Editorial.

Epiluminescence microscopy (dermatoscopy) is a technique that was developed to improve the diagnostic abilities of physicians examining pigmented lesions. In experienced hands, this can provide a valuable adjunct to diagnosis of melanoma, but this technique has not been applied to nonmelanocytic skin cancer. Nonmelanocytic skin cancer represents the most common form of all types of cancer, with basal cell carcinoma being the most common cutaneous malignancy. The lead article in this issue of the Journal evaluates the use of epiluminescence microscopy in basal cell carcinomas. The conclusions suggest that diagnostic clinical acumen and biopsy still remain the definitive diagnostic tool. Nonmelanoma skin cancers are a preventable form of cancer, and thus organizations such as the American Academy of Dermatology and the Canadian Dermatology Association have invested significant time and effort in educating the public on the value of sun protection strategies. Sunlight exposure is the environmental exposure most often associated with squamous cell carcinomas of the skin. The article by Bajdik and colleagues uses a case controlled analysis to determine the risk of sunlight exposure for squamous cell carcinoma of the skin of the head and neck and the protective effect, if any, associated with wearing a hat. Their results confirm those of many other studies; that there is a strong association between squamous cell carcinoma and skin type, as well as with sunburn occurring in childhood, and with sunlight exposure during adulthood. However, there was an unusual observation in this study in that there appeared to be an increased risk of squamous cell carcinoma associated with wearing a hat. The authors speculate this may be do to bias or confounding. I would refer you to the Critical Appraisal series of last issue, Volume 3, Number 1 in which Gallagher and Lee review the methods of assessing the incident rates in nonmelanoma skin cancer and highlight some of the difficulties inherent in these studies. Bajdik and coauthors finally conclude that the use of sun protection, particularly with hats, is an unproven means of protecting against squamous cell carcinoma. In spite of this study, I feel that there is sufficient biologic rationale to remain a strong proponent of sun protection including use of hats as part of overall strategies of sun safety. While prevention should be our major goal in nonmelanoma skin cancers, surgery is the mainstay of treatment of established skin cancers. Certain skin cancers, particularly more aggressive basal-cell or squamous cell carcinomas, require MOHS surgery. This surgical technique can result in extensive defects, and repair of these defects is becoming more complex. McGeorge describes a technique, the modified rhombic flap, for optimal closure of some of these defects. In the Basic Science Series, Hosoi and coworkers study whether stress can effect the cutaneous immune response. The above article clearly demonstrates that stress can affect the cutaneous immune response by altering the cell density, intensity and morphology of the major antigen presenting cells in the skin, namely the Langerhans' cells. This gives us further support to the hypothesis that stress can indeed modulate immune function. In our Grand Rounds series, Drs. Searles, Tredget and Lin describe fatal Toxic Epidermal Necrolysis (TEN) associated with vaginal suppositories. Thankfully, TEN is a rare complication; however it can be induced by a number of agents. It is crucial to recognize these changes early since aggressive management with wound care and protection are at present our only therapeutic options.