The use of botulinum toxin in the treatment of a parotid duct injury during Mohs surgery and review of management options.

BACKGROUND: Aggressive skin cancers on the cheeks may involve the parotid duct. For such tumors to be successfully removed, at least part of the parotid duct must be excised as well. Failure to properly address parotid duct injuries that result from Mohs micrographic surgery exposes the patient to a variety of adverse sequelae. OBJECTIVE: To discuss the various diagnostic and treatment options that should be considered when managing parotid duct injuries that result from skin cancer extirpation. MATERIALS AND METHODS: We describe a patient who sustained a parotid duct injury after Mohs micrographic surgery for treatment of squamous cell carcinoma. The patient was treated with intraparotid injections of botulinum toxin. RESULTS: Two weeks after treatment of the injury with botulinum toxin, the patient reported complete resolution of his symptoms. CONCLUSION: If a parotid duct injury is diagnosed at the time of tumor extirpation, then surgical repair of the duct should be attempted, but if surgical repair is not possible or if an injury remains unrecognized until well after tumor extirpation, then surgery is not necessary. In such cases, conservative, nonsurgical measures, such as treatment with botulinum toxin, will provide excellent results.

A better technique for taking Mohs sections involving cartilage.

BACKGROUND: When excising Mohs layers involving skin and cartilage in the conventional manner, it can be difficult to flatten the entire margin onto a single plane because of the inelasticity of the cartilage. This is undesirable, because it prevents a complete examination of the surgical margin. OBJECTIVE: We describe a modified technique for excising cartilaginous specimens that allows the entire margin of the specimen to be more easily flattened onto a single plane, so that a complete examination of the surgical margin can be performed. METHODS: When taking Mohs layers involving skin and cartilage, we propose excising an additional 1 to 2 mm of skin and creating edges with flatter bevels of 20 degrees to 30 degrees . RESULTS: The modified technique allows the peripheral edge of the skin, the peripheral edge of the cartilage, and the deep surface of the cartilage to all be easily flattened onto the same plane, so that a complete examination of the margins can take place. CONCLUSION: This technique allows a more thorough assessment of the margins of the excision, which will result in more successful tumor extirpation. This modified technique may be limited on cosmetically sensitive areas because it involves excising slightly more tissue than the conventional technique.

Numerous fibrous papules of the face unassociated with any genodermatosis.

Numerous angiofibromas on the face are commonly associated with tuberous sclerosis or multiple endocrine neoplasia type 1. We present a healthy 66-year-old female with numerous facial angiofibromas, without evidence of tuberous sclerosis, multiple endocrine neoplasia type 1, or any of the less common syndromes associated with many angiofibromas on the face. To our knowledge, there have been no previously reported cases of patients with numerous facial angiofibromas who did not have an associated genodermatosis.

Disseminated sporotrichosis mimicking sarcoidosis.

A 40-year-old Caucasian man presented to the dermatology clinic at Baylor College of Medicine, Houston, Texas, in February 2003, for the evaluation of three nonhealing ulcers. The patient's past medical history was significant for hypothyroidism and pulmonary sarcoidosis, the diagnosis of which was made in June 2000. In March 2000, the patient had complained of cough and shortness of breath. A purified protein derivative (PPD) (Mantoux text) was negative. Computed tomography (CT) scans of the chest revealed diffuse hilar and mediastinal adenopathy and bilateral interstitial and alveolar infiltrates. Although consistent with sarcoidosis, these findings were insufficient to exclude other etiologies, including disseminated fungal infection. Cultures and stains of subsequent bronchoscopy specimens failed to reveal any organisms, and histopathologic evaluation of the specimens was nondiagnostic. Based on the imaging studies and the negative cultures, a diagnosis of sarcoidosis was made, and the patient was started on therapy with prednisone. Before coming to our clinic, the patient had been on several courses of prednisone. In May 2002, the patient had presented to a private dermatologist with a 1-year history of a nonhealing 2.4 cm x 2.0 cm ulcer on the left medial forearm. Two biopsies were reported as nondiagnostic. The patient's presentation was interpreted as most consistent with Mycobacterium marinum infection, and so he was empirically treated with minocycline. This treatment was continued for almost 3 months without improvement in the ulcer. A few months after the minocycline had been discontinued, the patient was treated empirically for 2 months with ciprofloxacin. This treatment was also unsuccessful in ameliorating the ulcer. In between the two courses of antibiotics, specimens from the lesion were sent for bacterial and fungal cultures, which revealed normal skin flora. In January 2003, the patient returned to his private dermatologist with three ulcerations. In addition to the nonhealing ulcer on his left forearm, which he had acquired several months earlier, he had also developed a 3.0 cm ulcer on his right arm and a 3.0 cm ulcer on his central back. The patient refused biopsies at this visit. Given the patient's previous diagnosis of pulmonary sarcoidosis, it was thought that the skin lesions might represent ulcerative cutaneous sarcoidosis. Pyoderma gangrenosum was also considered to be a likely diagnosis. Therefore, the patient was started on a course of oral prednisone, an effective therapy for both sarcoidosis and pyoderma gangrenosum. Despite 1 month of treatment with 60 mg/day of prednisone, the ulcers increased, and the patient was subsequently referred to our clinic. Physical examination at the time of presentation revealed steroid acne on the trunk and upper extremities and three non-tender ulcers with erythematous, undermined borders (Figs 1-3). On the left arm, there was an adjacent nodule which the patient attributed to a scar from a previously healed ulcer. Histologic examination of biopsy specimens from all three sites showed similar findings. The lesion contained diffuse, suppurative, granulomatous, inflammatory infiltrates with extensive central necrosis. The infiltrates were composed of histiocytes, multinucleated foreign-body-type giant cells, plasma cells, lymphocytes, neutrophils, and neutrophil fragments. No organisms were seen in the initial, routinely stained sections. However, periodic acid-Schiff (PAS) staining demonstrated small fungal spores (Fig. 4) morphologically consistent with sporotrichosis, within the cytoplasm of multinucleated histiocytic giant cells (Fig. 5). Additional stains for bacteria and acid-fast organisms were negative. Cultures of the biopsy specimens from all three sites grew Sporothrix schenckii. Further questioning of the patient failed to reveal an obvious source of the infection. The patient denied any history of traumatic skin inoculation and did not engage in gardening or other outdoor activities that are classically associated with sporotrichosis. The patient did admit to blackberry picking on detailed retrospective questioning. Once the diagnosis of sporotrichosis was made, the patient was given 200 mg/day of itraconazole. After 2 months, the patient's ulcers were almost completely healed. The patient's pulmonary complaints were also much improved.

Complete resolution of generalized lichen planus after treatment with thalidomide.

Thalidomide has gained an infamous history due to severe birth defects observed in patients who had taken the drug to control nausea during pregnancy. The medication was withdrawn from the market because of its teratogenicity, but was approved by the FDA in 1998 for the treatment of erythema nodosum leprosum. However, thalidomide has been employed with success by dermatologists for a host of off-label uses including the treatment of lichen planus. Currently, no clinical trials or studies exist to evaluate the efficacy of using thalidomide to treat lichen planus, but case reports have been published in the medical literature supporting its therapeutic benefits. TNF-alpha is among the many cytokines that have been implicated in the pathogenicity of lichen planus. It is thought that thalidomide acts.

Hereditary papulotranslucent acrokeratoderma: a case report and literature review.

Hereditary papulotranslucent acrokeratoderma is a rare autosomal-dominant syndrome of the hands and feet characterized by persistent, asymptomatic, yellowish to white papules and plaques associated with fine-textured scalp hair and an atopic diathesis. Histopathologically, focal hyperkeratosis, hypergranulosis, and acanthosis of the epidermis are seen. We present a case of hereditary papulotranslucent acrokeratoderma in a young adult woman. The literature of this unusual condition is reviewed, and its relationship to acquired papulotranslucent acrokeratoderma is discussed.

Papulonodular mucinosis in systemic lupus erythematosus.

A 41-year-old man with systemic and serological manifestations of systemic lupus erythematosus presented with a diffuse eruption comprising annular plaques. Histopathology revealed diffuse deposition of mucin throughout the dermis, consistent with papulonodular mucinosis. This uncommon entity of unclear pathogenesis has been described in systemic lupus erythematosus, discoid lupus erythematosus, and subacute cutaneous lupus erythematosus.

Serum sickness due to infliximab in a patient with psoriasis.

Infliximab is a chimeric, murine-human, monoclonal antibody against tumor necrosis alpha which has shown great efficacy in the treatment of psoriasis. Serum sickness, which is an immune complex mediated syndrome consisting of a cutaneous eruption, fever, arthritis, edema, and lymphadenopathy, has been described in several patients receiving infliximab for the treatment of Crohn's disease. However, to our knowledge, this type of reaction has not been well described in a patient treated with infliximab for psoriasis. We describe a patient who developed serum sickness while receiving infliximab for psoriasis and discuss the pathogenesis, diagnosis, and treatment of serum sickness. We believe that with the increasing use of infliximab for psoriasis, more cases of serum sickness will occur. Therefore, awareness of this adverse effect is essential.