Skin cancer development in a birthmark Finstad, Alexandra C; Kirchhof, Mark G
Canadian Medical Association journal (CMAJ),
09/2019, Volume:
191, Issue:
39
Journal Article
Peer reviewed
Open access
57-year-old man presented with concerns about a new growth on his scalp. He was born with a birthmark on his scalp that had become bumpy over time, but over the previous year he had noticed the ...development of a new nodule. He had no personal or family history of skin cancer nor any history of severe sunburns or tanning bed use. He reported no regular use of medications and had no history of medical problems. Physical examination showed a pink and grey nodule within a verrucous plaque. Biopsy was performed and showed a pigmented basal cell carcinoma within a nevus sebaceus. Management of nevus sebaceus should be decided on a case-by- case basis. As malignant transformation is rare, especially in children, observation should be the standard of care until adolescence.
Background
Dermatological conditions are commonly seen in the emergency department and inpatient wards. The ability to access dermatology on-call services improves the accuracy of diagnosis and ...management of common and sometimes life-threatening conditions. Limitations of dermatologist availability led to the suspension of the dermatology on-call service for 3 months in Ottawa, Canada.
Objectives
Our objective was to assess the impact of this call suspension on patient care and the need for a dermatology on-call service at our hospital, as perceived by nondermatologist physicians at our center.
Methods
A survey was sent to all departments at The Ottawa Hospital, addressed to staff physicians and residents. Participation was entirely voluntary. Descriptive statistics were used to analyze survey responses.
Results
A total of 105 physicians completed the survey including staff physicians (85%) and resident trainees (15%). The most represented specialties were emergency medicine (N = 21), general internal medicine (N = 19), nephrology (N = 17), neurology (N = 13), and plastic surgery (N = 13). Over half of the respondents felt that the lack of dermatology on-call service impacted the care of their patients by a moderate or great extent. Over half reported performing dermatology-related clinical work during the call suspension and two-thirds of these individuals reported feeling uncomfortable or very uncomfortable doing so. Most (94%) participants felt that an on-call dermatology service was useful and 57% deemed it essential.
Conclusion
Our survey results demonstrate a significant impact of the suspension of a dermatology on-call service, as perceived by nondermatologist physicians. Hospitals need to recognize the importance of on-call dermatology consultations and provide support for divisions to enable this service to continue.
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Chronic kidney disease-associated pruritus leads to decreased quality of life and is an independent risk factor for mortality. There is limited evidence for treatment of chronic kidney ...disease-associated pruritus, with only one on-label treatment approved by the FDA and Health Canada. We present a case of a 69-year-old female with a history of chronic kidney disease, who presented to clinic with a several-year history of diffuse, intense pruritus. There were no primary lesions. She was started on dupilumab 600 mg loading dose, then 300 mg subcutaneously every 2 weeks. At her follow-up appointment 5 months after initiation of dupilumab, she reported her pruritus as 1/10, with no interruptions in her sleep. Her creatinine remained elevated and was stable throughout the follow-up period. This case demonstrates sustained improvement in chronic kidney disease-associated pruritus with dupilumab. Further research is required to quantify the efficacy of dupilumab for treatment of chronic kidney disease-associated pruritus.
Background
Surgical excision is considered standard treatment for nodular basal cell carcinoma (nBCC). However, patients who reject or are unsuited for surgery may benefit from imiquimod (IMQ) 5% ...cream as an alternative treatment.
Objectives
The objective of this study was to conduct a systematic review on the efficacy and safety of IMQ for the treatment of nBCC.
Materials and Methods
The terms basal cell carcinoma AND imiquimod OR Aldara were searched on Ovid-MEDLINE, EMBASE, and Cochrane Library databases. Articles were included if they reported the efficacy or side effects of IMQ for nBCC. Primary outcomes included clearance (clinical and histological), recurrence rates, and adverse events. Number of lesions/subjects, treatment regimens, length of treatment, and time to recurrence were secondary outcomes.
Results
Thirty-nine publications, totaling 738 lesions, revealed a 77.4% (335/433 lesions) clinical and 72.9% (390/535 lesions) histological clearance rate. Regimens ranged from once daily 2 days a week to twice daily 7 days a week. Average treatment duration was 8.81 (±3.49) weeks. There was a 1.80% recurrence rate after an average follow-up period of 13.03 (±15.09) months. Common adverse effects included erythema (77.2%), crusting (50.5%), pruritus (34.1%), tenderness/irritation (27.3%), ulceration (25.4%), burning (22.1%), and erosion (21.7%). Unforeseen side effects included conjunctivitis, keratitis, depigmentation, comedone formation, and ruptured epidermoid cysts.
Conclusion
Imiquimod showed clinical and histological clearance rates of over 70% for nBCC, with a recurrence rate of 1.80%. Although clearance rates are lower than surgery, IMQ can be considered as a treatment option for nBCC in those who decline or are unfit for surgical intervention.
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Idiopathic chilblains is a cold-induced inflammatory condition that causes significant morbidity. When preventative measures alone are inadequate, oral nifedipine is generally recommended as ...first-line pharmacologic therapy. Given the natural course of this spontaneously remitting/relapsing condition, controls are needed to critically appraise studies and determine the value of treatments. We report a systematic review of placebo-controlled or comparative therapeutic trials for the treatment of idiopathic chilblains. Our search of PubMed, Embase, and Cochrane databases, identified 11 studies that met our inclusion criteria for a combined study population n = 576. Therapies included nifedipine, pentoxifylline, tadalafil, topical glyceryl trinitrate (GTN), topical minoxidil, diltiazem, corticosteroids, and vitamin D. There was moderate evidence to support the use of nifedipine and pentoxifylline in the treatment of severe or refractory cases of idiopathic chilblains, while other therapies had inadequate evidence or nonsignificant results compared to placebo.
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Because of a lack of controlled trials on the risks and adverse effects of techniques for body hair removal, case reports provide most of our insight into the risks of body hair removal. One report ...discussed a patient with diabetes mellitus in whom life-threatening Streptococcus pyogenes and herpes simplex virus infections developed after Brazilian waxing.3 In another case report, an outbreak of methicillin-resistant Staphylococcus aureus was linked to cosmetic body shaving.4 Two cases of HPV infection linked to threading have been reported.5 These patients had facial hair removed by threading, and subsequently verrucae developed at the sites of hair removal. Furthermore, HPV has been shown to reside on pubic and perianal hairs.6 It follows that traumatic hair removal in these areas might result in an infection and subsequent clinical manifestation of HPV. In the case of our patient, HPV-associated epidermodysplasia verruciformis developed, secondary to pubic hair removal. There are two described subtypes of epidermodysplasia verruciformis, the classic type and the acquired type. Classic epidermodysplasia verruciformis is an autosomal recessive genodermatosis that increases susceptibility to particular HPV subtypes.7 The HPV subtypes that are commonly associated with epidermodysplasia verruciformis include HPV-5, -8, -9, -12, -14, -15, -17, -19, -25, -36, -38, -47 and -50.8 These HPV subtypes are also found on the skin of people without epidermodysplasia verruciformis; however, they are rarely pathogenic in immunocompetent individuals. 9 Although the actual pathogenesis for the development of epidermodysplasia verruciformis has not been completely elucidated, it is widely hypothesized to be associated with defects in cell-mediated immunity. Acquired epidermodysplasia verruciformis is more difficult to treat than the classic form.7 Topical imiquimod, topical 5-fluorouracil and isotretinoin have been tried in this patient group without success.7 Given the lack of evidence available regarding the ideal first-line treatment for acquired epidermodysplasia verruciformis, we engaged in a side-to-side com- parison of topical versus destructive therapy to assess the best course of action for our patient. Changing the immune status by putting patients with HIV on effective antiretroviral therapy has had mixed results.8 Consideration can be given to altering the dose or type of antirejection medications in the transplant population, but the risks of rejection must be weighed against the unproven clinical effects on epidermodysplasia verruciformis.
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