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Background: Actinic keratoses (AK) are sun-induced epithelial skin lesions, which are at risk to progress to squamous cell carcinoma. One of the treatments of AK is photodynamic therapy (PDT), which often has to be repeated. Another treatment for these lesions is diclofenac 3% gel. Although both treatments have shown to be effective, they have never been studied together. Objective: To investigate whether a pre-treatment of AK on the dorsum of the hands with diclofenac 3% gel improves the efficacy of PDT. Methods: In this placebo-controlled, randomized, double-blind, pilot study with 10 patients, both hands were pre-treated - one with diclofenac gel and the other with placebo gel - and then the hands were treated with ALA-PDT. Total lesion number scores, total thickness scores and global improvement scores were used to assess efficacy. Pain scores were recorded during PDT. Results: In both groups, the number of lesions significantly decreased. At 12 months' follow-up, significantly fewer AK were seen in the diclofenac group. Total lesion thickness scores decreased significantly in both groups. Pain during PDT was greater in the diclofenac group. Conclusions: Both treatments are effective in treating AK. A pre-treatment with diclofenac gel seems to result in fewer AK at 12 months' follow-up, compared to placebo. Side effects were worse when using the active drug. [ABSTRACT FROM AUTHOR]

The article focuses on nevoid basal cell carcinoma syndrome (NBCCS) or Gorlin-Goltz syndrome. It describes the management of basal cell carcinomas (BCCs) in three male patients diagnosed with NBCCS at an early age. A combination of treatment usually consisting of Mohs micrographic surgery (MMS), photodynamic therapy (PDT), and standard surgical excisions in one or more megasessions were made to treat numerous BCCs in these patients. The mean time for the overall sessions performed is also noted.

Summary: Background: Basal-cell carcinoma (BCC) is the most common form of skin cancer and its incidence is still rising worldwide. Surgery is the most frequently used treatment for BCC, but large randomised controlled trials with 5-year follow-up to compare treatment modalities are rare. We did a prospective randomised controlled trial to compare the effectiveness of surgical excision with Mohs'' micrographic surgery (MMS) for the treatment of primary and recurrent facial BCC. Methods: Between Oct 5, 1999, and Feb 27, 2002, 408 primary BCCs (pBCCs) and 204 recurrent BCCs (rBCCs) in patients from seven hospitals in the Netherlands were randomly assigned to surgical excision or MMS. Randomisation and allocation was done separately for both groups by a computer-generated allocation scheme. Tumours had a follow-up of 5 years. Analyses were done on an intention-to-treat basis. The primary outcome was recurrence of carcinoma, diagnosed clinically by visual inspection with histological confirmation. Secondary outcomes were determinants of failure and cost-effectiveness. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN65009900. Findings: Of the 397 pBCCs that were treated, 127 pBCCs in 113 patients were lost to follow-up. Of the 11 recurrences that occurred in patients with pBCC, seven (4·1%) occurred in patients treated with surgical excision and four (2·5%) occurred in patients treated with MMS (log-rank test χ2 0·718, p=0·397). Of the 202 rBCCs that were treated, 56 BCCs in 52 patients were lost to follow-up. Two BCCs (2·4%) in two patients treated with MMS recurred, versus ten BCCs (12·1%) in ten patients treated with surgical excision (log-rank test χ2 5·958, p=0·015). The difference in the number of recurrences between treatments was not significant for pBCC, but significantly favoured MMS in rBCC. In pBCC, Cox-regression analysis showed no significant effects from risk factors measured in the study. In rBCC, aggressive histological subtype was a significant risk factor for recurrence in the Cox-regression analysis. For pBCC, total treatment costs were €1248 for MMS and €990 for surgical excision, whereas for rBCC, treatment costs were €1284 and €1043, respectively. Dividing the difference in costs between MMS and surgical excision by their difference in effectiveness leads to an incremental cost-effectiveness ratio of €23 454 for pBCC and €3171 for rBCC. Interpretation: MMS is preferred over surgical excision for the treatment of facial rBCC, on the basis of significantly fewer recurrences after MMS than after surgical excision. However, because there was no significant difference in recurrence of pBCC between treatment groups, treatment with surgical excision is probably sufficient in most cases of pBCC. Funding: The Netherlands Organisation for Scientific Research ZonMW. [Copyright &y& Elsevier]

BACKGROUND The American Society for Dermatologic Surgery (ASDS) International Traveling Mentorship Program (ITMP) has initiated an International Mohs Fellowship Recognition Program, with 3 centers accredited to date. OBJECTIVE: To describe and compare the outcomes of Mohs micrographic surgery (MMS) at the three units. METHODS: From patient files, we extracted demographic information, as well as tumor type, location of tumor, tumor histology, stages of MMS, and outcomes. RESULTS: At the 3 units, 3,899 patients were treated withMMS over a 5-year period in the South African unit, and 1,141 cases in the Romanian unit. Over a 3-year period, 849 cases were treated in the Netherlands unit. Basal cell carcinomas (BCCs) constituted 78.9% (South African unit), 79% (Romanian unit), and 97.2% (Netherlands unit), and squamous cell carcinomas (SCCs) 17.7% (South African unit), 19% (Romanian unit), and 0.7% (Netherlands unit) of the tumors treated. The recurrence rate following MMS was low, at 0.1% (South African Unit) and 0.17% (Romanian Unit) of cases at the end of the study period, with a median follow-up time of 2 years. CONCLUSION: Mohs micrographic surgery is an effective treatment modality for removing BCC and SCC at ASDS ITMP-recognized International Mohs Fellowship units. [ABSTRACT FROM AUTHOR]

Background Basal cell carcinoma (BCC) is the most common form of cancer among Caucasians and its incidence continues to rise. Surgical excision (SE) is considered standard treatment, though randomised trials with long-term follow-up are rare. We now report the long-term results of a randomised trial comparing surgical excision with Mohs’ micrographic surgery (MMS) for facial BCC. Methods 408 facial, high risk (diameter at least 1 cm, H-zone location or aggressive histological subtype) primary BCCs (pBCCs) and 204 facial recurrent BCCs (rBCCs) were randomly allocated to treatment with either SE or MMS between 5th October 1999 and 27th February 2002. The primary outcome was recurrence of carcinoma. A modified intention to treat analysis was performed. Findings For primary BCC, the 10-year cumulative probabilities of recurrence were 4.4% after MMS and 12 . 2% after SE (Log-rank test χ 2 2.704, p = 0.100). For recurrent BCC, cumulative 10-year recurrence probabilities were 3.9% and 13.5% for MMS and SE, respectively (Log-rank χ 2 5.166, p = 0.023). A substantial proportion of recurrences occurred after more than 5 years post-treatment: 56% for pBCC and 14% for rBCC. Interpretation Fewer recurrences occurred after treatment of high risk facial BCC with MMS compared to treatment with SE. The proportion of recurrences occurring more than 5 years post-treatment was especially high for pBCC, stressing the need for long-term follow-up in patients with high risk facial pBCC. [ABSTRACT FROM AUTHOR]

Background: Around 100 to 200 patients undergo surgical reconstruction every year at our department of plastic and reconstructive surgery after Mohs micrographie surgery for nonmelanoma skin cancer. Objective: The aim of this report is to provide an overview of the type of facial reconstructions performed and investigate whether we achieved increased, definitive closure rates of the defect on the day of the excision after further improving the collaboration between the involved departments. Methods: All patients who underwent facial reconstruction at the Department of Plastic and Reconstructive Surgery following Mohs micrographie surgery between January 2006 and January 2011 were retrospectively systematically reviewed. Results: A total of 564 patients with 622 defects were identified. The different reconstructions used per aesthetic unit are described. The number of cases in which a reconstruction was performed on the same day as the resection significantly increased from 31 to 81% (p< .001). Conclusion: Facial reconstruction following Mohs micrographie surgery is challenging. The type of reconstruction used depends on the type of defect and patient characteristics. A structured multidisciplinary approach improves the process from defect to reconstruction and can facilitate referrals. [ABSTRACT FROM AUTHOR]

Background: Extensive Hailey-Hailey disease is often resistant to conventional topical and systemic therapies. The systemic and ablative therapies have many side effects and/or high recurrence rates. Therefore, an alternative safe and effective treatment is needed. Objective: To assess the effectiveness of botulinum toxin type A in the treatment of extensive Hailey-Hailey disease. Methods: The cases of six patients with extensive Hailey-Hailey disease resistant to multiple therapeutic regimens were studied and described. Adjuvant therapy with botulinum toxin type A/Dysport® was started in all six cases. Results: Marked improvement of the lesions was achieved with few side effects in all patients. Conclusion: Botulinum toxin type A is a safe and effective adjuvant treatment for extensive Hailey-Hailey disease. [ABSTRACT FROM AUTHOR]

Background. Actinic keratosis is an exceedingly common premalignant lesion that can develop into squamous cell carcinoma. There is an increasing prevalence of actinic keratosis with increasing age. Numerous treatment options are available for the treatment of actinic keratosis on the scalp. Although we know that atrophic skin heals slowly, one should be careful but should not hesitate to treat. Objective. We present three patients with widespread actinic keratotic lesions on the atrophic bald scalp who received different treatments. Methods. Patient 1 was treated with medium-depth chemical peel, patient 2 with cryopeel, and patient 3 with CO[sub 2] laser resurfacing. In all patients, the entire surface area was treated. Results. Despite the different treatment methods used, all three patients had severly delayed wound healing as a complication. Remarkably, all patients had a prolonged period of re-epithelialization. Conclusion. Care has to be taken in patients with widespread actinic keratosis on the atrophic bald scalp when treating the entire surface area regardless the treatment modality. [ABSTRACT FROM AUTHOR]

Background: Basal cell carcinoma (BCC) is the most common type of skin cancer with incidence rates rising each year. Mohs micrographic surgery (MMS) is most often chosen as treatment for BCC on the face for which each frozen section has to be histologically analysed to ensure complete tumor removal. This causes a heavy burden on health economics. Objectives: To develop and evaluate a deep learning model for the automated detection of BCC‐negative slides and classification of BCC in histopathology slides of MMS based on whole‐slide image (WSI). Methods: Two deep learning models were developed on the basis of 171 digitized H&E frozen slides from 70 different patients. The first model had a U‐Net architecture and was used for the segmentation of BCC. A subsequent convolutional neural network used the segmentation to classify the whole slide as BCC or BCC‐negative. Results: Quantitative evaluation over manually labelled ground truth data resulted in a Dice score of 0.66 for the segmentation of BCC and an area under the receiver operating characteristic curve (AUC) of 0.90 for the slide‐level classification. Conclusions: This study demonstrates that through WSIs deep learning models may be a feasible option to improve the clinical workflow and reduce costs in histological analysis of BCC in MMS. [ABSTRACT FROM AUTHOR]

BACKGROUND. Mohs micrographic surgery (MMS) is a technique that offers excellent cure rates in the treatment of basal cell carcinoma (BCC). One of the reasons for its success is the 100% visualization of the resection margins. Still, recurrences do occur in 2% to 5% of the treated BCCs. It has been suggested that BCC cells in frozen sections stained with hematoxylin and eosin (H&E) may be missed. OBJECTIVE. To determine whether an additional immunohistochemical staining with a cytokeratin marker (MNF 116) indicates BCC cells in sections in which the H&E-stained frozen sections were negative. METHODS. The Mohs procedure was performed under standard conditions in which H&E-stained slides were judged by the Mohs surgeon and the pathologist. After the H&E slides where judged negative, an extra slide was stained using immunohistochemistry and a monoclonal antibody against cytokeratin (MNF 116). RESULTS. A total of 143 complete slides were stained and judged by two Mohs surgeons and a pathologist. One of the 143 slides stained with MNF 116 showed positive staining where the H&E slides were negative, which is 0.7% of the slides. However, this single slide represents a failure of nearly 2% of the treated patients. CONCLUSION. Frozen sections stained with H&E in MMS offer enough security in detecting BCC cells during surgery; however, adjuvant cytokeratin staining can be useful in very selected cases of aggressive growing BCC. [ABSTRACT FROM AUTHOR]

Photodynamic therapy (PDT) with light emitting diode (LED) illumination is a frequently used treatment modality for actinic keratosis (AK) with excellent cosmetic outcome. A major disadvantage, however, is the high pain score. Pulsed dye laser (PDL) illumination has been suggested, but the long-term efficacy of this treatment is unknown. In this split-face study we prospectively treated 61 patients with AK, with both LED-PDT and PDL-PDT. The mean change in the number of lesions between the end of follow-up and start of therapy was -4.25 (95% confidence interval (95% CI) -5.07; -3.43) for LED-PDT and -3.88 (95% CI -4,76; -2.99) for PDL-PDT, with a non-significant difference (p = 0.258) of -0.46 (95% CI -1.28; 0.35). The percentage decrease from baseline in the total number of AK was 55.8% and 47.8%, respectively, at 12-month follow-up. Visual analogue scale pain score was lower after PDL (mean 2.64) compared with LED illumination (mean 6.47). These findings indicate that PDL-PDT is an effective alternative illumination source for AK when pain is a limiting factor for regular LED-PDT. [ABSTRACT FROM AUTHOR]

Summary: Background: Superficial basal-cell carcinoma is most commonly treated with topical non-surgical treatments, such as photodynamic therapy or topical creams. Photodynamic therapy is considered the preferable treatment, although this has not been previously tested in a randomised control trial. We assessed the effectiveness of photodynamic therapy compared with imiquimod or fluorouracil in patients with superficial basal-cell carcinoma. Methods: In this single blind, non-inferiority, randomised controlled multicentre trial, we enrolled patients with a histologically proven superficial basal-cell carcinoma at seven hospitals in the Netherlands. Patients were randomly assigned to receive treatment with methylaminolevulinate photodynamic therapy (MAL-PDT; two sessions with an interval of 1 week), imiquimod cream (once daily, five times a week for 6 weeks), or fluorouracil cream (twice daily for 4 weeks). Follow-up was at 3 and 12 months post-treatment. Data were collected by one observer who was blinded to the assigned treatment. The primary outcome was the proportion of patients free of tumour at both 3 and 12 month follow up. A pre-specified non-inferiority margin of 10% was used and modified intention-to-treat analyses were done. This trial is registered as an International Standard Randomised controlled trial (ISRCTN 79701845). Findings: 601 patients were randomised: 202 to receive MAL-PDT, 198 to receive imiquimod, and 201 to receive fluorouracil. A year after treatment, 52 of 196 patients treated with MAL-PDT, 31 of 189 treated with imiquimod, and 39 of 198 treated with fluorouracil had tumour residue or recurrence. The proportion of patients tumour-free at both 3 and 12 month follow-up was 72·8% (95% CI 66·8–79·4) for MAL-PDT, 83·4% (78·2–88·9) for imiquimod cream, and 80·1% (74·7–85·9) for fluorouracil cream. The difference between imiquimod and MAL-PDT was 10·6% (95% CI 1·5–19·5; p=0·021) and 7·3% (–1·9 to 16·5; p=0·120) between fluorouracil and MAL-PDT, and between fluorouracil and imiquimod was −3·3% (–11·6 to 5·0; p=0·435. For patients treated with MAL-PDT, moderate to severe pain and burning sensation were reported most often during the actual MAL-PDT session. For other local adverse reactions, local skin redness was most often reported as moderate or severe in all treatment groups. Patients treated with creams more often reported moderate to severe local swelling, erosion, crust formation, and itching of the skin than patients treated with MAL-PDT. In the MAL-PDT group no serious adverse events were reported. One patient treated with imiquimod and two patients treated with fluorouracil developed a local wound infection and needed additional treatment in the outpatient setting. Interpretation: Topical fluorouracil was non-inferior and imiquimod was superior to MAL-PDT for treatment of superficial basal-cell carcinoma. On the basis of these findings, imiquimod can be considered the preferred treatment, but all aspects affecting treatment choice should be weighted to select the best treatment for patients. Funding: Grant of the Netherlands Organization for Scientific Research ZONMW (08-82310-98-08626). [ABSTRACT FROM AUTHOR]

Abstract: Objective: The main objective of the study was to assess which health beliefs predict and explain satisfaction with the facial health state of patients undergoing surgery for basal cell carcinoma. Methods: Data were collected by administering a newly developed questionnaire pre-operatively and 6 months post-operatively (n =222). Results: Results show that satisfaction as measured by post-operative worrying, susceptibility and fear of developing a new BCC at other facial sites can be predicted by pre-operative health beliefs. In addition, some patients an increase in perceived susceptibility, fear of recurrence of BCC on the same site or fear of developing a new BCC at other facial sites. Conclusion: Our findings indicate that both pre- and post-operative perceptions predict and explain for a substantial part the extent to which patients are satisfied with their facial health state 6 months after surgery. Practice implications: Administering a short questionnaire at the start of the treatment period will give physicians a better understanding of how patients experience this skin disease. It will also help them to adjust information about BCC and its consequences to the needs of the patient. [Copyright &y& Elsevier]

BACKGROUND Diffuse widespread actinic keratoses (AK) are difficult to treat, have a tendency towards higher recurrence rates, and therefore require ablative treatment. Laser resurfacing is one of the treatment modalities that can treat whole surface areas. OBJECTIVE To evaluate patients who underwent laser resurfacing for widespread AK with long-term follow-up for recurrence rates, time until new lesions occur, and the most common side effects. METHODS Retrospective case-control study of 25 patients who underwent laser resurfacing for widespread AK on the scalp, forehead, or full face at our department. Follow-up varies from 7 to 70 months. Recurrence rates, adverse effects, and improvement were analyzed through chart analysis. RESULTS The mean average follow-up was 39 months. Forty-four percent of the patients had no recurrence during the time period. Fifty-six percent of the patients developed new lesions after treatment, but only a few. Of the recurrences, 20% occurred within 1 year and 36% occurred after 1 year. The most common short- and long-term side effects were infections (12%), hypopigmentation (48%), hyperpigmentation (8%), acne (12%), milia (12%), scar formation (8%), and atrophic and/or easily bruising skin (20%). CONCLUSION Laser resurfacing is an effective treatment modality for diffuse widespread AK with long-term recurrence-free intervals. [ABSTRACT FROM AUTHOR]