Dressing the part.

Wound care after cutaneous surgery can play an integral role in wound healing. Wound care regimens have changed dramatically over the last 35 years as the physiology of wound healing has become better understood. Foremost is the improvement in wound healing achieved by keeping the wound occluded and moist. This observation has led to an explosion of a whole new category of occlusive dressings at the surgeon's disposal in healing postoperative wounds. These dressings have numerous applications as discussed previously. Generally, for acute surgical wounds, occlusive dressings are most useful for split-thickness wounds, such as graft donor sites and after dermabrasion, chemical peel, or laser treatment, and full-thickness wounds allowed to heal by secondary intention. Occlusive dressings may have greater benefit for the treatment of chronic ulcers of varying etiologies. The different categories of dressings share the common disadvantage of being relatively expensive. For routine sutured wounds, the authors prefer the readily available and inexpensive Telfa-type dressing combined with a topical antibiotic ointment. Topical antiseptics are useful for reducing bacterial counts on intact skin in preparation for surgery. Povidone-iodine (Betadine) and chlorhexidine gluconate (Hibiclens) have emerged as the two agents of choice. However, antiseptics have been shown to be toxic to healing tissue, and should not be used on open wounds. In contrast, topical antibiotic ointments are safe to use on open wounds, effective in preventing wound infections, and promote wound healing by maintaining a moist wound environment. The authors prefer the combination antibiotic ointment Polysporin for routine postoperative wound care. Antibiotic prophylaxis in dermatologic surgery to prevent wound infection is appropriate in certain cases. Surgery performed on grossly contaminated or infected skin requires a full 7 to 10 day course of antibiotics. Procedures in anatomic areas considered contaminated as well as in clean areas with significant environmental or patient risk factors may benefit from antibiotic prophylaxis. The choice of antibiotics should be based on the organism most likely to cause wound infection at the particular surgical site. Evidence supports giving a single preoperative dose 1 hour before surgery with a second dose possible 6 hours later if the procedure is prolonged or delayed. The risk of bacterial endocarditis after dermatologic surgery is not known. Antibiotics are indicated for any procedure on obviously infected skin, but are not routinely required for very minor procedures, such as small biopsies, on intact skin. Antibiotic prophylaxis may be prudent for those patients classified as high risk by the (AHA). The antibiotic chosen should again cover the organism most likely to cause infection. One dose can be given 1 hour before surgery and repeated 6 hours postoperatively. Finally, wound healing can be greatly impacted by what the patient does or does not do after leaving the office. Therefore, wound care instructions should be clear, detailed, and provided in both oral and written form. Information should also be provided about what to expect as the wound heals.

Metastatic basal cell carcinoma. Report of five cases.

BACKGROUND: Metastatic basal cell carcinoma (MBCC) is rare. Risk factors for the development of MBCC include a history of persistent basal cell carcinoma (BCC) for many years, refractory to conventional methods of treatment and previous radiation treatment either in early adulthood or for localized cancer. Most MBCC originate from large tumors. METHODS: The authors report five patients with basal cell carcinomas (BCC) of the ear (two patients), scalp, inner canthus, and nasolabial fold that metastasized to the regional lymph nodes, skin, and submandibular gland. In addition, the authors reviewed more than 40 reports of MBCC (n = 65) from 1981 to 1991 and tabulated the primary tumors by size and depth of invasion according to TNM classification, a classification that previously has not been used for BCC. RESULTS: The authors tabulated the size distribution of tumors of 45 patients with MBCC. The overall mean and median diameters of the primary BCC were 8.7 and 7.0 cm, respectively. The mean area of the primary MBCC lesion that originated on the face and trunk was 62 and 217 cm2, respectively. Using the TNM classification, approximately 9% of MBCC originate from tumors smaller than 10 cm2. In addition, the authors found that large (T2 and T3) and deep (T4) BCC account for approximately 75% of the metastatic tumors. Metastatic BCC from primary tumors smaller than 1 cm in diameter are exceptionally rare. CONCLUSIONS: Approximately 67% of MBCC (n = 238) originate from facial sites. Using the data base of the Mohs Surgery Clinic, the authors found that BCC greater than 3 cm in diameter have approximately a 1.9% incidence of metastasis, and the overall rate of metastases for morpheaform BCC is less than 1%. Patients with tumors classified as T3 and T4 lesions ideally should be followed up for 10 or more years for the remote possibility of the development of MBCC.

Linear basal cell carcinoma.

Linear basal cell carcinoma is a rare morphologic variant of basal cell carcinoma. We present two cases of linear basal cell carcinoma. Both cases, treated by Mohs' micrographic surgery, demonstrated that there was lateral spread of the tumor that was not clinically present.

Rapid atraumatic nail plate removal using the cordless cautery unit.

This article describes the use of a handy, battery-powered, thermocautery unit to cut through the nail plate when performing dermatologic surgery involving nail tissue. Thermocauterization of keratin is a simple, atraumatic method of removing portions of the nail plate, so that the underlying soft tissue may be biopsied or treated. The units are inexpensive and safe to operate.

Failure to detect human papillomavirus DNA in extramammary Paget's disease.

Ten genital skin specimens, biopsy proven to be Paget's disease, were examined by human papillomavirus (HPV) in situ hydridization in an effort to detect DNA of HPV types 6, 11, 16, 18, 31, 33, and 35. All ten specimens showed no evidence of DNA of these HPV types. Extra-mammary Paget's disease is probably not a result of infection with HPV types 6, 11, 16, 18, 31, 33, or 35.

Cylindroma treated by Mohs micrographic surgery.

Cylindroma, a rare benign adnexal neoplasm, may occur in areas in which simple excision is either not possible or severely disfiguring. We present a case of cylindroma that was treated by Mohs micrographic surgery. Postsurgical evaluation of the tumor showed that the tumor had invaded a larger area than was initially suspected based on clinical examination alone.

Malignant cylindroma of the scalp.

Malignant cylindroma may develop via malignant transformation of cylindroma in rare instances or may develop de novo in others. We present a case of malignant cylindroma located on the left parietal-occipital scalp that was treated twice by Mohs micrographic surgery in an attempt to excise the tumor completely and to minimize the excision of normal tissue. Our case is the sixteenth reported case of malignant cylindroma in the world literature.

Metastatic basal cell carcinoma: report of twelve cases with a review of the literature.

Metastatic basal cell carcinoma was found in 12 patients at the University of Wisconsin Mohs Surgery Clinic during the period 1936 to 1989. All patients were white men. The time of onset of the primary tumor ranged from childhood to 71 years. Eleven patients had previous treatment for basal cell carcinoma; two patients had received x-ray radiation to the face for teenage acne. The locations of the primary basal cell carcinomas were the face (n = 10), back (n = 1), and arm (n = 1). The primary tumors ranged from 3.6 x 3.0 to 20.0 x 7.0 cm. The interval from onset to the first sign of metastases ranged from 7 to 34 years. In all cases, the primary tumor was histologically identical to the metastatic lesion. Perineural extension of the basal cell carcinoma in the primary lesion was found in five cases. Regional lymph nodes were the most frequent site of metastasis. Treatment consisted of a combination of surgery, radiation, and chemotherapy. Only two patients survived more than 5 years after surgical treatment. One patient has survived 25 years and is still alive.

Reticulate nonmelanocytic hyperpigmentation anomaly. A probable variant of Dowling-Degos disease.

A 26-year-old white woman had reticulate nonmelanocytic hyperpigmentation anomaly characterized by partially blanching red-brown papules and macules and a histologic picture of digitate epithelial budding proliferation with lightly pigmented rete ridges. Except for the classically described hyperpigmentation at the rete ridge tips, the patient has Dowling-Degos disease. This case of a reticulate nonmelanocytic hyperpigmentation anomaly is probably a variant of Dowling-Degos disease.

Disseminated cutaneous fungal infection and AIDS.

We report a case of recalcitrant generalized cutaneous polydermatophyte and Candida infection in an AIDS patient who responded very poorly to topical, oral, and intravenous therapy. The patient died of respiratory arrest secondary to pneumonia 14 months after a cutaneous fungal infection developed and 12 months after AIDS was diagnosed. Extensive cutaneous fungal infections refractory to treatment may be a presenting sign of HIV infection.

Transepidermal potassium ion, chloride ion, and water flux across delipidized and cellophane tape-stripped skin.

The skin barrier was evaluated as a function of transepidermal water loss (TEWL) and electrolyte loss. Combination electrodes for chloride and pH determinations and a potassium ion electrode were utilized. Delipidization of the skin did not impair the electrolyte barrier, but did damage the epidermal water barrier. Cellophane tape stripping of normal stratum corneum resulted in an increase in outward transepidermal potassium and chloride ion flux, an increase in skin surface pH, and an increase in TEWL. It appears that damage to the epidermal water barrier does not necessarily result in damage to the epidermal electrolyte barrier. We found the potassium electrode facile to use and believe that a combination potassium electrode would be useful for investigating and assessing the epidermal electrolyte barrier.