Edmund Wee

Background: Lymphocytic thrombophilic arteritis is a distinctive but poorly understood lymphocytic vasculitis. There is a need to better define this entity. Objective: We conducted a case-series analysis of all patients with a diagnosis of lymphocytic thrombophilic arteritis known to St Vincent’s Hospital Melbourne Dermatology Unit, in Victoria, Australia, a referral centre for cutaneous vasculitis and lymphocytic thrombophilic arteritis, to better characterise the clinicopathological features of this entity. Methods: All patients who met our clinicopathological criteria for this condition were included. Diagnostic clinical features included the presence of widespread blanchable livedo racemosa and/or macular pigmentation. Diagnostic histological features included the presence of a lymphocytic arteritis with fibrin deposition affecting vessels in the deeper dermis and/or upper subcutis. Cases of lymphocytic thrombophilic arteritis were assessed for demographics, comorbidities, clinical features, histopathology, treatments, and clinical response. Results: Thirty-six cases were identified including 26 female and 10 male patients with an average age of onset of 32.7 years. A high proportion of cases with Asian descent was noted (44.4%). Most cases (94.4%) presented with widespread livedo racemosa. Less common manifestations included petechiae (16.7%), macular pigmentation (22.2%), neuropathy (33.3%), and ulceration (33.3%). A significant association was noted between ulceration and superficial dermal vessel involvement on biopsy, similar to livedoid vasculopathy. All cases demonstrated a neutrophil-poor lymphocytic perivascular infiltrate with fibrinoid change in the deeper dermis/upper subcutis. A variety of vessels were affected; 44.4% involved vessels in the superficial dermis as well as the deep dermis/upper subcutis. A discrete concentric fibrin ring (41.7%) was not essential for diagnosis. Treatments targeting vascular fibrin deposition appeared effective for all manifestations other than livedo for which no cases responded. Conclusion: Lymphocytic thrombophilic arteritis has distinctive clinicopathological features and may lie on a spectrum with livedoid vasculopathy. Although livedo racemosa persists, other manifestations respond to antithrombotic treatments.

Background: Pyoderma gangrenosum (PG) is an ulcerative inflammatory dermatosis that is poorly characterised from a diagnostic and therapeutic perspective. We evaluated the clinical characteristics and healing outcomes in patients with PG according to ulcer size. Methods: We reviewed the medical records of patients with PG presenting to a tertiary hospital in Melbourne, Australia, from 20 December 2011 to 11 June 2024. We collected data on demographics, clinical characteristics, and classified cases into small (< 64 cm ² ) or large ulcers (≥ 64 cm ² or any tendon or muscle on view) according to the size of the largest ulcer during the treatment course. Healing outcomes assessed included rates of initial healing, healing time, recurrence rate, healing after recurrence, level of systemic treatment required, and mortality. Results: 81 cases of PG were identified, including 38 (46.9%) small and 43 (53.1%) large ulcers. Large ulcers were associated with a history of multiple ulcers, peripheral vascular disease, and higher rates of advanced treatment (biologic or intravenous immunoglobulin therapy). After adjusting for age, sex, and peripheral vascular disease, large ulcers remained independently associated with lower rates of initial healing, higher rates of recurrence, lower rates of healing after recurrence, and longer healing times (all p < 0.05). Ulcer size was not associated with age, sex, ulcer location, tissue pathergy, inflammatory bowel disease, haematological malignancy, inflammatory arthritis, or diabetes mellitus. Conclusion: PG is a highly morbid condition that is slow to heal and frequently recurs. Ulcer size is an important predictor of healing outcomes. It is thus a meaningful way of stratifying patients and may provide useful prognostic information regarding the expected disease course.

Lymphocytic thrombophilic arteritis and livedoid vasculopathy may both present with livedo racemosa and ulceration. We present 6 cases with features of both conditions, raising the possibility that they are either closely linked or are part of a spectrum of the same condition.

Background/Objectives Acral lentiginous melanoma (ALM) is a melanoma subtype associated with atypical locations on the hands and feet and advanced disease at diagnosis. There is a limited understanding of whether the survival is similar for nail, non‐nail, lower limb and upper limb ALM patients. We therefore explored clinicopathologic characteristics and melanoma‐specific survival of ALM patients according to tumour location. Methods A prospectively collected cohort study was performed of all primary invasive cutaneous acral lentiginous melanomas with known thickness and tumour location reviewed at a tertiary referral centre over 21 years. Results A total of 101 ALM patients were reviewed from 1994 until 2016. The majority of cases (82/101) occurred on the feet. Hand ALMs were thicker and more likely to be ulcerated than feet ALMs (P = 0.05 and 0.02, respectively); however, survival was not statistically different between these two groups (univariate HR 0.48 P = 0.11, 95% CI, 0.20–1.17; multivariate HR 0.67 P = 0.40, 95% CI, 0.27–1.69, respectively). Non‐nail ALM patients had longer survival when compared to nail ALM on univariate analysis (HR 0.40, 95% CI, 0.17 to 0.90) which was accounted for by Breslow thickness and ulceration (multivariate HR 0.56, 95% CI, 0.24 to 1.34). Conclusions The reduced melanoma‐specific survival in nail ALM patients was likely due to their greater thickness and ulceration. Although hand ALMs are thicker and more frequently ulcerated, this is likely due to the higher proportion of nail ALMs present in this location.

Background/Objectives: There is evidence that cutaneous melanomas at different anatomic sites present with distinctive clinicopathologic features. We examined the anatomic distribution of cutaneous melanoma and its variation by patient characteristics, subtype and Breslow thickness, using high‐resolution anatomic site data.Methods: A cross‐sectional study was performed of all primary cutaneous melanoma cases managed at a tertiary referral centre, analysing prospectively collected clinical data across 50 anatomic subsites.Results: The study included 5141 in situ or invasive melanomas; most were invasive (76.2%), and the median Breslow thickness of invasive lesions was 1.0 mm. Superficial spreading (57.2%), lentigo maligna (20.8%) and nodular (12.2%) were the most common histopathological subtypes. Sun‐exposed sites such as the female nose and cheek, the male ear, as well as the upper back in both sexes had the highest incidence of melanoma per unit area. When compared to the posterior forearm, the scalp, ear, preauricular, perioral, subungual and plantar sites had thicker invasive melanomas (each P < 0.05). The peri‐auricular, ear and cheek had the highest incidence of nodular melanoma per unit area. There were subtype‐, age‐ and sex‐specific differences in melanoma anatomic distribution.Conclusion: Melanoma most commonly arises in sun‐exposed facial areas, as well as the upper back. Increased thickness is found for melanoma in acral and many head and neck sites. Nodular melanoma is more likely to occur in head and neck sites including the peri‐auricular area, ear and cheek. Clinicians should carefully assess these sites during skin examinations.