1,135 results match your criteria Lentigo Maligna Melanoma
J Surg Oncol 2018 Jun 24. Epub 2018 Jun 24.
Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
Background: No consensus exists regarding the best surgical strategy to achieve clear surgical margins while minimizing tissue excision when definitely excising lentigo maligna melanoma in situ (LM). The staged margin controlled excision (SMEX) technique is a modification of the spaghetti technique that allows surgeons to minimize margins and ensure complete excision of LM.
Objectives: Our objectives were twofold: a) to evaluate the effectiveness of SMEX for treatment of LM and b) detail the SMEX technique. Read More
Am J Dermatopathol 2018 Jun 15. Epub 2018 Jun 15.
Department of Anatomic Pathology, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy.
Background: Equivocal pigmented lesions of the head are usually biopsied to avoid inappropriate treatment. Clinical approach has evolved from simple visual examination to sophisticated techniques for selecting the biopsy sites.
Objective: This study aimed to retrospectively evaluate the efficiency of dermoscopy (DE) and reflectance confocal microscopy (RCM) in sampling a histopathologically representative focus of lentigo maligna/lentigo maligna melanoma. Read More
Dermatol Surg 2018 Jun 21. Epub 2018 Jun 21.
ENT Department, University Clinic Ulm, Ulm, Germany.
Australas J Dermatol 2018 Jun 22. Epub 2018 Jun 22.
South Perth Specialist Skin Cancer Centre, Perth, Western Australia, Australia.
Background/objectives: There is a paucity of Australian data on the use of Mohs micrographic surgery for treating melanoma in situ and lentigo maligna. We share an Australian centre's experience with the technique.
Methods: A total of 62 patients with 62 lesions of melanoma in situ and lentigo maligna referred for treatment between 2015 and 2017 comprised the study group. Read More
An Bras Dermatol 2018 Jun;93(3):373-376
Department of Pathology, Universidade Estadual Paulista, Botucatu, SP, Brazil.
Background: The incidence of melanoma has been increasing in Brazil and all over the world. Despite improvements in diagnosis and treatment, mortality remains unchanged.
Objective: To associate clinical and histopathological aspects with the evolution of 136 cases of cutaneous melanoma. Read More
Dermatology 2018 Jun 12:1-6. Epub 2018 Jun 12.
Centro de Dermatologia Epidermis, Instituto CUF, Porto, Portugal.
Introduction: Lentigo maligna (LM) is a rare form of in situ melanoma, frequently seen as a large patch in elderly patients. The aim of this study was to assess clinical and dermoscopic features of LM.
Material And Methods: A retrospective study of LM patients presenting to our center between July 2007 and July 2017 was performed. Read More
Acta Dermatovenerol Croat 2018 Apr;26(1):64-67
Elena-Daniela Serban, MD, Department of Medical Oncology, University of Bologna, 40138 Bologna; Italy.
Worldwide melanoma incidence and mortality are increasing (1). Despite the ongoing research, advanced melanoma is still incurable; therefore, the most appropriate solution seems to be early detection combined with complete surgical excision (2). Since the diagnostic protocol of suspicious lesions includes a complete excision with safety margins (2), the problem of unnecessary scarring is significant. Read More
Curr Dermatol Rep 2018 25;7(2):105-118. Epub 2018 Apr 25.
6Medical Screening Unit, Sheba Medical Center, Ramat Gan 5262000, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Purpose Of Review: Reflectance confocal microscopy (RCM) enables imaging of skin lesions at cellular level resolution at the bedside (in vivo) or in freshly excised tissue (ex vivo). This article provides an overview of strengths and limitations of non-invasive RCM in skin cancer diagnosis.
Recent Findings: RCM features of common melanocytic and non-melanocytic skin neoplasms such as melanoma, actinic keratosis/squamous cell carcinoma, basal cell carcinoma, and nevi have been well defined and show good correlation with dermoscopic and histopathologic findings. Read More
J Neuropathol Exp Neurol 2018 Jul;77(7):549-554
Department of Neurosurgery at Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Tumor-to-tumor metastasis is an uncommon phenomenon, and a metastasis from an extracranial donor tumor to an intracranial recipient tumor is extremely rare. In particular, there are only 14 cases reported in the literature that describe a tumor-to-tumor metastasis involving a glioma. We present a rare case of an 83-year-old man with an 11-year history of lentigo maligna melanoma who presented with impaired balance and cognitive slowing and was found to have rapid progression of a previously known indolent right frontal brain mass. Read More
J Eur Acad Dermatol Venereol 2018 Apr 28. Epub 2018 Apr 28.
Medical Screening Institute, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
Background: Lentigo maligna may be challenging to clear surgically.
Objective: To evaluate feasibility of using superficial skin cuts as RCM imaging anchors for attaining negative surgical margins in lentigo maligna.
Methods: Included patients presented with lentigo maligna near cosmetically sensitive facial structures. Read More
J Cutan Pathol 2018 Jul 16;45(7):553-555. Epub 2018 May 16.
Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, New Jersey.
G Ital Dermatol Venereol 2018 Apr 19. Epub 2018 Apr 19.
Institute of Dermatology, Catholic University of Rome, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.
Lentigo maligna (LM) is an in situ subtype of melanoma, clinically presenting as a pigmented, asymmetric macule that originates mostly on the head and neck and spreads slowly. The diagnosis may be challenging both for clinicians and pathologists. Dermatoscopy and reflectance confocal microscopy represent a useful tool in the differentiation of LM from other pigmented lesions, such as pigmented actinic keratosis, solar lentigines, seborrheic keratosis and lichen planus-like keratosis. Read More
Eur J Dermatol 2018 Apr;28(2):162-168
Institute of Dermatology, Catholic University of Rome, Rome, Italy.
The clinical and dermoscopic diagnosis of facial lentigo maligna (LM) and pigmented actinic keratosis (PAK) remains challenging, particularly at the early disease stages. To identify dermoscopic criteria that might be useful to differentiate LM from PAK, and to elaborate and validate an automated diagnostic algorithm for facial LM/PAK. We performed a retrospective multicentre study to evaluate dermoscopic images of histologically-proven LM and PAK, and assess previously described dermoscopic criteria. Read More
Dermatol Surg 2018 Mar 13. Epub 2018 Mar 13.
Division of Dermatology, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.
Background: Lentigo maligna is an in situ form of cutaneous melanoma that commonly arises on the head and neck. Various surgical and nonsurgical treatment options are available but no randomized trials exist to guide practice.
Objective: To determine the current treatment practices for lentigo maligna of the head and neck in Ontario, Canada. Read More
J Dermatol 2018 May 11;45(5):564-570. Epub 2018 Feb 11.
Department of Dermatology, Hospital Universitari Arnau de Vilanova, University of Lleida, IRBLleida, Spain.
The incidence of lentigo maligna (LM), in situ (LM) or invasive (lentigo maligna melanoma, LMM), has increased during the last decades. Due to functional or cosmetic outcomes, optimal treatment with surgical excision may not be appropriate in some cases. We tried less invasive therapy, immunocryosurgery, as a single treatment for LM or combined with surgery for LMM, with better aesthetic results. Read More
J Eur Acad Dermatol Venereol 2018 Feb 8. Epub 2018 Feb 8.
Department of Dermatology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
Background: Lentigo maligna (LM), a form of melanoma in situ, is treated to prevent progression to lentigo maligna melanoma (LMM). Surgical treatment is the gold standard. However, treatment guidelines are based on expert opinion, and comparative studies are lacking. Read More
Skin Res Technol 2018 May 31;24(2):313-317. Epub 2018 Jan 31.
Division of Dermatology - Department of Medical, Surgical and Neuro Sciences, University of Siena, Siena, Italy.
Background: Though the combination/collision of nevi or lentigo simplex and hemangiomas is frequent, the malignant collision tumor melanoma-hemangioma is exceptional and can sometime clinically simulate a benign collision. To date, a series of collision tumors of hemangiomas associated with either benign or malignant melanocytic skin lesions (MSL) has yet to be studied by non-invasive imaging and clinico-pathologic correlates.
Methods: We present 10 cases of patients with collision tumors of hemangioma with different MSL including: 2 in situ lentigo-maligna melanoma, 1 invasive melanoma, 5 melanocytic nevi, and 2 lentigo simplex. Read More
J Eur Acad Dermatol Venereol 2018 Jan 17. Epub 2018 Jan 17.
Department of Dermatology, University Hospital of St-Etienne, Saint-Etienne, France.
Background: Several dermoscopic and in vivo reflectance confocal microscopy (RCM) diagnostic criteria of lentigo maligna (LM)/lentigo maligna melanoma (LMM) have been identified. However, no study compared the diagnostic accuracy of these techniques.
Objective: We evaluated the diagnostic accuracy of dermoscopy and RCM for LM/LMM using a holistic assessment of the images. Read More
Exp Dermatol 2018 Mar;27(3):227-232
Dermatology Department, University of Modena and Reggio Emilia, Modena, Italy.
Pigmented facial macules are common on sun damage skin. The diagnosis of early stage lentigo maligna (LM) and lentigo maligna melanoma (LMM) is challenging. Reflectance confocal microscopy (RCM) has been proven to increase diagnostic accuracy of facial lesions. Read More
Rom J Morphol Embryol 2017 ;58(3):717-721
Department of Pathophysiology, "Carol Davila" University of Medicine and Pharmacy, "Prof. Dr. Matei Bals" National Institute of Infectious Diseases, Bucharest, Romania;
Mechanisms involved in melanoma invasiveness and metastasis are essential to understanding the behavior of this aggressive melanocytic skin cancer. The epithelial-mesenchymal transition (EMT) is considered fundamental for overcoming the in situ stage of melanoma and its proliferation beyond the basal membrane. Matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) are key molecules involved in EMT about whose expression in lentigo maligna (LM) and lentigo maligna melanoma (LMM) little has been studied so far. Read More
Otol Neurotol 2018 Feb;39(2):e137-e142
Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
Objective: Malignant melanoma accounts for nearly 75% of all skin cancer deaths, and the incidence is on the rise in the United States. External ear melanoma (EEM) is rare, and there is little long-term data regarding the clinical behavior of this melanoma site. This study analyzes the demographic, clinicopathologic, and survival characteristics of EEM. Read More
Pigment Cell Melanoma Res 2018 Mar 10;31(2):337-340. Epub 2017 Dec 10.
Dermatology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
GATA2 deficiency is a recently described genetic disorder affecting hematopoietic stem cells and is associated with immunodeficiency, hematologic malignancy, and various cutaneous pathologies including cutaneous tumors. To explore the incidence and clinical course of melanoma in patients with germline GATA2 deficiencies, we conducted a retrospective chart review of 71 such patients and identified two with invasive melanoma. One melanoma was diagnosed early because it was associated with pruritus due to a graft-versus-tumor effect following bone marrow transplantation. Read More
Sci Rep 2017 Nov 16;7(1):15750. Epub 2017 Nov 16.
Experimental Dermatology Group, Institute of Medical Biology, A*STAR, 8- Biomedical Grove, Singapore, Singapore.
A strategy combining covalent conjugation of photosensitizers to a peptide ligand directed to the melanocortin 1 (MC1) receptor with the application of sequential LED light dosage at near-IR wavelengths was developed to achieve specific cytotoxicity to melanocytes and melanoma (MEL) with minimal collateral damage to surrounding cells such as keratinocytes (KER). The specific killing of melanotic cells by targeted photodynamic therapy (PDT) described in this study holds promise as a potentially effective adjuvant therapeutic method to control benign skin hyperpigmentation or superficial melanotic malignancy such as Lentigo Maligna Melanoma (LMM). Read More
Melanoma Res 2017 Dec;27(6):638-640
Department of Dermatology, St James' Hospital, Dublin, Republic of Ireland.
Prognosis has been shown to be worse for patients with multiple primary melanomas than those with a single melanoma. One recent retrospective study showed that older, white men were at higher risk of multiple primary melanomas. In our institution 2057 melanomas were diagnosed between January 1994 and March 2016. Read More
JAMA Dermatol 2017 Dec;153(12):1278-1284
Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
Importance: The management of lentigo maligna (LM) and LM melanoma (LMM) is challenging because of extensive subclinical spread and its occurrence on cosmetically sensitive areas. Reflectance confocal microscopy (RCM) improves diagnostic accuracy for LM and LMM and can be used to delineate their margins.
Objectives: To evaluate whether handheld RCM with radial video mosaicing (HRCM-RV) offers accurate presurgical assessment of LM and LMM margins. Read More
An Bras Dermatol 2017 Jul-Aug;92(4):565-567
Division of Dermatopathology in the Anatomical Pathology Service at Irmandade da Santa Casa de Misericórdia de São Paulo - São Paulo (SP), Brazil.
Lentigo maligna has an extensive and neoplastic character. It typically progresses slowly and may eventually develop into an invasive melanoma, which is called lentigo maligna melanoma. Ocular melanoma is the second most common type of melanoma. Read More
J Clin Investig Dermatol 2017 Feb 27;5(1). Epub 2017 Feb 27.
Department of Dermatology, Dermatologic and Mohs Micrographic Surgery Center, San Diego School of Medicine, University of California.
Background: Cutaneous melanoma is one of the fastest rising cancer diagnoses in recent years. Melanoma in situ (MIS) constitutes a large proportion of all diagnosed melanomas. While surgical excision is considered the standard of therapy, the literature is not clear on which surgical technique minimizes local recurrence. Read More
Dermatol Clin 2017 Oct 7;35(4):457-464. Epub 2017 Aug 7.
Department of Dermatology, Rutgers-Robert Wood Johnson Medical School, 1 Worlds Fair Drive, 2nd Floor, Suite 2400, Somerset, NJ 08873, USA.
Biopsy and histologic evaluation have been the gold standard to diagnose skin tumors. Reflectance confocal microcopy (RCM) is a noninvasive, innovative diagnostic technique that enables visualization of different skin layers at an almost histologic resolution. RCM has been proven beneficial in management of various cutaneous lesions. Read More
JAAD Case Rep 2017 Sep 12;3(5):379-383. Epub 2017 Aug 12.
Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy.
Open Access Maced J Med Sci 2017 Jul 19;5(4):458-461. Epub 2017 Jul 19.
Department of Anesthesiology & Intensive Care Medicine, Emergency Medicine & Pain Management, Hospital Dresden-Friedrichstadt, Academic Teaching Hospital of the Technical University of Dresden, Friedrichstrasse 41, 01067, Dresden, Germany.
Background: Lentigo malignant melanoma is a melanoma subtype of chronic sun-damaged skin in elderly Caucasians. Amelanotic variants of lentigo malignant are extremely rare.
Case Presentation: This is a case report of an 80-year-old male patient who presented with a non-pigmented exophytic tumour of his bald head. Read More
Lab Invest 2017 09 24;97(9):1063-1071. Epub 2017 Jul 24.
Department of Dermatology, Johns Hopkins University School of Medicine, Bloomberg Kimmel Institute for Cancer Immunotherapy, and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA.
PD-L1 expression in the tumor immune microenvironment is recognized as both a prognostic and predictive biomarker in patients with cutaneous melanoma, a finding closely related to its adaptive (IFN-γ-mediated) mechanism of expression. Approximately 35% of cutaneous melanomas express PD-L1, however, the expression patterns, levels, and prevalence in rarer melanoma subtypes are not well described. We performed immunohistochemistry for PD-L1 and CD8 on 200 formalin-fixed paraffin-embedded specimens from patients with acral (n=16), mucosal (n=36), uveal (n=103), and chronic sun-damaged (CSD) (n=45) melanomas (24 lentigo maligna, 13 'mixed' desmoplastic, and 8 'pure' desmoplastic melanomas). Read More
Acta Med Iran 2017 May;55(5):316-323
Department of Dermatopathology, Razi Dermatology Hospital, Tehran University of Medical Sciences, Tehran, Iran. AND Department of Pathology, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. AND Universal Scientific Education and Research Network (USERN), Tehran, Iran.
Cutaneous malignant melanoma (CMM) is currently the most fatal of skin cancers accounting for 50000 deaths annually. Five distinct melanomas are described histopathologically: superficial spreading, lentigo maligna, nodular, acral lentiginous and mucosal melanoma. The aim of this study was to investigate the characteristics of patients with various types of malignant melanoma and evaluate histopathological findings. Read More
Actas Dermosifiliogr 2017 Nov 11;108(9):844-851. Epub 2017 Jul 11.
Department of Dermatology, University Hospital Hassan II, Fez, Morocco.
The diagnosis of pigmented actinic keratosis (PAK) is often challenging because of overlapping features with lentigo maligna.
Objective: To investigate dermoscopic patterns of PAK according to their different evolutionary stages, and to correlate the pattern with clinical characteristics of the patients.
Methods: Descriptive and analytical study of 232 PAK. Read More
J Cutan Med Surg 2018 Jan/Feb;22(1):51-57. Epub 2017 Jul 7.
1 Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia, Canada.
Amelanotic lentigo maligna melanoma represents <2% of melanomas. Diagnosis is delayed owing to the lack of lesion pigmentation and advanced disease at presentation. Excision with appropriate margins is the treatment standard, but the starting point for such margins is often unclear. Read More
Cutis 2017 May;99(5):346-352
Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, New York, and Department of Dermatology, Weill Cornell Medical College, New York, USA.
Diagnosis and management of lentigo maligna (LM) and LM melanoma (LMM) is challenging. Novel noninvasive imaging technologies such as reflectance confocal microscopy (RCM) have advanced the ability to better diagnose and monitor challenging lesions. In addition, the new handheld RCM (HRCM) together with the use of videomosaics has allowed an accurate evaluation of large lesions in concave/convex areas of the body (eg, the face). Read More
Acta Med Litu 2017 ;24(1):25-34
Faculty of Medicine, Vilnius University.
Melanoma is the most dangerous form of skin cancer. Morbidity from melanoma is increasing every year. Previous studies have revealed that there are some demographic and clinical factors having effect on melanoma survival prognosis. Read More
J Drugs Dermatol 2017 May;16(5):508-511
The Food and Drug Administration approved Ruxolitinib in 2011 for the treatment of primary myelofibrosis. Five-year safety data showed a higher incidence of skin cancer in patients treated with Ruxolitinib compared to best available therapy for myelofibrosis. This report presents a series of five patients with history of myelofibrosis treated with Ruxolitinib who subsequently developed numerous skin cancers with aggressive biological behavior. Read More
JAMA Dermatol 2017 Aug;153(8):771-780
Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Univesitat Autònoma de Barcelona, Barcelona, Spain.
Importance: Pigmented facial macules on photodamaged skin are a clinical, dermoscopic, and histopathologic challenge.
Objectives: To clinically and dermoscopically characterize, by means of reflectance confocal microscopy (RCM), ambiguous pigmented facial macules and establish a correlation between RCM, histopathologic, and immunohistochemical findings.
Design, Setting, And Participants: A prospective study of ambiguous pigmented facial macules on photodamaged skin was conducted in a tertiary referral center for dermatology between January 1, 2009, and December 31, 2015. Read More
Lasers Surg Med 2017 Nov 29;49(9):819-826. Epub 2017 May 29.
Memorial Sloan Kettering Cancer Center, Dermatology Service, 16 E. 60th Street, 4th Floor Dermatology, New York, New York, 10022.
Introduction: Lentigo maligna (LM) is melanoma in situ on sun-damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes. Read More
Br J Dermatol 2017 05;176(5):1115-1116
Department of Dermatology, Pigmented Lesion and Melanoma Program, Stanford University Medical Center and Cancer Institute, 900 Blake Wilbur Drive, W3045, Stanford, CA, 94028, U.S.A.
Int J Surg Pathol 2017 Sep 24;25(6):497-501. Epub 2017 Apr 24.
2 Laboratory of Pathology, Division of Morphology, University of Crete, Heraklion, Greece.
Background: Protein kinase C βII promotes melanogenesis and affects proliferation of melanocytic cells but is frequently absent or decreased in melanoma cells in vitro.
Objective: To investigate PKC-βII expression and spatial distribution within a lesion in various benign and malignant melanocytic proliferations.
Methods: Expression of PKC-βII was semiquantitatively assessed in the various existing compartments (intraepidermal [not nested], junctional [nested], and dermal) of benign (n = 43) and malignant (n = 28) melanocytic lesions by immunohistochemistry. Read More
Int J Dermatol 2017 Sep 23;56(9):961-962. Epub 2017 Apr 23.
Department of Dermatology, Penn State Health Hershey Medical Center, Hershey, PA, USA.
Dermatol Surg 2017 Jul;43(7):911-919
*Department of Dermatology, Paracelsus Medical University of Salzburg, Salzburg, Austria; †Department of Dermatology, Medical University of Graz, Graz, Austria, Europe.
Background: Differentiation of melanotic macules from melanocytic lesions, most importantly of melanoma, is a common problem on clinical-dermoscopic examination.
Objective: To assess the value of noninvasive reflectance confocal microscopy (RCM) in the differential diagnosis of melanotic macules and melanocytic lesions.
Patients And Methods: Reflectance confocal microscopy images of 42 pigmented macules on mucocutaneous junctions of genitalia and lips, including 31 melanotic macules, 6 nevi, and 5 melanomas, were retrospectively and independently assessed in a blinded manner by one expert observer and 2 less experienced observers together. Read More
Medicine (Baltimore) 2017 Apr;96(15):e6258
aDepartment of Surgery, Saint Barnabas Medical Center, Livingston, NJ bSaint George's University School of Medicine, Grenada, West Indies cDepartment of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ dDepartment of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ.
Malignant melanoma accounts for 75% of all skin cancer deaths and is potentially curable if identified early. Although melanoma is rare in African-Americans (AA), it is associated with a worse prognosis than in Caucasians. This study examines the demographic, pathologic, and clinical factors impacting AA melanoma outcomes. Read More
Dermatol Surg 2017 Aug;43(8):1036-1041
*All authors are affiliated with the Department of Dermatology, University Clinic of Navarra, Pamplona, Spain.
Background: The typical reconstructive option for closing large-sized defects of the distal half of the nose is the paramedian forehead flap. Other alternatives are a melolabial interpolation flap and bilobed or trilobed flaps. The dorsal nasal (Rieger) flap is suitable for closing small-sized defects at this location, especially when they are medially located. Read More
Br J Dermatol 2017 07 23;177(1):324-325. Epub 2017 May 23.
Melanoma Institute Australia, Sydney, Australia.
Cureus 2017 Feb 13;9(2):e1026. Epub 2017 Feb 13.
Department of Dermatology, University of California, San Diego.
Tumoral melanosis is a form of completely regressed melanoma that usually presents as darkly pigmented lesions suspicious for malignant melanoma. Histology reveals dense dermal and subcutaneous infiltration of melanophages. Pembrolizumab is an antibody directed against programmed death receptor-1 (PD1) and is frontline treatment for advanced melanoma. Read More
Dermatol Surg 2017 05;43 Suppl 1:S111-S114
*Department of Ophthalmology, Hospital de l´Espearnça, Parc de Salut Mar, Barcelona, Spain; †Department of Dermatology, Hospital Universitario de Donostia, San Sebastian, Spain; and ‡Department of Dermatology, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.