Treatments for Common Birthmarks, Dysplastic Nevi and Congenital Nevi

A birthmark is a colored mark on or under the skin that’s present at birth or develops shortly after birth.Some birthmarks fade with time; others become more pronounced. Birthmarks may be caused by extra pigment in the skin or by blood vessels that do not grow normally. Most birthmarks are painless and harmless. In rare cases, they can cause complications or are associated with other conditions. All birthmarks should be checked by a doctor.

See  the slideshow here:   http://www.medicinenet.com/birthmarks_pictures_slideshow/article.htm

Former Soviet President Mikhail Gorbachev has a port wine stain.

Salmon Patches

Salmon patches are nests of blood vessels that appear as small, pink, flat marks on the skin. They occur in 1/3 of newborn babies. Salmon patches can appear on the back of the neck (“stork bite”), between the eyes (“angel’s kiss”), or on the forehead, nose, upper lip, or eyelids. Some fade as baby grows, but patches on the back of the neck usually don’t go away. Salmon patches require no treatment.

Port Wine Stains

A port wine stain begins as a flat, pinkish-red mark at birth and gradually becomes darker and reddish-purple with age. Most will get bigger and thicker, too. Port wine stains are caused by dilated blood capillaries. Those on the eyelid may increase the risk of glaucoma. Port wine stains may be a sign of other disorders, but usually not. Treatment includes laser therapy, skin grafts, and masking makeup.

Mongolian Spots

Mongolian spots are flat, smooth marks that are present from birth. Frequently found on the buttocks or lower back, they’re typically blue, but can also be bluish gray, bluish black, or brown. They may resemble a bruise. Mongolian spots are most common on darker-skinned babies. They usually fade by school age, but may never disappear entirely. No treatment is required.

Cafe-Au-Lait Spots

Cafe-au-lait spots are smooth and oval and range in color from light to medium brown, which is how they got their name, “coffee with milk” in French. They’re typically found on the torso, buttocks, and legs. Cafe-au-lait spots may get bigger and darker with age, but are generally not considered a problem. However, having several spots larger than a quarter is linked with neurofibromatosis and the rare McCune-Albright syndrome. Consult a doctor if your child has several spots.

Strawberry Hemangiomas

Hemangiomas are a collection of small, closely packed blood vessels. Strawberry hemangiomas occur on the surface of the skin, usually on the face, scalp, back, or chest. They may be red or purple; they can be flat or slightly raised, with sharp borders. Strawberry hemangiomas usually develop a few weeks after birth. They grow rapidly through the first year before subsiding around age 9. Some slight discoloration or puckering of the skin may remain at the site. No treatment is required, but when desired, medicines and laser therapy are effective.

Cavernous Hemangiomas

Present at birth, deeper cavernous hemangiomas are just under the skin and appear as a bluish spongy mass of tissue filled with blood. If they’re deep enough, the overlying skin may look normal. Cavernous hemangiomas typically appear on the head or neck. Most disappear by puberty. A combination of cavernous and strawberry hemangioma can occur.

Venous Malformation

Venous malformations are caused by abnormally formed, dilated veins. Although present at birth, they may not become apparent until later in childhood or adulthood. Venous malformations appear in 1% to 4% of babies. They are often found on the jaw, cheek, tongue, and lips. They may also appear on the limbs, trunk and internal organs, including the brain. They will continue to grow slowly, and they don’t shrink with time. Treatment — often sclerotherapy or surgery — may be necessary for pain or impaired function.

Pigmented Nevi (Moles)

Moles occur when cells in the skin grow in a cluster instead of being spread throughout the skin. They can appear anywhere on the body, alone or in groups. Moles are usually flesh-colored, brown, or black. Moles may darken with sun exposure and during pregnancy. They tend to lose color during adulthood and may disappear in old age. Most moles are not cause for alarm. However, moles may have a slightly increased risk of becoming skin cancer. Moles should be checked by a doctor if:

* They change size or shape
* They look diffrent from other moles
* They appear after age 20

Actress Eva Mendes sports a “beauty mark” on her check.

Congenital Nevi

Congenital nevi are moles that appear at birth. The skin texture may range from normal to raised, or nodular to irregular. Congenital
nevi can grow anywhere on the body and vary in size –from a small 1-inch mark to a giant birthmark covering half of the body or more. Small congenital nevi occur in 1% of newborns. Most moles are not dangerous. But congenital nevi, especially large ones, should always be evaluated by a doctor since they may have an increased risk of becoming skin cancer.

Dysplastic Nevi (Atypical Moles)

Atypical moles are generally larger (one-quarter inch across or more) than ordinary moles and have irregular and indistinct borders. They may resemble cancerous moles. They may have a mix of colors including pink, red, tan and brown.These moles tend to be hereditary. Atypical moles have an increased chance of developing into melanoma skin cancer. Have a doctor evaluate all moles that look unusual, grow larger, or change in any way.

Squamous Cell Carcinoma Treatments

Most squamous cell carcinomas may be treated by one of the following methods. More healthy tissue around the lesion is removed
than for basal cell carcinomas because of the potential of squamous cell carcinomas to spread. Nearby lymph nodes are also examined
carefully. The choice of treatment is influenced by:

* size, location, grade, and type of tumour
* whether the tumour is primary or is recurring
* person’s age and health
* people with organ transplants are at a high risk of aggressive squamous cell carcinoma, which is considered in their treatment plan
* availability of the treatment

Surgery (Wide Excision)

# used for:
- most small lesions that are less than 2 cm
- superficial or SCC that has not spread
- verrucous carcinomas (slow growing and less aggressive)
- tumours that have previously been treated with radiation therapy
- lesions on the eyelid, forehead, scalp, lip, penis, vulva and anus

Mohs Micrographic Surgery

* used for all types of squamous cell cancer
* commonly used for:
- areas that are at high risk of recurrence (eyelids, nose, ears, forehead, scalp), as well as areas that have - already recurred
- areas where it is important to keep function and appearance
- lesions that are larger than 2 cm, and lesions with poorly defined borders
- aggressive tumours, and invasive lesions that have spread to nerves, cartilage or bone
- tumours that have been left untreated for a long time
- lesions that had not been completely removed with prior surgery it involves a meticulous study of tissues removed by a  pathologist at the time of surgery

Radiation Therapy

* used after surgery for:
- elderly individuals
- ensuring cancer free margins
- treatment of involved lymph nodes
- squamous cell carcinoma that has recurred after surgery
- to relieve or control the symptoms of very large tumours
- for people who are unwilling or unable to undergo surgery
- tumours on the eyelid, cheek, earlobe and nose not used for verrucous carcinomas (slow growing and less aggressive)

Chemotherapy

* systemic chemotherapy is used for squamous cell cancer that has spread to other parts of the body
* drugs used most often in chemotherapy:
- cisplatin
- doxorubicin
- bleomycin

Curettage And Electrodesiccation (C & E)

used for
- small areas that are less than 2 cm
- lesions that haven’t spread
- squamous cell carcinoma with distinct margins in Actinic Keratosis should not be used for:

- larger lesions that are greater than 2 cm
- recurrent tumours
- aggressive squamous cell carcinoma
- lesions with poorly defined borders
- hairy areas like the underarms, scalp, and the pubic area
- areas where it is important to keep function and appearance uncommonly used

Treatment of Anogenital Warts

Safety, Efficacy & Recurrence Rates of Imiquimod Cream 5% for Treatment of Anogenital Warts

Imiquimod 5% cream (Aldara™, Graceway Pharmaceuticals) is an immune response modifier used for the topical treatment of anogenital warts in non-HIV-infected patients. Several randomized controlled trials have demonstrated that imiquimod 5% cream is a safe and efficacious treatment. Current data regarding efficacy shows that complete clearance of warts occurred in up to 50% of patients treated with imiquimod 5% cream applied once-daily, 3 times per week for up to 16 weeks. Recurrence rates ranged from up to 19% at 3 months to 23% at 6 months. Imiquimod 5% cream showed an acceptable safety profile; local inflammatory reactions were the most frequent adverse effects, with local erythema being the most common.

Imiquimod is an immune response modifier that was approved by the US FDA in 1997 for the topical treatment of anogenital warts in individuals 12 years old and older. An estimated 30%-50% of sexually active adults in the US are infected with human papillomavirus (HPV), and approximately 1%-2% of this same population have clinically evident genital warts.¹ This review will focus on studies that evaluate the safety, efficacy, and recurrence rates of imiquimod 5% cream in the treatment of anogenital warts in non-HIV-infected men and women. Local inflammatory reactions were the most frequent adverse effects, with local erythema being the most common. Overall, imiquimod 5% cream is a safe and efficacious treatment for anogenital warts.

Using Imiquimod

Imiquimod cream is supplied in individual packets. Each gram of the 5% cream contains 50mg of imiquimod in an off-white oil-in-water vanishing cream base.² The US Center for Disease Control recommends that imiquimod 5% cream be applied once daily at bedtime, 3 times per week for up to 16 weeks. The product should be washed off with mild soap and water 6-10 hours following application.^2-4 Many considerations exist when using imiquimod. Some of these are listed in Box 1. The US FDA provides a full list of considerations.³

Mechanism of Action

Imiquimod is a Toll-like receptor agonist that induces the production of local cytokines from predominantly T helper (Th) 1-type cells, thus stimulating both acquired and cellular immunity, which is important for fighting virus-infected and tumor cells.^5-7 Cytokines such as interferon (INF)-á, tumor necrosis factor (TNF)-á, interleukin (IL)-1, -6, -8, -10, and -12 stimulate tissue-specific apoptosis of virus-infected keratinocytes, thus leading to a viral load reduction of HPV types 6 and 11 with subsequent wart regression and normalization of keratinocyte proliferation.^5,6,8 Regression of warts after treatment with imiquimod is strongly associated with evidence of tissue production of INF-á, -â, and -ã and TNF-á as well as a decrease in the presence of HPV DNA and in the expression of mRNA for both early and late viral proteins.⁹

Points to consider when using imiquimod:

It is common for patients to experience local skin reactions and treatment can be resumed after the skin reaction has subsided. Sexual (genital, anal, oral) contact should be avoided while the cream is on the skin. Imiquimod may weaken condoms and vaginal diaphragms, therefore concurrent use is not recommended. Imiquimod is pregnancy category C and it is not known whether topically applied imiquimod is excreted in breast milk. New warts may develop during therapy, as imiquimod is not considered a cure.

Box 1: Information for patients being treated for external genital warts3

Safety

In all the randomized controlled trials (RCTs) examined, topical imiquimod 5% cream showed an acceptable safety profile. Local skin reactions are associated with a local inflammatory reaction including itching, erythema, burning, irritation, tenderness, ulceration, erosion, and pain.¹⁰ In several studies, local erythema was the most common reaction.^11-13 There were no differences in adverse systemic reactions or flu-like symptoms among treatment groups.^10,12,13 The optimal dosing regimen is 3 times per week. With more frequent applications (up to 3 times daily), wart clearance does not improve significantly and is associated with an increase in local adverse events, such as erythema, vesicle formation, ulceration, and excoriation.¹⁴ Imiquimod 5% cream is effective for up to 16 weeks of treatment for external anogenital warts and is well-tolerated for up to 32 weeks.¹¹ Imiquimod is contraindicated in individuals with a history of sensitivity reactions to any of its components and should be discontinued if hypersensitivity to any of its ingredients is noted. Overall, patient-applied imiquimod 5% cream is an effective treatment for external genital warts and has a favorable safety profile.

Efficacy and Recurrence

Several randomized controlled trials demonstrated that imiquimod 5% cream is an efficacious treatment for external anogenital warts when applied 3 times per week for up to 16 weeks. Complete clearance of warts occurred in up to 50% of patients treated with imiquimod 5% cream applied 3 times daily. At the end of 16 weeks, recurrence rates ranged from up to 19% after 3 months and 23% after 6 months.11 See Table 1 for comparisons. The recurrence rates of external genital warts were found to be similar at both 3- and 6-month follow-up, suggesting that after 3 months, the risk of developing recurrence is low.¹⁵

The studies that follow were chosen to evaluate imiquimod 5% cream for the treatment of anogenital warts because of sufficient data on efficacy, recurrence rates, and safety.^10-13 Studies that did not include this data were excluded. Several other studies focused on the treatment of anogenital or vulvar warts in the female population; however, the efficacy rates are generally higher for this population, ranging from 71%-77%.^12,16-18 To maintain continuity, this review focuses on comparing studies that include treatment of anogenital warts with imiquimod 5% cream in non-HIV-infected men and women.

Detailed Findings of This Study Can be Found Indexed by the US National Library of Medicine and PubMed

Monotherapy Compared with Combination Therapy: Imiquimod + Surgery

Carrasco et al.¹⁹ showed that treatment with imiquimod 5% cream followed by excision of remaining warts resulted in a lower recurrence rate compared with surgery alone. This strategy represents a viable option for those with residual lesions and may provide long-term clearance of anogenital warts in patients for whom imiquimod monotherapy is insufficient.¹⁹

Conclusion

Patient-applied imiquimod 5% cream is a first-line topical treatment for anogenital warts that is both safe and efficacious, and yields complete and partial responses in the majority of patients. Various studies demonstrate complete clearance rates of up to 50% and partial responses manifest as a 50%-90% reduction in baseline wart area.^12-14 Recurrence rates range up to 19% at 3 months and 23% at 6 months. More studies are needed to compare the efficacy of combination therapies vs. monotherapy vs. other treatment modalities. Longer follow-up is also needed to evaluate recurrence rates after monotherapy, as well as in combination with other treatments for anogenital warts.

M.L. Diamantis, BS¹; B.L. Bartlett, MD²; S.K. Tyring, MD, PhD³

1. The University of Texas Medical School at Houston, Houston, TX
2. Center for Clinical Studies, Houston, TX
3. The University of Texas Health Science Center at Houston and Center for Clinical Studies, Houston, TX

Staph Wound Infections and Staphylococcus aureus

Staph Wound Infections and Methicillin Resistant Staphylococcus aureus

Staphylococcus aureus, also called S. aureus or “staph,” is a bacterium that frequently colonizes the human skin and is present in the nose of about 25-30% of U.S. adults. S. aureus can exist in this form without harming its host or causing symptoms. However, if there is a break in the patient’s skin from a wound or surgery, or if there is a depression in the person’s immune system, then colonizing S. aureus can cause an infection. Staph frequently causes localized skin infections, such as folliculitis, furuncles, and impetigo. It can also cause abscesses and spread into the bones (osteomyelitis), lungs (staphylococcal pneumonia), blood (bacteremia or sepsis), heart (endocarditis – which can damage the heart valves), and other organs. Staph may also infect others as it can be passed from both infected and colonized people to other people through skin contact or through sharing contaminated objects, such as towels or razors.

Hospital-acquired infections
Staph infections acquired while a patient is in a hospital, long-term care facility, or other health care setting have been a challenge for many years. The confined population and the widespread use of antibiotics have led to the development of antibiotic-resistant strains of S. aureus. These strains are called methicillin resistant staphylococcus aureus (MRSA), named after the antibiotic treatment that was developed in 1960 to treat penicillin-resistant strains. Infections caused by MRSA are frequently resistant to a wide variety of antibiotics and are associated with ignificantly higher rates of morbidity and mortality, higher health care costs, and longer hospital stays than infections caused by methicillin susceptible S. aureus. Risk factors for MRSA infection in the hospital include surgery, prior antibiotic therapy, admission to intensive care, exposure to a MRSA-colonized patient or health care worker, being in the hospital more than 48 hours, and having an indwelling catheter or other medical device that goes through the skin.

One strategy that may be used in an effort to control the spread of infection includes active surveillance for the detection of MRSA in patients admitted to intensive care units (ICUs) and other high risk areas. Another approach is to screen all patients admitted to a health care facility. Community-acquired infections
MRSA infections have increased in importance in the community in recent years because they have been associated with a growing number of outbreaks and deaths in non-medical settings where individuals are in close contact such as prisons, day care facilities, military units, and contact sports. These infections are occurring in people who do not have classic MRSA risk factors as described above. A significant number of those affected have had to be hospitalized for what appears to be a simple but persistent skin infection or for pneumonia that develops after a bout of influenza.

Until recently, part of the problem with community-acquired MRSA (CA-MRSA) has been a lack of awareness in the medical community and the community at large. Historically, physicians have treated staph infections, based on their severity, with either over-the-counter triple-antibiotic ointments or with a standard course of antibiotics. They did not routinely order cultures to identify the organism and its antibiotic susceptibility profile unless the infection appeared extensive or the initial treatment was unsuccessful. With CA-MRSA, however, these conventional therapy options have frequently failed. A significant number of those affected have been hospitalized and a few previously healthy patients have died.

Investigations of these outbreaks have revealed that the CA-MRSA was spread from infected or colonized patients to those around them through skin contact (such as sports-related cuts and abrasions), through droplets from the respiratory tract, or through exposure to contaminated objects, such as shared sports equipment, towels, toys, or playground equipment. Investigations have also revealed that the S. aureus strains involved in CA-MRSA are genetically distinct from those that have been causing hospital-acquired MRSA. The CA-MRSA are resistant to methicillin and related antibiotics (oxacillin, dicloxacillin, nafcillin) and erythromycin but remain susceptible to many other antibiotics.

Laboratory Tests

The purpose of culturing wound infections is to identify the bacteria causing the infection and to determine the susceptibility of the microorganism to available antibiotics. If an infection is due to MRSA, it should be investigated to determine the source of the infection. This is especially important in CA-MRSA to prevent further cases from occurring.

The primary laboratory tests performed are:

* Cultures of the affected areas. Fluid or pus from a wound, sputum, blood, joint fluid, or even breast milk (in the case of an infected breast) is collected and spread onto a thin layer of nutrient gel and/or grown in a nutrient broth. Sometimes, multiple samples are collected to evaluate different body sites or to attempt to detect bacteria that may be present in small numbers.
* Nasal cultures (collected by inserting a swab inside the nose) used to screen healthy people may also be ordered to determine whether someone has been colonized with MRSA and is a carrier. The cultured samples are incubated and examined for the growth of characteristic S. aureus colonies. If they are present, susceptibility testing is performed to determine whether the strain is MRSA.
* Nasal swabs may be collected to detect MRSA colonization based on rapid molecular tests, which do not grow the bacteria but detect their presence and antibiotic resistance by detecting the genes responsible for the methicillin resistance.

Identifying MRSA can sometimes be challenging. The population of staph that a person has tends to be mixed. This means that even if a patient has CA-MRSA or hospital-acquired MRSA, not all of the staph present will be equally resistant. Since resistant strains may grow more slowly than susceptible strains, there is the potential for missing them.

A variety of methods may be used to track different strains of MRSA. These are used in the investigation of the spread of MRSA within a community or region but are not used in the treatment of an individual patient.

What is a skin tag?

A skin tag is a common, acquired benign skin growth that looks like a small piece of hanging skin. Skin tags are often described as bits of skin- or flesh-colored tissue that projects from the surrounding skin from a small, narrow stalk. They typically occur in characteristic locations including the neck, underarms, eyelids, and under the breasts (especially where underwire bras rub directly beneath the breasts). Although skin tags may vary somewhat in appearance, they are usually smooth or slightly wrinkled and irregular, flesh-colored or slightly more brown, and hang from the skin by a small stalk. Early or beginning skin tags may be as small as a flattened pinpoint-sized bump around the neck. Some skin tags may be as large as a big grape.

Where do skin tags occur?

Skin tags can occur almost anywhere there is skin. However, favorite areas for tags are the eyelids, neck, armpits, upper chest (particularly under the female breasts), and groin folds. Tags are typically thought to occur in characteristic locations where skin rubs against skin or clothing.

Who tends to get skin tags?

Nearly half of the population is reported to have skin tags at some time. Although tags are generally acquired (not present at birth) and may occur in anyone, more often they arise in adulthood. They are much more common in middle age and they tend to increase in prevalence up to age 60. Children and toddlers may also develop skin tags in the underarm and neck areas. Since they are thought to arise more readily in areas of skin friction or rubbing, tags are also more common in overweight people.

Picture of skin tags

Hormone elevations, such as those seen during pregnancy, may cause an increase in the formation of skin tags, as skin tags are more frequent in pregnant women. Tags may be easily removed during or after pregnancy.

Skin tags are a benign condition and not directly associated with any other major medical conditions, since tags are commonly found on healthy people.

Is a skin tag a tumor?

Skin tags are a type of growth or tumor, albeit a completely benign and harmless one. Tags are not cancerous (malignant) and not found to have potential to become cancerous if left untreated.

What does a skin tag look like under a microscope?

The outer layer of the skin (the epidermis) shows overgrowth (hyperplasia), and it encloses an underlying layer of skin (the dermis) in which the normally-present collagen fibers appear abnormally loose and swollen. Usually there are no hairs, moles, or other skin structures present in skin tags.

What problems do skin tags cause?

These tiny skin growths generally cause no symptoms unless they are repeatedly irritated as, for example, by the collar or in the groin. Cosmetic removal for unsightly appearance is perhaps the most common reason they are removed. Occasionally, a tag may require removal because it has become irritated and red from bleeding (hemorrhage) or black from twisting and dying of the skin tissue (necrosis). Sometimes they may become snagged by clothing, jewelry, pets, or seatbelts, causing pain or discomfort. Overall these are very benign growths that have no cancer (malignant) potential.

Occasionally a tag may spontaneously fall off without any pain or discomfort. This may occur after the tag has twisted on itself at the stalk base, interrupting the blood flow to the tag.