induction of KA by BRAF inhibitors and procedures of esthetic dermatology. Finally, treatment strategies are presented with surgical excision as a first option, followed by other modalities, including intralesional chemotherapy, topical and systemic agents, lasers, cryotherapy, and photodynamic therapy.

Keratoacanthoma of the Lip: Activation of the mTOR Pathway, Tumor Suppressor Proteins, and Tumor Senescence

The PI3K-PTEN-mTOR is one of the most important pathways involved in cancer development and progression; however, its role in keratoacanthoma (KA) is poorly understood. In this study, we investigated the activation of key proteins in the PI3K-mTOR pathway in lip KA. We analyzed the activation of the PI3K-PTEN-mTOR pathway using human tumor samples stained for well-established protein markers in this pathway, including pS6 and pAKT phosphoproteins. We assessed proliferation using Ki-67 and performed additional morphological and immunohistochemical analysis using anti-PTEN and anti-p16 antibodies.We found that the majority of KA labeled to pS6 and not pAKT. PTEN expression was inversely correlated with Ki-67 expression. In addition to PTEN expression, KA cells were positive for p16 senescence marker. PI3K-PTEN-mTOR pathway is activated in lip KA, leading to downstream activation of mTORC1, but not mTORC2. This pathway plays an important role in KA progression by promoting proliferation and activation of oncogenic-induced senescence.

pH dependent chemical stability and release of methotrexate from a novel nanoceramic carrier

The study reveals maximum chemical stability of methotrexate in LDH–MTX at pH 7.00 and controlled release profile of PLGA–LDH–MTX.

Intralesional methotrexate for the treatment of keratoacanthoma: retrospective study and review of the korean literature

Background

Although intralesional methotrexate (MTX) is an effective, nonsurgical treatment of keratoacanthoma (KA), there have not been many reports of on the MTX treatment for KA in Korea.

Objective

The purpose of this study was to evaluate the clinical efficacy of the intralesional MTX for the treatment of KA in Korean patients.

Methods

We retrospectively studied seven patients with KA who received intralesional injection of MTX in our department. The efficacy was evaluated based on the physician assessment. Our review also included the cases of KA treated with intralesional MTX in Korean patients from the previous reports. We then analyzed the therapeutic regimens in the Korean patients by comparing them with the Caucasian patients.

Results

We identified 11 cases of Korean KA patients treated with an intralesional MTX, including seven from our institution and four from the Korean literature. Ten of the 11 patients (91%) showed a complete resolution with an intralesional MTX. No adverse events were observed during the treatment and the follow-up periods. No recurrence was found during the follow-up. In therapeutic analysis, the Korean patients required 2 to 7 injections (mean 4.6 injections) to achieve a tumor resolution with the mean time to clearing at 7.6 weeks.

Conclusion

Intralesional MTX can be an effective and safe non-operative treatment modality for most Koreans with KA.

Recurrent facial keratoacanthoma in a patient with diabetes: a case report

Background

Keratoacanthoma is a relatively common low-grade malignancy that originates in the pilosebaceous glands. Pathologically, it closely resembles squamous cell carcinoma. Keratoacanthoma is believed to have a good prognosis; however, it has been reclassified as squamous cell carcinoma, keratoacanthoma type, to reflect the difficulty in histologic differentiation of this lesion as well as its uncommon but potentially aggressive nature. Keratoacanthoma infrequently presents as multiple tumors and may enlarge (5–15 cm), become locally aggressive, and rarely metastasize.

Case presentation

A 66-year-old Arab male patient with diabetes was referred to the Maxillofacial Surgery Department with a chief complaint of a dome-shaped nodule with a smooth, shiny surface and central crateriform ulceration with a keratin plug in the form of a horn-like projection. Skin papules were present in the right lateral canthal area and extended to the lateral border of the lower eyelid, measuring 1.3 cm. On palpation, the lesion was firm, movable, and tender. The patient had a history of a similar lesion in another area of his face that had spontaneously regressed.

Conclusion

Histological differentiation between keratoacanthoma and well-differentiated squamous cell carcinoma is difficult, particularly when a secondary infection is present. Careful establishment of the correlation among the history, clinical findings, and histopathology is highly indicated to avoid unnecessary surgical intervention.