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The alar-facial sulcus is an important topographical region because it represents a junctional zone of three cosmetic units: the nasal base, the medial aspect of the cheek, and the upper lip. Too often, the sulcus is violated by transposition flaps that have been harvested from the cheek to reconstruct defects of the nasal-alar lobule. When the sulcus is violated by surgery, it is difficult to restore a completely natural appearance. For this reason, we suggest an alternative method of reconstructing the alar lobule through the use of an interpolated flap. When defects extend into the alar-facial sulcus, reconstruction of the sulcus is necessary and should be accomplished with a separate skin flap from that used to repair the nasal component of the defect. When a single flap is used to reconstruct both lobule and sulcus, restoration of a completely natural-appearing sulcus is rarely achieved and usually involves multiple surgical procedures often facilitated by aggressive flap contouring, secondary intention healing, and Z-plasty. We describe our methodology in restoring the alar-facial sulcus after nasal reconstruction.

We describe our experience with two patients with xeroderma pigmentosum who underwent periodic trichloroacetic acid chemical peels. One also received a full-face dermabrasion. The effect of chemical peeling was more transient than dermabrasion but was associated with less morbidity. Both chemical peeling and dermabrasion provided a prophylactic effect against the development of skin malignancies; the latter had a more pronounced effect.

Background: Trichoblastic fibroma is a benign trichogenic tumor that has both epithelial and mesenchymal components and exhibits partial to complete follicular induction. We studied 10 cases of trichoblastic fibroma and reviewed their clinical and histologic features. Observations: All 10 tumors were located on the face. Nine of 10 patients were women. The mean age at presentation was 63.8 years (range, 35 to 81 years). Two distinct subsets of trichoblastic fibroma were identified: the nodular variant and the plaque variant. The nodular variant is well circumscribed, while the plaque variant is poorly circumscribed, has significant subclinical extension, and may represent the low-grade malignant counterpart of the classic nodular trichoblastic fibroma. Histologically, both variants demonstrate mesenchymal induction with keratin cysts, papillary mesenchymal bodies, and an inductive fibroblastic stroma. Conclusions: Trichoblastic fibroma may be confused clinically and/or histologically with basal cell carcinoma. Identification of the mixed epithelial-mesenchymal components is helpful in tumor recognition. The plaque variant trichoblastic fibroma has not been previously reported. Familiarity with this variant is important because of the potential for infiltrative growth. (Arch Dermatol. 1995;131:198-201)

Linear verrucous epidermal nevus (LYEN) is an uncommon cutaneous hamartoma first described by von Baerensprung in 18631 and later reported by Unna in 1896.2 It has since been given a variety of names, including epidermal linear nevus, ichthyosis hystrix, ichthyosis linearis neuropathica, nevusunius lateris, and inflammatory linear verrucous epidermal nevus.I? Three types of LYEN exist and include the localized, systemic, and the inflammatory linear verrucous varieties. Surgical and nonsurgical management of these nevi has proved difficult, even in localized cases. We report marked improvement of a large LYEN with a combination of topical tretinoin (Retin-A) 0.1% cream and 5% 5-fluorouracil (5-FU) (Efudex) cream under occlusion.

We examined the expression of two groups of matrix metalloproteinases (MMPs), stromelysin and interstitial collagenase, in human skin cancer by northern blot analysis and in situ hybridization. Stromelyins-3 (ST-3) mRNA was overexpressed more than tenfold in 17 of 19 (89%) specimens of basal cell carcinoma (BCC) but in only three of 13 (23%) cutaneous squamous cell carcinomas (SCCs). Stromelysin-1 and -2 (ST-1/2) mRNA was overexpressed in three of 19 (16%) BCC and three of 13 (23%) SCC. Collagenase mRNA was overexpressed in nine of 19 (47%) BCC and three of 13 (23%) SCC. No mRNA for ST-3, ST-1/2, or collagenase was detected by northern analysis in 21 specimens of adjacent normal skin. Because of these findings, we examined the specific location of the ST-3 mRNA in BCC specimens by in situ hybridization. ST-3 mRNA was particular abundant in the characteristic stroma adjacent to the invasive basaloid tumor islands of the BCC and absent in the malignant cells. Moreover, ST-3 mRNA was expressed and induced by phorbol ester treatment in adult dermal fibroblasts but not in keratinocytes. In vitro studies have shown that MMPs are involved in the degradation of extracellular matrix molecules. Our finding of ST-3 mRNA overexpression in 17 of 19 (89%) BCC specimens is consistent with a role for this molecule in local invasion of stroma by BCC. Our in situ hybridization data suggested that while ST-3 is not expressed by malignant basal cells themselves, these tumor cells may induce the expression of ST-3 in adjacent nonmalignant stromal elements such as fibroblasts. © 1994 Wiley-Liss, Inc.

BACKGROUND: Tissue expansion is a concept based on the skin's natural ability to stretch in response to an underlying force. OBJECTIVE: The purpose of this article is to review the histological and physiological changes that occur within the soft tissue and underlying structures during tissue expansion. METHODS: An extensive search of the literature reviewing these changes is summarized herein. RESULTS: Conventional tissue expansion may result in epidermal hypertrophy, decreased dermal, muscle, and adipose thickness, and bone resorption. A vascular capsule and angiogenesis provides a highly vascular flap and improves flap viability. Few soft tissue changes occur during rapid tissue expansion. The ability of the skin to increase in surface area during conventional tissue expansion is primarily because of biological tissue creep. Rapid expansion may result from mechanical tissue creep. CONCLUSION: Many soft tissue changes occur during tissue expansion. Most of these changes return to the pre-expansion state over time following discontinuation of the expansion process.

The technique of rapid intraoperative tissue expansion has been used with increasing frequency in the clinical setting over the last several years. This technique takes advantage of the skin's ability to immediately stretch and increase in surface area when expanded under a constant load. Sixteen random-pattern, rapidly expanded skin flaps on 10 domestic male pigs were studied to assess the predictive value of the fluorescein test for flap viability after rapid intraoperative tissue expansion. Partial fluorescence was found to be a more accurate predictor of flap survival in the experimental rapidly expanded flaps when compared to full fluorescence. Partial fluorescence was found to under-predict flap survival by 0.3 to 0.5 cm, whereas full fluorescence was found to under-predict flap survival by 2.5 cm. Additionally, histologic and ultrastructural changes were examined in rapidly expanded skin from the hip region in three pigs. The only microscopic change noted between control and experimental flaps was dilated capillaries in the dermis of expanded skin, which was noted by electron microscopy. Collagen and elastic tissue changes were not demonstrated in rapidly expanded pig skin by electron microscopy, direct immunofluorescence, collagen, and elastic tissue stains.

Background and Objective: Atypical Spitz tumors (AST) are rare spitzoid neoplasms with uncertain metastatic potential with overlapping histological features between Spitz nevi and spitzoid melanoma. Histopathological and clinical management of ASTs is complex and controversial. About 50% of ASTs have positive SLNB, but only 1.5% of ASTs metastasize. Our study was designed to characterize genetic abnormalities that can help to differentiate ASTs from melanoma or Spitz nevi. Methodology: We examined copy number variation in formalin-fixed paraffin-embedded (FFPE) samples using 44k array CGH from Agilent. Tissue blocks from 17 patients with AST (9 with positive sentinel lymph nodes biopsy (SLNB), 7 with negative SLNB, 1 with distant metastasis), 8 patients with Spitz nevi, and 4 patients with melanoma (3 spitzoid, 1 superficial spreading) were used for analysis. Results: We found chromosomal abnormalities in 7/17 ASTs, including 1 AST with distant metastases, spitzoid melanoma with positive SLNB, metastatic spitzoid melanoma, and invasive melanoma. Nine of 17 (53%) ASTs did not have chromosomal instability similar to the majority of Spitz nevi, and 7 of 16 (47%) of ASTs had gross chromosomal abnormalities, including those that are uncommon in invasive melanomas. Among Spitz nevi only one had amplification of the 11p15.5-p12 containing HRAS, a candidate region previously reported as amplified in Spitz nevi. Two ASTs with positive SLNB and one AST with negative SLNB share an amplification of an overlapping region on 1p containing oncogene JUN. Two ASTs have amplification and 2 ASTs have deletion of the whole chromosome 9, containing CDKN2A gene. Some chromosomal abnormalities (loss of 8p and 9, and gain of 8q (cMYC)) found in metastatic AST are common for invasive melanomas. On the other hand, metastatic AST did not have the most frequent changes involving chromosome 6 and 11q, which are loci for FISH probes recently developed to distinguish malignant melanoma from benign melanocytic lesions. In addition, there was no difference in chromosomal instability between AST patients with positive and negative SLNBs, questioning the value of SLNB in the management of ASTs. Spitzoid melanoma with positive SLNB had only deletion of chromosome 9, and metastatic spitzoid melanoma had deletion of 11q13 region (CCDN1) similar to invasive melanoma. No other common melanoma chromosomal abnormalities were detected in these two spitzoid melanomas. Conclusions: Array CGH analysis can be used to divide melanocytic lesions of uncertain biologic potential into three groups: AST without chromosomal aberrations, AST with chromosomal aberrations, and invasive melanoma. Tumor progression is associated with increasing frequency of complex structural and numerical aberrations in the digital karyotype. Considering this fact, ASTs with chromosomal abnormalities, although not similar to melanoma, can raise several questions regarding their malignant potential, prognosis, and clinical management. ASTs without chromosomal imbalances are best regarded as Spitz nevi with variably atypical histological features. An existing panel of limited FISH probes can fail to detect fatal metastatic AST and other melanocytic lesions. A more comprehensive, genome-wide approach to assess chromosomal abnormalities may have the potential to offer greater sensitivity and specificity to identify melanocytic lesions with uncertain malignant potential. Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr LB-349.

background : One consistent and undesired sequela resulting from scalp reductions has been the “slot” or “trough” defect, referring to the scar following the final reduction. Attempts to correct this have not been entirely satisfactory. objective : To present an approach to minimize the “slot” defect that consists of staged modified paramedian scalp reductions combined with a large posterior Z-plasty during the final reduction. methods : A paramedian crescent-shaped ellipse was marked onto the patient's scalp parallel and adjacent to the existing fringe hair. Subsequent reductions were performed in a similar manner approximately 2 months apart. The final reduction consisted of mobilization and transposition of the large flaps used in the posterior Z-plasty. results : Patients who underwent the staged modified paramedian reductions combined with a posterior Z-plasty had significant minimization and adequate camouflage of the undesirable “slot.” conclusion : Combining a large posterior Z-plasty with a paramedian reduction minimizes the slot defect. J Dermatol Surg Oncol 1992;18:996–998.

We report two cases of lupus erythematosus (LE) in which a truncal papulonodular eruption predominated. Histologically the lesions were characterized by diffuse dermal mucin without the usual inflammatory or epidermal changes of LE. It is uncommon in LE for dermal mucin to be present in a sufficient quantity to produce a papulonodular eruption in the absence of typical epidermal changes.

A retrospective study of 403 primary basal cell carcinomas treated with aggressive curettage followed immediately by excision revealed microscopic tumor present in the curettage margin in 64 (15.9%) of the patients and in the excisional margin in 12 (2.5%) after curettage and excision. In 92% (11 of 12) of patients with persistent tumor after the combined curettage and excision technique the tumors were of the aggressive growth (fibrosing, sclerosing, scirrhous, and morpheaform) variety of basal cell carcinoma. Both lateral and deep margins were involved with tumor. The short-term cure rate was 97.6% for the combined technique. Excluding aggressive growth BCCs, the use of curettage allows the surgeon to define tumor borders better before excision. This proves expecially beneficial in tumors with clinically indistinct borders.

Objective To evaluate the outcome of the square procedure, a multidisciplinary, staged excision technique using standard formalin-fixed, vertically oriented sections for periocular cutaneous melanoma. Design Observational, retrospective, case series. Participants Forty patients with periocular cutaneous melanoma treated with the square procedure. Methods Demographic features, tumor data, and recurrence rate were reviewed retrospectively for 40 patients with periocular cutaneous melanoma treated with the square procedure. Main Outcome Measure Local recurrence rate. Results Of 40 patients, 26 (65%) had lentigo maligna melanoma in situ (MIS), 12 (30%) had lentigo maligna melanoma, and 2 (5%) had superficial spreading melanoma. Tumor-free margins were reached within a mean margin of 13 mm for patients with MIS and of 16 mm for patients with invasive melanoma. There was no statistical difference for the margin width in patients with MIS and invasive melanoma. The lesion size and margin width were significantly correlated. Recurrence was observed in 1 (2.5%) patient at 8 months after the square procedure, and a Kaplan-Meier survival curve estimated a local recurrence rate of 2.5% at 8 years. Conclusions The square procedure is an effective procedure for management of periocular lentigo maligna melanoma in situ and lentigo maligna melanoma with a low local recurrence rate of 2.5% at 8 years. Financial Disclosure(s) The authors have no proprietary or commercial interest in any materials discussed in this article.

9037 Background: Early detection of invasive melanoma is critical for successful treatment, and most cutaneous melanomas are visible on the skin surface. Recent literature has emphasized the value ...

We report a modification of the controlled tissue expansion technique, that is, immediate intraoperative tissue expansion. The procedure is performed by placing tissue expanders at the time of surgery. After placement, three to four cycles of inflation/deflation of the expander for 3 to 5 minutes are performed. In a one-stage procedure the stretched skin is then immediately used to close the surgical defect. Three case reports demonstrating the immediate intraoperative tissue expansion technique, in which the Foley catheter balloon was used as the tissue expander, are presented. These cases illustrate that this technique may allow the surgeon to cover defects more easily with less tension and with a better cosmetic result than with other closure techniques.

In 2006, an estimated 62,190 new cases of melanoma will be diagnosed, and approximately 7910 patients will die of the disease in the United States. The incidence of melanoma continues to increase dramatically. Risk factors for melanoma include family history, dysplastic nevi, and fair skin that sunburns easily; however, melanoma can occur in any ethnic group and in people who have not had substantial sun exposure. The NCCN Melanoma guidelines attempt to distill and simplify an enormous body of knowledge and experience into fairly simple management algorithms. For the most recent version of the guidelines, please visit NCCN.org

Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous tumor that combines the local recurrence rates of infiltrative non-melanoma skin cancer with the regional and distant metastatic rates of thick melanoma. The mortality rate of MCC exceeds that of melanoma, and the 5-year disease-specific survival rate is 64%. These guidelines and most biomedical literature suggest that the workup of a patient with MCC should include chest radiograph and additional studies as clinically indicated. These guidelines, which the NCCN Non-Melanoma Skin Cancer Panel developed as a supplement to those for squamous cell and basal cell skin cancer, also outline treatment strategies. For the most recent version of the guidelines, please visit NCCN.org

Objective To determine (1) the reliability of sentinel lymph node (SLN) biopsy and (2) the need for cytokeratin 20 (CK-20) immunostaining in the staging of head and neck Merkel cell carcinoma (MCC). Design Retrospective cohort study (median follow-up of 34.5 months). Setting Tertiary care center. Patients Ten patients with head and neck MCC who underwent regional staging with SLN biopsy (SLNB) and CK-20 immunostaining. Interventions Sentinel lymph nodes were identified using preoperative lymphoscintigraphy, intraoperative gamma probe, and isosulfan blue dye. The SLNs were evaluated with hematoxylin-eosin and CK-20 immunostaining. Patients with negative SLNB results were followed up clinically. Main Outcome Measures Percentage of positive SLNs, regional recurrence in the setting of a negative finding from SLNB, and percentage of positive SLNs requiring CK-20 immunostaining for diagnosis of micrometastatic MCC. Results At least 1 SLN was identified in every patient. Of 24 nodes, 19 (79%) were from the neck region and 5 (21%) were from the parotid basin. Two of the 24 SLNs, in 2 (20%) of 10 patients, were positive for metastatic disease. Both positive SLNs appeared negative on hematoxylin-eosin–stained sections, but small foci of micrometastatic MCC were identified with CK-20 immunostaining. No cranial nerve complications occurred. Regional failure in the setting of a negative finding on SLNB was observed in 1 (12%) of 8 patients. Conclusions Biopsy of SLNs represents a safe and reliable technique for regional staging of MCC of the head and neck. It provides pathologists with a limited number of SLNs for focused analysis, which is imperative because hematoxylin-eosin immunostaining is often insufficient for identifying micrometastatic MCC. The use of anti–CK-20 antibody allows accurate identification of micrometastatic MCC.

1027 Background: Non-steroidal anti-inflammatory medications (NSAIDs) have been shown to inhibit tumor growth in melanoma cell lines and mouse models of melanoma. We investigated the association be...

Altruistic punishment is a behaviour in which individuals punish others at a cost to themselves in order to provide a public good. Fehr and Gachter present experimental evidence in humans indicating that negative emotions towards non-cooperators motivate punishment, which, in turn, provokes a high degree of cooperation. Using Fehr and Gachter's original data, we provide an alternative analysis of their experiment that suggests that egalitarian motives are more important than motives for punishing non-cooperative behaviour. This finding is consistent with evidence that humans may have an evolutionary incentive to punish the highest earners in order to promote equality, rather than cooperation.

ContextThe high prevalence of acne vulgaris and its significant morbidity underscore the need for convenient, low-risk, and efficacious therapy. Treatment with various lasers has been reported to improve acne.ObjectiveTo evaluate the clinical efficacy of pulsed dye laser therapy in the treatment of acne.Design, Setting, and PatientsRandomized, single-blind, controlled, split-face clinical trial of a volunteer sample of 40 patients aged 13 years or older with facial acne conducted at an academic referral center from August 2002 to September 2003.InterventionOne or 2 nonpurpuric pulsed dye laser treatments to half of the face (fluence of 3 J/cm2), serial blinded clinical assessments (lesion counts), and grading of acne severity using standardized bilateral serial photographs.Main Outcome MeasuresComparison of the changes in lesion counts from baseline to 12 weeks between treated and untreated sides of the face and changes in photographic evidence of acne severity as graded by a panel of dermatologists blinded to treatment assignment.ResultsAfter 12 weeks, using intent-to-treat analysis with last observation carried forward, there were no significant differences between laser-treated and untreated skin for changes in mean papule counts (−4.2 vs −2.2; P = .08), mean pustule counts (0 vs −1.0; P = .12), or mean comedone counts (2.9 vs 1.6; P = .63). Grading of serial photographs confirmed the clinical assessments, showing no significant mean (SE) differences in Leeds scores (range, 1-12) for treated skin (3.98 [0.32] at baseline and 3.94 [0.27] at week 12) compared with untreated skin (3.83 [0.32] at baseline and 3.79 [0.28] at week 12) (P>.99).ConclusionsIn this study, the nonpurpuric pulsed dye laser therapy did not result in significant improvement of facial acne. More research is needed before this laser therapy may be recommended as an acne treatment.

Objectives To determine (1) the reliability of sentinel lymph node mapping with biopsy (SLNB) in head and neck cutaneous melanoma to accurately stage nodal basins and (2) the safety of SLNB in both the neck and parotid regions. Design Retrospective cohort study with a median follow-up of 25 months. All patients had a minimum follow-up of 1 year. Setting Academic medical center. Patients Eighty evaluable patients diagnosed as having head and neck cutaneous melanoma and staged using SLNB. Interventions Sentinel lymph nodes were identified using preoperative lymphoscintigraphy and a combination of intraoperative gamma probe and isosulfan blue dye. Patients with a SLN positive for melanoma underwent therapeutic lymphadenectomy followed by an evaluation for adjuvant therapies. Patients with a negative SLNB result were followed up clinically. Main Outcome Measures Percentage of positive SLNs, regional recurrence in the setting of a negative SLNB result (false-negative rate), and procedure complications. Results The mean Breslow depth was 2.35 mm. A SLN was identified in 77 (96.3%) of cases, with an average of 2.18 nodes per patient. Of the sentinel nodes identified, 74% were from the neck region. The remaining 26% were from the parotid basin. No facial nerve complications occurred. Of the patients, 14 (18%) were SLN positive for metastatic melanoma. The regional failure rate in the setting of a negative SLNB result was 4.5%. Conclusions Sentinel lymph node mapping with biopsy is a reliable technique to diagnose regional spread from head and neck cutaneous melanoma. This procedure can be performed in both neck and parotid nodal basins with safety and accuracy similar to non–head and neck sites.

Objective To directly compare cosmetic improvement and postoperative sequelae resulting from dermabrasion of surgical scars with conventional motor-powered diamond fraise vs manual dermabrasion with medium-grade drywall sanding screen. Design Patients were randomly assigned to receive treatment with conventional diamond fraise dermabrasion to one half of the scar and manual dermabrasion with a drywall sanding screen to the other half in a prospective, comparative clinical study. Blinded observers assessed clinical variables during a 6-month follow-up period. Setting University hospital/cancer center–based cutaneous surgery unit. Patients Twenty-one healthy volunteers, Fitzpatrick skin type I to III, with contour irregularities resulting from granulation (7 patients) or reconstruction (14 patients) after skin cancer excision. Interventions One half of the patient's scar was treated with motor-powered diamond fraise dermabrasion and the other half was treated with manual dermabrasion with medium-grade drywall sanding screen. Main Outcome Measures Correction of contour, scarline visibility, time to reepithelialization, presence or absence of milia, degree of postoperative erythema, hypertrophic scarring, patients' subjective reports of postoperative pain, and presence of pigmentary changes were observed for both methods. Standardized scoring systems were used to quantify outcome measures. Results According to the standardized scoring systems, no differences were found between the 2 methods at any point. In addition, no significant differences were found between the methods for any measure at any of the time points. Conclusion Both dermabrasion techniques are equally effective in improving the cosmetic appearance of surgical scars.

Objective To review and report our experience with the subcutaneous pedicle flap in the reconstruction of defects adjacent to the melolabial crease. Design Retrospective review. Setting Cutaneous surgery unit of an academic tertiary referral center. Patients One hundred nine patients with defects of the lateral aspect of the upper lip, the medial aspect of the cheek, and the melolabial crease after Moh excision of cutaneous lesions. Conclusions In our experience, the subcutaneous pedicle advancement flap is often ideally suited to the reconstruction of cutaneous defects adjacent to the melolabial crease. We have been particularly satisfied with the results of this reconstructive technique when addressing deep defects adjoining the alar facial sulcus in patients with full cheeks.

This 392-page text is outstanding. Goepfert, Weber, and Miller are exceptional and distinguished clinicians and scholars. They have successfully edited and delivered a comprehensive textbook to serve as a resource for those physicians caring for patients afflicted with complex cutaneous basal cell and squamous cell carcinoma. This textbook emphasizes the multidisciplinary management of advanced basal cell and squamous cell carcinoma of the head and neck. The first 65 pages deal with epidemiology, pathology, molecular biology, immunobiology, and mechanisms of invasion and metastasis. The remaining majority of the text focuses on comprehensive clinical management of patients with advanced nonmelanoma skin cancer. Physicians treating nonmelanoma skin cancer will benefit from an understanding of management options and guidelines for the more advanced and complicated cases of nonmelanoma skin cancer. Several chapters are considerably interesting and will add to the dermatologist's library of standard cutaneous oncology and surgery texts. Specific examples of excellent and

Background and Design: The ability of superficial dermabrasion to improve clinical features of photoaged skin is well known, but the specific biological mechanisms involved are poorly understood. The so-called repair zone, as visualized by routine histologic examination, has been attributed to new collagen formation within the papillary dermis and may be responsible for clinical improvement following dermabrasion. We investigated molecular and histologic events occurring in dermabraded skin and correlated them with clinical improvement. Ten photoaged patients (mean age, 59 years) underwent facial dermabrasion to the level of the papillary dermis. Clinical severity of photoaging was graded in a blinded manner at baseline and 12 weeks after dermabrasion. Biopsy specimens obtained at baseline and 3 and 12 weeks after dermabrasion were analyzed histologically and by in situ hybridization for fibroblast procollagen I mRNA, immunohistologically and by Western blotting with a monoclonal antibody specific for the aminoterminal cleavage site of procollagen I. Results: Masson's trichrome staining demonstrated an increase in collagen from baseline (as an upper dermal band in the dermabrasion ''repair zone'') at 3 and 12 weeks' postdermabrasion. Immunohistologic examination demonstrated papillary dermal fibroblast staining for procollagen I at baseline that increased by threefold at 3 weeks' postdermabrasion and by 1.5-fold at 12 weeks' postdermabrasion. Western blotting demonstrated an average-fold increase in pN collagen I of 4.2± 1.5 at 3 weeks and of 2.7±0.7 at 12 weeks. By in situ hybridization, baseline levels of procollagen I mRNA in papillary dermal fibroblasts increased sixfold at weeks 3 and 12 postdermabrasion. Increase in procollagen I mRNA correlated with clinical improvement, ie, reduction in wrinkling. Conclusion: Superficial dermabrasion clinically improves photoaged skin, and this improvement correlates strongly with increased collagen I gene expression. (Arch Dermatol. 1994;130:1136-1142)

To the Editor.— Basaloid follicular hamartoma is a benign adnexal tumor characterized histologically by the presence of branching cords and thin strands of undifferentiated anastomosing, basaloid proliferations that are embedded in a fibrous stroma. It has been well described histologically, but there does not appear to be any specific clinical characteristics. We describe two distinctly different clinical presentations of histologically confirmed basaloid follicular hamartoma and review the previous literature. In addition, we report the occurrence of anodular basal cell carcinoma within ahamartomatous plaque on the neck of one of our patients. Report of Cases.—Case 1.— A 34-year-old white man presented with an enlarging 1-cm pearly nodule with a "birthmark" on the right side of his neck. Physical examination revealed a 10xl3-cm flesh-to-yellow plaque on the right side of the neck composed of multiple coalescent papules and scattered 1- to 2-mm milia (Fig 1). An excisional biopsy specimen of the new nodule was diagnostic for nodular basal cell carcinoma. Adjacent to the tumor were

To the Editor.— Two recent articles addressed some of the arguments for and against treating actinic keratoses (AKs).1,2Although Dodson et al1presented a patient-oriented perspective (the risk of malignant conversion over 10 years), and Marks2presented his practical and economic perspective, it is surprising that neither article addressed the most important justification for the treatment of AKs—ie, the AK is much more likely to convert into a squamous cell carcinoma (SCC) than the surrounding skin. The ability to identify high-risk individuals is of obvious importance in any screening program. The ability to identify high-risk areas of human tissue is exceptionally useful and unusual in medicine. We present our perspective on the relative risk of malignant transformation (to SCCs) in AKs compared with normal skin. Current concepts regarding malignant transformation of AKs to SCCs are largely based on work of Marks et al.3They conducted a

Enhancer of zeste homolog 2 (EZH2) is a histone methyltransferase that promotes tumorigenesis by epigenetic repression of tumor suppressor genes. Although EZH2 is overexpressed in many malignancies, activating EZH2 mutations have been described predominantly in follicular lymphoma and diffuse large B-cell lymphoma. EZH2 activating mutations in melanoma are not well described. Here, we report a case of cutaneous melanoma that displayed an EZH2 (Y641S) activating mutation detected by transcriptome sequencing as well as BRAF (V600K). The patient had concurrent follicular lymphoma that lacked both the EZH2 (Y641) and BRAF (V600K) mutations present in the patient's melanoma. Further, we screened publicly available sequence data and identified four additional melanoma cases harboring activating EZH2 mutation. Our findings provide additional evidence that activating recurrent EZH2 mutations occur in cutaneous melanoma, to our knowledge the first solid tumor shown to harbor such mutations. These tumors may be amenable to EZH2 inhibitor therapy.

SummaryWe investigated whether melanoma is hierarchically organized into phenotypically distinct subpopulations of tumorigenic and nontumorigenic cells or whether most melanoma cells retain tumorigenic capacity, irrespective of their phenotype. We found 28% of single melanoma cells obtained directly from patients formed tumors in NOD/SCID IL2Rγnull mice. All stage II, III, and IV melanomas obtained directly from patients had common tumorigenic cells. All tumorigenic cells appeared to have unlimited tumorigenic capacity on serial transplantation. We were unable to find any large subpopulation of melanoma cells that lacked tumorigenic potential. None of 22 heterogeneously expressed markers, including CD271 and ABCB5, enriched tumorigenic cells. Some melanomas metastasized in mice, irrespective of whether they arose from CD271− or CD271+ cells. Many markers appeared to be reversibly expressed by tumorigenic melanoma cells.

Seven patients receiving systemic chemotherapy for solid tumors developed an erythematous papulosquamous eruption resembling a drug eruption in sun-exposed areas. Careful examination revealed that the lesions were actually inflamed actinic keratoses. Biopsies of typical lesions in three of the patients confirmed this clinical impression. While one patient was receiving systemic 5-fluorouracil alone, and three were receiving 5-fluorouracil and cisplatin, three others developed inflammatory flares of actinic keratoses while receiving other chemotherapeutic drugs. One patient received doxorubicin and vincristine, one received doxorubicin alone, and one received the combination of dactinomycin, vincristine, and decarbazine. Since this phenomenon appears to be due to the effect of chemotherapy on the atypical keratinocytes present in actinic keratoses, discontinuation of the chemotherapy is not indicated in this situation.

To the Editor.— We report a case of erythema nodosum treated with potassium iodide with the development of profound hypothyroidism secondary to exogenous intake of iodide. It is known that the prolonged use of iodides can lead to hypothyroidism, termed the Wolff-Chaikoff effect. 1,2 Clinicians should be alert for signs and symptoms of hypothyroidism while treating patients with potassium iodide. Report of a Case.— A 67-year-old woman was seen in April 1986 with tender red nodules located mainly on the anterior surfaces of the legs. A biopsy specimen of one of the nodules showed a septal panniculitis consistent with erythema nodosum. Medications included insulin, prazosin hydrochloride, hydrochlorothiazide, potassium, and metaproterenol sulfate, none of which were recently started. Workup included chest roentgenogram, tuberculin skin test, chemistry profile, complete blood cell count, rapid plasma reagin, urinalysis, antistreptolysin-O titer, and antinuclear antibody, all of which showed negative or unremarkable results. The patient

• Human immunodeficiency virus (HIV) causes a spectrum of immunodysfunction, the most severe of which is the acquired immunodeficiency syndrome (AIDS). We have followed the course of psoriasis in 13 patients over 2 ½ years in a population of more than 1000 HIV-positive individuals. Four patients had a history of mild psoriasis that became severe and uncontrollable as symptoms of immunodeficiency developed. Psoriasis and HIV positivity, AIDS-related complex, or AIDS simultaneously developed in nine patients. In addition to psoriasis, Reiter's syndrome (arthritis, urethritis, and conjunctivitis) developed in one patient in the first group and three patients in the second group. Opportunistic infections, especially candidiasis andStaphylococcus, drugs, and an altered immune system may contribute to the development or flare of psoriasis in these patients. The appearance of severe psoriasis (especially in a patient with other risk factors for HIV) should prompt evaluation for HIV, and may be a poor prognostic indicator in HIV-positive patients, since nine of our 13 patients have died. Immunosuppressive therapy with methotrexate is contraindicated in this group of patients. Newer forms of drug therapy including etretinate show promising results for the management of AIDS-associated psoriasis. (Arch Dermatol1987;123:1622-1632)