Discrepancy in the use and interpretation of marker sutures among plastic surgeons and pathologists

Marker sutures are often used for excised cutaneous lesions to aid histological analysis, however, there are no current guidelines to facilitate this in practice. The authors hypothesised that a lack of guidelines causes a variation in clinical practice and confusion of meaning between plastic surgeons and pathologists. This questionnaire-based study confirms the authors' hypothesis and highlights a discrepancy both between surgeons and in individual surgical practice. More importantly, we identify discord between histopathologists and plastic surgeons in relation to marker suture placement and report interpretation, leading to potential undertreatment of patients. This paper adds to the growing literature calling for guidelines regarding marker suture placement for cutaneous excision biopsies.

PTEN as a target in melanoma

PTEN is a well-known tumour suppressor protein that is frequently found to be mutated, inactivated or deleted in a wide range of different cancers. Its tumour suppressive properties result predominantly from its inhibitory effects on the PI3K-AKT signalling pathway. In melanoma, numerous different PTEN mutations have been identified in both melanoma cell lines and melanoma tissue. A number of different molecules can act on PTEN to either promote its suppression of melanoma, while other molecules may antagonise PTEN to inhibit its mechanism of action against melanoma. This review will discuss how the interactions of PTEN with other molecules may have a positive or negative impact on melanoma pathogenesis, giving rise to the potential for PTEN-targeted therapies against melanoma.

Ligand-Independent Actions of the Vitamin D Receptor: More Questions Than Answers

Our predominant understanding of the actions of vitamin D involve binding of its ligand, 1,25(OH)D, to the vitamin D receptor (VDR), which for its genomic actions binds to discrete regions of its target genes called vitamin D response elements. However, chromatin immunoprecipitation‐sequencing (ChIP‐seq) studies have observed that the VDR can bind to many sites in the genome without its ligand. The number of such sites and how much they coincide with sites that also bind the liganded VDR vary from cell to cell, with the keratinocyte from the skin having the greatest overlap and the intestinal epithelial cell having the least. What is the purpose of the unliganded VDR? In this review, I will focus on two clear examples in which the unliganded VDR plays a role. The best example is that of hair follicle cycling. Hair follicle cycling does not need 1,25(OH)₂D, and Vdr lacking the ability to bind 1,25(OH)₂D can restore hair follicle cycling in mice otherwise lacking Vdr. This is not true for other functions of VDR such as intestinal calcium transport. Tumor formation in the skin after UVB radiation or the application of chemical carcinogens also appears to be at least partially independent of 1,25(OH)₂D in that Vdr null mice develop such tumors after these challenges, but mice lacking Cyp27b1, the enzyme producing 1,25(OH)₂D, do not. Examples in other tissues emerge when studies comparing Vdr null and Cyp27b1 null mice are compared, demonstrating a more severe phenotype with respect to bone mineral homeostasis in the Cyp27b1 null mouse, suggesting a repressor function for VDR. This review will examine potential mechanisms for these ligand‐independent actions of VDR, but as the title indicates, there are more questions than answers with respect to this role of VDR. © 2021 The Author. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Home-based narrowband UVB, topical corticosteroid or combination for children and adults with vitiligo: HI-Light Vitiligo three-arm RCT

BACKGROUND

Systematic reviews suggest that narrowband ultraviolet B light combined with treatments such as topical corticosteroids may be more effective than monotherapy for vitiligo.

OBJECTIVE

To explore the clinical effectiveness and cost-effectiveness of topical corticosteroid monotherapy compared with (1) hand-held narrowband ultraviolet B light monotherapy and (2) hand-held narrowband ultraviolet B light/topical corticosteroid combination treatment for localised vitiligo.

DESIGN

Pragmatic, three-arm, randomised controlled trial with 9 months of treatment and a 12-month follow-up.

SETTING

Sixteen UK hospitals - participants were recruited from primary and secondary care and the community.

PARTICIPANTS

Adults and children (aged ≥ 5 years) with active non-segmental vitiligo affecting ≤ 10% of their body area.

INTERVENTIONS

Topical corticosteroids [mometasone furoate 0.1% (Elocon®, Merck Sharp & Dohme Corp., Merck & Co., Inc., Whitehouse Station, NJ, USA) plus dummy narrowband ultraviolet B light]; narrowband ultraviolet B light (narrowband ultraviolet B light plus placebo topical corticosteroids); or combination (topical corticosteroids plus narrowband ultraviolet B light). Topical corticosteroids were applied once daily on alternate weeks and narrowband ultraviolet B light was administered every other day in escalating doses, with a dose adjustment for erythema. All treatments were home based.

MAIN OUTCOME MEASURES

The primary outcome was self-assessed treatment success for a chosen target patch after 9 months of treatment ('a lot less noticeable' or 'no longer noticeable' on the Vitiligo Noticeability Scale). Secondary outcomes included blinded assessment of primary outcome and percentage repigmentation, onset and maintenance of treatment response, quality of life, side effects, treatment burden and cost-effectiveness (cost per additional successful treatment).

RESULTS

In total, 517 participants were randomised (adults, n = 398; and children, n =  119; 52% male; 57% paler skin types I-III, 43% darker skin types IV-VI). At the end of 9 months of treatment, 370 (72%) participants provided primary outcome data. The median percentage of narrowband ultraviolet B light treatment-days (actual/allocated) was 81% for topical corticosteroids, 77% for narrowband ultraviolet B light and 74% for combination groups; and for ointment was 79% for topical corticosteroids, 83% for narrowband ultraviolet B light and 77% for combination. Target patch location was head and neck (31%), hands and feet (32%), and rest of the body (37%). Target patch treatment 'success' was 20 out of 119 (17%) for topical corticosteroids, 27 out of 123 (22%) for narrowband ultraviolet B light and 34 out of 128 (27%) for combination. Combination treatment was superior to topical corticosteroids (adjusted risk difference 10.9%, 95% confidence interval 1.0% to 20.9%; p = 0.032; number needed to treat = 10). Narrowband ultraviolet B light was not superior to topical corticosteroids (adjusted risk difference 5.2%, 95% confidence interval -4.4% to 14.9%; p = 0.290; number needed to treat = 19). The secondary outcomes supported the primary analysis. Quality of life did not differ between the groups. Participants who adhered to the interventions for > 75% of the expected treatment protocol were more likely to achieve treatment success. Over 40% of participants had lost treatment response after 1 year with no treatment. Grade 3 or 4 erythema was experienced by 62 participants (12%) (three of whom were using the dummy) and transient skin thinning by 13 participants (2.5%) (two of whom were using the placebo). We observed no serious adverse treatment effects. For combination treatment compared with topical corticosteroids, the unadjusted incremental cost-effectiveness ratio was £2328.56 (adjusted £1932) per additional successful treatment (from an NHS perspective).

LIMITATIONS

Relatively high loss to follow-up limits the interpretation of the trial findings, especially during the post-intervention follow-up phase.

CONCLUSION

Hand-held narrowband ultraviolet B light plus topical corticosteroid combination treatment is superior to topical corticosteroids alone for treatment of localised vitiligo. Combination treatment was relatively safe and well tolerated, but was effective in around one-quarter of participants only. Whether or not combination treatment is cost-effective depends on how much decision-makers are willing to pay for the benefits observed.

FUTURE WORK

Development and testing of new vitiligo treatments with a greater treatment response and longer-lasting effects are needed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17160087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 64. See the NIHR Journals Library website for further project information.

Demographic, Clinical, and Immunologic Correlates among a Cohort of 50 Cocaine Users Demonstrating Antineutrophil Cytoplasmic Antibodies

OBJECTIVE

Cocaine/levamisole-associated autoimmunity syndrome (CLAAS) is a poorly understood form of drug-induced autoimmunity. Our goals were to better characterize the spectrum of clinical and immunologic features of CLAAS, to identify demographic risk factors, and to generate new hypotheses regarding pathogenesis.

METHODS

CLAAS subjects were identified between 2001 and 2015 at the University of Washington Medical Center, Harborview Medical Center, and affiliated clinics in Seattle, Washington, USA. Demographic, clinical, and immunologic variables were collected and correlated using contingency and logistic regression analyses. We used similar analyses to compare CLAAS subjects with all individuals exhibiting antineutrophil cytoplasmic antibodies (ANCA+) or cocaine use (Cocaine+) in an associated deidentified clinical data repository.

RESULTS

We identified 50 CLAAS subjects. Compared to all Cocaine+ individuals (n = 2740), CLAAS subjects were more likely to be female and less likely to self-identify as black/African American. CLAAS subjects showed several ANCA patterns, including anti-MPO (myeloperoxidase)/anti-PR3 (proteinase 3) dual reactivity, a finding that appears to be specific to CLAAS. Hematologic, renal, and skin abnormalities were most frequently reported, including neutropenia and skin purpura. Finally, we observed strong, independent associations between the cytoplasmic ANCA (C-ANCA) pattern and mortality.

CONCLUSION

We identify sex and race as important risk modifiers in the developing CLAAS among cocaine users. The development of C-ANCA was associated with increased mortality. Moreover, we confirm the enriched presence of anti-MPO/anti-PR3 dual reactivity in CLAAS, further supporting the diagnostic utility of this feature.

The Microbiome in Psoriasis and Psoriatic Arthritis: The Skin Perspective

Psoriasis is a chronic, inflammatory immune-mediated skin disease that affects about 2% of the world's population. In 20% of patients with psoriasis, the characteristic skin lesions are accompanied by psoriatic arthritis (PsA). Psoriasis arises in genetically predisposed individuals who have a dysregulated immune response to various environmental factors. The human body is home to many microbial species, and both the skin and the gut microbiome influence the development and function of immune tissue development and function. Studies on the cutaneous microbiome show a trend toward an increased relative abundance of Streptococcus and a decreased level of Propionibacterium in patients with psoriasis compared to healthy controls. In the gut microbiome, the ratio of Firmicutes and Bacteroidetes was perturbed in psoriatic individuals compared to healthy controls. Actinobacteria was relatively underrepresented in patients with psoriasis compared to healthy individuals. A decrease in skin microbiome flora diversity seems to be a sign that a patient with psoriasis is at elevated risk for developing arthritis. Modulating the skin microbiota for therapeutic reasons can be achieved by antimicrobial (antibiotic) therapy, the application of prebiotics or probiotics, or the transplantation of an entire healthy microbial population.

Human polyomavirus DNA detection in keratoacanthoma and Spitz naevus: no evidence for a causal role

Keratoacanthomas (KA) and Spitz naevus (SN) are both lesions with unknown aetiology; therefore, the possibility of a viral involvement, more specifically the involvement of human polyomaviruses (HPyV), was investigated. In total, 22 cases of KA and 25 cases of SN were tested for the presence of HPyVs. DNA was extracted and amplified by multiplex PCR and thereafter tested with a multiplex bead-based assay for HPyVs (BKPyV, JCPyV, KIPyV, WUPyV, MCPyV, TSPyV, HPyV6, 7 and 9) and two primate viruses (SV40 and LPyV). HPyV DNA was found in 20 of the 47 lesions. There was no significant difference in HPyV DNA detection frequency between patients diagnosed with KA and patients diagnosed with SN, nor any over-representation of a specific HPyV type in any of the two patient categories. In conclusion, evidence for a specific aetiological role of any of the above tested HPyVs in either KA or SN was not disclosed.

Expression of embryonic stem cell markers in keloid-associated lymphoid tissue

AIMS

To identify, characterise and localise the population of primitive cells in keloid scars (KS).

METHODS

5-µm-thick formalin-fixed paraffin-embedded sections of KS samples from 10 patients underwent immunohistochemical (IHC) staining for the embryonic stem cell (ESC) markers OCT4, SOX2, pSTAT3 and NANOG, and keloid-associated lymphoid tissue (KALT) markers CD4 and CD20. NanoString gene expression analysis and in situ hybridisation (ISH) were used to determine the abundance and localisation of the mRNA for these ESC markers.

RESULTS

IHC staining revealed the expression of the ESC markers OCT4, SOX2, pSTAT3 and NANOG by a population of cells within KS tissue. These are localised to the endothelium of the microvessels within the KALTs. NanoString gene expression analysis confirmed the abundance of the transcriptional expression of the same ESC markers. ISH localised the expression of the ESC transcripts to the primitive endothelium in KS tissue.

CONCLUSIONS

This report demonstrates the expression of ESC markers OCT4, SOX2, pSTAT3 and NANOG by the endothelium of the microvessels within the KALTs. These findings show a unique niche of primitive cells within KS, expressing ESC markers, revealing a potential therapeutic target in the treatment of KS.

Molecular characteristics and potential therapeutic targets in Merkel cell carcinoma

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine skin tumour occurring preferentially in elderly and immunosuppressed individuals. Multiple studies have provided insight into the molecular alterations of MCC, leading to the design of several ongoing clinical trials testing chemotherapy, targeted therapy and immunotherapy in patients with recurrent or metastatic disease. The results of some of these studies are available, whereas others are eagerly awaited and will likely shed light on the understanding of MCC biology and potentially improve the clinical outcomes of patients with this rare disease.

A rare and unusual hyperkeratotic disorder

Clinical question

A 78-year-old female presented with a pruritic rash on her legs for many years. A biopsy was taken from the right leg. Review the high-quality, interactive digital Aperio slide at http://virtualacp.com/JCP_Case/index.php and consider your diagnosis.

What is your diagnosis?

Non-infectious granulomatous conditions of the skin: a clinicopathological approach to diagnosis

Granulomatous disorders of the skin are diverse and include infectious and non-infectious conditions. They are a source of confusion to many dermatologists and pathologists, including even the most experienced dermatopathologists. Correlation with clinical picture, serology, microbiology and careful morphological examination is essential for accurate diagnosis. Most cases require ancillary histopathological studies to reach a final diagnosis. This review discusses important non-infectious granulomatous conditions of the skin and presents a practical approach when confronted with such entities.

Skin dendritic cells in burn patients

The body's immunological response to burn injury has been a subject of great inquiry in recent years. Burn injury disturbs the immune system, resulting in a progressive suppression of the immune response that is thought to contribute to the development of sepsis. Dendritic cells (DCs) are potent antigen-presenting cells that possess the ability to stimulate naïve T cells.DCs are derived from bone marrow progenitors and circulate in the blood as immature precursors prior to migration into peripheral tissues. Within different tissues, DCs differentiate and become active in the taking up and processing of antigens, and their subsequent presentation on the cell surface is linked to major histocompatibility molecules. Upon appropriate stimulation, DCs undergo further maturation and migrate to secondary lymphoid tissues, where they present antigen to T cells and induce an immune response. The purpose of this study was to determine the effects of burn injury on skin DCs in terms of percentage, HLA-DR, and Toll-like receptor-4 (TLR-4) expression. The skin DCs were isolated from burned skin and non-burned skin in the same patient at 7 days post-injury, and skin DCs were isolated from unburned healthy individuals as control. DCs from burned skin notably express low levels of HLA-DR and TLR-4 soon after cell isolation. In the post-burn period the ability of skin DCs to respond to bacterial stimuli is impaired. These changes in DC behaviour might contribute to the impaired host defences against bacteria during burn sepsis.

Non-invasive preliminary experimental clinical trial

The aim of this trial was to measure the pH value of the skin of burn patients using a non-invasive method, from the acute phase through to complete re-epithelialization. The research was then completed by treating the patients with new materials and innovative methods to verify whether this had an effect on the skin pH and on re-epithelialization time. In this clinical trial, the patients were medicated repeatedly with hydrogel (Burnshield®) kept in place by a transparent, semipermeable adhesive film with a moisture vapour transmission rate equivalent to 1600 until day 5 or 6 post-burn. In one patient, treated silk (DermaSilk®) was applied several times until re-epithelialization; in another patient, synthetic hyaluronic acid (Hyalomatrix®) was applied. Various studies using Dermasilk® have confirmed that the fibroin in silk stimulates re-epithelialization, in addition to keeping the burned skin disinfected, thanks to the antimicrobial agent contained in the treated silk. Hyalomatrix® was used on the other patient, as in other studies, as a temporary substitute for the skin in deep burns. Late complications (keloids and hypertrophic scars) can give rise, even after prolonged periods of time, to Marjolin's ulcer (carcinoma but also melanoma and sarcoma), which can develop in the course of a year. A recent Danish trial affirms that appropriate burn treatment facilitates re-epithelialization and decreases the incidence of Marjolin's ulcer. For the trial, we used a centimetre-wide strip of reactive paper sensitive to pH variations and an acid test (Duotest® kit) as a reference, applied for more than one minute on the patient's burned and slightly damp skin. We performed control procedures on the patient's normal skin, away from the wound site. The pH was measured from day 1 post-burn and every other day thereafter until complete re-epithelialization. We found alkaline pH values for the burned skin from the day of the burn until day 12, with an alkaline pH peak on day 4 (10.5 in the first patient, 9.5 in the second). The values then gradually returned to normal (pH, 5.5) from day 13 onwards. The mean re-epithelialization time was similar in the two patients, equivalent to 24.5 days (25 days in the first patient, 24 in the second), with a mean follow-up of 21 months (33 months in the first case, 9 in the second). No early or late complications were observed.

Intermingled skin grafting: a valid transplantation method at low cost

The almost forgotten method of intermingled skin grafting of allogeneic material with small autogeneic islets, once developed in the People's Republic of China, proves the feasibility of permanent healing of even extensive burn wounds, at low cost, and therefore an effective treatment possibility in poorer countries, as well as under conditions of a burn disaster. Intermingled skin grafting obtains a better elasticity of the reconditioned skin as elastic fibres of the allodermis survive, and this results in fewer contractures. From the cosmetic point of view the transplantation of autologous keratinocytes results in a better aesthetic homogeneous texture.

Two Cases in Adult Patients

A review of the relative international literature of the last few years is followed by a description of two cases of staphylococcal scalded skin syndrome in adults. As in both cases the initial diagnosis was that of Lyell's syndrome, the main criteria for the differential diagnosis of the two pathologies are considered in order to permit specific and effective treatment.

Severe bullous skin diseases: analysis of seven children managed in a burns unit

Patients suffering from considerable cutaneous loss must be treated under strict aseptic conditions and with positive pressure ventilation, which is available in burns units. The differentiation of severe bullous skin diseases remains a challenge for the clinician. We report seven cases of severe bullous skin diseases in a paediatric age group treated in a burns unit with the cooperation of a paediatric intensive care unit (King Saud Hospital, Unizah, Kingdom of Saudia Arabia) between 2001 and 2005. Toxic epidermal necrolysis (Lyell's syndrome) was encountered in five cases, staphylococcal scalded-skin syndrome in one, and generalized drug eruption in one. The mortality rate was 14% (one of the seven patients). Most of the children presented with about 35% desquamation and 45% intact bullous formation (70-80% total body surface area involvement). The majority presented after the sudden onset of high fever, signs of systemic toxicity, and intense mucocutaneous exfoliation. The diagnosis was confirmed by skin biopsy and culture swabs. All the patients were managed as for mixed second-degree burns with regard to fluid calculation and hydrotherapy. We used the closed technique for dressing. The results are presented, and the literature was searched for similar cases reported in other parts of the world. The importance of diagnosis and appropriate treatment of the condition is emphasized.

Transplantation of Composite Skin Containing Keratinocytes Cultured on a Fibroblast-conditioned Acellular Dermal Matrix

To evaluate the role of fibroblasts in composite skin reconstructed in vitro, four different types of composite skin (A, B, C, and D) were prepared. Human keratinocytes were seeded onto the epidermal side of an acellular dermal matrix (ADM) in type A. Keratinocytes were seeded onto the epidermal side of an ADM and human fibroblasts onto the dermal side in type B. Both keratinocytes and fibroblasts were seeded onto the epidermal side in type C. Type D consisted of fibroblasts on both sides of the ADM and keratinocytes on the epidermal side. The adherence of keratinocytes to the ADM was observed. The composite skin was then transplanted onto full-thickness skin defect wounds in nude mice. Results showed that the adherence of keratinocytes to the ADM was improved when fibroblasts were pre-seeded onto the epidermal side of the ADM. The composite skin was able to close full-thickness skin defect wounds. The take rates were respectively 44.1 ± 7.8%, 47.3 ± 5.4%, 75.2 ± 8.8%, and 81.2 ± 8.1% for types A, B, C, and D. The take rates of types C and D were significantly higher than those of types A and D. There was no significant difference in take rate between types C and D. In conclusion, composite skin consisting of keratinocytes cultured on a fibroblast-conditioned ADM was a good skin substitute.

The role of non-precipitating antibodies in the passive sensitization of human skin by rabbit anti-ovalbumin

Sera of fourteen rabbits injected with alum-precipitated recrystallized ovaltumin, containing 0.046 to 0.604 mg. of precipitable antibody nitrogen per ml. (average 0.299 mg.), passively sensitized human skin, while the sera of nine rabbits injected with dissolved recrystallized ovalbumin, containing from less than 0.05 to 0.420 of antibody nitrogen per ml. (average 0.176 mg. or less), were inactive in human skin. The skin-sensitizing activity of the sera bore no relation to the precipitin content. Removal of 68 to 90 per cent of the precipitin nitrogen by a single addition of antigen did not affect the activity of the sera in sensitizing human skin. Removal of all precipitable antibody nitrogen in one serum by a single addition of antigen removed the skin-sensitizing activity. The "univalent" antibody remaining after complete removal of precipitin by fractional addition of antigen showed the same activity in passive sensitization of human skin as the original serum.