Damage to the Temporal Branch of the Facial Nerve From Mohs Micrographic Surgery.

BACKGROUND: The temporal branch of the facial nerve is at risk of damage during Mohs micrographic surgery (MMS). This complication leads to motor deficit in the ipsilateral upper face with resultant functional and cosmetic impairment. OBJECTIVE: To identify patient, tumor, and surgical risk factors associated with temporal nerve damage. MATERIALS AND METHODS: A single-institution, retrospective review of MMS cases involving anatomic sites within the temporal nerve danger zone was performed. Risk factors were compared between cases with and without nerve damage. RESULTS: Of 616 cases within the danger zone, 28 (4.5%) had postoperative nerve dysfunction. Variables significantly associated with dysfunction included patient immunosuppression, tumor size, aggressive tumor histology, recurrent tumors, high degree of subclinical spread, and greater average number of Mohs stages. Preoperative tumor size and postoperative defect size of ≥3 cm resulted in a ×37 and ×40 increased odds of nerve damage, respectively. Sex, age, and basal versus squamous cell carcinoma were not significantly associated with temporal nerve damage. No patients with a postoperative defect size measuring <2 cm had nerve damage. CONCLUSION: The overall risk of damage to the temporal nerve during MMS is low, but there are certain risk factors that warrant increased counseling about this potential complication.

Intralesional agents in the management of cutaneous malignancy: a review.

Intralesional agents have a role in the management of cutaneous malignancies. In this article, the efficacy, side effects, strengths, limitations, costs, and practical considerations regarding the use of intralesional agents to treat basal cell carcinoma, squamous cell carcinoma, selected cutaneous lymphomas, and even metastatic melanoma are reviewed. Intralesional administration of 5-fluorouracil, interferon, interleukin-2, bleomycin with electrochemotherapy, and aminolevulinic acid with photodynamic therapy are discussed as treatment modalities in basal cell carcinoma. Interferon (∼1.5 M IU, 3 times weekly × 3 weeks) is perhaps the most widely used regimen for basal cell carcinoma. With regard to squamous cell carcinoma, treatment with 5-fluorouracil, methotrexate, interferon, and bleomycin are reviewed. Methotrexate (∼0.3-2.0 mL of 12.5 or 25 mg/mL, two injections ∼2 weeks apart) was perhaps the most widely used agent. Interferon (3 M IU × 3 times weekly for ∼8.5 weeks) and rituximab (10-30 mg per lesion, 3 times weekly for 1 week, possibly repeated 4 weeks later) are sometimes used in the management of primary cutaneous B-cell lymphomas, whereas in primary cutaneous CD30(+) lymphoma intralesional methotrexate (0.4-0.5 mL of 50 mg/mL weekly for 2 weeks) has been used. Finally, the roles of BCG vaccine, cidofovir, rose bengal, and bleomycin with electrochemotherapy for the palliation of metastatic melanoma are reviewed. Intralesional management appears most useful when surgical intervention is not a viable option, for cases in which the cosmetic outcome may be superior, or for situations in which the side effects from systemic chemotherapeutic agents are to be minimized.

Pruritic urticarial papules and plaques of pregnancy with unusual and extensive palmoplantar involvement.

BACKGROUND: Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a specific dermatosis of pregnancy common to primigravid women in the third trimester. The rash usually begins on the lower abdomen within striae and spreads to the proximal extremities. Involvement of face, palms, and soles is unusual. Although intensely pruritic, the fetus is unaffected, and the condition does not usually recur. It can be difficult to distinguish PUPPP from pemphigoid gestationis, an autoimmune bullous disorder with potential fetal consequences that may recur with subsequent pregnancy, menses, or hormonal therapy. CASE: A young secundagravida at 36 weeks of gestation with monochorionic twins presented with a 3-week history of a pruritic papular eruption that began on the abdomen and spread to the extremities. She had extensive involvement of the distal extremities, including the palmoplantar surfaces, with small vesicles of 2-4 mm on acral skin. Because of her unusual presentation, she was thought initially to have pemphigoid gestationis. Subsequent dermatological evaluation and a biopsy confirmed the diagnosis of PUPPP. Shortly after admission she delivered 2 healthy male infants, and her rash cleared with conservative management. CONCLUSION: Pruritic urticarial papules and plaques of pregnancy often, but not always, spares the face, palms, and soles. Small vesicles can occur in PUPPP, but formation of true bullae is not observed. Careful dermatological examination and cutaneous biopsy can assist in differentiating PUPPP from pemphigoid gestationis, which is essential for treatment and prognosis.

Localized epidermolytic hyperkeratosis of the female genitalia: a case report and review of an underappreciated disorder of women.

Epidermolytic hyperkeratosis (EHK) is a distinct pathologic entity that may present as a generalized congenital disorder. A localized form occurring only upon the female genitalia may not be well appreciated by clinicians dealing with women. EHK of the female genitalia is a rare diagnosis, with just 6 cases reported within the indexed literature. Clinically, it may resemble condyloma, although involvement of human papillomavirus has never been demonstrated. Providers unfamiliar with this entity may be further confused by reports of the histopathologic features. Herein, we describe a case and review the literature with respect to EHK of the female genitalia. Familiarity with this condition is desirable, as confusion with condyloma is likely, yet the prognosis is decidedly different.

Multiple vaginal wall cysts: diagnosis and surgical management.

BACKGROUND: Simple cysts of the female genital tract may become symptomatic and require surgical removal. CASE: A 20-year-old woman had complaints of a vaginal bulge, pelvic pressure, dyspareunia, and stress urinary incontinence. Two cystic masses were seen in the vagina. A magnetic resonance imaging scan revealed 2 additional larger cysts. Urodynamic evaluation was significant for stress incontinence at 200 mL and a Valsalva leak-point pressure of 51 cm H(2)0. The 2 smaller cysts were removed intact through a superficial incision. The larger cysts were intentionally ruptured and dissected out. Histologic examination revealed a low cuboidal or a ciliated columnar epithelium that stained positive with mucicarmine, consistent with müllerian origin. One year after surgical excision, the patient remained symptom free with no urinary incontinence and no recurrence of the cysts. CONCLUSION: Magnetic resonance imaging was useful in delineating the course and anatomic arrangement of the vaginal cysts, but more importantly, identified another cyst that was not readily apparent at physical examination.