854 Commentaries
must be performed in a hospital. Skin grafting can also be problematic in specific dermatological diseases, because of the potential for pathergy.3 For these reasons, much effort has been dedicated to finding exogenous graft materials such as artificial skin substitutes, cadaveric skin or xenografts; however, these materials can bring about only temporary wound coverage.4 Alternative wound closure technologies that reduce donor-site morbidity and that could be performed easily in an outpatient scenario would be very useful in wound care management. In this issue of BJD, Purschke et al.5 investigate a novel technique designed to obtain epidermal grafting for the treatment of vitiligo or difficult-to-heal wounds by using microepidermal suction blisters. The authors used two different methodological strategies (elastic surgical dressings and ‘blister array’) and tested these models for feasibility, ease of use, reliability, and preservation of viability of the epidermal graft. The most important finding of the study was that both strategies showed blister roof with an intact epidermis and with preserved cell viability, including epidermal basal cells, melanocytes and the underlying dermis. The second technique (‘blister array’) was found to be more user friendly, particularly with respect to the simultaneous steps of blister raising, blister capture onto the dressing scaffold and blister harvesting. In our opinion, this novel technique opens up a great opportunity for the practical and potential application of epidermal grafting in skin diseases such as vitiligo, difficult-toheal wounds and other disorders where a normal epidermis is lacking. The major advantages we have observed are the simple and automated harvesting procedure, a completely outpatient-based procedure not requiring anaesthesia, and rapid healing with less scarring of the donor site. Future improvements in the technique could include a different scaffold material for suction blisters in order to keep wound exudate under control. Conflicts of interest None declared. Department of Dermatology, Wound Healing Research Unit, University of Pisa, Via Roma 67, 56126 Pisa, Italy E-mail: [email protected]
M. ROMANELLI V. DINI
References 1 Zhang AY, Meine JG. Flaps and grafts reconstruction. Dermatol Clin 2011; 29:217–30. 2 Han G. State of the art wound healing: skin substitutes for chronic wound. Cutis 2014; 93:13–26. 3 Richmond NA, Lamel SA, Braun LR et al. Epidermal grafting using a novel suction blister-harvesting system for the treatment of pyoderma gangrenosum. JAMA Dermatol 2014; 150:999–1000.
British Journal of Dermatology (2015) 172, pp844–860
4 Dini V, Romanelli M, Piaggesi A et al. Cutaneous tissue engineering and lower extremities wounds (part 2). Int J Low Extrem Wounds 2006; 5:27–34. 5 Purschke M, Asrani FA, Sabir SA et al. Novel methods for generating fractional epidermal micrografts. Br J Dermatol 2015; 172:1021–28.
Sentinel lymph node biopsy for cutaneous squamous cell carcinoma: valuable or not valuable? DOI: 10.1111/bjd.13601 ORIGINAL ARTICLE, p 1029 The incidence of cutaneous squamous cell carcinoma (SCC) is still increasing, and this tumour has the potential to metastasize. The risk of metastasis is around 3–6%, but may increase to 20% in high-risk SCC.1 The challenge in daily practice is to identify high-risk SCC and to detect a metastasis as early as possible.2 In this issue of BJD, Krediet et al.3 report a retrospective study of 143 patients in which they evaluated risk factors for metastasis of SCC, and the value of sentinel lymph node biopsy (SLNB). They confirmed that sex, age, and tumour localization, diameter, thickness and differentiation are significant risk factors for metastasis.4 They performed SLNB in 17 patients with high-risk SCC, two of which were positive. Of the other 15 patients, six still developed a metastasis later on, despite a negative SLNB. One patient developed a metastasis in the lymph node region that was subjected to SLNB, while the other five developed a metastasis in a distant region or developed a systemic metastasis. In contrast, nine (71%) of the 126 patients without SLNB developed a metastasis. It appears that the patients selected for SLNB were indeed patients with high risk of metastasis in general, as eight (47%) of 17 developed a metastasis. The most commonly used tool to identify high-risk SCC is the T stage of the TNM (tumour, nodes, metastasis) classification. The T staging system is subject to periodic revision, most recently in 2009 by the Union for International Cancer Control and in 2010 by the American Joint Committee on Cancer. But still these staging systems are not satisfactory, and several alternative T staging systems have been studied and proposed, primarily based on the presence or absence of independent risk factors.5–7 Lymph node palpation, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) are currently the most frequently used methods for the detection of metastasis. Palpation has a sensitivity of 60–75%, with CT, MRI, PET and ultrasound being slightly better.8 However, there is no consensus as to which of these methods should be used at what time points and how frequently. In patients with high-risk SCC and negative imag© 2015 British Association of Dermatologists
Commentaries
ing examination, SLNB can be theoretically used as an adjuvant method in detecting metastasis. A systematic review with pooled data showed a sensitivity of 77% and negative predictive value of 95% among 73 SLNBs.9 A meta-analysis of 130 SLNBs showed 16 positive cases and three false negatives.10 Using an alternative staging system in the analysis,6 rates of positive SLNB findings in patients with T2b lesions were statistically higher than in those with T2a lesions. It is important to keep in mind that a substantial part of metastasis does not develop in the sentinel node. Therefore, it is important to identify those patients who can benefit from SLNB. The place of SLNB in clinical practice in general or in patients with high-risk SCC in particular still has to be established, but the current study of Krediet et al.3 does not yet advocate the introduction of SLNB in clinical practice.
855
10 Schmitt AR, Brewer JD, Bordeaux JS, Baum CL. Staging for cutaneous squamous cell carcinoma as a predictor of sentinel lymph node biopsy results: meta-analysis of American Joint Committee on Cancer criteria and a proposed alternative system. JAMA Dermatol 2014; 150:19–24.
No difference in skin condition between workers exposed and not exposed to glove occlusion in a semiconductor company DOI: 10.1111/bjd.13652 ORIGINAL ARTICLE, p 1058
Conflicts of interest None declared. Department of Dermatology, B1-Q, Leiden University Medical Centre, PO Box 9600, Leiden 2300 RC, The Netherlands E-mail: [email protected]
R.E. GENDERS J.N. BOUWES BAVINCK
References 1 Weinberg AS, Ogle CA, Shim EK. Metastatic cutaneous squamous cell carcinoma: an update. Dermatol Surg 2007; 33:885–99. 2 Martorell-Calatayud A, Sanmartın-Jimenez O, Cruz Mojarrieta J, Guillen Barona C. Cutaneous squamous cell carcinoma: defining the high-risk variant. Actas Dermosifiliogr 2013; 104:367–79. 3 Krediet JT, Beyer M, Lenz K et al. Sentinel lymph node biopsy and risk factors for predicting metastasis in cutaneous squamous cell carcinoma. Br J Dermatol 2015; 172:1029–36. 4 Brantsch KD, Meisner C, Sch€onfisch B et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008; 9:713–20. 5 Breuninger H, Brantsch K, Eigentler T, H€afner HM. Comparison and evaluation of the current staging of cutaneous carcinomas. J Dtsch Dermatol Ges 2012; 10:579–86. 6 Jambusaria-Pahlajani A, Kanetsky PA, Karia PS et al. Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system. JAMA Dermatol 2013; 149:402–10. 7 Karia PS, Jambusaria-Pahlajani A, Harrington DP et al. Evaluation of American Joint Committee on Cancer, International Union Against Cancer, and Brigham and Women’s Hospital tumor staging for cutaneous squamous cell carcinoma. J Clin Oncol 2014; 32:327–34. 8 Veness MJ, Goedjen B, Jambusaria A. Perioperative management of high risk primary cutaneous squamous cell carcinoma: role of radiologic imaging, elective lymph node dissection, sentinel lymph node biopsy, and adjuvant radiotherapy. Curr Dermatol Rep 2013; 2:77–83. 9 Ahmed MM, Moore BA, Schmalbach CE. Utility of head and neck cutaneous squamous cell carcinoma sentinel node biopsy: a systematic review. Otolaryngol Head Neck Surg 2014; 150:180–7. © 2015 British Association of Dermatologists
People working in occupations that entail wet work (such as nursing) are at increased risk of developing occupational hand eczema.1,2 In occupational health research and policy, wet work is commonly defined as having wet hands for more than 2 h or hand cleansing more than 20 times per day.3 In addition, prolonged wearing of occlusive gloves has been suggested as a risk factor of similar importance, for instance by German occupational regulations.4 However, the evidence underpinning this notion is unclear. In this issue of BJD, Weistenh€ ofer and coworkers present a study investigating the effects of prolonged glove occlusion on skin condition and skin barrier functioning in a cohort of more than 300 employees of a semiconductor production company in Germany.5 They compared 177 clean-room workers who wore occlusive gloves (in the absence of any additional skin hazards) during their whole shifts, with 146 office employees who served as a control group. No significant difference was found for skin condition as measured by the Hand Eczema Score for Occupational Screening (HEROS).6 Transepidermal water loss (TEWL) and corneometry values were significantly higher in the exposed group, but interestingly the difference in TEWL values was noted only in the first 30 min after the gloves were taken off. It must be noted that significantly more workers in the exposed group than in the control group reported skin problems on the hands at the current workplace in their medical history. Furthermore, the use of after-work skincare creams was significantly associated with increased HEROS values. As discussed in the paper, this may point to underlying, potentially mild, skin problems that lead to the application of skincare creams. So perhaps the story is more complicated than the paper suggests at first sight. A cross-sectional study cannot disentangle the time sequence of events and hence causality cannot be analysed. Therefore future studies should ideally follow up groups exposed and not exposed to glove occlusion and investigate incident rather than prevalent skin lesions. However, this would likely require a rather long follow-up of several years to obtain numbers that allow meaningful epidemiological insights. British Journal of Dermatology (2015) 172, pp844–860
must be performed in a hospital. Skin grafting can also be problematic in specific dermatological diseases, because of the potential for pathergy.3 For these reasons, much effort has been dedicated to finding exogenous graft materials such as artificial skin substitutes, cadaveric skin or xenografts; however, these materials can bring about only temporary wound coverage.4 Alternative wound closure technologies that reduce donor-site morbidity and that could be performed easily in an outpatient scenario would be very useful in wound care management. In this issue of BJD, Purschke et al.5 investigate a novel technique designed to obtain epidermal grafting for the treatment of vitiligo or difficult-to-heal wounds by using microepidermal suction blisters. The authors used two different methodological strategies (elastic surgical dressings and ‘blister array’) and tested these models for feasibility, ease of use, reliability, and preservation of viability of the epidermal graft. The most important finding of the study was that both strategies showed blister roof with an intact epidermis and with preserved cell viability, including epidermal basal cells, melanocytes and the underlying dermis. The second technique (‘blister array’) was found to be more user friendly, particularly with respect to the simultaneous steps of blister raising, blister capture onto the dressing scaffold and blister harvesting. In our opinion, this novel technique opens up a great opportunity for the practical and potential application of epidermal grafting in skin diseases such as vitiligo, difficult-toheal wounds and other disorders where a normal epidermis is lacking. The major advantages we have observed are the simple and automated harvesting procedure, a completely outpatient-based procedure not requiring anaesthesia, and rapid healing with less scarring of the donor site. Future improvements in the technique could include a different scaffold material for suction blisters in order to keep wound exudate under control. Conflicts of interest None declared. Department of Dermatology, Wound Healing Research Unit, University of Pisa, Via Roma 67, 56126 Pisa, Italy E-mail: [email protected]
M. ROMANELLI V. DINI
References 1 Zhang AY, Meine JG. Flaps and grafts reconstruction. Dermatol Clin 2011; 29:217–30. 2 Han G. State of the art wound healing: skin substitutes for chronic wound. Cutis 2014; 93:13–26. 3 Richmond NA, Lamel SA, Braun LR et al. Epidermal grafting using a novel suction blister-harvesting system for the treatment of pyoderma gangrenosum. JAMA Dermatol 2014; 150:999–1000.
British Journal of Dermatology (2015) 172, pp844–860
4 Dini V, Romanelli M, Piaggesi A et al. Cutaneous tissue engineering and lower extremities wounds (part 2). Int J Low Extrem Wounds 2006; 5:27–34. 5 Purschke M, Asrani FA, Sabir SA et al. Novel methods for generating fractional epidermal micrografts. Br J Dermatol 2015; 172:1021–28.
Sentinel lymph node biopsy for cutaneous squamous cell carcinoma: valuable or not valuable? DOI: 10.1111/bjd.13601 ORIGINAL ARTICLE, p 1029 The incidence of cutaneous squamous cell carcinoma (SCC) is still increasing, and this tumour has the potential to metastasize. The risk of metastasis is around 3–6%, but may increase to 20% in high-risk SCC.1 The challenge in daily practice is to identify high-risk SCC and to detect a metastasis as early as possible.2 In this issue of BJD, Krediet et al.3 report a retrospective study of 143 patients in which they evaluated risk factors for metastasis of SCC, and the value of sentinel lymph node biopsy (SLNB). They confirmed that sex, age, and tumour localization, diameter, thickness and differentiation are significant risk factors for metastasis.4 They performed SLNB in 17 patients with high-risk SCC, two of which were positive. Of the other 15 patients, six still developed a metastasis later on, despite a negative SLNB. One patient developed a metastasis in the lymph node region that was subjected to SLNB, while the other five developed a metastasis in a distant region or developed a systemic metastasis. In contrast, nine (71%) of the 126 patients without SLNB developed a metastasis. It appears that the patients selected for SLNB were indeed patients with high risk of metastasis in general, as eight (47%) of 17 developed a metastasis. The most commonly used tool to identify high-risk SCC is the T stage of the TNM (tumour, nodes, metastasis) classification. The T staging system is subject to periodic revision, most recently in 2009 by the Union for International Cancer Control and in 2010 by the American Joint Committee on Cancer. But still these staging systems are not satisfactory, and several alternative T staging systems have been studied and proposed, primarily based on the presence or absence of independent risk factors.5–7 Lymph node palpation, ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) are currently the most frequently used methods for the detection of metastasis. Palpation has a sensitivity of 60–75%, with CT, MRI, PET and ultrasound being slightly better.8 However, there is no consensus as to which of these methods should be used at what time points and how frequently. In patients with high-risk SCC and negative imag© 2015 British Association of Dermatologists
Commentaries
ing examination, SLNB can be theoretically used as an adjuvant method in detecting metastasis. A systematic review with pooled data showed a sensitivity of 77% and negative predictive value of 95% among 73 SLNBs.9 A meta-analysis of 130 SLNBs showed 16 positive cases and three false negatives.10 Using an alternative staging system in the analysis,6 rates of positive SLNB findings in patients with T2b lesions were statistically higher than in those with T2a lesions. It is important to keep in mind that a substantial part of metastasis does not develop in the sentinel node. Therefore, it is important to identify those patients who can benefit from SLNB. The place of SLNB in clinical practice in general or in patients with high-risk SCC in particular still has to be established, but the current study of Krediet et al.3 does not yet advocate the introduction of SLNB in clinical practice.
855
10 Schmitt AR, Brewer JD, Bordeaux JS, Baum CL. Staging for cutaneous squamous cell carcinoma as a predictor of sentinel lymph node biopsy results: meta-analysis of American Joint Committee on Cancer criteria and a proposed alternative system. JAMA Dermatol 2014; 150:19–24.
No difference in skin condition between workers exposed and not exposed to glove occlusion in a semiconductor company DOI: 10.1111/bjd.13652 ORIGINAL ARTICLE, p 1058
Conflicts of interest None declared. Department of Dermatology, B1-Q, Leiden University Medical Centre, PO Box 9600, Leiden 2300 RC, The Netherlands E-mail: [email protected]
R.E. GENDERS J.N. BOUWES BAVINCK
References 1 Weinberg AS, Ogle CA, Shim EK. Metastatic cutaneous squamous cell carcinoma: an update. Dermatol Surg 2007; 33:885–99. 2 Martorell-Calatayud A, Sanmartın-Jimenez O, Cruz Mojarrieta J, Guillen Barona C. Cutaneous squamous cell carcinoma: defining the high-risk variant. Actas Dermosifiliogr 2013; 104:367–79. 3 Krediet JT, Beyer M, Lenz K et al. Sentinel lymph node biopsy and risk factors for predicting metastasis in cutaneous squamous cell carcinoma. Br J Dermatol 2015; 172:1029–36. 4 Brantsch KD, Meisner C, Sch€onfisch B et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008; 9:713–20. 5 Breuninger H, Brantsch K, Eigentler T, H€afner HM. Comparison and evaluation of the current staging of cutaneous carcinomas. J Dtsch Dermatol Ges 2012; 10:579–86. 6 Jambusaria-Pahlajani A, Kanetsky PA, Karia PS et al. Evaluation of AJCC tumor staging for cutaneous squamous cell carcinoma and a proposed alternative tumor staging system. JAMA Dermatol 2013; 149:402–10. 7 Karia PS, Jambusaria-Pahlajani A, Harrington DP et al. Evaluation of American Joint Committee on Cancer, International Union Against Cancer, and Brigham and Women’s Hospital tumor staging for cutaneous squamous cell carcinoma. J Clin Oncol 2014; 32:327–34. 8 Veness MJ, Goedjen B, Jambusaria A. Perioperative management of high risk primary cutaneous squamous cell carcinoma: role of radiologic imaging, elective lymph node dissection, sentinel lymph node biopsy, and adjuvant radiotherapy. Curr Dermatol Rep 2013; 2:77–83. 9 Ahmed MM, Moore BA, Schmalbach CE. Utility of head and neck cutaneous squamous cell carcinoma sentinel node biopsy: a systematic review. Otolaryngol Head Neck Surg 2014; 150:180–7. © 2015 British Association of Dermatologists
People working in occupations that entail wet work (such as nursing) are at increased risk of developing occupational hand eczema.1,2 In occupational health research and policy, wet work is commonly defined as having wet hands for more than 2 h or hand cleansing more than 20 times per day.3 In addition, prolonged wearing of occlusive gloves has been suggested as a risk factor of similar importance, for instance by German occupational regulations.4 However, the evidence underpinning this notion is unclear. In this issue of BJD, Weistenh€ ofer and coworkers present a study investigating the effects of prolonged glove occlusion on skin condition and skin barrier functioning in a cohort of more than 300 employees of a semiconductor production company in Germany.5 They compared 177 clean-room workers who wore occlusive gloves (in the absence of any additional skin hazards) during their whole shifts, with 146 office employees who served as a control group. No significant difference was found for skin condition as measured by the Hand Eczema Score for Occupational Screening (HEROS).6 Transepidermal water loss (TEWL) and corneometry values were significantly higher in the exposed group, but interestingly the difference in TEWL values was noted only in the first 30 min after the gloves were taken off. It must be noted that significantly more workers in the exposed group than in the control group reported skin problems on the hands at the current workplace in their medical history. Furthermore, the use of after-work skincare creams was significantly associated with increased HEROS values. As discussed in the paper, this may point to underlying, potentially mild, skin problems that lead to the application of skincare creams. So perhaps the story is more complicated than the paper suggests at first sight. A cross-sectional study cannot disentangle the time sequence of events and hence causality cannot be analysed. Therefore future studies should ideally follow up groups exposed and not exposed to glove occlusion and investigate incident rather than prevalent skin lesions. However, this would likely require a rather long follow-up of several years to obtain numbers that allow meaningful epidemiological insights. British Journal of Dermatology (2015) 172, pp844–860
