Surgical Tip: The Double-Bladed Scalpel in Mohs Micrographic Surgery

Mohs micrographic surgery is applied as the primary method of treatment for various cutaneous neoplasms. Many other methods that are modified applications of Mohs micrographic surgery have also been suggested. We introduce a technique, which is a modified vertical method of Mohs micrographic surgery using the double-bladed scalpel.

A Case of Milium-like Syringoma on Vulva / 대한피부과학회지

Milium-like syringoma is a rare variant of syringoma first described by Friedman and Butler in 1987. Clinically, it presents as milium, but histologically reveals syringoma with overlying keratin filled epidermoid cysts. It occurs predominantly on the periorbital area of middle-aged women. Syringomas on the genital area have rarely been reported. The lower portion of the cysts and keratin materials show positivity for CEA and negativity for CK7. The pathogenesis is not well defined, but there are some hypotheses, which include pruritus and increasing hormonal receptors (estrogen and progesterone receptors). We report a case of milium-like syringoma on the vulva.

The Effect of Montelukast in the Treatment of Atopic Dermatitis through the SCORAD Index / 대한피부과학회지

BACKGROUND: Atopic dermatitis (AD) is a chronic, relapsing, inflammatory skin disease, with genetic and environmental background. The pathogenesis is complex, and although the dermatitis fades during childhood in most cases, the course is unpredictable. Leukotrienes are potent proinflammatory mediators derived from arachidonic acid through the 5-lipoxygenase pathway. Leukotrienes are likely to play a role in the inflammation seen in AD. It is therefore of interest to attempt to reduce the activity of AD by the use of leukotriene antagonists. Montelukast (Singulair(R)) has shown promising results in the treatment of both children and adults with AD, and the safety profile of this medicament is excellent. OBJECTIVE: The objective of our study was to evaluate the efficacy of montelukast for severe AD. METHODS: Thirteen patients with moderate to severe AD were treated with montelukast. The dose of montelukast was 10 mg/day for 8 weeks. At enrollment and on each follow-up visit, every patient was assessed by a single observer and objectively scored for disease extent and severity using SCORing Atopic Dermatitis (SCORAD). In 6 of 13 patients, we measured serum cysteinyl leukotriene levels before and after treatment using ELISA and checked serologic marker such as total Ig E at the first visit and eosinophil counts at every follow-up visit. RESULTS: Patients with a median (range) age of 18.2 (7~38) years participated in the study. Their median SCORAD scores before treatment, at first follow-up (mean 4 weeks later), and at second follow-up (mean 8 weeks later) were 52.4, 35.7, and 29.5. All components of SCORAD (extent, intensity, symptoms) of all patients and eosinophil counts (n=6) had decreased significantly except the extent. Serum cysteinyl leukotriene levels (n=6) had decreased, but not significantly. CONCLUSION: According to our study, montelukast is an effective medicament in the treatment of severe AD patients. So we can take a montelukast as an alternated agent instead of steroid and immunosuppressant agents in severe AD.

A Case of Atypical Vascular Lesion of the Skin following Radiotherapy for Breast Carcinoma / 대한피부과학회지

"Atypical vascular lesions" is the term which was first used in 1994 by Fineberg and Rosen for vascular lesions after radiation therapy except for cutaneous angiosarcoma. Vascular lesions mostly occur after radiation therapy in breast cancer patients who have undergone mastectomy. The lesions are 5 mm or less, red or red-brown papules, histologically dilated vascular channels extended as the superficial and mid-dermis are observed. Post-radiation vascular lesions tend to follow a benign course with metastasis or death not having been reported yet. The lesions look histologically similar to well differentiated cutaneous angiosarcoma occurring after radiation therapy and breast reconstruction, indeed it is possible for post-radiation vascular lesions to become cutaneous angiosarcoma. Atypical vascular lesions have recently become a new issue for concern in some countries. Within Korea however, until now, a case it had not yet been reported. The patient was 50 year-old female who had chemotherapy after Modified Radical Mastectomy and salpingoophorectomy for breast cancer and endometriosis, atypical vascular lesions in the field of radiation therapy occurred. We report an interesting case of atypical vascular lesion.

Combination Nasolabial Transposition Flap and Island Pedicle Flap Following Mohs Surgery of Simultaneous Basal Cell Carcinomas Involving Both Nasal Alae

The nasal ala is a challenging area for surgical reconstruction, with thick sebaceous skin, the lack of an ample tissue reservoir, and an adjacent free margin. Numerous flaps have been reported for the repair of alae defects. A 71-year-old woman with simultaneous basal cell carcinomas involving both nasal alae was treated by Mohs micrographic surgery. The surgical defects measured 1.5x1.5 cm on the center of the right nasal ala and 1.0x1.0 cm on the left nasal ala, including the alar crease and rim. The right nasal ala was used as a nasolabial transposition flap and the left nasal ala was reconstructed by an island pedicle flap. The final shape and texture were satisfactory. The flaps survived and nasal symmetry was preserved. Combined nasolabial transposition and island pedicle flaps thus offer a superior esthetic and functional result owing to minimized tension. This may be a valuable reconstructive option in the repair of bilateral nasal alae defects.

A Case of Xanthoma Disseminatum with Diabetes Insipidus / 대한피부과학회지

Xanthoma disseminatum (XD) is a rare, potentially progressive non-Langerhans cell histiocytosis, which preferentially affects males in their childhood or young adulthood. It is characterized by the insidious onset of small, yellowish-red to brown papules and nodules that are discrete and disseminated. They characteristically involve the eyelids and flexural areas of the axillary and inguinal folds, and the antecubital and popliteal fossae. Systemic disease frequently occurs, the most common manifestation being diabetes insipidus (DI), which occurs in about 40% of cases and is due to deposition of xanthoma cells in the hypothalamic-pituitary axis. We present a case of XD with DI, which was treated with the combination therapy of CO2 laser vaporization, cyclophosphamide, electrocauterization and synthetic anti-diuretic hormone.

A Case of Pigmented Neurofibroma Associated with Giant Cafe-au-lait Patches / 대한피부과학회지

Pigmented neurofibroma is a rare cutaneous tumor accounting for less than 1% of all neurofibroma. It is characterized histologically by the coexistence of scattered melanin-laden cells and benign spindle cells with neural differentiation. The origin of these tumors are unknown, and they show a storifom pattern. In our case, the patient had giant cafe au lait patches on the left trunk which had been present since birth, freckles on both axilla, and two dark-red colored plaques which had appeared 2 years ago. Histologic examination revealed pigmented neurofibromas showing the melanin-laden, pigmented cells within the upper dermis and plexiform neurofibromas in the subcutaneous tissue. We describe a case of pigmented neurofbroma in a 13-year-old male patient.

A Case of Generalized Lichen Planus Treated with Topical Pimecrolimus / 대한피부과학회지

Lichen planus is a chronic papulosquamous disease chracterized by various clinical manifestations of the skin and mucous membrane. Although its etiology is not fully understood, lichen planus has been associated with viral infection, autoimmune disease, psychologic factors, and medications. Both antigen-specific and non-specific mechanisms may be involved in the pathogenesis of lichen planus. The former includes antigen presentation by basal keratinocytes and antigen-specific keratinocyte killing by CD8+ cytotoxic T cells, the latter includes mast cell degranulation and matrix metalloproteinase activation. A large variety of topical and systemic therapies are available for the treatment of lichen planus. Also, topical pimecrolimus (Elidel(R) 0.1% cream) may be used because of its inhibitory effect on activated T cells and mast cell degranulation. Recently, it has been shown to be effective in the treatment of oral and genital lichen planus. But, its effect in cutaneous lichen planus has not been reported to date. We report on the successful use of topical pimecrolimus in the management of a generalized lichen planus patient.

Histopathologic Gradings Correlate with Clinical Prognostic Factors and Therapeutic Effects in Patient with Alopecia Areata / 대한피부과학회지

BACKGRUND & OBJECTIVE: Prognosis of alopecia areata have been attributed to various factors; age of onset, duration before treatment, extent of hair loss, clinical type of alopecia areata, sex, nail changes or accompaniment of atopy. The study on prognostic factors has only been conducted from statistical data of patients and individualized medical conditions. The histopathologic findings of alopecia areata have been investigated by the minute pathologic changes associated with the hair growth cycle in the transverse section. Moreover, these findings were used mainly for diagnostic purpose, but clinical significance of histopathologic severity in prognosis has not been established to date. METHODS: A clinical study, including histopathological and clinical evaluation was conducted on 108 alopecia areata patients between July 1997 and August 2005 at the Department of Dermatology, Dong-A University Hospital. The evaluation criteria INCLUDED: sex, age, age at onset, duration before treatment, clinical types, extent of hair loss, nail changes, accompaniment of atopy, and scalp biopsy finding. The clinical types of alopecia areata were classified as follows; patchy, subtotalis, totalis, and universalis. The extent of hair loss before treatment was classified into 5 grades (S1~S5), according to the method designed by Olsen and Canfield. Clinical improvements after treatment were classified into 5 grades according to degree of regrowth and reduction of the alopecia areata area. Biopsy findings were classified into 4 grades (type I, II, III, and IV) according to classification by Uno and Orecchia. RESULTS: The mean age was 28.6 years, without any sex predominance. The severe histopathologic gradings were significantly associated with early age of onset (p=0.008), a long disease duration before treatment (p=0.003), a greater extent of hair loss (p=0.009), and poor response to treatment (p=0.036). The histopathologic gradings were not significantly associated with sex (p=0.657), clinical types of alopecia areata (p=0.529), nail changes (p=0.746), or accompaniment of atopy (p=0.924). CONCLUSION: Histopathologic gradings in alopecia areata, using vertical sections are significantly associated with prognostic factors such as age of onset, extent of hair loss, disease duration before treatment, as well as the response to treatment. Therefore we consider that the histopathologic grading system is recommendable as an independent prognostic factor in alopecia areata, in addition to the well-known clinical prognostic factors. They may also be used to predict the response to treatment.

Therapeutic Effects of Tazarotene on Psoriasis and Its Potential Action Mechanism in Inflammatory Angiogenesis / 대한피부과학회지

BACKGROUND: Psoriasis is characterized by chronic recurrent erythematous skin plaques that exhibit epidermal hyperplasia, inflammatory cell accumulation and abnormalities of the papillary dermal vasculature. Psoriatic skin lesions show enlargement and increased tortuosity of cutaneous microvessels without formation of new vessel sprouts, that is, inflammatory angiogenesis. Placental growth factor (PlGF) and Tie-2 were reported to be up-regulated during inflammatory angiogenesis. Tazarotene is the first receptor-selective retinoid and its effects include normalizing keratinocyte differentiation, reducing keratinocyte proliferation and reducing inflammation. OBJECTIVE: Our study evaluated the clinical efficacy of topical tazarotene treatment and clarified histological changes and possible action mechanisms of this agent in respect of inflammatory angiogenesis. METHODS: We selected patients with symmetric psoriatic lesions and applied 0.1% tazarotene gel (Tazorac(R)) versus calcitriol 3 microgram/g gel (Silkis(R)) twice a day for 12 weeks with a right-left comparison. We grouped the patients with treatment modalities. Clinical efficacy, which was measured by the overall lesional assessment (OLA) scores, was assessed at each visit in 2 week' intervals until treatment closed. Skin biopsies were performed before the treatment started and again at 4 weeks and 12 weeks after treatment. Immunohistochemistry of PlGF, Tie-2 and factor-VIII was performed to elucidate the anti-angiogenetic effect of tazarotene. RESULTS: At the completion of 12 weeks of treatment, the OLA score of tazarotene-treated lesions was more reduced than that of calcitriol-treated lesions combined with phototherapy, it was more effective. Several histologic features such as epidermal hyperplasia, inflammatory cell infiltration and vessel dilation/tortousity were improved with decreased PlGF and Tie-2 expressions. CONCLUSION: These results indicate that tazarotene is an effective topical agent for psoriasis by blocking inflammatory angiogenesis.

Treatment Outcome and Satisfaction after Micrographic Surgery Using Margin Strip Method / 대한피부과학회지

BACKGROUND: Mohs micrographic surgery (MMS) was known as an ideal treatment for non-melanocytic skin cancers. Recently, various modified MMS methods have been introduced. Margin strip method is a modified micrographic surgery technique that makes operation and reconstruction more easy. OBJECTIVE: The aim of this study was to evaluate the treatment results and patients' satisfaction of micrographic surgery using margin strip method. METHODS: We reviewed 72 cases of basal cell carcinomas (BCCs) and 36 cases of squamous cell carcinomas (SCCs) treated with micrographic surgery using margin strip method from January 2001 to December 2004. We analyzed them in aspects of the sex, age, duration, location, size and histological types of tumor. They were also evaluated in aspects of surgical margin, depth, stage, defect size and reconstruction methods. We also analyzed follow-up data concerning recurrence rate, complications and patients' satisfaction. RESULTS: SCCs were more common in older age groups, and BCCs were showing centrofacial distribution. Mean numbers of stage was 1.5 in BCC and 1.3 in SCC, and safety excised margins were 0.72 cm in BCC and 1.03 cm in SCC. Infiltrative type of BCC, the numbers of stage and size of safety excised margin were increased. The transposition and rotation flap were most commonly used in BCC and SCC, respectively. Patients' satisfaction were 8.06 in BCC and 7.76 in SCC. 6. Recurrence rate were 0% in BCC and 5.6% in SCC. CONCLUSION: Micrographic surgery using margin strip method may be a useful and satisfactory method for the treatment of non-melanocytic skin cancers.

A Case of Generalized Lichen Nitidus Treated with Low Dose Cyclosporine / 대한피부과학회지

Lichen nitidus is a rare and chronic inflammatory dermatosis first described by Pinkus in 1907. The etiology of it is still unknown and the majority of instances appear in children and young adults. The lesions are usually asymptomatic but may be mildly pruritic and the Koebner phenomenon may be observed. It is characterized by flesh-colored, minute, shiny papules occurring on the genitalia, abdomen, chest, and extremities. This disorder is most often localized, but there are rare reports of patients having a more generalized distribution of lesions. Although lichen nitidus is self-limited in most cases without any sequelae, the course of generalized lichen nitidus is unpredictable. We report a case of a 16-year-old girl diagnosed by generalized lichen nitidus refractory to general treatment and successfully treated with low dose cyclosporine (2 mg/kg/day).

A Case of Pseudocyst of the Auricle Treated by Incisional Biopsy / 대한피부과학회지

Pseudocyst of the auricle is an uncommon condition, which typically presents as an asymptomatic, noninflammatory swelling of the external ear. Most of the patients are usually young, healthy males without trauma. Histological examination is characterized by the intracartilaginous accumulation of serous fluid without an epithelial lining. The pathogenesis is unknown. Some theories about the release of lysosomal enzymes or inflammatory mediators and embryologic dysplasia of the auricle cartilage have been suggested. Treatment of pseudocyst of the auricle has usually involved a simple aspiration and compressive dressing, but this may often cause the fluid to reaccumulate. Treatment by surgical excision may result in a permanent deformity and scar of the auricle. Therefore, various treatments have been suggested. We report a case of pseudocyst of the auricle successfully treated by incisional biopsy only.

Multiple Cutaneous Edema and Infiltration of Signet-ring Cells in the Lymphatics as an Initial Manifestation of Metastatic Gastric Adenocarcinoma / 대한피부과학회지

Signet-ring cells are cells in which the nucleus is crescentically compressed with a cellular border, so that the cell looks like a signet-ring. Many cutaneous signet-ring cell neoplasms originate from the stomach, lung and breast, and these appear to be the most common sites of origin. In skin, the appearance of signet-ring cells within a neoplasm can indicate metastatic adenocarcinoma of the stomach, lung and breast. Thus, the primary origin and other metastatic sites should be evaluated. A 44-year-old man presented with a six month history of cutaneous swelling on the left axillary and left supraclavicular area. Histopathologic findings of the axillary lesion showed signet-ring cells in the lymphatics. These clustered cells were PAS-positive, diastase-resistant, and stained with colloidal iron and CEA. During the work-up study to find the primary origin, we discovered advanced gastric cancer and multiple lymph node metastases.

A Case of Calcifying Aponeurotic Fibroma with Gait Disturbance / 대한피부과학회지

Calvus, callus, plantar warts and piezogenic papules are well known to cause discomfort and disturbance of gait in ordinary physical and sports activities. Furthermore, calcifying aponeurotic fibroma, whose mass slowly grows on the palms and soles of children and young adults, leads to pain, disturbance of gait, and even to skeletal deformities. A 22-year-old woman noticed an elevated subcutaneous mass on the left plantar surface of her big toe, which was accompanied with pain, tenderness and gait disturbance. The histologic findings showed an ill-circumscribed fibroblastic proliferation with foci of calcification and chondroid differentiation. After total excision of the mass, the patient became free of the above symptoms and the lesion did not recur for 9 months.

A Case of Nicolau Syndrome Treated by Surgical Excision / 대한피부과학회지

Nicolau syndrome or embolia cutis medicamentosa is an acute necrotic condition of skin that follows intramuscular injection of drugs. A 36-year-old man developed a painful, purpuric and erythematous patch on his left buttock following an intramuscular injection of diclofenac sodium. Histologically, the patch lesion displayed epidermal necrosis, dermal degeneration, and vascular thrombosis. We report a rare case of Nicolau syndrome following intramuscular injection of diclofenac sodium. In our case, the patient was successfully treated by surgical excision with primary closure.

A Case of Lentigo Maligna Melanoma Treated with Mohs Micrographic Surgery / 대한피부과학회지

Lentigo maligna melanoma and lentigo maligna are typically located on photo-exposed sites such as the head and neck, with the cheek being the most common site. Since lentigo maligna melanoma and lentigo maligna are found predominantly on such cosmetically-sensitive areas, it is critical to determine the exact histologic margin for maximal sparing of tissue and complete extirpation of the tumor. Since Mohs micrographic surgery has been recommended for tumors on cosmetically-sensitive locations where the tumor margin is indistinct, it appears to be a reasonable treatment modality for this type of tumor. We describe a case of lentigo maligna melanoma on the cheek, which was resected with Mohs micrographic surgery.

A Study of Dermatosis and Characteristics of the skin in the Super-old ages and Centenarians / 대한피부과학회지

The increased aging of the population in the developed world is an accepted fact. Consequently, the number of patients aged 90 years or above (super-old age: from 90 to 99), and centenarians (above 100) will increase in the coming years. The objective was to determine the prevalence and characteristics of skin diseases in the population of super-old ages and centenarians. A total of 50 volunteers, aged from 90 to 106 years, were enrolled on this study. They completed a questionnaire about skin diseases and underwent a cutaneous examination during the period of July 26 to 30, and Aug 23 to 28, 2004. The average age of the volunteers was 96.3 years. 28 volunteers were women and 22 were men. The common diseases were found to be senile lentigo, seborrheic keratosis, idiopathic guttate hypomelanosis, xerosis, telangiectasia, onychomycosis, tinea pedis, and cherry hemangioma. Wrinkle grading of men was less severe than in women. The degree of pigmentation was independent of age and sex. However, activity and pigmentation scale showed a significant statistical correlation. Gray hair and alopecia in men was more severe than in women. As for aging factors, smoking, activity, location, and occupation did not appear to play an important role in wrinkle formation. The incidence of skin disorders increased with age, due to changes in skin structure and lifelong exposure to environmental aggravations. Super-old aged people often have many skin diseases. However, only a small number of volunteers were included in this study. Therefore, further dermatologic studies need to be conducted.

A Case of Primary Mucinous Carcinoma of the Skin / 대한피부과학회지

Primary mucinous carcinoma of the skin is a rare adnexal neoplasm with sweat gland differentiation. Mucinous carcinoma can occur in noncutaneous visceral sites and may metastasize in the skin. Thus it is important to exclude the possibility of a noncutaneous visceral primary tumor before diagnosing primary mucinous carcinoma of the skin. This tumor has a tendency for slow growth, local recurrence, and infrequent metastasis. To decrease local recurrence, Mohs micrographic surgery can be used to treat primary mucinous carcinoma of the skin. We describe a case of primary mucinous carcinoma of the skin which was resected by Mohs micrographic surgery.

Categorization of Vascular Lesions and Selection of Treatment Modalities Using Color Doppler Ultrasound / 대한피부과학회지

BACKGROUND: Vascular lesions can be diagnosed by biopsy, simple x-ray, ultrasound, CT, MRI, venography and MR angiography. These diagnostic tools can identify the detailed structure and abnormalities in the peri-lesional area of vascular lesions. Color Doppler ultrasound (CDU) can demonstrate the hemodynamic features, distribution of veins and arteries, shunts and structures of vascular lesions. Authors have tried to categorize vascular lesions with CDU and also applied this to the selection of treatment methods. MATERIALS AND METHODS: Forty-seven vascular lesions were evaluated by means of CDU. All patients underwent a complete clinical evaluation as well as peak systolic velocity (PSV), peak diastolic velocity (PDV), resistive index (RI) of feeding arteries. In particular, we evaluated the hemodynamic features and structures of vascular lesions. We categorized the vascular lesions and then treated them with systemic steroid, compression, SPTL1 Dye laser, steroid intralesional injection and sclerotherapy. We evaluated the clinical improvement and objective effects of treatments by CDU. RESULTS: There were 37 hemangiomas and 10 vascular malformations. Vascular lesions were classified by the hemodynamic features and structures: category Ia (infantile hemangioma, regressed infantile hemangioma), Ib (RICH), Ic (deep hemangioma, mixed hemangioma), II (arteriovenous malformation), III (venous malformation, verrucous hemangioma). The clinical improvement after treatment was associated with the decrease of PSV and RI values. The clinical improvement above 50% resolution of the lesion showed 70.9% in category Ia, 50% in Ib, 66.6% in Ic, 83.3% in II and 50% in III. CONCLUSIONS: The analysis of hemodynamic feature and structures by CDU can be helpful in the study of vascular lesions. These processes suggest CDU be a useful modality in differential diagnosis of vascular lesions and a more advantageous tool in the decision of treatment policy than the conventional modalities. And it is also useful for the evaluation of treatment effects.