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VIDEO: When to consider systemic exposure in patients with contact dermatitis
SAN FRANCISCO – When patients with contact dermatitis who have had a patch test positive to an allergen and are not improving despite avoiding cutaneous exposure, it’s important to consider the possibility of systemic exposure, according to Nina Botto, MD, of the department of dermatology, at the University of California, San Francisco.
“Theoretically, any allergen can cause a systemic contact dermatitis. The ones that we think about and encounter more frequently are earth metals like nickel and balsam of Peru, which is a component of many fragrances and flavorings,” she said in a video interview at the annual meeting of the Pacific Dermatologic Association.
In the interview, Dr. Botto, who is codirector of the Occupational and Contact Dermatitis Clinic at UCSF, provides recommendations on how to approach patients with systemic contact dermatitis, including dietary avoidance. But following these diets can be challenging. She recommends starting with avoiding cutaneous exposure to the suspected allergen. For patients not improving after two months of avoidance, “it may be reasonable to consider a diet,”she advised.
Dr. Botto cited the following two publications with tables and guidelines for diets as helpful resources for patients: Dermatitis. 2013 Jul-Aug;24(4):153-60 (for a diet low in balsam of Peru); and Dermatitis. 2013 Jul-Aug; 24(4):190-5 (for a diet low in nickel).
Another useful resource is the American Contact Dermatitis Society website, which produces a customized list of safe products for patients after they enter the allergen into the system.
Dr. Botto had no disclosures.
SAN FRANCISCO – When patients with contact dermatitis who have had a patch test positive to an allergen and are not improving despite avoiding cutaneous exposure, it’s important to consider the possibility of systemic exposure, according to Nina Botto, MD, of the department of dermatology, at the University of California, San Francisco.
“Theoretically, any allergen can cause a systemic contact dermatitis. The ones that we think about and encounter more frequently are earth metals like nickel and balsam of Peru, which is a component of many fragrances and flavorings,” she said in a video interview at the annual meeting of the Pacific Dermatologic Association.
In the interview, Dr. Botto, who is codirector of the Occupational and Contact Dermatitis Clinic at UCSF, provides recommendations on how to approach patients with systemic contact dermatitis, including dietary avoidance. But following these diets can be challenging. She recommends starting with avoiding cutaneous exposure to the suspected allergen. For patients not improving after two months of avoidance, “it may be reasonable to consider a diet,”she advised.
Dr. Botto cited the following two publications with tables and guidelines for diets as helpful resources for patients: Dermatitis. 2013 Jul-Aug;24(4):153-60 (for a diet low in balsam of Peru); and Dermatitis. 2013 Jul-Aug; 24(4):190-5 (for a diet low in nickel).
Another useful resource is the American Contact Dermatitis Society website, which produces a customized list of safe products for patients after they enter the allergen into the system.
Dr. Botto had no disclosures.
SAN FRANCISCO – When patients with contact dermatitis who have had a patch test positive to an allergen and are not improving despite avoiding cutaneous exposure, it’s important to consider the possibility of systemic exposure, according to Nina Botto, MD, of the department of dermatology, at the University of California, San Francisco.
“Theoretically, any allergen can cause a systemic contact dermatitis. The ones that we think about and encounter more frequently are earth metals like nickel and balsam of Peru, which is a component of many fragrances and flavorings,” she said in a video interview at the annual meeting of the Pacific Dermatologic Association.
In the interview, Dr. Botto, who is codirector of the Occupational and Contact Dermatitis Clinic at UCSF, provides recommendations on how to approach patients with systemic contact dermatitis, including dietary avoidance. But following these diets can be challenging. She recommends starting with avoiding cutaneous exposure to the suspected allergen. For patients not improving after two months of avoidance, “it may be reasonable to consider a diet,”she advised.
Dr. Botto cited the following two publications with tables and guidelines for diets as helpful resources for patients: Dermatitis. 2013 Jul-Aug;24(4):153-60 (for a diet low in balsam of Peru); and Dermatitis. 2013 Jul-Aug; 24(4):190-5 (for a diet low in nickel).
Another useful resource is the American Contact Dermatitis Society website, which produces a customized list of safe products for patients after they enter the allergen into the system.
Dr. Botto had no disclosures.
AT THE ANNUAL MEETING OF THE PACIFIC DERMATOLOGIC ASSOCIATION
Immunologic testing is key to diagnosing autoimmune blistering diseases
SAN FRANCISCO –
“You have to have some kind of immunological test,” according to Peter Marinkovich, MD. “Pathologists will try to give you as much information as they can on the routine histology, but don’t use that as a diagnostic.”
If not properly identified, autoimmune blistering diseases can lead to chronic overexposure to steroids and resultant side effects without addressing the underlying problem, said Dr. Marinkovich of the department of dermatology at Stanford (Calif.) University.
Dr. Marinkovich gave one example of a patient who had been diagnosed with bullous pemphigoid several years before, and who was becoming Cushingoid as a result of steroids. But the diagnosis was made on the basis of histopathology and clinical appearance alone.
“Nobody had done the immunofluorescence test,” he explained at the annual meeting of the Pacific Dermatologic Association. “I did it, and it turned out she had linear IgA disease. The patient went through 2 years of toxicity just because nobody had done the immunofluorescence test.” Instead, the patient improved when placed on dapsone, which is much less toxic than prednisone.
Direct/indirect immunofluorescence is the highest-yield test for patients with blistering disease. “It’s the best way, I believe, to make the diagnosis,” Dr. Marinkovich said. If that test isn’t available, serum taken during an active phase can also be used. But serum samples can turn up false negatives, so dermatologists should consider collecting and testing serum samples several times.
Another useful tool is salt-split skin analysis, which will demarcate antigens to the roof or floor of the blister. Specifically, it helps distinguish bullous pemphigoid and epidermolysis bullosa acquisita.
In the future, Dr. Marinkovich said, ELISA (enzyme-linked immunosorbent assay) testing will have greater importance for diagnosis and disease monitoring, not just for pemphigus but for subepidermal bullous disorders as well.
Autoimmune blistering diseases do respond to prednisone treatment, although not as well as some other conditions. However, symptom improvement can mask the true cause of the disease.
“It’s easy for physicians to give steroids, and the patients will be happy for the time being; but that doesn’t solve the problem in the long term,” Dr. Marinkovich cautioned. “These are chronic conditions, and the patient will continue to require prednisone, and they’ll get more and more side effects, which could have been avoided if someone had done a more thorough investigation.”
Topical agents such as tetracycline, niacinamide, and topical steroids are more useful in pemphigoid than for pemphigus, because pemphigoid involves local immune factors that the agents can target, while pemphigus can be driven by antibodies alone, which are not as responsive to these treatments.
When systemic therapies are necessary, prednisone is a useful tool, but aim for the lowest possible dose, he said. Reducing prednisone dose is challenging in and of itself. Dropping the dose too quickly can lead to more long-term exposure, because a steep drop can lead to a rebound in the disease, which leads to a higher dose.
“The patient is on this roller coaster ride, up and down, up and down, and that alone can ramp up disease activity,” said Dr. Marinkovich. “Lowering steroid more steadily is a better way to go. This calms the disease down by itself.”
When steroids can’t be completely tapered, which is almost always the case in pemphigus and common in pemphigoid, add steroid-sparing agents such as mycophenolate and azathioprine.
If the steroid-sparing agents don’t get patients down to 10 mg/day prednisone or below, then consider using rituximab and intravenous IgG.
In Europe, physicians are using rituximab earlier in the course of disease, a strategy that appeared effective in a study published in the Lancet (2017 May 20;389[10083]:2031-40). “The evidence suggests to me that earlier use of rituximab tends to reduce the total amount of steroids that the patients are using and has the potential to reduce the duration of the disease,” Dr. Marinkovich said. “That’s a trend that will be going on in the next couple of years here in the United States.”
Dr. Marinkovich is an investigator on a clinical trial funded by Syntimmune.
SAN FRANCISCO –
“You have to have some kind of immunological test,” according to Peter Marinkovich, MD. “Pathologists will try to give you as much information as they can on the routine histology, but don’t use that as a diagnostic.”
If not properly identified, autoimmune blistering diseases can lead to chronic overexposure to steroids and resultant side effects without addressing the underlying problem, said Dr. Marinkovich of the department of dermatology at Stanford (Calif.) University.
Dr. Marinkovich gave one example of a patient who had been diagnosed with bullous pemphigoid several years before, and who was becoming Cushingoid as a result of steroids. But the diagnosis was made on the basis of histopathology and clinical appearance alone.
“Nobody had done the immunofluorescence test,” he explained at the annual meeting of the Pacific Dermatologic Association. “I did it, and it turned out she had linear IgA disease. The patient went through 2 years of toxicity just because nobody had done the immunofluorescence test.” Instead, the patient improved when placed on dapsone, which is much less toxic than prednisone.
Direct/indirect immunofluorescence is the highest-yield test for patients with blistering disease. “It’s the best way, I believe, to make the diagnosis,” Dr. Marinkovich said. If that test isn’t available, serum taken during an active phase can also be used. But serum samples can turn up false negatives, so dermatologists should consider collecting and testing serum samples several times.
Another useful tool is salt-split skin analysis, which will demarcate antigens to the roof or floor of the blister. Specifically, it helps distinguish bullous pemphigoid and epidermolysis bullosa acquisita.
In the future, Dr. Marinkovich said, ELISA (enzyme-linked immunosorbent assay) testing will have greater importance for diagnosis and disease monitoring, not just for pemphigus but for subepidermal bullous disorders as well.
Autoimmune blistering diseases do respond to prednisone treatment, although not as well as some other conditions. However, symptom improvement can mask the true cause of the disease.
“It’s easy for physicians to give steroids, and the patients will be happy for the time being; but that doesn’t solve the problem in the long term,” Dr. Marinkovich cautioned. “These are chronic conditions, and the patient will continue to require prednisone, and they’ll get more and more side effects, which could have been avoided if someone had done a more thorough investigation.”
Topical agents such as tetracycline, niacinamide, and topical steroids are more useful in pemphigoid than for pemphigus, because pemphigoid involves local immune factors that the agents can target, while pemphigus can be driven by antibodies alone, which are not as responsive to these treatments.
When systemic therapies are necessary, prednisone is a useful tool, but aim for the lowest possible dose, he said. Reducing prednisone dose is challenging in and of itself. Dropping the dose too quickly can lead to more long-term exposure, because a steep drop can lead to a rebound in the disease, which leads to a higher dose.
“The patient is on this roller coaster ride, up and down, up and down, and that alone can ramp up disease activity,” said Dr. Marinkovich. “Lowering steroid more steadily is a better way to go. This calms the disease down by itself.”
When steroids can’t be completely tapered, which is almost always the case in pemphigus and common in pemphigoid, add steroid-sparing agents such as mycophenolate and azathioprine.
If the steroid-sparing agents don’t get patients down to 10 mg/day prednisone or below, then consider using rituximab and intravenous IgG.
In Europe, physicians are using rituximab earlier in the course of disease, a strategy that appeared effective in a study published in the Lancet (2017 May 20;389[10083]:2031-40). “The evidence suggests to me that earlier use of rituximab tends to reduce the total amount of steroids that the patients are using and has the potential to reduce the duration of the disease,” Dr. Marinkovich said. “That’s a trend that will be going on in the next couple of years here in the United States.”
Dr. Marinkovich is an investigator on a clinical trial funded by Syntimmune.
SAN FRANCISCO –
“You have to have some kind of immunological test,” according to Peter Marinkovich, MD. “Pathologists will try to give you as much information as they can on the routine histology, but don’t use that as a diagnostic.”
If not properly identified, autoimmune blistering diseases can lead to chronic overexposure to steroids and resultant side effects without addressing the underlying problem, said Dr. Marinkovich of the department of dermatology at Stanford (Calif.) University.
Dr. Marinkovich gave one example of a patient who had been diagnosed with bullous pemphigoid several years before, and who was becoming Cushingoid as a result of steroids. But the diagnosis was made on the basis of histopathology and clinical appearance alone.
“Nobody had done the immunofluorescence test,” he explained at the annual meeting of the Pacific Dermatologic Association. “I did it, and it turned out she had linear IgA disease. The patient went through 2 years of toxicity just because nobody had done the immunofluorescence test.” Instead, the patient improved when placed on dapsone, which is much less toxic than prednisone.
Direct/indirect immunofluorescence is the highest-yield test for patients with blistering disease. “It’s the best way, I believe, to make the diagnosis,” Dr. Marinkovich said. If that test isn’t available, serum taken during an active phase can also be used. But serum samples can turn up false negatives, so dermatologists should consider collecting and testing serum samples several times.
Another useful tool is salt-split skin analysis, which will demarcate antigens to the roof or floor of the blister. Specifically, it helps distinguish bullous pemphigoid and epidermolysis bullosa acquisita.
In the future, Dr. Marinkovich said, ELISA (enzyme-linked immunosorbent assay) testing will have greater importance for diagnosis and disease monitoring, not just for pemphigus but for subepidermal bullous disorders as well.
Autoimmune blistering diseases do respond to prednisone treatment, although not as well as some other conditions. However, symptom improvement can mask the true cause of the disease.
“It’s easy for physicians to give steroids, and the patients will be happy for the time being; but that doesn’t solve the problem in the long term,” Dr. Marinkovich cautioned. “These are chronic conditions, and the patient will continue to require prednisone, and they’ll get more and more side effects, which could have been avoided if someone had done a more thorough investigation.”
Topical agents such as tetracycline, niacinamide, and topical steroids are more useful in pemphigoid than for pemphigus, because pemphigoid involves local immune factors that the agents can target, while pemphigus can be driven by antibodies alone, which are not as responsive to these treatments.
When systemic therapies are necessary, prednisone is a useful tool, but aim for the lowest possible dose, he said. Reducing prednisone dose is challenging in and of itself. Dropping the dose too quickly can lead to more long-term exposure, because a steep drop can lead to a rebound in the disease, which leads to a higher dose.
“The patient is on this roller coaster ride, up and down, up and down, and that alone can ramp up disease activity,” said Dr. Marinkovich. “Lowering steroid more steadily is a better way to go. This calms the disease down by itself.”
When steroids can’t be completely tapered, which is almost always the case in pemphigus and common in pemphigoid, add steroid-sparing agents such as mycophenolate and azathioprine.
If the steroid-sparing agents don’t get patients down to 10 mg/day prednisone or below, then consider using rituximab and intravenous IgG.
In Europe, physicians are using rituximab earlier in the course of disease, a strategy that appeared effective in a study published in the Lancet (2017 May 20;389[10083]:2031-40). “The evidence suggests to me that earlier use of rituximab tends to reduce the total amount of steroids that the patients are using and has the potential to reduce the duration of the disease,” Dr. Marinkovich said. “That’s a trend that will be going on in the next couple of years here in the United States.”
Dr. Marinkovich is an investigator on a clinical trial funded by Syntimmune.
AT PDA 2017
Know the best specific signs for polycystic ovary syndrome
SAN FRANCISCO – Dermatologists are often on the frontline when it comes to diagnosing polycystic ovary syndrome (PCOS), which is one reason they should be up to date and aware of the changing diagnostic criteria for the condition, according to Kanade Shinkai, MD.
About one-quarter of patients who are diagnosed with PCOS are seen first by a dermatologist. That’s because skin conditions may be more concerning than reproductive issues in young women.
“Sometimes, people don’t see [irregular menstruation] as a problem,” explained Dr. Shinkai of the department of dermatology at the University of California, San Francisco. “Maybe they’re young, or they’re not trying to get pregnant. But if their hair is falling out, they see that as a problem, or if they have bad acne, or they’re becoming hirsute, they see that as a problem. So, they present to a dermatologist.”
Early recognition of PCOS is important, because many women with the condition go on to develop diabetes, impaired glucose intolerance, hyperlipidemia, hypertension, fertility problems, and obesity.
It used to be that physicians expected patients with PCOS to have menstrual irregularities, biochemical or clinical evidence of hyperandrogenism, and evidence of polycystic ovaries on ultrasound. But just two of the three are now considered enough to warrant a diagnosis.
“Our original view of the classic patient has gone away, and it’s really a heterogeneous phenotype,” Dr. Shinkai said. “Originally, it was all three [criteria], and the patient was obese, and they all had diabetes. Now, we know that’s not true. Every woman who has PCOS has her own version of PCOS.”
Dr. Shinkai’s team conducted a study of clinical markers associated with PCOS and found that some of the classic signs of PCOS may be unreliable.
“Alopecia turns out not to be a very reliable marker,” she explained. “That’s paradigm shifting, I think, because often if patients present with hair loss in a hormonal pattern, they get worked up for PCOS, and it turns out that workup is not always fruitful.” Acne can also be misleading, given its frequency in the general population.
More reliable signs include hirsutism and acanthosis nigricans; 70%-80% of women with hirsutism have PCOS, and 53% of patients with PCOS have hirsutism, most commonly on the trunk. Acanthosis nigricans occurs in 37% of PCOS patients.
“Those are the best specific signs for PCOS,” said Dr. Shinkai. “If we see those, we should probably work the patient up.”
In preparation, the patient should be off of birth control treatment for at least 4 weeks, because hormonal treatment can interfere with test results, Dr Shinkai noted.
She also recommended a transvaginal ultrasound and a free-testosterone test. Consensus statements recommend testing of 17-hydroxyprogesterone, but Dr. Shinkai said she isn’t so sure. “That’s only going to capture about 3% of your patients with cutaneous hyperandrogenism, so it’s pretty low yield,” she said.
For treatment of cutaneous symptoms of PCOS, it’s important for the patient to understand that treatment courses will last at least 6 months. “It’s not a quick fix,” said Dr. Shinkai. Oral contraceptives are a mainstay, and are often sufficient for mild hirsutism. But moderate or severe cases call for high doses of spironolactone (150-200 mg/day). She said she usually combines spironolactone with oral contraceptives, because the drug can lead to menstrual irregularities, which birth control pills can relieve.
Dr. Shinkai reported having no relevant financial disclosures.
SAN FRANCISCO – Dermatologists are often on the frontline when it comes to diagnosing polycystic ovary syndrome (PCOS), which is one reason they should be up to date and aware of the changing diagnostic criteria for the condition, according to Kanade Shinkai, MD.
About one-quarter of patients who are diagnosed with PCOS are seen first by a dermatologist. That’s because skin conditions may be more concerning than reproductive issues in young women.
“Sometimes, people don’t see [irregular menstruation] as a problem,” explained Dr. Shinkai of the department of dermatology at the University of California, San Francisco. “Maybe they’re young, or they’re not trying to get pregnant. But if their hair is falling out, they see that as a problem, or if they have bad acne, or they’re becoming hirsute, they see that as a problem. So, they present to a dermatologist.”
Early recognition of PCOS is important, because many women with the condition go on to develop diabetes, impaired glucose intolerance, hyperlipidemia, hypertension, fertility problems, and obesity.
It used to be that physicians expected patients with PCOS to have menstrual irregularities, biochemical or clinical evidence of hyperandrogenism, and evidence of polycystic ovaries on ultrasound. But just two of the three are now considered enough to warrant a diagnosis.
“Our original view of the classic patient has gone away, and it’s really a heterogeneous phenotype,” Dr. Shinkai said. “Originally, it was all three [criteria], and the patient was obese, and they all had diabetes. Now, we know that’s not true. Every woman who has PCOS has her own version of PCOS.”
Dr. Shinkai’s team conducted a study of clinical markers associated with PCOS and found that some of the classic signs of PCOS may be unreliable.
“Alopecia turns out not to be a very reliable marker,” she explained. “That’s paradigm shifting, I think, because often if patients present with hair loss in a hormonal pattern, they get worked up for PCOS, and it turns out that workup is not always fruitful.” Acne can also be misleading, given its frequency in the general population.
More reliable signs include hirsutism and acanthosis nigricans; 70%-80% of women with hirsutism have PCOS, and 53% of patients with PCOS have hirsutism, most commonly on the trunk. Acanthosis nigricans occurs in 37% of PCOS patients.
“Those are the best specific signs for PCOS,” said Dr. Shinkai. “If we see those, we should probably work the patient up.”
In preparation, the patient should be off of birth control treatment for at least 4 weeks, because hormonal treatment can interfere with test results, Dr Shinkai noted.
She also recommended a transvaginal ultrasound and a free-testosterone test. Consensus statements recommend testing of 17-hydroxyprogesterone, but Dr. Shinkai said she isn’t so sure. “That’s only going to capture about 3% of your patients with cutaneous hyperandrogenism, so it’s pretty low yield,” she said.
For treatment of cutaneous symptoms of PCOS, it’s important for the patient to understand that treatment courses will last at least 6 months. “It’s not a quick fix,” said Dr. Shinkai. Oral contraceptives are a mainstay, and are often sufficient for mild hirsutism. But moderate or severe cases call for high doses of spironolactone (150-200 mg/day). She said she usually combines spironolactone with oral contraceptives, because the drug can lead to menstrual irregularities, which birth control pills can relieve.
Dr. Shinkai reported having no relevant financial disclosures.
SAN FRANCISCO – Dermatologists are often on the frontline when it comes to diagnosing polycystic ovary syndrome (PCOS), which is one reason they should be up to date and aware of the changing diagnostic criteria for the condition, according to Kanade Shinkai, MD.
About one-quarter of patients who are diagnosed with PCOS are seen first by a dermatologist. That’s because skin conditions may be more concerning than reproductive issues in young women.
“Sometimes, people don’t see [irregular menstruation] as a problem,” explained Dr. Shinkai of the department of dermatology at the University of California, San Francisco. “Maybe they’re young, or they’re not trying to get pregnant. But if their hair is falling out, they see that as a problem, or if they have bad acne, or they’re becoming hirsute, they see that as a problem. So, they present to a dermatologist.”
Early recognition of PCOS is important, because many women with the condition go on to develop diabetes, impaired glucose intolerance, hyperlipidemia, hypertension, fertility problems, and obesity.
It used to be that physicians expected patients with PCOS to have menstrual irregularities, biochemical or clinical evidence of hyperandrogenism, and evidence of polycystic ovaries on ultrasound. But just two of the three are now considered enough to warrant a diagnosis.
“Our original view of the classic patient has gone away, and it’s really a heterogeneous phenotype,” Dr. Shinkai said. “Originally, it was all three [criteria], and the patient was obese, and they all had diabetes. Now, we know that’s not true. Every woman who has PCOS has her own version of PCOS.”
Dr. Shinkai’s team conducted a study of clinical markers associated with PCOS and found that some of the classic signs of PCOS may be unreliable.
“Alopecia turns out not to be a very reliable marker,” she explained. “That’s paradigm shifting, I think, because often if patients present with hair loss in a hormonal pattern, they get worked up for PCOS, and it turns out that workup is not always fruitful.” Acne can also be misleading, given its frequency in the general population.
More reliable signs include hirsutism and acanthosis nigricans; 70%-80% of women with hirsutism have PCOS, and 53% of patients with PCOS have hirsutism, most commonly on the trunk. Acanthosis nigricans occurs in 37% of PCOS patients.
“Those are the best specific signs for PCOS,” said Dr. Shinkai. “If we see those, we should probably work the patient up.”
In preparation, the patient should be off of birth control treatment for at least 4 weeks, because hormonal treatment can interfere with test results, Dr Shinkai noted.
She also recommended a transvaginal ultrasound and a free-testosterone test. Consensus statements recommend testing of 17-hydroxyprogesterone, but Dr. Shinkai said she isn’t so sure. “That’s only going to capture about 3% of your patients with cutaneous hyperandrogenism, so it’s pretty low yield,” she said.
For treatment of cutaneous symptoms of PCOS, it’s important for the patient to understand that treatment courses will last at least 6 months. “It’s not a quick fix,” said Dr. Shinkai. Oral contraceptives are a mainstay, and are often sufficient for mild hirsutism. But moderate or severe cases call for high doses of spironolactone (150-200 mg/day). She said she usually combines spironolactone with oral contraceptives, because the drug can lead to menstrual irregularities, which birth control pills can relieve.
Dr. Shinkai reported having no relevant financial disclosures.
AT PDA 2017
Mitotic rate not tied to SLN biopsy results in thin melanomas
SAN FRANCISCO –
The finding supports the 2017 revision in the American Joint Committee on Cancer guideline, which dropped mitotic rate from its criteria for upstaging thin melanomas.
An earlier version of the guideline, published in 2010, had called for upgrading thin (less than 1 mm), nonulcerated melanomas with a mitotic rate (MR) of at least 1/mm2 to T1B, which could then trigger an SLN biopsy.
SLN biopsy is controversial in thin melanomas, because there is no evidence that it has a survival benefit in these populations, though it is useful as a prognostic measure. However, the procedure carries a risk of complications.
“This makes judicious selection of patients for the procedures even more important,” Heidi Wat, MD, of the division of dermatology at the University of Alberta, Edmonton, said during her presentation of the research at the annual meeting of the Pacific Dermatologic Association.
The researchers set out to determine the predictive value of mitotic rate (the number of cells undergoing cell division) on SLN status, particularly when stratified by tumor thickness. They analyzed 990 SLN biopsy procedures performed in Alberta from January 2007 through December 2013, which were pulled from the Cancer Surgery Alberta tumor database and provincial pathology records. The mean age of the patients was 57 years (range, 15-93 years), and 55% were male; 171 records involved thin melanomas.
Overall, 25.4% of SLN biopsies came back positive, including 8.8% of thin melanomas. Among all cases, there was a statistically significant association between a mitotic rate of 1 or higher and a positive SLN biopsy.
However, when the researchers stratified the results by thickness, they found a statistically significant association only between mitotic rate and SLN biopsy positivity in thicker tumors (1-2 mm, P = .01).
Further analysis of factors including age, ulceration, and tumor location showed that MR and thickness measures were not independent, and the potential for MR to predict SLN biopsy positivity declined at lower thickness values.
“Performing sentinel lymph node biopsy in thin melanomas upstaged purely because of the finding of a single mitotic (event) has questionable clinical value,” said Dr. Wat.
The 2010 AJCC guidelines called for upgrading thin tumors with an MR of 1 or higher, or ulceration, to T1b. The new AJCC guidelines restrict the definition of T1b to tumors 0.8-1.0 mm in size with or without ulceration, or tumors 0.8 mm or smaller with ulceration.
“The results really confirm the latest recommendations,” said Nina Botto, MD, of the department of dermatology at the University of California, San Francisco, who chaired the session in which the research was presented.
SLN status remains a useful prognostic indicator, Dr. Wat said, and MR may still be useful for intermediate and thick melanomas.
Dr. Wat and Dr. Botto reported no relevant financial disclosures.
SAN FRANCISCO –
The finding supports the 2017 revision in the American Joint Committee on Cancer guideline, which dropped mitotic rate from its criteria for upstaging thin melanomas.
An earlier version of the guideline, published in 2010, had called for upgrading thin (less than 1 mm), nonulcerated melanomas with a mitotic rate (MR) of at least 1/mm2 to T1B, which could then trigger an SLN biopsy.
SLN biopsy is controversial in thin melanomas, because there is no evidence that it has a survival benefit in these populations, though it is useful as a prognostic measure. However, the procedure carries a risk of complications.
“This makes judicious selection of patients for the procedures even more important,” Heidi Wat, MD, of the division of dermatology at the University of Alberta, Edmonton, said during her presentation of the research at the annual meeting of the Pacific Dermatologic Association.
The researchers set out to determine the predictive value of mitotic rate (the number of cells undergoing cell division) on SLN status, particularly when stratified by tumor thickness. They analyzed 990 SLN biopsy procedures performed in Alberta from January 2007 through December 2013, which were pulled from the Cancer Surgery Alberta tumor database and provincial pathology records. The mean age of the patients was 57 years (range, 15-93 years), and 55% were male; 171 records involved thin melanomas.
Overall, 25.4% of SLN biopsies came back positive, including 8.8% of thin melanomas. Among all cases, there was a statistically significant association between a mitotic rate of 1 or higher and a positive SLN biopsy.
However, when the researchers stratified the results by thickness, they found a statistically significant association only between mitotic rate and SLN biopsy positivity in thicker tumors (1-2 mm, P = .01).
Further analysis of factors including age, ulceration, and tumor location showed that MR and thickness measures were not independent, and the potential for MR to predict SLN biopsy positivity declined at lower thickness values.
“Performing sentinel lymph node biopsy in thin melanomas upstaged purely because of the finding of a single mitotic (event) has questionable clinical value,” said Dr. Wat.
The 2010 AJCC guidelines called for upgrading thin tumors with an MR of 1 or higher, or ulceration, to T1b. The new AJCC guidelines restrict the definition of T1b to tumors 0.8-1.0 mm in size with or without ulceration, or tumors 0.8 mm or smaller with ulceration.
“The results really confirm the latest recommendations,” said Nina Botto, MD, of the department of dermatology at the University of California, San Francisco, who chaired the session in which the research was presented.
SLN status remains a useful prognostic indicator, Dr. Wat said, and MR may still be useful for intermediate and thick melanomas.
Dr. Wat and Dr. Botto reported no relevant financial disclosures.
SAN FRANCISCO –
The finding supports the 2017 revision in the American Joint Committee on Cancer guideline, which dropped mitotic rate from its criteria for upstaging thin melanomas.
An earlier version of the guideline, published in 2010, had called for upgrading thin (less than 1 mm), nonulcerated melanomas with a mitotic rate (MR) of at least 1/mm2 to T1B, which could then trigger an SLN biopsy.
SLN biopsy is controversial in thin melanomas, because there is no evidence that it has a survival benefit in these populations, though it is useful as a prognostic measure. However, the procedure carries a risk of complications.
“This makes judicious selection of patients for the procedures even more important,” Heidi Wat, MD, of the division of dermatology at the University of Alberta, Edmonton, said during her presentation of the research at the annual meeting of the Pacific Dermatologic Association.
The researchers set out to determine the predictive value of mitotic rate (the number of cells undergoing cell division) on SLN status, particularly when stratified by tumor thickness. They analyzed 990 SLN biopsy procedures performed in Alberta from January 2007 through December 2013, which were pulled from the Cancer Surgery Alberta tumor database and provincial pathology records. The mean age of the patients was 57 years (range, 15-93 years), and 55% were male; 171 records involved thin melanomas.
Overall, 25.4% of SLN biopsies came back positive, including 8.8% of thin melanomas. Among all cases, there was a statistically significant association between a mitotic rate of 1 or higher and a positive SLN biopsy.
However, when the researchers stratified the results by thickness, they found a statistically significant association only between mitotic rate and SLN biopsy positivity in thicker tumors (1-2 mm, P = .01).
Further analysis of factors including age, ulceration, and tumor location showed that MR and thickness measures were not independent, and the potential for MR to predict SLN biopsy positivity declined at lower thickness values.
“Performing sentinel lymph node biopsy in thin melanomas upstaged purely because of the finding of a single mitotic (event) has questionable clinical value,” said Dr. Wat.
The 2010 AJCC guidelines called for upgrading thin tumors with an MR of 1 or higher, or ulceration, to T1b. The new AJCC guidelines restrict the definition of T1b to tumors 0.8-1.0 mm in size with or without ulceration, or tumors 0.8 mm or smaller with ulceration.
“The results really confirm the latest recommendations,” said Nina Botto, MD, of the department of dermatology at the University of California, San Francisco, who chaired the session in which the research was presented.
SLN status remains a useful prognostic indicator, Dr. Wat said, and MR may still be useful for intermediate and thick melanomas.
Dr. Wat and Dr. Botto reported no relevant financial disclosures.
AT PDA 2017
Key clinical point: The results support the latest guidelines, which exclude mitotic rate in the criteria for upstaging thin melanomas.
Major finding: There was no association between mitotic rate and positive sentinel lymph node biopsy results.
Data source: A retrospective analysis of 990 patient records in Alberta, Canada.
Disclosures: Dr. Wat and Dr. Botto reported no relevant financial disclosures.
Bar soaps may be better than body washes for contact dermatitis patients
SAN FRANCISCO – Chronic contact dermatitis often is tied to hidden allergens found in shampoos, soaps, and body washes, according to Cory Dunnick, MD.“A lot of patients who get referred to my patch test clinic will have chronic dermatitis that isn’t responding to treatment or is worsening despite treatment, or they present with a pattern that is suggestive of contact dermatitis,” she said in an interview.
There is also a common perception that liquid body washes are better than bar soaps because they may be more moisturizing, but the results of a recently published study suggest otherwise, Dr. Dunnick of the department of dermatology at the University of Colorado at Denver, Aurora, said at the annual meeting of the Pacific Dermatologic Association.
Dr. Dunnick was one of the investigators in a study that compared ingredients in the top-selling 50 bar soaps and 50 body washes on Amazon.com to determine if there was a difference with respect to allergen content. They obtained the ingredients list for all the products and compared them with the American Contact Dermatitis Society Core Allergen Series. Counter to the common belief, results of the study indicated that liquid soaps were likely the worse choice for sensitive patients: They contained far more preservative and surfactant allergens than bar soaps, and there was no difference in fragrance content between the two classes (Dermatitis. 2017 May 23. doi: 10.1097/DER.0000000000000289).
Of the 50 liquid soaps, 44 had one or more preservative allergens, compared with none of the bar soaps (P less than .001), and 34 had at least one surfactant allergen, compared with seven of the bar soaps (P less than .001). Forty-eight body washes had fragrance, as did 47 of the bar soaps.
The most common allergens in body washes were methylisothiazolinone (19 of 50), quaternium-15 (16), sodium benzoate (15), methylchloroisothiazolinone/methylisothiazolinone (12), DMDM hydantoin (10), and phenoxyethanol (9). None of these allergens appeared in any of the bar soaps.
“If you have a patient who you suspect has a contact allergy to a preservative or surfactant ingredient, then you can recommend perhaps switching to a bar soap, maybe one that is fragrance free,” advised Dr. Dunnick.
The most common allergen they found in body washes, methylisothiazolinone (MI), is becoming an increasing concern, she said. It has been around for many years but became more prevalent when the Food and Drug Administration decided in 2005 to allow higher concentrations of MI to be used in skin care products. “It’s a pretty strong sensitizer. As a result, we’re seeing a lot more allergy,” she noted.
This soap/body-wash allergen study sends a clear message to dermatologists to individualize recommendations, she said. “A lot of dermatologists recommend what they think are mild soaps, but they don’t necessarily think about what contact allergens might be in those soaps, so maybe they need to make more specific recommendations. They might recommend Dove soap,” but there are different Dove soaps, she pointed out.
A bigger challenge is finding a shampoo for sensitive patients. Almost all contain fragrances, and MI is an ingredient in many shampoos as well. Dr. Dunnick has found the DHS brand, which is fragrance free, to be helpful in some cases, and the Nonscents brand, also fragrance free, is sometimes recommended as safe.
But, in the end, recommendations must be individualized for the patient’s specific allergies, and that requires a thorough work-up. “You don’t know what they are unless you do the patch test,” she said.
Dr. Dunnick reported having no relevant financial disclosures.
SAN FRANCISCO – Chronic contact dermatitis often is tied to hidden allergens found in shampoos, soaps, and body washes, according to Cory Dunnick, MD.“A lot of patients who get referred to my patch test clinic will have chronic dermatitis that isn’t responding to treatment or is worsening despite treatment, or they present with a pattern that is suggestive of contact dermatitis,” she said in an interview.
There is also a common perception that liquid body washes are better than bar soaps because they may be more moisturizing, but the results of a recently published study suggest otherwise, Dr. Dunnick of the department of dermatology at the University of Colorado at Denver, Aurora, said at the annual meeting of the Pacific Dermatologic Association.
Dr. Dunnick was one of the investigators in a study that compared ingredients in the top-selling 50 bar soaps and 50 body washes on Amazon.com to determine if there was a difference with respect to allergen content. They obtained the ingredients list for all the products and compared them with the American Contact Dermatitis Society Core Allergen Series. Counter to the common belief, results of the study indicated that liquid soaps were likely the worse choice for sensitive patients: They contained far more preservative and surfactant allergens than bar soaps, and there was no difference in fragrance content between the two classes (Dermatitis. 2017 May 23. doi: 10.1097/DER.0000000000000289).
Of the 50 liquid soaps, 44 had one or more preservative allergens, compared with none of the bar soaps (P less than .001), and 34 had at least one surfactant allergen, compared with seven of the bar soaps (P less than .001). Forty-eight body washes had fragrance, as did 47 of the bar soaps.
The most common allergens in body washes were methylisothiazolinone (19 of 50), quaternium-15 (16), sodium benzoate (15), methylchloroisothiazolinone/methylisothiazolinone (12), DMDM hydantoin (10), and phenoxyethanol (9). None of these allergens appeared in any of the bar soaps.
“If you have a patient who you suspect has a contact allergy to a preservative or surfactant ingredient, then you can recommend perhaps switching to a bar soap, maybe one that is fragrance free,” advised Dr. Dunnick.
The most common allergen they found in body washes, methylisothiazolinone (MI), is becoming an increasing concern, she said. It has been around for many years but became more prevalent when the Food and Drug Administration decided in 2005 to allow higher concentrations of MI to be used in skin care products. “It’s a pretty strong sensitizer. As a result, we’re seeing a lot more allergy,” she noted.
This soap/body-wash allergen study sends a clear message to dermatologists to individualize recommendations, she said. “A lot of dermatologists recommend what they think are mild soaps, but they don’t necessarily think about what contact allergens might be in those soaps, so maybe they need to make more specific recommendations. They might recommend Dove soap,” but there are different Dove soaps, she pointed out.
A bigger challenge is finding a shampoo for sensitive patients. Almost all contain fragrances, and MI is an ingredient in many shampoos as well. Dr. Dunnick has found the DHS brand, which is fragrance free, to be helpful in some cases, and the Nonscents brand, also fragrance free, is sometimes recommended as safe.
But, in the end, recommendations must be individualized for the patient’s specific allergies, and that requires a thorough work-up. “You don’t know what they are unless you do the patch test,” she said.
Dr. Dunnick reported having no relevant financial disclosures.
SAN FRANCISCO – Chronic contact dermatitis often is tied to hidden allergens found in shampoos, soaps, and body washes, according to Cory Dunnick, MD.“A lot of patients who get referred to my patch test clinic will have chronic dermatitis that isn’t responding to treatment or is worsening despite treatment, or they present with a pattern that is suggestive of contact dermatitis,” she said in an interview.
There is also a common perception that liquid body washes are better than bar soaps because they may be more moisturizing, but the results of a recently published study suggest otherwise, Dr. Dunnick of the department of dermatology at the University of Colorado at Denver, Aurora, said at the annual meeting of the Pacific Dermatologic Association.
Dr. Dunnick was one of the investigators in a study that compared ingredients in the top-selling 50 bar soaps and 50 body washes on Amazon.com to determine if there was a difference with respect to allergen content. They obtained the ingredients list for all the products and compared them with the American Contact Dermatitis Society Core Allergen Series. Counter to the common belief, results of the study indicated that liquid soaps were likely the worse choice for sensitive patients: They contained far more preservative and surfactant allergens than bar soaps, and there was no difference in fragrance content between the two classes (Dermatitis. 2017 May 23. doi: 10.1097/DER.0000000000000289).
Of the 50 liquid soaps, 44 had one or more preservative allergens, compared with none of the bar soaps (P less than .001), and 34 had at least one surfactant allergen, compared with seven of the bar soaps (P less than .001). Forty-eight body washes had fragrance, as did 47 of the bar soaps.
The most common allergens in body washes were methylisothiazolinone (19 of 50), quaternium-15 (16), sodium benzoate (15), methylchloroisothiazolinone/methylisothiazolinone (12), DMDM hydantoin (10), and phenoxyethanol (9). None of these allergens appeared in any of the bar soaps.
“If you have a patient who you suspect has a contact allergy to a preservative or surfactant ingredient, then you can recommend perhaps switching to a bar soap, maybe one that is fragrance free,” advised Dr. Dunnick.
The most common allergen they found in body washes, methylisothiazolinone (MI), is becoming an increasing concern, she said. It has been around for many years but became more prevalent when the Food and Drug Administration decided in 2005 to allow higher concentrations of MI to be used in skin care products. “It’s a pretty strong sensitizer. As a result, we’re seeing a lot more allergy,” she noted.
This soap/body-wash allergen study sends a clear message to dermatologists to individualize recommendations, she said. “A lot of dermatologists recommend what they think are mild soaps, but they don’t necessarily think about what contact allergens might be in those soaps, so maybe they need to make more specific recommendations. They might recommend Dove soap,” but there are different Dove soaps, she pointed out.
A bigger challenge is finding a shampoo for sensitive patients. Almost all contain fragrances, and MI is an ingredient in many shampoos as well. Dr. Dunnick has found the DHS brand, which is fragrance free, to be helpful in some cases, and the Nonscents brand, also fragrance free, is sometimes recommended as safe.
But, in the end, recommendations must be individualized for the patient’s specific allergies, and that requires a thorough work-up. “You don’t know what they are unless you do the patch test,” she said.
Dr. Dunnick reported having no relevant financial disclosures.
AT PDA 2017
Diagnosing high-risk keratinocyte carcinomas in the dermatology clinic
SAN FRANCISCO – Patients with high-risk keratinocyte carcinomas sometimes present with neurologic symptoms mimicking Bell’s palsy or trigeminal neuralgia, making the diagnosis of these perineural tumors challenging, Siegrid Yu, MD, said at the annual meeting of the Pacific Dermatologic Association.
Eventually, skin manifestations can land them in a dermatologist’s office. “There is a high incidence of delayed diagnosis and misdiagnosis, which affects the outcome of these patients,” said Dr. Yu of the department of dermatology, University of California, San Francisco.
She presented several cases illustrating the central role that dermatologists can play in the diagnosis and management of high-risk keratinocyte carcinomas. “All of these patients were seen by various doctors, sometimes multiple times, without a diagnosis,” she said.
Perineural invasion occurs in 2.6%-6% of squamous cell carcinoma (SCC) cases and 2% of basal cell carcinoma (BCC) cases. “Perineural invasion presenting with neurologic symptoms is not that common, which is part of why I think it’s easy to misdiagnose these patients,” said Dr. Yu, director of the Mohs Micrographic Surgery and Cutaneous Oncology Fellowship at the UCSF Dermatologic Surgery and Laser Center. In many cases, patients were diagnosed as having Bell’s palsy or trigeminal neuralgia for years before being diagnosed with skin cancer.
Common features of perineural invasion cases include midface location of the tumor, male gender, tumor size larger than 2 cm, recurrence, and poor histologic differentiation. Symptoms often include formication, pain, numbness, and facial weakness. Diagnosis is often delayed by 6 months to 2 years.
One case she described involved a 57-year-old immunosuppressed man who had previously undergone Mohs micrographic surgery for a primary SCC of the nasal sidewall. He experienced delayed numbness and pain of the upper lip and cheek near the surgical site 1 year later. There was no sign of cutaneous recurrence, and MRIs of the head and neck were normal. Examinations by dermatologists, neurologists, and otorhinolaryngologists yielded no diagnosis.
Two years after his initial surgery, the patient developed thickening of the scar from the Mohs surgery, without any overlying skin change. A punch biopsy showed only scar tissue, but a deeper incisional biopsy revealed a recurrence of the SCC. A second head/neck MRI, using a perineural protocol, showed abnormal enhancement at the V2 branch of the trigeminal nerve leading to the foramen rotundum. The patient underwent intensity-modulated radiation, which relies on computer-modeling to deliver doses to the precise location of the tumor. An MRI 2 months later showed a reduction in tumor size and radiographic resolution of trigeminal nerve involvement.
Another case involved a 75-year-old man with progressive right facial droop, who had experienced neurologic symptoms on the right side of his face, including numbness, tingling, oculomotor dysfunction, and radiating pain. He had been diagnosed with shingles on the right side of his face more than 20 years previously, but there was no history of postherpetic neuralgia. He also had hypertension and hypothyroidism, and had been prescribed levothyroxine, amlodipine, losartan, and gabapentin.
He had been evaluated by primary care, dermatology, and ophthalmology with no diagnosis. He then sequentially sought the opinion of four neurologists, and underwent lumbar puncture, serologic evaluation, head CT, and MRI with no findings that correlated with his symptoms. The patient’s neurological symptoms improved transiently with prednisone, and his pain improved slightly with gabapentin.
Finally, a skin biopsy of an ill-defined firmness in the right temple revealed infiltrative SCC. A repeat MRI, this time with perineural protocol, showed perineural spread along the trigeminal nerve, with involvement of the V2 and V3 branches, and possibly the V1 branch.
In another case, complete hemifacial palsy due to perineural spread of SCC was overlooked as having been related to the patient’s history of stroke. However, upon further questioning, the facial palsy involved all branches of the facial nerve, while the patient’s residual stroke symptoms of expressive aphasia and dysphagia were improving. “If you think about head and neck anatomy, an upper motor neuron lesion would not lead to complete facial nerve palsy. It could lead to palsy of the lower two-thirds of the face, sparing the temporal nerve due to cross innervation of the forehead. Only a lower motor neuron can result in progressive palsy of all branches of the facial nerve,” Dr. Yu said. In this case, the facial palsy was due to a large SCC of the external auditory canal.
Dr. Yu highlighted several considerations to keep in mind when examining these patients, including vigilance around prior skin cancer surgeries in cases with neurologic symptoms, the potential need for repeated imaging along with communication with the radiologist regarding suspicion of perineural spread, consideration of anatomy during the clinical exam, and correlation of clinical exam, histopathology, and radiographic findings.
When it comes to imaging, MRI is the most sensitive technique, she noted. It can show increase in nerve diameter, destruction of the nerve-blood barrier, obliteration of the fat below a foramen, nerve enhancement, and denervation atrophy.
Dr. Yu reported having no financial disclosures.
SAN FRANCISCO – Patients with high-risk keratinocyte carcinomas sometimes present with neurologic symptoms mimicking Bell’s palsy or trigeminal neuralgia, making the diagnosis of these perineural tumors challenging, Siegrid Yu, MD, said at the annual meeting of the Pacific Dermatologic Association.
Eventually, skin manifestations can land them in a dermatologist’s office. “There is a high incidence of delayed diagnosis and misdiagnosis, which affects the outcome of these patients,” said Dr. Yu of the department of dermatology, University of California, San Francisco.
She presented several cases illustrating the central role that dermatologists can play in the diagnosis and management of high-risk keratinocyte carcinomas. “All of these patients were seen by various doctors, sometimes multiple times, without a diagnosis,” she said.
Perineural invasion occurs in 2.6%-6% of squamous cell carcinoma (SCC) cases and 2% of basal cell carcinoma (BCC) cases. “Perineural invasion presenting with neurologic symptoms is not that common, which is part of why I think it’s easy to misdiagnose these patients,” said Dr. Yu, director of the Mohs Micrographic Surgery and Cutaneous Oncology Fellowship at the UCSF Dermatologic Surgery and Laser Center. In many cases, patients were diagnosed as having Bell’s palsy or trigeminal neuralgia for years before being diagnosed with skin cancer.
Common features of perineural invasion cases include midface location of the tumor, male gender, tumor size larger than 2 cm, recurrence, and poor histologic differentiation. Symptoms often include formication, pain, numbness, and facial weakness. Diagnosis is often delayed by 6 months to 2 years.
One case she described involved a 57-year-old immunosuppressed man who had previously undergone Mohs micrographic surgery for a primary SCC of the nasal sidewall. He experienced delayed numbness and pain of the upper lip and cheek near the surgical site 1 year later. There was no sign of cutaneous recurrence, and MRIs of the head and neck were normal. Examinations by dermatologists, neurologists, and otorhinolaryngologists yielded no diagnosis.
Two years after his initial surgery, the patient developed thickening of the scar from the Mohs surgery, without any overlying skin change. A punch biopsy showed only scar tissue, but a deeper incisional biopsy revealed a recurrence of the SCC. A second head/neck MRI, using a perineural protocol, showed abnormal enhancement at the V2 branch of the trigeminal nerve leading to the foramen rotundum. The patient underwent intensity-modulated radiation, which relies on computer-modeling to deliver doses to the precise location of the tumor. An MRI 2 months later showed a reduction in tumor size and radiographic resolution of trigeminal nerve involvement.
Another case involved a 75-year-old man with progressive right facial droop, who had experienced neurologic symptoms on the right side of his face, including numbness, tingling, oculomotor dysfunction, and radiating pain. He had been diagnosed with shingles on the right side of his face more than 20 years previously, but there was no history of postherpetic neuralgia. He also had hypertension and hypothyroidism, and had been prescribed levothyroxine, amlodipine, losartan, and gabapentin.
He had been evaluated by primary care, dermatology, and ophthalmology with no diagnosis. He then sequentially sought the opinion of four neurologists, and underwent lumbar puncture, serologic evaluation, head CT, and MRI with no findings that correlated with his symptoms. The patient’s neurological symptoms improved transiently with prednisone, and his pain improved slightly with gabapentin.
Finally, a skin biopsy of an ill-defined firmness in the right temple revealed infiltrative SCC. A repeat MRI, this time with perineural protocol, showed perineural spread along the trigeminal nerve, with involvement of the V2 and V3 branches, and possibly the V1 branch.
In another case, complete hemifacial palsy due to perineural spread of SCC was overlooked as having been related to the patient’s history of stroke. However, upon further questioning, the facial palsy involved all branches of the facial nerve, while the patient’s residual stroke symptoms of expressive aphasia and dysphagia were improving. “If you think about head and neck anatomy, an upper motor neuron lesion would not lead to complete facial nerve palsy. It could lead to palsy of the lower two-thirds of the face, sparing the temporal nerve due to cross innervation of the forehead. Only a lower motor neuron can result in progressive palsy of all branches of the facial nerve,” Dr. Yu said. In this case, the facial palsy was due to a large SCC of the external auditory canal.
Dr. Yu highlighted several considerations to keep in mind when examining these patients, including vigilance around prior skin cancer surgeries in cases with neurologic symptoms, the potential need for repeated imaging along with communication with the radiologist regarding suspicion of perineural spread, consideration of anatomy during the clinical exam, and correlation of clinical exam, histopathology, and radiographic findings.
When it comes to imaging, MRI is the most sensitive technique, she noted. It can show increase in nerve diameter, destruction of the nerve-blood barrier, obliteration of the fat below a foramen, nerve enhancement, and denervation atrophy.
Dr. Yu reported having no financial disclosures.
SAN FRANCISCO – Patients with high-risk keratinocyte carcinomas sometimes present with neurologic symptoms mimicking Bell’s palsy or trigeminal neuralgia, making the diagnosis of these perineural tumors challenging, Siegrid Yu, MD, said at the annual meeting of the Pacific Dermatologic Association.
Eventually, skin manifestations can land them in a dermatologist’s office. “There is a high incidence of delayed diagnosis and misdiagnosis, which affects the outcome of these patients,” said Dr. Yu of the department of dermatology, University of California, San Francisco.
She presented several cases illustrating the central role that dermatologists can play in the diagnosis and management of high-risk keratinocyte carcinomas. “All of these patients were seen by various doctors, sometimes multiple times, without a diagnosis,” she said.
Perineural invasion occurs in 2.6%-6% of squamous cell carcinoma (SCC) cases and 2% of basal cell carcinoma (BCC) cases. “Perineural invasion presenting with neurologic symptoms is not that common, which is part of why I think it’s easy to misdiagnose these patients,” said Dr. Yu, director of the Mohs Micrographic Surgery and Cutaneous Oncology Fellowship at the UCSF Dermatologic Surgery and Laser Center. In many cases, patients were diagnosed as having Bell’s palsy or trigeminal neuralgia for years before being diagnosed with skin cancer.
Common features of perineural invasion cases include midface location of the tumor, male gender, tumor size larger than 2 cm, recurrence, and poor histologic differentiation. Symptoms often include formication, pain, numbness, and facial weakness. Diagnosis is often delayed by 6 months to 2 years.
One case she described involved a 57-year-old immunosuppressed man who had previously undergone Mohs micrographic surgery for a primary SCC of the nasal sidewall. He experienced delayed numbness and pain of the upper lip and cheek near the surgical site 1 year later. There was no sign of cutaneous recurrence, and MRIs of the head and neck were normal. Examinations by dermatologists, neurologists, and otorhinolaryngologists yielded no diagnosis.
Two years after his initial surgery, the patient developed thickening of the scar from the Mohs surgery, without any overlying skin change. A punch biopsy showed only scar tissue, but a deeper incisional biopsy revealed a recurrence of the SCC. A second head/neck MRI, using a perineural protocol, showed abnormal enhancement at the V2 branch of the trigeminal nerve leading to the foramen rotundum. The patient underwent intensity-modulated radiation, which relies on computer-modeling to deliver doses to the precise location of the tumor. An MRI 2 months later showed a reduction in tumor size and radiographic resolution of trigeminal nerve involvement.
Another case involved a 75-year-old man with progressive right facial droop, who had experienced neurologic symptoms on the right side of his face, including numbness, tingling, oculomotor dysfunction, and radiating pain. He had been diagnosed with shingles on the right side of his face more than 20 years previously, but there was no history of postherpetic neuralgia. He also had hypertension and hypothyroidism, and had been prescribed levothyroxine, amlodipine, losartan, and gabapentin.
He had been evaluated by primary care, dermatology, and ophthalmology with no diagnosis. He then sequentially sought the opinion of four neurologists, and underwent lumbar puncture, serologic evaluation, head CT, and MRI with no findings that correlated with his symptoms. The patient’s neurological symptoms improved transiently with prednisone, and his pain improved slightly with gabapentin.
Finally, a skin biopsy of an ill-defined firmness in the right temple revealed infiltrative SCC. A repeat MRI, this time with perineural protocol, showed perineural spread along the trigeminal nerve, with involvement of the V2 and V3 branches, and possibly the V1 branch.
In another case, complete hemifacial palsy due to perineural spread of SCC was overlooked as having been related to the patient’s history of stroke. However, upon further questioning, the facial palsy involved all branches of the facial nerve, while the patient’s residual stroke symptoms of expressive aphasia and dysphagia were improving. “If you think about head and neck anatomy, an upper motor neuron lesion would not lead to complete facial nerve palsy. It could lead to palsy of the lower two-thirds of the face, sparing the temporal nerve due to cross innervation of the forehead. Only a lower motor neuron can result in progressive palsy of all branches of the facial nerve,” Dr. Yu said. In this case, the facial palsy was due to a large SCC of the external auditory canal.
Dr. Yu highlighted several considerations to keep in mind when examining these patients, including vigilance around prior skin cancer surgeries in cases with neurologic symptoms, the potential need for repeated imaging along with communication with the radiologist regarding suspicion of perineural spread, consideration of anatomy during the clinical exam, and correlation of clinical exam, histopathology, and radiographic findings.
When it comes to imaging, MRI is the most sensitive technique, she noted. It can show increase in nerve diameter, destruction of the nerve-blood barrier, obliteration of the fat below a foramen, nerve enhancement, and denervation atrophy.
Dr. Yu reported having no financial disclosures.
AT PDA 2017