Management of Post Dermato-Oncological Defects: A Case Series and Discussion of Treatment Options

  Abstract: Managing poorly healing wounds and large defects of the scalp after treatment of skin cancer in elderly men is a common and challenging problem. The increasing incidence of scalp pathology, and the often concomitant morbidity in these patients, often restricts invasive treatment options. Subsequently, this requires the dermatologist to look at alternative treatment options. Attention has been focused on well-tolerable treatments with good long-term outcomes. This report describes four patients who received treatment by either the use of a purse-string suture, pulsed dye laser (PDL) treatment, and/or healing by secondary intention. Additionally, recent literature concerning these management strategies is discussed.

Introduction

  The incidence of skin neoplasms is rapidly increasing. Roughly 1.2 million nonmelanoma skin cancers develop annually in the United States.¹ The highest incidence is found in the elderly. With an aging population, dermatologists are confronted with a growing number of elderly skin cancer patients. Treatment of skin cancers on the scalp often leads to poorly healing wounds in elderly men. In aging men, hair follicles undergo miniaturization, leaving a bald scalp that is highly susceptible to solar damage. A decrease in hair follicles, as well as solar damage, can result in a disturbed re-epithelialization of wounds. Other less common causes of scalp defects include trauma, burns, and congenital lesions.²   The following four cases describe a diverse number of slow healing (dermato-oncologic related) wounds of the scalp and various treatment modalities.

Case Reports

  Case 1: A 73-year-old, insulin dependent man with diabetes was referred to the authors’ department for treatment of a large, poorly healing defect on the vertex. The history showed a histologically proven actinic keratosis for which he received several treatments, including cryotherapy (several times), topical fluorouracil 5% cream, radiotherapy, and eventually excision. This patient was referred to the authors’ hospital 2 months after closure with a split-thickness skin graft ([STSG], Figure 1).   The authors decided to treat the wound in a conservative manner using topical fucidic acid cream, zinc oxide ointment, betamethasone (Diprosone®) 0.05% cream, and applying silver nitrate on a regular basis for the treatment of hypergranulating tissue. The defect was closed 19 months later (Figure 2). Currently, this patient is still under control for premalignant lesions, which are well controlled with cryotherapy on a regular basis without long-term side effects.   Case 2: Case 2 presents a 64-year-old man with a history of CREST-syndrome and irradiation of the scalp for eczema and alopecia in childhood. Since 2003, this patient was treated for extensive hyperkeratosis of the scalp, multiple relapses of squamous cell carcinoma on the scalp, Bowen’s disease, and actinic keratosis. Treatment included surgery and radiotherapy.   In July 2005, this patient presented in the authors’ hospital with a histologically proven recurrent squamous cell carcinoma ([rT2N0M0], Figure 3). The tumor was incompletely removed in the basal layer. Radiotherapy lasted from September to November 2005. In 2007, a CT-scan showed osteoradionecrosis, which progressed and resulted in two bone defects in the frontal area. There were no signs of invasive tumor growth. In the months after, the defect spontaneously slowly re-epithelialized (Figures 4, 5). The wound has remained stable and shows no signs of further peripheral growth. Unfortunately, this patient was recently diagnosed with a metastasized small cell lung tumor. Since then, there has not been any further follow-up with the authors’ department.   Case 3: The third case presents an 88-year-old man with a large, poorly healing wound on the scalp and exposure of the underlying calvarium. The patient’s history revealed multiple actinic keratoses and nonmelanoma skin cancer in the head and neck area since the early 1990s.   In 2000, a poorly healing wound was present on his scalp. Histopathology repeatedly showed chronic granulating inflammation without signs of (pre)malignancy. Erosive pustulosis of the scalp was set as a diagnosis, and treatment with oral prednisone lead to complete closure of the defect.   As a result of a friction trauma in 2005, the patient again developed a poorly healing defect on the scalp, and a plastic surgeon placed another STSG. This was followed by impaired wound healing with exposure of the calvarium.   Upon presentation at the authors’ hospital in July 2009, histopathological examination of several biopsies showed actinic keratosis of the Bowenoïd type (Figure 6). The authors decided to treat the patient with a 595-nm pulsed dye laser (PDL). The skin remarkably improved. However, every 3 months new crusty lesions combined with some pustules would occur, which were treated with PDL.   Case 4: The next case concerns an 85-year-old man with a history of multiple nonmelanoma skin cancers on the face and trunk. In April 2010, he was diagnosed with a squamous cell carcinoma in situ on the right frontoparietal vertex area. Treatment with photodynamic therapy failed. Therefore, excision of the lesion followed in July 2010 (Figure 7). Partial closure of the wound took place with a cuticular purse string suture (Figure 8). Fucidic acid cream was applied in the remaining defect and covered with soft silicone dressings and a pressure dressing (Figure 9). The patient reported no pain or other complaints. The wound was completely closed at follow up 6 weeks later (Figure 10). No postoperative complications occurred, and no physical and/or cosmetic complaints were reported.

Discussion

  Various surgical treatments for managing large scalp defects have been widely described in the literature, eg, local scalp flaps, skin grafts, and free tissue transfer. Although these methods show good success rates, they are mostly invasive and often limited according to the relatively advanced age of patients presenting with pathology of the scalp, and the frequent presence of comorbidities (eg, prior irradiation).   Secondary intention healing. The first two cases showed that secondary intention healing is an excellent method for the treatment of poorly healing wounds post radiotherapy and in patients with additional comorbidities. Despite the long treatment time, it was well tolerated in the two patients, both physically and cosmetically. Angelos and Downs² have reported this as well. Secondary intention healing is a practical solution, especially in patients with significant comorbidities in whom extensive reconstruction is contraindicated.   Laser therapy. Erosive pustular dermatosis of the scalp (EPDS) is a rare condition of unknown etiology. EPDS is more common in men—the female/male ratio is 2:3 and is predominant found in the elderly.³ EPDS presents most commonly erosive, sterile pustular, and crusty lesions often leading to scarring alopecia. Predisposing factors described include, among other things, scalp surgery and ultraviolet radiation.^3,4 Several treatment options for EPDS have been described. Recently, treatments with oral prednisone⁴ and PDT⁵ have been described. However, EPDS remains difficult to treat due to frequent relapses.⁴   In the literature, PDL treatment has been described for inflammatory diseases positioned on the scalp (eg, pyogenic granuloma and psoriasis). Wang and Goldberg⁶ showed complete re-epithelialization in two patients using a 595-nm, pulsed dye laser for the treatment of chronic ulcer with hypergranulation tissue.   Purse string suture. The cuticular purse string suture is easily learned, inexpensive, and can be performed rapidly. It is especially suitable for elderly patients with loose skin or thin, sun-damaged skin. Although healing time is longer compared to several other methods and requires frequent follow up, the cosmetic and functional results are excellent and well tolerated. A mean decrease in wound area of 60% (range, 6%–90%) has been observed.⁷ This leaves the cuticular purse string suture an optimal treatment for large scalp defects in patients with minimal skin laxity or in patients for whom surgery in contraindicated, and even provides a quick and minimally invasive way for re-excision to resolve incompletely removed tumors.

Conclusion

  Four elderly men received conservative treatment for large scalp defects or poorly healing scalp wounds following surgery and/or radiation therapy for dermato-oncologic (related) processes. Patients were treated via secondary intention healing, the use of a purse string sutures, and/or laser resurfacing. All of the patients tolerated the treatments well and the treatments led to cosmetically acceptable outcomes.

References

1. Ricotti C, Bouzari N, Agadi A, Cockerell CJ. Malignant skin neoplasms. Med Clin North Am. 2009;93:1241–1264. 2. Angelos PC, Downs BW. Options for the management of forehead and scalp defects. Facial Plast Surg Clin North Am. 2009;17:379–393. 3. Mastroianni A, Cota C, Ardigò M, Minutilli E, Berardesca E. Erosive pustular dermatosis of the scalp: A case report and review of the literature. Dermatology. 2005;211:273–276. 4. Allevato M, Clerc C, del Sel JM, Donatti L, Cabrera H, Juárez M. Erosive pustular dermatosis of the scalp. Int J Dermatol. 2009;48:1213–1216. 5. .Meyer T, López-Navarro N, Herrera-Acosta E, Jose A, Herrera E. Erosive pustular dermatosis of the scalp: a Succesful treatment with photodynamic therapy. Photodermatol Photoimmunol Photomed. 2010:26:44–45. 6. Wang SQ, Goldberg LH. Pulsed-dye laser treatment of nonhealing chronic ulcer with hypergranulation tissue. Arch Dermatol. 2007;143:700–702. 7. Cohen PR, Martinelli PT, Schulze KE, Nelson BR. The cuticular purse string suture: a modified purse string suture fot the partial closure of round postoperative wounds. Int J Dermatol. 2007;46:746–753. The authors are from the Department of Dermatology, Catharina Hospital, Eindhoven, The Netherlands. Address correspondence to: Sofie L. Roodbergen, MD Department of Dermatology, Catharina Hospital Eindhoven Michelangelolaan 2, Postbox 1350 5602 ZA Eindhoven The Netherlands sofie.roodbergen@cze.nl