BACKGROUND:With the newly described one step melanoma surgical approach, some patient groups could be successfully treated within one surgical session. Depending on the tumour thickness (measured preoperatively) at a later stage (also depending on the ultrasound findings of the locoregional lymph nodes) the respective surgical intervention is planned with the respective field of surgical safety (one-stage melanoma surgery with or without removal of lymph nodes). The innovations could make to some extent some of the already existing algorithms more difficult (due to the introduction of a high-frequency ultrasound to determine the tumor thickness preoperatively as an absolute prerequisite for dermosurgical centres), but it would also lead with absolute certainty to better or least optimal results regarding the prognosis, the side effects and the financial factor also.CASE REPORT:We present a patient from the Department of Dermatology, Venereology and Dermatologic Surgery at the Medical Institute-Ministry of Interior (MVR-Sofia), treated with the one-step melanoma surgery method with perfect final results. The preoperative tumour thickness determined via ultrasound and the postoperatively measured histological tumour thickness was identical: between 0.98 and 1 mm, which allowed removal of the melanoma lesion with a field of surgical security of 1 cm in all directions and did not require additional removal of a draining lymph node or excisions.CONCLUSION:Thanks to this new approach, some patients could avoid one surgical intervention, which could be interpreted as a significant advantage or probably also survival benefit. This methodology and its successful application were first officialised by the representatives of the Bulgarian Society for Dermatologic Surgery- (BULSDS), and the purpose of this action, in general, is to fully improve clinical management of patients suffering from cutaneous melanoma in terms of compactness by 1) reducing the number of unnecessary surgeries or the number of surgical interventions in general; 2) reducing side effects occurring in surgeries and 3) introducing a serious optimization in terms of financial resources needed or used in the second hospitalization of patients. The question remains open whether the accepted or the current recommendations for surgical treatment of melanoma will be transformed or adapted for the matching patient groups.

BACKGROUND:One step melanoma surgery is a new surgical approach by which specific groups of patients with cutaneous melanoma may be operated only by or within a single surgical session. Until now, the Bulgarian Society for Dermatologic Surgery (BULSDS) has presented models of clinical behaviour, in which preoperative measurement of tumour thickness in combination with echographic measurement of the locoregional lymph nodes could lead to the conduct of the so-called one-step melanoma surgery. Although this one step surgery currently does not fit in the recommended guidelines, it ensures compliance of the recommended boundaries of operational security while saving patients a repeated excision and relieves the healthcare institutions or the patients themselves financially.CASE REPORT:We at this moment present another case from the Bulgarian Society for Dermatologic Surgery (BULSDS) of one step melanoma surgery with a perfect end result, where the tumour thickness was not preoperatively determined by high-frequency echography. Preoperative assessment of tumour thickness was performed based on the clinical picture and dermatoscopy. The histologically established tumour thickness was identical to the preoperative assessment, i.e. <1 mm. Removal of the melanocytic lesion was performed with operational security field of 1cm in all directions, where, as a rule, no further removal of the draining lymph nodes is required.CONCLUSION:One step melanoma surgery has two significant advantages: 1) it saves a re-excision in certain groups of patients, which in turn is 2) significantly more favourable from a financial point of view. Its applicability in the appropriate groups of patients and the postoperative (although in a limited number of patients) results achieved indicate the need to optimise the current algorithms and direct them individually to each patient. Guidelines may not and should not be unified or set strict limits given the fact that they show a significant level of variability themselves regarding some key moments in the initial surgical treatment of melanoma. More than 10% of the primary melanoma cases refer to thin melanomas, and dermatoscopy and clinics are a sufficient method of optimising the planned surgical excision.

BACKGROUND:The Stewart-Treves syndrome with localisation in the region of the lower extremities is not something unusual as clinical pathology, but the clinical diagnostics is rather difficult, and it can be further complicated maximally because of: the similar locoregional findings in patients with other cutaneous malignancies.CASE REPORT:Presented is a rare form of an epithelioid variant of the Stewart Treves syndrome in a woman, aged 81, localised in the region of the lower leg and significantly advanced only for 2 months. The diagnosis was confirmed histologically and immunohistochemically. Amputation of the affected extremity was planned. Discussed are important etiopathogenetic aspects regarding the approach in patients with lymphedema and possibility for development of the Stewart Treves syndrome.CONCLUSION:Analyzing the evidence from the literature worldwide, we concluded that perhaps the only reliable (to some extent) therapeutic option in patients with Stewart Treves Syndrome is 1) the early diagnostics and 2) the following inevitable radical excision or amputation with the maximal field of surgical security in the proximal direction.

BACKGROUND:Modern drugs could sometimes be a good solution even to problematic patients. The cutaneous and systemic forms of the CD30 positive anaplastic large T-cell lymphoma could often be described as a suitable target for therapy with Brentuximab vedotin.CASE REPORT:We present the first case of a Bulgarian patient with a histologically confirmed primary cutaneous T-cell CD30+/ALK- large anaplastic cell lymphoma-cALCL (therapeutically resistant to therapy with Methotrexate, radiation therapy and systemic corticosteroid therapy) who was successfully treated with Brentuximab vedotin. In several years, the patient has developed a comparatively fast skin progression as well as an initial systemic one which impacts inguinal and mediastinal nodes. After the implementation of 4 therapy cycles with Brentuximab vedotin, complete regression of the described by previous hospitalisations lymph nodes as well as 80% reduction of the cutaneous and subcutaneous located tumour formations were observed.CONCLUSION:The therapy of CD30+/ALK- anaplastic large T-cell lymphoma is a significant challenge for oncologists and dermatologists because it requires maximally efficient and minimally traumatic treatment in parallel. Therapy with Brentuximab is a new direction which shows extremely good clinical results and can be applied to the cutaneous as well as to the systemic form of anaplastic large-cell CD30 positive lymphoma. The key element by treatment with Brentuximab is suppression of the CD30- expression which, in turn, could be the cause of relapses. On that ground, patients with these lymphomas should be strictly monitored.

Background: There are different literature data according to which small plaque parapsoriasis (SPP) and guttate parapsoriasis could be considered as part of the various clinical forms of MF. However, there are no literature data that compare different control groups of patients (receiving/ not taking antihypertensive medication) and the two important possibilities deriving from it, namely: 1) that certain drug forms could be inducers of parapsoriasis and 2) that other drug forms could potentiate the transformation of existing parapsoriasis into T-cell lymphoma. We describe a case of possible infectious and / or drug-induced SPP by discussing an important, albeit currently hypothetical link to the drug mediated cancerogenesis. Case report: We present a 39-year-old man with a disseminated eruptive erythemo-papulo-squamous rash, localized on the skin of the trunk and extremities. According to anamnestic data, skin symptoms date back to about 1 month when the patient was hospitalized in the ENT compartment for severe throat pain. Primary empirical antibiotic therapy with clindamycin 4x 600mg/ daily i.v was performed on a regimen and partial remission was achieved. Immediately afterwards there was a resumption of symptoms and the additional occurrence of skin lesions. From the conducted tests, the presence of acute tonsillopharyngitis, focal infection of dental origin and elevated antistreptolysin titer was found. In parallel, the patient receives antihypertensive therapy (ACE inhibitor and beta blocker) on the occasion of arterial hypertension. There was a suspicion for infectious and / or drug-triggered psoriasis gutata, as the subsequent histological study showed evidence of small plaque parapsoriasis. Conclusion: Although there are a number of literature data on the relationship between antihypertensive drugs and their pro-or anticancerogenic action against various types of tumors, there is currently no data available to compare the existing risk of developing T- cell lymphoma in patients with SPP and concomitant cardiac therapy with ACE inhibitors and beta blockers. We present a patient with triple histologically verified small plaque parapsoriasis and we are discussing a completely new pathogenetic element: triggering in the framework a possible chronic infection and systemic antihypertensive therapy. The selected retrospective or prospective analysis of wider groups of patients with chronic infections / systemic antihypertensive medication as well as proven T cell lymphomas could provide clarity with respect to the shared by us observations in single patients. Keywords: Small plaque parapsoriasis; antihypertensive drugs; chronic infections; triggers; drug mediated cancerogenesis;

Grover’s disease is a transient acantholytic dermatosis that usually disappears within a few weeks, but it can also be presented as a persistent variant with a duration of more than 3 years. The etiology of this disease is not entirely clear and possible causes include viral infections, drug reactions (BRAF inhibitors and allogeneic haematopoietic stem cell transplantation). In terms of treatment, topical and systemic steroids, oral vitamin A and PUVA therapy are described. We present a 79-year-old man with a 1-month complaint for a recurring, highly itchy, blistering rash on the skin of the upper limbs, back and chest. During the clinical examination, there was an erythemo-papulo-vesicular polymorphic rash , in places with xerosis areas, engaging the upper part of the trunk, as the initial data and subsequent histopathological verification data spoke undoubtly in direction of acantholytic dermatosis or Grover’s disease .During hospitalization, systemic antihistamine and topical steroid therapy was performed. Subsequently, ambulatory therapy with Acitretin 20 mg /daily per os and Methylprednisolone aceponate 0.1% x 2 / daily topically was given with a good therapeutic response. We believe that this case seems to be the first officially documented case of Morbus Grover associated with idiopathic low-grade thrombocytopenia. Key words: Morbus Grover; Idiopathic thrombocytopenia; Acitretin; Prednisolone; PSA

According to the literature data, pityriasis lichenoides chronica (PLC) can also be considered as a drug-induced disease among many other possible causes, e.g. parainfectious!. Currently, the following medications are described as possible triggers among drugs: antidepressants and statins, adalimumab, HMG-CoA reductase inhibitors, pemetrexed and infliximab. We present a 82-year-old man with ischemic cerebral infarction on the occasion of which he accepts acetylsalicylic acid 100mg (0-0-1) since December 2018. According to the patient, immediately (or about 2 months) after starting medication with acetylsalicylic acid, he observed raised itchy lesions on the skin of the trunk. During the dermatological examination, presence of disseminated erythemo-papulous, partially lichenoid lesions, excoriations and fine desquamation was established on the skin of the trunk and the extremities. Possibility for pityriasis lichenoides chronica, parapsoriasis small plaque form or lichen planus was considered. A skin biopsy was taken, and histological examination revealed evidence for pityriasis lichenoides chronica. Due to the suspicion for drug induced pityriasis, acetylsalicylic acid treatment was discontinued and replaced with clopidogrel. After a period of 6 weeks, we observed a good clinical response and reversal of the skin symptoms. We present the first case of acetylsalicylic acid induced PLC think the conclusion with certainty is not possible. Only the disappearance after change of medication does not prove the induction by ASS. In case of recurrence of the skin changes after reexposition with ASS could prove the causative role of ASS. Patients with this type of disease should be closely monitored because of the possibility for development of lymphoproliferative disorders.

BACKGROUND:Blue nevus is an interesting finding, which aetiology and risk of locoregional and distant metastasis have not yet been fully clarified. It may be inherited or acquired, with sporadic cases usually presented as solitary lesions. It is often localised in the area of the head and less often on the arms, legs or trunk. Blue nevi are formations with relatively low but still possible potential for switching to melanoma.CASE REPORT:The patient we described was hospitalised for pronounced cyanosis of the small toe of the right foot, accompanied by painful symptoms at rest and pain symptoms for a few weeks. Using inpatient paraclinical and instrumental tests, the patient was diagnosed with cholesterol microembolism. During the dermatological examination, blue nevus on the contralaterally localised limb was also diagnosed as a sporadic finding. According to the patient’s medical history, the finding had existed for many years, but in the last few months, the patient has observed growth and progression in the peripheral zone of the nevus without any additional clinical symptoms.CONCLUSION:Due to the risk of progression to melanoma, the lesion was removed by radical excision, and the defect was closed by tissue advancement flap.