Terbinafine-Induced Acute Generalized Exanthematous Pustulosis.

Severe cutaneous adverse drug reactions are uncommon but potentially critical clinical situations demanding prompt diagnosis and treatment. We report a rare and severe case of terbinafine-induced acute generalized pustulosis. The patient was directly referred to a Burn Unit where she underwent diagnostic confirmation, systemic supportive care, and wound care treatments. Clinical and histopathological differential diagnosis of severe cutaneous adverse drug reactions is fundamental due to their significantly different management and prognosis.

CO2 laser treatment of a kissing nevus of the penis: an alternative solution for a rare condition.

Divided or kissing nevi are a rare clinical variant of congenital melanocytic nevi developing in adjacent areas of the skin that undergo cleavage during embryogenesis. Penile lesions are even rarer, with only few cases described in the literature. Typically, they present as two opposing dark colored macular or papular lesions on the glans and prepuce, exhibiting a mirror-image symmetry relative to the coronal sulcus. The proposed management ranges from clinical follow-up to surgical excision. However, in this particularly sensitive location the risk of functional and esthetical complications is high, so an alternative treatment option was proposed. We report a case of a penile kissing nevus with its dermoscopic and histopathological characteristics as well as its successful treatment with the carbon dioxide (CO2) laser.

Versatility of the Supraclavicular Flap in Head and Neck Reconstruction.

Objective: Head and neck oncologic resections often leave intricate defects whose reconstruction remains a challenge. The pedicled supraclavicular artery perforator flap is an emerging option, and its applicability in head and neck reconstruction is gaining popularity. Methods: A retrospective analysis of patients regarding medical history, surgical indication, surgical technique, postoperative complications, and outcomes was carried out on all patients admitted to undergo pedicled supraclavicular artery perforator flap reconstruction within our institution. Results: Nine pedicled supraclavicular artery perforator flap reconstructions were performed. Surgical indications were 3 pharyngocutaneous fistulas, 2 tracheoesophageal fistulas, 2 cutaneous defects, 1 immediate pharyngoesophageal reconstruction, and 1 cutaneous and intraoral defect. All flaps survived completely. Excluding one patient who required a second flap due to plate reexposure, the remaining functional and esthetic outcomes were good. Conclusions: The pedicled supraclavicular artery perforator flap is reliable, is quick to harvest, and entails minimal donor site morbidity. Also, it is thin, is pliable, and has a wide arc of rotation, making it extremely versatile. It is an option that should be added to the spectrum of solutions of any head and neck reconstructive surgeon.

Pharyngocutaneous and tracheoesophageal fistula closure using supraclavicular artery island flap.

BACKGROUND: Pharyngocutaneous fistula is a common complication of laryngopharyngeal surgery, being associated with increased morbidity and mortality. Classical regional and free flaps, frequently used in the treatment of this complication, have several limitations, including bulking, donor site morbidity and long operative time. The supraclavicular artery island flap (SCAIF) is a fasciocutaneous flap and presents as an alternative option with good results and without the previously stated limitations. We describe our experience with SCAIF in pharyngocutaneous and tracheoesophageal fistula closure. METHODS: Between April and December 2017, four patients with pharyngocutaneous and two patients with tracheoesophageal fistula underwent fistula closure with SCAIF. Clinical records were retrospectively reviewed. RESULTS: Pharyngocutaneous fistulae were associated with anterior esophageal wall defects ranging from 4 to 13.5 cm2. Tracheoesophageal fistulae defects were smaller (approximately 2 cm2). Fistula closure was achieved in all patients, oral diet was started on the 14th day post-operative and there were no signs of recurrence during follow-up. The donor area was complicated with the formation of hematoma in two patients. CONCLUSIONS: The SCAIF has unique features that makes it an ideal option for pharyngocutaneous and tracheoesophageal fistula closure, namely, reliable perfusion, quick and simple dissection, pliability and minor donor site morbidity. Local complications do not significantly affect long term morbidity of the donor area and can be avoided with simple measures.

Management of Pharyngocutaneous Fistula With Negative-Pressure Wound Therapy.

BACKGROUND: Pharyngocutaneous fistula is a common complication of laryngopharyngeal surgery and is associated with increased morbidity and mortality. Beyond the classical management, negative-pressure wound therapy (NPWT) can be an alternative and effective treatment. CLINICAL REPORT: Two patients with pT3N0M0 squamous cell carcinoma of pyriform sinus were subjected to total laryngectomy and pharyngoesophageal reconstruction of a circular (patient 1) and an anterior wall defect (patient 2) with radial forearm free flap and pectoralis major muscle flap, respectively. Both developed a pharyngocutaneous fistula and NPWT was used.A significant decrease of the fistula aperture and exudate was observed after 22 and 21 days of NPWT in patients 1 and 2, respectively. After that standard wound care was instituted and closure of the fistulae was accomplished in 5 and 7 days, respectively. CONCLUSION: Negative-pressure wound therapy can be an effective treatment for pharyngocutaneous fistula closure, either in the setting of fistulae that persist besides multiple surgical revisions using muscle flaps or as a first-line therapy when fistulae develops.

The Keystone Perforator Island Flap and its Use in Complex Defects of the Trunk: a Case Report.

Complex defects of the trunk present a reconstructive challenge and conservative treatment is frequently unsuccessful. Perforator flaps have become a common option for this problem. The keystone perforator island flap (KPIF) is a fasciocutaneous advancement flap, based on randomly located perforators vessels, whose dissection and exposure is not required. Designed in a curvilinear trapezoidal shape, it allows primary closure of large defects, while avoiding secondary defects and minimizing the need for more complex pedicled flaps or microsurgical reconstructive techniques. The clinical case of a 52-year-old male with stable coronary artery disease and severe aortic stenosis, with severe left ventricular dysfunction, who underwent coronary artery bypass graft surgery and aortic valve replacement is presented. During the post-operative period, he developed anterior mediastinitis and presented a large median sternotomy wound dehiscence, refractory to medical treatment and surgical debridement. The patient underwent reconstruction of the defect with a bilateral KPIF and application of VAC therapy, with favorable outcome. The KPIF is an useful and reliable reconstruction technique for complex defects, that has shown shorter operative times, lower risk of total flap necrosis, reduced donor-site morbidity and favorable aesthetic results, making it a good option in patients with multiple comorbidities.

Os defeitos complexos do tronco constituem um desafio reconstrutivo e o tratamento conservador frequentemente não apresenta sucesso. Os retalhos perfurantes são uma solução cada vez mais utilizada para este problema. O retalho perfurante em ilha "Keystone" (RPIK) é um retalho fasciocutâneo de avanço, baseado em vasos perfurantes de localização conhecida, cuja disseção e exposição não é necessária. É desenhado na forma de um trapézio curvilíneo, permitindo o encerramento primário de grandes defeitos, evitando defeitos secundários e minimizando a necessidade de retalhos pediculados tecnicamente mais exigentes, ou métodos de reconstrução microcirúrgica. É apresentado o caso clínico de um homem de 52 anos de idade com doença coronária estável e estenose aórtica severa, com depressão severa da função ventricular esquerda, que foi submetido a cirurgia de revascularização do miocárdio e substituição da válvula aórtica. No período pós-operatório, desenvolveu mediastinite anterior e deiscência da ferida de esternotomia mediana, refratária a tratamento médico e re-intervenções cirúrgicas com desbridamento. O doente foi submetido a reconstrução do defeito com RPIK bilateral e colocação de vacuoterapia, com evolução clínica favorável. O RPIK é uma técnica reconstrutiva que demonstrou utilidade e fiabilidade na abordagem de defeitos complexos, demonstrando tempos operatórios mais curtos, menor risco de necrose total do retalho, escassa morbilidade da zona dadora e resultado estético favorável, tornando-a uma boa opção em pacientes com múltiplas comorbilidades.

Obesity: a key component of psoriasis.

Psoriasis has been associated with several cardiometabolic comorbidities as well as clinically significant increased risk of cardiovascular disease and mortality. Obesity seems to have a key role in linking psoriasis and cardiovascular disease. There are a growing number of epidemiological studies associating psoriasis and obesity. The mechanism responsible for this association is not certain, but it is probably multifactorial, involving genetic, environmental and immune-mediated factors. Nonetheless, the chronic inflammatory state associated with obesity appears to be a key component of this relationship. Obesity is, therefore, a major factor in the management of psoriatic patients, with implications in treatment efficacy and safety. Moreover, weight loss has been shown to have a positive effect on psoriasis severity and response to treatment. The aim of this review is to synthesize the current evidence on the association between psoriasis and obesity, exploring the physiopathological mechanisms that link both diseases and highlighting the importance of obesity control in the efficacy and safety of systemic treatment of psoriasis. All clinicians must be aware of this association, so they can recognize it and provide the patients a proper follow-up and multidisciplinary approach when needed.

[Normal and abnormal meningeal enhancement: MRI features]. / Les prises de contraste méningées normales et pathologiques en IRM.

The authors describe normal imaging of the meninges and meningeal spaces and MR (magnetic resonance) imaging findings in tumoral and nontumoral diseases. Dural or/and pial enhancement may be related to tumoral, infectious or granulomatous diseases.