Effects of pulsed dye laser treatment in psoriasis: A nerve-wrecking process?

Pulsed dye laser (PDL) therapy can be effective in treating psoriasis, with a long duration of remission. Although PDL therapy, albeit on a modest scale, is being used for decades now, the underlying mechanisms responsible for the long-term remission of psoriasis remain poorly understood. The selective and rapid absorption of energy by the blood causes heating of the vascular wall and surrounding structures, like perivascular nerves. Several studies indicate the importance of nerves in psoriatic inflammation. Interestingly, denervation leads to a spontaneous remission of the psoriatic lesion. Among all dermal nerves, the perivascular nerves are the most likely to be affected during PDL treatment, possibly impairing the neuro-inflammatory processes that promote T-cell activation, expression of adhesion molecules, leukocyte infiltration and cytokine production. Repeated PDL therapy could cause a prolonged loss of innervation through nerve damage, or result in a 'reset' of neurogenic inflammation after temporary denervation. The current hypothesis provides strong arguments that PDL treatment affects nerve fibres in the skin and thereby abrogates the persistent and exaggerated inflammatory process underlying psoriasis, causing a long-term remission of psoriasis.

Limitations of Dutch Growth Research Foundation Commercial Software Weight Velocity for Age Standard Deviation Score

Patient: Male, 1-year-old

Final Diagnosis: Healthy

Symptoms: None

Medication:—

Clinical Procedure: Foster care

Specialty: Pediatrics and Neonatology

Functioning in lymphedema from the patients' perspective using the International Classification of Functioning, Disability and health (ICF) as a reference

PURPOSE

To identify and quantify meaningful concepts in lymphedema from the patients' perspectives using the International Classification of Functioning, Disability and Health (ICF).

METHODS

Six focus group interviews in five different centers were organized, audiotaped, transcribed verbatim and analyzed.

RESULTS

A total of 2681 relevant ICF linkings were performed with the focus group data, resulting in 130 different second-level categories. Of these 130 second-level categories, 41 (31.5%) categories were categorized as Body Functions, 20 (15.5%) as Body Structures, 41 (31.5%) as Activities and Participation, and 28 (21.5%) as Environmental Factors. Overall, the most important issues according to the patients were the use of hosiery and bandages, support and relationships, and the shape of structures related to movement.

CONCLUSION

Based on their experiences with lymphedema, patients reported activity limitations and participation restrictions combined with impaired body functioning. Anatomical changes (Body Structures) were also often mentioned as a problem in daily life. Environmental factors may act as a barrier or facilitator for patient functioning. The ICF provides a valuable reference to identify concepts in statements from lymphedema patients. The results of this research will be used in the development of ICF Core Sets for lymphedema.

Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins

BACKGROUND

Many case series have been published on treatments of varicose veins, but comparative randomized controlled trials remain sparse.

OBJECTIVE

To compare the anatomic success rate, frequency of major complications, and quality-of-life improvement of endovenous laser ablation (EVLA), ultrasound-guided foam sclerotherapy (UGFS), and conventional surgery (CS), after 1-year follow-up.

METHODS

A total of 240 consecutive patients with primary symptomatic great saphenous vein reflux were randomized to EVLA, UGFS, or CS, consisting of high ligation and short stripping. Primary outcome was anatomic success defined as obliteration or absence of the treated vein on ultrasound examination after 1 year. Secondary outcomes were complications, improvement of the "C" class of the CEAP classification, and improvement of disease-specific (Chronic Venous Insufficiency Quality-of-Life Questionnaire) and general (EuroQol 5) quality-of-life scores.

RESULTS

More than 80% of the study population was classified as C2 or C3 venous disease. After 1 year, the anatomic success rate was highest after EVLA (88.5%), followed by CS (88.2%) and UGFS (72.2%) (P < .001). The complication rate was low and comparable between treatment groups. All groups showed significant (P < .001) improvement of EuroQol 5 and Chronic Venous Insufficiency Quality-of-Life Questionnaire scores after therapy; 84.3% of all treated patients showed an improvement of the "C" of the CEAP classification.

CONCLUSIONS

After 1-year follow-up, EVLA is as effective as CS and superior to UGFS according to occlusion on ultrasound duplex. Quality of life improves after treatment in all groups significantly.

Treatment of incompetent perforating veins using the radiofrequency ablation stylet: a pilot study

BACKGROUND

Although the role of incompetent perforating veins (IPV) in chronic venous insufficiency remains controversial, they are often treated by surgical or by minimal invasive techniques.

OBJECTIVES

To describe the procedure of radiofrequency ablation (RFA) of IPV and to evaluate its short-term effectiveness and safety.

METHODS

In a clinical pilot study, 14 IPV in 12 patients were treated with a radiofrequency stylet. After three months, ultrasound (US) examination was used to assess anatomical success rate and exclude deep venous thrombosis. Also, self-reported side-effects were investigated.

RESULTS

Of the 14 treated IPV, nine (64%) were obliterated on US examination and the others showed remaining reflux. Two patients reported localized paresthesia, but no deep venous thrombosis was recorded.

CONCLUSION

RFA of IPV may be a promising procedure, but patient and incompetent perforator vein selection is important and further standardization of the procedure is required. Comparative clinical trials between RFA and other therapies are warranted.

Waste of skin in elliptical excision biopsy of non-melanomatous skin cancer

Our objective was to quantify the skin wasted during elliptical excision biopsy. This is defined as the difference between the excised elliptical area and the area of the original lesion. We used geometrical calculations of 26 excisional biopsy specimens from patients with non-melanomatous malignant tumours. Relative to the lesion area, the largest waste of skin measured was 230% and the smallest was 34% with a mean of 130%. We conclude that for better preservation of tissue when closing circular defects, patterns other than an ellipse should be adopted.

Discriminating basal cell carcinoma from perilesional skin using high wave-number Raman spectroscopy

An expanding body of literature suggests Raman spectroscopy is a promising tool for skin cancer diagnosis and in-vivo tumor border demarcation. The development of an in-vivo diagnostic tool is, however, hampered by the fact that construction of fiber optic probes suitable for Raman spectroscopy in the so-called fingerprint region is complicated. In contrast, the use of the high wave-number region allows for fiber optic probes with a very simple design. We investigate whether high wave-number Raman spectroscopy (2800 to 3125 cm(-1)) is able to provide sufficient information for noninvasive discrimination between basal cell carcinoma (BCC) and noninvolved skin. Using a simple fiber optic probe, Raman spectra are obtained from 19 BCC biopsy specimens and 9 biopsy specimens of perilesional skin. A linear discriminant analysis (LDA)-based tissue classification model is developed, which discriminates between BCC and noninvolved skin with high accuracy. This is a crucial step in the development of clinical dermatological applications based on fiber optic Raman spectroscopy.

State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings

BACKGROUND

Current treatment modalities for chronic leg ulcers are time consuming, expensive, and only moderately successful. Recent data suggest that creating a subatmospheric pressure by vacuum-assisted closure (V.A.C., KCI Concepts, San Antonio, Texas) therapy supports the wound healing process.

METHODS

The efficacy of vacuum-assisted closure in the treatment of chronic leg ulcers was prospectively studied in a randomized controlled trial in which 60 hospitalized patients with chronic leg ulcers were randomly assigned to either treatment by V.A.C. or therapy with conventional wound care techniques. The primary outcome measure was the time to complete healing (days). Statistical analysis was performed on the intention-to-treat basis.

RESULTS

The median time to complete healing was 29 days (95% confidence interval [CI], 25.5 to 32.5) in the V.A.C. group compared with 45 days (95% CI, 36.2 to 53.8) in the control group (P = .0001). Further, wound bed preparation during V.A.C. therapy was also significantly shorter at 7 days (95% CI 5.7 to 8.3) than during conventional wound care at 17 days (95% CI, 10 to 24, P = .005). The costs of conventional wound care were higher than those of V.A.C. Both groups showed a significant increase in quality of life at the end of therapy and a significant decrease in pain scores at the end of follow-up.

CONCLUSIONS

V.A.C. therapy should be considered as the treatment of choice for chronic leg ulcers owing to its significant advantages in the time to complete healing and wound bed preparation time compared with conventional wound care. Particularly during the preparation stage, V.A.C. therapy appears to be superior to conventional wound care techniques.

Incidence of sexually transmitted diseases and HIV infection in men who have sex with men related to knowledge, perceived susceptibility, and perceived severity of sexually transmitted diseases and HIV infection: Dutch MSM-Cohort Study

BACKGROUND

This longitudinal study was conducted to investigate whether knowledge, perceived susceptibility, and perceived severity of HIV infection and sexually transmitted diseases (STDs) are associated with the incidence of STDs and new HIV infections among men who have sex with men (MSM).

METHODS

A 3-year cohort study was conducted among 190 HIV-negative MSM. Data were collected on the incidence of STDs and new HIV infections, as well as on knowledge and perceived susceptibility to and perceived severity of HIV infection and STDs. Knowledge and perceptions were assessed in self-administered questionnaires.

RESULTS

In the course of the 3-year study, six MSM (3.2%) HIV-seroconverted and 78 (41.1%) participants were diagnosed with at least one STD. MSM seemed to be better informed about HIV infection compared with STDs, and HIV infection was perceived as more severe than other STDs. In multivariable analyses, low perceived severity of HIV infection significantly (P = 0.025) predicted increased likelihood of infection with STDs or HIV, and the practice of anal intercourse was (marginally) associated with an increased risk of acquiring STDs or HIV (P = 0.052).

CONCLUSIONS

A high perceived severity of HIV infection seems to induce sexual behavior that protects against STDs and HIV infection. More research is needed to establish the specific behaviors by which perceived severity of STDs/HIV influences the incidence of STDs and HIV.

Optimizing the cut in Mohs' micrographic surgery in regard to skin sparing and microscopic view: is a round incision cut necessary?

Saucer incision is the common cut in Mohs' micrographic surgery. To date no proof as to the superiority of this cut over other patterns has been presented. In this work we examine the round pattern aspect of the saucer incision and answer two questions: does the round cut provide the best skin-sparing pattern? And, does it provide the best microscopic view? A two-dimensional geometric analysis is used to determine whether a round incision is optimal from the standpoint of skin sparing and microscopic view. Mohs' micrographic surgery views are used to back up the geometric hypothesis. The result is that the round incision pattern is skin-wasteful compared to an incision that follows the cancerous lesion. In the lesion presented here the two cuts have a ratio of 1.5 between the two excised skin areas, indicating a waste of healthy skin of 50%. It is also shown that specimens with a pointed edge provide better layer projection. The conclusion is that a tailored cut following the lesion pattern is the optimal Mohs' incision. Therefore in the first stage of Mohs' micrographic surgery the skin cut should replicate the lesion pattern instead of a round saucer cut. Though many Mohs' surgeons already implement this philosophy, in the literature the saucer incision recommended by Dr. Frederic Mohs' remains the norm.

The elastic properties of cancerous skin: Poisson's ratio and Young's modulus

BACKGROUND

The physical properties of cancerous skin tissue have rarely been measured in either fresh or frozen skin specimens. Of interest are the elastic properties associated with the skin's ability to deform, i.e., to stretch and compress. Two constants--Young's modulus and Poisson's ratio--represent the basic elastic behavior pattern of any elastic material, including skin. The former relates the applied stress on a specimen to its deformation via Hooke's law, while the latter is the ratio between the axial and lateral strains.

OBJECTIVES

To investigate the elastic properties of cancerous skin tissue. For this purpose 23 consecutive cancerous tissue specimens prepared during Mohs micrographic surgery were analyzed.

METHODS

From these specimens we calculated the change in radial length (defined as the radial strain) and the change in tissue thickness (defined as axial strain).

RESULTS

Based on the above two strains we determined a Poisson ratio of 0.43 +/- 0.12 and an average Young modulus of 52 KPa.

CONCLUSIONS

Defining the elastic properties of cancerous skin may become the first step in turning elasticity into a clinical tool. Correlating these constants with the histopathologic features of a cancerous tissue can contribute an additional non-invasive, in vivo and in vitro diagnostic tool.

Oral Lichen Planus and Allergy to Dental Amalgam Restorations

OBJECTIVES

To determine contact allergies in patients with oral lichen planus and to monitor the effect of partial or complete replacement of amalgam fillings following a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam.

DESIGN

In group A (20 patients), the oral lesions were confined to areas in close contact with amalgam fillings. In group B (20 patients), the lesions extended 1 cm beyond the area of contact with amalgam fillings. In group C (20 patients), the oral lesions had no topographic relationship with amalgam fillings. Partial or complete replacement of amalgam fillings was recommended if there was a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam. Control group D (20 patients) had signs of allergic contact dermatitis.

RESULTS

Amalgam fillings were replaced in 13 patients of group A, with significant improvement. Dental amalgam was replaced in 8 patients of group B, with significant improvement. In group C, amalgam replacement in 2 patients resulted in improvement in 1 patient. These results were evaluated after 3 months. No positive patch test reactions to mercury compounds were found in patients with concomitant cutaneous lichen planus and in group D.

CONCLUSIONS

Contact allergy to mercury compounds is important in the pathogenesis of oral lichen planus, especially if there is close contact with amalgam fillings and if no concomitant cutaneous lichen planus is present. In cases of positive patch test reactions to mercury compounds, partial or complete replacement of amalgam fillings will lead to a significant improvement in nearly all patients.

Resurgence of Lymphogranuloma Venereum in Western Europe: An Outbreak ofChlamydia trachomatisSerovar L2Proctitis in The Netherlands among Men Who Have Sex with Men

BACKGROUND

Lymphogranuloma venereum (LGV) is a sexually transmitted disease (STD) and is rare in the Western world. Recently, 3 men who have sex with men presented with LGV proctitis at the Erasmus Medical Center, Rotterdam, The Netherlands. We investigated a possible outbreak in a sexual network of men who have sex with men (MSM).

METHODS

After active case finding, a total of 15 men presented and were investigated. Serum antibody titers to Chlamydia trachomatis were determined. Urine and rectum specimens were analyzed by polymerase chain reaction (PCR) for the presence of C. trachomatis. C. trachomatis-positive specimens were genotyped to detect the specific C. trachomatis serovars. All subjects underwent routine STD screening. Sociodemographic, clinical, and endoscopic characteristics were evaluated.

RESULTS

Thirteen subjects had high immunoglobulin (Ig) G and IgA titers to C. trachomatis, suggesting an invasive infection. Rectal specimens of 12 subjects were PCR-positive for C. trachomatis. All urine specimens were negative. Genotyping revealed serovars L(2) (n=8) and L(1) (n=1). An ulcerative proctitis was found in all subjects obtaining sigmoidoscopy (n=9). Eleven of 13 subjects with an LGV diagnosis were seropositive for human immunodeficiency virus (HIV), 6 had another concomitant STD, and 1 had recently acquired a hepatitis C virus infection. Further sexual contacts were reported from The Netherlands, Germany, Belgium, the United Kingdom, and France.

CONCLUSIONS

We revealed an outbreak of LGV proctitis among MSM in The Netherlands. The ulcerous character favors transmission of HIV, other STDs, and blood-borne diseases. From a public health perspective, it seems important to increase the awareness of possible LGV in MSM with symptomatic proctitis.

Skin waste, vertex angle, and scar length in excisional biopsies: comparing five excision patterns--fusiform ellipse, fusiform circle, rhomboid, mosque, and S-shaped

The common excision skin pattern is either a fusiform ellipse or another pattern with dissimilar length and width. The purpose of this study was to define the most advantageous skin pattern regarding skin waste, vertex angle, and scar length. Five skin excision patterns used traditionally for closure of round lesions were analyzed: fusiform ellipse, fusiform circle, rhomboid, mosque, and S-shaped. In the analysis, the pattern characteristics were formulated by geometric principles, from which the results were compared. The smallest skin waste was found in rhomboid and mosque patterns, whereas the largest skin waste was found in the fusiform circle and ellipse. The vertex angle was found to decrease monotonously with the excision length-to-width ratio for all patterns except the mosque shape, which is zero per definition. The paradigm stating that a vertex angle of 30 degrees or less is maintained for length-to-width ratios below 4 in the surgical ellipse was found incorrect. It holds only for rhomboid and S-shaped excisions. The scar length was found almost independent of the pattern, with a variance of 3 percent. The authors conclude that the most advantageous surgical skin patterns are the rhomboid and mosque excisions.

Vasoconstrictive effect of topical applied corticosteroids measured by laser doppler imaging and reflectance spectroscopy

Topical application of corticosteroids induces blanching of the skin, based on changes of the underlying microcirculation of the skin. Usually the intensity of blanching after topical application of corticosteroids is measured subjectively by a trained observer using a visual score. In order to obtain an objective determination of the blanching effect and to assess the underlying effect of the skin perfusion, it is necessary to use noninvasive bioengineering techniques. The aim of this study was to compare changes in the vascular plexus during 72 h after topical application of corticosteroids of different potencies with control sites by two noninvasive techniques: laser Doppler imaging (LDI) and diffuse reflectance spectroscopy (DRS). We used the most potent vasoconstrictor, Clobetasol-di-propionate. After 8 h (1.49 Rm (mean reflectance) +/- 0.6 SEM) and after 30 h (0.52 Rm +/- 0.36) DRS showed significant changes in blood flow (during blanching and reactive hyperemia). LDI showed a slight change after 8 h (-0.04 aU (arbitrary units) +/- 0.02 blanching) and a second, significant reaction after 30 h (LDI: 0.18 aU +/- 0.04 reactive hyperemia). In LDI after 30 h higher values were found in men than in women (clobetasol-17-propionate under occlusion Deltat(30)-t(0) men: 0.47 aU +/- 0.18; n = 7; Deltat(30)-t(0) women: 0.14 aU +/- 0.02; n = 10; P = 0.025). This leads to the conclusion that DRS is of more value for the detection of blanching than LDI, which has its sensitivity in the hyperperfused skin. Measurement with both devices showed clear differences in men and women, which means that sex differences should be taken into account.

Basal cell carcinoma: treatment options and prognosis, a scientific approach to a common malignancy

The incidence of basal cell carcinoma is rapidly increasing and a number of treatment modalities are available. Treatment of basal cell carcinoma includes both surgical and nonsurgical approaches, some of which are traditional, and others experimental. The treatment modality utilized is dependent on both the tumor type and the patient. In order to choose between therapies, evidence-based research is necessary. In an extensive review of the literature concerning treatment options for patients with basal cell carcinoma, we found that there are a limited number of comparative, prospective, randomized, long-term follow-up studies. Based on the results of the available studies, surgical excision, Mohs surgery and cryosurgery are the three standard therapies of choice. Other treatment modalities should be considered secondary choices. There are also promising new treatment options, such as photodynamic therapy, which need further investigation. Special attention is needed when treating the more aggressive subtypes of the disease, such as the micronodular, infiltrative, adenoid and morpheic forms of basal cell carcinoma, as well as bigger basal cell carcinomas and basal cell carcinoma recurrences.

Discriminating basal cell carcinoma from its surrounding tissue by Raman spectroscopy

The objective of this in vitro study was to explore the applicability of Raman spectroscopy to distinguish basal cell carcinoma from its surrounding noncancerous tissue; therefore, identifying possibilities for the development of an in vivo diagnostic technique for tumor border demarcation. Raman spectra were obtained in a two-dimensional grid from unstained frozen sections of 15 basal cell carcinoma specimens. Pseudo-color Raman images were generated by multivariate statistical analysis and clustering analysis of spectra and compared with histopathology. In this way a direct link between histologically identifiable skin layers and structures and their Raman spectra was made. A tissue classification model was developed, which discriminates between basal cell carcinoma and surrounding nontumorous tissue, based on Raman spectra. The logistic regression model, shows a 100% sensitivity and 93% selectivity for basal cell carcinoma. The Raman spectra were, furthermore, used to obtain information about the differences in molecular composition between different skin layers and structures. An interesting finding was that in four samples of nodular basal cell carcinoma, the collagen signal contribution in spectra of dermis close to a basal cell carcinoma, was markedly reduced. The study demonstrates the sensitivity of Raman spectroscopy to biochemical changes in tissue accompanying malignancy, resulting in a high accuracy when discriminating between basal cell carcinoma and noncancerous tissue.