Neumann, H.A.M.

Treatment of frontal fibrosing alopecia and lichen planopilaris: A systematic review (Article)

2013-03-29T00:00:00Z

Frontal fibrosing alopecia (FFA) is a primary lymphocytic cicatricial alopecia with characteristic clinical pattern of progressive frontotemporal hairline recession, perifollicular erythema and hyperkeratosis and symptoms of itch and burning, occurring mainly in post-menopausal women. FFA is considered a subtype of lichen planopilaris (LPP), based on their identical histopathology. Currently, no evidence-based treatment is available for FFA. Our aim was to determine the effectiveness of available treatment options for FFA, and to identify promising treatment options for future studies. For this, literature search was conducted to find all primary studies on the treatment of FFA and LPP. From the primary studies, data were subtracted and analysed. No randomized controlled trials were found, and one controlled trial. Treatment of 114 patients is described in the literature. They received 10 different regimes, of which oral 5-alpha-reductase inhibitors were provided most often, resulting in good clinical response in 45% of them. Hydroxychloroquine resulted in good clinical response in 30% of the 29 treated patients. Topical corticosteroid preparations are ineffective in FFA. The remaining treatments were all reported in less than 10 patients. For the treatment of LPP, topical corticosteroid preparations are the first line of treatment, followed by oral cyclosporine and systemic corticosteroids, although they are characterized by a high relapse rate. Summarizing, there is currently no effective treatment of FFA, the most effective being oral 5-alpha-reductase inhibitors that possibly affect the accompanying androgenetic alopecia. We argue that oral cyclosporine A might be a good candidate for future studies on the treatment of FFA.

Oculocutaneous albinism and skin cancer risk (Article)

2013-03-01T00:00:00Z

Risk of second primary in situ and invasive melanoma in a Dutch population-based cohort: 1989-2008 (Article)

2012-12-01T00:00:00Z

Background Patients with melanoma are at increased risk of developing a subsequent melanoma. Objectives To estimate the risks of developing a second primary in situ or invasive cutaneous melanoma after a first melanoma, between 1989 and 2008. Methods Patients were followed until diagnosis of a second melanoma, date of death or end of study. Cumulative risks, standardized incidence ratio (SIR, observed second melanomas divided by background age-, calendar- and sex-specific incidence rates of melanoma, as recorded in the Netherlands Cancer Registry) and absolute excess risk (AER, observed minus expected per 10 000 person-years) of second melanomas were calculated. Results In total, 10 765 patients with in situ melanoma and 46 700 with invasive melanoma were included. The cumulative risks of a second invasive melanoma after a first in situ or invasive melanoma at 20 years of follow-up were 6·2% and 5·0%, respectively. The relative risk of developing any melanoma (in situ or invasive) after any first melanoma (measured as SIR) varied from 12·4-fold [invasive after invasive melanoma; 95% confidence interval (CI) = 11·6-13·2] to 26·4-fold (in situ after in situ melanoma; 95% CI = 22·6-30·7) increase compared with the general population. SIRs and AERs remained elevated up to 20 years after the first melanoma. Conclusions This study shows significantly increased long-term risks (both relative and absolute) of developing a second invasive melanoma after a first melanoma (invasive and in situ), and might serve as a basis for follow-up guidelines. © 2012 The Authors. BJD

The influence of the location of the lesion on the absolute risk of the development of skin cancer in a patient with actinic keratosis (Article)

2012-10-16T00:00:00Z

The objective of this paper is to answer the clinical question whether the location of the lesion in an individual patient with actinic keratosis (AK) influences the absolute risk of the development of skin cancer. Between 0.025% and 16% of AK lesions advance towards squamous cell carcinoma per year. It is not well known whether this risk differs between locations on the body. A systematic search of available literature resulted in seven articles of which the two highest scoring on relevance and validity were selected. These two studies indicate that the absolute risk on the development of skin cancer in patients with AK differs between locations of the lesion and that time to progression from AK to squamous cell carcinoma is not different among the locations of the lesions. However, both studies have very limited sample sizes. © 2012 The Authors. Journal of the European Academy of Dermatology and Venereology

Mohs micrographic surgery for basal cell carcinomas: Appropriateness of 'Rotterdam' criteria and predictive factors for three or more stages (Article)

2012-10-10T00:00:00Z

Background In the Netherlands basal cell carcinomas (BCC) are eligible for Mohs microscopic surgery (MMS) if certain criteria are fulfilled. Objective To study the MMS indication criteria practised at the department of dermatology of the Erasmus University Medical Center, Rotterdam and to identify predictive factors for extensive subclinical tumour spread among BCCs eligible for MMS. Methods Pre-operative patient and tumour characteristics were derived retrospectively between January 2nd 2006 and December 28th 2009 from 1174 patient records, accounting for 1464 BCCs. Multivariate logistic regression models were used to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for one vs. two or more stages and for narrow (≤2 stages) vs. extensive subclinical spread (≥3 stages). Results H-zone location [adjusted OR 1.51 (95% CI 1.16-1.96)], recurrent tumour [adjusted OR 1.50 (95% CI 1.11-2.02)], aggressive subtype [adjusted OR 1.25 (95% CI 1.01-1.56)] and tumour size ≥11mm [adjusted OR 1.53 (95% CI 1.20-1.96)] were significantly associated with two or more stages. Predictive factors for extensive subclinical spread were recurrent tumour [adjusted OR 2.26 (95% CI 1.61-3.17)], tumour size ≥21mm [adjusted OR 1.69 (95% CI 1.13-2.51)] and location in the H-zone [adjusted OR 1.68 (95% CI 1.15-2.46)]. Conclusion 'Rotterdam' indication criteria used for MMS are appropriate. Predictors for extensive subclinical spread are important for patients' and surgeons' expectations prior to the operation about time span, defect size, reconstruction and possible associated morbidity. © 2012 The Authors. Journal of the European Academy of Dermatology and Venereology

The skin-blanching assay (Article)

2012-10-01T00:00:00Z

The skin-blanching assay is used for the determination and bioequivalence of dermatologic glucocorticoids (GCs). The exact mechanism of the production of blanching is not fully understood, but it is considered that local vasoconstriction of the skin microvasculature and the consequent blood-flow reduction cause this phenomenon. Several factors influence skin blanching, including drug concentration, duration of application, nature of vehicle, occlusion, posture and location. The intensity of vasoconstriction can be measured in several ways: visual or quantitative methods, such as reflectance spectroscopy, thermography, laser Doppler velocimetry and chromametry. In literature, contradicting results in the correlation of the skin-blanching assay with different tests to determine GC sensitivity have been reported, limiting its clinical usefulness. © 2012 The Authors. Journal of the European Academy of Dermatology and Venereology

Duplication of the great saphenous vein: A definition problem and implications for therapy (Article)

2012-01-01T00:00:00Z

BACKGROUND: In the literature there is a range from 1% to 20% of duplication (up to 20%) of the great saphenous vein (GSV) reported, because there is a lack of an accurate definition of the GSV and objective parameters for an anatomical identification. OBJECTIVE: To investigate the frequency of true duplications of the GSV. MATERIALS AND METHODS: A systematic review of the literature, a retrospective analysis of duplex examinations, and a prospective study of duplex examinations to investigate the frequency of true duplications of the GSV. RESULTS: In the literature review, a great variety of definitions is used for duplication of the GSV. Before the consensus of the Union International de Phlébologie (UIP) in 2006, Only in a small number of studies, the definition of the GSV in the saphenous compartment between the fascial blades is mentioned. CONCLUSION: Phlebographic studies have been the criterion standard for the identification of venous anatomy. Now, duplex is regarded as the criterion standard for accurate detection of the veins. True duplication of the GSV is less common than the previous literature has suggested, namely 1.6% to 2%. It is recommended that the duplicated GSV should be treated to avoid an important risk of recurrence of venous insufficiency.

What's new in veins? (Article)

2011-12-01T00:00:00Z

Reflux cannot be interpreted without knowledge of the function of the calf muscle pump. The presence or absence of reflux alone has an insufficient predictive value for excellent functional treatment results. Valves are not simple moving slips but have an autonomous 4-step cycle movement that helps the calf muscle pump to be very effective. New calculations of the Starling equilibrium have shown that capillary filtration fraction returns mainly by the lymphatics. All these new findings help the phlebologist design a more precise and thus better treatment plan in phlebology practice.

Melanoma patients receive more follow-up care than current guideline recommendations: A study of 546 patients from the general Dutch population (Article)

2011-11-01T00:00:00Z

Background Follow-up of melanoma patients has been a continuing issue for discussion in the past years partly due to ever increasing incidence of this disease, as well as the lack of agreement regarding the reasons for, and the frequency of follow-up. Patients' perspectives are often not included in this continuing discussion on follow-up of melanoma patients. Objective To examine to what extent follow-up was experienced, according to the guideline of 2005, by physicians and melanoma patients in a Dutch population from the south-east area of the Netherlands. The patient's perspective and satisfaction over said follow-up shall also be taken into account. Methods Follow-up among melanoma survivors was investigated and compared with the recommendations of the current Dutch national guideline. All 699 melanoma patients registered at the Eindhoven Cancer Registry (between 1998 and 2008), and treated in 3 regional hospitals, were contacted via postal mail. The survey questioned about treatment, symptoms, impact on daily life and follow-up. Patients with multiple melanomas (n=16) were excluded. Results Response rate was 80%, 418 patients were still under surveillance for their melanoma. The average time since diagnoses was 4years, 71% had stage I melanoma. Almost 80% of patients with a Breslow thickness <1mm, reported more frequent follow-up visits than the guideline recommends. Only 5% of the patients wanted to reduce their follow-up frequency. Eighty percent of patients were under supervision of a dermatologist: physical examination (25%), lymph node palpation (11%) and/or scar inspection (20%) did not regularly occur. These proportions were significantly higher among other specialism. Conclusion Follow-up frequency was higher than recommended by the current melanoma guideline in a large group of patients, mainly those with lower Breslow thickness. © 2011 The Authors. Journal of the European Academy of Dermatology and Venereology

Monitoring blood volume and saturation using superficial fibre optic reflectance spectroscopy during PDT of actinic keratosis (Article)

2011-10-01T00:00:00Z

Optically monitoring the vascular physiology during photodynamic therapy (PDT) may help understand patient-specific treatment outcome. However, diffuse optical techniques have failed to observe changes herein, probably by optically sampling too deep. Therefore, we investigated using differential path-length spectroscopy (DPS) to obtain superficial measurements of vascular physiology in actinic keratosis (AK) skin. The AK-specific DPS interrogation depth was chosen up to 400 microns in depth, based on the thickness of AK histology samples. During light fractionated aminolevulinic acid-PDT, reflectance spectra were analyzed to yield quantitative estimates of blood volume and saturation. Blood volume showed significant lesion-specific changes during PDT without a general trend for all lesions and saturation remained high during PDT. This study shows that DPS allows optically monitoring the superficial blood volume and saturation during skin PDT. The patient-specific variability supports the need for dosimetric measurements. In DPS, the lesion-specific optimal interrogation depth can be varied based on lesion thickness.

One-stop-shop treatment for basal cell carcinoma, part of a new disease management strategy (Article)

2011-07-22T00:00:00Z

Background The number of skin cancer patients, especially patients with basal cell carcinoma (BCC), is rapidly increasing. Resources available at dermato-oncology units have not increased proportionally, which affects the throughput time of patients. Objective To assess the feasibility and safety of implementation of the one-stop-shop concept for the treatment of patients with BCC at a dermato-oncology unit. Methods A pilot study on a one-stop-shop concept for BCC was performed to investigate procedure safety and patient satisfaction. Fresh frozen sections were used to diagnose the tumours, and subsequently treatment with photodynamic therapy or excision was performed on the same day. Time spent in the hospital was measured and questionnaires were used to evaluate patient satisfaction. Results Sixteen patients, who together had 19 tumours, were included. Diagnoses were made within a mean time of 100min (range 27-160min). The mean throughput time was 4hours and 7min (range 60-420min). No complications were observed, and patient satisfaction was high. Conclusion The one-stop-shop concept for the treatment of skin cancer patients is feasible and efficient for both patients and dermato-oncology units. Further research is necessary to investigate cost-effectiveness when larger patient groups are involved. © 2011 The Authors. Journal of the European Academy of Dermatology and Venereology

Improved hair restoration method for burns (Article)

2011-05-01T00:00:00Z

Background: Extracted partial longitudinal follicular units can be used as complete follicular units to regenerate completely differentiated hair growth. The partial follicular units that remained in the dermis in the donor area can survive and produce hairs. This technique enables us to multiply hair follicles in vivo, while preserving the donor area and therefore is suitable in persons, who have a relative small donor area compared to the recipient area, as in scalp burns. Objectives: With this study, we try to determine if partial longitudinal follicular unit transplantation (PL-FUT) can be used for facial and/or scalp burns. Materials and methods: Four burn victims (age 22-39 years, mean 27.75 years) were treated in the face (eyebrows, and beard) and/or on the scalp with PL-FUT. The grafts were harvested with hollow wave-tipped needles with an inner diameter of 0.6 mm from the occipital area of the scalp. The suitable longitudinal partial follicular units were impregnated with a preservative medium, and implanted into the recipient area. Hair growth in the donor area as well as the recipient area was observed before treatment, and at intervals of 1 week, 3 months and 1 year after the treatment. Results: After evaluation of the donor area, sometimes a few little white spots were visible, but almost all hair follicles in the donor site re-produce hairs after 2 years. All treated patients had satisfactory or very satisfactory cosmetic results in the treated area. Conclusions: Longitudinal partial follicular unit transplantation (LP-FUT) may represent the first reliable patient-friendly method to generate two hair follicles from one hair follicle with consistent results and preservation of the donor area. Therefore, this method is very suitable for people with facial and/or scalp burns.

A longitudinal study of changes in provider-patient interaction in treatment of localized prostate cancer (Article)

2011-04-11T00:00:00Z

Purpose: Whilst much is known as to the met and unmet communication needs of prostate cancer patients, few studies have been conducted on the changes in communication between provider and patient over time. Therefore, the aim of our study is to examine (a) whether there are changes over time in the quality of psychosocial care in long-term treatment of localized prostate cancer and (b) whether those changes are associated with the treatment decision. Methods: HAROW is a prospective, observational study designed to collect clinical data and patient reported outcomes (PROs) of different treatment options (hormonal therapy, active surveillance, radiation, operation, watchful waiting) for newly diagnosed patients with localized prostate cancer under real conditions. At 6-month intervals, general clinical data, PROs (e.g. quality of life, quality of physician-patient interaction) and individual costs are documented. We analysed data of N = 1,216 patients at the time of initial diagnosis (T1) and after 6 months (T2). Results: There is a significant decline in shared decision-making behaviour of physicians for the group of patients undergoing a prostatectomy and for the hormonal therapy group at the time of initial diagnosis and after 6 months. In terms of emotional support by physicians, there is a significant difference between the treatment groups at the time of initial diagnosis with patients undergoing a prostatectomy reporting significantly less support than the hormonal therapy group. Conclusion: Future research from both, the providers' and the patients' perspective, will have to clarify if we can interpret our results as change in the communication behaviour once the treatment decision for prostatectomy or hormonal therapy is made.

Laser fibre stabs the catheter: A serious complication of endovenous laser ablation (Article)

2011-04-01T00:00:00Z

An 82-year-old woman was treated with endovenous laser ablation for insufficiency of the right great saphenous vein. Because of a very thick layer of subcutaneous fat, puncturing the vein and introducing the laser fibre was difficult. The patient reported pain after activation of the laser. Subsequently, the procedure was discontinued and the catheter was removed. Inspection of the disposables showed that the laser fibre had punctured the catheter and was therefore located outside the lumen. Fortunately, there were no harmful sequelae in this case, but as device-related complications of EVLA are serious, reporting them is important.

Methodological pluralism in health communication research (Article)

2011-03-01T00:00:00Z

Incidence, Prevalence and Future Trends of Primary Basal Cell Carcinoma in the Netherlands (Article)

2011-01-24T00:00:00Z

Abstract: Basal cell carcinoma (BCC) incidence rates are increasing worldwide. This study’s objective was to estimate the occurrence of BCC in the Netherlands in terms of incidence and prevalence. Data on first primary carcinomas were retrieved from the Eindhoven Cancer Registry and extrapolated to the Dutch population. Extrapolated data showed a total of 444,131, histologically confirmed cases in the Netherlands between 1973 and 2008. During this period, age-adjusted incidence rates (European Standard Population) increased approximately three-fold from 40 to 148 per 100,000 in males and from 34 to 141 in females. Lifetime risk of BCC was 1 in 5–6 for Dutch citizens. Disease prevalence in the Netherlands was 1.4% and almost four times higher than this (5.4%) in the oldest age group (age 65 years or more). Predictions of future trends showed no signs of a plateau in the number of cases. These estimates should urge Dutch policymakers to provide solutions for the growing group of patients with BCC.

Proof-of-principle study of steam ablation as novel thermal therapy for saphenous varicose veins (Article)

2011-01-01T00:00:00Z

Introduction During the last decade, thermal ablation techniques such as endovenous laser ablation have been challenging the position of traditional surgery for the treatment of saphenous varicose veins. The newest method of thermal ablation is pulsated steam, which works by heating the vein with steam at 120°C. This study assessed the effectiveness of steam ablation of varicose veins in sheep and in humans. Methods The safety of the procedure in sheep was assessed by cardiovascular monitoring during treatment. We used ultrasound imaging to examine occlusion of the veins. Changes in treated veins were examined microscopically. In a pilot study, 20 veins in 19 patients with insufficiency of the great or the small saphenous vein were treated with pulsated steam ablation. Anatomic success, patient satisfaction, and complications were investigated for 6 months after the procedure. Results All veins in the sheep were occluded. No cardiovascular changes occurred during treatment. Histologic examination of treated veins showed typical changes of the vein wall, such as disappearance of the endothelial layer, fibrotic thrombosis, and major alterations in collagen fibers in the media. Steam ablation was effective in the 19 patients: 13 of 20 veins were completely closed, and 7 showed a very small segment of recanalization after 6 months of follow-up that did not seem to be clinically relevant. Nine patients had some ecchymoses at the puncture site, and one patient had a transient superficial phlebitis. A median maximal pain score of 1 (range, 0-10) was reported. No serious side effects, such as deep vein thrombosis, nerve injury, skin burns, or infections, were reported. Patients were very satisfied with the treatment, with a median satisfaction score of 9.25 (range, 0-10). Conclusions In this proof-of-principle study, pulsated steam ablation was an effective treatment for saphenous varicose veins.

Treatment of vitiligo with khellin liposomes, ultraviolet light and blister roof transplantation (Article)

2011-01-01T00:00:00Z

Background Various surgical and non-surgical methods are available to treat vitiligo. Surgical techniques such as epidermal blister graft transplantation may be effective for the re-pigmentation of stable, but refractory vitiligo areas. Khellin has phototherapeutic properties that are similar to those of the psoralens, but with substantially lower phototoxic effects and DNA mutation effects. Its penetration into the hair follicles is enhanced by encapsulating it into liposomes. Subsequent activation of the khellin with UV light stimulates the melanocytes in the hair follicles. Objective The first objective was to evaluate the additional value of combining blister roof transplantation (BRT) with khellin in liposomes and ultraviolet light (KLUV) in the treatment of recalcitrant vitiligo patches. The second objective was to assess patients' satisfaction. Materials and methods Nineteen patients with vitiligo lesions which did not respond to KLUV treatment for at least a year were treated with BRT followed by KLUV. The transplantation was performed by creating blisters with a suction device, preparing the target site with Erbium laser ablation and the actual transplantation. Locations where randomly assigned. A blinded observer established the results. Results Seventy-five percent of the patients were satisfied with the cosmetic result. All of the patients would recommend the treatment to other vitiligo patients. More than 75% re-pigmentation of the vitiligo areas was noted in 47% of the patients according to the blinded evaluation of photographs taken before and after the treatment.

Assessing the public's preference for surgical treatment of primary basal cell carcinoma: A discrete-choice experiment in the South of the Netherlands (Article)

2010-12-01T00:00:00Z

Background Basal cell carcinoma (BCC) is a slowly growing nonmelanoma type of skin cancer that often is located on the face. Different therapies are available to treat BCC, of which surgical excision (SE) and Mohs micrographic surgery (MMS) are the most frequently used surgical procedures. ObjectiveS To examine which attributes of a surgical treatment the general public values as important and to determine the incremental willingness to pay for MMS versus SE. Methods A discrete-choice experiment (DCE) was conducted among members of the general public to examine which attributes of a surgical treatment for primary BCC are valued as important. In addition, based on the attributes included in the experiment, the willingness to pay for MMS versus SE was determined. Results Respondents (N=312) preferred a treatment with a lower recurrence rate, shorter surgery time, shorter travelling time, shorter waiting time, no risk for re-excision, and lower cost. The incremental willingness to pay for MMS was 847 euro ($1,203). Conclusions Results from this DCE indicate that, when outcome and process attributes are considered from a societal perspective, MMS is preferred over SE for primary BCC.

The heat-pipe resembling action of boiling bubbles in endovenous laser ablation (Article)

2010-11-01T00:00:00Z

Endovenous laser ablation (EVLA) produces boiling bubbles emerging from pores within the hot fiber tip and traveling over a distal length of about 20 mm before condensing. This evaporation-condensation mechanism makes the vein act like a heat pipe, where very efficient heat transport maintains a constant temperature, the saturation temperature of 100°C, over the volume where these non-condensing bubbles exist. During EVLA the above-mentioned observations indicate that a venous cylindrical volume with a length of about 20 mm is kept at 100°C. Pullback velocities of a few mm/s then cause at least the upper part of the treated vein wall to remain close to 100°C for a time sufficient to cause irreversible injury. In conclusion, we propose that the mechanism of action of boiling bubbles during EVLA is an efficient heat-pipe resembling way of heating of the vein wall.

Donor hair follicle preservation by partial follicular unit extraction. A method to optimize hair transplantation (Article)

2010-11-01T00:00:00Z

Background: There are different stem cell pools located in the hair follicle. Objective: To try to determine whether follicular units can survive a partial extraction and whether this partial extracted follicular unit can regenerate new hairs. Methods: From five individuals, between 100 and 150 grafts were harvested from the occipital area of the scalp. Suitable grafts were implanted into the recipient area. Hair growth and characteristics in the donor area and the recipient area were observed at different intervals. Results: After 3 months, between 92.1% and 104.1% (mean 97.7%) of the partial follicular units in the donor sites survived and produced hairs with the same characteristics. After 1 year, 91.1-101.7% (mean 95.9%) of the implanted partial follicular units regenerated hair growth with the same characteristics as the hairs in the donor area. Conclusions: We revealed that extracted partial longitudinal follicular units transplanted to the recipient area can be used as complete follicular units to regenerate completely differentiated hair growth with the same characteristics as in the donor area. We also revealed that the partial follicular units in the donor area can survive and produce the same number of hairs with the same characteristics. This technique enables us to generate two hair follicles from one follicle with consistent results and preserve the donor area.

Use of ultrasound to provide overall information on facial fillers and surrounding tissue (Article)

2010-11-01T00:00:00Z

Background Information on fillers and their behavior over time in the different layers of tissue is limited. Ultrasound may be used to visualize these fillers and their surrounding tissue to broaden knowledge. OBJECTIVE To evaluate the use of ultrasound as a diagnostic and research tool to obtain information on facial fillers and their behavior in human tissue. Methods and Materials Patients with a history of facial filler treatment were examined using ultrasound in an outpatient setting. Results Seventy-two patients were examined. Hydrophilic fillers were echo visible, whereas tissue-generating fillers, permanent and resorbable, could be detected according to their tissue-generating reaction within the tissue. Filler characteristics such as longevity and reaction within the tissue and complications such as migration and granulomas could be visualized. Conclusion The use of ultrasound may provide information to broaden our knowledge of facial fillers and may improve the performance and safety of filler treatments. The authors have indicated no significant interest with commercial supporters.

Fractionated illumination at low fluence rate photodynamic therapy in mice (Article)

2010-09-01T00:00:00Z

Photodynamic therapy (PDT) for actinic field cancerization is effective but painful. Pain mechanisms remain unclear but fluence rate has been shown to be a critical factor. Lower fluence rates also utilize available oxygen more efficiently. We investigated PDT effect in normal SKH1-HR mice using low and high fluence rate aminolevulinic acid (ALA) PDT and a fractionated illumination scheme. Six groups of six mice with different light treatment parameters were studied. Visual skin damage was assessed up to 7 days post-PDT. Fluorescence and reflectance spectroscopy during illuminations provided us with real-time information about protoporphyrin IX (PpIX) photobleaching. A novel dosing approach was introduced in that we used a photobleaching percentage instead of a preset fluence. Data show similar total and maximum damage scores in high and low fluence rate groups. Photobleaching of PpIX in the low fluence rate groups shows a trend toward more efficient photobleaching. Results indicate that low fluence rate PDT is as effective as and more efficient than high fluence rate PDT in normal mouse skin. Low fluence rate PDT light protocols need to be explored in human studies in search for an effective and well-tolerated treatment for actinic field cancerization.

Arteriolosclerotic ulcer of Martorell (Article)

2010-08-01T00:00:00Z

In 1945, Martorell described ischaemic leg ulcers in patients with hypertension. He suggested that the ischaemic necrosis was secondary to a hypertensive arteriolar disease and referred to them as 'hypertensive ischaemic ulcers'. In recent years, the specific entity of these ulcers has been questioned. Others claim they have a much higher incidence, but presume the diagnosis is frequently missed. Almost 900 cases of Martorell's ulcers have been reported in literature since the first description. A systematic review and comprehensive search of literature (evidence-based) was needed to characterize this type of ulcer. Based on aetiology and histopathology, it seems to be justified to maintain the name 'arteriolosclerotic ulcer of Martorell'. We conclude that the arteriolosclerotic ulcer of Martorell is a specific entity with its own clinical and histological diagnostic keys, wound management and preventive measures. We introduce a set of criteria that may be used to facilitate diagnosing arteriolosclerotic ulcer of Martorell as well as a flowchart that includes diagnosis, treatment and prevention of this particular type of vascular leg ulcer.

FUS pathology defines the majority of tau-and TDP-43-negative frontotemporal lobar degeneration (Article)

2010-07-01T00:00:00Z

Through an international consortium, we have collected 37 tau-and TAR DNA-binding protein 43 (TDP-43)-negative frontotemporal lobar degeneration (FTLD) cases, and present here the first comprehensive analysis of these cases in terms of neuropathology, genetics, demographics and clinical data. 92% (34/37) had fused in sarcoma (FUS) protein pathology, indicating that FTLD-FUS is an important FTLD subtype. This FTLD-FUS collection specifically focussed on aFTLD-U cases, one of three recently defined subtypes of FTLD-FUS. The aFTLD-U subtype of FTLD-FUS is characterised clinically by behavioural variant frontotemporal dementia (bvFTD) and has a particularly young age of onset with a mean of 41 years. Further, this subtype had a high prevalence of psychotic symptoms (36% of cases) and low prevalence of motor symptoms (3% of cases). We did not find FUS mutations in any aFTLD-U case. To date, the only subtype of cases reported to have ubiquitin-positive but tau-, TDP-43-and FUS-negative pathology, termed FTLD-UPS, is the result of charged multivesicular body protein 2B gene (CHMP2B) mutation. We identified three FTLD-UPS cases, which are negative for CHMP2B mutation, suggesting that the full complement of FTLD pathologies is yet to be elucidated.

Carbonized blood deposited on fibres during 810, 940 and 1,470 nm Endovenous laser ablation: thickness and absorption by optical coherence tomography (Article)

2010-05-01T00:00:00Z

Endovenous laser ablation (EVLA) is commonly used to treat saphenous varicosities. Very high temperatures at the laser fibre tip have been reported during EVLA. We hypothesized that the laser irradiation deposits a layer of strongly absorbing carbonized blood of very high temperature on the fibre tip. We sought to prove the existence of these layers and study their properties by optical transmission, optical coherence tomography (OCT) and microscopy. We analysed 23 EVLA fibres, 8 used at 810 nm, 7 at 940 nm and 8 at 1,470 nm.We measured the transmission of these fibres in two wavelength bands (450-950 nm; 950-1,650 nm). We used 1,310 nm OCT to assess the thickness of the layers and the attenuation as a function of depth to determine the absorption coefficient. Microscopy was used to view the tip surface. All fibres showed a slightly increasing transmission with wavelength in the 450-950 nm band, and a virtually wavelength-independent transmission in the 950-1,650 nm band. OCT scans showed a thin layer deposited on all 13 fibres investigated, 6 used at 810 nm, 4 at 940 nm and 3 at 1,470 nm, some with inhomogeneities over the tip area. The average absorption coefficient of the 13 layers was 72± 16 mm-1. The average layer thickness estimated from the transmission and absorption measurements was 8.0±2.7 μm. From the OCT data, the average maximal thickness was 26± 6 μm. Microscopy of three fibre tips, one for each EVLA wavelength, showed rough, cracked and sometimes seriously damaged tip surfaces. There was no clear correlation between the properties of the layers and the EVLA parameters such as wavelength, except for a positive correlation between layer thickness and total delivered energy. In conclusion, we found strong evidence that all EVLA procedures in blood filled veins deposit a heavily absorbing hot layer of carbonized blood on the fibre tip, with concomitant tip damage. This major EVLA mechanism is unlikely to have much wavelength dependence at similar delivered energies per centimetre of vein. Optical-thermal interaction between the vein wall and the transmitted laser light depends on wavelength.

Photodynamic therapy of acne vulgaris using 5-aminolevulinic acid 0.5% liposomal spray and intense pulsed light in combination with topical keratolytic agents (Article)

2010-04-01T00:00:00Z

Background Increasing antibiotic resistance of Propionibacterium acnes and growing awareness on the side effects of topical and systemic drugs in the treatment of acne vulgaris by physicians and patients have paved the way for a search into new efficacious and safe treatment modalities such as photodynamic therapy (PDT). Although the efficacy of PDT using 20% 5-aminolevulinic acid (ALA) cream has been established, phototoxic side effects limit its use. The 5-ALA concentration can be lowered by a factor of 40 by changing the vehicle of 5-ALA from a moisturizing cream to liposome encapsulation. Objectives Assessment of the efficacy and the safety of PDT using 5-ALA 0.5% in liposomal spray and intense pulsed light (IPL) in combination with topical peeling agents (Li-PDT-PC) in acne vulgaris. Materials and Methods 32 patients suffering from acne participated in this randomized, prospective, single blind study. All patients were treated with Li-PDT-PC. During the study nine patients were additionally treated with topical or systemic antibiotics (Li-PDT-PC-AT). These patients were removed from the study although their results were recorded. Results After a mean period of 7.8 months and a mean number of 5.7 treatments the mean total number of lesions dropped from 34.6 lesions to 11.0 lesions, resulting in a mean improvement of 68.2%. Side effects were minimal. Additionally, an intention to treat analysis was conducted. Conclusion Photodynamic therapy of acne vulgaris using 5-ALA 0.5% liposomal spray and IPL in combination with topical peeling agents is safe and efficacious, even in patients with acne recalcitrant to standard therapy.

Common variants at 7p21 are associated with frontotemporal lobar degeneration with TDP-43 inclusions (Article)

2010-03-01T00:00:00Z

Frontotemporal lobar degeneration (FTLD) is the second most common cause of presenile dementia. The predominant neuropathology is FTLD with TAR DNA-binding protein (TDP-43) inclusions (FTLD-TDP). FTLD-TDP is frequently familial, resulting from mutations in GRN (which encodes progranulin). We assembled an international collaboration to identify susceptibility loci for FTLD-TDP through a genome-wide association study of 515 individuals with FTLD-TDP. We found that FTLD-TDP associates with multiple SNPs mapping to a single linkage disequilibrium block on 7p21 that contains TMEM106B. Three SNPs retained genome-wide significance following Bonferroni correction (top SNP rs1990622, P = 1.08 × 10 11; odds ratio, minor allele (C) 0.61, 95% CI 0.53-0.71). The association replicated in 89 FTLD-TDP cases (rs1990622; P = 2 × 10 4). TMEM106B variants may confer risk of FTLD-TDP by increasing TMEM106B expression. TMEM106B variants also contribute to genetic risk for FTLD-TDP in individuals with mutations in GRN. Our data implicate variants in TMEM106B as a strong risk factor for FTLD-TDP, suggesting an underlying pathogenic mechanism.

Cellular and molecular effects of pulsed dye laser and local narrow-band UVB therapy in psoriasis (Article)

2010-03-01T00:00:00Z

Background and Objectives: Pulsed dye laser (PDL) therapy is effective in clearing psoriasis plaques, but the mechanism of action is only partially understood. Local narrow-band ultraviolet B (NB-UVB), which has a better-defined mode of action, is an effective standard treatment for psoriasis. Our aim was to evaluate the cellular and molecular effects of PDL and to compare them with those of local NB-UVB in order to gain further insight into their mechanisms of action in psoriasis. Study Design/Patients and Methods: Nineteen patients with stable plaque-type psoriasis were treated either with PDL or NB-UVB. Lesional punch biopsies were obtained from all patients before treatment. Additional biopsies were obtained at 3 and 24 hours after PDL treatment in five of these patients. In 14 patients additional biopsies were taken after 7 and 13 weeks of treatment. Samples were histopathologically examined for the level of dermal T cell infiltrate, and the expression of epidermal β-defensin 2, immune cell-derived tumor necrosis factor (TNF)-α, endothelial E-selectin, vascular endothelial growth factor receptor (VEGFR) 2 and 3, and the expression of interleukin (IL)-23 before and after treatment. Results: The expression of VEGFR2, VEGFR3, and E-selectin was decreased in clinically high responders within 24 hours after PDL treatment. The expression of IL-23, TNF-α mRNA, and E-selectin protein were significantly reduced after two PDL treatments, whereas the expression of all epidermal markers and dermal T cell infiltrates had normalized after four treatments. The expression of epidermal activation markers and E-selectin were significantly reduced after 13 weeks of NB-UVB treatment. Conclusions: The expression of epidermal activation markers and the dermal T cell infiltrates were decreased after both treatments. The decreased expression of VEGFR2 and VEGFR3 followed by the down-regulation of TNF-α and IL-23p19 may be contributory factors in the efficacy of PDL in stable plaque-type psoriasis.

Lipoedema: From clinical presentation to therapy. A review of the literature (Article)

2009-11-01T00:00:00Z

Lipoedema is an infrequently recognized disorder in women. Lipoedema is characterized by bilateral enlargement of the legs due to abnormal depositions of subcutaneous fat associated with often mild oedema. There is substantial variability in disease severity. The diagnosis should be made as early as possible to prevent complications of the disorder, which is associated with increasing functional and cosmetic morbidity. This review describes clinical manifestations, pathogenesis, technical investigations, management and therapies of lipoedema, with the aim of optimizing management and care of patients with lipoedema.

Psoriasis may not be an independent predictor for the use of cardiovascular and anti-diabetic drugs: A 5-year prevalence study (Article)

2009-10-26T00:00:00Z

Most studies investigating the association between psoriasis and cardiovascular disease have shown a significant relationship. This comparison study investigated the association between psoriasis and prevalent use of cardiovascular drugs. Drug exposure data for 1998 to 2006 were extracted from the Dutch PHARMO-Record Linkage System database. Psoriasis patients were selected using an algorithm of hospitalization and drug dispensing records specific for psoriasis and matched with controls for gender, age and time-period. From the records of 2.5 million Dutch residents, 9,804 (0.4%) psoriasis patients and 15,288 (0.6%) controls were selected. Psoriasis patients used significantly more anti-hypertensives, anti-coagulant and anti-platelet agents, digoxin, nitrates, lipid-lowering and anti-diabetic drugs than the reference population during a 5-year period observation. In a multiple linear regression model adjusting for the number of unique drugs used, psoriasis was no longer significantly associated with any of these drug classes. Psoriasis patients used more cardiovascular-related drugs, but surveillance bias appears to affect this association considerably.

Increase in basal cell carcinoma incidence steepest in individuals with high socioeconomic status: Results of a cancer registry study in the Netherlands (Article)

2009-10-01T00:00:00Z

Background Development of both basal cell carcinoma (BCC) and cutaneous malignant melanoma (MM) is associated with acute and intermittent sun exposure. In contrast to MM, the association between socioeconomic status (SES) and BCC is not well documented. Objectives To investigate the incidence of BCC according to SES, stratifying by age and tumour localization in a large population-based cohort. To assess changes over time in the distribution of the patients with BCC across the SES categories. Methods All patients with a histologically confirmed first primary BCC (n = 27027) diagnosed between 1988 and 2005 in the Southeast of the Netherlands were stratified by sex, age (25-44, 45-64 and ≥ 65 years), period of diagnosis, SES category (based on income and value of housing) and localization of the BCC. Age-standardized BCC incidence rates were calculated for the year 2004 by SES category and localization. Ordinal regression was used to assess changes over time in the proportion of patients with BCC by sex, age and SES. Results For men in all age groups higher BCC incidence in the highest SES category was observed, which remained significant after stratification for tumour localization. For women a consistent relationship was found only in younger women (< 65 years) for truncal BCCs, which occurred more frequently in high SES groups. Between 1990 and 2004, the proportion of BCC patients with high SES increased (+6%) and the proportion with low SES decreased (-7%). Conclusions High SES is associated with increased incidence of BCC among men. Our data suggest that BCC is changing from a disease of the poor to a disease of the rich.

Persistent reflux below the knee after stripping of the great saphenous vein (Article)

2009-10-01T00:00:00Z

Objectives: This prospective study investigated persistent reflux of the below knee great saphenous knee (GSV) 2 years after stripping the above knee GSV and the effect on reflux of postoperative incompetent perforating veins (IPVs). Methods: Included were 59 consecutive ambulatory patients in a community hospital with untreated primary varicose veins and reflux of the saphenofemoral junction and at least the GSV in the upper leg. Patients underwent a preoperative clinical examination and color flow duplex ultrasound imaging. Postoperative evaluations were at 6 months and 2 years, and 67 limbs were re-evaluable. This analysis was adjusted for age, CEAP, follow-up period, and preoperative reflux using a multivariate logistic regression model. The difference in diameter of the GSV below the knee before and after surgery was measured and tested with the paired t test. Results: Clearly visible varicose veins in the GSV below the knee were seen in 49 limbs (73%) before surgery and after surgery in 11 limbs (16%) at 6 months and in 15 limbs (22%) at 2 years. Reflux in the below knee main stem increased from 81% before surgery to 84% at 6 months and 91% at 2 years after surgery. Reflux in the posterior calf tributary of the GSV decreased from 67% before surgery to 64% at 6 months and 59% at 2 years after surgery. The mean diameter of the below knee GSV main stem decreased from 4.7 mm before surgery to 3.3 mm 6 months after surgery (P < .001), but increased to 3.6 mm 2 years after surgery (P < .05). The mean diameter of the posterior calf tributary of the GSV decreased from 3.5 mm before surgery to 2.7 mm at 6 months (P < .001), but increased to 2.9 mm at 2 years (P < .05). Univariate and multivariate logistic regression shows no association between reflux in one of the GSV below knee branches and postoperative IPVs. Conclusion: Many patients (91%) that undergo a short stripping procedure will have a persistent reflux of the remnant below knee GSV tributaries postoperatively. This incompetence of the distal GSV is independent from the proximal GSV as well from insufficient perforating veins. There seems to be a tendency to worsening of the clinical signs and symptoms between 6 months and 2 years after surgery, and this goes along with an increase of reflux and diameters of the GSV below knee remnants.

Complications after treatment with polyalkylimide (Article)

2009-10-01T00:00:00Z

Background Polyalkylimide is a nonresorbable, biocompatible polymeric filler that has been used for several years to treat soft tissue deficits. The literature has shown a minor complication rate. We noticed that complications typically appear several years after injection. Objective To evaluate the complications reported after treatment with polyalkylimide. Methods and materials We describe a retrospective evaluation, reported by members and candidate members of the Dutch Society of Cosmetic Medicine, of complications after use of polyalkylimide. Results In total, 3,196 patients were treated, and 4,738 treatments were performed, from which 154 complications (patient complication rate 4.8%, treatment complication rate 3.3%) were reported. The most common complication was inflammation; other complications were hardening, migration, and accumulation of the product. In some patients, skin biopsy followed by histologic examination was performed. Conclusion Treatments with polyalkylimide have been reported to give rise to complications years after treatment. Even though the study described is a retrospective evaluation, we consider an overall complication rate of 4.8%, the severity of the complications, and the difficulty in treating them too high a risk for a cosmetic treatment. The Dutch Society of Cosmetic Medicine advises against the use of polyalkylimide.

Treatment of incompetent perforating veins using the radiofrequency ablation stylet: A pilot study (Article)

2009-10-01T00:00:00Z

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.

Photodynamic therapy with topical metatetrahydroxychlorin (Fosgel) is ineffective for the treatment of anal intraepithelial neoplasia, grade III (Article)

2009-09-01T00:00:00Z

Endovenous laser ablation-induced complications: Review of the literature and new cases (Article)

2009-08-01T00:00:00Z

BACKGROUND In the last decade, minimally invasive techniques have been introduced in the treatment of lower extremity varicosities. Of these therapies, endovenous laser ablation is the most widely accepted and used treatment option for insufficient great and short saphenous veins. OBJECTIVE To present a review of reported common and rare and minor and major complications associated with endovenous laser ablation. METHODS A systematic review of studies and case reports on endovenous laser ablation-induced complications. The complications were classified as minor or major according to the Society of Interventional Radiology Standards of Practice Committee guidelines on reporting complications. A case-series of complications after endovenous laser ablation is presented. RESULTS Ecchymoses and pain are frequently reported side effects of endovenous laser ablation. Nerve injury, skin burns, deep vein thrombosis and pulmonary embolism seldom occur. An exceptional complication is a material or device that by accident remains inside the body after the procedure. Ecchymosis, pain, induration, skin burns, dysesthesia, superficial thrombophlebitis, and hematoma were classified as minor complications. Deep vein thrombosis and nerve injury were classified as major complications. CONCLUSION Endovenous laser ablation may be considered a safe treatment of lower extremity varicosities. The incidence of common side effects may decrease with better laser parameters. The authors have indicated no significant interest with commercial supporters.

Neoplasms of the Facial Skin (Article)

2009-07-01T00:00:00Z

Neoplasms of the skin are found most often on the face. Malignant tumors of the facial skin pose a challenge in treatment, prohibiting compromises between oncologically responsible surgery and functional plus cosmetic outcome. The incidence of melanoma and nonmelanoma skin cancers is rising. Not all malignancies of the skin need to be treated by surgery. For in situ variants there are other options, such as photodynamic therapy and medical treatment. Knowledge of the clinical manifestation, behavior, and prognosis and histopathologic analysis lead to correct diagnosis and choice of suitable treatment. This article presents a synopsis of nonmelanoma, melanoma, and other cancers of the skin.

Liposomes in dermatology today (Article)

2009-05-01T00:00:00Z

Liposomes are vesicles consisting of spherical phospholipid bi-layers with specific properties making them useful for topical application of drugs. Liposome research has expanded considerably over the last 30 years and nowadays, it is possible to construct a wide range of liposomes varying in size, phospholipids composition and surface characteristics to suit the specific application for which they are intended. In dermatology, the topical application of liposomes has proven to be of therapeutic value. Liposomes can be used as carriers for hydrophilic as well as lipophilic therapeutic agents because of their amphipathic character. They may improve stabilization of instable drugs by encapsulating them and serve as penetration enhancers facilitating the transport of compounds that otherwise cannot penetrate the skin. Liposomes help in reducing skin irritation by sustaining the release of drugs and by hydration of the epidermis. They also have the potential to target drugs into the pilosebaceous structures and hence they have an additional advantage for treatment of hair follicle-associated disorders. Clinical data indicate that 5-ALA encapsulated in liposomes improves the quality of Fluorescence Diagnosis by ALA-induced Porphyrins (FD) and optimizes the results of Photodynamic Therapy (PDT).

Unusual late nodular presentation of secondary syphilis (Article)

2009-04-01T00:00:00Z

A 20-year-old man presented with a five-week history of an eruption of papules and nodules disseminated over his body and face. We propose that this patient has a late form of secondary syphilis with a nodular, granulomatous inflammation in urgent need of treatment. Otherwise late irreversible sequelae could develop and unwanted possible further sexual transmission could take place.

Heat conduction from the exceedingly hot fiber tip contributes to the endovenous laser ablation of varicose veins (Article)

2009-03-01T00:00:00Z

Lower-extremity venous insufficiency is a common condition, associated with considerable health care costs. Endovenous laser ablation is increasingly used as therapy, but its mechanism of action is insufficiently understood. Here, direct absorption of the laser light, collapsing steam bubbles and direct fiber-wall contact have all been mentioned as contributing mechanisms. Because fiber tips have reported temperatures of 800-1,300°C during endovenous laser ablation, we sought to assess whether heat conduction from the hot tip could cause irreversible thermal injury to the venous wall. We approximated the hot fiber tip as a sphere with diameter equal to the fiber diameter, having a steady state temperature of 800°C or 1,000°C. We computed venous wall temperatures due to heat conduction from this hot sphere, varying the pullback velocity of the fiber and the diameter of the vein. Venous wall temperatures corresponding to irreversible injury resulted for a 3 mm diameter vein and pullback velocities <3 mm/s but not for 5 mm and 1 mm/s. The highest wall temperature corresponded to the position on the wall closest to the fiber tip, hence it moves longitudinally in parallel with the moving fiber tip. We concluded that heat conduction from the hot fiber tip is a contributing mechanism in endovenous laser ablation.

Fluorescence detection and diagnosis of non-Melanoma skin cancer at an early stage (Article)

2009-02-01T00:00:00Z

Background: The occurrence of non-melanoma skin cancer (NMSC), including actinic keratosis (AK) is increasing all over the world. The detection and diagnosis of NMSC is not optimal in clinical practice. Complementary methods for detection and accurate demarcation of NMSC at an early stage are needed in order to limit the damage caused by tumours. Objective: The purpose of the present study was to use a large area skin fluorescence detection system to detect early NMSCs (clinical visible as well as non-visible lesions) in the face, neck, chest, back and hands of patients treated with UV and outdoor workers. Methods: Fluorescence detection with a purpose-made digital camera and software (Dyaderm®) combined with 5-aminolevulinic acid (5-ALA) encapsulated in liposomes. Results: In 93 consecutively referred patients positive skin fluorescence was detected in 61 patients. After histological examination the positive fluorescence appeared to be correlated to benign lesions in 28 patients (sebaceous gland hyperplasia in 22 patients) and to (pre-) malignant lesions in 33 patients (actinic keratosis in 29, BCC in 3 and SCC in 1 patient). False negative fluorescence was found in only one lesion. In five patients the FD technique used in this study appeared to be more sensitive for the identification of (pre-) malignant lesions than the clinical examination. This is in contrast with FD techniques used in previous studies. Conclusion: Diagnostic skin fluorescence using liposomal encapsulated 5-ALA and a specialised computerised detection and visualisation system offers the possibility for detection of NMSC at an early, pre-clinical stage. The technique is well suited to examine large areas of skin. It also identifies areas of most interest for performing confirmatory skin biopsies, as well as pre-operative assessment of boundaries of skin malignancies, and finally, the technique is applicable in the control and follow-up of skin cancer treatment.

Changes in the pressure and the dynamic stiffness index of medical elastic compression stockings after having been worn for eight hours: A pilot study (Article)

2009-02-01T00:00:00Z

Objectives: There is no data available at present on the changes in the exerted pressure together with the dynamic stiffness index (DSI) of medical elastic compression stockings (MECS). The objective of this pilot study was to measure the pressure and calculate the DSI of 12 different brands of MECS before and after having been worn for eight hours. Methods: In all, 12 different commercially available brands of MECS that were divided into two categories (class I round-knitted and class II flat-knitted MECS) were tested. The pressure was measured, and the DSI of the MECS was first calculated at the B1 level before wearing in the morning and again eight hours after they had been worn. All laboratory measurements were performed using a newly developed dynamic leg-segment model. Results: The pressure at the B1 level dropped significantly in all 12 brands of MECS after having been worn for eight hours, whereas the DSI remained unchanged. Conclusion: The DSI of MECS reflects an important and particularly consistent therapeutic effect. As the pressure drops during the day, the pressure amplitude or pulsations remain the same. The pressure drop may be due to fatigue of the elastic material. The DSI would therefore form a valuable indicator for prescribing the most effective MECS for the patient.

Endovenous therapies of lower extremity varicosities: A meta-analysis (Article)

2009-01-01T00:00:00Z

Background: Minimally invasive techniques such as endovenous laser therapy, radiofrequency ablation, and ultrasound-guided foam sclerotherapy are widely used in the treatment of lower extremity varicosities. These therapies have not yet been compared with surgical ligation and stripping in large randomized clinical trials. Methods: A systematic review of Medline, Cochrane Library, and Cinahl was performed to identify studies on the effectiveness of the four therapies up to February 2007. All clinical studies (open, noncomparative, and randomized clinical trials) that used ultrasound examination as an outcome measure were included. Because observational and randomized clinical trial data were included, both the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and Quality Of Reporting Of Meta-analyses (QUORUM) guidelines were consulted. A random effects meta-analysis was performed, and subgroup analysis and meta-regression were done to explore sources of between-study variation. Results: Of the 119 retrieved studies, 64 (53.8%) were eligible and assessed 12,320 limbs. Average follow-up was 32.2 months. After 3 years, the estimated pooled success rates (with 95% confidence intervals [CI]) for stripping, foam sclerotherapy, radiofrequency ablation, and laser therapy were about 78% (70%-84%), 77% (69%-84%), 84% (75%-90%), and 94% (87%-98%), respectively. After adjusting for follow-up, foam therapy and radiofrequency ablation were as effective as surgical stripping (adjusted odds ratio [AOR], 0.12 [95% CI, -0.61 to 0.85] and 0.43 [95% CI, -0.19 to 1.04], respectively). Endovenous laser therapy was significantly more effective compared with stripping (AOR, 1.13; 95% CI, 0.40-1.87), foam therapy (AOR, 1.02; 95% CI, 0.28-1.75), and radiofrequency ablation (AOR, 0.71; 95% CI, 0.15-1.27). Conclusion: In the absence of large, comparative randomized clinical trials, the minimally invasive techniques appear to be at least as effective as surgery in the treatment of lower extremity varicose veins.

A comparative study on the efficacy of treatment with 585 nm pulsed dye laser and ultraviolet B-TL01 in plaque type psoriasis (Article)

2009-01-01T00:00:00Z

BACKGROUND: Narrow-band ultraviolet-B and pulsed dye laser (PDL) affect psoriasis but via different pathways. OBJECTIVE: To compare the results of PDL with ultraviolet-B light therapy (UVB) and to look for synergism of both therapies in patients with plaque type psoriasis. METHODS: In each eligible individual, four similar target plaques were selected, and halves of these plaques were treated using PDL, UVB, or a combination of PDL and UVB or were not treated. Results: were recorded single-blind using the Physician's Global Assessment score at study enrolment and Week 13. Nonparametric, paired statistical tests were used to test for differences within and between therapies.The results were also analyzed after dichotomization of the changes in the Physician's Global Assessment score into responsive and nonresponsive to treatment. RESULTS A significant improvement of the psoriasis lesions was noted at Week 13 (P<.001) with each therapy. No significant differences were noted between the therapies. Synergism of PDL and UVB was not observed. CONCLUSIONS: PDL is safe for treating plaque type psoriasis, but its efficacy is limited to a subgroup of patients. Combining PDL with UVB has no additional benefit.

Minimally invasive techniques in the treatment of saphenous varicose veins (Article)

2009-01-01T00:00:00Z

Lower extremity venous insufficiency is common and increases with age. In addition to classical symptoms, it may result in skin changes and venous ulcers. Chronic venous insufficiency has a great impact on patients' health-related quality of life and is associated with considerable health care costs. Surgical ligation of the junction with or without stripping has been the standard of care in the treatment of insufficient great and small saphenous veins. However, the recurrence rates are relatively high and surgery may be associated with serious adverse events and considerable down time; it is also cosmetically suboptimal. To improve efficacy, patients' health-related quality of life and treatment satisfaction and to reduce serious side effects, costs, and postoperative pain, several minimally invasive techniques have been introduced in the last decade. Dermatologists have played an important role in the development of these new therapies of truncal varicose veins. Of the new therapies, ultrasound-guided foam sclerotherapy, endovenous laser therapy, and radiofrequency ablation are the most common and challenge surgery as the "gold standard" of care for patients with varicose veins. The objective of this review is to inform clinicians about these 3 therapeutic options for truncal varicose veins and to describe and compare the procedures, indications, efficacy, and safety profile.

Surgical excision versus Mohs' micrographic surgery for primary and recurrent basal-cell carcinoma of the face: a prospective randomised controlled trial with 5-years' follow-up (Article)

2008-12-01T00:00:00Z

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 χ20·718, 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 χ25·958, 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.

Fractionated 5-aminolaevulinic acid-photodynamic therapy vs. surgical excision in the treatment of nodular basal cell carcinoma: Results of a randomized controlled trial (Article)

2008-10-01T00:00:00Z

Background: Skin cancer incidence rates have been increasing for decades and this increase is expected to continue. Surgical excision (SE) is the treatment of first choice for nodular basal cell carcinoma (nBCC). Photodynamic therapy (PDT) has proven to be an effective treatment for superficial basal cell carcinoma. Its long-term efficacy in nBCC has not yet been established. Objectives: Prospectively compare the efficacy of 5-aminolaevulinic acid (ALA)-PDT and SE in terms of failure rates with long-term follow-up. Determinants of failure in the study population, such as the effect of tumour depth, were analysed retrospectively. Methods: A randomized controlled trial in 173 primary nBCCs in 149 patients. Primary nBCCs were randomly assigned either to PDT (n = 85) or to SE (n = 88). Tumours treated with PDT were illuminated twice on the same day, 4 h after application of ALA cream, 3 weeks after debulking. SE was performed under local anaesthesia with a 3-mm margin, followed by histological examination. An intention-to-treat analysis was performed. Results: In total, 171 primary nBCCs in 149 patients were treated. A 3-year interim analysis revealed that the cumulative incidence of failure was 2.3% for SE and 30.3% for PDT (P < 0.001). Tumour depth and other analysed determinants of failure were not significantly related to treatment failure. Conclusions: SE proved to be significantly more effective than treatment with fractionated illumination ALA-PDT. Therefore, in the treatment of primary nBCC, SE is preferred over PDT following this treatment regimen.

Repigmentation of vitiligo during efalizumab (Article)

2008-08-01T00:00:00Z

A review of photodynamic therapy in cutaneous leishmaniasis (Article)

2008-08-01T00:00:00Z

We present a review of six clinical studies investigating the use of photodynamic therapy (PDT) using porphyrin precursors for the treatment of Old World cutaneous leishmaniasis (CL). Thirty-nine patients with a total of 77 lesions received PDT using a range of treatment schedules following topical application of aminolevulinic acid (ALA) or methyl-aminolevulinate (MAL). The tissue response to PDT is accompanied by a mild burning sensation, erythema and reversible hypo- and hyperpigmentation. Few mechanistic studies have addressed the principles underlying the use of PDT for CL. All six reviewed papers suggest that PDT with porphyrin precursors is relatively effective in treating CL. Data are still limited, and PDT cannot at this point be recommended in routine clinical practice. The mechanism of action of this promising therapeutic modality needs to investigated further and additional controlled trials need to be performed.

Classification of compression bandages: Practical aspects (Article)

2008-05-01T00:00:00Z

BACKGROUND: Compression bandages appear to be simple medical devices. However, there is a lack of agreement over their classification and confusion over the use of important terms such as elastic, inelastic, and stiffness. OBJECTIVES: The objectives were to propose terms to describe both simple and complex compression bandage systems and to offer classification based on in vivo measurements of subbandage pressure and stiffness. METHODS: A consensus meeting of experts including members from medical professions and from companies producing compression products discussed a proposal that was sent out beforehand and agreed on by the authors after correction. RESULTS: Pressure, layers, components, and elastic properties (P-LA-C-E) are the important characteristics of compression bandages. Based on simple in vivo measurements, pressure ranges and elastic properties of different bandage systems can be described. Descriptions of composite bandages should also report the number of layers of bandage material applied to the leg and the components that have been used to create the final bandage system. CONCLUSION: Future descriptions of compression bandages should include the subbandage pressure range measured in the medial gaiter area, the number of layers, and a specification of the bandage components and of the elastic property (stiffness) of the final bandage.

Variation in the dynamic stiffness index of different types of medical elastic compression stockings (Article)

2008-04-01T00:00:00Z

Objectives: To calculate the dynamic stiffness index (DSI) of 18 different brands of medical elastic compression stockings (MECS). Methods: In all, 18 different brands of MECS that were divided into five categories (class II round-knitted, class II flat-knitted, class III round-knitted, class III flat-knitted and class IV flat-knitted MECS) were tested. The static pressure and dynamic pressure pulsations at the B1 level were measured with a newly developed dynamic pressure-determining device. The DSI was calculated. Results: The DSI of all 18 brands of MECS showed higher values compared with the static stiffness. A wide range of dynamic stiffness indices was observed not only between all brands of MECS, but also within the five categories. Conclusions: The DSI of MECS is independent of the compression class and the type of knit. The variation in the DSIs between MECS is not because of any measurement error and would indicate that different therapeutic effectiveness may be expected within one compression class. Therefore, a refinement in the current classification system for MECS with other characteristics such as the DSI is warranted.

Fractionated aminolevulinic acid-photodynamic therapy provides additional evidence for the use of PDT for non-melanoma skin cancer (Article)

2008-04-01T00:00:00Z

Background: Photodynamic therapy (PDT) is an accepted treatment for superficial basal cel carcinoma (sBCC) and Bowens disease. In Rotterdam, extensive preclinical research has lead to an optimized twofold illumination scheme for aminolevulinic acid-PDT (ALA-PDT). Objective: To provide additional evidence of ALA-PDT for sBCC, Bowens disease (BD), nodular BCC (nBCC) and actinic keratosis (AK) using a 2-fold illumination scheme after a single application of ALA. Methods: Five hundred fifty-two lesions (430 sBCC, 20 nBCC, 32 BD, 70 AK) were treated with ALA-PDT using a twofold illumination scheme. ALA was applied topically for 4 h. Lesions were treated with two light fractions of 20 and 80 J/cm2separated by a 2-h dark interval. Results: After a minimum follow-up of 12 months, in average follow-up of 2 years, an overall complete response of 95% was seen for all lesions. For sBCC, the complete response at 2 years was 97% (for AK 98%, for BD 84% and for nBCC 80% after 2 years). A sub-analysis of the results of lesions larger than 2 cm showed CR at 2 years of 89% for all lesions (n = 57). Cosmetic outcome was good to excellent in 95% of the treated lesions. Conclusion: ALA-PDT using a twofold illumination scheme of 20 plus 80 J/cm2separated by a 2-h dark interval leads to high complete response rates at 2 years and can be regarded as an evidence-based treatment modality for superficial growing non-melanoma skin cancer and the (pre)malignant AK. The Rotterdam fractionated approach should be included in future guidelines. © Journal compilation

Technical Review of Endovenous Laser Therapy for Varicose Veins (Article)

2008-01-01T00:00:00Z

Background: In the last decade, several new treatments of truncal varicose veins have been introduced. Of these new therapies, endovenous laser therapy (EVLT) is one of the most widely accepted and used treatment options for incompetent greater and lesser saphenous veins. Objective: The objective of this report is to inform clinicians about the EVLT procedure and to review its efficacy and safety in treatment of truncal varicose veins. Also, we discuss some of the underlying theoretical principles and laser parameters that affect EVLT. Methods: We carried out a literature review of EVLT`s efficacy and safety. We included reports that included 100 or more limbs with a follow-up of at least 3 months. The principals and procedure of EVLT are described. Of the laser parameters, mode of administration, wavelength, fluence, wattage and pullback speed are discussed. Conclusion: EVLT appears to be a very effective and safe option in the treatment of varicose veins but large randomized comparative studies are needed.

Diode laser hair removal around ileo-colo ostomys is safe, effective and beneficial: A pilot study (Article)

2007-12-01T00:00:00Z

Background and Objective: Hair removal around an ileo-colo ostomy can cause a number of problems. We compared laser hair removal with mechanical shaving around the ostomy. Method: Eleven patients were selected with hairy skin around the ostomy for therapy with an AlGaAs diode laser at 800 nm. Three to four treatments were given with an interval of 6 weeks. Results: Ten patients completed laser therapy. The average hair reduction was 60% based on visual inspection. Shaving frequency reduced from once a week to once every 6 weeks. Conclusions: Laser hair removal likely becomes the preferred method in ostomy patients.

Question the obvious (Article)

2007-11-01T00:00:00Z

Successful treatment of periungual warts using photodynamic therapy: A pilot study (Article)

2007-10-01T00:00:00Z

Aim: The aim of this pilot study was an investigation on photodynamic therapy (PDT) whether it is a good alternative for treating periungual and subungual warts of the hands. Study design: Twenty patients (mean age: 30.5 years) with a total of 40 periungual and subungual warts were treated with PDT. A photosensitizer, 20%δ-aminolevulinic acid was applied on the warts. After a mean incubation time of 4.6 h (SD: 1.2), the warts were irradiated with the VersaLight® for 5-30 min (15.2 ± 4.3 min). Results: After a mean of 4.5 treatments a mean clearance of 100% was achieved in 90% of the patients. One patient (5%) showed a clearance of 50% and another showed no improvement. The subungual or periungual location of the wart had no influence on the number of treatments or end result (P > 0.05). There were two recurrences during the mean follow-up period of 5.9 months (SD: 7.6). Besides mainly pain and hyperpigmentation, most treatments had no side-effects. Conclusion: PDT can offer a good alternative for treating periungual warts of the hands. Larger studies are indicated. © 2007 The Authors Journal compilation

Perceptions of facial aesthetics in surgical patients with basal cell carcinoma (Article)

2007-10-01T00:00:00Z

Background: Basal cell carcinoma (BCC) is a non-melanoma form of skin cancer that is frequently localized within the cervicofacial area. So far, little research is available on how patients perceive their facial aesthetics after surgical treatment for BCC. Objectives: To analyse (i)if there was a statistically significant improvement over time with regard to the perceived facial aesthetics of surgical patients; (ii) if there was a significant difference between primary and recurrent BCC patients; and (iii) between patients who had Mohs micrographic surgery (MMS) or surgical excision (SE). To assess (iv) which baseline perceptions and/or clinical parameters may predict the evaluation of facial aesthetics at 6 months after surgery. Methods: Parallel to a clinical trial, a survey was carried out in which patients were asked, by means of a newly developed disease-specific questionnaire, about perceptions with regard to their facial aesthetics before and after surgery. Results: Aesthetic perceptions of all surgical patients improved over time. There was no statistically significant difference on facial aesthetics between the group with a primary or recurrent BCC and patients treated with MMS or SE. Results also showed that the evaluation of postsurgical facial aesthetics can be predicted by both visibility of the tumour and preoperative perceptions. Conclusion: It is recommended to administer preoperatively a short questionnaire in which perceptions related to facial aesthetics are included. In doing so, physicians will become more familiar with the aesthetic problems patients might have regarding their afflicted facial site. Ultimately, it may help physicians in deciding whether patients will benefit from additional cosmetic procedures after surgery. © 2007 The Authors Journal compilation

Quality of clinical practice guidelines in dermatological oncology (Article)

2007-10-01T00:00:00Z

Background: Clinical practice guidelines are increasingly used. To determine the quality of guidelines the Appraisal of Guidelines and Research and Evaluation (AGREE) instrument was developed and introduced in 2001. The AGREE instrument consists of 23 criteria, grouped in six domains. Objective: Assessment of quality of evidence-based guidelines in dermatological oncological care according to the AGREE instrument. Methods: We searched MEDLINE, PubMed, EMBASE and Cochrane literature and relevant websites of guidelines development programmes and the national dermatological society to identify evidence-based dermatological guidelines especially in the treatment of to basal cell carcinoma, squamous cell carcinoma and melanoma. Twenty guidelines, published between 1990 and 2005, were appraised according to the AGREE instrument by three authors. Standardized domain scores were calculated as advised by AGREE. We compared guidelines published before 2002 with those published later. Results: Domain scores in the domains Scope & Purpose and Clarity were scored best. Applicability and Editorial Independence were scored worst (see Table 1). In time a weak trend towards better guidelines was seen. This trend can be attributed to better scores in the domains Search Strategy and Level of Evidence which are closely related to evidence-based medicine. The increase in score is due to more explicitly mentioning the search strategy, possible conflict of interest and involvement of different specialties in development of the guideline. Using the Mann-Whitney test to compare guidelines published before the AGREE and afterwards only a statistically significant better score was found for the domain Clarity (P < 0.05; Table 2). Conclusions: Guidelines in dermatological oncological care are of reasonable quality according to the AGREE instrument. The domains in the AGREE instrument concern especially the methods of development of guidelines. The score according to AGREE can be improved by explicitly mentioning the different items. As clinical guidelines are regarded to be an important instrument to improve quality of care, improvements are needed. © 2007 The Authors Journal compilation

Analyses of skin waste during excision of benign skin lesions: Is the surgical ellipse cut necessary? [35] (Article)

2007-06-01T00:00:00Z

Surgical excision versus curettage plus cryosurgery in the treatment of basal cell carcinoma (Article)

2007-05-01T00:00:00Z

BACKGROUND: Both cryosurgery, with and without prior curettage, and surgical excision (SE) are common therapeutic strategies for basal cell carcinoma (BCC). OBJECTIVE: The objective was to compare the efficacy between curettage plus cryosurgery (C&C) and SE in nonaggressive BCC of the head and neck. MATERIALS AND METHODS: A randomized controlled trial was carried out, in which tumors were assigned to either C&C (n=51) or SE (n=49). C&C was performed with a double freeze-thaw cycle after prior curettage of the tumor. SE was performed with a margin of 3 mm and with delayed histologic examination. RESULTS: Recurrences occurred 9 times after C&C (17.6%) and 4 times after SE (8.2%). The overall 5-year recurrence probability was 19.6% for C&C and 8.4% for SE (p=.10). A hazard ratio of 2.57 (95% CI, 0.79-8.34) indicated a putative, but not statistically significant, advantage of SE. CONCLUSION: These data reflect the outcome of the first randomized controlled trial with long-term follow-up in the treatment of BCC, comparing C&C with SE. Although not statistically significantly different, the observed differences could still be of clinical relevance. Owing to the trend toward lower recurrence rates, better cosmetic results, and reduced wound healing time, we believe that SE should be preferred to C&C in the treatment of primary, nonaggressive BCC of the head and neck.

Unfavorable cardiovascular risk profiles in untreated and treated psoriasis patients (Article)

2007-01-01T00:00:00Z

Psoriasis is a chronic inflammatory skin disease that is associated with an increased cardiovascular risk profile. The systemic inflammation present in psoriasis, various systemic treatments for psoriasis and an increased prevalence of unhealthy life style factors may all contribute to this unfavorable risk profile. The purpose of this article is to provide an overview of what is known about these risk factors in psoriasis, the way they influence the cardiovascular risk of psoriasis patients, and what can be done to reduce this risk. Genetic studies demonstrate that psoriasis and cardiovascular disease share common pathogenic features in which, for example inflammatory cytokines like TNF-α and IL-1 play an important role. The chronic inflammation in psoriasis has an unfavorable effect on the cardiovascular risk profile. Multiple cardiovascular risk factors seem to be influenced; the blood pressure, oxidative stress, dyslipidemia, endothelial cell dysfunction, homocysteine levels and blood platelet adhesion. Moreover, classic cardiovascular risk factors like smoking and obesity that have an increased prevalence among patients with psoriasis, indirectly also worsen the cardiovascular risk profile by stimulating the psoriasis activity. Systemic treatments in psoriasis reduce the cardiovascular risk by diminishing the inflammation, but it should be taken into account that most therapies also have adverse cardiovascular effects like dyslipidemia, hyperhomocysteinemia and hypertension. As a consequence preventive measures may be indicated at least during long-term treatments. Prospective research is warranted to accurately estimate the increased cardiovascular risk in psoriasis, to determine the underlying processes and to consider preventive measures according to the absolute risk of cardiovascular disease. The present overview provides data to advice health care providers to pay more attention to the cardiovascular risk profile in psoriasis patients.

Unusual presentation of early lymphogranuloma venereum in an HIV-1 infected patient: effective treatment with 1 g azithromycin (Article)

2003-01-01T00:00:00Z

The incidence of lymphogranuloma venereum (LGV) is low in the western world. Early LGV is characterised by bubonic disease following a painless papule or small ulcer. We report a white bisexual male who presented with a painful perianal ulcer, inguinal lymphadenitis, and concomitant infection with human immunodeficiency virus 1 (HIV-1). Chlamydia trachomatis serovar L2 was identified as the cause after polymerase chain reaction and genotyping the major outer membrane protein by restricted fragment length polymorphism. Treatment with a single dose of 1 g azithromycin was effective. This case illustrates that early LGV may mimic other genital ulcer diseases, such as genital herpes or chancroid, especially in HIV infected patients. In the western world, LGV must still be included in the differential diagnosis of bubonic disease with or without sexually acquired ulcers.

Licht beweegt de huid (Inaugural Lecture)

2002-04-19T00:00:00Z