DERMATOLOGY BULLETIN

1Dermatology BulletinVolume 20 No: 2 2009

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A Bulletin to Promote Education and Research in Dermatology

DERMATOLOGY BULLETINInstitute Of Dermatology, Singapore

Procedural Dermatology

MICA (P) NO. 102/09/2009 VOLUME 20 NO: 2 2009

Invited Article

3 Light Therapies For Acne. Dr Chua Sze Hon

6 Unwanted Hair Removal – An Update. Dr Priya Sen

Original Articles

9 A Retrospective Review of Mohs Micrographic Surgery Performed At The National Skin Centre, SingaporeDr Tan Wee Ping, Dr Heng Yee Kiat. Dr Melvin Ee Hock Leong

11 Clinical Outcomes In Patients With Incomplete Mohs Excisions For Periocular Non Melanoma Skin Cancer. Dr Melvin Ee Hock Leong, Dr Nabeel Malik, Dr Raman Malhotra, Dr Richard Collin, Dr Naresh Joshi, Dr Jane Olver, Dr Richard Barlow

15 Fractional Ablative Skin Resurfacing With A Novel Carbon Dioxide Laser System In The Treatment Of Atrophic Acne Scars In Asian Skin. Dr Melvin Ee Hock Leong, Dr Chua Sze Hon, Dr Tan Sze-Chin, Dr Priya Sen, Clin Prof Goh Chee Leok

20 Body Dysmorphic Disease In Patients Attending An Aesthetic Dermatology Clinic At The National Skin Centre – A Preliminary Prevalence Study. Clin Prof Goh Chee Leok, Dr Chua Sze Hon, Dr Priya Sen, Dr Melvin Ee Hock Leong

23 Side Effects And Complications Of Fractional Carbon Dioxide Laser Photothermolysis: Experience With 201 Treatments.Dr Tan Wee Ping, Dr Melvin Ee Hock Leong, Dr Priya Sen, Clin Prof Goh Chee Leok, Dr Chua Sze Hon

Case Reports

26 A Case Of Microcystic Adnexal Carcinoma Treated With Mohs Micrographic Surgery. Dr Raymond Kwah Yung Chien, Dr Tan Suat Hoon, Dr Ong Beng Hock, Dr Melvin Ee Hock Leong

29 Management Of Extramammary Paget’s Disease With Moh’s Micrographic Surgery. Dr Raymond Kwah Yung Chien, Dr Tan Suat Hoon, Dr Wong Siew Ngoh, Dr Ong Beng Hock, Dr Melvin Ee Hock Leong

32 Gorlin Syndrome-related Basal Cell Carcinoma Treated With Mohs Micrographic Surgery. Dr Lee Ee Ching, Dr Melvin Ee Hock Leong, Dr Tan Suat Hoon

Surgical Reconstruction

35 Burow’s Graft In The Reconstruction Of Nasal Side Wall. Dr Tan Wee Ping, Dr Melvin Ee Hock Leong

37 Nasal Reconstruction With A Local Flap. Dr Raymond Kwah Yung Chien, Dr Melvin Ee Hock Leong

40 Island Pedicle Flap For The Repair Of Defect Of The Upper Lateral Cutaneous Lip. Dr Tan Mei Ling, Dr Melvin Ee Hock Leong

42 Pivotal Advancement Flap In The Reconstruction Of A Medial Cheek And Nasojugal Defect. Dr Tan Wee Ping, Dr Melvin Ee Hock Leong

Joint Teaching Seminar

44 Report On An In-House Joint Teaching Seminar On Oral Cavity Symposium. Dr Hazel Oon Hwee Boon

STI Update

46 Update On Diagnostic Testing In Sexually Transmitted Infections. Dr Priya Sen

Pharmacy Page

49 Hyaluronic Acid In Dermatology. Ms Elizabeth Tian

2 Volume 20 No: 2 2009 Dermatology Bulletin2 Volume 20 No: 2 2009 Dermatology Bulletin


Light Therapies For Acne

Dr Chua Sze Hon*

Introduction

Medical therapy remains the 1st line treatment of acne vulgaris. However, while effective, growing concerns over antibiotic resistance with the use

of topical and systemic antibiotics, and potential serious adverse effects with the use of systemic isotretinoin have led physicians to explore alternative acne therapies. Of these, lasers and other light sources, including photodynamic therapy (PDT), have been shown to be safe and effective and may play an increasing role in the future management of infl ammatory acne.

Lasers and light sources that have been developed to treat infl ammatory acne act primarily in two ways: 1. Destroy the sebaceous gland, and 2. Kill Propionibacterium acnes (P. acnes) via the photo-activation of endogenous porphyrins.

1. Lasers

Lasers are able to clear infl ammatory acne vulgaris by targeting and destroying sebaceous glands. Most studies have been done using the near-infrared 1450nm diode laser. Near-infrared lasers target water, which is the dominant chromophore in the sebaceous glands.

Paithankar, et al (2002) used the 1450nm diode laser with a cryogen spray in 27 patients. Infl ammatory truncal acne was targeted. Results after 4 treatments spaced 3 weeks apart showed a 98% reduction in infl ammatory acne lesions.1

Friedman, et al (2004) performed an open trail with 19 patients with facial infl ammatory acne using the 1450nm diode laser and found progressive clinical improvements with multiple treatments. Lesion counts decreased 37% after one treatment, 58% after two treatments, and 83% after three treatments.2

Jih, et al (2006) treated 20 patients in a split-face study with 3 sessions of the 1450nm diode laser at 3-4 week intervals. High fl uences were used (14 or 16 J/cm2). Clinical improvements were observed after the 1st treatment and after 3 treatments; there was reduction in mean acne lesion counts of 75.1% (14 J/cm2) and 70.6% (16 J/cm2). Signifi cant long-term remission up to 12 months was reported.3

Treatment with high fl uences (14-16J/cm2) of the 1450nm diode laser often results in signifi cant pain experienced by the patient. In the attempt to reduce the pain during treatment, Bernstein, et al (2009) used 2 passes employing low fl uences (averaging 7.8 J/cm) and a larger 12mm spot for treatment. The authors found signifi cant clinical

improvements in 8/11 patients and subjective reduction in skin oiliness. Acne counts were 67% lower after the 4th treatment.4 The effectiveness of using low-energy, double-pass treatment protocol was also verifi ed by Noborio, et al (2009). The authors treated 30 Japanese patients in an open study and found signifi cant clinical improvements in the 27 patients who completed the study.5 Chi, et al (2009) treated 26 patients (skin phototypes IV–V) with 3 passes of the 1450nm diode laser using a low fl uence of 8 J/cm2 with dynamic cooling of 25ms to minimize PIH. After 4 treatment sessions, in the group with moderate acne, a mean reduction of 40% in infl ammatory acne was reported 6 months after the last treatment.6

2. Phototherapy

The basis of phototherapy of acne centres on the production of porphyrins (especially coproporphyrin III) by P. acnes. The mechanism of action involves the photo-excitation of the P. acnes porphyrins after exposure to the appropriate light source and the subsequent formation of singlet oxygen within the microorganism itself which results in destruction of the bacteria.

The major absorption peak for these porphyrins is in the blue range of the visible light spectrum around 405-420nm (Soret band). A second absorption peak occurs in the red range of the visible light spectrum at around 620-660nm. These major absorption peaks have led to the development of light devices utilizing either blue or red light for the treatment of infl ammatory acne.

Blue light

Several trials involving blue light have been reported in the literature. Papageorgiou, et al (2000) compared a daily mixed blue and red light phototherapy system (415nm and 660nm) with either blue light or white light applied 15 minutes daily for 12 weeks. The combination of blue and red light reduced infl ammatory acne vulgaris lesions by 76% vs. 58% in the blue light only group. Both were superior to white light (25%).7

Tzung, et al (2004) attempted to determine the profi le of a good candidate for blue light acne phototherapy. The authors performed a split-face study on 31 Asian patients with infl ammatory facial acne. Clinical improvements after blue light irradiation were verifi ed; success in treatment was not dependent on gender, scar type, pore size or pretreatment facial follicular porphyrin fluorescence intensity. They found that nodulocystic lesions tended to worsen despite treatment and suggested that patients without nodulocystic lesions were better candidates for blue light irradiation.8

INVITED ARTICLE 1

* Senior Consultant Dermatologist, National Skin Centre

4 Volume 20 No: 2 2009 Dermatology Bulletin


Lee, et al (2007) investigated the effi cacy of combined blue and red light-emitting diode (LED) phototherapy for acne vulgaris. The authors conducted an open trial involving 24 patients with a LED device emitting alternating blue (415 nm) and red (633 nm) light. Improvements in both infl ammatory as well as non-infl ammatory acne lesions were reported with greater improvements seen in the infl ammatory lesions (77.93% c/w 34.28%). Secondary benefi ts included brightened skin tone and improved skin texture in 14/24 patients.9

Noborio, et al (2007) treated 10 Japanese patients with infl ammatory acne with targeted blue light phototherapy using the MultiClear. Of the 10 patients, eight had a signifi cantly reduced acne severity score without any side effects, while 2 patients discontinued the study because of unsatisfactory results.10

Red light

While less favoured as a light source for mono-phototherapy of infl ammatory acne due to poorer absorption by P. acnes porphyrins, red light has nevertheless also been shown to be effective in the treatment of infl ammatory acne. Na, et al (2007) treated 28 patients with a portable red light-emitting device for 15 minutes twice a day for 8 weeks. In this split-face trial, randomized trial, statistical improvements were noted on the treated side compared to the untreated control side at week 8.11 Zane, et al (2008) demonstrated a signifi cant improvement of acne lesions and a signifi cant decrease of skin sebum excretion and TEWL of the face in patients (n=15) treated with broad-band red (600-750 nm) light twice weekly for 4 weeks.12

3. PDT

Photodynamic therapy (PDT) is a non-invasive therapy that utilizes light treatments along with an application of a photosensitizing agent such as 5-aminolevulinic acid (ALA) or methyl aminolaevulinate (MAL). The photosensitizing agent accumulates in the pilosebaceous unit after being applied topically and incubated for a period of time (75min –180 min).13 This is followed by the administration of light treatment to induce the photodynamic reaction. PDT in the treatment of infl ammatory acne works via several mechanisms including killing of P. acnes following photo-excitation of endogenous porphyrins as well as by destruction of sebaceous glands.

Hongcharu, et al (2000) conducted a randomized controlled trial of ALA-PDT for infl ammatory acne. 22 subjects with acne on the back were treated with ALA (3 hour incubation) followed by irradiation with a 550nm-700nm broad band light source. Signifi cant clinical clearance was evident after 4 weekly ALA-light treatments that lasted for at least 20 weeks. Reduction of sebaceous gland size on histology and reduction of sebum excretion were demonstrated 20 weeks after PDT. Side effects included skin peeling and post-infl ammatory hyperpigmentation.14

Pollock, et al (2004) conducted another randomized intraindividual controlled study of ALA-PDT (3 h, 635nm) on 10 patients. Patients were treated weekly for 3 weeks. Signifi cant reduction of infl ammatory acne lesion counts were found at the ALA-PDT site but not at the control sites. The authors however did not fi nd any reduction of sebum

excretion unlike Hongcharu, et al and postulated that photodynamic killing of the P. acnes may be an alternative mechanism of action.15

Hörfelt, et al (2006) conducted blinded, prospective, randomized, placebo-controlled multicentre study involving 30 patients with moderate to severe acne. This was a split-face study, with a 3-hour drug incubation (using MAL) followed by illumination with red light. A second treatment was given 2 weeks later. At the end of the clinical trial, 12 weeks after the last treatment, there was a statistical reduction in acne lesions of 54% vs. 20% in the control group. As expected, MAL-PDT treated side was associated with more pain than the control side.16

ALA-PDT using IPL as the light source has also been reported to be effective in the treatment of infl ammatory acne. Santos, et al (2005) explored the effectiveness of ALA-PDT in moderate-to-severe infl ammatory acne vulgaris lesions utilizing ALA-PDT and IPL. In this split-face study, 13 patients were treated with the IPL device alone on 1 side of the face and with ALA augmentation on the other (3 hour drug incubation). The procedure was done twice at 2-week intervals. Improvement was more marked in the ALA-treated side of the face starting 4 weeks after treatment. The improvement persisted till 8-week post-treatment. On the other hand, the facial half treated with intense pulsed light only showed a return to baseline of their facial acne.17

In another split-face clinical trial, Rojanamatin, et al (2006) confi rmed the results described by Santos, et al. They evaluated 14 patients in a split-face study with an IPL (3 treatment sessions at 3-4 week intervals) and found that the ALA-IPL combination was superior to treatment with the IPL alone. Lesion counts decreased 87.7% on the ALA pretreated side at 12 weeks as compared to 66.8% on the non-pretreated side.18

Conclusion

Lasers and other light devices are increasingly being shown to be effective in treating infl ammatory acne lesions and their mechanism of actions progressively illuminated. Refi nement in the treatment protocols such as using lower laser fl uences (for the 1450nm diode laser), combining blue and red light (for phototherapy), using lower drug concentrations and shorter drug incubation periods (for PDT) are translating to less patient discomfort and fewer side effects while maintaining treatment effi cacy. The possibility of inducing long-term remission after treatment is exciting. These light modalities are likely to play a signifi cant role in the future management of infl ammatory acne.

References

1. Paithankar DY, Ross EV, Saleh BA, Blair MA, Graham BS. Acne treatment with a 1,450 nm wavelength laser and cryogen spray cooling. Lasers Surg Med 2002;3:106-14

2. Friedman PM, Jih MH, Kimyai-Asadi A, Goldberg LH. Treatment of infl ammatory facial acne vulgaris with the 1450-nm diode laser: a pilot study. Dermatol Surg 2004;30:147-51

3. Jih MH, Friedman PM, Goldberg LH, Robles M, Glaich AS, Kimyai-Asadi A. The 1450-nm diode laser for facial infl ammatory acne vulgaris: dose-response and 12-month follow-up study. J Am Acad Dermatol 2006;55:80-7



4. Bernstein EF. Double-pass, low-fl uence laser treatment using a large spot-size 1,450 nm laser improves acne. Lasers Surg Med 2009;41:116-21

5. Noborio R, Nishida E, Morita A. Clinical effect of low-energy double-pass 1450 nm laser treatment for acne in Asians. Photodermatol Photoimmunol Photomed 2009;25:3-7

6. Yeung CK, Shek SY, Yu CS, Kono T, Chan HH. Treatment of infl ammatory facial acne with 1,450-nm diode laser in Type IV to V Asian skin using an optimal combination of laser parameters. Dermatol Surg 2009;35:593–600

7. Papageorgiou P, Katsambas A, Chu A. Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. Br J Dermatol 2000;142:973-8

8. Tzung TY, Wu KH, Huang ML. Blue light phototherapy in the treatment of acne. Photodermatol Photoimmunol Photomed 2004;20:266-9

9. Lee SY, You CE, Park MY. Blue and red light combination LED phototherapy for acne vulgaris in patients with skin phototype IV. Lasers Surg Med 2007;39:180-8

10. Noborio R, Nishida E, Kurokawa M, Morita A. A new targeted blue light phototherapy for the treatment of acne. Photodermatol Photoimmunol Photomed.. 2007;23:32-4

11. Na JI, Suh DH. Red light phototherapy alone is effective for acne vulgaris: randomized, single-blinded clinical trial. Dermatol Surg 2007;33:1228-33

12. Zane C, Capezzera R, Pedretti A, Facchinetti E, Calzavara-Pinton P. Non-invasive diagnostic evaluation

of phototherapeutic effects of red light phototherapy of acne vulgaris. Photodermatol Photoimmunol Photomed 2008;24:244-8

13. Sakamoto FH, Tannous Z, Doukas AG, Farinelli WA, Smith NA, Zurakowski D, Anderson RR. Porphyrin distribution after topical aminolevulinic acid in a novel porcine model of sebaceous skin. Lasers Surg Med 2009;41:154-60

14. Hongcharu W, Taylor CR, Chang Y, Aghassi D, Suthamjariya K, Anderson RR. Topical ALA-photodynamic therapy for the treatment of acne vulgaris. J Invest Dermatol 2000;115:183-92

15. Pollock B, Turner D, Stringer MR, Bojar RA, Goulden V, Stables GI, Cunliffe WJ. Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical effi cacy and mechanism of action. Br J Dermatol 2004;151:616-22

16. Hörfelt C, Funk J, Frohm-Nilsson M, Wiegleb Edström D, Wennberg AM. Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study. Br J Dermatol 2006;155:608-13

17. Santos MA, Belo VG, Santos G. Effectiveness of photodynamic therapy with topical 5-aminolevulinic acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: comparative study. Dermatol Surg 2005;31:910-5

18. Rojanamatin J, Choawawanich P. Treatment of infl ammatory facial acne vulgaris with intense pulsed light and short contact of topical 5-aminolevulinic acid: a pilot study. Dermatol Surg 2006;32:991-6


Unwanted Hair Removal – An Update

Dr Priya Sen

Background

Hair removal has been practised for centuries in almost all human cultures. Many cultures have an aesthetic ideal amount of hair for both males and

females and any individual whose amount or distribution of hair exceeds this may seek treatment for this. Hair is commonly removed for social reasons related to acceptance in society. The methods used vary according to the region involved as well as accessibility to modern technology such as hair removal light devices and lasers. The removal of unwanted hair has become an increasingly sought after cosmetic procedure by patients attending the National Skin Centre (NSC). In 2007 and 2008, the number of laser hair removal procedures performed at NSC was 642 and 674 respectively.

Common Reasons for Seeking Hair Removal

• Beauty enhancement• Temporary methods such as shaving and waxing

bothersome • Hirsutism related to genetics, hormonal imbalance or

side-effects of drugs• Sexual enhancement and hygiene• Sportsmen to reduce resistance against air or water• Medical indications such as folliculitis, shaving

eczema, acne

Temporary Methods of Hair Removal

Depilation

This involves removal of hair only to the level of skin. The hairs grow back within hours to days. This includes manual or electric devices used for shaving or trimming as well as depilatory creams or shaving powders which chemically dissolve hair.

Epilation

This involves removal of the entire hair including the root. The hairs grow back within days to weeks. Methods include plucking with tweezers, waxing where a hot or cold layer is applied to the skin and then removed with porous strips, sugaring which is similar to waxing but with a sticky paste and threading where a twisted cotton thread catches hairs as it is rolled across the skin. Epilators are mechanical devices which rapidly grasp hairs and then pull them out.

Permanent Methods of Hair Reduction

These methods target areas regulating hair growth. The FDA does not allow for the marketing of technologies and services that state permanent hair removal. The 1998 FDA defi nition states that “Permanent hair reduction is the

long term, stable reduction in the number of hairs regrowing after a treatment regime”.

Permanent Methods of Hair Reduction

1. Electrolysis2. Lasers 3. Intense Pulsed Light (IPL)4. Enzymes that inhibit the development of new hair cells

e.g. efl ornithine hydrochloride (13.9%) or Vaniqa

1. Electrolysis

Electrolysis is a way of removing individual hairs from the face or body. These devices destroy the growth center of the hair using chemical or heat energy. A very fi ne probe is inserted into the hair follicle at the surface of the skin. The hair is then removed harmlessly with forceps.

2. Laser Hair Removal

Hair removal lasers use the principle of selective photothermolysis to remove hair. Melanin pigment is the primary chromophore. There are two types of melanin in hair: eumelanin (which gives hair brown or black color) and pheomelanin (which gives hair blonde or red color). Because of the selective absorption of photons of laser light, only black or brown hair can be removed. By selectively targeting melanin in the hair follicle, the heat generated during the treatment only damages the hair follicle allowing for protection of the surrounding skin structures. Current lasers have epidermal cooling systems incorporated to allow for use of higher fl uences whilst reducing pain and side-effects especially in darker skin types.

There are a multitude of hair removal lasers in the market of varying wavelengths and are defi ned by the lasing medium used to create the wavelength (measured in nanometers (nm). At NSC, the long pulsed Nd:YAG (1064nm) is used as it is safe for all skin types especially those with darker skin.

Types of Hair Removal Lasers

• Long pulsed Ruby (694nm) not safe in non-white skin Epilaser, EpiTouch Silk Laser, Rubystar, Chromos• Long pulsed Alexandrite (735nm) most effective but

safest on light skin Apogee, PhotoGenica, EpiTouch 5100, GentleLase

• Long pulsed Diode (810nm) light to medium type skin

Lightsheer, LaserLite• Long pulsed Nd:YAG (1064nm) safe for all skin types

esp dark skin Coolglide, Lyra, GentleYAG, Sciton, Xeo

INVITED ARTICLE 2

* Consultant Dermatologist, National Skin Centre


Fig 1. Facial hair reduction with the long-pulsed Nd:YAG laser

Before Treatment After 4 laser treatments + daily use of Vaniqa®

Fig 2. Facial hair reduction with the long-pulsed Nd:YAG laser

Before Treatment After 5 Treatments

Fig 3. Axillary hair reduction with the long-pulsed Nd:YAG laser

Before Treatment After 2 Treatments

Update on hair removal


Laser Parameters

1. Pulse width – Published studies have shown that longer pulse widths are safer in darker skin

2. Spot size – larger spot sizes enable more hairs to be removed at the same time

3. Fluence (J/cm2) – the higher the fl uence the higher the chance of permanent hair reduction

4. Repetition rate – shooting more than 1 pulse with a specifi c delay between pulses can cause a slight improvement in the heating of a particular area

Number of laser treatments required

This is dependent on a multitude of factors including skin type, thickness of hair, colour of hair, stage of hair cycle, area being treated and sex of the patient. Lasers work best in the anagen phase of hair growth when melanin is most abundant. Treatments should be spaced at least 4 weeks apart to allow a suffi cient interval for shedding of the treated hairs.

Treatment Area Average no. of sessions required

Axillae 4-6 sessions

Lower legs 5-7 sessions

Face 5-7 sessions

Bikini line/brazilian 4-6 sessions

Arms 5-7 sessions

It is important to exclude underlying hormonal imbalances when treating female patients with male pattern hirsutism. In females with hirsutism check blood for DHEA,17-OHprogesterone, free or total testosterone

3. IPL

This is a fl ashlamp that emits non-coherent light at a spectrum of wavelengths 500-1200nm. The intense light travels through the tissue of the skin until it strikes

the hair shafts or the bulb (root) of the hair. The bulb is usually where the highest concentration of melanin is located, as opposed to the rest of the hair shaft. The light is converted to heat energy. The bulb and most of the hair shaft are instantly vaporized. The intense heat radiated by the hair also destroys the hair-producing papilla or the entire hair follicle. The number of sessions required when using IPL is similar if not slightly increased when compared to using lasers. It works better than lasers for skin types I-II when the hairs are brown and not black; however is not as safe as the long pulsed Nd:YAG in darker skin types.

Neither IPL nor lasers work on white or very fine vellus hair and patients have to be told this before any treatment is commenced. The ideal candidate for lasers or IPL is an individual with fair skin and thick dark hair which is in the anagen phase of hair growth.

4. Efl ornithine hydrochloride (13.9%) cream (Vaniqa®)

This has been FDA approved for reducing the growth of unwanted facial hair in women. It inhibits hair growth by irreversible blockage of ornithine decarboxylase resulting in a decrease in polyamines which are critical binding blocks for rapidly dividing tissues such as hair. Clinical studies have shown that Vaniqa® improves the effectiveness of laser hair removal when used in combination and can reduce the number of laser sessions required to achieve clearance of hair. It takes up to 8 weeks to see the effects. In clinical trials, some women reported mild and temporary skin irritations such as redness, stinging, burning, tingling, acne or rash.

Discussion

In our Asian context, it is important to understand the skin types and technologies available for safe and effective reduction in hair growth. Patients must be counseled on the risks and precautions to be taken. The long pulsed Nd:YAG laser is a safe and effective choice in achieving permanent hair reduction in Asian skin.

Update on hair removal


A Retrospective Review Of Mohs Micrographic Surgery Performed At The National Skin Centre

Dr Tan Wee Ping*, Dr Heng Yee Kiat**, Dr Melvin Ee Hock Leong***

*Associate Consultant Dermatologist**Registrar***Consultant Dermatologist, National Skin Centre

ORIGINAL ARTICLE 1

Introduction

Mohs micrographic surgery (MMS) has been practised for more than 70 years and is considered the treatment of choice for certain non melanoma

skin cancers with high risk characteristics. The technique involves a series of excisions of thin layers of tissue1,2. Each layer is subdivided, colour-coded with ink, carefully mapped corresponding to its anatomic orientation, then prepared with frozen sections for histologic review. Tissue sections on microscope slides, corresponding to each of the mapped subdivisions of the tumour, are examined under the microscope by the Mohs surgeon. The histologic sections are cut in a special horizontal fashion so that they completely reveal the peripheral margins of the surgical specimen, both deep and lateral. When a microscopic section contains tumour cells, it means that the tumour has extended to the peripheral margin of the surgical specimen in that subdivision. The Mohs surgeon examines the slides and notes all areas of tumour on the tissue map. The next surgical stage involves taking a thin layer of tissue only from areas that correspond to the mapped positive margins. In this fashion, consecutive layers are taken as the clinically silent extensions of tumour are traced out and resected.MMS using horizontal frozen sections has achieved wide acceptance as the optimal treatment for basal cell carcinomas (BCC) and squamous cell carcinomas (SCC) which fulfi ll certain characteristics. Incompletely excised or recurrent tumours, tumours on the face, genitalia or extremities where tissue conservation is crucial are best treated by MMS. Certain morphological or histological features of tumours e.g. morpheaform, infi ltrating, micronodular BCC or moderately or poorly differentiated SCC, associated with a higher probability of recurrence should ideally be treated with MMS. BCC and SCC larger than 6mm in areas like ears, lip, nose, temples and periorbital skin are best treated by MMS. Similarly, those larger than 10mm over the cheek, forehead and scalp should be referred for MMS. MMS using frozen sections has also been described in the treatment of

other tumours, including extramammary Paget’s disease, microcystic adnexal carcinoma and primary cutaneous neuroendocrine tumours.

The Mohs micrographic surgical service commenced at the National Skin Centre, Singapore in November 2007. In this report, we describe our experience with 120 patients in whom MMS was performed.

Methods

We reviewed the medical records of 120 patients treated at the National Skin Centre, Singapore with MMS between 1 January 2008 and 31 December 2008. The following information was extracted from each patient’s records: age, gender, race, tumour type and location, history of previous treatment, pre-operative tumour size, size of postoperative surgical defect, number of stages required to complete the procedure, type of surgical repair and number of recurrences.

Mohs Procedure

All patients are screened pre-operatively for the suitability of MMS. Standard informed consent is obtained pre-operatively. After these arrangements, the patient is prepped and draped under a clean environment. Local anaesthesia is achieved with 1% lignocaine and 1:100000 epinephrine mixed with sodium bicarbonate. The margins of the neoplasm are assessed clinically and marked with skin marker. The lesion is fi rst debulked by curettage whenever possible and tumour margins delineated. A 1mm margin is scored around the surgical defect before it is excised with a scalpel using a 45º inward bevel. The depth of excision is based on the clinical extent of the neoplasm. Following removal, strict orientation and mapping of the specimen is performed and it is immediately transported to the histopathology laboratory. Haemostasis is achieved using electrofulgaration and a pressure dressing is applied.

Abstract

Introduction: The Mohs micrographic surgical service commenced at the National Skin Centre, Singapore in November 2007. In this report, we describe our experience with 120 patients in whom MMS was performed. Methods: A retrospective case records review of patients treated at the National Skin Centre with MMS between 1 January 2008 and 31 December 2008 was conducted. Results: A total of 129 tumours in 120 patients were removed by MMS during this period. The most common tumour was basal cell carcinoma, accounting for 85.3%, followed by squamous cell carcinoma (11.6%). The indications for MMS included recurrent or persistent tumours after previous excisions, site and/or size of tumours and aggressive histological subtypes of tumours. Complications of surgery occurred in only seven of the 129 tumours treated (5.4%). Conclusion: MMS is a safe and reliable method of treatment for a variety of skin tumours. Superior cure rates are achieved compared to other skin cancer treatment modalities because it uses the most complete and accurate method for microscopically checking all of the surgical margins of the resected tissue, whilst keeping resection of surrounding normal tissue to a minimum.


The processed slides is presented back to the dermatologist/mohs surgeon for assessment and if any margins are positive for tumour, the patient is prepped and draped in a clean fashion and local anaesthesia in the area of residual tumour is achieved. A further 1mm margin of normal-appearing skin is excised to encompass the areas noted to be positive for neoplasm on the previous stage or a deeper section is procured. This process of histological wound examination and further excision continues till all the margins are histologically free of tumour. The patient will then return for wound closure by the same dermatologist/mohs surgeon.

Results

A total of 129 tumours in 120 patients were removed by MMS during this period. Nine patients had more than one tumour; eight of these patients had two BCC and one patient had one each of BCC and SCC. The most common tumour was BCC, accounting for 85.3%, and the most common BCC histologic subtype was the nodular subtype. SCC accounted for the majority of the rest (11.6%), and the remaining were two cases each of sebaceous carcinoma and extramammary Paget’s disease. Most were performed over the head and neck, with only one over the chest (morpheaform BCC) and two over the genitalia (extramammary Paget’s disease). Nineteen MMS were performed on incompletely excised tumours; seventeen tumours had one previous excision and two had two previous excisions.

117 were standard MMS, with use of horizontal frozen sections. Three required the use of paraffi n-embedded sections (two cases of sebaceous carcinoma and one extramammary Paget’s disease). The mean number of surgical stages necessary to clear margins was 1.78. Four or more stages were required in nine cases of BCC (two infi ltrative and seven nodular) and one case of moderately-differentiated SCC. Most of the surgical defects were closed by the Mohs surgeon. The wounds were closed directly in 46.5% of the cases. A variety of fl aps, including different types of advancement, transposition and rotation fl aps were required in 23 cases (17.8%). Full thickness skin grafts were necessary in ten (7.8%). Nine of these were for defects over the nose and one over the forehead. The wounds were left to heal by secondary intention in six cases (4.7%) involving the concavities of the ala nasi and ears. Nine MMS performed over the periorbital region required assistance from oculoplastic surgeons for closure. Three large defects over the scalp, cheek and forehead were referred to plastic surgeons for repair.

Complications of surgery occurred in seven patients. Two patients had mild wound dehiscence over the scalp. Two patients had partial tip necrosis of their fl aps and one patient had partial graft necrosis. All recovered well with secondary intention healing of their wounds. One patient developed hypertrophy of the fl ap and the last patient developed keloids after surgery over the chest requiring intralesional triamcinolone injections. All patients were followed up for a minimum of three to six months and none had recurrence at this duration of follow-up.

Discussion

Our study has shown that MMS can be used effectively to treat a variety of neoplasms locally. It is a microscopically

controlled method of tumour excision, allowing maximal tissue conservation while minimizing recurrence rates.

In our series, 21 tumours treated with MMS were BCC or SCC of histological subtypes associated with higher risk of recurrence and 19 tumours were recurrent or persistent tumours. 51 were performed over sites where tissue conservation was important such as periorbital region, ears, nose, lip and temples. The modifi cation of MMS with paraffi n-embedded sections has also allowed it to be used successfully to treat some other types of skin tumours like sebaceous carcinoma and dermatofibrosarcoma protuberans. In our series, paraffi n-embedded sections were used in the treatment of sebaceous carcinoma and extramammary Paget’s disease. Other types of skin tumours that may be treated with this modifi cation of MMS include microcystic adnexal carcinoma, dermatofi brosarcoma protuberans and Merkel cell carcinoma3.

Because of the more accurate determination of tumour-free margins in MMS, superior cure rates of BCC and SCC result after MMS when compared to other treatment modalities4,5. Five-year recurrence rates for primary BCC following MMS and conventional surgical excision with predetermined margins are 1% and 10% respectively. For recurrent BCC, superior cure rates are also seen following MMS, with recurrence rates of 5.6% compared to 17.4% following conventional surgical excision. For SCC, fi ve-year recurrence rates for primary SCC of the skin and lip following MMS and conventional surgical excision are 3.1% and 10.9% respectively. In our cohort of patients, none recurred after a follow-up of at least 3-6 months. This contrasts sharply with the clearance rates of 84.9% and 84.1% previously reported for conventional BCC and SCC excision from our centre6,7.

In conclusion, MMS is a safe and reliable method of treatment for a variety of skin tumours. It may be performed with frozen section method or paraffi n-embedded method. Superior cure rates are achieved compared to other skin cancer treatment modalities because it uses the most complete and accurate method for microscopically checking all of the surgical margins of the resected tissue, whilst keeping resection of surrounding normal tissue to a minimum.

References:

1. Buker JL, Amonette RA. Micrographic surgery. Clin Dermatol 1992;10:309-15.

2. Telfer NR. Mohs Micrographic surgery for nonmelanoma skin cancer. Clin Dermatol 1995;13:593-600.

3. Barlow RJ, Ramnarain N, Smith N, et al. Excision of selected skin tumours using Moh’s micrographic surgery with horizontal paraffi n-embedded sections. Br J Dermatol 1996;135:911-17.

4. Rowe DE. Comparison of treatment modalities for basal cell carcinoma. Clin Dermatol 1995;13: 617-20.

5. Geisse JK. Comparison of treatment modalities for squamous cell carcinoma. Clin Dermatol 1995; 13:621-6.

6. Goh BK, Ang P, Wu YJ, Goh CL. Characteristics of basal cell carcinoma amongst Asians in Singapore and comparison between completely and incompletely excised tumours. Int J Dermatol 2006; 45: 561-4.

7. Ang P, Tan AW, Goh CL. Comparison of completely versus incompletely excised cutaneous squamous cell carcinomas. Ann Acad Med Singapore 2004; 33: 68-70.

Mohs micrographic surgery at NSC


Clinical Outcomes In Patients With Incomplete Mohs Excisions For Periocular Non Melanoma Skin Cancer

Dr Melvin Ee Hock Leong*, Dr Nabeel Malik**, Dr Raman Malhotra**, Dr Richard Collin***, Dr Naresh Joshi****, Dr Jane Olver*****, Dr Richard Barlow******

*Consultant Dermatologist, National Skin Centre, Singapore**Queen Victoria Hospital NHS Foundation Trust, United Kingdom***Moorfi elds Eye Hospital NHS Foundation Trust, United Kingdom****Chelsea and Westminster Hospital NHS Foundation Trust, United Kingdom*****Western Eye Hospital, Imperial College Healthcare NHS Trust, United Kingdom******St John’s Institute of Dermatology, St. Thomas’ Hospital, United Kingdom

ORIGINAL ARTICLE 2

Introduction

Up to 10% of skin cancers occur in periocular tissue, namely the upper lid and eyebrow, the lower lid to the orbital rim, the lateral and medial

canthi1. At these sites, both complete tumour removal and preservation of surrounding unaffected skin are particularly important for functional and cosmetic reasons.

Mohs micrographic surgery is associated with cure rates of approximately 95-100% for primary periocular skin tumours and 92% for “recurrent”/persistent lesions, respectively2,3. When performing periocular Mohs micrographic excisions under local anaesthetic, it may be diffi cult or impossible to dissect a further horizontal layer when tumour extends onto the bulbar conjunctiva or deep retro-orbital fat or when it is adherent to the episclera or bone. Under these circumstances, tumour can be assumed to persist on or in these tissues.

We report a series of 12 such patients. In addition to unanticipated incomplete Mohs excisions, micrographic surgery is sometimes undertaken with the limited objective of obtaining tumour-free cutaneous margins in the context of known extension of tumour onto orbital tissue or bone.

In both groups, subsequent management may consist of further attempted clearance of tumour under general anaesthetic, possibly with exenteration, or may be limited to reconstruction and observation.

Materials and Methods

We reviewed the notes of all patients (treated at St John’s Institute of Dermatology between January 1999 and

December 2007) in whom attempted Mohs excisions had been suspended despite positive margins involving bone, the globe, or retro-orbital fat. All were referred by oculoplastic units, where they were managed post-operatively.

Mohs micrographic surgery was performed with dissection of horizontal layers, 1-2 mm in thickness. After infi ltration with 2% lidocaine containing epinephrine, curettage or excision was used to debulk the tumour and to defi ne its clinical margins. The fi rst layer was then cut, notched and

Abstract

We reviewed the case notes of 12 patients with periocular non-melanoma skin cancer in whom attempted Mohs excisions had been incomplete. Subsequent management was conservative in six patients and surgical in six. Approximately 1000 periocular Mohs procedures were performed between January 1999 and December 2007. We were unable to obtain tumour free margins in 12 of these patients because of involvement by tumour of the globe, deep retro-orbital fat or bone. Six patients had basal cell carcinomas (BCC), fi ve squamous cell carcinomas (SCC) and one a sebaceous gland carcinoma (SGC) with Pagetoid spread onto the bulbar conjunctiva. Five (two BCC, three SCC) of the six patients with primary tumours were subsequently managed conservatively. The sixth patient had a large SCC and was subjected to local orbital clearance (local orbitectomy). All of the remaining six patients had had previous surgery or radiotherapy. Five (four BCC, one SCC) were treated with local orbitectomy. The twelfth patient had a sebaceous gland carcinoma (SGC) and was managed with exenteration. Only one patient (with a BCC treated with radiotherapy before persistent disease was recognised and referred for Mohs surgery) has manifested continued persistent tumour in the form of an orbital mass one year after orbitectomy. This was treated with exenteration.


transferred so that anatomical orientation was maintained. The tissue layer was divided into sections, colour coded and mapped. Frozen sections were prepared in 11 patients, stained with haematoxylin and eosin and examined by the Mohs surgeon. In one patient with a sebaceous carcinoma, paraffi n-embedded sections were used in order to track Pagetoid spread in the conjunctiva.

We recorded age, sex, diagnosis, treatment history, tumour site, fi nal wound size, number of Mohs layers and area of histological persistence. We also reviewed subsequent surgical management, if any, including post operative imaging and long term follow up for persistence.

Results

Over 4,000 Mohs procedures were performed between 1999-2007, of which approximately a quarter included periocular tumours. Of these, we identifi ed 12 patients (8 female), mean age 70 (range 51-88) years in whom tumour was known to persist at the conclusion of Mohs surgery. The mean duration from onset was 1.95 (range 0.5-5) years (Table 1) and the mean follow-up period was 3.7 (range 0.5–7) years.

Basal cell carcinomas (BCC) were present in six patients, squamous cell carcinomas (SCC) in fi ve and a primary

Table 1: Biographical and surgical data

Patient Age (years)

Time from onset

(years)

Treatment history Site Wound size (mm)

Mohs layers

Area of Persistence

A (8) 89 1.5 Primary BCC Medial canthus 12x12 4 Retro orbital fatB (9) – 1 Primary BCC Medial canthus 12x6 3 Bulbar conjunctivaC (6) 67 0.5 Primary SCC Medial canthus 13x10 3 Bulbar conjunctiva,

retro-orbital fatD (7) 89 1 Primary SCC Lower Lid 18x11 3 Retro-orbital fatE (10) 67 2 Primary SCC Upper Lid 10x5 2 Bulbar conjunctiva,

nasal boneF (11) 73 1 Primary SCC Lateral canthus 21x40 15 Bulbar conjunctivaG (1) 84 2 BCC post

radiotherapyMedial canthus 15x8 5 Episclera

H (4) 56 5 BCC post radiotherapy

Medial canthus 20x16 2 Bulbar conjunctiva, retro-orbital fat

I (2) 74 1.5 BCC post surgery Lower Lid 12x4 3 Bulbar conjunctivaJ (12) 74 1.5 Recurrent BCC Lateral canthus 9x32 7 Bulbar conjunctivaK (5) 86 2 SCC post

radiotherapyUpper Lid 16x4 2 Bulbar conjunctiva,

retro-orbital fatL (3) 62 3 Sebaceous ca,

post surgeryUpper Lid 15x7 2 Slow Bulbar conjunctiva

Table 2: Subsequent clinical course

Patient Post-Mohs intervention Post Op Imaging Follow up (years) Subsequent courseA Nil Nil 5 Clinically clearB Nil Nil 1.5 Clinically clearC Nil 2 yearly MRI 9 Clinically clearD Nil Nil 2 (died, unrelated

causes)Clinically clear

E Nil Nil 7 Clinically clearF Local

orbitectomy + IMRTYearly 1 Clinically clear

G Local orbitectomy Nil 1 Eyelid mass. Subsequent exenteration

H Local orbitectomy Yearly MRI 5 Clinically clear I Local orbitectomy Nil 1 Clinically clearJ Local orbitectomy Yearly 1 Clinically clearK Local orbitectomy Nil 2 (died, unrelated

causes)Clinically clear

L Exenteration Nil 3 Clinically clearIMRT=Immune-modulated radiotherapy

Periocular non melanoma skin cancer


sebaceous gland carcinoma in the remaining patient. Six patients, (two BCC, four SCC) had not been treated previously. The remaining patients (four BCC, one SCC, one sebaceous carcinoma) had lesions which had persisted despite previous surgery or radiotherapy.

The medial canthus was the site most commonly affected (5), followed by the upper eyelid (3), lower eyelid (2) and lateral canthus (2). All tumours required at least two Mohs levels (range 2-15).

Of the six patients with primary tumours (patients A-F), fi ve (four BCC, one SCC) were subsequently managed conservatively (Table 2). This decision was largely a consequence of these patients declining further surgery. None of this group has manifested persistent tumour. The sixth patient (patient F) had a large SCC and was subjected to local orbital clearance, or orbitectomy (globe-sparing excision of orbital tissue in the involved orbital quadrant). This patient was also subjected to further adjunctive immune-modulated radiotherapy.

All of the remaining six patients (patients G-L) had had previous surgery or radiotherapy. Five of these (four BCC, one SCC) were subsequently managed with orbitectomy. The remaining patient (patient L) had a sebaceous gland carcinoma and was treated with exenteration because of Pagetoid extension beyond the fornix superiorly and onto the bulbar conjunctiva. This patient has been followed for three years without clinical or radiographic evidence of persistent or metastatic disease.

Of all 12 patients, only one has developed persistent tumour (Patient G). This patient had previously had radiotherapy for a medial canthal BCC and was subjected to orbitectomy following incomplete Mohs surgery. The patient developed a frozen orbit post-operatively. One year later, she developed an orbital recurrence which was treated with exenteration. There has been no clinical evidence to date (4 years) of persistent disease.

Discussion

Mohs micrographic surgery (MMS) is widely recognized as the optimal surgical procedure for removing non-melanoma skin cancer involving the eyelid. Malhotra et al2 reported fi ve-year recurrence rates of 0% and 7.8% for primary and persistent periocular BCC, respectively. Similarly, the Australian database for periocular SCC managed by MMS reported a recurrence rate of 3.64%, which is lower than other treatment modalities.3

Our study describes the clinical features and treatment outcomes in 12 patients in whom Mohs surgery had been attempted for periocular non-melanoma skin cancer and was incomplete. These represent a small fraction of the more than 1,000 periocular Mohs procedures performed in our Unit between 1999-2007. Some patients had primary and others had persistent tumours. The medial canthus was the commonest anatomical site. In contrast to previous reports4, there was no correlation between the number of Mohs levels and the likelihood of incomplete excision.

Although it was not the aim of our study to identify patients with a likely outcome of incomplete Mohs surgery, our

experience was similar to that of Madhani et al5. Factors predictive of incomplete excisions included previous surgery or radiotherapy, a periocular (and especially medial canthal) site, infi ltrative BCC and poorly differentiated or large (> 1cm) SCC.

In our study, one patient had tumour extending into episcleral tissue, nine patients had tumour extending into conjunctiva, three had tumour involving the conjunctiva and retro orbital fat and two patients had tumour involving the retro orbital fat alone. (Table1). Of these, the only patient (patient G) who developed persistent disease had a treatment history of radiotherapy for a medial canthal BCC. There was no evidence of any bony involvement pre-operatively on computerised tomography (CT) nor any soft tissue involvement on magnetic resonance imaging (MRI). Mohs surgery was incomplete because tumour was adherent to the episclera. The patient was submitted for orbitectomy but subsequently developed an orbital mass and required exenteration.

The subsequent management of patients with incompletely excised non-melanoma skin cancer is sometimes infl uenced by the consideration that tumour persistence is not inevitable. In reports of patients reviewed after incomplete excision of unselected non-melanoma skin cancer 8-12, subsequent recurrence rates varied from 35% to 67%. Furthermore, studies of incompletely excised BCCs on the eyelids have shown that up to 65% do not persist clinically13-15. In another study16 of 1392 unselected BCC, 7% were reported as incompletely excised. Of the 75% that were re-excised, residual tumour was reported histologically (again with vertical sections) in 54%. In the same study, 13% of peri-ocular lesions were reported as incompletely excised whereas, in contrast, only 25% of re-excisions showed residual tumour. Some authors will therefore argue for a conservative approach to the management of patients with incompletely excised periocular tumours, particularly when the alternative would be exenteration of the eye.

Whatever their views on BCC, most practitioners seem to proceed to re-excision of incompletely excised SCC. In this group, data is limited for histological examination of re-excised tissue. In a retrospective study of 676 SCCs, 17.6% of the cases were incompletely excised. The majority were re-excised and histological examination revealed residual SCC in 28.6% of these specimens.

We have been able to fi nd only one other study18 of the signifi cance of positive margins after attempted Mohs excisions in patients with periocular tumours. All six patients were subjected to further surgery, which involved exenteration in two. Five patients remained clinically tumour-free at four months, while the sixth had tumour persisting despite exenteration and further excisions. In summary, incomplete Mohs excisions are unusual but may be more common around the eye. In our patients, this outcome was more likely in the elderly and after radiotherapy, in patients with medial canthal tumours, infi ltrative BCC or poorly-differentiated SCC. All six patients who were managed conservatively were done so largely owing to their reluctance about further surgery. Tumour persistence has not be noted in this group though has




occurred in one of the six patients managed with further surgery. This is the only patient in whom Mohs surgery was abandoned because of infi ltration by tumour of the episclera. In view of the functional and other implications of orbitectomy or exenteration, these data may give cause for cautious optimism in conservative or relatively conservative management of patients with incomplete Mohs excisions of periocular tumours .

References:

1. Kleinstein RN, Lehman HF. Incidence and prevalence of eye cancer. Am J OptomPhysiol Optics 1977;54:49 –51

2. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database, part II: periocular basal cell carcinoma outcome at 5-year follow-up. Ophthalmology.2004 ;111:631-6

3. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs database: periocular squamous cell carcinoma. Ophthalmology 2004;111:617– 623

4. Malhotra R, Huilgol SC, Huynh NT, Selva D. The Australian Mohs Database, Part I Periocular Basal Cell Carcinoma Experience over 7 Years. Ophthalmology 2004:624-630

5. Madani S, Huilgol SC, Carruthers A. Unplanned incomplete Mohs micrographic surgery.Am Acad Dermatol. 2000 May;42(5 Pt 1):814-9

6. Bovill ES, Cullen KW, Barrett W, Banwell PE. Clinical and histological fi ndings in re-excision of incompletely excised cutaneous squamous cell carcinoma. JPlastReconstrAesthet Surg. 2008 Jan 19. [Epub ahead of print]

7. Hamada S, Kersey T, Thaller VT. Eyelid basal cell carcinoma: non-Mohs excision, repair, and outcome. Br J Ophthalmol 2005;89:992–994

8. Shanoff LB, Spira M, Hardy SB. Basal cell carcinoma: a stat ist ical approach to rat ional management. OphthalmolPlastReconstrSurg 1967;39:619 – 624.30

9. DeSilva SP, Dellon AL. Recurrence rate of positive margin basal cell carcinoma results of a fi ve-year prospective study. J SurgOncol 1985; 28: 72 ± 4

10. Sarma DP, Griffing CC, Weilbaecher TG. Observations on the inadequately excised basal cell carcinomas. J SurgOncol 1984;25:79 – 80

11. Richmond JD, Davie RM. The signifi cance of incomplete excision in patients with basal cell carcinoma. Br J PlastSurg 1987; 40: 63 ± 7

12. Hauben DJ, Zirkin H, Mahler D, et al. The biologic behavior of basal cell carcinoma: analysis of recurrence in excised basal cell carcinoma: part II. PlastReconstrSurg 1982;69: 110 –116

13. Dellon AL, DeSilva S, Connolly M, Ross A. Prediction of recurrence in incompletely excised basal cell carcinoma. PlastReconstrSurg 1985; 75: 860 -71

14. Liu FF, Maki R, Warde P, Payne D, Fitzpatrick P. A management approach to incompletely excised basal cell carcinomas of skin. Int J RadiatOncolBiol Phys 1991; 20: 423 - 8

15. Gooding CA, White G, Yatsuhashi M. Signifi cance of marginal extension in excised basal cell carcinoma. N Engl J Med 1965; 273:923 - 4

16. Griffi ths RW.Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision.Br J Plast Surg. 1999 Jan;52:24-8

17. Berlin J, Katz KH, Helm KF, Maloney ME. The signifi cance of tumor persistence after incomplete excision of basal cell carcinoma. J Am Acad Dermatol. 2002 Apr;46(4):549-553

18. Boynton JR, Rounds MF, Quatela VC, Brown MD. The significance of positive margins (known and unknown) at the conclusion of Mohs surgery in the orbital region. OphthalPlastReconstr Surg.1996 ;12:51-7

19. Sussman LA, Liggins DF. Incompletely excised basal cell carcinoma: a management dilemma? Aust N Z J Surg 1996;66:276–8


Fractional Ablative Skin Resurfacing With A Novel Carbon Dioxide Laser System In The Treatment Of Atrophic Acne Scars In Asian Skin

Dr Melvin Ee Hock Leong*, Dr Chua Sze Hon**, Dr Tan Sze-Chin***, Dr Priya Sen*, Clin Prof Goh Chee Leok**

* Consultant Dermatologist** Senior Consultant Dermatologist***Medical Offi cer, National Skin Centre

ORIGINAL ARTICLE 3

Introduction

Ablative carbon dioxide (CO2) resurfacing has always been regarded as the gold standard for skin resurfacing. Clinical improvements of 30% to 75%

can be achieved for patients with atrophic acne scars.1-2 However, it is coupled by a long downtime and carries with it a risk of prolonged erythema and dyspigmentation, making it less attractive as a treatment option among patients. As a result, the concept of fractional resurfacing was recently introduced. Although the results are in general not as dramatic as with carbon dioxide lasering, they purport to be remarkable, measurable, and consistent. In particular, the lack of downtime and the decreased risk for complications make them a more attractive alternative to carbon dioxide laser resurfacing.

Recently, 2 studies have successfully demonstrated the use of ablative fractional CO2 on human skin 3-4. There is at present little published data on the clinical effectiveness of such fractional ablative lasers in the treatment of atrophic acne scars and the safety of their use in patients with darker skin types. The aim of this preliminary study was to determine the clinical effectiveness and safety of a novel fractional ablative carbon dioxide laser in the treatment of facial atrophic acne scars in darker skin Asian patients. Secondary benefits such as reduction in seborrhea, reduction in pore size, and improvement in skin texture were also evaluated.

Methodology

This is a prospective noncomparative open study. 17 consecutive patients with moderate to severe facial

atrophic acne scars and no active acne vulgaris were recruited for the study from December 2007 to February 2008. The study protocol also conformed to the guidelines of the 1975 Declaration of Helsinki. All patients were counseled and informed consent was obtained before commencement of the study. Inclusion criteria were age greater than 18 years of age (minimal age of consent in Singapore), facial acne scars of the atrophic type, and no active inflammatory acne over the past 6 months. Patients with the following exclusion criteria were not included: patients with active acne, patients on systemic isotretinoin therapy over the past 12 months, pregnant women, patients with hypertrophic or keloidal acne scars, and patients who were on other forms of acne scar treatment, for example, other forms of resurfacing techniques over the past 6 months.

Treatment protocol

Patients were treated with a new carbon dioxide laser (SLIM Evolution, Lasering, Modena, Italy) with a fractional modality (MiXto SX) coupled to a high-speed scanner. The MiXto SX™ is a microspot fractional carbon dioxide laser coupled with a computerized pattern generator. It can perform fractional resurfacing with a spot size of 300 microns, at depths ranging from 20-500 microns and treating 20-100% of the scanned areas. Pretreatment anesthetic cream (EMLA, AstraZeneca) was applied 2 hours before the laser treatment to minimize patient discomfort during the procedure. The following treatment variables were used: Index 6-8 (pulse duration: 2.5-3.5ms); power 8-14 watts; fluence, 28 to 69 J/cm2. The acne scars were treated with 1– 3 overlapping passes over the affected

Abstract

Aims: This preliminary study aims to document the clinical effectiveness and the safety of its use in patients with darker skin types in the treatment of facial atrophic acne scars in Type IV-V Asian skin. Methods: This is a prospective non-comparative open study. Seventeen patients with moderate to severe facial atrophic acne scars were recruited. Only one laser treatment session was performed. Clinical evaluations of skin texture, side effects and photography were conducted before the procedure, immediately after and at 30 days after treatment. Both patients and two blinded non-treating dermatologists subjectively assessed the degree of improvement. Patient satisfaction surveys were also obtained. Results: Even at 1 month, subjective grading by the patients and blinded dermatologists confi rmed that 5.88% vs. 35.3% no change (0%), 76.5% vs. 47% mild improvement (<25% improvement), 5.88% vs. 17.65% moderate improvement (25-49% improvement) and 11.8% vs. 0% marked improvement (50-74%) respectively. There were also documented improvement in reduction in pore size, skin texture and skin tightening over treated areas in 29%, 35% and 6% of the patients respectively. Patient satisfaction survey results mirrored the observed improvement. Common side effects included moderate pain during the treatment, transient erythema lasting up to 7 days and exacerbation of acne vulgaris in 1 case, which was promptly resolved with oral antibiotics. There was 1 (6%) case of pigmentary disturbance but no herpes activation or increased scarring. Conclusions: Fractional ablative carbon dioxide laser resurfacing is a modestly effective modality in improving facial atrophic scars after one treatment. The procedure is associated with minimal downtime and is safe for use in darker skin Types IV and V.


areas and the surrounding skin. Only one treatment session was performed.

Post-operatively, the lasered areas were cleansed with normal saline 4 hourly and emollient (white soft paraffi n) applied 3-4 times a day till the process of scabbing passed. The patients were instructed to keep away from the sun and to avoid the use of cosmetics for 2 weeks. They restarted their use of sunscreen after the scabbing has cleared.

Assessment of response

The patients were evaluated at baseline and 1 month postoperatively. Photographs were obtained from the front and side of both cheeks at every visit. The same photographer took these with the same camera settings and ambient lighting.

Patients were asked to grade their treatment response subjectively. The patients graded the degree of improvement at 1 month. The degree of improvement was graded into 5 levels of response, no change (0%), mild improvement (<25% improvement), moderate improvement (25-49% improvement), marked improvement (50-74%) and almost to complete clearance (75-100%). In addition, 2

independent blinded dermatologists (Sen & Chan) who were not involved in patient treatment were also asked to grade the improvement using photographs (baseline and 1 month post treatment). The lower determination of the 2 was used as the fi nal result.

Complications including erythema, increased scarring, acne exacerbation, hyperpigmentation and hypopigmentation were also recorded and graded (nil, mild, moderate and severe) by the primary investigators and blinded dermatologists.

Secondary response variables such as effects on seborrhea, skin texture, pore size, and skin tightening over the treated areas as reported by patients was also recorded. These variables were assessed by direct questioning of the patients 1 month after the treatment in the form of a structured questionnaire in which patients were asked to rate each variable as being worse, no change, or improved compared with the same variable before treatment.

Pain intensity was also assessed using a visual analogue scale with a grading of 0 to 10. (Table 1) In addition, satisfaction scores were derived using a 10-point scale. (Table 2)

Fractional CO2 laser treatment of atrophic acne scars

Figure 1: (A, B, C). Baseline Photographs. Figure (D, E, F) Moderate improvement 1 month after 1 treatment.

A B C

D E F



Table 1 Patient subjective satisfaction grading system

Score 1-2 3-4 5-6 7-10Patient’s

satisfactionDisappointed A little

satisfi edQuite

satisfi edVery

satisfi ed

Table 2 Patient subjective pain scoring system

Score Characteristic of Pain

0 No pain

1-2 Mild pain, annoying

3-4 Nagging pain, uncomfortable, annoying

5-6 Miserable, distressing

7-8 Intense, dreadful, horrible

9-10 Worst pain possible, unbearable

Results

The clinical data of 17 patients who completed just one treatment were analyzed. All patients were of Fitzpatrick skin types IV and V. The mean age was 36 years (range, 18–64 years). The male-to-female ratio was 4.5:1. All the patients completed the treatment and were assessed at 1-month post treatment.

Subjective patient assessment

Subjectively, almost every patient (16/17) felt that they had at least mild improvement. The majority (13/17) felt they had mild (<25%) improvement while 1 felt there was moderate (25-49%) improvement and 2 indicated marked (50-74%) improvement. 1 patient felt there was no improvement.

Patients assessment of secondary response after 1 month are as follows: improvement was reported in 70% of cases for seborrhea, 35% in skin texture, 29% in pore size, and 6% in skin tightening over the treated area.

The majority of patients derived some satisfaction from the treatment. 59% of patient reported that they were a little satisfi ed with the treatment results, 12% quite satisfi ed, 12% very satisfi ed and 17% of patients were not satisfi ed. All patients tolerated the laser procedure. The mean pain score was 5.5 (range 0-9). The pain score varied with the number of passes as well as the energy and laser pulse duration per pass. With conservative treatment parameters (Index 8, 8W, 1 pass) all patients (2) did not feel any pain. With more aggressive treatment parameters (Index 6, 12-14W, 2-3 passes), all described pain scores of at least 5.

Figure 2: (A, B, C). Baseline Photographs. Figure (D, E, F) Moderate improvement 1 month after 1 treatment.


Adverse effects were short lived and self-limiting. Erythema is the most common (82%) side effect followed by oedema (65%), pinpoint bleeding (24%), hyperpigmentation (24%) and crusting (4%). While erythema lasted a mean of 4.8 days (range: 3-7 days), oedema was evident for 2.8 days (range 1-7 days). Crust formation lasted for 7 days and only developed in 1 case. Pinpoint bleeding developed in 24% of cases and resolved within 48 hours. 12% of cases felt they developed hyperpigmentation 2 weeks after the procedure, which had resolved at the 1-month review. Subjective blinded dermatologist assessment

2-blinded dermatologists rated 18% of patients (3 out of 17) to have achieved moderate improvement (25-49% improvement) while another 47% (8 out of 17) had mild improvement (<25% improvement). They noted 35% (6 of 17) had no discernible improvement.

Clinical improvement was most discernible in patients who had more aggressive treatment protocols (Index 6, 12-14W, 2-3 passes). All cases with moderate improvement were treated with the more aggressive protocol (Figure 1 and 2). Of the cases that managed to achieve some mild improvement, one third of the cases underwent more conservative treatment protocols (Index 8, 8W, 1 pass) while the rest were treated with more aggressive protocols.

Adverse effects were minimal. At 1-month post treatment, only 1 cases developed hyperpigmentation, which resolved promptly in 2 months with sun block. No acne exacerbation, erythema, hypopigmentation, edema, pin point bleeding, blistering or increased scarring were noted in any of the cases at 1 month.

Discussion

Acne scars can be a psychologically debilitating condition for many patients. The promise with various laser systems in the past purported to improve acne scarring with minimal downtime and yet yield good results had not been fulfi lled. These tended to give variable results and can be rather diffi cult to satisfy the patients’ expectations. Full ablative carbon dioxide resurfacing techniques has long been the gold standard with regards to achieving scar improvement, but is coupled with a long downtime as well as increased morbidity. Even then, it can only give a modest improvement of 40-60%. This is more predictable and shows more consistent results with less inter patient variability. As such it can be quite bewildering for the practicing laser surgeon how non- ablative laser treatment modalities can yield results superior to traditional carbon dioxide resurfacing.

Fractional carbon dioxide laser has been introduced recently with much hype in the hope of providing acne scar improvement with just 1 treatment and yet with the unique healing properties of being fractional, it is able to reduce the downtime to just 3–7 days depending on the intensity of treatment.

In this study, we assessed a new carbon dioxide laser (SLIM Evolution, Lasering, Modena, Italy) with a fractional modality (MiXto SX) coupled to a high-speed scanner. With a microspot (300 microns) fractional modality and a novel-scanning algorithm that keeps the longest possible interval


between two adjacent spots in order to minimize the heat accumulation around the treated areas, it is believed that both pain and probabilities of adverse events can be reduced signifi cantly.

The patients selected had moderate to severe acne scarring as determined by the global acne scarring classfi cation 5.The scars were atrophic and were obvious at social distances of 50cm or greater and were not covered easily by makeup or the normal shadow of shaved beard hair in males. Clinically these were rolling, ‘‘box car,’’ mild to moderate hypertrophic or papular scars The present study has shown that even after a short follow up of 1 month, both patients and blinded physicians can observe discernible benefi ts. As one would expect, patient subjective assessment of improvement surpassed that of blinded dermatologist. In our study, with the exception of 1 patient, the rest felt they had a degree of improvement with up to a fi fth felt they achieved at least 25% improvement. Interestingly, blinded investigators had a congruent result rating almost a fi fth achieving at least 25% improvement but about a third having no improvement whatsoever while the rest achieving up to 25% improvement. We believe that after 1 month, post procedural oedema has abated and an element of fi brosis in skin effected to show initial effects of the laser.

As expected, more improvement is consistently demonstrated if more aggressive protocols were utilized. This includes a variety of different parameters including increasing the pulse duration (dwell time of the laser), power and the number of passes. These increments were limited to patient tolerability of the procedure. It is currently diffi cult to postulate the optimum treatment parameters and more studies are required to ascertain this.

We (Ee & Chua) employed multiple (up to 3) passes on patients who can tolerate the procedure well. One may argue that this might not be a “true” fractional approach and although we agree that multiple passes may approach the realms of full ablative resurfacing, the down time of the patient does not mimic so. It can be postulated that the use of the fractional photothermolysis concept coupled with ablative and microthermal zones in both the epidermis and dermis can effect a better treatment outcome as well as decreasing downtime.

The results here are consistent and expected when compared to previous modalities used for resurfacing acne scars. Non-ablative lasers in the infrared range which initially promised improvement with minimal downtime can be somewhat unpredictable. A previous study by Chua et al6 using a non ablative diode laser to treat Asian patients with acne scars only managed at 17.3% and 5% improvement when graded by patients and blinded investigators respectively after 6 treatments. A further study by Tay et al7 with a Erbium:Yag resurfacing laser a showed mild to moderate improvement (up to 50% improvement) in all treated patients after 2 treatment sessions. The use of another non ablative Erbium glass1540nm laser device (Fraxel, Reliant) at our centre has also only produced results with less optimism (communications). On the other hand, Goh et al reported traditional ablative resurfacing can improve acne scarring by 25-75% in Asian patients only after 1 treatment2. It is therefore not surprising that


fractional CO2 resurfacing, which is a less aggressive form of laser resurfacing will elicit a lesser degree of fi brosis and as such a more modest degree of improvement.

Our study also demonstrated subjective improvements in seborrhea, pore size, skin tightening and skin texture as reported by patients although these improvements were not validated by objective measurements. As such, we hesitate to recommend this treatment for these complaints until objective and sustainable results can be demonstrated by further studies.

Pain experienced during treatment is also significant despite 2-hour pretreatment of anesthetic cream (EMLA, AstraZeneca) application. This was fl eeting and settled promptly after the procedure with the application of a saline-soaked facial mask. All patients experienced side effects of erythema, edema, and desquamation. Epidermal sloughing was evident by day 2 of treatment. While treating with more conservative protocols had limited erythema and swelling confi ned to 4 days, more aggressive protocols with multiple passes can result in erythema, swelling and desquamation lasting up to a week. No infections and increased scarring were encountered and reepithelialization with normalization of external skin architecture occurred within a week. 1 case developed an element of post infl ammatory hyperpigmentation, which spontaneously settled after 2 month with just the use of a sunscreen. Not surprisingly, a more aggressive regime had been employed for this patient.

As with the other less aggressive resurfacing modalities, we expect better results with successive treatments. We are in the process of recruiting a larger cohort with longer-term data and various treatment protocols to investigate the outcome of multiple treatments.

Conclusions

Fractional carbon dioxide resurfacing is moderately effective in treating atrophic acne scars. The results are discernibly evident even at 1-month post procedure and can be applied safely on facial areas in type 4 photo types. Post treatment adverse events are minimal and tolerable. With more studies and better optimization of parameters, this system may offer clinical results closer to those seen in traditional carbon dioxide resurfacing but without the adverse effects.

References

1. Walia S, Alster TS. Prolonged clinical and histologic effects from CO2 laser resurfacing of atrophic acne scars. Dermatol Surg 1999; 25:926–30

2. Goh CL, Khoo L. Laser skin resurfacing treatment outcome of facial scars and wrinkles in Asians with skin type III/IV with the Unipulse CO2 laser system. Singapore Med J 2002;43:28–32

3. Hantash BM, Bedi VP, Kapadia B, Rahman Z, Jiang K, Tanner H, Chan KF, Zachary CB. In Vivo Histological Evaluation of a Novel Ablative Fractional Resurfacing Device. Lasers in Surgery and Medicine 2007; 39:96 – 107

4. Hantash BM, Bedi VP, Chan KF, Zachary CB. Ex Vivo Histological Characterization of a Novel Ablative Fractional Resurfacing Device. Lasers in Surgery and Medicine 2007; 39:87 – 95

5. Goodman GJ, Baron JA. Postacne Scarring: A Qualitative Global Scarring Grading System. Dermatol Surg 2006;32:1458–1466

6. Chua SH, Ang P, Khoo LS, Goh CL. Nonablative infrared skin tightening in Type IV to V Asian skin: a prospective clinical study. Dermatol Surg 2007;33:146-51

7. Tay YK, Kwok C. Minimally ablative erbium:YAG laser resurfacing of facial atrophic acne scars in Asian skin: a pilot study. Dermatol Surg.2008 ;34:681-5



Body Dysmorphic Disease In Patients Attending An Aesthetic Dermatology Clinic At The National Skin Centre – A Preliminary Prevalence Study

Clin Prof Goh Chee Leok*, Dr Chua Sze Hon*, Dr Priya Sen**, Dr Melvin Ee Hock Leong**

* Senior Consultant Dermatologist** Consultant Dermatologist, National Skin Centre

ORIGINAL ARTICLE 4

Introduction

Body dysmorphic disorder (BDD) is a psychiatric condition that is characterised by a distressing and impairing preoccupation with a non-existent or

minimal defect in appearance.1,2 This condition has been described by other authors as dysmorphic syndrome, dermatologic hypochondriasis and dermatologic non-disease. BDD is regarded by some as a variant of monosymptomatic hypochondriasis.

Patients with BDD are distressed by their perceived physical defect and may withdraw from family, work and social activities. In the extreme form, BDD may be associated with severe depression and may even lead to suicide. Patients with BDD may present to their dermatologist complaining repeatedly of their skin “defects” despite assurance that no signifi cant abnormalities are present after a thorough clinical examination. Doctor-hopping and low satisfaction with treatment outcomes is typical. Patients with BDD are often dissatisfi ed with the surgical or laser treatments they have received and often adopt a demanding and unreasonable approach towards the attending doctor. In the clinics, BDD may go unrecognised and hence may be inappropriately managed. Recognition of BDD is crucial not only to avoid performing unnecessary aesthetic procedures, but also to initiate the appropriate psychiatric management to treat the underlying psychiatric disease.

The prevalence of BDD in Singapore is unknown. BDD is likely to present more commonly to the dermatologic surgeon and aesthetic dermatologist who deal frequently with patients with cosmetic concerns. In previously reported studies, the prevalence of BDD is estimated to be between 0.7 and 2.4% of the population in Western countries3,4 and has been shown to reach 7-15% in patients undergoing aesthetic procedures.5-7

A validated questionnaire system reported recently appears to be a quick and simple tool that can be used to identify BDD. This questionnaire is based on the standard defi nition of BDD which consists of the following 3 criteria: (1) the patient is preoccupied with an imagined defect in appearance; if a slight physical anomaly is present the concern is markedly excessive; (2) the concern causes clinically significant distress or impairment in functioning and (3) the appearance preoccupation is not better accounted for by another mental disorder. The questionnaire was validated by a study in the United States. The questionnaire previously revealed a 15% prevalence of patients with BDD in a cosmetic setting in the United States. It was reported to have a sensitivity of 100% and a specifi city of 92.3%. It had a positive predictive value of 70% and a negative predictive value of 100%.4 By correlating the answers with the psychiatric diagnosis of BDD, this brief questionnaire had been shown to be able to detect and calculate the prevalence of BDD in patients undergoing cosmetic dermatological procedures.5

Methodology

This preliminary study on the prevalence of BDD among patients attending the NSC aesthetic dermatology clinic used such a questionnaire. The study was conducted at the Centre’s aesthetic dermatology clinic in patients over the age of 21 undergoing aesthetic procedures (Aesthetic Group) and compared the results with patients attending the general dermatology outpatient clinic (Control Group). Aesthetic procedure was defi ned as a procedure designed primarily to enhance the appearance without a primary medical dermatological condition. The study period was carried out between August 2008 and January 2009. The study protocol conformed to the hospital’s ethical guidelines and was approved by the Domain-Specifi c Review Board (DSRB) of the National Healthcare Group (NHG). All patients gave informed consent.

Abstract

Aims: Body dysmorphic disorder (BDD) is a psychiatric condition characterised by a distressing and impairing preoccupation with a non-existent or minimal defect in appearance. A validated patient questionnaire appears to be a quick and simple method for identifying BDD. This study aims to determine the prevalence of BDD among patients attending the NSC aesthetic dermatology clinic with the use of such a questionnaire. Methodology: The study group consisted of 24 patients attending the Centre’s aesthetic dermatology clinic. The control group consisted of 198 patients attending the general dermatology outpatient clinic with medical dermatological problems. Patients completed a questionnaire form which assisted in the identifi cation of those with features of BDD. Results: 8/24 (33%) of patients in the Aesthetic Group had features suggestive of BDD. In contrast, only 8/198 (4%) of patients in the control group had features suggestive of BDD. Conclusions: A high proportion of patients attending the aesthetic dermatology clinic may have BDD compared to those attending the general dermatology outpatient clinic. Screening for BDD should perhaps be performed prior to the performance of aesthetic procedures for this group of patients.


24 patients were recruited for the study. Their cosmetic problems included facial pigmentation such as melasma, lentigenes, nevus of Ota as well as acne scars and unwanted hair. The Control Group consisted of 198 consecutive patients with medical dermatology problems seen at general dermatology outpatient clinic; their dermatological problems included viral warts, eczema and urticaria.

Patients fi lled up a questionnaire.8 In the questionnaire, patients were asked a screening question: “Are you very concerned about the appearance of some part of your body, which you consider especially unattractive?”. A “no” answer excluded BDD.

If the answer to the screening question was “yes”, they were then asked 2 following questions: (a) Has your defect often caused you a lot of distress, torment or pain? How much? (b) Has your defect caused you impairment in social, occupational, or other important areas of functioning? How much? The patient was considered to have BDD if he/she answered “yes” to either question (a) and (b) with moderate distress or impairment in functioning.

Data was collated and the prevalence of BDD between patients attending the aesthetic dermatology clinic and those attending the general outpatient dermatology clinic was determined. Cross tabulation analysis was used to compare the case and control groups. The Chi square test was used for statistical analysis.

Results

24 patients were recruited from the aesthetic dermatology clinic and 198 controls from the general dermatology outpatient clinic. The mean age of Aesthetic Group was 40 (19-60) years compared to 37(19-76) years of the Control Group (statistically not signifi cant, p=0.07). There was a preponderance of female patients in the Aesthetic Group compared to the Control Group (75% vs. 27%) (Table 1). The ethnic distribution (Chinese, Malays and Indians) was similar in both groups.

54% (13/24) in the Aesthetic Group answered “yes” when asked the BDD screening question compared to only 7% (14/198) in the Control Group (p<0.05). For these groups of patients, their answers to the follow-up questions (a) and (b) were as follows (Table 2):

(a) Question (a): 5 patients or 21% (5/24) in the Aesthetic Group answered that their condition caused moderate to severe distress (BDD defi ning threshold) compared to 7 patients or 3.5% (7/198) in the Control Group (p < 0.001).

(b) Question (b): 4 patients or 17% (4/24) in the Aesthetic Group answered that their condition caused moderate to severe impairment (BDD defining threshold) compared to 2 patients or 1% (2/198) in the Control Group (p<0.05).

Of the above, there was 1 overlap patient in the Aesthetic Group; hence 33% (8/24) in the Aesthetic Group had features suggestive of BDD. In the Control Group, there was also 1 overlap patient; hence 4% (8/198) had features suggestive of BDD.

Table 1. Demographic characteristics of patients from the Aesthetic Group vs.Control Group.

Aesthetic Group (n=24)

Control group (n=198)

Sex• Female 18 (75%) 53 (26.8%)• Male 6 (24.2%) 145 (73.2%)Race• Chinese 20 (83.2%) 170 (85.9%)• Malay 2 (8.4%) 17 (8.6%)• Indian 1 (4.2%) 11 (5.6%)• Other 1 (4.2%) 0 (0%)

Table 2 Answers to questions (1), (a) and (b) from patients from Aesthetic Group vs. those from the Control Group

Aesthetic Group (n=24)

Control Group (n=198)

Answer to question (1)No 11 184Yes 13 14Answers to question (a) 13 14a1. “No” 1 4a2. Mild and not too disturbing 7 3a3. Moderate and disturbing,

but still manageable4 4

a4. Severe and very disturbing 1 3a5. Extreme and disabling 0 0Answers to question (b) 13 14b1. No limitation 5 11b2. Mild interference, but overall

performance not impaired4 1

b3. Moderate defi nite interference, but still manageable

3 2

b4. Severe, causes substantial impairment

1 0

b5. Extreme, incapacitating 0 0

Question (1) = Are you very concerned about the appearance of some part of your body, which you consider especially unattractive?

Question (a) = Has your defect often caused you a lot of distress, torment or pain? How much?

Question (b) = Has your defect caused you impairment in social, occupational, or other important areas of functioning? How much?

Based on the diagnostic criteria for BDD suggested by Dufresne5, it would appear that 33% of patients attending the aesthetic dermatology clinic (Aesthetic Group) have features suggestive of BDD. This prevalence is signifi cantly higher than those attending the general dermatology outpatient clinic (Control Group) in which only 4% had similar features.

Discussion

Prevelance of BDD in the general population range from 0.7% to 2.2% indicating that it is not a rare disorder.3,4

Body dysmorphic disease – a prevalence study


Body dysmorphic disease – a prevalence study

Our preliminary study suggests a fairly high proportion of patients attending the aesthetic dermatology clinic may have BDD (33%) compared to those attending the general dermatology outpatient clinic (4%). Other studies have reported the prevalence of BDD in cosmetic surgery practices to be around 6-15%.5,6 Thus, it is not uncommon for dermatologists to encounter such patients in their practice.

Treating patients with BDD can be frustrating and challenging until the underlying problem is identifi ed. Patients with BDD often have consulted numerous doctors for their perceived defects and are often not satisfi ed with the treatments they have received. They may demand for inappropriate and at times overly aggressive treatment for their perceived defects. Reassuring patients with BDD that there is nothing seriously wrong with them and that no treatment is necessary is often ineffective. Refusing treatment often drives such patients to seek treatment from another doctor and doctor-hopping is a common phenomenon. Even if minor defects are present and corrected, the patient will often shift the focus on a new perceived defect, requesting for additional procedures to be performed. Satisfaction after treatment is often poor, and patients may end up feeling depressed and suicidal8 angry; abusing the doctor and seeking litigation.

The pathogenesis of BDD is complex and likely stems from an imbalance in neural processing in the hemispheric, limbic system and frontal-subcortical circuits.9 This condition is best viewed as psychiatric in nature and hence treated as such. Treatments reported to be benefi cial include the use of serotonin reuptake inhibitors (e.g. fl uvoxamine, fluoxetine, citalopram, sertraline or paroxetine) and cognitive behavioural therapy. 10,11

As the percentage of BDD appears much higher in patients attending an aesthetic dermatology clinic due to referral bias, it may be appropriate that screening for BDD be performed for this group of patients prior to the performance of aesthetic procedures. This screening can

be quickly carried out using a simple patient questionnaire. Identifi cation of patients who may have BDD from the screening process will help avoid the trap of performing procedures in this group of patients who are likely not to be satisfi ed with the treatment outcome. It will also allow the doctor to decide on the most appropriate management such as a referral to the psychiatrist.

References

1. Allen A, Hollander E. Body Dysmorphic Disorder; Allen et al. Psychiatr Cln N Am 2000;23(3):617-28

2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th ed. Washington, DC: Am Psychiatr Assn,1994

3. Koran LM, Abujaoude E, Large MD, Serpe RT, The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectr 2008;13:316-22

4. Vinkers DJ, van Rood YR, van der Wee NJ. Prevalence and comorbidity of body dysmorphic disorder in psychiatric outpatients. Tijdschr Psychiatr 2008;50:559-65

5. Dufresne R, Phillips K. Vittorio C et al., A screening questionnaire for body dysmorphic disorder in a cosmetic dermatologic surgery practice. Dermatol Surg 2001; 27:457-62

6. Nachshoni T, Kotler M, Legal and medical aspects of body dysmorphic disorder. Med Law. 2007;26:721-35

7. Phillips KA, Dufresne R. Body dysmorphic disorder: a guide for dermatologists and cosmetic surgeons. Am J Clin Dermatol 2000;1:235-43

8. Phillips KA, Suicidality in Body Dysmorphic Disorder. Prim psychiatry 2007;14(12):58-66

9. Feusner JD, Yaryura-Tobias J, Saxena S. The pathophysiology of body dysmorphic disorder. Body Image 2008;5:3-12, Epub 2008 Mar 7

10. Buhlmann U, Reese HE, Renaud S, Wilhelm S, Clinical considerations for the treatment of body dysmorphic disorder with cognitive-behavioral therapy. Body Image 2008;5:39-49. Epub 2008 Mar 4

11. Phillips KA. Pharmacological treatment of body dysmorphic disorder: a review of empirical data and a proposed treatment algorithm. Psychia Clin N Am 2000;7:59-82


Side Effects And Complications Of Fractional Carbon Dioxide Laser Photothermolysis: Experience With 201 Treatments

Dr Tan Wee Ping*, Dr Melvin Ee Hock Leong**, Dr Priya Sen**, Clin Prof Chee Leok***, Dr Chua Sze Hon***

*Associate Consultant Dermatologist**Consultant Dermatologist*** Senior Consultant Dermatologist, National Skin Centre

ORIGINAL ARTICLE 5

Introduction

The carbon dioxide laser is commonly used in facial resurfacing, exerting its effects through the vaporization of intracellular and extracellular water

molecules, causing thermal damage to the surrounding tissues. This insult prompts fi broblasts to increase collagen production, resulting in desirable effects of wrinkle and photodamage reduction. However, the prolonged recovery time and complication risk of full ablative laser resurfacing has prompted the advancement of laser technology, with the development most recently of ablative fractional photothermolysis.

Fractional resurfacing thermally ablates microscopic columns of epidermal and dermal tissue in a regularly spaced array comprising a fraction of the skin surface1. It can be achieved through fractionate 10600nm CO2, 1410nm erbium-doped fibre or 2940nm erbium:YAG lasers. This intermediate approach purports to increase the effi cacy as compared to non-ablative resurfacing and at the same time decreases post treatment downtime and potential complications as compared to full ablative resurfacing.

Side effects may still occur following fractional laser resurfacing, particularly the problem of dyspigmentation2. Post-infl ammatory hyperpigmentation is the most common adverse event, and has been said to be more frequently observed in individuals of skin types III-VI, in sunny regions. However, prior studies on fractional photothermolysis in patients predominantly of this skin types are lacking. Hence the aim of this study was to determine the side effects and complications associated with fractional photothermolysis in a cohort of patients with darker skin types.

Methods

A retrospective case records review was conducted at the National Skin Centre, Singapore. National Skin Centre is a tertiary dermatology centre that serves the Singapore population of 3.86 million, comprising an ethnic mix of 77.7% Chinese, 14.1% Malays, 7.1% Indians and 1.1% others3. Medical records and laser charts of patients who underwent fractional 10600nm CO2 laser (Mixto Sx™) during the period of November 2007 to September 2008 were reviewed.

The treatment protocol for all patients involved the application of topical lidocaine and prilocaine (EMLA®) 1.5 hours prior to the procedure with occlusion. Treatment was then delivered to the areas with the 10600nm carbon dioxide laser device equipped with a 300μm hand piece. Forced air cooling (Zimmer MedizinSystems, Irvine, CA) may be used to alleviate discomfort during the procedure. All treatments were then followed by forced air cooling together with wet cotton mask applied over the entire face. Treatment may subsequently be repeated at six to eight weekly intervals.

Patients were instructed to use a mild cleanser post treatment. They were also instructed to use a moisturizer (La Roche Posay Cicaplast cream) several times a day for the fi rst post operative week. All patients received follow-up one month after each treatment session.

The data collected included the patients’ age, gender, skin phototype, preoperative diagnosis, the number of treatment sessions delivered and laser parameters. Complications were evaluated by review of the medical records, as well as from doctor-administered questionnaires which were completed by the patients at each subsequent visit.

Abstract

Introduction: Fractional photothermolysis has proven effi cacy in the management of rhytides, photodamaged skin as well as acne scarring. However, the evaluation of its potential complications in darker skin type patients is lacking. The aim of this study was to determine the side effects and complications associated with fractional photothermolysis in a cohort of patients with darker skin types. Methods: A retrospective case records review was conducted for patients who underwent fractional 10600nm CO2 laser (Mixto Sx™) during the period of November 2007 to September 2008. Complications were evaluated by review of the medical records, as well as from doctor-administered questionnaires. Results: 201 treatments in 83 patients were included in the data analysis. Adverse events occurred in 21 treatments. The most common adverse event was hyperpigmentation followed by acneiform eruption. No signifi cant association was found between the likelihood of developing complications and index level (p= 0.417), fl uence of energy delivered (p= 0.118) or number of passes (p= 0.592). Conclusion: Fractional photothermolysis with a 10600nm CO2 laser is a safe treatment modality in skin phototype four patients. The incidence of complications was low at 10%, and the risk of hyperpigmentation was 4.5%. Due to its known clinical effi cacy and low complication profi le, fractional photothermolysis may be considered as a treatment option for cutaneous resurfacing even in patients with darker skin types.


Table 1.

IV V VI

Number of treatments 187 10 4

Number of patients, n, (percentage of males) 77 (51.9) 4 (50.0) 2 (50.0)

Age (Mean, range) 34.9 (17-64) 39.5 (31-56) 27 (26-28)

Diagnosis (n = number of patients) Acne scars Wrinkles Melasma Photoaged skin Others

654116

4 2

Treatment Index, mean (range)Fluence (J/cm2), mean (range) Number of passes, n (%) 1 2 3 4

6.4 (3-11)12.8 (6-18)

2715172

6.7 (6-8)13.5 (8-16)

01000

6 (6)13 (10-16)

0400

Mean duration of erythema, days (range) 5.7 (2-30) 5.8 (3-10) 4.5 (4-5)

Mean duration of oedema, days (range) 2.3 (0-8) 4.75 (1-10) 2.5 (2-3)

Presence of pinpoint bleeding, n (%) 12 (15.6) 1 (25) 0 (0)

Complications Pain Prolonged erythema > 30days Swelling Hyperpigmentation Blisters/ Erosions Acneiform eruption Others

2116071

0003000

0000000

SPSS version 17.0 was used to analyze the data. Generalized estimating equations (GEE) model was utilized to evaluate the association between developing complications and index level, fl uence of energy delivered and number of pass.

Results

A total of 260 treatment sessions in 139 patients were performed during the study period. Of these, 201 treatments in 83 patients were included in the data analysis; 52 patients were excluded due to loss to follow-up after the fi rst visit and one patient who declined participation in all types of studies. Three Caucasian patients were also excluded. One hundred and nine treatments (54.2%) were performed on males and 92 on females of skin phototypes IV to VI. All treatments were performed on the face with the majority for treatment of acne scars (Table 1). Other indications included wrinkles, photodamaged skin, syringomas and post-traumatic scarring. Some patients had more than one indication for treatment, e.g. acne scars and wrinkles.

The mean index and energy delivered were 6.5 and 12.1 J/cm2 respectively. For patients with skin phototype four, the mean index and fl uence were 6.4 and 12.8 J/cm2 respectively. Most of patients had two passes during each treatment (80.2%).

Side effects and complications occurred in 21 treatments (Table 1). No serious adverse events e.g. scarring or permanent hypopigmentation occurred. The mean duration of erythema following treatment was 5.31 days. The majority of patients experienced erythema of less than 14 days with only one patient with prolonged erythema of 30 days duration (This patient had three passes at index 6, 16 J/cm2). The most common adverse event was hyperpigmentation (Figure 1) followed by acneiform eruption (Figure 2). There was no signifi cant association between the likelihood of developing complications and index level (p= 0.417), fl uence of energy delivered (p= 0.118) or number of passes (p= 0.592).

Acneiform eruption occurred following seven treatments. Five patients required treatment with oral doxycyline and topical clindamycin gel, as for management of a fl are of acne vulgaris, and one patient with a one week course of oral augmentin. In fi ve of these patients, laser treatment was continued according to schedule, whilst one patient had treatment deferred by three weeks.

Discussion

Though ablative carbon dioxide laser resurfacing has proven high effi cacy, it is also associated with a prolonged post-treatment downtime and signifi cant risks especially pigmentary complications in darker skin types4. Our study

Complications of fractional photothermolysis


has shown that fractional photothermolysis is a safe treatment modality in darker skin types, with relatively low risks of side effects and complications. Despite the high levels of energy delivered, the overall complication rate in our cohort of patients was low at 10%. Though hyperpigmentation was the most common adverse event, the incidence rate was low at 4.5%.

There are some limitations to our analysis. Our cohort comprised mainly of Chinese patients with skin phototype

Complications of fractional photothermolysis

four, with relatively small numbers of skin types fi ve and six. The incidence of complications in these darker skin types may not be truly representative. Also, as this was a retrospective review, some missing data could not be accounted for.

A study by Tan et al had also shown similarly low risk of post infl ammatory hyperpigmentation in skin phototypes four and five patients treated with fractional carbon dioxide laser5. In their small prospective study involving seven subjects, none developed complications, including post infl ammatory hyperpigmentation, following a single treatment with a non sequential fractional carbon dioxide laser using an energy level of 60mJ and density setting of one, translating to ablation of 60% of facial skin surface (Ultrapulse® Encore™; Lumenis Inc, Santa Clara, CA).

Other studies have often cited a much higher incidence of post infl ammatory hyperpigmentation in darker skin types with non-ablative fractional resurfacing. Graber et al reported that the incidence of post-infl ammatory hyperpigmentation in skin phototypes four and fi ve following fractional photothermolysis with a 1550nm erbium-doped laser (Fraxel, Reliant Technologies Inc) was 11.6% and 33% respectively6. Similarly Chan et al reported higher rates of post-infl ammatory hyperpigmentation following treatment in a cohort of Chinese patients following non-ablative fractional resurfacing7. This suggests that the risk of post-infl ammatory hyperpigmentation in darker skin types may be lower with fractional carbon dioxide laser compared to non-ablative fractional resurfacing.

Previous small prospective studies have documented similar low risks of adverse events with fractional carbon dioxide laser. Rahman et al treated the forearm skin of twenty-four healthy volunteers with fractional carbon dioxide laser (Reliant technologies Inc, Mountain View, CA) at settings of 5-40mJ/MTZ and 400MTZ/cm2. No serious adverse events were reported, and the incidence of erythema and oedema one month post-treatment were 33% and 10% respectively. A relatively high rate of post-infl ammatory hyperpigmentation was observed in six subjects of skin types II and III (20%), albeit mild. No association between skin type and post infl ammatory hyperpigmentation was observed.

Regardless of the intrinsic skin type, patients with suntans should avoid treatment until their tans fade to reduce the likelihood of laser-induced melanocytic stimulation with subsequent postoperative hyperpigmentation. Treatment options to hasten the recovery of hyperpigmentation include the use of broad spectrum sunscreens and topical bleaching agents including hydroquinone, kojic acid and retinoids.

Conclusion

Fractional photothermolysis with a 10600nm CO2 laser was a safe treatment modality in skin phototype four patients. The incidence of complications was low at 10%. The most common adverse event was hyperpigmentation at 4.5%. Due to its known clinical effi cacy and low complication profi le, fractional photothermolysis should be considered as a treatment option for cutaneous resurfacing even in patients with darker skin types.

Continue on page 28

Figure 1. Post infl ammatory hyperpigmentation post fractional ablative laser resurfacing

Figure 2. Acneiform eruption following fractional carbon dioxide laser resurfacing.


A Case Of Microcystic Adnexal Carcinoma Treated With Mohs Micrographic Surgery

Dr Raymond Kwah Yung Chien*, Dr Tan Suat Hoon**, Dr Ong Beng Hock***, Dr Melvin Ee Hock Leong****

* Associate Consultant Dermatologist** Senior Consultant Dermatologist, Deputy Director, National Skin Centre*** Visiting Consultant, Pathologist, Singapore General Hospital**** Consultant Dermatologist, National Skin Centre

CASE REPORT 1

Introduction

Microcystic adnexal carcinoma (MAC) is a rare malignant cutaneous neoplasm with pilar and sweat gland differentiation. The cell of origin is

not defi nitively known, but is generally thought to be a pluripotent adnexal keratinocyte that remains capable of differentiating into both sweat ducts and hair follicles.1 The tumour typically extends centimeters beyond the clinically visible margins and deeply to the subcutaneous fat or deeper structures. In fact, Chiller et al reported a large defect to lesion size and opined that a margin for excision cannot be safely predicted.2 Mohs micrographic surgery (MMS) which gives a three-dimensional view of all clinical margins and traces the subclinical extension of the tumour allows for better tumour extirpation.

The proposed etiology of MAC includes UV damage3 and past radiation exposure.4

Case Report

A 28-year-old Chinese gentleman presented with a lump over the left shoulder of 1 year duration. The lesion was dark pigmented and was asymptomatic. It measured 8mm in diameter. The initial impression was dermatofi broma and an excision biopsy was performed. Histology revealed nests, clusters and cords of cells within the dermis. (Fig 1) These cells form solid and ductal patterns. Some nests have small rounded spaces. The nuclei are vesicular and some show small nucleoli. They are oval to round and are bland. Clear cells are also present. In the mid and lower dermis the tumour cells are surrounded by dermoplastic bands. A superfi cial and deep perivascular infi ltrate of lymphocytes, few plasma cells and eosinophils are seen.

The infl ammatory cells also infi ltrate nests of tumour. The lower dermis shows infi ltrate of tumour nests between the collagen fi bres and to the upper subcutis. The fi ndings were consistent with MAC. As the tumour margin was not cleared on histology, he underwent MMS for tumour extirpation for better delineation of the tumour margins. A 1 stage 4 section procedure was performed with a fi nal defect size measuring 37x28mm. (Fig 2) The defect was closed directly. 20 months post-MMS, there was no clinical recurrence of the tumour.

Discussion

MAC has a predilection for the head and neck, particularly the central face.1 MAC typically presents as a smooth-surfaced, non-ulcerated, flesh-colored to yellowish asymptomatic nodule, papule, plaque, or cystic lesion that either gradually grows over time or seems to have stable size for an extended period, followed by more rapid growth.5 This tumor is locally aggressive and may present with perineural invasion with consequent numbness, paresthesia or burning.3 Our patient had perineural involvement despite being asymptomatic. Extension to muscle, vascular adventitia, perichondrium, periosteum, and bone marrow had been reported.6,7 To date, metastases have been reported in only 6 of over 274 published cases, an incidence of 2.2%.3,8,9,10 Only one death has occurred resulting from the tumor, giving a death rate of 0.4%.7

Treatment modalities that have been used for MAC include surgical excision (SE), MMS, radiation and chemotherapy. Radiotherapy had been used as monotherapy or adjuvant therapy in MAC management. However studies are limited and to date, the outcome is unpredictable. Recurrence post radiation had been reported. In fact Stein et al reported clinically more extensive and histologically more aggressive form of MAC recurring post therapy.11 Chemotherapy as treatment for MAC had been reported once in the literature.6 It was used as an adjunct to surgery and radiotherapy. The tumour persisted despite chemotherapy, necessitating further surgery and radiotherapy.

Surgery is currently the standard of care with the aim of complete removal of the tumour. Margins for surgical excision have been reported to vary from a few millimeters to 3–5 cm.12 However, there is often microscopic extension beyond the clinically apparent margins as demonstrated by Chiller et al.1 and Thomas et al.12 Both teams reported a large defect size/lesion size ratio ranging from 4-6.2 following MMS. This is similar to our patient whose

Fig 1: Dermis is diffusely infi ltrated by epithelial strands of neoplastic cells forming small ductules (arrows), in a sclerotic stroma (magnifi cation 100X)


Fig 2: (A) Scar following excision biopsy. (B) A 1 stage 4 section procedure was performed with a fi nal defect size measuring 37x28mm. (C) Direct closure of wound. (D) 20 months post MMS

B

D

A

C

Microcystic adnexal carcinoma

defect size was larger than the lesion. Although surgical complication rates were similar between patients that had WSE and those that had MMS, 30% of patients treated initially with SE required at least one additional procedure (excision or MMS) due to pathologic confirmation of positive margins on the excision specimen. None of the MMS required a further procedure.1 Furthermore, recurrence rates reported for SE ranged between 40-60%5,13 while that for MMS ranged 0-12%.14

Friedman and colleagues published their experience using Mohs surgery to treat MAC and documented no recurrences in 11 patients after a mean follow-up of 5 years.15 Snow et al16 reported similar success in his 13 patients that were followed up between 1.0 to 8.0 years (mean 5.0 years). His team also analyzed 39 cases of MAC (including his 13 cases) treated with MMS with follow up of at least 2 years in the literature and reported a overall 2-year success rate of 89.7% (35 of 39).16


The evidence to date supports the use of MMS as fi rst-line treatment for MAC management. Our patient whom not only had persistent disease also had perineural involvement with deep infiltration on histology. MMS was thus used to trace the ramifi cations of the tumour to minimize recurrence risk.

Conclusions

MAC is a rare tumour. Due to its presentation, there may be a delayed diagnosis. MMS should be the 1st line of treatment if surgery is amenable. It is still early to comment on the outcome of the treatment for our patient. Most recurrences reported occurred within 2-3 years of tumour extirpation.17,18 However, it is still prudent to follow up a patient indefi nitely as late recurrence, as long as 30 years,19 had been reported.

References

1. Robyn Wetter, Glenn Goldstein. Microcystic adnexal carcinoma: a diagnostic and therapeutic challenge. Dermatol Therapy, Vol. 21, 2008, 452–458

2. Chiller K, Passaro D, Scheuller M, Singer M, McCalmont T, Grekin RC. Microcystic adnexal carcinoma: forty-eight cases, their treatment, and their outcome. Arch Dermatol 2000;136:1355–1359

3. Chiller K, Passaro D, Scheuller M, Singer M, McCalmont T, Grekin RC. Microcystic adnexal carcinoma: forty-eight cases, their treatment, and their outcome. Arch Dermatol 2000;136:1355–1359

4. Abbate M, Zeitouni NC, Seyler M, et al. Clinical course, risk factors, and treatment of microcystic adnexal carcinoma: a short series report. Dermatol Surg 2003;29:1035–1038

5. Carroll P, Goldstein GD, Brown CW Jr. Metastatic microcystic adnexal carcinoma in an immunocompromised patient. Dermatol Surg 2000;26:531–534

6. Yuh W, Whitaker D, Engelken J, Dolan K. Bone marrow invasion of microcystic adnexal carcinoma. Ann Otol Rhinol Laryngol 1991;100:601–603

7. Cooper PH, Mills SE. Microcystic adnexal carcinoma of the scalp. J Am Acad Dermatol 1984;10:908–914

8. Bier-Laning CM, Hom DB, Gapany M, et al. Microcystic adnexal carcinoma: management options based on long-term follow-up. Laryngoscope 1995;105:1197–201

9. Yugueros P, Kane WJ, Goellner JR. Sweat gland carcinoma: a clinicopathologic analysis of an expanded series in a single institution. Plast Reconstr Surg 1998;102:70–10

10. Rotter N, Wagner H, Fuchshuber S, Issing WJ. Cervical metastases of microcystic adnexal carcinoma in an otherwise healthy woman. Eur Arch Otorhinolaryngol 2003;260:254–7

11. Stein J, Ormsby A, Esclamado R, Bailin P. The effect of radiation therapy on microcystic adnexal carcinoma: a case report. Head Neck 2003;25:251–4

12. Thomas CJ, Wood GC, Marks VJ. Mohs micrographic surgery in the treatment of rare aggressive cutaneous tumors: the Geisinger experience. Dermatol Surg 2007;33:333–339

13. Cooper PH. Sclerosing carcinomas of sweat ducts (microcystic adnexal carcinoma). Arch Dermatol 1986;122:261– 264

14. Robyn Wetter, Glenn Goldstein. Microcystic adnexal carcinoma: a diagnostic and therapeutic challenge. Dermatol Therapy, Vol. 21;2008, 452–458

15. Friedman P, Friedman R, Jiang B, et al. Microcystic adnexal carcinoma: collaborative series review and update. J Am Acad Dermatol 1999;41:225–31

16. Snow S, Madjar DD, Hardy S, et al. Microcystic adnexal carcinoma: report of 13 cases and review of the literature. Dermatol Surg 2001;27:401–408

17. Bier-Laning CM, Hom DB, Gapany M, et al. Microcysticadnexal carcinoma: management options based on longterm follow-up. Laryngoscope 1995;105 : 1197–1201

18. LeBoit PE, Sexton M. Microcystic adnexal carcinoma of the skin: a reappraisal of the differentiation and differential diagnosis of an under recognized neoplasm. J Am Acad Dermatol 1993;29:609–618

19. Lupton G, McMarlin S. Microcystic adnexal carcinoma. Report of a case with 30-year follow-up. Arch Dermatol 1986;122:287–289

Microcystic adnexal carcinoma

Acknowledgements

We would like to thank Ms Shen Liang, senior biostatistician, Medicine Dean’s offi ce, NUS, for her help in the statistical analysis.

References

1. Manstein D, Herron GS, Sink RK et al. Fractional photothermolysis: a new concept of cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004; 34:426-38.

2. Laubach HJ, Tannous Z, Anderson RR, Manstein D. Skin responses to fractional photothermolysis. Lasers Surg Med 2006; 38:142-9.

3. Singapore Census of Population 2000. Statistical release 1: demographic characteristics. Singapore: Department of Statistics; 2001.

4. Nanni CA, Alster TS. Complications of carbon dioxide resurfacing. An evaluation of 500 patients. Derm Surg 1998;24:315-20.

5. Tan KL, Kurniawati C, Gold MH. Low risk of post infl ammatory hyperpigmentation in skin types 4 and 5 after treatment with fractional CO2 laser device. J Drugs Dermatol 2008; 7:774-7.

6. Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: Experience with 961 treatments. Derm Surg 2008; 34: 301-5.

7. Chan HH, Manstein D, Yu CS, et al. The prevalence and risk factors of post-infl ammatory hyperpigmentation after fractional resurfacing in Asians. Laser Surg Med 2007; 39:87-95.

8. Rahman Z, Macfalls H, Jiang K, et al. Fractional Deep Dermal Ablation induces tissue tightening. Lasers Surg Med 2009;41: 78-86.

9. Chapas AM, Brightman L, Sukal S, et al. Successful Treatment of acneiform scarring with CO2 ablative fractional resurfacing. Lasers Surg Med 2008;40:381-6.

Continued from page 25

Complicationa of fractional photothermolsis


Management Of Extramammary Paget’s Disease With Moh’s Micrographic Surgery

Dr Raymond Kwah Yung Chien*, Dr Tan Suat Hoon**, Dr Wong Siew Ngoh**, Dr Ong Beng Hock***, Dr Melvin Ee Hock Leong****

* Associate Consultant Dermatologist, National Skin Centre** Senior Consultant Dermatologist, Deputy Director, National Skin Centre*** Visiting Consultant, Pathologist, Singapore General Hospital****Consultant Dermatologist, National Skin Centre

CASE REPORT 2

Introduction

Extramammary Paget’s disease (EMPD) is a rare neoplastic condition of apocrine gland-bearing skin. It tends to affect the older age group with a

predilection for males in the Asian population.1 The risk of associated underlying malignancy appears to be lower in Asians compared to Caucasians.1 Due to the irregular projections of the tumour and possible multi-centricity of the tumour, there is usually sub-clinical extension of the tumour. This results in a high risk of tumour recurrence following conventional wide excision. Moh’s micrographic surgery (MMS) has been reported to have a lower recurrence rate compared to wide excision. Recurrence is still possible but this may be due to the multi-focal nature of the tumour.

Case 1

A 74-year-old Chinese man presented with erythematous plaque over the scrotum of 6 months duration. He had been seen by General Practitioners and had been treated with a variety of topical steroids and antifungal creams without improvement. A biopsy of the lesion revealed atypical cells with abundant pale staining cytoplasm and large nuclei at all levels of the hyperplastic epidermis. These cells stained positive with PAS and were diastase resistant. (Fig 1) The histology was consistent with EMPD.

He underwent endoscopic evaluation of the upper and lower gastrointestinal tract and was diagnosed to have

Helicobacter pylori related gastritis and a recto-sigmoid polyp (histology consistent with benign tubulovillous adenoma). Genitourinary assessment included cystoscopy and bladder washing for cytology which were normal. Computer tomogram of the abdomen and pelvis was also unremarkable. Tumour markers such as Prostate Specifi c Antigen (PSA) and Carcinoembryonic Antigen (CEA) were also normal. Wide local excision (2 cm margin) failed to expirtate the tumour and a repeat wide local excision with intraoperative frozen section performed reported full tumour expirtation.

2 years later, an erythematous plaque reoccured at the surgical site and a repeat biopsy showed EMPD. The patient then underwent Mohs micrographic surgery (MMS). Pre operatively, the lesion measured 40x30mm. The patient underwent a 2 stage 11 section procedure with a resultant defect measuring 70x40mm involving the left penile shaft, base of penis and the suprapubic area. (Fig 2) The defect was closed directly. 14 months post MMS, the patient had no recurrence of lesion.

Case 2

A 67-year-old Chinese man presented with pruritic plaque over the left aspect of the penile shaft of 4 years duration. He had been treated with topical steroids and antifungal by General practitioners without improvement. A biopsy of the lesion was done and the histology was consistent with EMPD. Gastroscopy and colonoscopy were performed. He was found to have a hyperplastic polyp as well as a benign tubulovillous adenoma in the descending colon. Cystoscopy was normal. He underwent MMS. Pre operatively, the lesion measured 60x40mm. The patient underwent a 3 stage 14 section procedure with a resultant defect measuring 100x50mm involving the left penile shaft, base of penis and the left aspect of the scrotum. The defect was closed directly. 15 months post MMS, the patient had no recurrence of lesion.

Discussion

EMPD is a rare neoplastic condition of apocrine gland-bearing skin and usually presents in the anogenital or axillary regions. It tends to occur in older patients, whereby 90% of patients are older than 50.2 Multifocal EMPD has been reported, usually occurring simultaneously in the anogenital and axillary areas, or less frequently as concurrent mammary and extramammary diseases.3,4 When found on non-apocrine bearing sites, it is referred to as ectopic EMPD.5

Fig 1: Epidermis is infi ltrated by Paget’s cells at all levels, occurring singly and in clusters (magnifi cation 200X)


Extramammary Paget’s disease

EMPD has an insidious onset. The diagnosis is usually delayed by fi ve to ten years.6 EMPD may occur as a primary process, where the Paget’s cells represent erratic pluripotent cells of the epidermis or adnexae, or as an epidermotropic extension from underlying contiguous gastrointestinal or genitourinary carcinomas or from a noncontiguous carcinoma, where the Paget’s cells are theorized to refl ect the invasion of epidermotropic malignant cells.7 Thus EMPD may be associated with an underlying malignancy. Vulvar EMPD has been reported to be associated with an adnexal adenocarcinoma in 4% of cases and a distant malignancy in 20%,8 while perianal EMPD has been reported to be associated with an adnexal adenocarcinoma in 7% of cases and an internal malignancy in 14%.9

Vulvar and perianal EMPD accounts for 65% and 20% of EMPD cases respectively.7 These are sites where tissue conservation is important for optimal cosmetic and functional outcome. Thus non-surgical modalities have been employed. These include topical chemotherapy, such as bleomycin, 5 Fluorouracil (5FU) and imiquimod.

Watring et al10 used bleomycin to treat seven patients with recurrent vulval EMPD. Four patients (57%) achieved complete responses after one or two treatment cycles of which one relapsed at 30 months and required a further treatment with bleomycin to achieve prolonged disease remission. Bewley et al11 reported success with 5FU,

however Lee et al1 reported partial remission after 6 months of 5FU in 1 patient. Shepherd5 opined that 5FU may not be a reliable therapy as EMPD tends to involve deeper epidermal layers and adnexal structures while 5FU has poor penetration which may be further compromised by the hyperkeratosis commonly associated with EMPD.

Imiquimod was used to treat two cases of EMPD over a period of 7.5 to 12 weeks with both patients demonstrating clinical and histological cure at the end of treatment.12 However, Lee et al1, had 2 patients treated with imiquimod, 1 achieved partial response and the other achieved remission but developed subsequent recurrence. The treatment was intermittent due to intolerable side effects.

Another modality, radiotherapy, had also been employed successfully. Besa et al.13 reported complete remission in 7 patients with intraepithelial EMPD with no local recurrence. However in the 2 patients with invasive EMPD, 1 (50%) had a recurrence. Burrows et al.14 demonstrated, in their series of fi ve EMPD patients, local control without recurrence over a mean follow up period of four years was achievable.

With limited data and inconsistency of outcomes, most of the above discussed modalities have been recommended as treatment options for inoperable lesions or as an adjunct to surgery.7,16 Thus, surgical excision is still regarded as the treatment of choice for local EMPD.

Fig 2: (A) Pre-MMS lesion measuring 40x30mm. (B) The patient underwent a 2 stage 11 section procedure with a resultant defect measuring 70x40mm involving the left penile shaft, base of penis and the suprapubic area. (C) Direct closure of the wound. (D) 14 months post MMS.

B

D

A

C


Metastasis of EMPD is related to the aggressive nature of the tumor rather than the effi cacy of treatment methods while the local recurrence of EMPD is related to an incomplete resection of a discontinuously spreading tumor.15 EMPD may be multi-centric and has irregular margins.16,17 Mohs18 reported that clinically unapparent microscopic tumour often extended for 2 to 5 cm beyond clinical margins. Hendi et al19 reported that conventional surgical margins of 2 cm would have cleared only 59% of the tumours. Furthermore, conventional “breadloaf” frozen section effectively assess only 1% of the histological tumor margin.20 Thus local recurrence rates of up to 44% following conventional surgical treatment have been reported.21 Even radical surgeries do not prevent recurrence. Fanning et al8 reported high recurrence rate following radical surgery of vulva EMPD (31% recurrence with radical vulvectomy, 20% with radical hemivulvectomy and 43% with modifi ed superfi cial vulvectomy). Furthermore, these procedures can result in high morbidity and mortality.

MMS on the other hand, provides a three-dimensional histological view of all clinical margins. This will result in a lower recurrence rate. Among treatments for vulvar EMPD, proponents of MMS showed a superior result. The recurrence rate of MMS versus wide local excision was 27%16 versus 43%8 respectively, while in perianal EMPD it was recurs in 28%6 versus 50%9. Lee et al1 also reported similar results in his cohort, showing that MMS had a recurrence rate of 18.2% versus 36.4% for patients who underwent wide excision. Thus MMS which employs tissue conservation technique resulting in potentially smaller defects coupled with a lower recurrence rate may be better option for the treatment of EMPD.

Conclusion

It is too early in the follow up of both our patients to comment on the effectiveness of MMS in the management of EMPD as the reported median time to recurrence after MMS ranges from 30 to 36 months.8,16 However, the data available thus far is promising for MMS as an initial treatment option for EMPD and should be considered.

References

1. Lee KY, Roh MR, Chung WG, Chung KY. Comparison of Mohs micrographic surgery and wide excision for extramammary Paget’s Disease: Korean experience. Dermatol Surg. 2009 Jan;35(1):34-40

2. Salamanca J, Benito A, Garcia-Penalver C et al. Paget’s disease of the glans penis secondary to transitional cell carcinoma of the bladder: a report of two cases and review of the literature. J Cutan Pathol 2004;31:341–345

3. Kitajima S, Mitsusashi Y, Yoshikawa K, Kondo S. A case

of triple extramammary Paget’s disease. J Dermatol 1997;24:535–8

4. Popiolek DA, Hajdu SI, Gal D. Synchronous Paget’s disease of the vulva and breast. Gynecol Oncol 1998;71:137–40

5. Shepherd V, et al. Extramammary Paget’s disease. BJOG: An International Journal of Obstetrics & Gynaecology 2005;112:273

6. Henning JS. Extramammary Paget’s disease of the penis and scrotum. J Drugs Dermatol 2006;5:652

7. Kanitakis J. Mammary and extramammary Paget’s disease. J Eur Acad Dermatol Venereol 2007;21:581

8. Fanning J, Lambert HC, Hale TM et al. Paget’s disease of the vulva: prevalence of associated vulvar adenocarcinoma, invasive Paget’s disease, and recurrence after surgical excision. Am J Obstet Gynecol 1999;180:24-7

9. Marchesa P, Fazio VW, Oliart S et al. Long-term outcome of patients with perianal Paget’s disease. Ann Surg Oncol 1997; 4: 475-80

10. Watring WG, Roberts JA, Lagasse LD, et al. Treatment of recurrent Paget’s disease of the vulva with topical bleomycin. Cancer 1978; 41(1):10–11

11. Bewley AP, Bracka A, Staughton RC, Bunker CB. Extramammary Paget’s disease of the scrotum: treatment with topical 5-fl uorouracil and plastic surgery. Br J Dermatol 1994;131:445-6

12. Zampogna JC, Flowers FP, Roth WI, Hassenein AM. Treatment of primary limited cutaneous extramammary Paget’s disease with topical imiquimod monotherapy: two case reports. J Am Acad Dermatol 2002;47(4):S229– S235

13. Besa P, Rich TA, Delclos L, Edwards CL, Ota DM, Wharton JT. Extramammary Paget’s disease of the perineal skin: role of radiotherapy. Int J Radiat Oncol Biol Phys 1992;24(1):73–78.

14. Burrows NP, Jones DH, Hudson PM, Pye RJ. Treatment of extramammary Paget’s disease by radiotherapy. Br J Dermatol 1995;132(6):970– 972

15. Jones RE, Austin C, Ackerman AB. Extramammary Paget’s disease: a critical reexamination. Am J Dermatopathol 1979;1:101–32

16. Coldiron BM, Goldsmith BA, Robinson JK. Surgical treatment of extramammary Paget’s disease. A report of six cases and a reexamination of Mohs micrographic surgery compared to with conventional surgical excision. Cancer 1991;67:933-8

17. Gunn RA, Gallager HS. Vulvar Paget’s disease: a topographic study. Cancer 1980;46:590-4

18. Mohs FE. Chemosurgery: microscopically controlled surgery for skin cancer. Springfi eld (IL): Charles C. Thomas; 1978. p. 219.

19. Hendi A, Brodland D, Zitelli J. Extramammary Paget’s disease: surgical treatment with Mohs micrographic surgery. J Am Acad Dermatol 2004;51: 767–773

20. Abide JM, Nahai F, Bennett RG. The meaning of surgical margins. Plast Reconstr Surg 1984;73:492-6

21. Zollo JD, Zeitouni NC. The Roswell Park Cancer Institute experience with extramammary Paget’s disease. Br J Dermatol 2000;142:59–65

Extramammary Paget’s disease


Gorlin Syndrome-related Basal Cell Carcinoma Treated with Mohs Micrographic Surgery

Dr Lee Ee Ching*, Dr Melvin Ee Hock Leong**, Dr Tan Suat Hoon***

* Medical Offi cer** Consultant Dermatologist*** Senior Consultant Dermatologist, National Skin Centre

CASE REPORT 3

Abstract

Gorlin syndrome, also known as nevoid basal cell carcinoma syndrome is a rare autosomal dominant multisystem disorder due to germline mutations

in the human homolog of the patched (PTCH) gene. It is characterised by developmental abnormalities and early onset of multiple basal cell carcinoma. We report a case of Gorlin syndrome with recurrent basal cell carcinomas on the face and nose, who had multiple standard conventional excision surgeries done and eventually treated by Mohs micrographic surgery. This case highlights Mohs micrographic surgery as the gold standard of treatment for basal cell carcinomas in Gorlin syndrome.

Introduction

Gorlin syndrome, also known as nevoid basal cell carcinoma syndrome is a rare autosomal dominant multisystem disorder due to germline mutations in the human homolog of the patched (PTCH) gene. It is characterised by developmental abnormalities and multiple, early onset of basal cell carcinoma. Treatment of Gorlin syndrome-related basal cell carcinoma can be challenging and surgical excision is the common approach. Currently there are various treatment modalities available and the ideal treatment would be those that had higher cure rate, minimal side effects together with the maximal preservation of normal surrounding skin. We report a case of Gorlin syndrome with recurrent basal cell carcinomas on the face and nose, who had multiple standard conventional excision surgeries done and eventually treated by Mohs micrographic surgery.

Case history

A 44-year-old man with family history of Gorlin Syndrome was diagnosed with the disease when he fi rst presented with multiple jaw cysts in 1984.He was seen in National Skin Centre for multiple fl eshy-pigmented naevus on his face and trunk since 1998. Histopathological fi ndings from the skin lesions were consistent with basal cell carcinoma. On follow up, this patient had multiple recurrent basal cell carcinomas over his face and nose that required removal by standard conventional excision surgeries from year 1998-2007. This patient also tried topical imiquimod with no regression of his skin lesions.

In February 2008, he presented with a biopsy proven recurrent of basal cell carcinoma (nodular and micronodular subtype) (Fig. 1 and 2) over the left alar and a primary right lateral canthus basal cell carcinoma. He was then referred for Mohs micrographic surgery. At the presentation to Mohs micrographic surgery, physical examination revealed a 10mm x 9mm plaque with telangiectasia over left alar (Figure 3) and an 8mm x 7mm round, fl esh-colour papule with telangiectasia over the right lateral canthus.

Fig. 1: Left nasal region; micronodular basal cell carcinoma extending to the deep resection margin. The top right hand corner shows a smaller area of nodular basal cell carcinoma. (Magnifi cation X400)

Fig. 2: Small basaloid tumour nests embedded in a fi brous stroma, with amyloid deposits and melanin pigmentation (magnifi cation X200)

Fig. 3: A 10mm x 9mm plaque with telangiectasia over left alar.


He underwent fi rst Mohs micrographic surgery in March 2008. The initial size of the right lateral canthus tumour was 8mm x 7mm and after a 1-stage and 2 sections of Mohs surgical procedure, the fi nal defect was 16mm x 10mm. This was repaired with a direct closure. The left alar tumour measured 11mm x 12mm. Tumour extirpation was complete after 5-stage, 9 sections Mohs surgical procedure with a tumour free surgical defect of 20mm x 20mm. This was repaired with a melolabial transposition fl ap. (Fig. 4a and 4b)

Subsequently there was another histological proven recurrent BCC noted over his right cheek. He underwent Mohs micrographic surgery in June 2008 for recurrent basal cell carcinoma over his right cheek. This lesion was previously excised by conventional excisional technique but remained persistent. This tumour was extirpated in a four-stage, 16 sections Mohs surgical procedure with the tumour free surgical defect measuring 43mm x 42mm.This patient had no evidence of recurrent of basal cell carcinoma on the face and nose on follow up. (Fig. 5)

Discussion

Gorlin syndrome is a rare genetic disorder that predisposes to early onset of multiple basal cell carcinomas. Treatment for basal cell carcinoma associated with Gorlin syndrome can be challenging and diffi cult because of the large number of skin lesions.

There are many treatment modalities for basal cell carcinoma reported in the literature. Surgical options include Mohs micrographic surgery, excisional surgery, cryosurgery, laser ablation, electrodesiccation and curettage. Non-surgical options are photodynamic therapy, chemotherapy (Topical fluorouracil (5-FU), tretinoin),

immunotherapy and radiation therapy. Treatment approach should be tailored to each case.

There had been reports which showed that the 5 years cure rate for low risk BCC treated with curettage and electrodesiccation and cryosurgery is 95% or better but these treatment modalities are not appropriate for recurrent, large or morphoeic tumours. In addition, there are inadequate or no tissue samples available for histological examination from these treatment methods.1-4

The use of UltraPulse CO2 laser for treatment of superfi cial BCC had been reported to be an effective treatment option with a cure rate of 97%.5 The advantages includes low risk of scarring, superior cosmetic result, decreased postoperative pain and shortened healing time.6 However this method is not suitable for larger nodular tumour with the diameter greater than 10mm.7

Photodynamic the rapy us ing top ica l methy l 5-aminolevulinate as the photosensitizer has shown to be effective treatment for nodular BCC with good cosmesis. But higher recurrent rate had been noted with this treatment method.8

Radiotherapy is a treatment option for patient who are not a candidate for surgical interventions, and for those with tumour in diffi cult to treat locations. The disadvantages for this method are poor long-term cosmetic result and potential risk of carcinogenesis.4,9

Imiquimod 5% cream, an immune response modifier had been used for treatment for superfi cial basal cell carcinoma with clearance rate around 70-100% depending on the frequency of application. However dose related infl ammatory skin reaction had been reported and it is not indicated for high-risk tumour.4,10 Another topical treatment is fl uorouracil 5% cream but this treatment modality is restricted to superfi cial basal cell carcinoma at non high risk area.11

The above modalities remain options for low risk non melanoma skin cancers. Our patient has Gorlin Syndrome which automatically categorised him as a high risk case. Surgical excision is the common approach for treatment of BCC that give an advantage of histological evaluation of the tumour. However conventional excision surgery without margin control gives a 5 year recurrence rate of 10.1% for primary tumour and 17.4% for recurrent tumour.12

Mohs micrographic surgery is a technique that allowed microscopic control of all surgical margins and maximum sparing of tumour free adjacent tissue. The horizontal frozen histological sections of the excised tumour allow more complete microscopic examination of the surgical margin and thus offer a higher cure rate compared to other treatment modalities.13 It had been recommended for the treatment of high risk tumour which include tumour at the central portion of the face, size larger than 2cm, aggressive histological subtype (morphoeic, infi ltrative, basosquamous, or micronodular), recurrent, poorly defined BCCs, and previously incompletely excised tumour.14,15 Other indications include tumour arising in immunosuppressed patient as well as syndromes predisposing to the development of non melanoma

Fig. 4a and 4b: The left alar BCC was excised with Mohs micrographic surgery with a tumour free surgical defect of 20mm x 20mm. This was repaired with a melolabial transposition fl ap

Fig. 5: 3 months post Mohs micrographic surgery for left alar BCC.

Gorlin Syndrome


skin cancers e.g. Gorlin syndrome (as in this case) and xeroderma pigmentosum.

Mohs micrographic surgery had been reported to have high clearance rate of 99% for primary tumour and 95% for recurrent tumours.16,17 A prospective study by Leibovitch et al on outcomes at 5 years follow up for BCC treated with Mohs micrographic surgery showed 5-year recurrence rate in primary cases was 1.4%, whereas in recurrent cases was 4.0%. The overall 5-year recurrence rate was 2.6%, which is considered to be low in view of the signifi cant number of high-risk tumours, were included in this study.18 A systemic review by Thissen et al on treatment modalities of primary BCC from 18 large, prospective series with 5 years follow up concluded that Mohs micrographic surgery provides the lowest recurrent rates as compare to surgical excision and curettage and electrodesiccation, even for BCCs localized in the anatomical site at risk of recurrent.19 Retrospective study by Smeets et al review 5 year recurrent rates for Mohs micrographic surgery for treatment of BCC on the face were 3.2% for primary BCC and 6.7% for recurrent BCC This study recommended Mohs micrographic surgery as the fi rst choice treatment for primary facial BCCs with aggressive histological subtype and for recurrent BCCs.20

As compare to standard conventional excision surgery, recent prospective randomised control trial by Mosterd et al showed that Mohs mircrographic surgery is preferred over surgical excision for the treatment of facial recurrent BCC on the basis that fewer recurrences after Mohs micrographic surgery. This difference in recurrence between the two groups might be because of the use of different histopathological assessment in the two groups. This study however did not showed any difference in the number of recurrences between two treatment groups for primary facial BCC.21

Our patient with Gorlin syndrome who had multiple recurrent BCCs with aggressive histological subtype over central portion of his face, which failed to clear by standard conventional excision surgery, is considered to be a high-risk case. This case was eventually treated with Mohs micrographic surgery and had remained tumor free at review. In summary, Mohs micrographic surgery is the treatment of choice for high-risk non melanoma skin cancer in order to reduce the recurrence of the tumor.

References

1. Silverman MK, Kopf AW, Grin CM, Bart RS, Levenstein MJ. Recurrence rates of treated basal cell carcinomas. Part 2: curettage-electrodessication. J Dermatol Surg Oncol 1991; 17:720-6.

2. Kufl ik EG, Gage A. The fi ve-year cure rate achieved by cryosurgery for skin cancer. J Am Acad Dermatol 1991; 24:1002-4.

3. Wong CSM, Strange RC, Lear JT. Basal cell carcinoma. BMJ 2003; 327: 794-798.

4. Rubin AI, Chen EH, Ratner D. The New England Journal of Medicine 2005; 353: 2262-2269.

5. Iyer S, Bowes L, Kricorian, Friedli A, Fitzpatrick RE. Treatment of basal cell carcinoma with the pulsed carbon dioxide laser: A retrospective analysis. Dermatologic Surgery 2004; 30: 1214-1218.

6. Wheeland RG, Bailin PL, Ratz JL, Roenigk RK. Carbon dioxide laser vaporization and curettage in the treatment of large or multiple superfi cial basal cell carcinoma. J Dermatol Surg Oncol 1987; 13: 119-25.

7. Horlock N, Grobbelaar AO, Gault DT. Can the carbon dioxide laser completely ablate basal cell carcinoma? A histologic study. Br Plast Surg 1999; 53: 286-93.

8. Rhodes LE, de Rie M, Enstrom Y, Groves R, Morken T, Goulden V, Wong GAE, Grob J, Varma S, Wolf P. Photodynamic therapy using topical methyl aminolevulinate vs surgery for nodular basal cell carcinoma. Arch Dermatol 2004; 140: 17-23.

9. Veness M, Richards S. Role of modern radiotherapy in treating skin cancer. Austras J Dermatol 2003; 44: 159-66.

10. Marks R, Gebauer K, Shumack S, Amies M, Bryden J, Fox TL, Owens ML. Imiquimod 5% cream in the treatment of superfi cial basal cell carcinoma: Result of a multicenter 6 week dose-response trial. J Am Acad Dermatol 2001; 44: 807-813.

11. Goette DK. Topical chemotherapy with 5-fl uorouracil. J Am Acad Dermatol 1981; 4: 633-49.

12. Rowe DE. Comparison of treatment modalities for basal cell carcinoma. Clin Dermatol. 1995; 13:617-20

13. Shriner DL, McCoy DK, Goldberg DJ, Wagner RF Jr. Mohs microscopic surgery. J Am Acad Dermatol 1998; 39:79-97.

14. Telfer NR, Colver GB, Bowers PW. Guidelines for the management of basal cell carcinoma. British Association of Dermatologists. Br J Dermatol 1999; 141:415-23.

15. Swanson NA. Mohs surgery. Technique, indications, applications and the future. Arch Dermatol 1983; 119: 761-73

16. Rowe DE, Carroll RJ, Day CL Jr. Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol. 1989; 15:315-328.

17. Rowe DE, Carroll RJ, Day CL. Mohs surgery is the treatment of choice for recurrent (previously treated) basal cell carcinoma. J Dermatol Surg Oncol. 1989; 15:424-31.

18. Leibovitch I, Huilgol SC, Selva D, Richards S, Paver R. Basal cell carcinoma treated with Mohs Surgery in Australia. II. Outcome at 5-year follow up. J Am Acad Dermatol 2005; 53: 452-457.

19. Thissen MR, Numann MH, Shouten LJ. A systemic review of treatment modalities for primary basal cell carcinoma. Arch Dermatol 1999; 135:1177-83.

20. Smeets NWJ, Kuijpers DIM, Nelemans P, Ostertag JU, Verhaegen, Krekels GAM, Neumann HAM. Mohs’ micrographic surgery for treatment of basal cell carcinoma of the face-results of a retrospective study and review of literature. British Journal of Dermatology 2004; 151: 141-147.

21. Mosterd K, Krekels GAM, Nieman FHM, Ostertag JU, Essers BA, Dirksen CA, Steijlen PM, Vermeulen A, Neumann HAM, Smeets NWJ. 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. Lancet Oncology 2008; 9: 1149-1156.

Gorlin Syndrome


Case Report

A 93-year-old Chinese female presented with a defect of the left nasal sidewall extending into the medial cheek after Mohs surgery for a basal cell carcinoma (Fig. 1).

The fi nal defect was 15mm by 15mm (Fig. 2). Following Mohs surgery, defects in the perialar area often extend across one or more creases or folds, thus requiring repair of more than one reconstructive subunit. Attempts must be made to maximally camoufl age scars and to avoid manoeuvres that would result in bridging or blunting of creases and folds. How would you reconstruct this defect?

Burow’s Graft In The Reconstruction Of Nasal Side Wall

Dr Tan Wee Ping*, Dr Melvin Ee Hock Leong**

* Associate Consultant Dermatologist** Consultant Dermatologist, National Skin Centre

SURGICAL RECONSTRUCTION 1

Resolution

Reconstructive techniques of the nasal sidewall includes simple direct closure along relaxed skin tension lines, full thickness skin grafting, secondary intention healing and transposition or advancement fl aps. Direct closure may be possible for smaller defects, but larger ones may run the risk of signifi cant ala distortion. Transposition fl aps can be used on the cheek and lateral nasal sidewall. However, these fl aps often require incisions that may not fi t into the natural lines of the face, and the aesthetic results can be disappointing with trapdoor deformity

despite good undermining and squaring of edges. Secondary healing can produce aesthetically pleasing results, especially for defects over the concavity of the ala crease. However in this case, as the defect is deep and not situated in the concavity, the results will be poorer.

After tumour removal, the mobility of the surrounding tissue was determined. The defect was segmented and closure lines were planned to place in the junctions of the cosmetic units without crossing the junctions. The excision line was enlarged superiorly along the nasofacial sulcus and the dog ear (Burow’s triangle) removed. After adequate undermining at the upper level of the subcutaneous fat, this defect was closed directly. After excising the burow’s graft, adequate defatting with removal of all adipose tissue from beneath the dermis was performed before replacement on to the wound defect. The graft was then sutured in place with prolene 6-0. A small 2mm defect over the ala crease was left to heal by secondary intention, recreating the natural concavity of this location (Fig. 3).

The benefi ts of using Burow’s graft compared to other full thickness skin grafts that use skin from other anatomical areas are that the proximity of the donor site

2Fig 2: Defect after Mohs excision.

1

3 4

Fig 1: Pre-operative photo of left perialar basal cell carcinoma.

Fig 3: Burow’s graft in place and direct closure superiorly and inferiorly along the nasofacial and melolabial sulcus respectively. Small defect at the ala crease was left to heal by second-intention.

Fig 4: 3 months post-operative results


provides an excellent tissue match because colour, texture, thickness, sebaceous features, actinic damage and hair density are similar to the recipient site. Wound closure is orientated in relaxed skin tension lines, which allows better cosmetic results with hidden scars (Fig. 4). This graft also enables surgeons to choose one or two donor sites depending on the size of defect that needs to be repaired. However, some potential pitfalls include increased risk of necrosis if the recipient site is bone or cartilage or with an increase in thickness of the donor site, especially over the nose. This problem can be solved by adequately trimming any residual adipose tissue from the underside of the graft. In this case, the recipient site was not bone or cartilage.

A melolabial transposition fl ap can also be used effectively for repair of nasal sidewall defects (Fig. 5A, 5B, 5C and 5D). Trap-door deformities may be minimized by various methods including wide undermining around the margins of the wound, squaring of the defect edges and by approximation of deep tissue layers creating eversion of all skin edges.

Key points

• Burow’s graft can be used effectively for the repair of nasal sidewall defects with excellent tissue match

• Wound closure orientated in relaxed skin tension lines allows better cosmetic results with hidden scars

• Defects over the ala crease may be left to heal by secondary intention, recreating the natural concavity of this location

References

1. Carbeza-Martinez R, Leis V, Campos M, et al. Burow’s grafts in the facial region. J European Acad Dermatol Venereol 2006;20:1266-70

2. Levasseur JG, Mellette JR Jr. Techniques for reconstruction of perialar and perialar-nasal alar combined defects. Dermatol Surg 2000;26:1019-23

3. Baker SR: Reconstruction of the nose. In Baker SR. Local fl aps in facial reconstruction, St Louis, Mosby, 2007, pp 415-474.

Fig. 5: (A)Pigmented basal cell carcinoma over the concavity of the left ala crease. (B)Defect after excision of tumour. (C) Melolabial transposition fl ap for repair of a left nasal sidewall-ala crease defect. (D) 3 months post-operative results.

A B C D

Burow’s graft


Nasal Reconstruction With A Local Flap

Dr Raymond Kwah Yung Chien*, Dr Melvin Ee Hock Leong**


Case Report 1

A 71-year-old Caucasian presented with a 6-months history of a skin coloured papule over the left nasal ala. (Fig. 1) The lesion was asymptomatic. A biopsy

was performed and the histology was consistent with Basal Cell Carcinoma. He underwent Moh’s micrographic surgery. Preoperatively, the lesion measure 4x4mm. A 2 stage 3 section tumour extirpation was performed with resultant defect size of 10x9mm. The wound was closed with a bilobed fl ap.

Case Report 2

A 63-year-old Caucasian lady presented with a scaly plaque measuring 9x9mm over the right nasal sidewall. (Fig. 2) Biopsy was performed and the histology was consistent with Basal Cell Carcinoma. Moh’s micrographic surgery was performed. A 2 stage 3 section extirpation of the tumour was performed with resultant defect size of 10x11mm. The wound was closed with a rhombic fl ap.

Fig 1: (A) Skin coloured papule over the left nasal alar. (B) Following tumour extirpation with design of bilobe fl ap. (C) Post wound closure. (D) 3 months post operation

Fig 2: (A) Tumour over the right nasal wall. (B) Tumour extirpated with defect measuring 10x11mm. Flap design shown. (C) Closure of defect with a rhombic fl ap. (D) 3 months post operation.

A

A

B

B

C

C

D

D



Local fl ap nasal reconstruction

Discussion

The nose occupies a prominent position of visual attention in the central face. The nose can be divided into 9 aesthetic subunits. The ability to recreate proper nasal topography, minimize or avoid introducing asymmetry and placing surgical lines along natural occurring boundaries will ensure good post operative cosmesis.

To begin nasal reconstruction, the location of the wound with respect to the quality and availability of the surrounding skin must be noted.

Options for wound closure of the nose includes• healing by secondary intent• direct closure• skin grafts• local fl aps

Healing by secondary intention can be considered if wounds are small (less than 1 cm in diameter), shallow, located within concave areas and located at a signifi cant distance ( at least 0.5cm) from the mobile alar margin. For case 1, although the defect size was small, it was located near the alar margin. Thus healing by secondary intent may result in wound contraction with consequent alar elevation. For case 2, although the defect was small and located signifi cantly away from the alar margin, the defect was located near the convexity of the nose (nasal tip) and thus not ideal for secondary intention healing.

In both cases, the defects are small enough to consider direct closure. However, the defects are both located near the nasal tip. The removal of dog ear may result in an extension of the wound into the nasal tip (cross another nasal aesthetic subunit) which would result in cosmetically undesirable outcome. This method may also result in ipsilateral alar elevation.

Due to the general lack of abundant available donor tissue on the nose, skin grafts are sometimes employed to close nasal wounds. To achieve good cosmetic outcome, it is important to choose donor sites that share similar colour and texture with the nasal skin. This may be diffi cult and subtle differences in these characteristics may result in noticeable, cosmetically undesirable outcome. In both cases, the defect is close to the nasal tip which is thick and more glabrous which may pose a challenge to fi nding a suitable graft match. Skin graft also has limited ability to offer suffi cient volume replenishment for deeper nasal wounds, thus creating undesirable outcome. Furthermore, the graft is dependent on the underlying vascular bed for perfusion. There is thus a risk of graft failure and necrosis with resultant poor scarring.

Cutaneous fl aps are able to cover deeper and complicated nasal wounds. As skin adjacent to the wound is more likely to have similar texture, colour and thickness, it allows for better cosmetic outcome post wound repair. The perfusion of a well design fl ap is also protected. This provides for better survival rates of fl aps compared to skin grafts. Options available includes a Bilobed fl ap and a Rhombic Flap.

A bilobed fl ap was decided for Case 1 as the defect was located close to the nasal tip which was convex. The bilobe

fl ap provides the best means of restoring the curvature of the nasal tip. The location of the defect is also located at a site where the skin is thicker and less compliant. The bilobe fl ap allows more mobilization of the lax skin from the nasal sidewall to close the defect in 1 stage.

In Case 2, the defect is located at the lower pole of the nasal side wall. The sidewall has relatively lax skin. The rhombic fl ap allows for the mobilization of the lax skin to allow for closure of the defect. As the defect was located a signifi cant distance from the free margin of the nasal ala, there is a lower risk of distortion of the nasal free margin.

Bilobed Flap

The bilobed flap is a transpostion flap that was 1st introduced by Esser in 1918 and later modifi ed by Zitelli. It is a single- stage fl ap that is considered by many experts as the choice for reconstruction of defects, measuring up to 20 mm1, on the lower third of the nose,2 which has limited mobility that restrict its recruitment for local fl aps. Furthermore, the skin texture is unique such that only nearby skin will provide an adequate match. The utilization of this fl ap for nasal reconstruction has the advantage of recruiting skin of similar texture and colour from areas of skin redundancy that are not adjacent to the defect. The main disadvantage of this fl ap is that most of the incisions required for fl ap creation do not run parallel to the relaxed skin tension lines and may cross the boundary lines separating the nasal aesthetic units.

In the original Esser’s design, each lobes had to transpose a full 90 degrees in order to cover the primary and secondary defects. The required large arcs of tissue movement are accomplished with signifi cant surgical effort and consequently higher wound closure tensions, even when the fl ap is properly undermined. This results in cosmetically unpleasant alar displacement. The original design also inevitably creates a dog ear adjacent to the original defect.

Zitelli’s fl ap design help minimize dog ear creation as the primary defect is triangulated and the anticipated Burow’s triangle is surgically removed at the time of the initial fl ap placement. Furthermore there are smaller transposition angles. Zitelli’s fl aps rotate/transpose a total of 90–100 degrees.3 This minimize the distortion of free margins such as the alar and the nasal tip and risk of pincushioning.

The Zitelli’s fl ap consists of 2 lobes. (Fig.. 3) The fl ap’s primary lobe is transposed to cover a primary surgical defect. This transposition of the primary lobe of the fl ap creates a secondary defect, which is adequately covered by the flap’s secondary lobe. The movement of the secondary fl ap creates a tertiary defect which is closed in a primary, side to-side manner. The width of the primary lobe is equal to the width of the defect and the width of the secondary lobe is similar or slightly less than that of the primary lobe. The length of the secondary lobe is approximately 1.5 to 2 times greater than the primary lobe. The primary lobe is similar in shape to the defect while the secondary lobe is triangular. The linear axes passing through the centre of each lobe and the primary defects are positioned approximately 45 degrees to each other. The resulting burrow’s triangle is excised.


Local fl ap nasal reconstruction

One of the problems encountered with the Zitelli’s fl ap design is that of pincushioning. Moy et al4 reported an incidence of 5%. Dinehart5 described a double-rhombic transposition fl ap with the aim of further reducing incidence of pincushioning, achieved via its angulated fl ap that redirect fl ap tension vectors. With a rounded tip, tension is evenly distributed throughout the curvature of the arc, which may result in contraction of the fl ap seen as pincushioning. Pointed or angular tips change the direction of these tension vectors into a more linear fashion, which should result in less pincushioning of the fl ap.

Rhombic Flap

Like the bilobe fl ap, the rhombic fl ap is a random fl ap that relies on the dermal-subdermal plexus of blood vessels for nourishment. Pedicle width controls the amount of circulation within the dermal-subdermal plexus to some extent. Generally, the accepted safe maximum length-to-width ratio of the pedicle in the head and neck is 2-4:1. The geometry and reliability of the rhombic fl ap allows the surgeon to anticipate the position of the scars and the effects of wound closure on the surrounding structures.

Limberg6 described a technique for closing a 60° rhombus-shaped defect with a transposition flap. (Fig. 4) This involves designing a rhombus with angles of 60° and 120° is around the defect. A line equal in length to the short axis of the rhombus is drawn. A second line of the same length is also drawn to meet the fi rst line, creating an angle of 60 degrees.

This fl ap results in the main wound tension at the donor defect wound closure site. Tension is also generated at

the tip of the fl ap with minimal tension over the lateral margins.

Dufourmental7 modifi ed this technique in 1962. The angle of the tip of the secondary defect is more acute and this results in a shorter arc of rotation for the fl ap, facilitating easier closure of the secondary defect and sharing of the tension between the primary and secondary defects. It involves drawing the 1st line, equal to the length of one side of the rhombus, which bisects the angle formed by the 1st line of the classic rhombic fl ap and the line formed by extending one of the sides of the rhomboid from the same corner. The 2nd line is drawn parallel to the long axis of the rhomboid, starting from the free end of the 1st line. (Fig. 5)

This design allows for a slightly widened pedicle base, thus better blood supply to the fl ap, and a decrease in the arc of pivot, thus creating s smaller dog ear, reduce tension at the donor site and redistribute vertical tension at the leading tip to the lateral margin of the defect compared to the Limberg fl ap.

Webster8 published a third signifi cant modifi cation in 1978. The Webster 30° fl ap attempts to decrease wound closure tension at the donor site and reduce the size of the dog ear. However, the fl ap width is approximately half of that of the defect and thus the fl ap only relieves about half of the tension of the primary defect. This fl ap is usually coupled with a W-plasty at the fl ap base to facilitate wound closure. The design is planned similar to the Dufourmental except the distal tip of the fl ap is constructed to have an angle of 30 degrees.

Fig 3: The bilobe design.

The angles AOB and BOC = 45 degrees

Fig 4: Classic Rhombic fl ap (Limberg Design)

Fig 5: Dufourmentel Rhombic fl ap

Fig 6: Webster 30° fl ap

Continue on page 48


Case Report

A 60-year-old gentleman presented with basal cell carcinoma at the left upper lateral lip measuring 11.1mm x 9.0mm. The tumour was excised with

Mohs microsurgery. Five stages were required to clear the tumour, resulting in the full-thickness defect pictured below measuring, 25x21mm. (Fig1)

Resolution

This defect involved three cosmet ic subunits: the inferior nasal ala including the alar rim and the left lateral upper cutaneous lip. The repair required reconstruction of portion this cosmetic subunits while attempting to reconstitute the normal anatomic boundaries between them. The nasolabial fold is an important facial sulcus, which anatomically defi nes the border between the medial cheek and the lateral lip. When distorted, the resulting facial asymmetry is readily noticeably by others.

A number of options for repair were considered at the time of surgery including primary closure, transposition, rotation, advancement fl aps and skin grafting. Primary closure may be possible for smaller defect, but larger defect may run the risk of signifi cant puckering of the lip upwards and traction of the nasal ala. Healing by secondary intention would cause retraction of the nasal ala, narrowing of the nostril and possibility of upward traction of the upper cutaneous lip.2,3 Furthermore secondary intentions on convex surfaces of the face might not give a favourable outcome as well. Both of the options would not be acceptable cosmetically.

Lateral advancement fl ap of the upper cutaneous lip can be facilitated by perialar crescent excision to leave the nasal base undisturbed. Since a pure advancement fl ap has an unequal length being drawn together, there is a signifi cant of tissue distortion of this method.1 The fourth method was a nasolabial transposition fl ap. However utilizing this method will require a substantial amount of burrows triangle to be excised inferiorly to facilitate fl ap transposition which was deemed unnecessary. OT advancement closure if executed will most probably distort the philtrum which can be cosmetically counterproductive.

For defect of the lateral cutaneous lip, island pedicle fl aps are ideally suited for repair. After clearance of the

Island Pedicle Flap For The Repair Of Defect Of The Upper Lateral Cutaneous Lip

Dr Tan Mei Ling*, Dr Melvin Ee Hock Leong**

* Medical Offi cer** Consultant Dermatologist, National Skin Centre

tumour, a fl ap was designed and mobilised where the length was approximately three times the width of that defect. The length of the fl ap depends on the mobility of the surrounding tissue and the need to provide an acute enough angle at the distal end to avoid dog ear formation. The width of the fl ap is usually lesser than the defect to prevent pin cushioning except when adjacent to a free edge and care must be taken to avoid fl ap that is too narrow. A wide undermining advancing edge around the primary and secondary edges assist in mobility of the fl ap. The fl ap was incised inferiorly along the lateral lip and along the melolabial sulcus. The skin was advanced medially and superiorly. The inferior aspect was closed primarily with a tip stitch as well as interrupted

sutures. The fl ap was sutured in place with both vicryl 5/0 and prolene 6/0 sutures.5,6

The key stitch was from the rotating edge of the fl ap to the opposite edge of the fl ap. The component of rotation present in the closure assist in the avoidance of ectropion and eclabium.1,3 (Fig 2) The post operative course was uncomplicated and sutures were removed 10 days later with a good outcome seen at 4 months. (Fig 3)

References

1. Hairston BR, Nguyen TH. Innovations in the island pedicle fl ap for cutaneous facial reconstruction. Dermatol Surg 2003;29:378–85

2. Cvancara JL, Jones MS, Wentzell JM, Lenticular island pedicle fl ap. Dermatol Surg 2005; 31:195-200

3. Salmon PJ, Klaassen MF. The rotating island pedicle fl ap: an aesthetic and functional improvement on the subcutaneous island of pedicle fl ap. Dermatol Surg 2004;30:1223-1228

4. Li JH, Xin X, Ouyang TX, Li P, Xu J, Guo ET. Subcutaneous pedicle Limberg fl ap for facial reconstruction. Dermatol Surg 2005;31:949-952

5. Braun, Jr, Cook J. The island pedicle fl ap. Dermatol Surg 2005;31:995-1005

6. Cvancara JL, Wentzell JM. Shark island pedicle fl ap for repair of combined nasal ala-perialar defects. Dermatol Surg 2006;32:726-729

A B C D

Fig. 1. Surgical defect after fi ve stages of Mohs micrographic surgery

Fig. 2. Island pedicle advancement fl ap in place

Fig.3. Post operative follow-up at 4 months


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79550_CTP_Avene outline.indd 1 9/3/09 12:37:58 PM


Pivotal Advancement Flap In The Reconstruction Of A Medial Cheek And Nasojugal Defect

Dr Tan Wee Ping*, Dr Melvin Ee Hock Leong **


Resolution

Medium-sized medial cheek defects can be reconstructed using a number of different methods, including primary closure, transposition, rotation, advancement fl aps and skin grafting. Local and regional fl aps are the fi rst choice for repair. Primary closure may be possible for smaller defects, but larger defects may run the risk of signifi cant eyelid distortion and subsequent ectropion development. Rhombic transposition fl aps may be used, and when properly executed can provide excellent aesthetic results. Skin grafts generally give inferior cosmetic outcomes and are used only as a last resort.

units without crossing the junctions. The advancement fl ap had two lateral curvilinear incisions tangential to the defect superiorly along the lower eyelid-cheek junction and inferiorly along the nasolabial fold. This design shares some similarities with the Tenzel semicircular rotation fl ap. The incision on the lateral edge of the defect extends past the lateral canthus, upward in a semicircular fashion. The fl ap was undermined at the upper level of the subcutaneous fat, mobilized and advanced medially. The fl ap was appropriately thinned in the region of the lower eyelid for a better tissue match. Meticulous haemostasis using atraumatic pinpoint electrocoagulation of bleeding vessels was performed before suturing the fl ap. Suspension sutures were used to attach the subcutaneous-advanced tissue to the periosteum of nasofacial contour, and to sculpt the rolled contour of the fl ap.

Fig.2. Defect after Mohs excision.Fig.1. Pre-operative photo of medial cheek basal cell carcinoma.


Case Report

A 60-year-old Chinese man presented with a defect of the right medial cheek and nasojugal fold after Mohs surgery for a basal cell carcinoma (Fig. 1).

The fi nal defect was 29mm by 14mm (Fig. 2). How would you repair this defect?

Advancement fl aps are useful because of the considerable mobility of the skin of the medial cheek. This mobility is related to the ample subcutaneous fat located beneath the skin of the medial cheek. Generally, fl aps used to repair medial cheek defects involve some component of pivotal motion in addition to advancement. For defects of the cheek that are located in the superior aspect of the medial unit, pivotal advancement fl aps are ideally suited for repair.

After tumour removal, the mobility of the surrounding tissue was determined. The defect was segmented and closure lines were planned to place in the junctions of the cosmetic


Fig.4 3 months post-operative results

The extension of the incision above the lateral canthal angle ensures elevation of the lower eyelid during wound healing avoiding potentially devastating ectropion. The only pitfall can be the superfi cial temporal branch of the facial nerve that crosses near the upper incision at the zygomatic arch. This can be avoided by preoperative anatomical markings as well as keeping the dissection as superfi cial as possible in the subcutaneous level.

Fig.3 Flap advanced and wound closed. Excision of Burow’s triangle and suspension sutures attaching the dermis of the fl ap to the periosteum of the inferior bony orbital rim

Pivotal Advancement Flap

These sutures minimize distortion of adjacent facial structures and retraction of the lower eyelid. An absorbable suture, 5-0 vicryl was used to avoid vascular compromise of the fl ap. The “puckering” of the surface of the fl ap is avoided with a good design. Skin edges were approximated with 6-0 prolene sutures (Fig. 3).

Pivotal advancement fl aps of the cheek maintains the cosmetic units, avoids distortion of anatomical structures and allows closure lines to be placed discretely along the lower eyelid-cheek junction and nasolabial fold (Fig. 4). Considerable mobility of the skin over the cheek, coupled with a rich vascular supply, allows a large superfi cial area to be lifted with very little risk of necrosis. This fl ap permits the movement of the cheek upward and medially until it covers the defect.

References

1. Robinson JK. Segmental reconstruction of the face. Dermatol Surg 2004;30:67-74

2. Jelks GW, Jelks EB. Prevention of ectropion in reconstruction facial defects. Clin Plast Surg 2001; 28:297-302

3. Salasche SJ, Jarchow R, Feldman BD, et al. The suspension suture. J Dermatol Surg Oncol 1987;13: 973-8

Key points

• Pivotal advancement fl aps are ideal for repair of medial cutaneous cheek defects

• Incisions placed at the junction of cosmetic units and advancement flap to replace resected tissue with similar tissue allows facial contours to be restored with aesthetically pleasing results

• Suspension sutures anchoring the fl ap to the periosteum of the inferior bony orbital rim will avoid excessive downward traction on the eyelid


A B C D

The Oral Cavity Symposium

Reported by Dr Hazel Oon Hwee Boon*

* Registrar, National Skin Centre

JOINT TEACHING SEMINAR

The joint teaching seminar on the Oral Cavity was held on 30 June, 2009. The following topics were covered: I. Oral Manifestations of Systemic Diseases by Dr Tan

Kian Teo, Consultant, National Skin Centre; II. Common Oral Lesions by Dr Wong Wai Yee, Associate Consultant, Oral Maxillofacial Surgeon, Alexandra Hospital; III. Overview of Aesthetic Dentistry by Dr Christina Sim, Senior Consultant, Department of Restorative Dentistry, National Dental Centre.

Oral Manifestations of Systemic Diseases

A number of systemic diseases have oral manifestations which may present to the dermatologist or dentist. In certain cases, the oral lesion may precede the systemic symptoms and serve as an important lead in to the diagnosis of the underlying medical disorder. Dr Tan highlighted the various dental manifestations of haematological disease, malignancy, connective tissue disorders, renal, gastrointestinal and endocrine disorders (Table 1).

Fig 1: XR of Langerhans’ cell histiocytosis demonstrating ‘fl oating teeth’ surrounded by large radiolucent areas.

II. Common Oral Lesions

Oral lesions can be broadly defi ned into those related to the bone, teeth or soft tissue. The commonest bony disorders are exostoses or bony protuberances arising from the cortical plate. They generally do not require surgical treatment unless symptomatic or need to accommodate a denture.

The clinical presentation, aetiology and treatment of a number of tooth disorders were discussed by Dr Wong. These included tooth discolouration, enamel hypoplasia, tooth erosion and abrasion, impacted teeth and dental infections. Treatment of a parulis (focus of pus in the gingival), orofacial abscess and fi stula require removal of the affected tooth, incision and drainage and antibiotic therapy.

Soft tissue disorders are further subdivided into infective, noninfective, disorders of the tongue, premalignant, malignant and benign conditions (Table 2). Important pearls shared by Dr Wong include: (1) tuberculosis can present as an angular or stellate ulcer on the mid-dorsum of the tongue with overhanging edges, (2) chronic denture stomatitis necessitates treatment of the denture with an overnight soak in 0.1% hypochlorite solution or miconazole gel prior to insertion of the affected denture to prevent recurrence and (3) the management of dysplastic soft tissue lesions include behaviour modifi cation (cessation of smoking and betel nut chewing), treatment of underlying candidiasis and anaemia, biopsy of the dysplastic area, assessment of risk of malignancy based on a clinical and histological correlation, consideration of local ablation and subsequent vigilance for malignant transformation.

Table 2: Soft Tissue disorders

Soft Tissue Disorders ExamplesMucosal• Infective

• Noninfective

• Tongue

HerpesHand foot mouth diseaseTuberculosis, syphilisLichen planusRecurrent apthous stomatitisPemphigus vulgarisMucous membrane pemphigoidBullous erythema multiformeOral hairy leukoplakiaGeographic tongueHairy tongue

Premalignant• Erythroplasia• LeukoplakiaMalignant Squamous cell carcinoma

Overview of Aesthetic Dentistry

Dental aesthetics is a combination of the occlusive aspect of the bony structures of the jaw, teeth and the visual component of the smile from red aesthetics (gum) and white aesthetics (teeth). The ratio of red-white aesthetics is perturbed in conditions such as root recession and gingival hyperplasia from cyclosporine use. Treatment options include tooth whitening, orthodontics, orthognathic surgery, grafting, cauterization of excess gingival, dentures, bridges and implants. Management should be tailored individually to the patient with consideration of the dental pathology, patient expectation and budget. Dr Sim shared with us the advances in orthodontics (Invisalign, lingual braces), tooth whitening procedures (dentist supervised home bleaching and plasma arc light activation of hydrogen peroxide) and endodontics.


Table 1: Dental Manifestations of Systemic Diseases

Systemic Disease Dental ManifestationHaematological Disease• Iron defi ciency anaemia

• Leukaemia

• Multiple myeloma

Atrophic glossitisAngular cheilitisMucosal pallor

Petechiae, gingival haemorrhageGingival hypertrophyMucosal ulcerationChemotherapy-related complications (reactivation of HSV, mucositis)

Jaw swelling, pathological fractureInfection- candidiasis, oral hairy leukoplakiaMacroglossia from amyloid deposition

Rheumatological Diseases• Lupus Erythematosus

• Rheumatoid Arthritis

• Sjogren’s Syndrome

• Behcet’s disease

Oral ulcersEcchymoses, petechiaeSecondary Sjogren’s

Temporal mandibular joint arthritisSecondary Sjogren’s

XerostomiaParotid/submandibular gland enlargementDental caries

Oral ulcers (apthous/herpetiform)Oncological Disease• Metastases

• Langerhans’ cell histiocytosis

Jaw tumours, less commonly oral soft tissue

Alveolar bone lossXR teeth ‘fl oating in air’ (Fig.1)

Endocrine Disorders• Diabetes mellitus

• Cushing’s syndrome or disease

• Acromegaly

• Renal Disease

XerostomiaBenign migratory glossitisCaries, gingivitisDiabetic sialadenosis (parotid gland hypertrophy)Burning mouth syndromeInfection – candida, mucormycosis

CandidiasisPathological fracture of mandible, maxilla or alveolar bone

Mandibular enlargementSplayed teeth

Uraemic stomatitisGastrointestinal Disorders• Crohn’s disease

• Ulcerative colitis

Angular cheilitisCobblestoning of buccal mucosaNon-necrotising submucosal granulomas

Pyostomatitis vegetans or ulcerans

Oral cavity symposium


Introduction

S exually transmitted infections (STIs), both bacterial and viral are on the rise in Singapore. The number of attendances at the Department of STI Control

Clinic (DSC) has almost doubled from 17,089 attendances in the year 2000 to 32,900 attendances in 2008. In order to cope with this increase in patient numbers, the laboratory at DSC has had to expand its workspace and increase its staffi ng capacity in order to anticipate the processing of approximately 50,805 laboratory tests for the public patients annually.

Diagnostic testing for STIs has evolved over time. It is important for physicians treating these patients to be aware of and to perform accurate and appropriate testing for STIs to avoid the long-term sequelae of infection, to halt transmission and to improve associated morbidity.

Basic Principles in Diagnostic Tests

• Antibody – substances the body produces in response to an infectious organism

• Antigen – the organism itself• False negatives – people who test negative but are

actually infected (missed infections)• False positives – people who test positive but who are

actually not infected• Sensitivity – how good a test is at identifying people

who are infected. The higher the sensitivity, the lower the rate of false negatives (missed infections)

• Specifi city – how good a test is at identifying people who are not infected. The higher the specifi city, the lower the rate of false positives

Ideally one would like a test that has 100% sensitivity (i.e. everyone who is infected tests positive) and 100% specificity (i.e. everyone who is not infected tests negative).

Types of tests used in STI Diagnostics

• A. Directly visualizing the organism under the microscope. E.g : gram staining for gonorrhea, wet mount for yeast, and dark fi eld microscopy for syphilis.

• B. Using antibody tests that measure the body’s response to the organism. E.g: testing for syphilis or HIV antibodies.

• C. Culturing the organism (i.e., growing it in the laboratory). E.g: culturing chlamydia and gonorrhea. Enables antimicrobial susceptibilities to be determined.

• D. Methods for detecting antigen (the organism itself) or antibody. E.g: enzyme immunoassay (EIA) for chlamydia.

Update On Diagnostic Testing In Sexually Transmitted Infections

Dr Priya Sen*

* Consultant Dermatologist, National Skin Centre

STI UPDATE

• E. Non-amplifi ed techniques for detecting DNA from the organism. E.g : nucleic acid hybridization

• F. Amplifi ed techniques for detecting DNA from the organism. E.g : PCR (polymerase chain reaction),TMA (transcription mediated amplifi cation).

• G. Rapid Point-of-care Tests are used to guide treatment so that patients can be treated without a return visit. Most use immunochromatography to detect antigens or antibodies in a dipstick or lateral fl ow format

Bacterial Vaginosis

Bacterial vaginosis (BV) is a condition resulting from replacement of the normal H2O2-producing Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria (e.g. Prevotella sp. and Mobiluncus sp.), Gardnerella vaginalis and Mycoplasma hominis. The exact role of sexual transmission in the pathogenesis of BV is unclear. BV may be asymptomatic or present with a foul-smelling, thin homogenous vaginal discharge.

Laboratory Tests

3 out of 4 of the following criteria should be present (Amsel Criteria)• thin homogenous vaginal discharge that coats the

vaginal wall• vaginal pH > 4.5• positive amine (fi sh-like) odour test (“sniff test”) before

or after addition on 10% KOH• presence of clue cells on microscopy of vaginal

discharge

Culture of G. vaginalis is not recommended because it is not specifi c.

Candidiasis

Genital candidiasis is the infection of the vulva, vagina, prepuce and glans penis by Candida albicans or occasionally by other Candida sp., Torulopsis sp. or other yeasts. It is not generally considered a sexually-transmitted infection.

Laboratory Tests

• Gram-stain or wet mount (saline or 10% KOH) of swabs from the vulva/vaginal wall, or penis/prepuce will reveal budding yeast cells and pseudohyphae (sensitivity 60%)

• culture on Sabouraud media (isolation in the absence of symptoms and negative direct smear is not an indication for treatment)


Chancroid

Chancroid is a sexually transmitted disease caused by the bacterium Haemophilus ducreyi. This infection is very uncommon in Singapore, but still common in parts of India and South East Asia.

Laboratory Tests

• direct microscopy of smear from ulcer showing Gram-negative coccobacilli (arranged in “shoals of fish” pattern)

• culture for H. ducreyi of smear from ulcer or aspirate from buboes (sensitivity <80%)

• diagnosis is often based on typical clinical presentation and after exclusion of syphilis and HSV infection

• PCR detection – commercial kits available soon

Chlamydia Urethritis and Cervicitis

Chlamydia trachomatis is the most commonly notifi ed STI in both males and females in Singapore. It is asymptomatic in up to 80% of women and 50% of men and is important to diagnose as if left untreated may have serious sequelae such as pelvic infl ammatory disease, ectopic pregnancy and tubal infertility in women and epididymitis, chronic prostatitis and urethral strictures in men.

Laboratory Tests

• PCR testing from urine in males and cervical swabs in female – new gold standard

• antigen detection methods - direct fl uorescent antibody (DFA)

• cell culture for chlamydia in McCoy cell monolayers

Serological tests not useful in the diagnosis of acute chlamydial infections because of cross-reactivity between chlamydial species, and the high prevalence of Chlamydia antibodies in high risk populations.

Rectal and pharyngeal infections are best detected by culture or DFA, the performance of NAAT on these samples is undefi ned.

Gonorrhoea

Gonorrhoea is caused by Neisseria gonorrhoeae. The common sites of infection include the urethra, the endocervix, the rectum, the pharynx and the conjunctiva. It is characterised clinically by a profuse purulent discharge from the affected mucosalsite, often accompanied by local pain or discomfort. However, asymptomatic infection occurs in 10% of urethral infection, >50% of cervical infection, >80% of pharyngeal and rectal infection.

Laboratory Tests

• Direct microsopy showing Gram-negative intracellular diplococci in a Gram-stained smear of the discharge

• Culture on Thayer-Martin Selective Agar – allows for antibiotic sensitivity testing and only test validated for rectal and pharyngeal sites

• PCR testing on urine samples from males and cervical swabs from females (>90% sensitivity for genital sites)

The gonococcal complement fi xation test (GC-CFT) is useless for diagnosing gonorrhoea

Genital Herpes

This is caused by Herpes simplex virus, usually HSV type 2 but also by type 1 and is the most common cause of genital ulcers in Singapore.

Laboratory Testing

• virus isolation in cell culture (gold standard) - sensitivity declines as the lesions heal, viral typing possible

• HSV antigen detection – by DFA or EIA techniques, insensitive, viral typing not possible, economical, quick

• PCR detection of viral nucleic acid – sensitivity highest, viral typing possible, expensive

• type-specifi c serological tests (TSST) for HSV 1 & 2 – based on recombinant type-specifi c glycoproteins G1 and G2 are now available, they have good sensitivity and specificity, and are useful in certain clinical situations e.g. confi rming a clinical diagnosis of genital herpes, counselling of sexual partners of infected persons, detection of unrecognized infection, and for seroepidemiological studies; examples of these tests are the HerpeSelect 1 & 2 ELISA and Immunoblot test kits.

Many commercial tests for HSV antibodies are not type specifi c and are of NO value in the management of genital herpes.

Human Immunodefi ciency Virus (HIV)

HIV causes a chronic but treatable infection that results in a spectrum of disease. It can be transmitted through sexual intercourse with an infected person, the use of contaminated syringes and needles, transfusion of infected blood and blood products, and from infected mothers to babies.

Laboratory Tests

• Screening Tests: enzyme-linked immunosorbent (EIA) or the particle agglutination (PA) techniques. This includes the Rapid HIV tests from saliva or blood. Though very sensitive in detecting antibodies they must be confi rmed by a confi rmatory test.

• Confi rmatory Test: Western Blot

Rapid tests (e.g. Determine test, Hemastrip test, Orasure) for HIV are as accurate as EIA tests for HIV-1 and 2, results are available in 10 – 15 minutes. Negative tests do not need to be confi rmed, positive tests must be confi rmed by EIA and WB.

Human Papilloma Virus Infection (HPV)

Over 30 types of HPV can infect the anogenital tract.

Laboratory Tests

• Pap Smear• HPV typing (commercial kits expensive and not readily

available)

Diagnostic Testing in STIs


Syphillis

Syphilis is a systemic infection caused by Treponema pallidum. With the exception of mother-to child transmission syphilis is almost exclusively spread by direct contact with infectious lesions.

Laboratory Tests

• Non-Treponemal Tests: RPR or VDRL• Treponemal Tests: TPHA or TPPA or EIA or LIA

A positive VDRL/RPR test needs to be confi rmed by a confi rmatory treponemal test. RPR/VDRL are monitored serially to assess the serological response to treatment. The titres of treponemal tests are not useful in monitoring treatment response.

Rapid diagnostic tests (e.g. Abbott Determine Syphilis TP) and the treponemal EIA test are specifi c and can be used as screening tests. A positive result should be confi rmed by another specifi c test.

Trichomoniasis

Trichomoniasis is an infection of the genital tract by the protozoan Trichomonas vaginalis. Women are the main carriers of the disease. Infected men are usually asymptomatic or may present with urethritis.

Laboratory Tests

• direct microscopy of a wet mount of vaginal secretions mixed with normal saline

• culture on Feinberg-Whittington media (sensitivity >90%)

• Rapid strip tests e.g. Xenostrip-Tv test-are also useful

Discussion

It is important that clinicians keep abreast with the evolution of diagnostics and availability of testing for STIs in Singapore. Older tests which have no diagnostic value due to inaccuracy and crossreactivity should not be used any longer. Accurate and appropriate testing for STIs is important to reduce patient morbidity, anxiety, onward transmission and for public health.

Diagnostic Testing in STIs

All rhomboid flaps are closed under some degree of tension, and this tension is characteristically unevenly distributed along the fl ap’s length. Areas of maximal tension are subject to preferential widening and depression along the line of tension. Pin-cushioning or trap-door deformities may develop and may be related to inadequate incision of wound edges, incomplete undermining, or postoperative scar thickening.

A thickened scar may be managed with intralesional corticosteroid injections in the early postoperative period, or by secondary revision surgery. A poorly planned fl ap will distort anatomical landmarks and leave a poorly oriented scar.

References

1. Fujiwara M. One-stage reconstruction of an alar defect using a bilobed nasolabial-nasal tip flap based on the

aesthetic subunits in Orientals: case report. Aesth Plast Surg 2004;28:13–6

2. Zitelli JA, Baker SR. Bilobe fl aps. In: Baker SR, Swanson NA, eds. Local Flaps in Facial Reconstruction. St. Louis: Mosby, 1995:165–80

3. Zitelli JA. The bilobed fl ap for nasal reconstruction. Arch Dermatol 1989;125:957-9

4. Moy RL, Grossfeld JS, Baum M, Rivlin D, Eremia S. Reconstruction of the nose using a bilobed flap. Int J Dermatol 1994;33:657–60

5. Dinehart SM. The rhombic bilobed fl ap for nasal reconstruction. Dermatol Surg 2001;27:501–4

6. Limberg AA. Design of local fl aps. In Gibson T (ed). Modern Trends in Plastic Surgery, Sevenoaks, England, Butterworth, 1966

7. Dufourmental C. An L – shaped fl ap for lozenge –shaped defects. In transactions of the Third International Congress of Plastic Surgery, Amsterdam, Excerpta Medica, 1964

8. Webster RC, Davidson TM, Smith RC. The 30 degree transposition fl ap. Laryngoscope 88:85, 1978

Continued from page 39

Nasal Reconstruction With A Local Flap


Introduction

Hyaluronic acid (HA) – biochemically identifi ed as a glycosaminoglycan – was isolated in 1934 from the vitreous humor. HA, which is widely distributed in

body tissues, is an important component of extracellular matrix.

The term hyaluronan was introduced to conform with the international nomenclature of polysaccharides. It was coined to encompass the different forms the molecule can take, e.g. the acid form, hyaluronic acid, and the salts, such as sodium hyaluronate, which form at physiological pH1.

Chemical Description

HA is a polysaccharide built up from repetitive units of D-glucuronic and D-N-acetylglucosamine disaccharides. An average HA chain contains up to 10,000 dissaccharide repeats with a high molecular weight ranging from 2 x 105 to 107 Da. HA is produced primarily in the connective tissue; synthesized by a class of integral membrane proteins (hyaluronan synthases), and degraded by a family of enzymes called hyaluronidases1.

Properties and Functions of HA in Skin

HA demonstrates remarkable rheological, viscoelastic and hygroscopic properties which are relevant for dermal tissue function.

HA functions are diverse. Besides being a matrix in which cells are embedded, HA has been found to have an increasing number of functions in skin. It can immobilize water to the tissue and thereby change dermal volume and compressibility2. HA is also capable of interacting with a number of receptors resulting in the activation of signaling cascades that infl uence cell migration, proliferation, and gene expression1.

The physiological effects of HA depend to a large degree on the size (molecular weight) of its chains. Enzymatic degradation fragment HA into lower molecular weight

Hyaluronic Acid In Dermatology

Ms Elizabeth Tian*

* Principal Pharmacist, National Skin Centre

PHARMACY PAGE

molecules (low molecular weight HA, LMWHA) that have different functions than the parent molecule. When HA is degraded during infection and injury, LMWHA forms are generated whose interactions infl uence infl ammation and angiogenesis. Intact high molecular weight HA (HMWHA), conversely, conveys anti-infl ammatory signals3.

Medical Applications of HA

Because of its unique physicochemical properties, and in particular its non-immunogenicity, HA has found medical applications for many years. The fi rst HA biomedical product, developed in the 1950s, was used as a vitreous substitution during eye surgery1. HA is also used in a treatment called viscosupplementation for osteoarthritis of the knee4.

HA is currently used as a surgical aid to encourage healing and regeneration of surgical wounds. Investigators have found that cross-linked HA hydrogel fi lms accelerate the healing of full-thickness wounds1. Several in vitro studies suggest that HA is part of a feedback loop that promotes cell proliferation and migration in actively growing tissues. Alternatively, the role of HA in water homeostasis could favor tissue hydration, which has a well-known benefi cial effect on healing5.

HA has also been used in the synthesis of biological scaffolds for wound healing applications. These scaffolds typically have proteins such as fi bronectin attached to the HA to facilitate cell migration into the wound. This is particularly important for individuals with diabetes who suffer from chronic wounds6.

The prophylactic use of a cream with hyaluronic acid has been shown to reduce the incidence of high grade radio-epithelitis, suggesting an interesting role of the hyaluronic acid cream as supportive treatment to improve compliance and quality of life in patients undergoing radiation therapy7.

As a topical drug delivery system for diclofenac, an HA gel (Solaraze®) has recently been approved in the USA and Europe for the treatment of actinic keratoses8.

Cosmetic Applications

Investigators cite decreased turgor, reduced support for the microvasculature, wrinkling and sagging, and altered elastic response due to the decreased levels of HA.

A number of wrinkle fi llers have been developed on the basis of HA. Originally extracted from rooster combs, HA is

CH2OH

N-acetyl-D-glucosamine D-glucuronic acid

Structural formula of hyaluronic acid

O

O

O

n

OH

OH

OH

NHCOCH3

OCOOH


now produced as a reactive byproduct of a benign bacteria and is identical to the substance found within the skin.

HA has a unique hydroscopic property; it binds a large amount of water (about 1000-fold its own weight). Its high water-binding capacity (humectancy) preserves tissue hydration in skin, hence, is often used as a moisturizing agent in cosmetic formulations. However, there is a controversy whether concentrated HA formulas should be used as a moisturizer in dry climate. When air humidity is very low, HA may preferentially pull water from the skin rather than from the air, thus producing the opposite effect9.

There is a considerable interest in using topical HA as a potential wrinkle cure. HA that are typically used in skin care have relatively long chains (molecular weight 500,000 Da or more) and these seem unlikely to penetrate the skin well enough to affect dermal matrix. LMWHA (5,000 – 20,000 Da) may penetrate into the dermis in signifi cant amounts. However, it appears that small size HA seems to have the opposite effect to large size HA (or HMWHA), which is anti-infl ammatory. Therefore, even if LMWHA can penetrate the skin, it may not be a good skin rejuvenation agent9. The effectiveness of topical HA for wrinkles is yet to be proven. In a small study in Europe, stimulation of HA production in skin by a device that produces a specifi c pulsed electromagnetic fi eld (electorydesis) seemed to have improved the appearance of wrinkles10.

Conclusion

Hyaluronic acid (HA) is a natural biopolymer that can be very effective for skin hydration and moisturizing, if used properly. All functions of HA on the skin are not known

at present, but it has been suggested to have benefi cial actions in wound healing. Clinical applications of this glycosaminoglycan in dermatology will undoubtedly expand in the near future.

References

1. Necas J, Bartosikova L, Brauner P, et al. Hyaluronic acid (hyaluronan): a review. Veterinarni Medicina 2008 (8); 53: 397–411

2. Juhlin L. Hyaluronan in skin. J Intern Med 1997; 242: 61–6

3. Bollyky PL, Lord JD, Masewicz SA, et al. Cutting edge: High molecular weight hyaluronan promotes the suppressive effects of CD4+CD25+ regulatory T cells. Journal of Immunology 2007; 179: 744 -747

4. Puhl W; Scharf P. Intra-articular hyaluronan treatment for osteoarthritis. Ann Rheum Dis 56 (7); 637–40

5. King SR, Hickerson WL, Proctor KG. Benefi cial actions of exogenous hyaluronic acid on wound healing. Surgery 1991 Jan; 109(1): 76-84

6. Shu XZ, Ghosh K, Liu Y et al. Attachment and spreading of fi broblast on an RGD peptide-modifi ed injectable hyaluronan hydrogel. J Biomed Materials Res 2004; 68: 365-75

7. Liguori V, Guillemin C, Pesce GF et al. Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy. Radiother Oncol 1997 Feb; 42(2): 155-61

8. Weindl G, Schaller M, Schäfer-Korting M et al. Hyaluronic acid in the treatment and prevention of skin diseases: molecular biological, pharmaceutical and clinical aspects. Skin Pharmacol Physiol 2004; 17: 207-213

9. Todorov G. Hyaluronic acid for skin hydration and possibly a lot more. http://www.smartskincare.com/treatments/topical/hyaluronic-acid.html

10. Paye M, Barel AO. Handbook of Cosmetic Science and Technology 2nd Ed 2006

J&J-018-09 CleoMagFPFC.ai 5/7/09 3:18:41 PM

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National Skin Centre • 1 Mandalay Road • Singapore 308205 • Tel: 6253 4455 • Fax: 6253 3225 • Website: www.nsc.gov.sg

The printing of this Dermatology Bulletin was made possible by the co-sponsorship of the following in support of continuing education in Dermatology:

• L’Oreal Singapore Pte Ltd • Neutrogena • ICM Pharma Pte Ltd • Color Play Enterprise Pte Ltd

Editor : Dr Chua Sze Hon

Members : Dr Audrey Tan

Dr Mark Tang

Dr Goh Boon Kee

Mrs Tang Lee Foon

Ms Elizabeth Tian

Ms Kong Kim Yoke

Advisor : Prof Roy Chan Kum Wah

The Dermatology Bulletin is an in-house publication for internal circulation.

The opinions expressed in this publication are those of the authors concerned. The claims made in any advertisements are those of the sponsors. The mentioning of any product by the authors does not imply any official endorsement of the product by National Skin Centre (S) Pte Ltd.

No part of the material in this bulletin may be reproduced or transmitted by any process in whole or in part without prior permission in writing. The contents of this bulletin is available on-line at www.nsc.gov.sg/bulletin/bulletin.html

Hyaluronic acid in dermatology


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DERMATOLOGY BULLETIN

Health & Medicine

Transcript of DERMATOLOGY BULLETIN