Leonardo Marini, SDC The Skin Doctors’ Center Trieste (I)

Photodynamic therapy is a well-established, non-invasive treatment option for a variety of dermatologic disorders, including actinic keratosis and photo-aging. Conventional PDT, usually associated with significant levels of pain during and immediately after light-activating procedures, has been recently innovated with the introduction of the so-called daylight approach. PDT requires three major “ingredients”: a topical photosensitizer – most commonly 5-ALA or 5-MAL, an appropriate light source, and good levels of tissue oxygen. Various pre-treatment ancillary procedures have been proposed to improve trans-cutaneous penetration and localized absorption of photosensitizers, leading to significant improvements of treatment efficacy. There is no wide agreement to the organization of the sequential steps characterizing PDT: skin preparation, topical photosensitizer application, incubation time, light source exposure. Recently fractional ablative lasers have proven quite effective in allowing a much better trans-cutaneous penetration and more uniform photosensitizer distribution within selected skin areas. PpIX tissue accumulation after photosensitizer conversion varies according to original pharmacologic concentration and incubation time. PDT effect needs proper concentrations of tissue oxygen to achieve higher levels of ROS-associated results. Two types of irradiation techniques have been used to activate PDT effects: continuous and sequential exposures. Continuous exposure is easier but less effective since tissue oxygen reduces its concentration during irradiation due to increased tissue edema. Sequential exposures allow tissue oxygen reservoirs to replenish during resting intervals. Warming tissue during intervals using long pulse IR lasers can potentially increase tissue oxygen levels further improving PDT effects. Strategic combinations of ancillary techniques can lead to better and more reproducible clinical results.

Since 1990 our Laser & Vascular Anomaly clinic has been treated vascular malformations and tumours with lasers and since 1998 IPL as an adjuvant tool. Appropriate treatment begins with the correct diagnosis. Therefore ISSVA´s classifications are of extreme importance.
Capillary malformations responds well but needs a lot of treatments and it is rare with total blanching. Maintenance treatments.
Venous malformation, especially focal and smaller and less deep thatn7 mm responds well with long pulsed Nd:YAG laser with cold air but needs several treatments and need sometimes combination with surgery or sclerotherapy. Maintenance treatments usually. Blue Rubber Blebs should be treated as early as possible to prevent growth to larger lesions.
Infantile Hemangiomas (IH): In a retrospective study 2000 -2006 of the treatment of superficial small ones, we found that out of 283 we treated only 109. Treatments were given until sign of regression which in average was seen after 3 treatments in 88 % of the patients. Maximum 6 treatments. 39 % needed additional treatments e.g. steroids, surgery. No side effects were seen in 80% of the patients.
Since 2008 we have been using Propranolol systemically in severe cases with excellent results. Therefore, we do much less lasers and/IPL of IH. Ulcerated IH, very superficial IH  and when there is a contra indication for systemic propranolol or when parents refuse systemic propranolol ,we often treat with laser or IPL in combination with topical propranolol with very good results but slower effect than with systemic treatment.  We only recommend laser and IPL treatments if the physician is an expert in vascular anomalies as well as expert in lasers.
Machines that have been used are: IPL VL 555 -950 nm,  9 ms , 15 -17 J/cm2 and PR 535 – 750 nm , PDL 10 mm spot, 10 ms, 8 J/cm2 , diode 910 nm and  long pulsed Nd:YAG cold air , 3 ms , 32 ms , 254 -300 J/cm2.
A multidisciplinary vascular lesion team is highly recommended when determining appropriate therapeutic strategies and our group who has worked together since 1994 also now has telemedicine with videoconference unit connected to a multi conference unit where specialists from other sites can connect for participation. The conference room includes workstations for the disciplines showing images like CT/MR, histological images, visual light images but also patient record text.

Microcystic adnexal carcinoma is a rare low-grade malignant adnexal tumor that usually affects middle aged and older adults. It took until 1982, when the tumor was first described by Goldstein. The exact pathogenesis is still unknown, but experts suggest that a pluripotent stem cell, that is able to differentiate further into sweat glands, is responsible for this tumor. The tumor is mainly located in the face. The clinical presentation is not specific and mostly clinically misdiagnosed as basal cell carcinoma. The tumor tends to have a quite extensive subclinical involvement and therefore Mohs micrographic surgery is the treatment of choice. Mohs micrographic surgery has better cure rates than wide local excision. Especially in cases of perineural invasion, which is quite often the case in this kind of tumors, the tumor can be treated with Mohs micrographic surgery. I will focus on a larger series of previously biopsied microcystic adnexal carcinomas, which were operated between 2010 and 2017 at Erasmus MC. In only half of the cases, the diagnosis microcystic adnexal carcinoma could be confirmed during and after surgery. In most of the cases in which the tumor was a different kind of cutaneous malignancy, this has been without consequences. On the other hand, especially the misdiagnosis of syringoma is potentially dangerous and can lead to large defects for a benign lesion.

Eckart Haneke

Dept Dermatol, Inselspital, Univ Bern, Switzerland
Dermatol Practice Dermaticum, Freiburg, Germany
Centro Dermatol Epidermis, Inst Cuf, Porto, Portugal
Dept Dermatol, Univ Hosp, Gent, Belgium

Many surgical interventions on the nails leave a defect and many of these defects are challenging to close. Secondary intention healing may be an option and often gives good aesthetic and functional results. Direct closure with suture is restricted to very small and ideally located defects of the nail unit. In contrast, free grafts very often yield excellent results both considering function as well as cosmesis. Their unsurpassed advantage in nail cancer surgery, however, is that tumor removal is not hampered by fear of a large defect, which cannot be closed. Depending on the nature of the defect and its specific localization within the nail organ’s subunits, various grafts are appropriate. Split-thickness skin grafts are good for small to medium-sized defects of the proximal nail fold not reaching its free margin and the hyponychium. Large defects including the proximal and lateral nail folds are repaired with a full-thickness skin graft. Nailbed defects can be closed with a reversed dermal graft that often takes on nailbed characterists in contrast to split and full-thickness grafts. Finally, grafts are a good option for defects in special localizations. Lateral defects including the lateral matrix and nailbed with or without the lateral nail fold are excised in the manner of a lateral longitudinal nail excision; a bridge flap from the lateral aspect of the distal phalanx  permits the defect to be sutured with ease. Transposition flaps are ideal for defects of the proximal nailfold after myxoid cyst resection, but also after extirpation of small cancers. The use of matrix and nailbed flaps in cancer surgery is limited as they only allow very small defects to be covered.

Many options exist in nail surgery to achieve a satisfactory result after tumor removal.