Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.

International clinical recommendations on scar management.

We reviewed all studies (since 1947) reporting recurrence rates for treatment of primary (previously untreated) basal cell carcinomas using surgical excision, radiotherapy, cryotherapy, curettage and electrodesiccation, and Mohs micrographic surgery. Our findings indicate that recurrences following treatment of primary basal cell carcinoma appear later than is generally acknowledged in the literature. We found that less than one-third of all recurrences appear in the first year following treatment; only 50% appear within the first 2 years following treatment; and only 66%, or nearly two-thirds, appear within the first 3 years following treatment. A good rule of thumb is that the 10-year recurrence rate is double, or 2 times, that of the 2-year recurrence rate. Furthermore, 18% of recurrences appear between the fifth and tenth year following treatment. These results held true, irrespective of treatment modality examined. Seventy-two studies reporting short-term recurrence rates (follow-up less than 5 years) had a weighted average recurrence rate of 4.2%, whereas 34 long-term studies (follow-up of 5 years) had a weighted average recurrence rate of 8.7%, or more than 2 times the short-term rate. Five-year recurrence rates by treatment modality are as follows: Mohs micrographic surgery 1.0%, surgical excision 10.1%, curettage and electrodesiccation 7.7%, radiation therapy 8.7%, and cryosurgery 7.5%. We conclude that the reporting of recurrence rate data for basal cell carcinoma should be standardized using 5-year life table analysis, and even more important is our conclusion that lifetime follow-up is necessary after treatment of primary basal cell carcinoma in order both recurrences and new primaries.

Long‐Term Recurrence Rates in Previously Untreated (Primary) Basal Cell Carcinoma: Implications for Patient Follow‐Up

We report five cases of metastasizing basal cell carcinoma. The incidence of metastases in all patients with basal cell carcinomas who had surgery in the same period was 0.1%. There was no squamous differentiation in the histology of any of the primary lesions, but we found some squamous differentiation in a late recurrence in one patient and in the metastases in two patients. All other histologic features were identical in both the primary tumor and in the metastases. Perineural spread and blood vessel invasion were evident in the primary tumor and/or recurrence of three of the five patients and may be important pointers to possible recurrence and metastasis. Of 205 cases of metastasizing basal cell carcinomas mentioned in the literature, we accepted and evaluated 170 cases of tumors of the skin with histologic proof of metastasis. The male-to-female ratio was 2:1, median age at onset of primary tumor, 45 years, median interval between onset of tumor and first sign of metastasis, 9 years, median age at first sign of metastasis, 59 years, and median survival after first sign of metastasis, only 8 months. The site of the primary tumors is similar to that in nonmetastasizing basal cell carcinoma. Metastatic spread is most often to lymph nodes, lungs, and bones with lymphogenic and hematogenic spread equally frequent. Age or sex of the patient seemed to have no influence on survival or way of metastatic spread. As metastasis of basal cell carcinoma is extremely rare (1 in 1,000 to 35,000), many authors sought or postulated histologic "degeneration" into a squamous cell carcinoma, but no such unequivocal evidence has ever been found. Areas of squamous differentiation were reported in less than 15% of both primary and metastatic lesions of metastasizing basal cell carcinoma. The mode of metastatic spread and the characteristics of the histology make it rather unlikely that metastasis of a basal cell carcinoma is due to a change toward squamous cell carcinoma.

Metastatic basal cell carcinoma: Report of five cases and review of 170 cases in the literature

Pyoderma gangrenosum is a rare but significant cause of ulcerations. It is a diagnosis of exclusion. Herein, we suggest diagnostic criteria and some historical perspectives on the diagnosis of pyoderma gangrenosum.

Pyoderma gangrenosum: clinicopathologic correlation and proposed diagnostic criteria.

Hailey-Hailey disease (HHD, MIM 16960) is inherited in an autosomal dominant manner and characterized by persistent blisters and erosions of the skin1. Impaired intercellular adhesion and epidermal blistering also occur in individuals with pemphigus (which is due to autoantibodies directed against desmosomal proteins) and in patients with Darier disease (DD, MIM 124200), which is caused by mutations in a gene encoding a sarco/endoplasmic reticulum (ER)-Golgi calcium pump2. We report here the identification of mutations in ATP2C1, encoding the human homologue of an ATP-powered pump that sequesters calcium into the Golgi in yeast, in 21 HHD kindreds. Regulation of cytoplasmic calcium is impaired in cultured keratinocytes from HHD patients, and the normal epidermal calcium gradient is attenuated in vivo in HHD patients. Our findings not only provide an understanding of the molecular basis of HHD, but also underscore the importance of calcium control to the functioning of stratified squamous epithelia.

Mutations in ATP2C1, encoding a calcium pump, cause Hailey-Hailey disease

Fregert'sManual of Contact Dermatitisis packed with useful information and is highly recommended as a primer for those learning dermatology and as a brief refresher text for the practicing clinician. Of special usefulness to the clinician are tables of suitable patch test concentrations, a compilation of irritants and sensitizers in common occupations, and excellent discussions about where the more common allergens may be encountered. Every dermatologist would benefit from reading this succinct and well written manual.

Manual of Contact Dermatitis

Contact dermatitis in children.

Objective To analyze studies on oral treatment of toenail onychomycosis so as to aid clinicians and patients in making informed decisions. Data Sources Studies dealing with treatment of toenail onychomycosis were identified by means of 2 MEDLINE search strategies. One was a title search using the word "toenail"; the other search used the combined Medical Subject Headings "onychomycosis" and "therapy." Study Selection Articles were read to ascertain that they (1) described results in toenails, (2) used both culture and microscopy, and (3) included a clinical evaluation. Not included were case reports, series of fewer than 15 subjects, reports that combined fingernail onychomycosis and toenail onychomycosis in their statistics, and articles reporting only the total number of toenails cured without providing data as to how many subjects were cured. Data Extraction This elimination process left 26 articles, which were then analyzed by means of a checklist that included a morphologically normal nail, mycological findings, and methodological items including recurrence rate, intent-to-treat analysis, placebo group, and whether terms were defined. Data Synthesis When there was sufficient data, the frequency with which the treatment achieved normal mycological results, a clinically normal nail, and a disease-free nail (normal-appearing nail plus normal mycological results) was calculated. Confidence intervals were calculated for disease-free nail results. Conclusions Standard courses of terbinafine achieved a disease-free nail in approximately 35% to 50% of patients. For itraconazole, the relevant disease-free nail rate was about 25% to 40%. Disease reappearance is an important issue; unfortunately data are lacking as to its frequency.

https://jamanetwork.com/journals/jamadermatology/articlepdf/189694/dre8025.pdf

How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data.

SUMMARY

This study evaluated the accuracy of visual determination of tumour margins in basal cell carcinomas. Using a 2.5 × binocular magnifier, the apparent tumour margin was marked pre-operatively by light electrodesiccation. Following excision, the electrodesiccation mark was compared to the actual tumour edge by microscopy of step level sections. It was possible to delineate the tumour margins with an accuracy of 1 mm in 94% of a selected series of 101 basal cell carcinomas. These findings support the view that a 2 mm margin of normal tissue is adequate in the surgical treatment of most basal cell carcinomas.

How accurate is the visual assessment of basal carcinoma margins

Monsel's solution is simply ferric sulfate solution. Its styptic action depends upon its content of ferric ion, as ferric ion is a powerful protein precipitant. Ferric chloride is a more convenient source of ferric ions than Monsel's solution, National Formulary; a 3.8 molar solution of ferric chloride can replace Monsel's solution as a styptic for minor surgery.

Ernst Epstein

Papers

Manual of Contact Dermatitis

Contact dermatitis in children.

How often does oral treatment of toenail onychomycosis produce a disease-free nail? An analysis of published data.

How accurate is the visual assessment of basal carcinoma margins

Monsel's solution; history, chemistry, and efficacy.