Lesional CD8+ T-Cell Number Predicts Surgical Outcomes of Melanocyte-Keratinocyte Transplantation Surgery for Vitiligo

The melanocyte-keratinocyte transplantation procedure (MKTP) treats stable and recalcitrant vitiligo. Despite careful selection of candidates based on clinical stability, the success of the procedure is unpredictable. The aim of our study was to define the immunological profile of stable vitiligo lesions undergoing MKTP and correlate them with clinical outcomes. We included 20 MKTP candidates with vitiligo and a patient with piebaldism as a control. Prior to MKTP, T-cell subsets and chemokines in the recipient skin were measured by flow cytometry and ELISA. During MKTP, melanocytes in the donor skin were quantified by flow cytometry. After MKTP, patients were followed for 12 months and repigmentation was assessed clinically and by ImageJ analysis of clinical photographs. Baseline immunologic biomarkers, duration of clinical stability, and transplanted melanocyte number were correlated to postsurgical repigmentation scores. CD8+ T cells were elevated in 43% of the clinically stable vitiligo lesions. CD8+ T-cell number negatively correlated with postsurgical repigmentation scores (r = -0.635, P = 0.002). Duration of clinical stability, skin chemokines, and transplanted melanocyte number did not influence postsurgical repigmentation. This study demonstrates that CD8+ T-cell number correlates negatively with success of postsurgical repigmentation and can be a biomarker to identify ideal surgical candidates.

Wound Care Adherence in Mohs Micrographic Surgery: A Prospective Cohort Study

BACKGROUND

Patients undergoing Mohs micrographic surgery (MMS) are given detailed wound care instructions to prevent postoperative complications. Previous studies have revealed low treatment adherence in general dermatology, but adherence to postoperative wound care and its potential association with poor surgical outcomes remain largely unstudied.

OBJECTIVE

To determine the frequency and causes of wound care nonadherence in patients who underwent MMS.

MATERIALS AND METHODS

A questionnaire containing a modified Eight-Item Morisky Medication Adherence Measure Scale was administered to Mohs patients at their 1 to 2 weeks postoperative visit.

RESULTS

Sixty-three patients were solicited and consented to completing the questionnaire. The average modified Eight-Item Morisky Medication Adherence Measure Scale score was 7.4 of 8, indicating high adherence. Old age and wound care assistance were associated with increased adherence. Factors contributing to nonadherence included feeling well, being too busy, wound care causing discomfort, and being with friends or family. One patient (1.6%) with high adherence developed an epidermal inclusion cyst within the scar. No other complications were observed.

CONCLUSION

Most MMS patients demonstrated high adherence to wound care instructions, and nonadherence was not associated with postoperative complications.

Results of a National Survey on the Definition of Surgical Site Infections After Mohs Micrographic Surgery

BACKGROUND

There is no standardized definition of surgical site infections (SSI) after Mohs micrographic surgery (MMS) used in the clinical or research settings, which may contribute to heterogeneity in the differences in infection rates reported.

OBJECTIVE

To use an electronic survey of Mohs surgeons across the country to better understand how Mohs surgeons define SSI after MMS.

METHODS

A web-based survey was developed and distributed to Mohs surgeons. Respondents were asked to respond to several different scenarios that could represent SSI after MMS.

RESULTS

Of potential 1,500 respondents, 79 (5.3%) responded to the survey. Presentation of a surgical site with warmth, swelling, erythema, and pain at 7 days postoperatively resulted in 79.7% consensus of SSI. Surgical sites that were cultured and found to be Staphylococcus aureus-positive resulted in 100% agreement of SSI. There was no consensus regarding timing after MMS.

CONCLUSION

There is consensus on numerous aspects of SSI after MMS among Mohs surgeons, which may allow for development of standardized definition in the future.

CXCL9 Links Skin Inflammation and Fibrosis through CXCR3-Dependent Upregulation of Col1a1 in Fibroblasts

Morphea is characterized by initial inflammation followed by fibrosis of the skin and soft tissue. Despite its substantial morbidity, the pathogenesis of morphea is poorly studied. Previous work showed that CXCR3 ligands CXCL9 and CXCL10 are highly upregulated in the sera and lesional skin of patients with morphea. We found that an early inflammatory subcutaneous bleomycin mouse model of dermal fibrosis mirrors the clinical, histological, and immune dysregulation observed in human morphea. We used this model to examine the role of the CXCR3 chemokine axis in the pathogenesis of cutaneous fibrosis. Using the REX3 (Reporting the Expression of CXCR3 ligands) mice, we characterized which cells produce CXCR3 ligands over time. We found that fibroblasts contribute the bulk of CXCL9-RFP and CXCL10-BFP by percentage, whereas macrophages produce high amounts on a per-cell basis. To determine whether these chemokines are mechanistically involved in pathogenesis, we treated Cxcl9-, Cxcl10-, or Cxcr3-deficient mice with bleomycin and found that fibrosis is dependent on CXCL9 and CXCR3. Addition of recombinant CXCL9 but not CXCL10 to cultured mouse fibroblasts induced Col1a1 mRNA expression, indicating that the chemokine itself contributes to fibrosis. Taken together, our studies provide evidence that CXCL9 and its receptor CXCR3 are functionally required for inflammatory fibrosis.

Recurrence and Mortality of Melanoma In Situ of the Trunk or Extremities: A Surveillance, Epidemiology, and End Results Analysis

BACKGROUND

Recent studies demonstrate comparable outcomes of Mohs micrographic surgery (MMS) versus local excision (LE) for melanoma in situ. These studies are limited by their focus on the head and neck.

OBJECTIVE

The primary objective was to compare 5-year overall and melanoma-specific mortality among patients with melanoma in situ of the trunk or extremities who undergo MMS versus LE. The secondary objective was to compare 5-year local recurrence among the same cohort of patients who undergo MMS versus LE.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results (SEER) database (2000-2015) was queried to identify patients who underwent MMS versus LE for melanoma in situ of the trunk, upper extremities, or lower extremities. Outcomes were 5-year recurrence, melanoma-specific mortality, and overall mortality. Multivariable regression analyses were performed.

RESULTS

Thirty three thousand nine hundred eighty-three patients underwent surgical treatment (MMS 3%; LE 97%). In adjusted analyses, there was no difference in local recurrence (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.56-1.78), melanoma-specific mortality (HR 0.89, 95% CI 0.12-6.47), nor overall mortality (HR 1.10, 95% CI 0.82-1.48) between MMS versus LE.

CONCLUSION

There is no difference of 5-year local recurrence, melanoma-specific mortality, nor overall mortality associated with MMS versus LE for melanoma in situ of the trunk or extremities.

Quantitative skin color measurements in acanthosis nigricans patients: colorimetry and diffuse reflectance spectroscopy

Tristimulus colorimetry and diffuse reflectance spectroscopy (DRS) are white-light skin reflectance techniques used to measure the intensity of skin pigmentation. The tristimulus colorimeter is an instrument that measures a perceived color and the DRS instrument measures biological chromophores of the skin, including oxy- and deoxyhemoglobin, melanin and scattering. Data gathered from these tools can be used to understand morphological changes induced in skin chromophores due to conditions of the skin or their treatments. The purpose of this study was to evaluate the use of these two instruments in color measurements of acanthosis nigricans (AN) lesions. Eight patients with hyperinsulinemia and clinically diagnosable AN were seen monthly. Skin pigmentation was measured at three sites: the inner forearm, the medial aspect of the posterior neck, and anterior neck unaffected by AN. Of the three, measured tristimulus L*a*b* color parameters, the luminosity parameter L* was found to most reliably distinguish lesion from normally pigmented skin. The DRS instrument was able to characterize a lesion on the basis of the calculated melanin concentration, though melanin is a weak indicator of skin change and not a reliable measure to be used independently. Calculated oxyhemoglobin and deoxyhemoglobin concentrations were not found to be reliable indicators of AN. Tristimulus colorimetry may provide reliable methods for respectively quantifying and characterizing the objective color change in AN, while DRS may be useful in characterizing changes in skin melanin content associated with this skin condition.

Bendamustine-induced "flagellate dermatitis"

BACKGROUND

The term "flagellate erythema" after bleomycin therapy was described as bleomycin-induced linear hyperpigmentation. Since then, this pattern has not been related to any other chemotherapeutic regimen.

OBSERVATION

We report a rare patient with chronic lymphocytic leukemia who developed "flagellate dermatitis" induced by bendamustine.

CONCLUSION

Chemotherapy induced "Flagellate Dermatitis" is a rare finding reported only after bleomycin therapy. We describe the first case with this characteristic eruption pattern after administration of bendamustine.

Histopathologic study of hidradenitis suppurativa following long-pulsed 1064-nm Nd:YAG laser treatment

OBJECTIVE

To assess clinical and histopathologic changes occurring after long-pulsed 1064-nm Nd:YAG laser treatment of hidradenitis suppurativa (HS).

DESIGN

Prospective, controlled clinical and histologic study of patients with Hurley stage II HS disease.

SETTING

Outpatient dermatology department at Henry Ford Hospital, Detroit, Michigan.

PARTICIPANTS

Nineteen patients with Fitzpatrick skin types II to VI with Hurley stage II HS lesions of the axilla and groin. Interventions Two monthly laser sessions were performed using the long-pulsed 1064-nm Nd:YAG laser. Main Outcome Measure Clinical response was scored using the modified Sartorius scale for HS reflecting Lesion Area and Severity Index (LASI). Histologic changes were examined before treatment and 1 week, 1 month, and 2 months after treatment.

RESULTS

The percentage change in HS severity after 2 sessions of laser treatment was -31.6 over all anatomic sites (P < .005), -24.4 for the axillary site (P = .008), and -36.8 for the inguinal site (P = .001). Histologic changes corresponded to clinical response. Findings from serial biopsy specimens showed increased inflammation at 1 week after treatment and decreased inflammation with resulting fibrosis and scarring at 1 month and 2 months after treatment.

CONCLUSIONS

The long-pulsed 1064-nm Nd:YAG laser is a novel effective treatment option for HS. Our histopathologic data suggest that HS is primarily a follicular disorder. The Nd:YAG laser penetrates for selective photothermolysis of the follicular unit and destruction of organized inflammatory lesions in the superficial to mid dermis. Our study offers insight into the pathogenesis of HS and the mechanism of the Nd:YAG laser in treatment of patients with this chronic, debilitating disease.

Prospective controlled clinical and histopathologic study of hidradenitis suppurativa treated with the long-pulsed neodymium:yttrium-aluminium-garnet laser

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving the intertriginous areas.

OBJECTIVE

We sought to conduct clinical and histopathologic evaluation of the efficacy of long-pulsed neodymium:yttrium-aluminium-garnet laser treatment for HS.

METHODS

We conducted a prospective, randomized, right-left within-patient controlled trial for HS (n = 22). Four monthly laser sessions were performed. Disease activity was measured at baseline, and treatment response was assessed before each laser session and monthly for 2 months after the completion of laser treatment, using a modified scoring system based on Sartorius score. Histologic examination was performed at baseline, immediately after laser treatment, and at 1 and 4 weeks after treatment. A patient questionnaire was circulated on the last visit to assess patients' level of satisfaction.

RESULTS

There was progressive improvement in disease activity, most significantly during the 4 months of treatment, which was maintained during the 2-month posttreatment follow-up period. Averaged over all anatomic sites, the percent improvement was 72.7% on the laser treated side, and 22.9% on the control side (P < .05). Histologic examination showed an initial acute neutrophilic infiltrate. Granulomatous inflammation was present on follow-up biopsy specimens 4 weeks later. An inflammatory infiltrate surrounded the hair shaft remnants, denoting destruction of hair follicles.

LIMITATIONS

Small sample size was a limitation.

CONCLUSIONS

Long-pulsed neodymium:yttrium-aluminium-garnet laser, together with topical benzoyl peroxide and clindamycin, is significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS. Preliminary review of histopathology suggests the mechanism of action is destruction of the hair follicle. The overall success of the treatment in both clearing pre-existing lesions and preventing new eruptions, coupled with high patient satisfaction, makes the neodymium:yttrium-aluminium-garnet laser a promising treatment advance for this highly disabling condition.

Randomized control trial for the treatment of hidradenitis suppurativa with a neodymium-doped yttrium aluminium garnet laser

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic suppurative condition for which there is limited efficacy of medical and surgical treatments.

OBJECTIVE

To assess whether the 1,064-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser is an effective treatment for HS.

MATERIALS AND METHODS

Prospective, randomized, controlled study for patients with stage II to III HS disease (n=22). A series of 3 monthly laser sessions were performed. Treatment response was measured before each laser session and 1 month after the completion of laser treatment (HS Lesion, Area, and Severity Index (HS-LASI) scale). A modification was made to include symptoms (erythema, edema, pain, and purulent discharge; modified HS-LASI, 0-3 scale).

RESULTS

The percentage change in HS severity after 3 months of treatment was -65.3% over all anatomic sites, -73.4% inguinal, -62.0% axillary, and -53.1% inframammary. For all anatomic sites combined and each individual anatomic site, the change in HS severity from baseline to month 3 was statistically significant at the treated sites (p<.02 for modified HS-LASI and HS-LASI) but not at the control sites (p>.05 for modified HS-LASI and HS-LASI).

CONCLUSIONS

The long-pulse Nd:YAG laser is effective for treatment of HS. The effectiveness of Nd:YAG laser, a hair epilation device, supports the primary follicular pathogenesis of the condition.

An update on new and emerging options for the treatment of vitiligo

Vitiligo is an acquired leukoderma that results from the loss of epidermal melanocytes, and is characterized by macules and patches of depigmented skin. With a relatively high rate of prevalence, vitiligo occurs in localized, generalized, or segmental patterns; it can run a rapidly progressive course or remain stationary. The pathogenesis of vitiligo is not yet fully understood, but the autoimmune hypothesis is the most commonly accepted one, based on which, many treatment modalities have been described. Although many therapeutic options exist and new modalities are still emerging, treatment challenges persist, as not all patients respond to available therapies. Variables that affect the choice of treatment include the extent, distribution, and progression rate of the lesions. Another challenge is the lack of a standardized scoring system, which hampers the production of level 1a evidence studies for the treatment of this condition.