Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study

Importance

It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs.

Objective

To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals.

Design, Setting, and Participants

This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019.

Exposures

Mohs surgery for nonmelanoma skin cancer.

Main Outcomes and Measures

Reason for treatment selection.

Results

Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]).

Conclusions and Relevance

This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Almond Consumption Increased UVB Resistance in Healthy Asian Women

Objectives

Almonds are a rich source of phenolic and polyphenolic compounds, which have antioxidant activity. In vitro and in vivo studies have demonstrated that topical application of almond oil and almond skin extract reduces UVB-induced photoaging. Ultraviolet-B (UVB) protection by oral almond consumption has not been previously studied in humans. It was the objective to investigate whether oral almond consumption can increase resistance to UVB radiation and reduce skin aging in healthy Asian women.

Methods

Thirty-nine female participants (18–45 years) with Fitzpatrick skin type II-IV were randomly assigned to consume either 1.5 oz of almonds or 1.8 oz of pretzels daily for 12 weeks. Minimal erythema dose (MED) was determined using a standardized protocol, which determined the minimal radiation inducing erythema on the inner arm 24 hours following UVB exposure. Facial skin texture was evaluated by two dermatologists using the Clinician's Erythema Assessment scale and Allergan Roughness scale. Facial melanin index, hydration, sebum, and erythema were determined using a cutometer.

Results

Women who consumed almonds, experienced a significant increase in MED from 415 ± 64 to 487 ± 59 (18.7 ± 19.2%, P = 0.006) from baseline to week 12 compared to women in the pretzel group from 415 ± 67 to 421 ± 67 (1.8 ± 11.1%). The exposure time to reach minimal erythema was also increased significantly in the almond group from 160 ± 23 to 187 ± 25 (17.5 ± 22.2%) compared to the pretzel group from 165 ± 27 to 166 ± 25 (1.7 ± 14%) (p=0.026). There were no differences noted between the groups consuming almonds versus pretzels in Allergan roughness, melanin, hydration, or sebum on facial skin.

Conclusions

Our findings suggest that daily oral almond consumption may lead to enhanced protection from UVB photodamage by increasing the MED. Protection from other UV radiation was not tested and therefore almond consumption will not replace other methods of sun protection such as application of sunscreen or wearing protective closing.

Funding Sources

Almond Board of California.

Almond consumption increased UVB resistance in healthy Asian women

BACKGROUND

Almonds are a rich source of phenolic and polyphenolic compounds, which have antioxidant activity. In vitro and in vivo studies have demonstrated that topical application of almond oil and almond skin extract reduces UVB-induced photoaging. Ultraviolet-B (UVB) protection by oral almond consumption has not been previously studied in humans.

OBJECTIVES

To investigate whether oral almond consumption can increase resistance to UVB radiation and reduce skin aging in healthy Asian women.

METHODS

Thirty-nine female participants (18-45 years) with Fitzpatrick skin type II-IV were randomly assigned to consume either 1.5 oz of almonds or 1.8 oz of pretzels daily for 12 weeks. Minimal erythema dose (MED) was determined using a standardized protocol, which determined the minimal radiation needed to induce erythema on the inner arm following UVB exposure. Facial skin texture was evaluated by two dermatologists using the Clinician's Erythema Assessment scale and Allergan Roughness scale. Facial melanin index, hydration, sebum, and erythema were determined using a cutometer.

RESULTS

The MED was increased in the subjects consuming almonds compared to the control group consuming pretzels. There were no differences noted between the groups consuming almonds versus pretzels in Allergan roughness, melanin, hydration, or sebum on facial skin.

CONCLUSIONS

Our findings suggest that daily oral almond consumption may lead to enhanced protection from UV photodamage by increasing the MED.

Pityriasis amiantacea following bone marrow transplant

Pityriasis amiantacea (PA) is a hair disorder characterized by matting of multiple hair shafts, typically occurring as an idiopathic condition. A 67-year-old woman with multiple myeloma who developed PA following a bone marrow transplant with melphalan conditioning is described.She noted initial changes in scalp hair regrowth 4 weeks posttransplant. During the next 4 months she developed multiple lesions of PA that rapidly responded to management, including mineral oil under occlusion in the evening followed by daily shampooing with alternating coal tar, salicylic acid, and ketoconazole shampoos. We review medications that have been associated with PA and conditions related to PA, including atopic dermatitis, bacterial infection, fungal infection, psoriasis, and seborrheic dermatitis. Our patient developed PA that was associated with either melphalan conditioning, bone marrow transplant, or both.

Compound heterozygous mutations in desmoplakin associated with skin fragility, follicular hyperkeratosis, alopecia, and nail dystrophy

Desmoplakin mutations are associated with a wide variety of phenotypes affecting the skin, nails, hair, and heart. A 21-month-old boy was born with multiple erosions resembling epidermolysis bullosa, complete alopecia, nail dystrophy, palmoplantar keratoderma, and areas of follicular hyperkeratosis. He was found to have two heterozygous mutations in the desmoplakin gene: c.478 C>T in exon 4 (p.Arg160X) and c.3630T>A in exon 23 (Tyr1210X). This case expands the clinical spectrum associated with desmoplakin mutations and highlights a mutation in exon 23 that has not been previously reported in the literature.

Clinical Characteristics of Lower Extremity Surgical Site Infections in Dermatologic Surgery Based Upon 24-Month Retrospective Review

Dermatologic surgery performed on the lower extremities has an increased risk for surgical site infections (SSI). Our objective was to evaluate the clinical characteristics associated with SSI following Mohs micrographic surgery (MMS) and wide local excisions (WLE) performed below the knee. We performed a single-center retrospective chart review of patients (n=271) that underwent these procedures. Within 14 days of the lower extremity procedure, four of 175 MMS patients (2.3%) developed SSI compared to eight of 96 WLE patients (8.3%; P=0.029). Subcuticular sutures and vertical mattress sutures as a group were associated with reduced 30-day infection rate when compared to other suture methods (P=0.006). Comparison of patients on prophylactic antibiotics to control patients without antibiotics did not reveal a statistically significant difference in infection rate. MMS infection rates trended lower as compared to WLE in the 14-day post-operative window. Doxycycline prophylaxis did not produce a statistically significantly lower rate of SSI, though results approached significance. A prospective study may be warranted to further compare cephalexin and doxycycline for dermatologic surgery below the knee. Subcuticular or vertical mattress sutures may be preferred when closing wounds due to their association with reduced infection rate. J Drugs Dermatol. 2018;17(7):766-771.

Toxic epidermal necrolysis-like acute cutaneous lupus erythematosus: report of a case and review of the literature

Severe bullous eruptions in systemic lupus erythematosus (SLE) patients include bullous SLE, Rowell syndrome, toxic epidermal necrolysis (TEN), and TEN-like eruption of acute cutaneous lupus (TEN-like ACLE). TEN-like ACLE, a rare manifestation of SLE that closely mimics TEN, can be distinguished by characteristic clinical and laboratory findings. A 27-year-old man with SLE who developed TEN-like ACLE after initiating mycophenolate mofetil for active SLE is reported. The reports of 37 women and six men  including our patient with TEN-like ACLE were also reviewed. The diagnosis of SLE or subacute cutaneous lupus erythematosus was either previously confirmed or established at the time of diagnosis of TEN-like ACLE in 41 patients. Fever was present in 59% of patients. The onset of TEN-like ACLE was either subacute (73%) or acute (27%). Thirteen cases did not clarify the nature of disease onset. The skin lesions often presented initially on sun-exposed sites (29 patients) and involved one or more mucous membranes (21 patients). A new medication may have caused the TEN-like ACLE in 67% of the patients. Systemic corticosteroids either alone or combined with hydroxychloroquine, intravenous immunoglobulin, or mycophenolate mofetil were the most commonly used treatment. Patients with TEN-like ACLE patients had an 89% survival.

Genitogluteal porokeratosis in an HIV-positive man: a case report and review of the literature on genital porokeratosis

Genitogluteal porokeratosis is a disorder of keratinization that may present in men in their fourth decade of life. We describe a 52-year-old human immunodeficiency virus (HIV)-positive man with history of anal squamous cell carcinoma who developed verrucous lesions on the buttocks and genitals. The buttock lesions presented shortly after radiotherapy for anal carcinoma a decade prior, whereas the genital lesions presented three months prior in areas treated with injectable medication for erectile dysfunction. Skin biopsy revealed a cornoid lamella, leading to the diagnosis of genitogluteal porokeratosis. The buttock lesions were treated with shave excision and the genital lesions were treated with topical agents. Using the PubMed database, a literature search was performed with combinations of the following key words: acuminata, condyloma, cornoid lamella, genital, genitogluteal, HIV, penile, porokeratosis, verrucous, vulvar. The generated papers and their references were reviewed. To the best of our knowledge, we present the first reported case of genitogluteal porokeratosis in an HIV-positive man. Notably, these lesions developed in sites of prior radiation or injection. This condition should be included in the differential diagnosis of chronic lesions of the genitals and buttocks in patients with HIV and/or history of radiation treatment and/or trauma to the genitogluteal region.

Pediatric penile porokeratosis: A case report

We present what we believe to be the second case of pediatric penile porokeratosis and the youngest case reported. A 6-year-old boy presented with a pruritic, verrucous growth at the urethral meatus that recurred after two meatotomies. The diagnosis of porokeratosis was confirmed by biopsy. Porokeratosis should be added to the differential diagnosis of chronic hyperkeratotic penile lesions in children.

Eosinophilic dermatosis of hematologic malignancy mimicking varicella zoster infection: report in a woman with chronic lymphocytic leukemia and review of the literature

Eosinophilic dermatosis of hematologic malignancy is a rare papulovesicular eruption that presents in patients with hematoproliferative disorders, particularly chronic lymphocytic leukemia. A 59-year-old woman with chronic lymphocytic leukemia who developed eosinophilic dermatosis of hematologic malignancy mimicking varicella zoster infection is described. PubMed database was searched with the key words: chronic, dermatosis, eosinophilic, hematologic, infection, leukemia, lymphocytic, malignancy, varicella, zoster. The papers generated by the search and their references were reviewed. The patient presented, on more than 20 occasions, with a dermatomal vesicular eruption. Her oncologist, based on the clinical presentation, treated each episode as recurrent varicella zoster virus infection. A complete workup of the patient not only demonstrated negative viral studies but also revealed pathologic changes consistent with eosinophilic dermatosis of hematologic malignancy on lesional skin biopsy. The recurrence of the patient's dermatosis was less frequent when her malignancy was under better control. Eosinophilic dermatosis of hematologic malignancy may mimic other reactive dermatoses. The morphology of our patient's recurrent dermatosis resembled varicella zoster virus infection. Disseminated zoster virus infection with dermatomal and non-dermatomal distribution should be added to the clinical differential diagnosis of eosinophilic dermatosis of hematologic malignancy.

Hereditary hemorrhagic telangiectasia and pregnancy: potential adverse events and pregnancy outcomes

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant condition with a prevalence of ~1 in 5,000 individuals. The pathophysiology of this condition centers on the lack of capillary beds between arterioles and venules, leading to direct contact between these vessels. This results in telangiectases on characteristic locations such as the face, fingers, mouth, and nasal mucosa. Visceral arteriovenous malformations (AVMs) are also observed in many patients, and these are most commonly seen in the brain, gastrointestinal tract, and lungs. Liver AVMs are present in many patients with HHT, though these individuals are usually asymptomatic; however, liver AVMs may lead to serious complications, such as high output cardiac failure. Diagnosis of HHT hinges upon fulfilling three out of four criteria: family history of the condition, mucocutaneous telangiectases, spontaneous and recurrent episodes of epistaxis, and visceral AVMs. Management is guided by international consensus guidelines and targets patients’ specific AVMs. Prognosis is good, though severe complications including hemorrhage and paradoxical emboli are possible. Novel therapeutics are being explored in clinical trials; bevacizumab and pazopanib inhibit angiogenesis, while thalidomide bolsters blood vessel maturation. Pregnancy in patients with HHT is considered high risk. While the majority of pregnancies proceed normally, severe complications have been reported in some women with HHT; these include heart failure, intracranial hemorrhage, pulmonary hemorrhage, and stroke. Such complications occur most often in the second and third trimesters when maternal changes such as peripheral vasodilation and increased cardiac output are at their maximum. Awareness of the diagnosis of HHT has been associated with improved outcomes in pregnancy. Management guidelines for pregnant patients with HHT are reviewed.

Successful Management of Zoon's Balanitis with Topical Mupirocin Ointment: A Case Report and Literature Review of Mupirocin-Responsive Balanitis Circumscripta Plasmacelluaris

INTRODUCTION

Zoon's balanitis, also referred to as balanitis circumscripta plasmacellularis (BCP), is an idiopathic, benign inflammatory condition of the glans penis and foreskin most often seen in elderly uncircumcised men. A patient with a biopsy-confirmed diagnosis of BCP who was successfully treated with topical mupirocin ointment is described.

METHODS

The PubMed database was searched with the key words: bactroban, balanitis, cell, circumscripta, mupirocin, plasma, plasmacellularis, tacrolimus, Zoon. The papers generated by the search and their references were reviewed.

RESULTS

Treatments for BCP have previously included circumcision and topical calcineurin inhibitors. Our patient with BCP rapidly resolved after initiating treatment with mupirocin 2% ointment.

CONCLUSION

BCP is a benign dermatosis affecting the glans penis and foreskin. We confirm an earlier observation demonstrating successful management of this condition with topical mupirocin 2% ointment. Previously reported therapies include circumcision, topical calcineurin inhibitors, phototherapy, and laser therapy. However, based on our observations, topical mupirocin 2% ointment therapy may be considered for the initial management of patients with suspected BCP. Prompt response to mupirocin 2% ointment is highly suggestive of the diagnosis of BCP since morphologically similar skin conditions do not respond to this treatment.

Cutaneous Metastasis From Tonsillar Squamous Cell Carcinoma: Report and Review of the Literature

Tonsillar squamous cell carcinoma, which represents 10% of head and neck malignancies, rarely manifests with cutaneous metastases; to date, only three prior patients with tonsillar squamous cell carcinoma have been reported to develop cutaneous metastases. We describe the clinical features of a 59-year-old man with squamous cell carcinoma of the tonsil who developed cutaneous metastases within his prior radiation port and review the literature of prior patients with cutaneous metastases from tonsillar squamous cell carcinoma. The PubMed database was searched for the following keywords: carcinoma, cutaneous, metastasis, squamous, and tonsil. The papers generated by the search and their references were reviewed. Cutaneous metastasis from tonsillar cancer is rare but should be considered in patients with a history of a squamous cell carcinoma of the tonsil; new skin lesions, both overlying the visceral malignancy and at more distant sites, should be biopsied since prognosis in these patients is poor. Management has thus far been palliative and should be individualized to the patient.

Tumoral Melanosis Associated with Pembrolizumab-Treated Metastatic Melanoma

Tumoral melanosis is a form of completely regressed melanoma that usually presents as darkly pigmented lesions suspicious for malignant melanoma. Histology reveals dense dermal and subcutaneous infiltration of melanophages. Pembrolizumab is an antibody directed against programmed death receptor-1 (PD1) and is frontline treatment for advanced melanoma. An 81-year-old man with metastatic melanoma treated with pembrolizumab who developed tumoral melanosis at previous sites of metastases is described. The PubMed database was searched with the key words: antibody, immunotherapy, melanoma, melanosis, metastasis, pembrolizumab, and tumoral. The papers generated by the search and their references were reviewed. The patient was initially diagnosed with lentigo maligna melanoma on the left cheek three years earlier, and he was treated with wide local excision. The patient was subsequently diagnosed with epidermotropic metastatic malignant melanoma on the left parietal scalp 14 months later and was treated with wide local excision. Three months later, the patient was found to have metastatic melanoma in the same area of the scalp and was started on pembrolizumab immunotherapy. The patient was diagnosed with tumoral melanosis in the site of previous metastases nine months later. The patient remained free of disease 13 months after starting pembrolizumab. Tumoral melanosis may mimic malignant melanoma; hence a workup, including skin biopsy, should be undertaken. Extensive tumoral melanosis has been reported with ipilimumab, and we add a case following treatment with pembrolizumab. Additional cases of tumoral melanosis may present since immunotherapy has become frontline therapy for advanced melanoma. 

Isotretinoin therapy for the treatment of acne in patients with cystic fibrosis: a case series and review of the literature

BACKGROUND

Cystic fibrosis (CF) is the most common severe autosomal recessive disorder in Caucasians. Viscous secretionstypically obstruct the lungs, pancreas, and gastrointestinal tract. As disease management improves, patients will increasingly seek care for conditions such as acne. Isotretinoin therapy for acne in patients with CF is controversial owing to concerns that the medication may exacerbate CF-related hepatic, pulmonary, and ocular complications.

PURPOSE

We describe two patients with CF treated with isotretinoin from our clinic and also provide a literature review of 11 similar cases. We describe patient outcomes, common complications, and the risks for severe adverse effects.

MATERIALS AND METHODS

The clinical courses of two patients with CF who were treated with isotretinoin for moderate-severe acne are presented. Using PubMed, we analyzed previous case reports of patients with CF who were prescribed isotretinoin and review complications associated with systemic retinoids.

RESULTS

Based on a synthesis of the literature and our own experience, it appears that isotretinoin therapy for CF patients with moderate-severe acne may be an appropriate option when clinically indi ated. If dermatologists monitor lab values and adverseeffects carefully, patients with CF can benefit from isotretinoin therapy.

Growth patterns and anaemia status of HIV-infected children living in an institutional facility in India

OBJECTIVE

To understand the health status of HIV orphans in a well-structured institutional facility in India.

METHOD

Prospective longitudinal analysis of growth and anaemia prevalence among these children, between June 2008 and May 2011.

RESULTS

A total of 85 HIV-infected orphan children residing at Sneha Care Home, Bangalore, for at least 1 year, were included in the analysis. Prevalence of anaemia at entry into the home was 40%, with the cumulative incidence of anaemia during the study period being 85%. At baseline, 79% were underweight and 72% were stunted. All children, irrespective of their antiretroviral therapy (ART) status, showed an improvement in nutritional status over time as demonstrated by a significant increase in weight (median weight-for-age Z-score: -2.75 to -1.74, P < 0.001) and height Z-scores (median height-for-age Z-score: -2.69 to -1.63, P < 0.001).

CONCLUSION

These findings suggest that good nutrition even in the absence of ART can bring about improvement in growth. The Sneha Care Home model indicates that the holistic approach used in the Home may have been helpful in combating HIV and poor nutritional status in severely malnourished orphaned children.