A single postoperative application of nitroglycerin ointment does not increase survival of cutaneous flaps and grafts.

BACKGROUND: Nitroglycerin is a vasodilator that has been reported to improve cutaneous flap and graft survival. It has not been tested in controlled studies. OBJECTIVE: We designed our study to test the effectiveness of a single postoperative application of nitroglycerin on flap and graft survival. METHODS: Eighty-eight surgical repairs received topical nitroglycerin and 85 received control ointment (polysporin). Treatment sites were evaluated on postoperative day 7 and assigned a percentage of surface area survival. RESULTS: There was no significant difference in the complication rate of flaps and grafts treated with nitroglycerin (12.5%) compared with those treated with control ointment (8.4%) (P = .244). Subset analysis of flaps as a group and grafts as a group were not meaningful because the complication rates were so low. CONCLUSION: There is no survival increase of flaps and grafts treated with a single application of nitroglycerin ointment.

Mohs micrographic surgery using HMB-45 for a recurrent acral melanoma.

BACKGROUND: Acral melanomas are uncommon. Due to the thick overlying stratum corneum, accurate estimation of margins is difficult for minimally pigmented or amelanotic melanomas on the palm or sole. OBJECTIVE: To describe the use of Mohs micrographic surgery using frozen sections and HMB-45 immunostaining in the treatment of a multiply recurrent acral melanoma that had failed both standard surgery and Mohs surgery. METHODS: The melanoma was excised by Mohs technique, and the margins were checked by frozen section and HMB-45 immunostaining. RESULTS: The melanoma was completely excised in 11 stages, resulting in a defect that covered much of the plantar surfaces of the ball of the left foot, great, second, third, fourth, and fifth toes. No recurrence has been noted in 22 months of follow-up. CONCLUSIONS: HMB-45 immunostaining is a very valuable adjunct to examination of surgical margins for melanoma, particularly when combined with such histologic features as clustering of cells, melanocyte position within the epidermis, and cytologic atypia.

Intra-incisional prophylactic antibiotics for dermatologic surgery.

OBJECTIVE: To determine the efficacy of intra-incisional antibiotics in decreasing the risk of wound infections in cutaneous surgery. DESIGN: Prospective, blinded, randomized, placebo-controlled trial conducted during an 8-month period. SETTING: A private practice Mohs micrographic surgery referral center. PATIENTS: Seven hundred ninety consecutive patients referred for Mohs surgery or other dermatologic surgery were randomized to receive anesthesia either with study compound or placebo. The 2 groups were equivalent with respect to age and sex distribution and the lesions treated were similar in character. No patients were withdrawn for adverse effects. INTERVENTIONS: Patients received local anesthesia before surgery with either buffered lidocaine hydrochloride or a solution consisting of nafcillin sodium in buffered lidocaine. MAIN OUTCOME MEASURES: All surgical wounds were evaluated in a blinded fashion at the time of suture removal (5-7 days) and scored according to a standardized assessment chart based on erythema, edema, and the presence of purulent discharge. RESULTS: Seven hundred ninety consecutive patients with 908 surgical wounds were enrolled in this study. A total of 12 wound infections were recorded. Eleven (2.5%) of these occurred in the control group, while only 1 (0.2%) occurred in the nafcillin group. This difference was highly significant (P = .003). Observers were blinded to patient groupings particularly for surgical wound scoring. CONCLUSIONS: This study offers strong supporting data for the use of a single intra-incisional dose of an antibiotic administered immediately before dermatologic surgery. The use of nafcillin and buffered lidocaine solution is inexpensive, safe, convenient, and effective.

Adult-type colloid milium of hands and face successfully treated with dermabrasion.

Colloid milium is an unusual cutaneous disorder characterized by multiple cystic papules. The adult form develops in sun-exposed parts of the body in patients who have actinic-damaged skin. We describe the case of a patient with the classic clinical and histologic features of this disorder. The patient was successfully treated by dermabrasion to the hands and affected facial regions and, 10 months later, has not shown any signs of recurrence.

An unusual presentation of incontinentia pigmenti in a 4-month-old girl.

A four month old girl initially presented with a crusted nodule on her right index finger. Evaluation was unremarkable for infectious causes or malignancy. She ultimately developed similar hyperkeratotic plaques and papules of the right hand and ultimately linear hyperpigmented patches of her arms and legs. The diagnosis of Incontinentia Pigmenti (IP) was then made. The diagnosis of IP and the differential diagnosis of IP-like lesions is presented.

Dog, cat, and human bites: a review.

It is estimated that half of all Americans will be bitten by an animal or another human being during their lifetimes. The vast majority of the estimated 2 million annual mammalian bite wounds are minor, and the victims never seek medical attention. Nonetheless, bite wounds account for approximately 1% of all emergency department visits and more than $30 million in annual health care costs. Infection is the most common bite-associated complication; the relative risk is determined by the species of the inflicting animal, bite location, host factors, and local wound care. Most infections caused by mammalian bites are polymicrobial, with mixed aerobic and anaerobic species. The clinical presentation and appropriate treatment of infected bite wounds vary according to the causative organisms. Human bite wounds have long had a bad reputation for severe infection and frequent complication. However, recent data demonstrate that human bites occurring anywhere other than the hand present no more of a risk for infection than any other type of mammalian bite. The increased incidence of serious infections and complications associated with human bites to the hand warrants their consideration and management in three different categories: occlusional/simple, clenched fist injuries, and occlusional bites to the hand. This article reviews dogs, cat, and human bite wounds, risk factors for complications, evaluation components, bacteriology, antimicrobial susceptibility patterns, and recommended treatments. Epidemiology, clinical presentation, and treatment of infections caused by Pasteurella multocida, Capnocytophaga canimorsus, Eikenella corrodens, and rhabdovirus (rabies only) receive particular emphasis.

Histologic patterns of basal cell carcinoma based upon patient immunostatus.

BACKGROUND: The biologic behavior of basal cell carcinoma (BCC) seems to be dictated by the histologic subtype. Moreover, BCCs in immunosuppressed patients appear to show a more aggressive biologic behavior. OBJECTIVE: The purpose of this study was to retrospectively investigate different histologic subtypes of BCC to determine whether a particular subtype would predominate in immunosuppressed patients. METHODS: The histologic patterns of 112 primary BCCs from 77 immunosuppressed patients and 60 primary BCCs from 46 patients who are endogenously immunocompromised, due to diabetes mellitus and/or chronic renal failure, were examined. The results were compared with 488 primary BCCs of 318 immunocompetent patients. RESULTS: The nodular subtype was the predominant pattern among all patients. However, a statistical difference was found in the immunosuppressed patients in that there was a lower percentage of nodular pattern (P = .0038), and a higher percentage of infiltrative pattern (P = .0002). The higher frequency of the infiltrative pattern in the immunosuppressed group was particularly prominent among chronic alcoholics. CONCLUSION: In immunosuppressed patients, the higher frequency of the infiltrative subtype of BCC, particularly among chronic alcoholics, may have a predictive role in the management of these cases.