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The incidence of primary cutaneous melanoma has been increasing dramatically for several decades. Melanoma accounts for the majority of skin cancer–related deaths, but treatment is nearly always curative with early detection of disease. In this update of the guidelines of care, we will discuss the treatment of patients with primary cutaneous melanoma. We will discuss biopsy techniques of a lesion clinically suspicious for melanoma and offer recommendations for the histopathologic interpretation of cutaneous melanoma. We will offer recommendations for the use of laboratory and imaging tests in the initial workup of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, we will provide recommendations for surgical margins and briefly discuss nonsurgical treatments. Finally, we will discuss the value and limitations of sentinel lymph node biopsy and offer recommendations for its use in patients with primary cutaneous melanoma.

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the AmericanAcademy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients' needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

Background Evidence-based clinical guidelines are developed to educate and inform physicians about best practices in patient care, and assist providers in the application of treatments and technologies that can improve outcomes. Clinical guidelines also aid appeal of payment decisions; serve as the basis for quality measure development, appropriateness criteria, and maintenance of certification modules; and help identify areas for further clinical research. Objective For guidelines to serve dermatologists effectively in these diverse roles, they must be current, varied in clinical focus, and developed with a high degree of rigor that includes attention to potential conflicts of interest. Method To address these needs and keep pace with advances in medicine, the American Academy of Dermatology (AAD) recently revised the evidence-based guideline development process. Results Key changes include development of a yearly needs assessment process to determine what guidelines are most needed, the development of focused guidelines that address rapidly evolving clinical topics, a formal method of vetting guidelines produced by other societies, and a scheduled reassessment of existing guidelines to ensure they provide current and practical information. The process for identifying and managing potential conflicts of interest was also revised and expanded to meet current expectations and evolving standards. Limitations The impact of these changes to the AAD's guideline development process will not be fully realized for several years. Conclusions These changes will help ensure the AAD will be able to provide its members with continued evidence-based guidance to support patient care across the scope of dermatologic practice.

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this fifth of 6 sections of the guidelines of care for psoriasis, we discuss the use of ultraviolet (UV) light therapy for the treatment of patients with psoriasis. Treatment should be tailored to meet individual patients' needs. We will discuss in detail the efficacy and safety as well as offer recommendations for the use of phototherapy, including narrowband and broadband UVB and photochemotherapy using psoralen plus UVA, alone and in combination with topical and systemic agents. We will also discuss the available data for the use of the excimer laser in the targeted treatment of psoriasis. Finally, where available, we will summarize the available data that compare the safety and efficacy of the different forms of UV light therapy.

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this fourth of 6 sections of the guidelines of care for psoriasis, we discuss the use of traditional systemic medications for the treatment of patients with psoriasis. Treatment should be tailored to meet individual patients' needs. We will discuss in detail the efficacy and safety, and offer recommendations for the use of the 3 most commonly used, and approved, traditional systemic agents: methotrexate, cyclosporine, and acitretin. We will also briefly discuss the available data for the use of azathioprine, fumaric acid esters, hydroxyurea, leflunomide, mycophenolate mofetil, sulfasalazine, tacrolimus, and 6-thioguanine in psoriasis.

Psoriasis is a common, chronic, inflammatory, multi-system disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this third of 6 sections of the guidelines of care for psoriasis, we discuss the use of topical medications for the treatment of psoriasis. The majority of patients with psoriasis have limited disease (

To estimate the clinical efficacy of topical sinecatechins, a defined green tea extract, in the treatment of external genital and perianal warts.This was a randomized, double-blind, vehicle-controlled trial involving 502 male and female patients aged 18 years and older, with 2-30 anogenital warts ranging from 12 to 600 mm(2) total wart area. Patients applied sinecatechins ointment 15% or 10% or vehicle (placebo) three times daily for a maximum of 16 weeks or until complete clearance of all warts, followed by a 12-week treatment-free follow-up to assess recurrence.Complete clearance of all baseline and newly occurring warts was obtained in 57.2% and 56.3% of patients treated with sinecatechins ointment 15% and 10%, respectively, compared with 33.7% for vehicle (both P.001). Significance was observed at weeks 4 and 6 and all subsequent visits. Numbers needed to treat were 4.3 and 4.4. Partial clearance rates of at least 50% were reported for 78.4% and 74.0% of patients in the sinecatechins ointment 15% and 10% groups compared with 51.5% of vehicle patients. During follow-up, recurrence of any wart was observed in 6.5%, 8.3%, and 8.8% in the sinecatechins ointment 15% group, sinecatechins ointment 10% group, and vehicle patients, respectively. A total of 3.7%, 8.3%, and 0.0% developed new warts, respectively. A total of 87.7% and 87.3% of patients in the sinecatechins ointment 15% and 10% groups, and 72.1% of vehicle patients experienced application site reactions; 49.2%, 46.2%, and 65.4% of those, respectively, were mild or moderate.Topical sinecatechins ointments 15% and 10% are effective and well-tolerated in the treatment of anogenital warts.ClinicalTrials.gov, www.clinicaltrials.gov, NCT00449982.I.

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this second of 5 sections of the guidelines of care for psoriasis, we give an overview of psoriatic arthritis including its cardinal clinical features, pathogenesis, prognosis, classification, assessment tools used to evaluate psoriatic arthritis, and the approach to treatment. Although patients with mild to moderate psoriatic arthritis may be treated with nonsteroidal anti-inflammatory drugs and/or intra-articular steroid injections, the use of disease-modifying antirheumatic drugs, particularly methotrexate, along with the biologic agents, are considered the standard of care in patients with more significant psoriatic arthritis. We will discuss the use of disease-modifying antirheumatic drugs and the biologic therapies in the treatment of patients with moderate to severe psoriatic arthritis.

External genital warts (EGWs) are visible warts that occur in the perigenital and perianal regions. They are due primarily to non-oncogenic human papillomavirus (HPV) types, usually types 6 and 11. Physical examination assisted by bright light and magnification is the recommended approach for primary diagnosis. Biopsy is indicated when EGWs are fixed to underlying structures or discolored or when standard therapies are not effective. Recurrences are common, and there is no single treatment that is superior to others. Among women with atypical squamous cells, molecular HPV testing may be useful in determining who should be referred for colposcopy. Condoms may provide some protection against HPV-related diseases and thus are recommended in new sexual relationships and when partnerships are not mutually monogamous. Because the efficacy of cesarean section in preventing vertical transmission of HPV infection from women with EGWs to their progeny has not been proved, it is not recommended.

Over the past decade, a large amount of attention has been directed toward the human papillomavirus (HPV) infection of the genital tract, whereas nongenital infections have been overlooked. These infections are clinically manifested as common warts. In essence, there is a broad spectrum of disease produced at nongenital sites by HPV. Different populations have different susceptibilities and consequences of HPV infection. The purpose of this paper is to review the clinical manifestations of nongenital HPV infection in the immunocompetent and the immunocompromised and those patients with epidermal dysplasia verruciformis. Consideration is given to the differential diagnosis and treatment.

Genital warts are a common sexually transmitted disease caused by human papillomavirus. Imiquimod is a novel immune-response modifier capable of inducing a variety of cytokines, including interferon alfa, tumor necrosis factor-alpha, as well as interleukins 1, 6, and 8. In animal models imiquimod has demonstrated antiviral, antitumor, and adjuvant activity. In vitro, imiquimod has no antiviral or antitumor activity.Our purpose was to determine the safety and efficacy of topical imiquimod for the treatment of external genital warts.This prospective double-blind, placebo-controlled, parallel design clinical trial was performed in three outpatient centers, a public health clinic, a university-based clinic, and a private practice. One hundred eight patients with external genital warts (predominantly white men) were entered into the trial. Fifty-one patients were randomly selected to receive 5% imiquimod cream; 57 patients were randomly chosen to receive placebo cream. Study medication was applied three times weekly for up to 8 weeks. Patients whose warts cleared completely were observed for up to 10 weeks to determine recurrence rates.In the intent-to-treat analysis, the warts of 37% (19 of 51) of the imiquimod-treated patients and 0% (0 of 57) of the placebo group cleared completely (p0.001). In addition, many patients experienced a partial response. A reduction in baseline wart area of 80% or more was observed in 62% of imiquimod-treated patients (28 of 45) and 4% of the placebo group (2 of 50) (p0.001); a 50% reduction or more in wart area was noted in 76% of imiquimod-treated patients (34 of 45) and 8% of placebo recipients (4 of 50) (p0.001). Of imiquimod-treated patients whose warts cleared completely and who finished the 10-week follow-up period, 19% (3 of 16) experienced recurrences of warts. Imiquimod-treated patients experienced a significantly greater number of local inflammatory reactions than the placebo group. Symptoms and signs associated with the local inflammatory reactions included itching (54.2%), erythema (33.3%), burning (31.3%), irritation (16.7%), tenderness (12.5%), ulceration (10.4%), erosion (10.4%), and pain (8.3%). There were no differences in systemic reactions or laboratory abnormalities between treatment groups.Topical 5% imiquimod cream appears to have a significant therapeutic effect in the treatment of external genital warts.

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this fourth of 6 sections of the guidelines of care for psoriasis, we discuss the use of traditional systemic medications for the treatment of patients with psoriasis. Treatment should be tailored to meet individual patients' needs. We will discuss in detail the efficacy and safety, and offer recommendations for the use of the 3 most commonly used, and approved, traditional systemic agents: methotrexate, cyclosporine, and acitretin. We will also briefly discuss the available data for the use of azathioprine, fumaric acid esters, hydroxyurea, leflunomide, mycophenolate mofetil, sulfasalazine, tacrolimus, and 6-thioguanine in psoriasis.

Human papillomavirus infection represents the most common mucocutaneous viral infection, and 3% to 5% of all patients have clinically evident warts. Human papillomavirus infections of the genital tract are one of the most common sexually transmitted viral infections in the United States. Data from STD clinics and private physicians' offices reveal that genital warts, one manifestation of genital HPV infection, have been diagnosed more frequently in recent years. With the use of a variety of diagnostic techniques, asymptomatic HPV infection has been identified in men and women and is probably much more common than is clinically apparent infection.

Onychomycosis is a fungal infection of the fingernails and toenails that results in thickening, discoloration, splitting of the nails and lifting of the nail from the nail bed. The disease is caused by dermatophytes and has a high incidence within the general population, especially among older individuals. Present treatment options include both oral and topical drugs, with oral therapies giving better outcomes; however, neither of these treatment options provides high cure rates that are durable. The difficulty in treating onychomycosis results from the deep-seated nature of the infection within the nail unit (nail plate, nail bed and surrounding tissue) and the inability of drugs to effectively reach all sites. Ongoing drug development activities have focused on novel delivery technologies to facilitate penetration of existing antifungal drugs through the nail plate and on the discovery of inherently penetrable antifungals. AN-2690 represents an oxaborole antifungal that is designed to penetrate the nail plate and is showing promising results in clinical trials.

Over the past several years, there has been an increase in knowledge pertaining to the diagnosis and management strategies for the herpes family (Types 1-8), the pox viruses, mumps, measles, rubella, and parvovirus B19 as well as the viral etiologies of hepatitis. Various antiviral treatments, such as nucleoside analogs and interferon therapy, have been available to reduce the signs and symptoms of these common viral infections. This article summarizes the preferred treatment strategies to be employed for each of the viruses for reducing severity, duration, recurrences (notably in the herpes family), transmission rates, as well as preventive alternatives. The majority of the therapeutic options attenuate the course of disease. Treatment decisions are driven by knowledge of the natural history and often are tailored to incorporate clinical circumstances for individual patients. Promotion of community awareness and the development of vaccines should be emphasized in the battle against these common viruses, particularly the herpes simplex viruses, the pox viruses, and hepatitis B.

To determine whether men are able to self-diagnose external genital warts (EGWs), we studied data from 1115 men with and without human immunodeficiency virus infection. Men were largely unable to accurately assess the presence of EGWs. Self-reporting of EGWs was not a sensitive tool; only 38% of men who had EGWs diagnosed by a trained examiner who used bright light and visual inspection also reported having them. When we controlled for other covariates in a multivariate model, men who had EGWs diagnosed by an examiner were 14 times less likely to show concordance between examiner findings and self-report than were men who did not have EGWs diagnosed by an examiner (odds ratio, 0.07; 95% confidence interval, 0.06-0.09). Self-diagnosis and self-assessment may not accurately reflect the presence of EGWs, and self-diagnosis should not be used in place of an examiner's findings for epidemiologic studies that seek to determine the cause of disease.

Background: Basal cell carcinoma (BCC) responds to interferon therapy. Imiquimod is a cytokine and interferon inducer. Objective: This randomized, double-blind pilot trial evaluated the safety and efficacy of imiquimod 5% cream versus vehicle in the treatment of BCC. Methods: In this population of 35 patients with BCC, 24 received imiquimod 5% cream and 11 received vehicle cream in 1 of 5 dosing regimens for up to 16 weeks. Six weeks after treatment, an excisional biopsy of the target site was performed. Results: BCC cleared (on the basis of histologic examination) in all 15 patients (100%) dosed twice daily, once daily, and 3 times weekly; in 3 of 5 (60%) patients dosed twice weekly; 2 of 4 (50%) dosed once weekly; and in 1 of 11 (9%) treated with vehicle. Adverse events were predominantly local reactions at the target tumor site, with the incidence and severity of local skin reactions declining in groups dosed less frequently. Conclusion: Imiquimod 5% cream shows clinical efficacy in the treatment of BCC. (J Am Acad Dermatol 1999;41:1002-7.)

Education and counseling constitute a substantial portion of management of patients with genital herpes. Innovative methods for education about genital herpes are needed.To test the ability of an interactive, computer-based program to educate patients about genital herpes.Persons seeking care at five urban offices were asked to participate. A knowledge test about genital herpes was administered before and after participation. Participants' satisfaction was assessed with a questionnaire.Four hundred thirty-five participants enrolled, and 428 completed the herpes knowledge test. Of six questions evaluated, a statistically significant increase in the proportion of correct answers was noted on five of six questions. Fifty-one percent of participants answered all the questions correctly after the program, compared with 39% before the program. Satisfaction with the program was very high.Innovative, computer-based programs can provide education and assist in the management of chronic sexually transmitted infections.

Genital warts are manifestations of a common viral sexually transmitted disease (STD) that are often diagnosed and treated with a variety of clinical specialties. Unlike for other STDs, there is a general lack of a well-established treatment algorithm for the management of external genital warts. This, coupled with a wide variety of treatments and clinical settings, makes the development of a simple algorithm virtually impossible. In this review what is known and not known about current treatments and case management will be discussed.

A multi-center, randomized, double-blind, placebo-controlled trial was performed to evaluate the effectiveness of butenafine, a fungicidal benzylamine derivative, in the once daily treatment of interdigital tinea pedis. One hundred and fifty patients with interdigital tinea pedis characterized by a minimum erythema score of 2 and a minimum score of 2 for either pruritus or scaling (on a scale of 0–3, where ‘2’ defines moderate severity) were initially enrolled, pending confirmation by mycologic culture and KOH testing. Patients were excluded if the evaluation of tinea pedis might have been impaired by concomitant conditions, if they were hypersensitive to allylamines or ingredients of the study medications, or if they had clinically significant abnormal laboratory values. Women of childbearing potential were also excluded if they were pregnant, lactating, or not using adequate contraceptive measures. The patients were randomized and given study formulations in coded tubes containing either butenafine hydrochloride cream 1% (butenafine) or the vehicle. They were instructed to apply the formulation to all tinea pedis lesions one daily, for 4 weeks. They were evaluated after 1, 2, and 4 weeks of treatment, and again 4 weeks post-treatment, using the following measures: (i) mycologic cure: negative fungal culture and KOH test; (ii) effective treatment: mycologic cure and investigator global assessment of 80% or more improvement in signs and symptoms; (iii) investigator global assessment of clinical response: cleared (100% improvement in signs and symptoms), excellent (80–99% improvement), good (50–79% improvement), fair (25–49% improvement), poor (less than 25% improvement), unchanged, or worse, (iv) patient’s assessment of change since baseline: 5=greatly improved, 4=somewhat improved, 3=the same, 2=somewhat worse, and 1=much worse. Mycologic cure and effective treatment were each analyzed using the Cochran–Mantel–Haenszel (CMH) test of response by treatment partialled on investigator. Patient perceptions and investigator evaluations of global response were analyzed as ordered categorical data using the CMH mean score test with uniform scores.

Genital human papillomavirus infection is one of the most common sexually transmitted diseases. Imiquimod is a new agent, an immune-response modifier, that has been demonstrated to have potent in vivo antiviral and antitumor effects in animal models. The present prospective, multicenter, double-blind, randomized, vehicle-controlled trial evaluated the efficacy and safety of daily patient-applied imiquimod for up to 16 weeks for the treatment of external genital warts. Wart recurrence was investigated during a 12-week treatment-free follow-up period. In the intent-to-treat analysis, baseline warts cleared from 49 of 94 (52%) patients treated with 5% imiquimod cream, 13 of 90 (14%) patients treated with 1% imiquimod cream, and 3 of 95 (4%) vehicle-treated patients; the differences between the groups treated with vehicle and imiquimod were significant ( P < 0.0001). For subjects who completed the follow-up period, recurrence rates after a complete response were 19% (9 of 48 patients) in the 5% imiquimod cream group, 17% (2 of 12) in the 1% imiquimod cream group, and 0% (0 of 3) in the vehicle-treated group. There were no systemic reactions, although local skin reactions (generally of mild or moderate severity) were common, particularly in the 5% imiquimod cream group. Local reactions caused two patients to discontinue treatment. The most frequently reported local skin reactions were erythema, excoriation or flaking, and erosion. Patient-applied 5% imiquimod cream is effective for the treatment of external genital warts and has a favorable safety profile.

The relationship between human papilloma virus (HPV) and cervical cancer is in the process of being defined. This potential opportunity to understand a human oncogenic virus has drawn significant attention to HPV. While cervical cancer is a potentially fatal outcome of HPV infection, genital warts are the most common manifestation of genital HPV infection. In addition to knowledge of etiology, natural history, and therapeutic options, patients and providers need to consider emotional impact to successfully manage the care of patients with this common infection. This article summarizes current knowledge of recent advances of HPV infection of the vulva.

The objective of this study was to evaluate the patient acceptability of a 10% sodium sulfacetamide and 5% sulfur cleanser in patients with mild-to-severe rosacea. This was a single-center, open-label, 4-week study involving 34 enrolled patients (31 of whom completed all visits). All patients were prescribed (metronidazole gel 0.75%) to be used twice daily after washing with the sulfacetamide/sulfur cleanser. The investigator’s assessment of product tolerability involved a 4-point scale to evaluate dryness, scaling, pruritis, and stinging/burning. Patients were asked to assess various skin sensations after product use (eg, “feels soft/smooth‘) on a 6-point scale. In addition, the investigators performed an inflammatory lesion count and assessed erythema severity and global rosacea severity. Investigator assessment of product tolerability showed that the average score for each potential adverse effect decreased over the course of the study. Patient evaluation demonstrated that the average score for each subjective assessment decreased from or remained similar to baseline at the week 4 visit. There was a numerical trend toward improvement in disease-state evaluations (lesion counts, erythema severity score, and global rosacea severity score) over the course of the study.

This book was a true pleasure to read and would be a valuable addition to any dermatologist's library. This book demonstrates the progress that has been made in our understanding of warts since the first edition of the book was published a decade ago. Single-group authorship makes this book coherent and concise, although not encyclopedic. The book is organized into three parts: ''Papillomavirus Virology and Biology,'' ''Cutaneous Warts,'' and ''Mucocutaneous Warts.'' One seeking a broad overview of viral warts would do well in reading this book. In ''Papillomavirus Virology and Biology,'' the clinically relevant basic science and epidemiology of human papillomavirus are reviewed. The level is quite appropriate for a clinician and gives one the basic understanding that would allow for effective reading of more technical original research articles. The ''Cutaneous Warts'' and ''Mucocutaneous Warts'' sections are a review of the clinical manifestations and treatment of warts. An algorithm for

Until a modern equivalent of spunk water is available, what are reasonable expectations of wart therapy? What is the oncogenic potential of human papillomavirus (HPV) and what should we tell patients to adequately inform them without terrorizing them? Despite a great increase in the number of publications and an ever growing body of information about HPV infection, HPV molecular biology, and virology, there remains a paucity of clinically applicable knowledge about this common infection. This brief overview summarizes the current knowledge relevant to common clinical issues in an attempt to bridge the gap between information and knowledge. It is clear that HPV produces a latent infection. Human papillomavirus(es) is a group (at least 60 types) of epithelialtrophic viruses that result in latent infection and a spectrum of clinical disease. 1,2 The latent nature of the infection is demonstrated by at least four observations. First, subjects with no clinical history of HPV infection have antibodies to HPV. 3 Second, HPV DNA is present in normal mucosa from patients with laryngeal papillomatosis." Third, HPV DNA is present in normal tissue obtained 0.5 to 1.0 cm beyond surgical margins in women with vulvar warts. 5

Of porri, verucae, and eondylomata of the pudenda. There remains a fourth species of venereal disease to be added to those which we have already described, viz, warty excrescences of the genitals, which sometimes succeed impure coition, but for the most part follow other porky disorders that have been iU managed. Sometimes they wither of themselves and fall off, leaving a root behind them, from whence they spring up afresh; sometimes they are permanent, but are flaccid, soft, and almost void of sense; sometimes hard, dry, rigid, horny, destitute of sense, and perfectly callous; but sometimes they are painful, having an ichorous discharge from their heads, and seem to be of a cancerous nature.--dohn Astruc (Treatis of Venereal Diseases in Nine Books, 1737)

† A 44-year-old man with Hodgkin's disease developed fever and erythematous macules and plaques associated with doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy. Biopsy results demonstrated a neutrophilic infiltrate around sweat glands and degeneration of eccrine glands. These findings are characteristic of neutrophilic eccrine hidradenitis, which, to our knowledge, has previously been reported only in patients with acute myelogenous leukemia who were receiving cytarabine chemotherapy. Neutrophilic eccrine hidradenitis may represent a reaction pattern to chemotherapeutic agents and may not be specific for a particular disease or drug. (Arch Dermatol1986;122:809-811)