Postsurgical wound management.

Successful outcomes in cutaneous surgery depend on a variety of factors, including preoperative assessment of the patient's health and expectations, intraoperative skill and attention to detail, and managing the postoperative period. Once the procedure is complete, careful selection of dressings, provision of adequate analgesia, judicious management of complications and monitoring the phases of early maturation while providing patient education improve the likelihood of long-term patient and physician satisfaction.

Treatment of atrophoderma of Pasini and Pierini-associated hyperpigmentation with the Q-switched alexandrite laser: a clinical, histologic, and ultrastructural appraisal.

BACKGROUND AND OBJECTIVE: Atrophoderma of Pasini and Pierini (APP) is an uncommon cutaneous disorder, with no known effective treatment, manifested by hyperpigmented patches that appear to be depressed compared with surrounding skin. This study investigated the effectiveness of the Q-switched alexandrite laser on a patient with extensive APP, and evaluated histopathologic and ultrastructural changes. STUDY DESIGN/MATERIALS AND METHODS: A man with stable APP underwent Q-switched alexandrite laser treatment to a patch on the trunk. Biopsies were obtained from treated and untreated sites of involvement. Light and transmission electron microscopic evaluation was performed to investigate melanosome number, size, and volume, as well as melanin granule number and size. RESULTS: After three treatment sessions, the treated area showed marked clinical improvement. Electron microscopy showed a 19% reduction in melanin granule number and size and a 65% reduction in melanosome number, size, and volume in larger melanosomes in treated compared with untreated sites. CONCLUSION: Treatment of APP with the Q-switched alexandrite laser results in clinical improvement. Electron microscopic evaluation suggests that the mechanism may be a reduction in the number, size, and volume of larger melanosomes as well as a decrement in melanin granule number and size.

Pulsed-dye laser versus conventional therapy in the treatment of warts: a prospective randomized trial.

BACKGROUND: The clinical management of verrucae vulgaris is often challenging, and no ideal treatment currently exists. Early studies suggested that pulsed-dye laser (PDL) therapy might be highly effective in the treatment of verrucae, although more recent reports have been less optimistic. Previous studies have been retrospective or have consisted of a series of patients treated with PDL alone. OBJECTIVE: Our objective was to prospectively evaluate the efficacy of PDL therapy versus conventional therapy with liquid nitrogen cryotherapy or cantharidin in the treatment of warts. METHODS: Forty healthy adult patients with verrucae were randomized to receive either PDL (585 nm) therapy or conventional therapy. All enrollees also performed home therapy. Patients were eligible for up to 4 treatment sessions at 1-month intervals. Warts were individually counted and measured at the time of each treatment session. Complete response was defined as complete absence of verrucae with the presence of dermatoglyphics, and partial response was defined as a 50% or greater reduction in wart size. RESULTS: A total of 194 warts were evaluated by the conclusion of the study. Complete response was noted in an average of 70% of the warts treated with conventional therapy and in 66% of those in the PDL group; this was statistically insignificant. Partial response was observed in an average of 82% of the warts in patients treated with conventional therapy and 87% in the PDL group. Verruca vulgaris responded more readily than verruca plantaris in both treatment groups. The mean number of treatments to achieve success was similar in both groups. CONCLUSION: The PDL is an efficacious form of therapy for verrucae, as is conventional therapy. PDL therapy should be considered among the better established approaches in the treatment of warts, although data from this trial suggest that this approach is probably not superior.

Injectability and tissue compatibility of poly-(N-vinyl-2-pyrrolidone) in the skin of rats: a pilot study.

BACKGROUND: Filling substances have been used in dermatologic surgery for decades, but an ideal agent has yet to be discovered. Poly-(N-vinyl-2-pyrrolidone) is a hydrogel that has been used in medical settings for more than 50 years, but not as a cutaneous filling agent. OBJECTIVE: We investigated the intracutaneous injectability and tissue compatibility of this hydrogel in a rat model. Particular attention was paid to ease of injection through small needles, volume retention of the implant, clinical course, and histocompatibility. METHODS: The shaved backs of 12 anesthetized Sprague-Dawley rats were injected with the sterilized hydrogel and the rats closely observed. The rats were sacrificed in groups of four at 2, 4, and 12 weeks after implantation. Implant size was measured, volume calculated, and biopsies taken at each time interval. RESULTS: Poly-(N-vinyl-2-pyrrolidone) is easily injected through 30-gauge needles. All rats tolerated the implants well clinically. Histopathology revealed well-circumscribed implants with pseudoencapsulation, neoangiogenesis, and mixed inflammatory cells predominating at the periphery. Volume calculations revealed an average of 33% reduction at 4 weeks and 35% reduction at 12 weeks. CONCLUSION: Poly-(N-vinyl-2-pyrrolidone) is easy to inject intracutaneously and is well tolerated in the rat model. Short-term volume retention is good. Histopathology suggests a subclinical inflammatory reaction expected with implantation of a synthetic substance into the skin. Additional studies are necessary to investigate the continued persistence of the hydrogel and its long-term effects on surrounding tissue.

Treatment of multiple cutaneous leiomyomas with CO2 laser ablation.

BACKGROUND: Cutaneous leiomyomas are benign tumors that can be exquisitely painful. Symptomatic lesions often necessitate treatment, but many options are inadequate or create substantial morbidity. Without a definitive therapy of first choice, the search continues for alternative methods to alleviate discomfort in affected patients. OBJECTIVE: To describe the use of CO2 laser ablation for the symptomatic treatment of a 73-year-old woman with multiple cutaneous leiomyomas in whom pharmacologic therapy was contraindicated and surgical excision was impractical. METHODS: CO2 laser ablation of six symptomatic cutaneous leiomyomas was performed under local anesthesia. After initial success, all remaining symptomatic lesions were treated. RESULTS: There was complete pain relief in the originally treated lesions 9 months postoperatively, and in all remaining treated lesions 3 months postoperatively. CONCLUSION: CO2 laser ablation may be an effective alternative treatment for symptomatic cutaneous leiomyomas.

Porcine heterografts in dermatologic surgery and reconstruction.

BACKGROUND: Porcine heterografting is a method that can be used to reestablish the protective integrity of skin after cutaneous injury. These grafts may be used in an assortment of clinical situations for chronic and acute wounds, burn injury, and partial- or full-thickness areas of skin loss. OBJECTIVE: The purpose of this article is to address the indications for using porcine heterografts in dermatologic surgery, the advantages and disadvantages of their use, and the technique of graft application. METHODS: Indications for porcine heterografts and the methodology of graft application are discussed. RESULTS: Porcine heterografts serve as a valuable tool in a variety of reconstruction settings in dermatologic surgery. CONCLUSIONS: Heterografts provide an inexpensive method to facilitate wound care and promote healing, and serve as an effective repair option for a variety of surgical defects.

Management of multiple miliary osteoma cutis.

BACKGROUND: Multiple miliary osteoma cutis of the face is a variant of osteoma cutis that usually occurs in women with a previous history of acne vulgaris. OBJECTIVE: To effectively treat cosmetically objectionable lesions of multiple miliary facial osteomas. METHODS: We report a patient with multiple miliary osteoma cutis, without a previous history of acne vulgaris, and the results of treatment of these lesions with curettage and the carbon dioxide continuous-wave laser. RESULTS: The patient had an excellent cosmetic outcome with minimal scarring and faint hypopigmentation after 3 treatment sessions. CONCLUSION: Surgical ablative therapy remains the treatment of choice for patients with this condition, and the use of curettage and carbon dioxide laser ablation provided excellent results for our patient. To our knowledge, this approach to treatment has not been previously described.

Persistent keratoacanthoma: challenges in management.

BACKGROUND: Keratoacanthoma is a common cutaneous neoplasm, although the persistent form is less common and often more difficult to manage. Multiple treatment approaches have been attempted with variable efficacy. Establishing the diagnosis and selecting a treatment plan for persistent keratoacanthoma is often challenging. OBJECTIVE: Our purpose is to describe the difficulty one may encounter in the diagnosis and treatment of persistent keratoacanthoma. Hopefully, review of this clinical conundrum may facilitate the management of the reader's future patients. METHODS: We describe a case of persistent keratoacanthoma where the diagnosis was initially elusive and the management challenging. Our thought process during each stage of diagnosis and management is described in the form of "issues" with references to the appropriate literature. RESULTS: After several diagnostic and therapeutic interventions, successful treatment was achieved with administration of oral isotretinoin. Long-term remission continued as the dosage was tapered. CONCLUSION: Persistent keratoacanthoma may be challenging to diagnose and manage, presenting a clinical conundrum. Careful review of the clinicopathologic presentation and an understanding of the various treatment options may result in a successful outcome.

Biopsy of the skin. Thoughtful selection of technique improves yield.

Skin biopsy can serve both diagnostic and therapeutic purposes. Site selection is not of major importance in the many types of lesions suggestive of malignancy but is crucial with diffuse eruptions. The shave technique is appropriate for many neoplastic lesions, while punch or incisional/excisional biopsy is necessary for more deeply invasive lesions. A variety of anesthetics are available to aid in patient comfort, as are a number of techniques for accomplishing the procedure to achieve the best cosmetic result.

The lips. Excision and repair.

Dermatologists commonly encounter lesions arising on the lips that require excision either for biopsy or treatment. Several surgical techniques used for excision and repair of the lip in the treatment of these conditions are reviewed. Topics covered include the importance of the lip, lip anatomy as it pertains to cutaneous surgery, techniques for obtaining lip anesthesia, partial-thickness and full-thickness lip excision and repair, surgical vermilionectomy, and carbon dioxide laser vermilionectomy. Emphasis will be placed on those surgical techniques that might commonly be used in a general dermatology practice.

Congenital miliaria crystallina: case report and literature review.

Generalized congenital miliaria crystallina occurred in a black newborn boy. Although miliaria crystallina occurring in infancy and beyond is well established, congenital occurrence is very rare. The pathogenesis of the disorder is not well understood. We discuss some hypotheses of pathogenesis in the context of our patient, as well as a differential diagnosis and a comparison with a previously reported case. Miliaria crystallina should be considered in the differential diagnosis of vesiculobullous eruptions in newborns.

Childhood epidermolysis bullosa acquisita. Report of three cases and review of literature.

Epidermolysis bullosa acquisita is an acquired subepidermal blistering disease with variable clinical, pathologic, and immunologic features. The disease has been reported infrequently in adults and only rarely in children. We describe three new cases of childhood epidermolysis bullosa acquisita, review three previously reported cases, and contrast the features of the disease in children with those in adults. The results suggest that both children and adults with epidermolysis bullosa acquisita have variable clinical and pathologic features that may mimic other bullous diseases. Epidermolysis bullosa acquisita is characterized by a chronic course, poor response to therapy, and occasional clinical remissions.