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British Society for Dermatological Surgery: Summaries of Papers DS-1 Treatment of lentigo maligna with imiquimod P. ORMOND, C.BLASDALE, N.LEONARD* AND C.M.LAWRENCE Departments of Dermatology and *Histopathology, Royal Victoria Infirmary, Newcastle upon Tyne, U.K. Lentigo maligna (LM), the in situ phase of lentigo maligna melanoma, most commonly occurs on the face and neck. Treatment of recurrent or large LMs can be difficult due to previous surgical repairs, scarring, anatomical site and patient characteristics. Intralesional interferon alpha has been reported to be of use in both LM and recurrent LM. 1 Imiquimod 5% cream is an immunomodulatory agent that induces interferon alpha within the skin, and has been used successfully in one patient with LM. 2 Patients presenting with recurrent LM where re-excision could be disfiguring, or those who declined surgery, were offered imiquimod therapy. Five patients were treated, all female, aged 71–93 years. Four had recurrences on the eyelids, nose or ear. The fifth patient, who refused surgical intervention, had a large lesion involving the upper and lower eyelids, lateral canthus and temple. Patients applied imiquimod 5% cream (Aldara Ò ) to the affec- ted area once daily for 6 – 12 weeks depending on their ability to tolerate treatment. Patients were followed for up to 6 months. Imiquimod application caused inflammation of the skin during the application period. All patients responded with partial or total clearance. Clinical improvement was seen within weeks, although the length of time to maximal clinical response varied between patients. One patient had post-treat- ment biopsies, which showed absence of atypical melanocytes. Imiquimod cream, a topical immune response modifier, may have a role to play in the management of LM. References 1 Cornejo P, Vanaclocha F, Polimon I et al. Intralesional interferon treatment of lentigo maligna. Arch Dermatol 2000; 136: 428–30. 2 Ahmed I, Berth-Jones J. Imiquimod: a novel treatment for lentigo maligna. Br J Dermatol 2000; 143: 843–5. DS-2 The use of a dermatoscope in a pigmented lesion clinic S.A. LATEO, H.BENBOW AND C.M.LAWRENCE Dermatology Department, Royal Victoria Infirmary, Newcastle upon Tyne, U.K. Dermatoscopy has been recommended for the clinical examination of pigmented lesions, as an aid to help distinguish malignant from benign lesions. We are cur- rently examining the application of the dermatoscope in a pigmented lesion clinic and how frequently the use of this instrument results in a change in clinical practice or diagnosis. All patients attending the pigmented lesion clinic were assessed by one of three experienced dermatologists. In each case a clinical diagnosis or differential diagnosis was made. If the observer felt that dermatoscope examination was required this was then performed and the effect on the original clinical diagnosis assessed and recorded as one of the following six alternatives: (1) confused situation; (2) did not help confirm the diagnosis; (3) confirmed consistent with diagnosis that was made clinically; (4) confirmed diagnosis which was not definite clinically; (5) changed diagnosis; (6) changed man- agement. To date, over a 4-week period, 159 subjects have been examined. In 65% of cases the dermatoscope was used. The dermatoscope was not used in obvious benign lesions such as benign moles, seborrhoeic warts and dermatofibromas. For the 103 pigmented lesions where it was used, in 1% its use confused the clinician, in 20% its use did not help, in 50% it showed changes consistent with the clinical diagnosis and in 27% it confirmed the diagnosis which was not definite clinically. Its use never suggested an alternative diagnosis or altered management. It was particularly useful in distinguishing haemangiomas from melanin pigmented lesions. The use of the dermatoscope is limited by the expertise of the observer. Users have to acquire experience in the use of this tool as the physical signs it reveals are different in substance and type from those observed with the unaided eye. British Journal of Dermatology (2002) 147 (Suppl. 62): 57–65 Ó 2002 British Association of Dermatologists 57

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British Society for Dermatological Surgery:Summaries of Papers

DS-1Treatment of lentigo maligna with imiquimodP . O R M O N D , C . B L A S D A L E , N . L E O N A R D *A N D C . M . L A W R E N C EDepartments of Dermatology and *Histopathology, Royal VictoriaInfirmary, Newcastle upon Tyne, U.K.

Lentigo maligna (LM), the in situ phase of lentigo malignamelanoma, most commonly occurs on the face and neck.Treatment of recurrent or large LMs can be difficult due toprevious surgical repairs, scarring, anatomical site andpatient characteristics.

Intralesional interferon alpha has been reported to be of usein both LM and recurrent LM.1 Imiquimod 5% cream is animmunomodulatory agent that induces interferon alphawithin the skin, and has been used successfully in onepatient with LM.2

Patients presenting with recurrent LM where re-excisioncould be disfiguring, or those who declined surgery, wereoffered imiquimod therapy. Five patients were treated, allfemale, aged 71–93 years. Four had recurrences on theeyelids, nose or ear. The fifth patient, who refused surgicalintervention, had a large lesion involving the upper andlower eyelids, lateral canthus and temple.

Patients applied imiquimod 5% cream (Aldara�) to the affec-ted area once daily for 6 – 12 weeks depending on their abilityto tolerate treatment. Patients were followed for up to6 months.

Imiquimod application caused inflammation of the skinduring the application period. All patients responded withpartial or total clearance. Clinical improvement was seenwithin weeks, although the length of time to maximal clinicalresponse varied between patients. One patient had post-treat-ment biopsies, which showed absence of atypical melanocytes.

Imiquimod cream, a topical immune response modifier,may have a role to play in the management of LM.

References1 Cornejo P, Vanaclocha F, Polimon I et al. Intralesional interferon

treatment of lentigo maligna. Arch Dermatol 2000; 136: 428–30.2 Ahmed I, Berth-Jones J. Imiquimod: a novel treatment for lentigo

maligna. Br J Dermatol 2000; 143: 843–5.

DS-2The use of a dermatoscope in a pigmentedlesion clinicS . A . L A T E O , H . B E N B O W A N D C . M . L A W R E N C EDermatology Department, Royal Victoria Infirmary, Newcastleupon Tyne, U.K.

Dermatoscopy has been recommended for the clinicalexamination of pigmented lesions, as an aid to helpdistinguish malignant from benign lesions. We are cur-rently examining the application of the dermatoscope in apigmented lesion clinic and how frequently the use of thisinstrument results in a change in clinical practice ordiagnosis.

All patients attending the pigmented lesion clinic wereassessed by one of three experienced dermatologists. In eachcase a clinical diagnosis or differential diagnosis was made. Ifthe observer felt that dermatoscope examination was requiredthis was then performed and the effect on the original clinicaldiagnosis assessed and recorded as one of the following sixalternatives: (1) confused situation; (2) did not help confirmthe diagnosis; (3) confirmed ⁄ consistent with diagnosis thatwas made clinically; (4) confirmed diagnosis which was notdefinite clinically; (5) changed diagnosis; (6) changed man-agement.

To date, over a 4-week period, 159 subjects have beenexamined. In 65% of cases the dermatoscope was used. Thedermatoscope was not used in obvious benign lesions suchas benign moles, seborrhoeic warts and dermatofibromas.For the 103 pigmented lesions where it was used, in 1% itsuse confused the clinician, in 20% its use did not help, in50% it showed changes consistent with the clinicaldiagnosis and in 27% it confirmed the diagnosis whichwas not definite clinically. Its use never suggested analternative diagnosis or altered management. It wasparticularly useful in distinguishing haemangiomas frommelanin pigmented lesions. The use of the dermatoscope islimited by the expertise of the observer. Users have toacquire experience in the use of this tool as the physicalsigns it reveals are different in substance and type fromthose observed with the unaided eye.

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DS-3Two cases of malignant melanoma arisingin familial cancer syndromes: highlightingthe need for skin examination in thesepatient subgroupsA . O ’ H A G A N , O . D O L A N A N D A . B I N G H A MRoyal Victoria Hospital, Belfast, U.K.

Retinoblastoma and Cowden syndrome are two autosomaldominant familial cancer syndromes (FCS) that have beenassociated with multiple tumours.

We report two adults with these conditions who developedcutaneous malignant melanoma. The first patient had ahistory of childhood bilateral retinoblastoma and subse-quently developed two primary cutaneous malignant melan-omas. The second was a 17-year-old boy with Cowden’ssyndrome who developed a facial cutaneous malignantmelanoma.

These cases highlight the importance of regular total bodyskin examination in patients with FCS and may represent anadditional subgroup for screening and surveillance ofhigh-risk individuals.

DS-4Giant basal cell carcinomasA . D . M O R R I S , I . C . P E A R S O N , * B . C . G E E ,C . C . H A R L A N D * A N D L . G . M I L L A R DDepartments of Dermatology, University Hospital, Nottinghamand *St Helier Hospital, Carshalton, U.K.

Giant basal cell carcinomas (BCCs; >5 cm in diameter) areuncommon, representing less than 1% of BCCs.1 However,these tumours demonstrate aggressive local invasion, oftenresulting in considerable disfigurement, and they not infre-quently metastasize. We report three patients with giant BCCs:

Case 1: 50-year-old man with a BCC on his hip for years.Found to have bone metastases.

Case 2: 75-year-old man with BCC on occiput. Refusedsurgery and treated with radiotherapy. Four years laterpresented with unilateral hearing loss. Recurrent tumourfound destroying petrous temporal bone and invading intovertebral foramen.

Case 3: 68-year-old woman with 10-year history of lumbarBCC. Radiotherapy failure requiring extensive surgical exci-sion including spinous processes.

These three cases demonstrate the typical features associ-ated with giant BCCs. Neglect or denial, leading to delay inpresentation, is a common feature of these large tumours,whose size is related to their duration rather than unusuallyrapid growth. This form of abnormal illness behaviour isassociated with low social support, personality disorders anddepression. Giant BCCs are twice as common in men and tendto occur in older patients. Many giant BCCs result from theinadequate treatment of smaller lesions, with radiotherapyfailures at highest risk. Histologically, giant lesions tend todisplay a more invasive subtype (micronodular, morphoeic ormetatypical).

Metastatic BCCs are very rare, with incidence ratesreported between 0Æ0028% and 0Æ55%. Giant BCCs areresponsible for 80% of metastatic BCCs.2 It is not surprising,therefore, that the risk factors for metastasis are the same asthose for the development of a giant BCC. Unlike the giantlesions, metastatic BCCs are more common in certain sites,with lesions of the scalp and ears at most risk. BCCsrecurrent after radiotherapy seem at particular risk forsecondary spread, which is often to lymph nodes or, lessfrequently, lung, bone and skin. Metastatic lesions have avery poor prognosis, with a mean survival of 8 months afterdiagnosis.

It is important for dermatologists to be aware of the riskfactors for giant BCCs, in particular when selecting therapyfor recurrent tumours, especially if radiotherapy has beenpreviously employed. This may help to avoid turning aneasily curable problem into a mutilating and potentially life-threatening one.

References1 Randle HW, Roenigk RK, Brodland DG. Giant basal cell carcino-

mata (T3). Who is at risk? Cancer 1993; 72: 1624–30.

2 Snow SN, Sahl W, Lo JS et al. Metastatic basal cell carcinoma.

Report of five cases. Cancer 1994; 73: 328–35.

DS-5Treatment outcomes at a regionalcutaneous laser surgery centreW . K . W O O A N D J . H A N D L E YDepartment of Dermatology, Ulster Hospital, Belfast, U.K.

We used the pulsed dye laser (585 nm, 0.45 ms) alone ortogether with the variable pulse width Nd:YAG laser(532 nm, 2–50 ms) to treat various cutaneous vascularlesions. The frequency doubled Q-switched Nd:YAG laser(532 nm and 1064 nm, 10–50 ns) was used to treatpigmented skin lesions or tattoos. We aimed to determineour clinical efficacy and complication rates following treat-ment of 189 patients with a variety of skin lesions. Patientswere assessed by comparing pre- and post-treatment photo-graphs.

Ninety-seven patients had port-wine stains, mean age 31Æ5years (range 6–66), with 64 females. Twenty-eight per centof patients had >75% lightening, another 28% had 50–75%lightening, 27% had 25–49% lightening and 16% had <25%lightening. Two per cent of patients had 100% clearance.Thirty per cent of patients had significant subjectiveimprovement in terms of self-esteem. Twenty-two per centof patients used less cosmetic camouflage post-treatment.Complication rates for atrophic scarring, hypertrophicscarring, hyperpigmentation, hypopigmentation, blisteringand crusting were 4%, 1%, 7%, 13%, 20% and 35%,respectively.

We also treated other skin conditions. The followingproportion of patients had >75% lightening: nine of 19patients with telangiectatic rosacea, five of 12 (leg telangiec-tasias), 10 of 17 (professional tattoos), two of four (amateur

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tattoos), four of seven (venous lake), two of five (spider naevi),one of three (cafe-au-lait macules), two of two (strawberrynaevi), one of three (adenoma sebaceum), none of two(lymphangiomas), none of three (verrucous haemangioma),none of six (congenital melanocytic naevi) and none of twopatients with hypertrophic scars. One patient with bluerubber bleb syndrome, one patient with pigmented atrophicscars and one patient with viral warts also had >75%improvement.

We found that laser treatment of port-wine stains,telangiectatic rosacea, leg telangiectasias, venous lakes,spider naevi, and professional and amateur tattoos to beeffective, with relatively few irreversible complications.

The authors have no financial interest in this study.

DS-6Helical rim advancement flap in six patientsJ . A . A . L A N G T R YDepartment of Dermatology, Sunderland Royal Hospital,Sunderland SR4 7TP, U.K.

Full thickness surgical defects of the upper helical rim may bereconstructed in various ways. Single stage repairs includewedge excision and the Antia-Buch repair. The helical rimadvancement flap is described and the results reviewed in sixpatients.

All were men, aged 66–92 years (mean 76), with foursquamous cell carcinomas and two basal cell carcinomasaffecting the helical rim of the supero-posterior quadrant ofthe ear. The tumours ranged from 10 to 25 mm diameter(mean 14 mm). A 4-mm excision margin was undertaken forfive tumours and a 6-mm margin for the largest. One patientwas reconstructed after excision and five patients werereconstructed 1 week later when histology indicated tumourexcision. Antibiotics were given to all patients undergoingdelayed repair.

After infiltration with 0Æ5% lignocaine with 1 in 200 000adrenaline, the incision is marked in the junction between thescapha and the helix anteriorly and at the same distance fromthe helical rim posteriorly and extended inferiorly into theearlobe. The incision frees the helical rim and a Burrow’striangle is taken in the earlobe. The helical rim is advanced toclose the wound and sutured without tension with monofil-ament nylon. A wedge of cartilage may be removed to allowclosure of a large defect.

All patients achieved an acceptable to excellent outcomedespite duskiness of the flap and partial debridement in onepatient (insulin-dependent diabetic with ischaemic heartdisease and peripheral vascular disease).

This reconstruction differs from the Antia-Buch repairwhich combines rotation and advancement. The concept isthat of a Burrow’s triangle helical rim advancement flap. Itdepends on the outstanding blood supply of the external earand the reservoir of tissue available in the earlobe. A normalauricular shape is maintained and conspicuous scars areavoided.

DS-7Quality of life evaluation following endoscopictransthoracic sympathectomy for upper limband facial hyperhidrosisM . N I C O L A O U , M . C . S W A N A N D T . P A E SThe Hillingdon Vascular Unit, Hillingdon Hospital, ImperialCollege, London, U.K.

The results of endoscopic transthoracic sympathectomy (ETS)for hyperhidrosis of the hands, axillae and face have beenshown by surgical teams around the world to be very goodbut there are few quality of life studies to evaluate ETS.

In this prospective cohort study, the outcome of bilateralETS was assessed using the Dermatology Life Quality Index(DLQI) questionnaire.

Twenty consecutive patients who underwent two-stagebilateral ETS for primary hyperhidrosis were assessed. Fivepatients had concomitant facial blushing. Symptomaticimprovement was achieved in all patients.

Statistical analysis (one-tailed Wilcoxon rank test) demon-strated a significant (P < 0.05) step-wise improvement inquality of life after each stage. This has not previously beendescribed for two-stage bilateral ETS and confirms thesuitability of this technique in the definitive management ofrefractory primary hyperhidrosis.

We present the result of DLQI questionnaire before andafter surgery and at a later follow-up stage which shows thatthe improvement in quality of life has been sustained withoutfurther intervention, either dermatological or surgical.

DS-8Shave excision of intradermal naevi:a survey of patient satisfactionJ . B O N G A N D W . P E R K I N SDepartment of Dermatology, Queen’s Medical Centre,Nottingham, U.K.

Shave excision is a widely used procedure to remove benignnaevi. In our department, patients who had shave excision ofbenign moles were not routinely given follow up appoint-ments after their procedures. The aims of this survey were toassess patient satisfaction with the procedure and to quantifythe risk of recurrence.

Consecutive patients who had shave excision betweenJanuary 1999 and July 2000 were identified from the theatreregister. Inclusion criteria included facial mole, histology-confirmed benign mole and a minimum of 12 months sincethe procedure. A two-part, 12-item questionnaire wasdesigned. The first part was on the appearance of the scar,complication and recurrence. The second part included threestatements designed to assess patient satisfaction using a five-point scale (5 ¼ strongly agree and 1 ¼ strongly disagree).The questionnaire was piloted in the department to check forcompleteness and ambiguity.

Ninety-three questionnaires were sent. Seventy-six (82%)patients with a total of 83 moles responded. Of theresponders, 82% were female and 18% were male. Mean

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age was 46 years (median 43Æ5). Seventy-seven per cent ofthe moles were removed for cosmetic reasons. There weresignificantly more females in this group (P ¼ 0Æ05). Ninety-five per cent were intradermal naevi on histology, the restwere compound naevi. Most moles were brown (69%) andnon-hairy (65%). Twenty-three (28%) of moles were repor-ted to have recurred 12 months after the procedures. Ahigher recurrence rate was noted with hairy moles (41%, P¼ 0Æ04). Colour, sites and grade of surgeon did not influencerecurrence. Thirty-three per cent reported no scar, 26% ofscars were white and flat, 19% depressed, 15% raised and7% pigmented. A few depressed scars were also pigmentedand one had hair growing from it. Most patients (85Æ5%)thought their scars looked better than the moles. Seventy-nine per cent were happy with the scar and 88% werehappy that the moles had been removed. Patients who hadrecurrence or depressed scars were offered further appoint-ments to the department. Nine patients attended, two hadfurther procedures.

We found the risk of recurrence was high after shaveexcision of moles. However, most recurred moles remainedcosmetically acceptable to the patients. More than half of thepatients reported no scar or had a white and flat scar. Insummary, patients find shave excision an acceptable proce-dure for removing benign moles.

DS-9Venous lakes of the vermilion lip treatedby infrared coagulationA . A H - W E N G , S . V E L A N G I , S . N A T A R A J A NA N D J . A . A . L A N G T R YDepartment of Dermatology, Sunderland Royal Hospital,Sunderland, U.K.

Various methods have been described for treating venouslakes including infrared coagulation,1 cryotherapy, simpleexcision, electrocautery and laser surgery. We review 20venous lakes over the vermilion of the lips treated by infraredcoagulation (IRC).

The infrared coagulator is a portable device that emitsnon-coherent visible and infrared radiation from 400 to2500 nm with a maximal output in the infrared range. Theemitted radiation is delivered via a solid glass quartz rod andby contact application directly to the tissue, where heatenergy results in coagulation. An advantage is its ability tocompress vascular swellings.

In the treatment of venous lakes, infrared energy wasdelivered for a duration of 1Æ0 s followed by repeatedincrements of 0Æ125 s to 1Æ25–1Æ375 s, until just perceptibleblanching resulted. In all cases local anaesthetic withadrenaline was used.

Twenty lesions in 18 patients (11 females), age range39–84 years (median 61), were treated over 6 years bythree consultants and two training registrars. All but onehad lower lip lesions. In 17 venous lakes one treatmentsession resulted in a good outcome and cosmesis: apparent

clearing of the venous lakes and imperceptible scar. In theother three venous lakes, after the first treatment there wasbreakdown bleeding in one, partial improvement in another,and no effect seen in the third. One lesion needed threetreatment sessions. A review was undertaken 1–4 monthsafter the last treatment and complete clearance wasachieved in all. Scarring was noticeable in four cases,which included the patient who needed three treatments.IRC is a good option for treatment of venous lakes on thevermilion of the lip.

Reference1 Colver GB, Hunter JAA. Venous lakes: treatment by infrared

coagulation. Br J Plast Surg 1987; 40: 451–3.

DS-10Pulsed dye laser treatment of port-winestains: clinical response and treatmentcharacteristicsW . K . W O O A N D J . H A N D L E YDepartment of Dermatology, Ulster Hospital, Belfast, U.K.

We carried out a retrospective study on 97 patients with port-wine stains who attended for treatment with the pulsed dyelaser (585 nm, 0.45 ms). Treatments usually began withrelatively low fluences (starting fluence) increasing slowlywith each subsequent treatment to a maximal fluence astolerated. Treatments were usually continued at 3-monthlyintervals until response plateaued.

We aimed to see if there were any characteristic differencesbetween patients who had an excellent response (>75%lightening) and those who did not (<75% lightening).Pre- and post-treatment photographs were taken and usedto determine treatment efficacy.

Ninety-seven patients were assessed, age range 6–66 years(mean 31Æ5), with 64 females. Twenty-eight per cent ofpatients had an excellent response (>75% lightening).Patients with >75% lightening received a higher meannumber of treatments at 16Æ7 sessions compared with 13Æ9sessions in the <75% lightening group (P ¼ 0Æ08). The meanmaximal fluence was 7Æ00 J cm)2 in the excellent responsegroup compared with 6.69 J cm)2 in the other group(P ¼ 0Æ04). There was no difference in the starting fluencebetween the two groups (5.59 J cm)2 compared with5.62 J cm)2 ). There were also no differences in terms ofanatomical site and lesion colour. Side-effects were morecommon in the excellent response group – atrophic scarring,hypertrophic scarring, crusting and hypopigmentation werehigher at 7Æ7%, 3Æ8%, 46Æ2% and 19Æ2%, respectively,compared with 3%, 0%, 31Æ8% and 10Æ6%.

Port-wine stain patients with an excellent response topulsed dye laser therapy more often received a higher numberof treatments and with a higher maximal fluence.

The authors have no financial interest in this study. Thisstudy has been presented at the British Skin Laser StudyGroup Annual Meeting.

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DS-11Red ink tattoo reactions: successful treatmentwith the Nd:YAG laserF . C . A N T O N Y A N D C . C . H A R L A N DDepartment of Dermatology, St Helier Hospital, Carshalton SM51AA, U.K.

Granulomatous and lichenoid reactions to red dye in tattooshave been previously reported.1 Most reactions settle with theuse of topical steroid preparations. In our region there was anunprecedented number of lichenoid reactions which occurredin patients who had visited a local tattoo parlour that hadobtained a batch of red ink containing trace amounts ofcinnabar and mercury – compounds known to cause allergicreactions.2 Topical Dermovate� (clobetasol propionate0Æ05%) ointment alone had little impact on the reaction.We report our success with the 532-nm Nd:YAG laser inflattening the reaction and producing symptomatic relief ofitch.

An open, non-randomized clinical trial was conducted.Patients with skin types I–III and histologically provenlichenoid reactions to the red dye were selected. Subjectswere patch tested to mercury prior to undergoing treat-ment with the 532-nm Nd:YAG laser, 2-mm beam diam-eter, at increasing fluences ranging from 1Æ4 to 6Æ4 J cm)2.Laser treatments were delivered at 6-weekly intervals by asingle operator. Patients also applied topical Dermovate�

ointment once daily between treatments. Treatment wasdiscontinued when clinically apparent flattening of thereaction occurred.

Clinical photographs were assessed at baseline and priorto each laser treatment. Patients also evaluated outcomes.Seven patients were enrolled in the study (four females,three males, mean age 39 years). All patients completedthe trial. Patch testing to mercury was universally negativeat 48 and 96 h. Two tattoos were located on the leg, twoon the arm and three on the back. Substantial flatteningand whitening of red tattoo reactions were noted onaverage after six laser treatments. However, hypertrophic,lichenified reactions on the lower leg were slower torespond. No adverse effects were recorded. All patientsreported immediate relief of pruritus on completion of thetreatment.

In conclusion, the 532-nm Nd:YAG laser in combinationwith topical Dermovate� ointment is a safe and effectivemethod of treating red ink tattoo reactions. Although patchtesting to mercury was negative in our patient population,the red ink used in these patients was later found to containcinnabar, a heavy metal that has been banned from tattoopigments in the U.S.A.

References1 Sowden JM, Cartwright PH, Smith AG et al. Sarcoidosis presenting

with a granulomatous reaction confined to red tattoos. Clin ExpDermatol 1992; 17: 446–8.

2 Timko AL, Miller CH, Johnson FB et al. In vitro quantitative

chemical analysis of tattoo pigments. Arch Dermatol 2001;

137: 143–7.

DS-12Audit of patient satisfaction with laserhair removalP . W . P R E S T O N A N D S . L A N I G A N *City Hospital and *Lasercare Clinics, Birmingham, U.K.

Forty-three patients attending a laser hair removal cliniccompleted a questionnaire to determine their satisfaction withtheir treatment. The clinic offered ruby or alexandrite lasertreatment for Fitzpatrick skin types I–III and Nd:YAG lasertreatment for Fitzpatrick skin types IV–V.

Frequency of hair removal before (and after) laser hairremoval was: daily 30% (10%); up to weekly 38% (27%); upto monthly 22% (37%); greater than monthly 3% (25%).Sixty-one per cent of patients spent less time removing hairafter laser treatment than before.

Satisfaction with laser treatment was recorded on alinear analogue scale (LAS) with 0 ¼ not at all satisfiedand 10 ¼ extremely satisfied. Twenty-four patients withskin types I–III scored a mean of 6Æ5, 74% scoring 6 orgreater. Ninteen patients with skin types IV–V scored amean of 5Æ5, 53% scoring 6 or greater (differences notsignificant).

Laser treatment compared favourably with electrolysis,mean LAS 8Æ6 (median 9Æ3) and waxing, mean LAS 7Æ7(median 8.4) with 0 ¼ laser treatment very much worse and10 ¼ laser treatment very much better.

Side-effects were experienced by nine (21%) patients. Theseincluded transient erythema and blistering. Thirty-three(79%) patients reported no side-effects.

Patients were asked how likely they would be to recom-mend laser treatment to other patients with unwanted hair.Twenty-three patients with skin types I–III scored a meanLAS of 8Æ2 (median 9Æ4) and 18 patients with skin types IV-Vscored a mean LAS of 8Æ1 (median 9Æ1) where 0 ¼ I wouldnever recommend laser hair removal and 10 ¼ I wouldalways recommend laser hair removal.

In conclusion, patients attending for laser hair removaldemonstrated a high degree of satisfaction with the treatment.

DS-13Axillary skin excision for hyperhidrosisC . M . L A W R E N C E A N D A . L O N S D A L E – E C C L E S *Department of Dermatology, Royal Victoria Infirmary, Newcastleupon Tyne and *Dermatology, James Cook University Hospital,Middlesbrough, U.K.

Axillary skin excision for hyperhidrosis (Shelley’s procedure)is effective but the operation is associated with considerablemorbidity and extensive scarring. The aim is removal of thehair-bearing axillary skin, i.e. presumably where apocrinesweat glands predominate. Alternative procedures such asBotox� injections have been suggested, although these aretemporary and painful. Similarly, endoscopically directedsympathectomy is associated with distressing reactive hyper-hidrosis at distant sites. We have adapted Shelley’s original

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procedure in an attempt to reduce the risk of the knowncomplications.

Five axillae in three female patients (ages 32, 30 and26 years) have been treated and followed up for3–12 months. In order to reduce scarring and morbidity,while still producing a significant reduction in sweating, thefollowing procedures were adopted:1 The excision lines were placed along, rather than across,

skin crease lines.2 The amount of skin excised was limited to an ellipse,

approximately 40 · 10 mm, centred on the area of max-imal visible sweating.

3 When axillary skin is excised apocrine and eccrine sweatglands can be seen protruding from the undersurface of theskin. These structures can be snipped off or destroyed byelectrodesiccation. Visible sweat glands on the undersurfaceof the surrounding skin were destroyed or removed in thisway to a distance of approximately 3 cm from the cut edge.

Sweating was significantly reduced in all subjects and allpatients were satisfied with the result. Wound infectionsoccurred in two axillae.

The technique has the potential to allow sweat glanddestruction to take place with either limited or no skinexcision, provided the undersurface of the sweat gland-bearing skin can be adequately visualized.

DS-14Factors influencing tumour-free marginsin excised basal cell carcinomaC . B L A S D A L E , F . C H A R L T O N * A N D C . M . L A W R E N C EDepartments of Dermatology and *Histopathology, Royal VictoriaInfirmary, Newcastle upon Tyne, U.K.

Although most dermatologists follow the recommendationthat a 3–4 mm margin should be taken when excising well-defined nodular basal cell carcinomas (BCCs), equivalenttumour-free margins are rarely reported histologically.

It has been shown that shrinkage of on average 52%occurs following excision and fixation of a lesion,1 but therelative contraction of tumour and surrounding normal skinhas not been established. In addition, subclinical extension ofBCC beyond the clinical margins is well recognized.

This study attempts to determine the relative contributionsof these two factors to the discrepancy between clinical andhistological tumour-free margins.

Well-defined BCCs were measured prior to injection of localanaesthetic, and predetermined margins accurately measuredand marked at each of four poles. The clinical tumour marginwas then permanently marked by light incision with thescalpel around its circumference. The specimen was orienta-ted by a suture to ensure that the selected poles wererepresented on the eventual histology slides. Measurement ofslides was carried out by C.B. using the Vernier method.

By this method the degree of contraction of the tumourmargin could be accurately measured, with the incisedclinical tumour margin allowing comparison with histolog-ical margins.

Our results to date have shown that for well-defined BCCs,examined and marked carefully under good light, clinical andhistopathological tumour margins correlate closely. Shrink-age postexcision and fixation was observed in 65% ofmargins, with an average reduction of 23%.

Our results suggest that although careful observation mayallow accurate determination of the extent of well-definedBCCs, tissue shrinkage postexcision and fixation will lead toapparent reduction of the tumour-free margin.

Reference1 Hudson-Peacock MJ, Matthews JNS, Lawrence CM. Relation

between size of skin excision, wound and specimen. J Am AcadDermatol 1995; 32: 1010–15.

DS-15Setting up a Mohs service: psychosocialimplicationsG . M . C O U G H L A N A N D S . H . C L I F F *Changing Faces, and *Epsom and St Helier NHS Trust, U.K.

An audit project explored psychosocial and informationalneeds of patients treated with Mohs’ micrographic surgeryfor basal cell carcinoma. A semistructured interview andstandardized scales measuring anxiety and depression, socialanxiety and avoidance, body image changes and quality oflife were completed by 22 new and follow-up patients.Interviews were conducted by a clinical psychologistemployed by a lay-led organization. The mean age of thesample was 64 years (range 37–87; SD ¼ 14). Ten (45%)were female.

Collectively, patients’ scores on quality of life, socialanxiety and avoidance, anxiety and depression were withinnormal limits. Six (24%) patients reported mild to moderatebody image dissatisfaction before or after surgery. Largestandard deviations revealed considerable individual vari-ation which was not obviously related to physical factors(location, severity and visibility) or time of interview inrelation to treatment. The most frequently reported prob-lems were fears of recurrence, the practicalities of sunavoidance and social embarrassment caused by facialdisfigurement.

Most patients reported positively on their treatmentoutcome and hospital experiences. Many patients presentedwith expectations based on the small size of their skin cancerand knowledge of minor dermatological surgery. The projectidentified problems experienced by patients together withappropriate solutions to these problems.

Items from the audit interview schedule, and an exten-sion of the nursing role, were used to facilitate assessmentof patient understanding and the emotional impact of theircondition and its treatment. The assessment of patient needis recorded in a way that facilitates regular reassessmentand follow-up by all members of the multidisciplinary teamand provides a trail of the process of obtaining informedconsent.

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DS-16Preoperative monitoring of warfarinin cutaneous surgeryA . A H - W E N G , S . V E L A N G I , S . N A T A R A J A NA N D J . A . A . L A N G T R YDepartment of Dermatology, Sunderland Royal Hospital,Sunderland, U.K.

We report a case of warfarin-induced postoperative bleedingwhich led to a change of policy in the monitoring ofinternational normalization ratio (INR) before cutaneoussurgery. A 63-year-old man, on warfarin for 4 years forperipheral vascular disease and atrial fibrillation, under-went excision followed by full thickness skin graft recon-struction of a basal cell carcinoma over his forehead. HisINR had been consistently within therapeutic limits foryears at a dose of 3 mg warfarin daily, and a month beforesurgery it was 2Æ4. There had been �no change� in hismedication and no history of self-medication. There was noexcessive intraoperative haemorrhage but 6 h later bleedingwas continuous from both graft and donor sites. He wasadmitted and INR found to be 6Æ6. His bleeding stoppedfollowing treatment with two units of fresh frozen plasma.The patient had denied any change in medication preop-eratively but it transpired that he had received a repeatprescription for warfarin 2 weeks before surgery, at theusual dose of 3 mg. However, the tablets given to him wereblue (3 mg) instead of the customary white (1 mg) tablet,and he took three of these each day, interpreting this as�no change�.

It has now become our routine to check INR within24 h of surgery. We reviewed the perioperative outcome ofall patients on warfarin from January 1999 to December2001, when 2798 patients attended for skin surgery. Fifty-four patients (1.9%), 34 males, were on warfarin, inwhom 68 skin procedures were undertaken. Local anaes-thesia was with 0Æ5–2% lignocaine and adrenaline in 30excisions, 12 curettages, 11 punch biopsies, nine diagnos-tic biopsies, three shave biopsies, two Mohs micrographicsurgical excisions and one delayed reconstruction. Otherrepairs included 41 direct closures, five secondary inten-tion healing, four flaps, two full skin thickness grafts and15 by electrocautery. Sites of operation were the head andneck (48), trunk (11) and limbs (nine). Forty-threepatients had INR checked on the day of surgery, 23within 24 h, and two within 2 days. The preoperative INRranged from 1Æ1 to 3Æ4, median 2Æ5. There was no excessintraoperative or postoperative bleeding or haematoma forall patients.

Our data support the experience of Alcalay,1 indicatingthat it is safe to continue warfarin during cutaneous surgery,with an INR <3Æ5. We recommend a routine INR 24 h beforeoperation.

Reference1 Alcalay J. Cutaneous surgery in patients receiving warfarin

therapy. Dermatol Surg 2001; 27: 756–8.

DS-17Clinical effect of the pulsed dye laser at600 nm and 595 nm in the treatmentof 585 nm resistant port-wine stainsK . F . B A X T E R , S . B A R O N , S . S O M M E RA N D R . A . S H E E H A N - D A R ELeeds Dermatology Laser Centre, Leeds Centre for Dermatology,Leeds, U.K.

A retrospective study of 75 patients with port-wine stains(PWS) resistant to a 585-nm pulsed dye laser (PDL) wasconducted. One hundred and sixty-nine test areas wereanalysed in total (87 with 595 nm PDL, 82 with 600 nmPDL). Clinical outcome at 3 months review was recorded aspoor, moderate, good or excellent and any adverse events alsorecorded. Patient ages ranged from 3 to 75 years (median24 years). Twenty-seven per cent were male. All had beentreated previously with the 585 nm PDL (Candela SPTL1-band ⁄ or Sclerolaser) and had failed to show continuedimprovement with maximum fluences of 7–15 J cm)2

(median 9 J cm)2) spot sizes 7–10 mm diameter, number oftreatments 3–31 (median 13 treatments). Most PWS (81.5%)were located on the head ⁄ neck. Thirty-four per cent of thesewere purple, 53% were pink and 13% were red in colour. Testareas were carried out with a Candela Sclerolaser using adynamic cooling device (DCD). Fluences at 595 nm rangedfrom 10 to 15 J cm)2 with a 7-mm spot (DCD 30 ms spray,30 ms delay) and 20 J cm)2 with a 5-mm spot. Fluences at600 nm ranged from 11 to 18 J cm)2 with a 7-mm spot (DCD30 ms spray 30 ms delay) and 20 J cm)2 with a 5-mm spot(40 ms spray, 40 ms delay). Overall clinical outcome of595 nm PDL test areas was: 55Æ2% poor, 33Æ3% moderateand 11Æ5% good. Clinical outcome of 600 nm PDL test areas:48% poor, 36Æ5% moderate, 15Æ5% good. At 595 nm with7-mm spot, 12% of PWS had a good clinical response, 33Æ3%had a moderate response and 54.7% had a poor response. At595 nm with 5-mm spot, 33.3% and 66.6% had a moderateand poor response, respectively. At 600 nm with 7-mm spot,18Æ5% had a good response, 35Æ3% a moderate response and46Æ2% a poor response. At 600 nm with 5-mm spot 6%, 41%and 53% had a good, moderate and poor response, respect-ively. There were no excellent responses at either wavelength.Interestingly, the clinical effect was similar for 595 nm and600 nm PDL at each site. PWS on hands and chest failed toimprove with either wavelength. PWS on limbs were moreresistant than facial PWS, but greater marginal improvementwas possible using 600 nm at higher fluences. Importantly,adverse events were low and comparable in both groups: 3%of test areas blistered (four patients), 7% of test areas crusted(six patients), 2% had transient hyperpigmentation, 0Æ5%suffered hypopigmentation. There were no reports of scarringor secondary infection.

Testing PWS resistant to 585 nm PDL treatment withlonger wavelengths is worthwhile as improvement can beexpected in approximately 50% of cases, although benefits aremoderate in most and non-head ⁄ neck sites are unlikely torespond well.

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BSDS Posters

DS-18Horn cysts: no reason for complacencyB . C . G E E , I . L E A C H , * A . D . M O R R I S A N DS . M . L I T T L E W O O D�Departments of Dermatology and *Histopathology, Queen’sMedical Centre, Nottingham and �Department of Dermatology,Kingsmill Hospital, Mansfield, U.K.

The decision to remove a lesion is based upon the history andthe presence or absence of certain features on clinicalexamination. In the setting of a pigmented lesion clinic horncysts are usually considered a feature of seborrhoeic keratosesand therefore benign. This is not always true. Our caseillustrates how this misconception could lead to the wrongdiagnosis and management.

An 81-year-old woman attended clinic with a pigmentedlesion on her left flank. It had been present for 7 months andhad recently become troublesome after trauma. Examinationrevealed a pigmented, excoriated lesion measuring 15 mm indiameter with horn cysts and the verrucous appearance of aseborrhoeic keratosis. The lesion was treated by curettage andcautery.

Histology showed an acanthotic hyperkeratotic epidermaltumour with horn cysts resembling a seborrhoeic keratosis.Closer examination of the epidermis revealed numerous well-defined nests of cells with small regular nuclei and patchy fociof ductal differentiation. Some of the epidermal nestscontained cells that were more pleomorphic with mitoses.These nests merged with foci of invasive poorly differentiatedcarcinoma. Immunohistochemistry supported the diagnosisof an eccrine porocarcinoma originating from a pre-existingsyringoacanthoma.

Horn cysts are a common clinical feature of seborrhoeickeratosis but are not pathognomonic. They can occur in anylesion with papillomatous outgrowths of the epidermis andcan therefore be seen in many lesions such as the onedescribed. As horn cysts are also seen in melanocytic naevithey should not be used as a differentiating feature in thecontext of pigmented lesions. This case also highlights thedifficulty of clinically diagnosing malignant lesions with anapparent benign epidermal component.

DS-19Solitary neurofibromas – a retrospective surveyP . W . P R E S T O N , S . T A I B J E E A N D C . T A NCity Hospital, Birmingham, U.K.

A solitary neurofibroma is defined as an isolated neuroma notrelated to von Recklinghausen’s disease. They may occur ineither sex and at any cutaneous site. Reports also documentinternal visceral involvement.

A retrospective survey was performed of 41 patients with ahistopathological diagnosis of neurofibroma in whom adiagnosis of von Recklinghausen’s disease had not beenmade, to determine clinical features.

Sex incidence was approximately equal with 24 malepatients (59%) and 17 female patients (41%). Mean age attime of excision was 49 (median 46, range 20–90) years.Common sites included the back, limbs and face. Clinicaldiagnoses prior to excision included: epidermoid cyst, lipoma,skin tag, neurofibroma, benign naevus, ganglion, histiocy-toma, haemangioma, fibrous papule and cystic basal cellcarcinoma. Three (7%) were correctly identified prior toexcision, which was performed by dermatologists (37%),general (35%), orthopaedic (12%), plastic (10%), ear noseand throat (3%) and maxillofacial (3%) surgeons.

In conclusion, solitary neurofibromas occur at any age inadulthood in both sexes. They are excised by a varietyof clinicians but are only occasionally correctly identifiedprior to excision.

DS-20Audit of drug therapies prior to dermatologicalsurgery with particular emphasis on aspirinS . L A U B E A N D C . T A NBirmingham Skin Centre, City Hospital, Birmingham, U.K.

The aim of this audit was to assess if drug therapies wererecorded correctly from patients attending the DermatologyDepartment prior to a surgical procedure. The case notes of82 patients who attended for a minor operation during1 month were reviewed.

Eighty-seven per cent of general practitioners did notprovide a drug history of their patients. Forty-four per centof the patients were not asked in the dermatology clinicabout their medication and in 13% that information wasincorrect. Only 11% of theatre records including consentforms showed that the operating surgeon had taken a drughistory.

This audit identified a significant gap in the preoperativeassessment of patients attending for dermatological surgeryand therefore potentially increasing the associated morbidityand mortality risk.

Of 82 patients, six (7%) were taking aspirin. In only one ofthe six cases it was recorded that aspirin had been stopped7 days prior to the minor operation (curettage and cautery).In the other five cases (one excision, three punch biopsies andone electrocautery) aspirin was either not discontinued or norecord was made if it had been withheld.

There is ongoing controversy if and when aspirin therapyshould be discontinued before dermatological surgical proce-dures. In other specialties such as ophthalmology, anaes-thesiology and dentistry there are also no nationally agreedguidelines on preoperative management of patients who areon aspirin or warfarin.

Studies have shown a prolonged bleeding time in only 25%of aspirin-treated patients; intraoperative bleeding complica-tions occurred in some of these patients.1 Another prospectivestudy found no significant difference in the incidence ofbleeding complications after cutaneous surgery betweenpatients taking regular aspirin and no aspirin when thesurgeon was aware of the patient’s aspirin use.2

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The overall conclusion from published studies is thataspirin does not have to be stopped routinely preoperatively.However, good practice dictates a careful drug history prior tosurgery, patients taking aspirin being warned about bleedingtendency, and surgeons taking extra care in achievinghaemostasis during surgery.

References1 Lawrence C, Sakuntabhai A, Tiling-Crosse S. Effect of aspirin and

nonsteroidal antiinflammatory drug therapy on bleeding compli-

cations in dermatologic surgical patients. J Am Acad Dermatol1994; 31: 988–92.

2 Bartlett GR. Does aspirin affect the outcome of minor cutaneous

surgery? Br J Plast Surg 1999; 52: 214–16.

DS-21Non-ablative resurfacing using the pulseddye laser and variable pulse width Nd:YAG(Versapulse) laserW . K . W O O A N D J . H A N D L E YDepartment of Dermatology, Ulster Hospital, Belfast, U.K.

There have been reports of successfully using the pulsed dyelaser1 and Q-switched Nd:YAG laser2 in non-ablative resur-facing of skin wrinkles.

The aim of this study was to evaluate the efficacy of pulseddye laser and the variable pulse width Nd:YAG laser(Versapulse) in the treatment of facial wrinkles.

Seven subjects had one side of their facial wrinkles (crow’sfeet) treated with pulsed dye laser (585 nm, 0.45 ms) using afluence of 2.5 J cm)2, single pass with 10% overlap. Theyeach had three treatments 4–6 weeks apart. The second partof the study involved using the variable pulse width Nd:YAGlaser (532 nm, 2 ms using a 3-mm spot) to treat thecontralateral wrinkes in five subjects. Again, each subjecthad three treatments 4–6 weeks apart. During treatment,each wrinkle received three laser passes at a fluence of 7.0 Jcm)2 with contact cooling. Pre- and post-treatment photo-graphs were taken and blinded assessors were asked to choosethe better of the two unlabelled photographs in terms ofcosmetic appearance.

None of the subjects developed any side-effects or symp-toms. No purpura, erythema or oedema were noted imme-diately or soon after treatment. Assessors found that two ofthe seven subjects had a better post-treatment photograph

compared to the pretreatment one using the pulsed dye laser.Three of five subjects had a better post-treatment photographusing the variable pulse width Nd:YAG laser.

We did not find using the pulsed dye laser or variable pulsewidth Nd:YAG laser at the above parameters effective in thetreatment of facial wrinkles.

The authors have no financial interest in this study. Thisstudy has been presented at the British Skin Laser StudyGroup Annual Meeting.

References1 Zelickson BD, Kilmer SL, Bernstein E et al. Pulsed dye laser therapy

for sun damaged skin. Lasers Surg Med 1999; 25: 229–36.

2 Cisnero JL, Rio R, Palou J. The Q-switched Nd:YAG laser withquadruple frequency. Clinical histological evaluation of facial

resurfacing using different wavelengths. Dermatol Surg 1998; 24:

345–50.

DS-22Successful palliation of cutaneous calcinosisin CREST syndrome with carbon dioxide laserA . J . C H A M B E R L A I N A N D N . P . J . W A L K E RDepartment of Dermatology, Churchill Hospital, Oxford, U.K.

Cutaneous calcinosis in scleroderma or dermatomyositis isresponsible for significant morbidity and at the present time,therapeutic options are limited.

We describe a 40-year-old nursing sister with CRESTsyndrome who had failed medical therapy with calcium-channel blockers and warfarin for symptomatic calcinosis of anumber of fingertips. Over 5 years, six separate digits withcutaneous calcinosis were successfully treated with carbondioxide laser vaporization under local anaesthesia. Theaverage time for wound granulation was 6 weeks. Eachtreatment resulted in a significant remission in symptoms andhas enabled her to remain in full-time employment. Inaccordance with the experience of others1 we found thistreatment to be effective in the palliation of symptomaticcutaneous calcinosis.

Reference1 Bottomley WW, Goodfield M, Sheehan-Dare RA. Digital calcifica-

tion in systemic sclerosis: effective treatment with good tissue

preservation using the carbon dioxide laser. Br J Dermatol 1996;

135: 302–4.

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