Eccrine porocarcinoma treated with Mohs micrographic surgery: A report of five cases.

BACKGROUND: Eccrine porocarcinoma is a rare, locally aggressive, potentially fatal neoplasm. While wide local excision has traditionally been the treatment of choice, recurrences following excision are common. OBJECTIVE: The purpose of this study was to review the traditional treatments of eccrine porocarcinoma as well as to introduce Mohs micrographic surgery as an alternative to wide local excision. METHODS: We reviewed all cases of eccrine porocarcinoma seen at Emory University between 1985 and 1999. All cases were treated definitively with Mohs micrographic surgery. The clinical characteristics and outcome of each case are summarized. RESULTS: Five patients with eccrine porocarcinoma were treated with Mohs micrographic surgery. There have been no recurrences to date, with an average follow-up of 2.1 years (ranging from 5 months to 4 years). CONCLUSION: Follow-up of five patients supports the view that Mohs micrographic surgery may be an effective treatment for eccrine porocarcinoma.

Early motion after repair of Achilles tendon ruptures.

The purpose of this study was to evaluate the clinical outcome of patients treated with limited immobilization and early motion after repair of acute Achilles tendon ruptures. Thirteen consecutive patients with complete ruptures of the Achilles tendon were identified, repaired, and rehabilitated with early motion starting an average of 10 days after surgery. Active range of motion was begun at an average of 23 days and weightbearing in a walking boot was started at an average of 3.5 weeks after surgery. The average length of follow-up was 27 months. Twelve of 13 patients returned to running activities in an average of 3 months. All 12 patients who participated in lateral motion activities before their injury returned to similar activities in an average of 7 months. The patients rated their overall status at an average of 93% of their preinjury level. Follow-up Cybex testing demonstrated plantarflexion strength averaging 92%, plantarflexion power averaging 88%, and plantarflexion endurance averaging 88% of the nonindexed extremity. Early range of motion after Achilles repair is safe and there is no increased risk of rerupture in compliant patients. The patients achieved good return of plantarflexion strength, power, and endurance.

Toxic erythema of palms and soles associated with high-dose mercaptopurine chemotherapy.

We encountered a case of distinctive palmar-plantar erythema with desquamation of the fingers in a patient receiving high-dose mercaptopurine combined with allopurinol. He was receiving 400 mg/d of mercaptopurine with 200 mg/d of allopurinol when a painful, livid erythema involving his hands and feet developed. Over the ensuing 24 hours, desquamation of the distal fingertips was noted. The mercaptopurine was discontinued and the patient was treated with topical fluocinonide ointment under occlusion. Over the next 96 hours, the erythema and pain resolved entirely. To date, this is the eighth case of a painful desquamating erythema of the palms and soles occurring as a complication of chemotherapy. We suggest that high-dose mercaptopurine combined with allopurinol that blocks xanthine oxidase, a necessary enzyme in the catabolism of mercaptopurine, was responsible for our patient's clinical presentation.

Soft tissue fixation to bone.

This experiment was designed to compare the immediate fixation strengths of various methods of soft tissue fixation techniques. The fixation techniques tested were the barbed staple, stone staple, suture techniques, screw with spiked plastic washer, and the screw with spiked soft tissue plate. Cadaveric soft tissue specimens were classified into three distinct morphologic types: capsular, tendinous, and extensor mechanism tissue. Each specimen was fixed to bone by one of the fixation techniques. The specimens were loaded in a cyclical fashion until fixation failure occurred. One hundred thirty-seven trials were performed. The screws with the spiked plastic washer and soft tissue plate proved superior overall for all three tissue types. The stone staple was the poorest technique tested. Therefore, if cyclic loading or tension is anticipated at the fixation site, the fixation technique of choice would be the screw with spiked plastic washer or soft tissue fixation plate.

Delayed hypersensitivity to a corticosteroid suspension containing methylprednisolone. Two cases of conjunctival inflammation after retrobulbar injection.

Two patients with chronic iridocyclitis had a delayed hypersensitivity reaction, characterized by severe conjunctival inflammation, after retrobulbar injections with a commercial suspension of methylprednisolone acetate. Although patch test reactions to methylprednisolone at enhanced concentrations were negative, delayed hypersensitivity could be easily demonstrated by intradermal testing with this corticosteroid. Both patients also had concomitant delayed hypersensitivity to a proprietary preservative (myristyl gamma-picolinium chloride) in the commercial corticosteroid suspension, which was confirmed by intradermal testing. These observations (negative patch test reactions, positive intradermal test reactions) suggest that the route of administration may be an important determinant of antigenic hapten-protein complex formation and subsequent delayed hypersensitivity responses involving cutaneous or mucocutaneous tissue.

Excess granulation tissue responses associated with isotretinoin therapy.

Multiple polypoid projections of granulation tissue developed in two patients receiving isotretinoin for acne. Histological study of the lesions revealed increased amounts of non-sulphated acid mucopolysaccharides in the ground substance of the granulation tissue stroma. Complete resolution occurred following curettage with or without chemical cautery. The role of isotretinoin in the development of these lesions is discussed.

Pyoderma gangrenosum at the parastomal site in patients with Crohn's disease.

Pyoderma gangrenosum is a rare idiopathic skin condition often associated with other diseases, including Crohn's disease. We believe this is the first report of cases in which pyoderma gangrenosum was identified at the parastomal site in patients with Crohn's disease. Four episodes of the condition occurred in three patients. In these patients, pyoderma gangrenosum first appeared after two to three surgical procedures and between ten months and five years after the initial surgery. The disease course varied from resolution within two months with corticosteroid therapy to resolution only after revision or relocation of the stoma with resection of recurrent disease segments. Parastomal pyoderma gangrenosum at the ileostomy site in patients with Crohn's disease may be more common than previously thought. Optimal treatment has not yet been established, and treatment needs to be tailored for each patient.

Basal-cell carcinomas of the temple.

A size comparison of basal-cell carcinomas on the temple referred for microscopically controlled excision (chemosurgery, fresh-tissue type) with those on the cheek confirms that tumors in the former area are larger than those in the latter. Possible reasons for this size difference are considered. Of the most interest is the fact that the size differential was not due to a higher incidence of larger, sclerosing tumors. The temple should probably be considered a "high risk" location similar to the perinasal, periocular, and periauricular areas and the scalp.

Generalized ulcerative sarcoidosis.

Cutaneous involvement is present in approximately 25% of patients with sarcoidosis. A large variety of morphologic patterns has been well described; ulcerative lesions are rare. A 30-year-old black man had generalized cutaneous granulomas, many of which demonstrated superficial ulceration. The exudative quality of these lesions was probably secondary to recurrent bacterial infection. Use of oral antibiotics, prednisone, and hydroxychloroquine sulfate controlled his disease activity.

Balloon dilatation in the treatment of early intermittent claudication.

Balloon dilation of atherosclerotic arteries is an established procedure with a high success rate and low morbidity. In the past 18 months, 71 patients underwent balloon dilatation at the Royal Melbourne Hospital, with a success rate of 90%. This technique is most successful in short stenoses or occlusions, and earlier investigation of selected patients with intermittent claudication is recommended.

Treatment of psoriasis with 8-methoxypsoralen and sunlight.

Photochemotherapy with 8-methoxypsoralen and sunlight (PUVA-SOL), administered three times weekly, proved effective in the treatment of psoriasis. Weekend photochemotherapy (modified PUVA-SOL) also appeared useful as an adjunct to standard topical corticosteroid therapy. Careful measurement of ambient long-wave ultraviolet light (UVA) in the treatment locale and respect for the phototoxic potential of PUVA-SOL are necessary for success. The long-range toxicity of psoralen photochemotherapy remains undetermined.