366
anaerobes. The mechanism of antimicrobial action of SS has not been well elucidated, but it seems that promotes bacterial lysis.4 Adverse systemic effects appear when SS is applied to large areas. There is a risk of producing blood disorders and cutaneous side-effects, like ACD, erythema multiforme and argyria (blue-gray pigmentation of the skin, caused by the deposition of silver, with possible systemic involvement5,6). Last cases reported in the literature of ACD by SS date from 1992 to 1995, from Fraser-Moodie and McKenna, respectively, who reported cases of hypersensitivity to SS after its topical use in burns. The first author objectified reactivity in patch tests to silver nitrate and cetyl alcohol (components of Flamazineâ). In our case, cetyl alcohol was also tested and was negative. The main factors involved in hypersensitivity are the alteration of skin barrier, prolonged use and application in occlusion.7 We report a case of allergic contact dermatitis to Silvedermaâ cream 1% attributed to silver contained in this product. We tested all the components of this cream, observing positivity for silver and negativity for the other preservatives. We emphasize that nitrofurazone was well tolerated by the patient even though in our medium it is considered as one of the main contact allergens. When ACD to topical antibiotic is suspected, it is recommended to suspend the administration and replace it with another one. Furthermore, it is important to perform patch tests to confirm hypersensitivity to the allergen involved and prevent its future use. A.A. Garcıa,1 A. M. Rodrıguez Martın,2 E. Serra Baldrich,3 E. Manubens Mercade,3 L. Puig Sanz3 tzer, Palma de Mallorca, Department of Dermatology, Hospital Son Lla Spain, 2Department of Dermatology, Hospital Universitario Reina Sofıa, rdoba, Spain, 3Department of Dermatology, Hospital de la Santa Creu i Co Sant Pau, Barcelona, Spain *Correspondence: A. A. Garcıa. E-mail: [email protected] 1
Letters to the Editor
A fistula in disguise- a case report Editor At the outpatient clinic of Dermatology, a female patient presented with a retracted scar with granulation tissue on the right cheek (Fig. 1). Intraorally, a fibrotic cord was palpated just above the first molar of the right upper jaw. Several months earlier, she underwent surgical revision of a keloidal scar on her right cheek, which was the result from a former excision of a presumed epidermal cyst. Subsequently, a persistent distension in the course of the scar developed with production of blood and pus, despite several courses of oral antibiotics. As we suspected a dentogenic cause of the problem, the patient was referred to the oral-maxillofacial surgeon. Supplementary radiographic examination showed deep caries of the first upper molar with apical radiolucency, indicating apical periodontitis (Fig. 2, arrow). The diagnosis of an odontogenic fistula was thereby confirmed, also known as ‘(cutaneous) (odontogenic) sinus tract’, ‘extraoral sinus tract’, ‘orocutaneous fistula’, ‘dentocutaneous sinus’ and ‘cutaneous facial sinus tract of dental origin’. The dentogenic focus was instantly eliminated by the oral-maxillofacial surgeon, the remaining scar will be surgically corrected in 6–12 months. Odontogenic fistulas often remain unrecognized by many physicians. Dental abscesses are a common manifestation, and in advanced stages may drain extraorally, depending on the causative tooth, root location, bone thickness and muscle inserts. Often the patient does not present with obvious dental symptoms, especially if the infection is of a chronic and low-grade nature.1 Clinically, it generally concerns a long-standing, funnelshaped retraction of the skin with granulation tissue or a small crust at the bottom. However, in some cases it may appear as a
References 1 Prieto A, Baeza M, Herrero R et al. Contact dermatitis to furacin. Contact Derm 2006; 54: 126. 2 C ordoba Guijarro S, Sanchez Perez J, Garcıa Dıaz A. Allergic Contact Dermatitis to Polyethylene glycol and nitrofurazone. Am J Contact Derma 1999; 16: 226–227. 3 Conde Salazar L, Gutmaraens D, Gonzalez MA et al. Occupational allergic contact dermatitis from nitrofurazone. Contact Derm. 1995; 32: 307. 4 Hussain S, Fergusson C. Best evidence t opic report. Silver sulphadiazine cream in burns. Emerg Med J 2006; 23: 929. 5 Fuller FW. The side effects of silver sulfadiazine. J Burn Care Res 2009; 30: 464–470. 6 Myerson Fisher N, Marsh E, Lazova R. Scar-localized argyria secondary to silver sulfadiazine cream. J Am Acad Dermatol 2003; 49: 730. 7 Mckenna SR, Latenser BA, Jones LM et al. Serious silver sulphadiazine and mafenide acetate dermatitis. Burns 1995; 21: 310. DOI: 10.1111/jdv.12785
JEADV 2016, 30, 320–386
Figure 1 Female patient presenting with a retracted scar with granulation tissue on the right cheek.
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
367
(a)
(b)
Figure 2 Radiographic examination showing deep caries of the first upper molar with apical radiolucency (arrow).
pustule or small subcutaneous abscess. Intraoral palpation is essential to identify the sinus tract, which facilitates continuity of the skin lesion with the underlying infected bony tissue. The therapy consists of removal of the dentogenic focus, sometimes combined with surgical embellishment of the remaining scar.2 Early correct diagnosis and treatment of an odontogenic fistula could help prevent unnecessary and ineffective antibiotic therapy, or surgical treatment. P. Smit,1,* D.C.M.S. Wiryasaputra,2 M.B.A. van Doorn1 1
Department of Dermatology and Venereology, Erasmus MC, Rotterdam, the Netherlands, 2Department of Oral-maxillofacial Surgery, Erasmus MC, Rotterdam, the Netherlands *Correspondence: P. Smit. E-mail: [email protected]
References 1 Abuabara A, Schramm CA, Zielak JC, Baratto-Filho F. Dental infection simulating skin lesion. An Bras Dermatol 2012; 87: 619–621. 2 Vriezen TC. [Dentogenic fistulas of the face]Dentogene fistels in het gelaat. Ned Tijdschr Geneeskd 1968; 112: 65–69. DOI: 10.1111/jdv.12786
Neglected skin carcinomas: What should not be Editor Basal cell (BCC) and squamous cell (SCC) carcinomas are the two most frequent non-melanoma skin cancers that affect humans.1 Multiple treatment options are now available, and precise guidelines give patients better outcomes. In developing countries like Mexico sanitary systems are not always well employed and patients can fall into a gap between misdiagnosis, wrong treatments and poorly conducted follow-ups. We present five cases of highly invasive, neglected cutaneous carcinomas. Case 1: A 68-year-old male with an ulcerated 10 9 15 cm mass over his right hemi-facial area with complete destruction
JEADV 2016, 30, 320–386
Figure 1 Time between the initial lesion and the diagnosis: (a) 17 years, (b) 15 years.
of the orbit and its content. Skin biopsy revealed a moderately differentiated squamous cell carcinoma (Fig. 1a). Case 2: An 88-year-old female with a 10 9 7 cm ulcerated mass over her left orbital region. Skin biopsy was consistent with a basosquamous carcinoma (Fig. 1b). Case 3: A 55-year-old male with 10 different lesions on his scalp, forehead and nasal areas; seven of them were exophytic, while the rest were large ulcerated plaques with yellow and haematic crusts. All skin biopsies revealed infiltrative basal cell carcinomas (Fig. 2a). Case 4: A 71-year-old female with an exophytic 7 9 8 cm multilobular mass that replaced her nasal anatomy, with central ulceration and haematic crusts. Skin biopsy revealed an infiltrative basal cell carcinoma (Fig. 2b). Case 5: A 69-year-old male with a 15 9 10 cm ulcerated plaque over the lateral aspect of the left hemi-facial region and complete destruction of the ear. Skin biopsy revealed an infiltrative basal cell carcinoma (Fig. 2c). Giant basal cell carcinomas are defined as a tumour of 5 cm or more in maximum diameter that are locally aggressive, have a greater risk of metastasis and are associated with a poor prognosis.2 Squamous cell carcinomas classified as high risk types are tumours characterized by thickness greater than 4 mm, perineural invasion and poor differentiation.3 Highest cure rates are achieved by complete excisional surgery, but can result in disfigurement and poor acceptance from the patient.4 Alternative therapeutic measures, such as electrosurgery, chemotherapy and radiotherapy as well as newer agents that inhibit the hedgehog pathways are being used as neoadjuvant treatments to reduce tumour size. Patients presenting with horrifying/giant BCC and SCC pose a therapeutic challenge requiring multidisciplinary team efforts. The described cases are a few of the neglected skin carcinomas we still receive annually at our outpatient clinic. Although BCC rarely metastasize, they can be very locally aggressive, causing
© 2014 European Academy of Dermatology and Venereology
anaerobes. The mechanism of antimicrobial action of SS has not been well elucidated, but it seems that promotes bacterial lysis.4 Adverse systemic effects appear when SS is applied to large areas. There is a risk of producing blood disorders and cutaneous side-effects, like ACD, erythema multiforme and argyria (blue-gray pigmentation of the skin, caused by the deposition of silver, with possible systemic involvement5,6). Last cases reported in the literature of ACD by SS date from 1992 to 1995, from Fraser-Moodie and McKenna, respectively, who reported cases of hypersensitivity to SS after its topical use in burns. The first author objectified reactivity in patch tests to silver nitrate and cetyl alcohol (components of Flamazineâ). In our case, cetyl alcohol was also tested and was negative. The main factors involved in hypersensitivity are the alteration of skin barrier, prolonged use and application in occlusion.7 We report a case of allergic contact dermatitis to Silvedermaâ cream 1% attributed to silver contained in this product. We tested all the components of this cream, observing positivity for silver and negativity for the other preservatives. We emphasize that nitrofurazone was well tolerated by the patient even though in our medium it is considered as one of the main contact allergens. When ACD to topical antibiotic is suspected, it is recommended to suspend the administration and replace it with another one. Furthermore, it is important to perform patch tests to confirm hypersensitivity to the allergen involved and prevent its future use. A.A. Garcıa,1 A. M. Rodrıguez Martın,2 E. Serra Baldrich,3 E. Manubens Mercade,3 L. Puig Sanz3 tzer, Palma de Mallorca, Department of Dermatology, Hospital Son Lla Spain, 2Department of Dermatology, Hospital Universitario Reina Sofıa, rdoba, Spain, 3Department of Dermatology, Hospital de la Santa Creu i Co Sant Pau, Barcelona, Spain *Correspondence: A. A. Garcıa. E-mail: [email protected] 1
Letters to the Editor
A fistula in disguise- a case report Editor At the outpatient clinic of Dermatology, a female patient presented with a retracted scar with granulation tissue on the right cheek (Fig. 1). Intraorally, a fibrotic cord was palpated just above the first molar of the right upper jaw. Several months earlier, she underwent surgical revision of a keloidal scar on her right cheek, which was the result from a former excision of a presumed epidermal cyst. Subsequently, a persistent distension in the course of the scar developed with production of blood and pus, despite several courses of oral antibiotics. As we suspected a dentogenic cause of the problem, the patient was referred to the oral-maxillofacial surgeon. Supplementary radiographic examination showed deep caries of the first upper molar with apical radiolucency, indicating apical periodontitis (Fig. 2, arrow). The diagnosis of an odontogenic fistula was thereby confirmed, also known as ‘(cutaneous) (odontogenic) sinus tract’, ‘extraoral sinus tract’, ‘orocutaneous fistula’, ‘dentocutaneous sinus’ and ‘cutaneous facial sinus tract of dental origin’. The dentogenic focus was instantly eliminated by the oral-maxillofacial surgeon, the remaining scar will be surgically corrected in 6–12 months. Odontogenic fistulas often remain unrecognized by many physicians. Dental abscesses are a common manifestation, and in advanced stages may drain extraorally, depending on the causative tooth, root location, bone thickness and muscle inserts. Often the patient does not present with obvious dental symptoms, especially if the infection is of a chronic and low-grade nature.1 Clinically, it generally concerns a long-standing, funnelshaped retraction of the skin with granulation tissue or a small crust at the bottom. However, in some cases it may appear as a
References 1 Prieto A, Baeza M, Herrero R et al. Contact dermatitis to furacin. Contact Derm 2006; 54: 126. 2 C ordoba Guijarro S, Sanchez Perez J, Garcıa Dıaz A. Allergic Contact Dermatitis to Polyethylene glycol and nitrofurazone. Am J Contact Derma 1999; 16: 226–227. 3 Conde Salazar L, Gutmaraens D, Gonzalez MA et al. Occupational allergic contact dermatitis from nitrofurazone. Contact Derm. 1995; 32: 307. 4 Hussain S, Fergusson C. Best evidence t opic report. Silver sulphadiazine cream in burns. Emerg Med J 2006; 23: 929. 5 Fuller FW. The side effects of silver sulfadiazine. J Burn Care Res 2009; 30: 464–470. 6 Myerson Fisher N, Marsh E, Lazova R. Scar-localized argyria secondary to silver sulfadiazine cream. J Am Acad Dermatol 2003; 49: 730. 7 Mckenna SR, Latenser BA, Jones LM et al. Serious silver sulphadiazine and mafenide acetate dermatitis. Burns 1995; 21: 310. DOI: 10.1111/jdv.12785
JEADV 2016, 30, 320–386
Figure 1 Female patient presenting with a retracted scar with granulation tissue on the right cheek.
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
367
(a)
(b)
Figure 2 Radiographic examination showing deep caries of the first upper molar with apical radiolucency (arrow).
pustule or small subcutaneous abscess. Intraoral palpation is essential to identify the sinus tract, which facilitates continuity of the skin lesion with the underlying infected bony tissue. The therapy consists of removal of the dentogenic focus, sometimes combined with surgical embellishment of the remaining scar.2 Early correct diagnosis and treatment of an odontogenic fistula could help prevent unnecessary and ineffective antibiotic therapy, or surgical treatment. P. Smit,1,* D.C.M.S. Wiryasaputra,2 M.B.A. van Doorn1 1
Department of Dermatology and Venereology, Erasmus MC, Rotterdam, the Netherlands, 2Department of Oral-maxillofacial Surgery, Erasmus MC, Rotterdam, the Netherlands *Correspondence: P. Smit. E-mail: [email protected]
References 1 Abuabara A, Schramm CA, Zielak JC, Baratto-Filho F. Dental infection simulating skin lesion. An Bras Dermatol 2012; 87: 619–621. 2 Vriezen TC. [Dentogenic fistulas of the face]Dentogene fistels in het gelaat. Ned Tijdschr Geneeskd 1968; 112: 65–69. DOI: 10.1111/jdv.12786
Neglected skin carcinomas: What should not be Editor Basal cell (BCC) and squamous cell (SCC) carcinomas are the two most frequent non-melanoma skin cancers that affect humans.1 Multiple treatment options are now available, and precise guidelines give patients better outcomes. In developing countries like Mexico sanitary systems are not always well employed and patients can fall into a gap between misdiagnosis, wrong treatments and poorly conducted follow-ups. We present five cases of highly invasive, neglected cutaneous carcinomas. Case 1: A 68-year-old male with an ulcerated 10 9 15 cm mass over his right hemi-facial area with complete destruction
JEADV 2016, 30, 320–386
Figure 1 Time between the initial lesion and the diagnosis: (a) 17 years, (b) 15 years.
of the orbit and its content. Skin biopsy revealed a moderately differentiated squamous cell carcinoma (Fig. 1a). Case 2: An 88-year-old female with a 10 9 7 cm ulcerated mass over her left orbital region. Skin biopsy was consistent with a basosquamous carcinoma (Fig. 1b). Case 3: A 55-year-old male with 10 different lesions on his scalp, forehead and nasal areas; seven of them were exophytic, while the rest were large ulcerated plaques with yellow and haematic crusts. All skin biopsies revealed infiltrative basal cell carcinomas (Fig. 2a). Case 4: A 71-year-old female with an exophytic 7 9 8 cm multilobular mass that replaced her nasal anatomy, with central ulceration and haematic crusts. Skin biopsy revealed an infiltrative basal cell carcinoma (Fig. 2b). Case 5: A 69-year-old male with a 15 9 10 cm ulcerated plaque over the lateral aspect of the left hemi-facial region and complete destruction of the ear. Skin biopsy revealed an infiltrative basal cell carcinoma (Fig. 2c). Giant basal cell carcinomas are defined as a tumour of 5 cm or more in maximum diameter that are locally aggressive, have a greater risk of metastasis and are associated with a poor prognosis.2 Squamous cell carcinomas classified as high risk types are tumours characterized by thickness greater than 4 mm, perineural invasion and poor differentiation.3 Highest cure rates are achieved by complete excisional surgery, but can result in disfigurement and poor acceptance from the patient.4 Alternative therapeutic measures, such as electrosurgery, chemotherapy and radiotherapy as well as newer agents that inhibit the hedgehog pathways are being used as neoadjuvant treatments to reduce tumour size. Patients presenting with horrifying/giant BCC and SCC pose a therapeutic challenge requiring multidisciplinary team efforts. The described cases are a few of the neglected skin carcinomas we still receive annually at our outpatient clinic. Although BCC rarely metastasize, they can be very locally aggressive, causing
© 2014 European Academy of Dermatology and Venereology
