Clinicopathological profile and management of 161 cases of actinic cheilitis

BACKGROUND

Actinic cheilitis (AC) is a potentially malignant disorder of the lip caused by chronic exposure to ultraviolet radiation from the sun.

OBJECTIVES

To evaluate the clinical, demographic, morphological and therapeutic management in AC cases data associating to the histopathological grading.

METHODS

Demographic, clinical and management data of 161 patients with AC were analyzed. In biopsied cases, two calibrated examiners performed histopathological grading by binary system.

RESULTS

There was a prevalence of males (79.5%), aged 40 years or older (77.5%), light-skinned (85.7%), experiencing occupational exposure to sunlight (80.3%), with AC presenting clinically as white lesions (33.6%). Conservative treatment was adopted in 78 cases and biopsy in 83 cases (60.2% graded as low-risk AC). There were no significant associations between histopathological grading and gender (p= 0.509), age (p=0.416), ethnicity (p=0.388), occupational exposure to sunlight (p=1.000) or clinical presentation (p=0.803).

CONCLUSION

This study reinforces the hypothesis that demographic and clinical characteristics of AC are not related to histopathological grading. Advice on protection from sun exposure should be encouraged to avoid progression of AC and invasive therapies.     

Tumefactive amyloidosis: a plantar pedal presentation

Tumefactive or nodular amyloidosis represents an uncommon variant of the disease. Localized tumorous masses, which are lardaceous in appearance, rubbery in texture, and approaching several centimeters in diameter, typify the presentation. Such lesions pose unique problems when situated on the weight-bearing regions of the plantar foot. The author discusses the use of accommodative weight-dispersing insoles as an alternative to surgical excision for the treatment of such lesions.     

Localized morphea treated with imiquimod 5% and dermoscopic assessment of effectiveness

The cases are reported of two women patients presenting asymptomatic solitary lesions: one in the anterior tibial region of the right leg, the other on the right arm. The first patient's lesion was 3 cm in diameter and had appeared 2 years earlier as a translucent oval atrophic patch with a definite border. The second patient presented a whitish area with a lilac ring, 2.5 cm in diameter, which had appeared nearly a year earlier. Both patients had no other similar cutaneous lesions, and their family histories for cutaneous disease were negative. The lesions underwent punch biopsy, and the histopathological findings confirmed the diagnosis of morphea. Laboratory investigations showed no abnormalities. Imiquimod 5% cream was prescribed for 5 consecutive days a week for 16 weeks. Clinical and dermoscopic assessment of the lesions was performed before treatment, during follow-up and at treatment end point. No local or systemic side effects were observed during treatment. Following treatment, both patients achieved complete clinical remission of the lesions, with a definitive improvement in the lesions' initial disfiguring features.     

Wound healing on the lower leg after radiotherapy or cryotherapy of Bowen's disease and other malignant skin lesions

To investigate lower leg wound healing after treatment of skin tumours, the results of external beam radiotherapy were assessed for 141 lesions in 91 patients. Poor healing or failure to heal occurred in 33%, and was related to the age of the patients, the diameter of the radiotherapy field, and the dose and energy of radiotherapy used. No effect, of fractionation on healing was apparent, but only 14% of patients were exposed to regimens with a nominal standard dose of over 1800 rets. Age > 90 years, field diameter > 4 cm and dose > 3000 cGy were all associated with a risk of impaired healing of over 50%. The most frequent single diagnosis (59 lesions) in the radiotherapy patients was Bowen's disease. The results of wound healing in these patients were compared with the results of cryotherapy to 82 lower leg Bowen's disease lesions in 49 dermatology patients. Only 2% of the cryotherapy lesions failed to heal compared with 20% of the radiotherapy wounds, although 6% of cryotherapy cases had local recurrence compared with none in the radiotherapy group. Serial overlapping cryotherapy fields of up to 2 cm diameter were shown to be a valid treatment option for Bowen's disease, as no patients had therapy-related failure to heal. To avoid the requirement for potentially more difficult post-radiotherapy salvage surgery, intra- epidermal non-invasive skin tumours >4 cm in diameter on the lower leg are probably initially best treated by a primary surgical procedure or by staged cryotherapy. Invasive carcinoma of >4cm diameter is best treated by surgical excision. Invasive tumours < 2cm in diameter are suitable for excision or radiotherapy, but tumours of 2-4 cm diameter may not heal after radiotherapy.     

DISSEMINATED ROSACEA

SUMMARY.— Fourteen patients are described who, in the course of typical facial rosacea, developed papular lesions on the limbs similar in appearance to those on the face. In some cases the lesions were small and numerous; in others the individual lesions Mere large (up to 1 cm. in diameter) dark red or mauve and deeply set. The histology of these extra-facial lesions resembles that of the facial lesions as far as the inflammatory cellular infiltrate is concerned but there is a more prominent vascular component.
The relationship of these lesions to rosacea is discussed.     

Clinical and histopathologic analyses of pigmented macular lesions on the soles of Japanese--proposal of a clinical guideline for detection of early malignant melanoma on the sole

Of 92 pigmented macular lesions on the soles of Japanese, 88 lesions were histologically confirmed to be melanocytic: 65 ordinary acquired melanocytic nevi, 9 congenital melanocytic nevi, 5 dysplastic nevi, and 5 possible and 4 definite lesions of early malignant melanomas. None of the ordinary acquired melanocytic nevi were more than 7 mm in maximum diameter. Excluding congenital melanocytic nevi, there were 8 lesions whose greatest diameters were more than 7 mm: 2 dysplastic nevi, and 2 possible and 4 definite lesions of early malignant melanoma. Judging from the data obtained in this study, we propose the following clinical guideline for the detection of early lesions of malignant melanoma on the sole. If the pigmented lesions have no possibility of being congenital melanocytic nevus, black heel, lesions of Peutz-Jeghers syndrome, or 5-FU induced lesions, measure the maximum diameters. 1) Lesions with a diameter of more than 7 mm should be excised for histological evaluation. 2) Lesions with a diameter between 6 and 7 mm should be examined histologically when they show conspicuous irregularity in shape, color and/or border or are observed on the soles of a patient older than 50.     

颊部滑行瓣一期修复唇缺损

目的探讨应用颊部滑行瓣修复唇缺损的方法。方法对于唇缺损1/3者采用单侧颊部滑行瓣或带黏膜瓣的鼻唇沟瓣修复;对于唇缺损1/2者采用双侧颊部滑行瓣修复;对于全下唇缺损者则采用双侧颊部滑行瓣加延长颊黏膜瓣修复。结果本组13例患者术后伤口均一期愈合,唇外形及功能恢复满意。结论应用颊部滑行瓣修复唇缺损,操作较简便。术后唇的外形和功能的恢复较远位皮瓣或皮管修复好,尤其适用于中老年唇缺损患者。     

Three Cases of 'Morsicatio Labiorum'

Morsicatio labiorum is a form of tissue alteration caused by self-induced injury, mostly occurring on the lips, and is considered to be a rarely encountered mucocutaneous disorder. Clinically, it is a macerated grey-white patch and plaque of the mucosa caused by external stimuli (self-induced injury) such as habitual biting, chewing, or sucking of the lip. It is often confused with other dermatological disorders involving the oral mucosa, which can lead to a misdiagnosis. We herein report three cases of morsicatio labiorum; two cases were misdiagnosed as exfoliative cheilitis at the time of the first visit.     

Relation of maximum diameters of plantar malignant melanoma to various prognostic factors and prognosis of patients

The following factors were investigated in 43 cases of plantar malignant melanoma: maximum diameters of primary lesions, Clark's subtypes, clinical stages, UICC's stages, Clark's levels of invasion, Breslow's tumor thickness, and prognosis of patients. Relation of maximum diameter of primary lesions to various prognostic factors and prognosis of the patients was analysed. It was revealed that there were no statistically significant relationships between maximum diameters and other various factors. In our series, however, all patients with plantar malignant melanoma less than 14 mm in diameter are alive without metastasis. Judging from our previous and present studies, the following two points are the most important for improving the prognosis of patients with plantar malignant melanoma: 1) Catching all pigmented lesions on the sole that are more than 7 mm in diameter and examining them histologically, if they have no possibility of being congenital melanocytic nevus or black heel. 2) Treating plantar malignant melanomas adequately before they become 14 mm in maximum diameter.     

A Malignant Melanoma Associated with a Blue Nevus of the Lip

Blue nevi are characterized by a collection of pigment-producing melanocytes in the dermis. These lesions clinically present as well demarcated cerulean-blue or bluish black colored papules or plaques that usually measure less than 1 cm in diameter. They are typically found on the dorsal surface of the hands and feet or in the head and neck region; however, they are rarely found in the oral cavity. These lesions are usually benign and stable over time. However, malignant melanomas developing in or associated with a blue nevus (which is also called malignant blue nevus) have been only rarely reported. A malignant blue nevus might develop in a common blue or cellular blue nevus, a giant congenital nevus or in a nevus of Ota, or it may be malignant from the start. Malignant blue nevi most commonly are found on the scalp. A malignant blue nevus of the lip has not been previously reported in the medical literature. We report here on a patient with a malignant melanoma associated with a blue nevus of the lip. The malignant melanoma was presumed to have developed from a blue nevus that was present on the upper lip of a 50-year-old male.     

Desmoplastic nevus: An entity distinct from spitz nevus and blue nevus

Desmoplastic (sclerotic) nevus is an infrequently reported poorly characterized benign melanocytic proliferation, with only 4 case series published to date. To better define this nevus, we examined the clinical and histologic features of 25 lesions. Desmoplastic nevus is seen in both children and adults and can be located on the face, trunk, or extremities. There is a female predominance. Clinically, it can resemble intradermal nevus, atypical nevus, melanoma, and pigmented basal cell carcinoma. These are generally small, symmetric, and well-circumscribed lesions, averaging 3.5 mm in diameter. The most distinctive features include predominantly compound growth, a zonal configuration with greater cellularity in the superficial portion of the lesion, and a mixture of melanocytic phenotypes including type A, B, and C nevus cells, ovoid and dendritic melanocytes, and Spitzoid melanocytes. A distinctive eosinophilic stroma which either resembles that of a dermatofibroma or neurofibroma is always present. Variable amounts of melanin pigment are found in both tumor cells and macrophages, but this is not a prominent feature. Mitotic activity is exceedingly rare (1 case), and pleomorphism is minimal. These lesions are distinct from typical compound nevus, Spitz nevus, epithelioid blue nevus, and desmoplastic melanoma, to which they are often compared. Strict application of these histologic features allows definitive diagnosis of desmoplastic nevus as a distinct form of a benign melanocytic nevus.     

Pityriasis pigmentosa: the clinical features of pathogenic Pityrosporum ovale

This paper proposes a new skin disease entity—pityriasis pigmentosa. Characteristic lesions of this disease are well defined, oval or round, pigmented patches covered with fine, adherent, wrinkled scales. The size of the lesions varies from 0.5–3 cm in diameter. Some lesions gyrate or coalesce into larger patches. The lesions are typically located on the waist and the extremities and are particularly common on the volar aspect of the upper arms and the posterior aspect of the upper thighs. Using Wood's light examination, a bright golden fluorescence is inevitably seen. Rapid identification can be made by use of the KOH/Parker Ink preparation. This reveals characteristic branched, segmented hyphae and clusters of budding, oval-shaped yeast cells. Pityrosporum ovale produces hyphae when cultured in glycine-ammonium phosphate buffered media. Pityrosporum orbiculare does not produce hyphae by this method. These clinical and laboratory findings distinguish a clinical entity differing from Tinea (Pityriasis) versicolor which is caused by Pityrosporum orbiculare.     

Dermoscopic features of small size pigmented basal cell carcinomas

Dermoscopic images of histologically proven pigmented basal cell carcinomas (BCC) were retrospectively assessed to compare the dermoscopic features of BCC of 3 mm or less in diameter (n = 6) with BCC of 4–6 mm in diameter (n = 11). All lesions lacked the presence of a pigment network. BCC with a diameter of 3 mm or less had fewer positive dermoscopic features compared with the 4–6 mm in diameter BCC. Multiple blue‐gray globules and large blue‐gray ovoid nests were frequently present. Dermoscopy is a useful tool for early diagnosis of pigmented BCC, even when they are small.     

肉芽肿性口周皮炎二例

报告2例肉芽肿性口周皮炎。例1男,6岁。面部红斑、丘疹5个月就诊。曾外用糖皮质激素软膏后皮疹渐增多。例2女,28岁。口周、鼻周红斑、小丘疹2个月余就诊。2例均表现为面部腔口周围直径1—3mm大小的淡红色坚实小丘疹,皮损组织病理检查：真皮毛囊周围上皮样细胞肉芽肿改变。结合临床表现及组织病理学检查,2例均确诊为肉芽肿性口周皮炎。例1口服琥乙红霉素颗粒200mg/次,每日4次、1％克林霉素凝胶和0．03％他克莫司软膏外用,治疗2个月后皮疹完全消退,1个月后口周皮疹又复发。例2在行组织病理活检后皮疹自行消退,提示本病具有临床自愈倾向。     

Effect of lesion size on the diagnostic performance of dermoscopy in melanoma detection

BACKGROUND: Dermoscopy is able to correctly classify a higher number of melanomas than naked-eye examination. Little is known however about factors which may influence the diagnostic performance during practice. The aim of the study was to analyze the effect of size of the lesion on diagnostic performance of dermoscopy in melanoma detection. METHODS: Eight dermatologists examined clinical and, separately, clinical and dermoscopic (combined examination) images of 200 melanocytic lesions previously excised [64 melanomas, 24 in situ and 40 invasive (median thickness 0.30 mm) and 136 melanocytic nevi]. After examination, diagnostic performance was analyzed in accordance with the major diameter of the lesions divided into 3 groups, i.e. small (less than 6 mm), intermediate (between 6 and 9 mm) and large (10 mm or more) lesions. These groups were shown to be highly comparable concerning the microstaging of melanomas (median thickness value 0.30, 0.22 and 0.32 mm, respectively). RESULTS: Dermoscopy increased the diagnostic performance of naked-eye examination of both intermediate and large lesions [sensitivity value: +19.3 (p = 0.002) and +10.3 (p = 0.007); diagnostic accuracy value: +7.4 (p = 0.004) and +6.1 (p = 0.07)]. On the contrary, no statistically significant increase was found dealing with small lesions (sensitivity +3.7, p = 0.66; diagnostic accuracy -1.7, p = 0.55). CONCLUSIONS: The diagnostic improvement associated with the addition of dermoscopy to naked-eye examination is influenced by the size of the lesion, i.e. it is lacking with lesions up to 6 mm in diameter. The optimized use of dermoscopy in melanoma detection is obtained dealing with melanocytic lesions 6 mm in diameter or larger.     

Huge cutaneous plasmacytomas complicating multiple myeloma

The case of a 46-year-old woman with multiple myeloma and extramedullary dissemination to the urinary bladder and skin is described. Cutaneous plasmacytomas were scattered as firm, violaceous-red, lesions of variable diameter (2–13 cm) which were extremely tender. Despite combined chemotherapy and half-body irradiation, the lesions progressed until the patient died 8 months following diagnosis.     

硬化萎缩性苔藓并发局限性硬皮病1例并文献复习

目的探讨硬化萎缩性苔藓(LSA)并发局限性硬皮病(LoS)的临床表现、组织病理学特点及诊断,提高对本病的认识,更好地理解硬皮病的疾病谱。方法分析1例LSA并发LoS的临床表现及组织病理特点,复习相关文献并进行讨论。结果患者全身皮损进行性增多无痛痒5年余。2年前初次就诊时明确诊断为LSA,治疗后皮损仍进行性增多,且硬化。此次就诊时皮肤科检查:躯干、四肢散在或密集粟粒至黄豆大瓷白色、略带光泽的扁平丘疹,部分萎缩、硬化;四肢、左手足片状或带状暗红色硬化性斑,部分皮损上有瓷白色扁平丘疹。初次就诊时背部皮损组织病理检查结果显示符合LSA。此次就诊时左小腿皮损组织病理检查结果符合LSA并发硬皮病。结合临床表现和组织病理检查结果,诊断为LSA并发LoS。结论该例LSA并发LoS的患者临床过程、临床表现和组织病理学改变表明,硬皮病可能是谱系性疾病,或许可以认为LSA是浅表性硬皮病。     

Culture of Vibrio extorquens from severe, chronic skin ulcers in a Puerto Rican woman

A 48-year-old Puerto Rican woman developed extensive ulcers on her buttocks, right arm, and thighs over a 3 1/2-year period. The lesions began as small, subcutaneous nodules which subsequently ulcerated and expanded up to 19 cm in diameter. Biopsy of both ulcerated and nonulcerated lesions showed acid-fast bacilli. Culture of both types of lesions grew Vibrio extorquens, a partially acid-fast methanolophilic organism not previously associated with disease in humans. The patient developed agglutinating antibody, titer 1:80, to this organism. The disease responded to treatment with antibiotics to which the organism was sensitive in vitro.     

Malignant granular cell tumor

We report a case of malignant granular cell tumor present in the left medial mid-thigh of a 69-year-old black male. The lesion was grossly fungating, partially ulcerated and measured 14 cm in largest diameter. Light microscopy, electron microscopy and immunohistochemistry techniques were used to confirm the preliminary cytologic diagnosis of malignant granular cell tumor. Diagnostic criteria of malignancy for such lesions are reviewed. Immunohistochemical and ultrastructural analyses support a neural or Schwann cell origin for the tumor. Clinical outcome for such lesions is discussed.     

棘状角皮症

报告5例多发性棘状角皮症。患者的皮损直径均为0．5～2．0mm,突出皮面1．0～4．0mm的似棘状角化性突起主要分布于手掌。组织病理检查示表皮角化过度和界限清楚的角化不全柱,其下表皮凹陷,颗粒层变薄或正常,棘层肥厚,真皮无明显异常。超微结构显示角质层细胞内角质透明蛋白颗粒正常,角质微丝排列稍疏松。