Topical 5-flurouracil Research Articles

Cemiplimab for Locally Advanced Cutaneous Squamous Cell Carcinoma: A Case Series of 3 Unique Scenarios.

Cemiplimab, a monoclonal antibody directed against programmed death receptor 1 (PD-1), has shown promising results in cutaneous squamous cell carcinoma (cSCC). In a nonrandomized trial where cemiplimab 3 mg/kg was given every 2 weeks for up to 96 weeks, a 44% response rate was noted. This case series discusses 3 unique scenarios of patients with advanced cSCC treated with cemiplimab. The first case is of an end stage kidney disease (ESKD) patient with failed living donor kidney transplant who had developed recurrent cSCC despite several excisions and topical 5-flurouracil and acitretin therapy. He received 8 cycles of cemiplimab leading to resolution. This case serves as an example of the safety and efficacy of cemiplimab in a complex patient who is a kidney transplant recipient on hemodialysis. The second case describes an elderly gentleman with inoperable cSCC initially treated with radiotherapy who later received 9 cycles of cemiplimab for recurrent metastatic disease with excellent response. This case supports the safe and effective use of cemiplimab in an elderly patient. In the third case, cSCC presented itself as a large fungating mass that would have otherwise necessitated limb amputation and was successfully treated with 18 cycles of cemiplimab. This case highlights the dramatic response to cemiplimab obviating the need for surgical intervention and resulting in limb salvage.

Role of Topical 5-Flurouracil Combined with Microneedling in Stable Vitiligo

Background: Vitiligo is a chronic acquired disorder characterized by the development of depigmented macules which slowly enlarges with the concurrent appearance of new lesions.Aim: The aim is to study the efficacy of treating vitiligo by microneedling followed by application of 5-fluorouracil on vitiligo patches.Materials and Methods: This study was conducted in a tertiary hospital from March 2019 to August 2019. For this study, we selected about 50 patients in the age group of 10–50 years who had been taking treatment for vitiligo for 2–3 years without much improvement. We suggested them about needling with 5-fluorouracil application over vitiligo patches. The procedure was performed at a gap of 2 weeks on vitiligo patches of various patients for about 3 months.Result: After about 1 month of this procedure, we noticed an improvement in about 40% of patients with some erythema and hyperpigmentation developing on the margins of vitiligo patches. Gradually more than 50% of patients had similar improvement by the end of 2 months. After 3 months, about 60% of patients had hyperpigmentation in the vitiligo lesions with almost complete pigmentation in very small patches; larger ones had less pigmentation and 40% did not have any pigmentation from the previous state.Conclusion: 5-fluorouracil is a simple and effective method for treating small vitiligo patches (< 5 cm diameter generally) with no major side effects. It is a cost-effective procedure in treating a very resistant disease, i.e., vitiligo, especially for small lesions.

Study the effect of erbium:YAG laser plus topical 5‐flurouracil in stable vitiligo resistant to NB‐UVB phototherapy

NB-UVB phototherapy is still an effective treatment in vitiligo but requires more than 1year for its completion. Topical 5-flurouracil could improve the proliferation and migration of melanocytes. Laser-assisted dermabrasion results in stimulation of the inactive melanocytes present at the outer root sheath of the lower portion of the hair follicle, which migrates upward until they reach the surface of the skin. To evaluate the effect of Er:YAG laser skin ablation followed by topical 5-flurouracil on the outcome of NB-UVB phototherapy as a short term technique in resistant and stable vitiligo. The current study included 40 patients suffering from bilateral stable vitiligo resistant to NB-UVB. For each patient, one side of the body subjected to 4months NB-UVB sessions (control side). While the other side of the body subjected to one session of Er:YAG laser ablation combined with topical 5% 5-flurouracil application under occlusion followed by NB-UVB sessions for 4months after complete re-epithelization. Outcomes were evaluated objectively based on standard digital photographs, histopathological examination, patient satisfaction, and adverse effects. There was a statistically significant improvement in the repigmentation in laser side compared with control side. Histopathological examination revealed expression of prominent melanin pigmentation, with marked expression for Melan-A in laser side, whereas these findings were negative in control side. Er:YAG laser ablation, followed by 5FU application before NB-UVB phototherapy for vitiligo, is a safe and tolerable technique that improves the outcome of short-term NB-UVB therapy and is expected to increase patient compliance.

Practical indications for the management of non-melanoma skin cancer patients.

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), together encompassed in the term non-melanoma skin cancers (NMSC), are the most common cancers among fair-skinned populations. Individuating accurate risk stratification of NMSC patients is crucial to select different options among various treatment strategies. The majority of low risk NMSCs are easily treated with surgery, offering excellent cure rates and cosmetic results. Other treatment modalities include physical destruction (curettage, cautery and cryotherapy), chemical destruction (photodynamic therapy and topical 5-flurouracil) and immunomodulatory therapy (topical imiquimod). However, there is a subset of "high-risk" NMSC characterized by prognostic factors associated to aggressive behavior, such as tumor location and size, clinical margins, histopathological variants, recurrence or previous treatment. These lesions need to be treated accordingly also by mean of adjuvant treatments. The contribution of a multidisciplinary team is necessary to appropriately manage patients affected by advanced NMSC. The aim of these practical indications is to provide a useful guidance for risk stratification of NMSC patients in clinical setting and for consequential treatment choice, resulting in individualized management strategies.

Automated microneedling and topical 5-flurouracil solution may help in treating acral vitiligo

Automated microneedling and topical 5-flurouracil solution may help in treating acral vitiligo

Non-melanoma skin cancer

Non-melanoma skin cancer (NMSC) comprises basal cell carcinoma (BCC) and squamous cell carcinoma, together with a host of rare tumours. NMSC is the commonest malignancy among Caucasians and its incidence continues to rise annually. Exposure to UV radiation initiates approximately 90% of NMSC, causing malignant transformation of keratinocytes and suppression of the inflammatory response. Risk factors include sun exposure and immunosuppression. There are several subtypes of BCC, although histological overlap is common. Surgery has traditionally been regarded as the 'gold-standard' treatment, offering excellent cure rates and cosmetic results. Other treatment modalities include physical destruction (radiotherapy, curettage and cautery, and cryotherapy), chemical destruction (photodynamic therapy and topical 5-flurouracil) and immunomodulatory therapy (topical imiquimod). The recent development of novel hedgehog pathway inhibitors for high-risk BCC (including oral vismodegib and sonidegib) may represent a paradigm shift towards medical management of NMSC.

Skin SCC following mustard gas testing in a British Army recruit

An 84-year-old army veteran presented with a 1.5×1-cm keratotic lesion on the dorsum of his right hand. The lesion had developed at the site of previous mustard gas testing, which he had been subjected to as a soldier in the British army in 1944. He reported that the site had been painful, erythaematous and ulcerated for a number of years following the mustard gas tests. This had eventually settled, leaving a flat, erythaematous but generally asymptomatic lesion described as a ‘burn’ that the patient had ignored. Over the past 10 years, however, the lesion had become raised and increasingly symptomatic, with itching and occasional bleeding. It was treated by dermatologists with topical 5-flurouracil and serial curettage for 8 years but had persistently recurred. Serial biopsies had shown chronic, severely inflamed skin with evidence of Bowen’s disease. The patient was referred to our plastic surgery oncology clinic (Fig. 1). A detailed history was taken, which revealed the mustard gas tests. He had no past history or family history of skin malignancies. Examination showed an irregularly shaped pigmented lesion measuring 15 mm in diameter × 3 mm in height. Systemic examination demonstrated no palpable peripheral lymphadenopathy and no other skin malignancies. He underwent excision of the lesion under local anaesthesia with a 10-mm clearance margin. The defect required a full-thickness skin graft. Histological assessment of the lesion demonstrated a welldifferentiated, squamous cell carcinoma, measuring 3.5 mm in width × 2.2 mm in depth. The overlying epidermis was hyperplastic, with a hyperkeratotic surface, but demonstrated no evidence of dysplasia in the epidermal keratinocytes, a possible result of previous topical treatments. Vascular invasion was not identified and excision margins were clear (Fig. 2). The patient recalled that the process of mustard gas testing involved the application of a spoonful of mustard gas paste onto the back of the hand, followed by a 30-min period of observation, after which the soldiers were permitted to wash their hands. This test was conducted on 30 soldiers from his regiment. He and the rest of the subjects, at the time, were not aware of the reasons for the test.

Autosomal dominant epidermodysplasia verruciformis: A clinicotherapeutic experience in two cases

Epidermodysplasia verruciformis (EV) is a rare genodermatosis characterized by a unique susceptibility to cutaneous infection by a group of phylogenetically related human papilloma viruses (HPVs). These patients show a defect in cell-mediated immunity specific toward the causative HPVs that lead to lifelong disease. The defect is usually inherited as autosomal recessive trait and presents clinically with plane warts, pityriasis versicolor-like lesions and reddish verrucous plaques. Dysplastic and malignant changes in the form of actinic keratoses, Bowen's disease and squamous cell carcinoma (SCC) are common but metastasis occurs rarely. A totally effective treatment against EV is as yet highly desirable. Two siblings having autosomal dominant EV presented with multiple actinic keratoses in addition to classic lesions. One of them had also developed well-differentiated SCC over forehead with metastases to regional lymph nodes. They were treated with combination of excision of small malignant/premalignant lesions, topical 5-flurouracil and sun protection. Additionally, elective excision/grafting of large SCC was performed after chemotherapy/radiotherapy in patient with metastatic SCC. Oral acitretin (25 mg/day) was of benefit in the other patient. Overall clinicotherapeutic experience in both the patients is discussed here.

Treatment of periungual vitiligo with Erbium‐YAG‐laser plus 5‐flurouracil: a left to right comparative study

Despite the multiple treatment modalities available for vitiligo, none of them gives satisfactory results in the periungual type. In this study we tried to explore and evaluate the effects of the combination treatment of erbium:YAG laser resurfacing and topical 5-flurouracil in periungual vitiligo. Nine adult patients presenting with periungual vitiligo lesions were included in this prospective left-right comparative study. The desirable inflammation was achieved after a mean of 4.7 days of 5-flurouracil application. The mean re-epithelization time in the treatment sessions was 11.3 days. The patients received a mean of 3.4 sessions in a mean duration of 7.6 months. The mean overall response to therapy in the treated group was 47.8% while in the control group it was 1.1% (P < 0.0001). No side effects necessitated the stoppage of treatment. This study points to the efficacy and safety of this combination in the treatment of periungual vitiligo.

High Frequency 40-MHz Ultrasound A Possible Noninvasive Method for the Assessment of the Boundary of Basal Cell Carcinomas

Ultrasound imaging systems operating close to 20 MHz in frequency have been used to image skin tumors. Ultrasound imaging at 20 MHz has been used to determine the boundaries of basal cell carcinomas (BCCs). An inherent shortcoming of imaging systems operating at these frequencies is their limited resolution. We investigated whether 40-MHz ultrasound imaging could provide higher resolution compared with the lower frequency systems and thus be a superior, noninvasive method of assessing the boundaries of BCCs. Nine BCCs from six individuals were examined clinically and ultrasonographically, and then biopsied to confirm diagnosis. The depth of BCCs measured on histological sections was compared with the corresponding value obtained using ultrasound. For this study we required a nonsurgical, nondestructive means of treating BCCs that would allow repeated ultrasound imaging, and therefore topical 5-flurouracil (5-FU) was chosen. Following 5-FU therapy a biopsy was obtained from the site of the treated BCC after ultrasound imaging had been performed. Clinical, ultrasonic and histopathologic evaluation of each BCC was carried out independently by different individuals. At the end of the study all the BCC sites were treated surgically be electrodesiccation and curettage or completely excised. High resolution ultrasound images of BCCs were obtained with agreement between histology and ultrasound findings in all none lesions prior to therapy and in eight of none lesions posttherapy. There was a significant correlation between the depth of BCCs measured histologically and using ultrasound (P = 0.0004, r = 0.92). This study suggests that 40-MHz ultrasound may provide an estimate of the boundary of a BCC in vivo. High frequency 40-MHz ultrasound imaging may be an adjunct to clinical and histologic evaluation but does not replace the need to obtain tissue for microscopic examination.