Comparison of electrodessication with CO2 laser for the treatment of actinic cheilitis.

BACKGROUND: Actinic cheilitis is a common premalignant condition that is most often treated with destructive therapy. The most effective technique is usually considered to be CO2 laser resurfacing. Little has been written on the use of electrodessication for this condition. OBJECTIVE: We designed a study to compare these two treatment modalities for the treatment of biopsy-confirmed actinic cheilitis. METHODS: A random half of the lower lip was treated with electrodessication. The contralateral half was then treated with CO2 laser. Healing time, subjective pain during healing, and clinical outcome at 3 months was compared. RESULTS: The side treated with electrodessication took significantly longer to heal than the side treated with the CO2 laser (23 versus 14 days, P <.001). There was no difference in subjective pain or clinical appearance at 3 months. CONCLUSION: Although the healing time is longer with electrodessication, this modality represents an inexpensive practical ablative treatment method for actinic cheilitis.

Evaluation and management of nonmelanoma skin cancer. The military perspective.

As the incidence of melanoma skin cancer continues to increase in this country, so does the need for early detection and treatment of these tumors. This article discusses a military skin cancer screening clinic that encourages patient participation and the criteria and statistics regarding the different treatment modalities we employ to treat these skin cancers.

Positive surgical excision margins of a basal cell carcinoma.

This case illustrates two strongly and diametrically opposed options advocated in the literature for dealing with positive surgical margins. The best plan is to individualize the decision-making process based on the available variables (histology, location of positive margins), the patient's age and health, and a "guided," but informed decision by the patient.

Lower extremity purpura associated with new-onset autoimmune hepatitis: an unusual presentation.

Autoimmune hepatitis is a chronic necroinflammatory disorder of unknown cause. The morbidity and mortality of this potentially lethal disorder can be minimized by timely diagnosis and treatment. Patients can present with a wide variety of clinical and laboratory manifestations, including high titers of antinuclear antibody and other autoantibodies commonly associated with dermatologic disorders. Overt evidence of hepatic injury can be a late finding. An unusual presentation of autoimmune hepatitis and a brief review of its clinical features are presented, with an emphasis on those findings most relevant to a practicing dermatologist.

Alabaster skin after carbon dioxide laser resurfacing with histologic correlation.

BACKGROUND: Carbon dioxide laser resurfacing has gained popularity as a relatively safe and effective method of facial rejuvenation. Original reports describe mostly reversible side effects and a low incidence of scarring. Only very recently have reports of delayed hypopigmentation surfaced. This effect is not visible until several months after resurfacing, and most likely represents a permanent change. OBJECTIVE: To provide an additional clinical description of the complication of delayed hypopigmentation along with the first published histologic correlation. METHODS: Clinical records along with a preprocedure and 7-month postprocedure full-thickness skin biopsy were used for this report. RESULTS: This patient experienced a striking leukoderma 6 months after a full facial carbon dioxide laser resurfacing procedure done for widespread actinic keratoses. There was a zone of dermal fibrosis extending approximately 0.4 mm on the postprocedure biopsy. Comparison of the preprocedure and postprocedure biopsies revealed no difference in the number of melanocytes by MART-1 immunohistochemical staining, but there was a significant decrease in epidermal melanin as determined by Fontana-Mason staining. CONCLUSION: This patient experienced a profound expression of an increasingly recognized and reported complication of carbon dioxide laser resurfacing. Histologic correlation is similar to the results previously reported after phenol chemical peels, demonstrating a normal number of melanocytes but a decrease in epidermal melanin.

Pravastatin-induced lichenoid drug eruption.

Although drug eruptions caused by pravastatin and other lovastatin analogs have previously been described, reports of lichenoid eruptions are rare. We report a patient whose lichenoid lesions developed after initiation, resolved on discontinuation, and reappeared on rechallenge with pravastatin therapy. A brief review of lichenoid drug eruptions and skin lesions due to 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors is discussed.

5-fluorouracil iontophoretic therapy for Bowen's disease.

BACKGROUND: Topical 5-fluorouracil (5-FU) is an accepted therapy for Bowen's disease. Recurrences with this method have been attributed to deep follicular involvement and poor patient compliance because of the prolonged treatment time required. OBJECTIVE: We sought to determine whether iontophoresis of 5-FU is an effective therapy for Bowen's disease. METHODS: Twenty-six patients with biopsy-proven Bowen's disease received eight 5-FU iontophoretic treatments in 4 weeks. Local excision was done 3 months after the last treatment. The specimens were step-sectioned and evaluated for any histologic evidence of bowenoid changes. RESULTS: Only 1 of 26 patients showed histologic evidence of Bowen's disease 3 months after treatment. CONCLUSION: 5-FU iontophoresis appears to be a safe, effective, and well-tolerated therapy for Bowen's disease.

How many nonmelanoma skin cancers require Mohs micrographic surgery?

BACKGROUND: Cost containment in health care is currently a subject of much debate. The rapid spread of managed care is an attempt to influence practice trends and contain costs. Although seldom directly stated, it is implied that some physicians may perform high-cost procedures when not necessarily indicated, an example being Mohs micrographic surgery (MMS). OBJECTIVE: There are little data in the literature indicating what percentage of skin cancers treated by MMS would be appropriate. For such data to be meaningful, a model would have to exist wherein there is no financial incentive or disincentive for performing the procedure. Military medicine provides this unique environment. METHODS: In a retrospective review, we counted the total number of basal cell carcinomas and squamous cell carcinomas diagnosed at Brooke Army Medical Center (BAMC) over a 5-year period. We then determined the number of MMS cases performed on these cancers. RESULTS: A total of 5193 nonmelanoma skin cancers (NMSC) were diagnosed at BAMC and 1701 of these were treated by MMS. Overall, the percentage of NMSC treated by MMS was 32.7% for the 5-year period. CONCLUSION: This information may serve as a framework for physicians and health delivery systems as they negotiate managed care contracts for the management of skin cancer.

A pigmented scalp nodule: malignant blue nevus.

The malignant blue nevus is an aggressive dermal melanocytic neoplasm. The lesion occurs most frequently on the scalp of men in their fifth decade of life, often metastasizes to the regional lymph nodes, and commonly results in fatality. Controversy exists as to whether this lesion is a malignant melanoma in the dermis or a separate neoplasm arising in the architecture of a cellular blue nevus. The lesion is treated with wide local excision and close monitoring for the occurrence of metastatic disease.

Dilantin hypersensitivity reaction.

Dilantin hypersensitivity syndrome is characterized by fever, rash, lymphadenopathy, facial edema, and hepatitis. Anemia, pharyngitis, diarrhea, and nephritis may also be present. The eruption may present as the classic erythematous follicular papules and pustules; or it may be pleomorphic, presenting as a morbilliform eruption, erythroderma, or toxic epidermal necrolysis. Early recognition and discontinuation of the medication are necessary to prevent a potentially fatal outcome. A case is presented and the literature reviewed.

Tattoo pigment mimicking metastatic malignant melanoma.

BACKGROUND: The benefits of elective lymph node dissection (ELND) in the treatment of melanoma remain controversial, however, it may be beneficial in some patients. Tattoo pigment from decorative tattoos may migrate to the regional lymph nodes. In patients who develop malignant melanoma and who have been tattooed, this pigment may clinically mimic metastatic disease. OBJECTIVE: We wish to alert clinicians that pigment from tattoos may migrate to the regional lymph nodes. In the unusual instance of a tattooed patient who develops malignant melanoma, when undergoing ELND, surgeons should rely on histologic confirmation of metastatic disease before altering operative plans. METHODS: ELND for malignant melanoma, in a patient with a history of decorative tattoos that had been removed by dermabrasion, was performed. Black lymph nodes that clinically resembled metastatic disease were identified. Subsequent histologic examination revealed normal lymph node architecture with a heavy collection of black pigment. Mass spectrophotometry showed this pigment to be consistent with tattoo dye. RESULTS: A patient who had undergone dermabrasion for removal of decorative tattoos developed malignant melanoma in the same extremity. Clinically suspicious black lymph nodes were identified during ELND. Histologic examination did not reveal metastatic disease. Additional therapy was not considered intra- or postoperatively even though the clinical suspicion of metastatic disease was high. The patient was not subjected to any unnecessary emotional or physical distress pending histologic confirmation. CONCLUSIONS: Tattoo pigment in the lymph nodes may clinically mimic metastatic melanoma. Histologic confirmation of metastatic disease should always be obtained before additional therapy is considered.

Surgical wound healing complicated by Aspergillus infection in a nonimmunocompromised host.

BACKGROUND: An unusual complication of cutaneous surgery and its management is presented. Aspergillus flavus was identified from a nonhealing surgical wound of the ear undergoing cartilaginous necrosis in an immunocompetent host. OBJECTIVE: We wish to alert clinicians that Aspergillus may infect surgical wounds of the ear causing significant morbidity. METHOD: A healthy man underwent Mohs micrographic surgery for invasive Bowen's disease of the ear. Due to the size and location of the defect it was allowed to heal by secondary intent. The patient developed inflammation and subsequent destruction of the ear cartilage. Aspergillus was demonstrated by touch preps and cultured from swabs and tissue from the necrotic wound. RESULTS: In spite of aggressive topical and oral antifungal therapy severe distortion of the pinna occurred, resulting in surgical removal of the upper two-thirds of the ear. CONCLUSIONS: In the presence of cartilage necrosis following surgery on the ear, Aspergillus infection should be considered. Early aggressive management with surgical debridement, and topical and oral antifungal therapy may prevent destruction of the cartilage and a significant cosmetic defect.

Ischemic complications of tubular gauze dressings.

BACKGROUND: Ischemic pressure complications associated with tubular gauze digital dressings have been occasionally reported in the medical literature. Previous authors have implicated specific mechanisms. We report a 10th case of this type of complication and hypothesize that a "Chinese finger trap" mechanism was responsible. OBJECTIVE: To compare pressures generated using different application techniques of tubular gauze digital dressings. METHODS: A simple device to measure dressing pressure was constructed. Comparative pressure measurements using different application techniques were obtained. RESULTS: Too many layers, excess longitudinal traction during application, using more than a 90 degrees twist during application, and rolled proximal dressing edges all increased measured pressures significantly. CONCLUSIONS: Physicians and other health care providers involved in the application of these dressings should be aware of their correct application and the mechanisms that may produce complications.