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fig. 2 Squamous cell carcinoma of the left sub-
auricular region. (a) Planning of the surgical
margins; (b) partial direct closure of the distal
extremity of the primary defect and incision of
the opposing rotation flap; (c) tip of the rotation
flap moved into the defect; (d) final appearance
of the repair.
it has been assessed that the primary defect is not suitable for complete side-to-side closure. It allows the recovery of 1 Mellette JR Jr. Facial reconstruction in the elderly. J Geriatr free tissue as a rotation flap that would otherwise be dis- Dermatol 1995; 3: 286–297.
carded as a dog-ear. Cosmetic and functional results have 2 Schmidt DKT, Mellette JR Jr. The dog-ear rotation flap for the been highly satisfactory in all cases, as an excellent match repair of large surgical defects on the head and neck. Dermatol in skin colour and texture has always been maintained Surg 2001; 27: 908–910.
This surgical procedure has produced minimal tensionacross the wound edges, with less scarring and little or no distortion of adjacent anatomic structures. Though mainly applied on the head, the flap has been successfullyperformed on any anatomic location. According to our Therapeutic use of mistletoe
experience the comet flap can be a valuable surgical for CD30+ cutaneous
option for closure of round to oval defects of any size in lymphoproliferative disorder/
dermatological surgery reconstruction.
lymphomatoid papulosis
Dermatology Unit, ‘A. Murri’ Hospital Via dei Colli, 52 60035 Jesi – AN, Italy, *Corresponding author, Lymphomatoid papulosis (LyP) is defined in the WHO tel. +39 0731534145; fax +39 0731534035; classification as a CD30+ cutaneous lymphoproliferative lymphoma (CLPD) and is regarded as a condition of JEADV 2007, 21, 536– 578 2006 European Academy of Dermatology and Venereology
uncertain malignant potential.1 The incidence of LyP in ALCL were effective. As seen in our patient, relapse of LyP children is relatively low compared to that in adults.2 It skin lesions is common. The good response of the second is correlated with malignant lymphomas in 5 to 20% of relapse of LyP to MT is suggestive but could also represent adult LyP patients.3,4,5 In children, an increased risk for the the natural history of LyP. After the third cutaneous relapse development of malignant lymphoma is observed.6,7 The of LyP and the subsequent positive response to MT the clinical course is often chronic. The most common treatments therapeutic efficacy of MT in this patient seems evident.
for LyP are topical steroids, antibiotics, phototherapy and In particular, the temporal association between the MT low-dose methotrexate, all of which are associated with injections and the response and the typical local reaction an excellent prognosis, even for patients with anaplastic to MT are indications of a connection in this case. MT is widely used in Europe as an additional therapy for cancer An 8-year-old boy presented with reddish nodules patients10 and no adverse or long-term effects have been (maximum of 7 cm in diameter) on his right forearm and left leg. Immunohistochemical analysis identified a CD30+,large, T-cell type non-Hodgkin’s lymphoma of the skin.
G Seifert,*† C Tautz,‡ K Seeger,† G Henze,† A Laengler‡ Topical steroids were effective but 6 months later the patient †Charité – Universitätsmedizin Berlin, Otto-Heubner-Centre for developed axillary lymph-node swelling. Classifying the Paediatric and Adolescent Medicine (OHC), Klinik für Pädiatrie condition now as ALCL without signs of systemic involve- mit Schwerpunkt Onkologie/Hämatologie, Mittelallee 6a, ment, combination chemotherapy according to the German Augustenburger Platz 1, 13353 Berlin, Department of ALCL trial (high-risk group)9 was given for 6 months. All Paediatrics, Gemeinschaftskrankenhaus Herdecke, Germany, nodules (cutaneous and lymphoid/axilla) resolved within *Corresponding author, tel. +49 30 450 666087; a few weeks. However, 2 months after cessation of chem- fax +49 30 450 566946; E-mail: otherapy a new skin nodule on the left forearm appeared.
No specific therapy was given. In the following 2 monthsthe patient developed two further solid and painful skin lesions. We started subcutaneous therapy with Abnoba 1 Willemze R, Meijer CJ. Primary cutaneous CD30-positive Viscum fraxini® (ABNOBA Heilmittel GmbH, Pforzheim, lymphoproliferative disorders. Hematol Oncol Clin North Am Germany) a mistletoe extract (MT). A schedule of two 2003; 17: 1319–1332.
injections per week was initiated, starting with a dose of 2 Zirbel GM, Gellis SE, Kadin ME, Esterly NB. Lymphomatoid 20 mg in the first week, but choosing the subsequent exact papulosis in children. J Am Acad Dermatol 1995; 33: 741–
dosages with a view to obtaining a marked local reaction with mild fever and local swelling. MT was injected sub- 3 Wang HH, Myers T, Lach LJ, Hsieh CC, Kadin ME. cutaneously close to the largest lesions. One day following Increased risk of lymphoid and nonlymphoid malignancies the first local injection of MT, a fever of 38 °C was observed, in patients with lymphomatoid papulosis. Cancer 1999; 86:
plus local swelling and redness. The skin nodules started to decrease and MT injections into all lesions were continued.
4 Beljaards RC, Willemze R. The prognosis of patients with Within the following 2 weeks the skin lesions resolved. After lymphomatoid papulosis associated with malignant regression of all local symptoms, subcutaneous MT therapy lymphomas. Br J Dermatol 1992; 126: 596–602.
with two injections of 0.2 mg per week was continued.
5 Fink-Puches R, Chott A, Ardigo M et al. The spectrum of Two months later, the patient developed two new small cutaneous lymphomas in patients less than 20 years of age.
Pediatr Dermatol 2004; 21: 525–533.
nodules that responded within a few days to an increased 6 Nijsten T, Curiel-Lewandrowski C, Kadin ME. dose of MT. During 2 years of follow-up therapy with MT Lymphomatoid papulosis in children: a retrospective cohort the boy remained without clinical signs of either LvP or study of 35 cases. Arch Dermatol 2004; 140: 306–312.
ALCL. After 2 years, MT therapy was stopped. Unfortu- 7 Kadin ME, Carpenter C. Systemic and primary cutaneous nately, 3 weeks after cessation of MT therapy the patient anaplastic large cell lymphomas. Semin Hematol 2003; 40:
developed a relapse, displaying generalized reactivation of the cutaneous LyP with typical nodules (maximum 1 cm 8 Reiter A, Schrappe M, Tiemann M et al. Successful treatment in diameter) all over the body. Subcutaneous and local strategy for Ki-1 anaplastic large-cell lymphoma of intralesional MT therapy was resumed and the cutaneous childhood: a prospective analysis of 62 patients enrolled in LyP regressed completely within 2 weeks without additional three consecutive Berlin-Frankfurt-Munster group studies. J Clin Oncol 1994; 12: 899–908.
It is known that CD30+ CLPDs have an overall excellent 9 Kienle GS, Berrino F, Bussing A, Portalupi E, Rosenzweig S, outcome.8 In our patient, initial topical MT therapy of LyP Kiene H. Mistletoe in cancer – a systematic review on and subsequent systemic combination chemotherapy of controlled clinical trials. Eur J Med Res 2003; 8: 109–119.
JEADV 2007, 21, 536– 578 2006 European Academy of Dermatology and Venereology
10 Augustin M, Bock PR, Hanisch J, Karasmann M, Schneider B. Safety and efficacy of the long-term adjuvant treatment
of primary intermediate- to high-risk malignant melanoma
(UICC/AJCC stage II and III) with a standardized fermented
European mistletoe (Viscum album L.) extract. Results from
a multicenter, comparative, epidemiological cohort study in
Germany and Switzerland. Arzneimittelforschung 2005; 55:
Scleredema adultorum associated
with type 2 diabetes mellitus: a

fig. 1 Induration of the skin of the face, neck, trunk and upper arms.
report of three cases
Scleredema adultorum is a rare disease of unknownaetiology that can be associated with type 2 diabetesmellitus. Therapeutic options are limited, but successfultreatment with ultraviolet A1 (UVA-1) or antibiotics hasbeen described.
Here, we report three cases of type 2 diabetes-associated The first patient, a 55-year-old Caucasian man presented with a 2-year history of thickening of the skin resultingin reduced mobility of the neck and shoulders, withoutsystemic manifestations. He was treated with systemicpsoralen and UVA (PUVA) followed by UVA-1 therapy,without success, 2 years ago.
fig. 2 Histopathology: thickening of collagen bundles with interposed
The patient was again treated with UVA-1 (90 J/cm2) five mucin (magnification ×100; staining with colloidal iron).
times per week and by physiotherapy, resulting in softeningof the skin and enhanced mobility within 4 weeks ofinitiation of treatment.
Histopathology was typical for scleredema, with mucin The second patient, a 57-year-old Caucasian woman interposed between thickened collagen bundles, which had a 20-year history of thickening of the skin of the nape was shown by colloidal iron staining (fig. 2).4,8,9 The same of the neck, trunk, upper arms, back and dorsal thighs.
histological findings were detected in specimens from the Mobility of the neck and shoulders was decreased. She other two patients. Because of the short history of her dis- was treated with UVA-1 several times without success.
ease the patient was treated with intravenous penicillin The patient was retreated with UVA-1 50 J/cm2 on the (3 × 5 million U/day) for 2 weeks despite the absence of whole body and additional 40 J/cm2 on the nape of the clinical signs of infection. Two months later the patient neck and back. She suffered from sinusitis which was presented with remarkable improvement. Softening of treated with intravenous clindamycin (3 × 600 mg/day) the skin as well as increased mobility (especially of facial for 2 weeks because she was allergic to penicillin. The muscles and arms) had taken place; therefore, a scheduled patient responded slightly with decrease of skin rigidity within 4 weeks after initiation of treatment.
Scleredema adultorum is a rare disease of unknown The third patient, a 58-year-old Arab woman presented aetiology, which was first described by Buschke in 1900.1 with thickening of the skin resulting in reduced mobility It is characterized by non-pitting induration of the skin, of her mimic muscles, neck and shoulders starting only with no defined boundary between normal and diseased about 2 months prior to admission to our clinic. Facial skin and symmetric induration of the face, neck and nape.
involvement resulted in a mask-like expression of the face This can spread to the upper trunk and upper arms, or, (fig. 1). Mobility of arms and neck was also significantly more rarely, to other body regions. Moreover, multiple reduced. The patient denied any previous infection.
organs can be involved with respective complications. Skin , 536– 578 2006 European Academy of Der


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