treatment of basal cell epithelioma by curettage and electrodesiccation

IIIII II II d l l I I [L Hill I

Treatment of basal cell epithelioma by curettage and electrodesiccation William F. Spiller, M.D., and Rachel F. Spiller, M.D. Houston, TX

A total of 233 biopsy-proved basal ceil epitheliomas (BCEs) treated by curettage and electrodesiccation (C&D) in our office in 1976 and 1977 were followed a minimum of 5 years. There were seven recurrences, a cure rate of 97.0%. Our results, both for recurrence rates and cosmetic appearance, varied according to the size and location of the cancers. The cosmetic results were generally excellent especially in the smaller cancers. Smaller BCEsqess than 2 cm diameter, excluding the nose and nasolabial area, had our highest cure rate, 99.4% (171/172). Our treatment method is described in detail. Although not a complicated procedure, C&D does require skill, thoroughness and selection of patients to achieve high cure rates and is still an excellent treatment choice for many BCEs. (J AM ACAD DERMATOL 11:808-814, 1984.)

Curettage and electrodesiccation (C&D) is probably the method most frequently used by dermatologists for the treatment o f small basal cell epitheliomas (BCEs). In 1960, Knox et al ~ reported their results of C&D treatment of 765 skin cancers, including both basal and squamous cell- types followed for 6 months to 19 years, with a cure rate of 98.30%. Kopf et al 2 in 1977 reported their results of C&D treatment of BCEs with recurrence rates of from 5.7% in private practice to 18.8% in clinic patients and summarized the re- suits of six previous reports by other authors, "~-8 with recurrence rates ranging from 0.0% to 12.2%. There have been two recent reports indi- cating fairly high rates of residual tumor ceils after C&D treatment of BCEs~'I°; however, both authors stipulate that these histopathologic findings should not be interpreted as implying a similar rate of clinical recurrence after C&D. There has also been one report of a 26.0% 5-year recurrence of

From the Departments of Dermatology, Baylor College of Medicine, and the University of Texas Medical School.

Accepted for publication May 11, 1984.

Reprint requests to: Dr. William F. Spiller, 3801 Kirby Dr., Suite 300, Houston, TX 77098.

808

BCEs treated by C&D, la and there have been reports stating that other methods, such as curettage alone ~2-14 or combined curretage and cryosurgery, 1'~ give superior cosmetic results. Since we have used C&D for BCEs in selected cases in our private practice since 1951 and have been well pleased with both the cure rates and the cosmetic results, we have studied a selected group of our patients.

Because of the difficulty of examining older records and calling into the office for follow-up all of the patients we have treated for BCEs by C&D, which we estimate at approximately 2,000 patients over 32 years, we called in for examination all biopsy-proved BCE patients treated in our office by C&D in the years 1976 and 1977 for evaluation of results of treatment. These years were chosen to provide at least a 5-year follow-up. Although BCEs treated before or after these years were not included, we believe the results are representative of our practice.

METHOD

The treatment site is wiped with 70% alcohol. Lidocaine hydrochloride 1%, without epinephrine, is injected around and under the tumor, A bright light is

Volume 1 i Number 5, Part 1 November, 1984

Treatment of BCE by curettage and electrodesiccation 809

used to illuminate the operating field, and a magnifying loop is worn by the operator. A large, medium, or small curette is used, depending on the tumor size, to vigorously scrape away the BCE and the material is presented for biopsy. On BCEs, especially larger ones, on which we have doubt as to the clinical diagnosis, a curette, a shave, or rarely a punch biopsy is done and treatment is deferred until the histologic diagnosis is established. We are aware that some authors TM recom- mend deferring treatment of all BCEs until the biopsy diagnosis has been ascertained. This may be the safest medicolegal procedure and probably wisest for trainees, but it does increase the cost and inconvenience to the patient as it requires two procedures done on different visits. We believe that on small tumors, especially those under 1 cm in diameter, on which the clinical diagnosis seems secure, it is often in the patient's best interest to remove the entire tumor at the time of biopsy when the treatment to be chosen is C&D, but on questionable tumors to await the results of biopsy.

After curetting out all visible and palpable tumor, usually a smaller curette is used to complete the curettage. If there has been any undermining by curettage of peripheral skin around the lesion, scissors are used to cut off this overhanging tissue. Curettage is continued to include a margin of variable distance, usually 2 to 4 ram, depending on the size of the tumor being treated. Bleeding is controlled first by fresh Monsel's solution taking care not to rub in the solution but to gently roll a "not too moist" cotton swab over the treated surface. Care should also be taken not to apply any precipitated material that frequently forms in the bottom of the Monsel's bottle and also not to apply it under any un- dermined edges. In our practice we are not aware of any tattooing from Monsel's solution but others ~r have reported this. Monsel 's solution is not used on exposed subcutaneous tissue. Light electrodesiccation is then used to complete hemostasis and destroy another I to 2 mm of tissue at the edges and base. On larger tumors and any smaller ones in which the cancer does not appear to the operator to have been entirely removed by the first vigorous curettage, a second curettage is done of the desiccated tissue and bleeding again is controlled as before by Monsel's solution and electrodesiccation. On a few of the larger tumors treated, we repeated the curettage and electrodesiccation a third time. It has been suggested by Knox 1 that routine C&D x 2 may improve the cure rate and by Salasche TM that a "stan- dardized" approach should be C&D × 3, but we have individualized our treatment according to the site and size of the tumors. BCEs smaller than 1 cm and those in which the first curettage clinically looks and feels to

Table I . BCEs less than 2 cm t reated by C & D

Location I Treated [ Recurred % recurrence

Nose 36 2 5.56 Cheeks 35 0 0 Forehead and temple 34 0 0 Arms 34 0 0 Ears 18 0 0 Neck 12 0 0 Chin and upper lip 9 0 0 Back 7 0 0 Scalp 7 g 0 Chest 5 0 0 Shoulder 5 1 20.0 Eyelids 4 0 0 Legs 1 0 0 Hands 1 0 0

Total 208 3 1.44

have removed the entire tumor received only a single C&D. This was done to minimize scarring; however, it is best done after experience and with caution as Robins and Albom 1~ reported a higher recurrence rate in young women in a series of 1,170 patients, which they attributed to inadequate treatment due to cosmetic consid- erations. In our series selective C&D x 1 did not result in any of our recurrences, and Edens et al's ~° study using Mohs type excisional technics found no correlation of residual tumor to the number of times up to three that C&D was performed. After treatment the site was usually left unbandaged and the patient was instructed to keep the area as dry as practical and was allowed to apply Band-Aids if desired for cosmetic purposes and to protect the area from rubbing by glasses frames.

S E L E C T I O N OF PATIENTS

A total of 461 biopsy-proved BCEs in 397 patients were treated in our office in 1976 and 1977. This total does not include one patient with basal cell nevus syn- drome who has had an average of 75 BCEs removed annually for more than 20 years, including 1976 and 1977. He was excluded from the study even though many of his BCEs had been removed by C&D and were biopsy-proved. The large number of BCEs in this patient prevented any accurate assessment of the recurrence rate although there were no known recurrences. Of the total of 461 BCEs, 233 in 192 patients were treated by C&D and followed for at least 5 years after treatment. An additional eighteen BCE patients were treated by C&D and were not followed for 5 years. Of these eighteen patients, twelve were lost to follow-up because of death unrelated to treatment and six because

8 1 0 Spiller and Spiller Journal of the

American Academy of Dermatology

T a b l e I I . BCEs 1 cm and less treated by C&D

Location :T~aied I Recurred [ % recurrence

Arms 34 0 0 Nose 31 2 6.45 Forehead and temple 29 0 0 Cheeks 22 0 0 Ears 13 0 0 Neck 9 0 0 Chin and upper lip 6 0 0 Scalp 6 0 0 Chest 4 0 0 Shoulder 3 0 0 Back 3 0 0 Eyelid 2 0 0 Legs 1 0 0

Total 163 2 1.23

Tab l e I I I . BCEs 1 to 2 cm treated by C&D

Location Treated. Recurred 1% recurrence

Cheek 13 0 0 Forehead and temple 5 0 0 Ear 5 0 0 Nose 5 0 0 Back 4 0 0 Neck 3 0 0 Upper lip 3 0 0 Eyebrow 2 0 0 Shoulder 2 1 50.0 Scalp 1 0 0 Hand 1 0 0 Chest 1 0 0

Total 45 1 2.22

of our inability to locate them. None of these eighteen had any evidence of recurrence before being lost to follow-up, but they are not included in this series. There were 228 BCEs treated by other methods, 208 by combination curettage, electrodesiccation, and cryosurgery treatment, and twenty by cryosurgery alone. Six additional patients with biopsy-proved BCEs were referred elsewhere for treatment by plastic surgery or Mohs' surgery because of the large size of the tumors.

The selection of patients to be treated by C&D was biased in that cancers with indefinite borders or depth in which there was doubt that curettage had disclosed the limits of the tumor were more likely to be treated by combination treatment of C&D and cryosurgery than by C&D alone. Thus BCEs treated by C&D were generally smaller and more well defined than those treated by combination treatment, although some larger tumors were treated by C&D.

T a b l e IV. BCEs larger than 2 cm treated by C&D

Forehead and temple 10 2 20.00 Ears 6 2 33.33 Cheeks 4 0 0 Back 3 0 0 Neck 1 0 0 Chest 1 0 0

Total 25 4 16.00

R E S U L T S

Our results varied according to the size of the treated BCE. A total of 233 BCEs o f all sizes in 192 patients were treated by C & D and there were seven recurrences, a recurrence rate of 3.00%. Of this total of 233 there were 208 BCEs that were smaller than 2 cm and twenty-five BCEs that were over 2 cm. O f the 208 smaller BCEs there were three recurrences, a recurrence rate o f 1.44%, and o f these 208 there were forty-five between 1 and 2 cm. One of the three recurrences was in this group of forty-five, a recurrence rate of 2.22%. Of the twenty-five BCEs over 2 cm there were four recurrences, a recurrence rate o f 16%. The locations and numbers treated are outlined in Tables I to IV.

Of the three recurrences among the smaller BCEs, two were on the nose. There were thirty-six treated on the nose by C&D, giving a recurrence rate of 5.56%. Excluding the thirty-six BCEs on the nose there were 172 BCEs smaller than 2 cm treated by C & D and one recurrence, a recurrence

rate o f less than 0.6%. One BCE on the tip of the nose recurred within 9 months at the center of the scar, and a second BCE on the r ight ala nasi recurred at the edge of the scar 4 years after C&D and may possibly have been a new cancer as this patient had multiple BCEs. Nei ther of the recurrent BCEs on the nose were larger than 1 cm prior to treatment and neither was considered " inva- s i v e " by the histopathologist. Both recurrences were treated by combinat ion C & D and cryosurgery and neither had recurred again at the time of writing.

The other recurrence was a 1.5 cm BCE on the shoulder. (There were only five BCEs treated on the shoulder by C&D, a recurrence rate of 20%,

Volume 11 Number 5, Part 1 November, 1984


but the numbers treated are too small to be mean- ingful.) This recurrence was retreated by combination C&D and cryosurgery and had remained clear after 4 years.

All four of the larger (over 2 cm in diameter) BCEs that recurred after C&D treatment were in BCEs that were recurrent from prior treatment elsewhere at the time of treatment. There were twelve recurrent BCEs larger than 2 cm at time of treatment, giving a failure rate of 33.33% in this select group of large recurrent BCEs. There were no recurrences in the group of thirteen large BCEs that had not been treated before.

Of the four larger BCEs that recurred, two were on an ear and two on the forehead-temple area. One was retreated by combination C&D and cryosurgery and remained clear after 3 years. The other three were referred elsewhere for plastic surgery or Mohs' surgery. Carruthers et al 2° emphasized that the forehead and temple areas have a significant number of large and invasive type BCEs and should be considered one of the "high- r isk" locations, along with the perinasal, periocu- lar, and periauricular areas and the scalp. All four recurrences of the larger (over 2 cm in diameter) BCEs in our series were reported by our patholo- gist as " invasive" histologically.

DISCUSSION

The comparison of cosmetic results is largely a subjective judgment but is an important consideration in evaluation of treatment results. The difficulty is compounded when attempting to compare results of different methods reported by different authors. McDanie112 stated that he uses curettage-only therapy because of dissatisfaction with C&D's more frequent hypertrophic scar for- mation. In our experience, using electrodesiccation sufficient to stop bleeding and destroy a min- imal additional safety margin of tissue, we have only rarely seen permanent hypertrophic scarring and then only in larger tumors, and none was seen in this series. The amount of scarring we observed appeared directly related to the size and location of the treated BCE and was most commonly hypopigmentation that improves with time but is some- times permanent, especially on the neck, arms, and trunk. Areas of least scarring in this series were cheeks, ears, and below the eyes. The cos-

metic results of the smaller tumors were very good to excellent with many treatment sites being indis- cernible. We have reported elsewhere 21'z2 our results of combination curettage, electrodesiccation, and cryosurgery for medium-sized and larger tumors. We have treated enough smaller tumors by this combination treatment to make some com- parisons of cosmetic results and find very little difference; although there may be slightly more hypopigmentation using the combination treatment, we find this a difficult judgment to make because both treatments leave so little scarring in small tumors.

It is difficult to explain the difference in our low recurrence rate for small tumors (1.17%) and also the low recurrence rate (1.67%) of Knox et al 1 with the high recurrence rate of 26.0% reported by Dubin and Kopf. 1, The difference can only partly be explained by the size of the treated lesions because in Dubin and Kopf 's series there was a recurrence rate of 15.2% for BCEs 2 to 5 mm in diameter and of 19.6% for BCEs 6 to 10 mm in diameter; however, Dubin and Kopf state that patients who did not have recurrences may have been less likely to return for follow-up visits, "resulting in inflated recurrence ra tes ." Kopf stated that in his series of 3,531 BCEs only 53.4% met their previously reported follow-up evaluation criteria. 2,~ In our study we hired extra help for the purpose of contacting all of our patients to come in for follow-up examination. It is to be noted that in Dubin and Kopf's series "practically all of the curettage-electrodesiccation treatments were performed by dermatology residents'"1; however, in Knox's study some of the treatments were also performed by residents. It is to be emphasized that although C&D is not a complicated procedure it does require skill, concentration, and thoroughness with attention to details, as has been emphasized before by many authors. 4'6-9'11 As Dubin and Kopf's excellent multivariate analysis illus- trates, many factors, including the experience of the operator, should determine which treatment is used in individual cases.

Both Salasche's 9 and Edens et al 's ~° studies in- dicate that in a significant percentage of BCEs, treatment by C&D does not remove all tumor cells after apparently adequate curettage followed by electrodesiccation but that clinical recurrences are

812 Spiller and Spiller Journal of the


of much lower incidence. Salasche 9 found histologic evidence by Mohs ' "chemo-check" procedure of 30% residual tumor cells in BCEs of the nose and nasolabial fold areas following "stan- dard" C&D treatment, but stated that judging from reported cure rates, many of his positive "chemo-checks '" would probably not have resulted in recurrences if C&D alone had been done.

Even though some tumor cells remain at the base of margins after C&D, other factors such as local inflammation and fibrosis following treatment or alterations in the body ' s immune response may be sufficient to destroy the remaining de- creased number of tumor cells in some c a s e s . 24"2'5

A recurrence rate as high as 35% has been reported if the surgical margins revealed residual tumor cells on surgical excision of BCEs. ~c~-2'~ Salasche postulated that the greater inflammatory response following electrodesiccation compared to the lesser inflammation after surgical excision may account for the lower recurrence rates for C&D when tumor cells do remain at the margins of both treatments. The inflammation of the electrodesiccation portion of the procedure could also be a theoretical reason for using C&D instead of curettage alone. McDaniel TM reported a 91.5% cure rate using curettage alone as treatment for 644 BCEs, and Reymann TM reported an 83.23% cure rate with curettage alone in a "41A-year experimental peri- o d " in 155 patients. Reymann also reported a cure rate of 98.49% for curettage alone in 1,057 BCEs in 182 patients with multiple BCEs. Since the cure rates and cosmetic results of C&D and curettage alone are in the same range, the experience of the operator should be important in the treatment de- cision.

Brooks 3° stated that curettage followed by shave excision offers histologic control with no more sacrifice of normal tissue than C&D. Of 100 cases (88 BCEs and 12 squamous cell carcinomas), nineteen presented a problem in interpretation, sixty were clear of tumor on histologic examination, and twenty-one showed residual carcinoma, which was eliminated by a single repeat shave excision. As Salasche 's stated, this technic is only quantitatively different from Mohs ' surgery, and special training in histopathologic interpretation of horizontal sections is necessary. Also, Brooks'

technic would not be likely to stimulate the inflammation and possible immune changes that have been postulated to account for the docu- mented high cure rates of C&D in selected cases. To insist on histologic control of treatment of all BGEs would effectively eliminate all treatments other than Mobs ' surgery, resulting in unnecessary high costs to the patient in time, money, and scarring.

Salasche is correctly emphasizes that close supervision during training is the key to the technic of C&D and extols the value of "chemo-checks" as a teaching aid, but it should be emphasized that excellent cure rates have been and are being ob- tained by dermatologists who have never been trained in Mohs ' surgery. However, it is true that high recurrence rates such as the 26% reported by Dubin and Kopf from the resident's clinic at New York University Hospital should emphasize the importance of supervision and also reemphasize that C&D does not always result in high cure rates.

We disagree with Salasche's TM statement that the criteria for electing C&D as the treatment mo- dality should be a lesion less than 1 cm in size and less than 2 years in duration. In our series the history given by the patients as to the duration of their cancer prior to treatment varied from a few weeks to over 10 years even for smaller BCEs, but too many were of unknown duration or unrecorded on our charts to allow for statistical study. Pascal et al2r stated that there was no correlation between the preoperative duration of the tumor and the recurrence rate in their series. Our results of 97.7% cure rate in forty-five BCEs between 1 and 2 cm in size and Shanoff et a l ' s 7 r e p o r t of 100% cure rate by C&D of BCEs between 1 and 2 cm in size treated at the Veterans Administration Hospital in Houston suggest that C&D can give excellent cure rates in BCEs up to 2 cm in size.

Our higher recurrence rate of 5.56% in BCEs treated on the nose compared to 0.01% of all smaller tumors excluding the nose supports Dr. Salasche's and others findings that the nose and nasolabial folds are relatively high-risk areas for recurrences. However, our cure rates and cosmetic results in these areas are still excellent enough that C&D carefully done is our treatment of choice in

Volume 11 Number 5, Part 1 November, 1984


selected cases. Recurrent tumors and large initial tumors in these areas warrant consideration of other methods such as M o h s ' surgery, surgical excision, cryosurgery, combinat ion C & D and cryosurgery, or radiation therapy by experienced therapists. It is a rare dermatologis t who has ex-

perience in all o f these modes of therapy, but for- tunately for m a n y patients there are often several a lmost equally good methods for treatment of many BCEs, especial ly smaller ones, and we should be slow to c la im superiori ty for the method

in which we personal ly are most experienced.

For many BCEs the " b e s t " t reatment is often the one in which the particular dermatologist seeing the patient is mos t experienced. C & D ranks with curettage alone, cryosurgery alone, and combination C & D and cryosurgery as being a rapid, cost-effect ive t reatment for small BCEs that can be per formed in one office visit and usually with excel-

lent cosmetic results. It should be stressed that whatever method of t reatment is chosen, t ime should be taken to impress the pat ient with the importance of regular fol low-up examinat ion ex- tending over a period of years as all methods have some recurrences that are best dealt with when they

are small. In summary , a total of 233 BCEs o f all sizes

were treated by C & D and fol lowed for at least 5 years. There were seven recurrences, a cure rate of 97.0%. Our results varied according to size

and location of the treated BCEs. Of 208 BCEs smaller than 2 c m there were three recurrences, a cure rate of 98.56%. Excluding those on the nose and nasolabial areas there were 172 BCEs smaller than 2 cm and one recurrence, a cure rate of

greater than 99.4%. There were two recurrences of thirty-six smaller BCEs on the nose, a cure rate of 94.44%. There were four recurrences of twenty-f ive BCEs over 2 cm in diameter , a cure rate of 84%. Our series supports earlier studies of excellent cure rates by C & D especially of smaller tumors, and reemphasizes that larger recurrent BCEs and those on the nose or nasolabial folds are

more likely to recur. The cosmet ic results were general ly excellent, especial ly in the smaller cancers. C & D is again confirmed as an excellent office procedure for the t reatment of selected BCEs.

REFERENCES

1. Knox JM, Lyles TW, Shapiro CM, Martin RD: Curet- tage and electrodesiceation in the treatment of skin cancer. Arch Dermatol 82:197-204, 1960,

2. Kopf AW, Bart RX, Schrager D, et al: Curettage- eleetrodesiccation treatment of basal cell carcinomas. Arch Dermatol 113:439-443, 1977.

3. Sweet RD: The treatment of basal-cell carcinoma by curettage. Br J Dermatol 75:137-148, 1963.

4. Knox JM, Freeman RG, Duncan WC, et al: Treatment of skin cancer. South Med J 60:241-246, 1967.

5. Crissy JT: Curettage and electrodesiccation as a method of treatment for epitheliomas of the skin. J Surg Oncol 3:287-291, 1971.

6. Jackson R: The treatment of basal-cell carcinomas. Cutis 5:1,231-1, 234, 1969.

7. Shanoff LB, Spira M, Hardy SB: Basal-cell carcinoma: A statistical approach to rational management. Plast Re- constr Surg 39:614-619, t962.

8. Williamson GS, Jackson R: Treatment of basal-cell carcinoma by electrodesiccation and curettage. Can Med Assoc J 86:855-862, 1962.

9. Salasche SJ: Curettage and electrodesiccation in the treatment of midfaeial basal cell epithelioma. J AM ACAD DERMATOL 8:496-503, 1983.

10. Edens BL, Bartlow GA, Haghighi P, et a1: Effectiveness of curettage and electrodesiccation in the removal of basal cell carcinoma. J AM ACAD DERMATOL 9:3 83-388, 1983.

11. Dubin N, Kopf AW: Multivariate risk score for recurrence of cutaneous basal cell carcinomas. Arch Dermatol 119:373-377, 1983.

12. McDaniel WE: Therapy for basal cell epitheliomas by curettage only. Arch Dermatol 119:901-903, 1983.

13. Reymann F: Treatment of basal cell carcinomas of the skin with curettage. Arch Dermatol 103:623-627, 1971.

14. Reymann F: Basal cell carcinomas of the skin: Treatment with curettage. Arch Dermatol 111:877-879, 1975.

15. Abadir DM: Combined curettage and cryosurgery for treatment of epithelial cancers of the skin. J Dermatol Surg Oncol 6:633-635, 1980.

16. Chernosky ME: Squamous cell and basal cell carcinomas: Preliminary study of 3,816 primary skin cancers. South Med J 71:802-806, 1978.

17. Camisa C, Roberts W: Monsel solution tattooing. (Letter to Editor.) J AM ACAD DERMATOL 8:753-754, 1983.

18. Salasche SJ: Status of curettage and desiccation in the treatment of primary basal cell carcinoma. J AM ACAD DERMATOL 10:285-287, 1984.

19. Robins P, Albom MJ: Recurrent basal cell carcinomas in young women. J Dermatol Surg Oncol 1:49-51, 1975.

20. Carruthers JA, Stegman S J, Tromovitch TA, et al: Basal cell carcinomas of the temple. J Dermatol Surg Oncol 9:759-761, 1983.

21. Spiller WF, Spiller RF: Treatment of basal-cell carcinomas by a combination of curettage and cryosurgery. J Dermatol Surg Oncol 3:443-448, 1977.

22. Spiller WF, Spiller RF: Cryosurgery and adjuvant surgical techniques for cutaneous carcinomas, in Zacarian SA, editor: Cryosurgery for skin cancer and cutaneous disorders. St. Louis, 1984, The C. V. Mosby Co., chap. 15.

Spiller and Spiller Journal of the


23. Kopf AW: Computer analysis of 3531 basal cell carcinomas of the skin. J Dermatol 6:267-282, 1979.

24. Editors note, in Dobson RL, Thiers BH, editors: Year book of dermatology, 1981. Chicago, 1981, Year Book Medical Publishers, Inc., p. 106.

25. Jackson R: Why do basal cell carcinomas recur (or not recu÷) following treatment? J Surg Oncol 6:245-251, i974.

26. Gooding C, White G, Yatsuhashi M: Significance of marginal extension in excised basal cell carcinoma. N Engl J Med 273:923-924, 1965.

27. Pascal R, Hobby L, Lattes R, Crieklair G: Prognosis of "incompletely excised" versus "completely excised" basal cell carcinoma. Plast Reconstr Surg 41:328-332, 1968.

28. Thomas P: Treatment of basal cell carcinoma of the head and neck. Rev Surg 27:293-294, 1970.

29. Taylor AG, Barisoni D: Ten years' experience in the surgical treatment of basal cell carcinoma. Br J Surg 60:522-525, 1973.

30. Brooks NA: Curettage and shave excision. J A~ ACiD DERMATOL 10:279-284, 1984.

II I

Studies on the anti-inflammatory properties of thalidomide: Effects on polymorphonuclear leukocytes and monocytes R a y m o n d L. Barnhil l , M . D . , N. James Doll , M.D. , LaiTy E. Mil l ikan, M . D . , and

Rober t C. Hast ings , M . D . , Ph .D. New Orleans and Carville, LA

The effects of thalidomide on polymorphonuclear leukocyte (PMN) and monocyte function were studied in vitro. Phagocytosis of latex beads by both PMNs and adherent monocytes was significantly depressed (p < 0.01) after a I-hour incubation of ceils with 10/zg/ml of thalidomide. Concentrations of 1 /zg/ml stimulated monocyte phagocytosis (p < 0.01) but did not influence PMNs. Incubation of monocytes with 10/zg/ml resulted in a significant reduction of chemiluminescence (CL) but had no effect at 1 /zg/ml concentrations. There Was no significant action on PMN CL at either concentration. Finally, 10/zg/ml concentrations of thalidomide were not cytotoxic for either cell type after 18-hour incubations. In conclusion, the results of these studies may at least partially explain the efficacy of thalidomide in some inflammatory conditions. (J AM ACAD DERMATOL 11:814-819, 1984.)

Tha l idomide has been used successful ly in the t rea tment of var ious in f l ammatory conditions

From the Departments of Dermatology and Medicine (Clinical Im- munology), Tulane University School of Medicine, New Orleans, and the Laboratory Research Branch, National Hansen's Disease Center, CarviIle.

Accepted for publication May 11, 1984. Reprint requests to: Dr. R. L. Bamhill, Dermatopathology Labora-

tory, Department of Dermatology, P.O. Box 3333, Yale Univer- sity, New Haven, CT 06510.

814

character ized by tissue infiltration with polymorphonuclear leukocytes (PMNs) , t e .g . , erythema nodosum leprosum (ENL), 1-4 p y o d e r m a gangre-

nosum, ~ recurrent necrotic giant mucocutaneous aphthae and aphthosis, G'7 and Behget ' s syn- drome. 7's Therapeut ic benefi t has been attributed

to depression o f PMN chemotaxis" and possibly also P M N phagocytosis.Z° H o w e v e r , thalidomide has also been reported to be effect ive in other in- f lammatory processes with p redominan t ly mono-

treatment of basal cell epithelioma by curettage and electrodesiccation

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