Anatomy of the cutaneous surface of the male genitalia, with elaboration upon the inner preputial coronal-shaft junction.

INTRODUCTION: Descriptions of the penile prepuce in anatomical and clinical texts either omit details or contain a small, yet potentially serious, error with regard to the manner of its attachment to the penis. OBJECTIVE: This study sought to cast light on a ubiquitous but poorly understood and under-appreciated structure, while correcting a long-standing mistake in the medical literature. STUDY DESIGN: The foreskins of five male stillborn babies were dissected and carefully examined. Tissue from the apposing surfaces of the various regions of the inner and outer prepuce surfaces and the transition zone itself were collected, embedded in paraffin, sectioned, stained, examined and photographed under microscopy. RESULTS: Contradicting the prevailing descriptions in the literature that the inner prepuce is a single, uniform sheath, this study's observations and histological findings demonstrated that it actually splits into separate laminae that connect distally to the shaft at the base of the corona and proximally with the shaft fascia, respectively (Figure). DISCUSSION: The penile prepuce is a discrete and deceptively complex part of the male anatomy, yet key details of its interposing surfaces are inaccurately described or entirely omitted in the literature. Understanding the normal anatomy of the prepuce is critically relevant, particularly for urologists and others involved in the performance of circumcision. For example, avoiding potentially catastrophic avulsion of the inner preputial remnant beyond the coronal sulcus during circumcision and accurate assessment of tissue positioning prior to penile reconstruction in cases of hypospadias. CONCLUSION: The findings of this study correct a misunderstanding in the anatomy of the prepuce.

An independent comparison of terbinafine and itraconazole in the treatment of toenail onychomycosis.

BACKGROUND: Previously, sponsored publications have shown that either terbinafine or itraconazole (pulse regimen) are effective for patients with toenail onychomycosis. However, independent comparative studies are lacking. OBJECTIVES: To objectively compare treatment with terbinafine and itraconazole in patients with toenail onychomycosis. METHODS: The effectiveness of terbinafine (250 mg/day 3 months) versus itraconazole pulse regimen (400 mg/day for the first week of each month, for three cycles) was retrospectively evaluated in patients with toenail onychomycosis using mycological tests and subjective outcome measures. Statistical analyses were performed using one-way analyses of variance (ANOVA) for continuous variables and Fisher exact tests for categorical variables. RESULTS: Included in the study were 117 patients (74 patients treated by terbinafine and 43 patients treated with itraconazole). Patients were examined at an average period of 20 months after the end of therapy. Mycological cure was observed in 70.6% and 62.8% of the patients who were treated by terbinafine or itraconazole, respectively (not statistically significant). Mean visual analogue scale assessment of treatment outcome was 79.9 mm (SD 24.7 mm) and 65.2 mm (SD 34.6 mm) for patients treated by terbinafine or itraconazole, respectively (p=0.008). When the results were stratified according to age and gender, it was observed that the advantage of terbinafine versus itraconazole retained statistical significance only for patients who were 55 years old and above, or females. CONCLUSIONS: Mycological cure proportions were not statistically significant between patients treated by terbinafine or itraconazole for toenail onychomycosis. However, better subjective outcome measures indicated an advantage for terbinafine over itraconazole, noticeable in females and patients 55 years old and above.

Treatment of multiple miliary osteoma cutis of the face with local application of tretinoin (all-trans-retinoic acid): a case report and review of the literature.

BACKGROUND: Multiple miliary osteoma cutis of the face represents primary extra-skeletal bone formation that arises within the skin of the face. METHODS: A 60-year-old woman with multiple miliary osteoma cutis of the face was treated by application of 0.05% tretinoin (all-trans-retinoic acid) cream nightly. RESULTS: After 3 months of therapy there were fewer papules and a decrease in size of remaining lesions. In a literature search, it was found that local application of tretinoin was successful and achieved a decrease in the number of papules over the face in all patients with multiple miliary osteoma cutis of the face; however, the length of time to achieve response varied from a few weeks to 6 months. CONCLUSION: It is suggested that local application of tretinoin cream should be considered in the therapy of multiple miliary osteoma cutis of the face, particularly when the lesions are small and superficial.

Elastic adhesive dressing treatment of bleeding wounds in trauma victims.

Conventional methods for hemorrhage control in the trauma patient fall short of providing a full solution for the life-threatening bleeding injury. The tourniquet is limited specifically to injuries of the distal limbs. Local pressure or tight bandaging with military bandages is cumbersome and often insufficient. Therefore, we sought a superior method to stop bleeding in emergency situations. Our objective is report and description of our experience with this method. Since 1992 our trauma team repeatedly encountered multiple trauma victims presenting with bleeding wounds. We achieved hemorrhage control by means of an adhesive elastic bandage applied directly over a collection of 4 x 4 gauze pads placed on the wound surface. The roll is then wrapped around the body surface, over the bleeding site, until sufficient pressure is reached to terminate ongoing hemorrhage. Three typical cases are described in detail. Adhesive elastic dressing compression was successful in fully controlling bleeding without compromise of distal blood flow. Our method corresponded to the demand for an immediate, effective and lasting form of hemorrhage control without complications. Furthermore, this technique proved successful even over body surfaces normally recognized as difficult to compress. We experienced equal favorable success while working during transit by either ambulance or helicopter transportation. We find our preliminary experience using elastic adhesive dressing for bleeding control encouraging and suggest that this may substitute existing practices as the selected treatment when indicated. This method is presently underrecognized for this purpose. Development of a single unit bandage may further enhance success in the future.

Plantar hidradenitis in children induced by exposure to wet footwear.

Painful erythematous papules and nodules involving either the palms of the hands, or, more commonly, the soles of the feet, characterize palmoplantar eccrine hidradenitis or palmoplantar hidradenitis (PH). The younger pediatric population is predominately affected. Histologically, the eccrine gland apparatus is the target of inflammatory neutrophilic infiltrates. This entity has been reported under a variety of names, including traumatic plantar urticaria, neutrophilic eccrine hidradenitis, plantar erythema nodosum, and idiopathic recurrent palmoplantar hidradenitis. All are essentially the same process, described in different forms. Despite the growing number of reported cases, the pathogenesis remains obscure. We present four children with PH of the soles of the feet, who shared a common recent history of exposure to cold, damp, footwear. The temporal relationship between exposure to dampness and cold and the appearance of the skin lesions suggest a possible pathogenetic mechanism.

Davener's dermatosis: a variant of friction hypermelanosis.

BACKGROUND: As part of our clinical experience we encountered a group of patients from a specific population with a similar peculiar pigmentation over the lower dorsal spine. OBJECTIVE: We investigated these patients to see whether we could determine a common origin. METHODS: Patients meeting the inclusion criteria underwent detailed history and complete physical examination; biopsy specimens from 3 patients were studied. RESULTS: All 13 patients were full-time male students at Orthodox Jewish Talmudic seminaries (Yeshivas). The lesion consisted of an elongated, vertical, midline, hyperpigmented patch with indistinct borders, which was distributed along the skin overlying the bony protuberances of the inferior thoracic and lumbar vertebrae. It was often unrecognized by the patients. Mean body mass index was lower than that for the general population. Histologic study showed a marked diffuse hyperkeratosis and hyperplastic epidermis with diffuse hyperpigmentation. We attributed the phenomenon to friction from the rigid backrests against the cutaneous surface of the lower back generated by the characteristic swaying activity that traditionally accompanies Torah study or "davening" (praying) and termed it Davener's dermatosis. CONCLUSION: We believe this phenomenon represents a new form of benign friction hypermelanosis. This report highlights the importance of a thorough history in patients presenting with pigmented lesions.

[Primary dermatology--who is the gate keeper?].

For several years health funds in Israel have allowed patients to see dermatologists, gynecologists, orthopedic surgeons and ENT specialists without being referred by their primary care physician. There is heated debate about whether this practice is justified and if it is cost effective. Is it better medicine for the patient? What are the roles of the primary care physician and of the primary dermatologist in the care of skin diseases? What do patients want? We examined the practices of 4 dermatology clinics and discuss the issues involved.

[Esophageal carcinoma presenting as fever of unknown origin].

Fever of unknown origin presents both a clinical and diagnostic challenge and is usually caused by inflammatory and neoplastic diseases. We present a unique case of a previously healthy 77-year-old woman whose sole complaint was fever. Complete hospital investigation failed to reveal the underlying process. 4 months after the onset of fever, dysphagia appeared and she was then diagnosed as suffering from squamous cell carcinoma of the esophagus. The question of early barium swallow X-ray in such cases is raised.