Net-like pattern of calcification on plain soft-tissue radiographs in patients with calciphylaxis.

BACKGROUND: Calciphylaxis is a rare, life-threatening syndrome marked by vascular calcification and cutaneous necrosis. The role of radiographic imaging in assisting in diagnosis has not been established. OBJECTIVE: To investigate the potential role of plain radiographic imaging in the diagnosis of calciphylaxis. METHODS: We searched for cases of patients at our tertiary referral center with a diagnosis of calciphylaxis between Jan 1, 1996, and Dec 31, 2010. Two control patients receiving dialysis but without calciphylaxis were age- and sex-matched to each study patient. Plain radiographs were obtained from the date closest to diagnosis in patients with calciphylaxis and from matched controls at approximately the same dates. Two radiologists, masked as to cases and controls, read each image together. Size of calcified vessels, pattern and extent of calcifications, presence of net-like or other calcifications, and bone density/mineralization were recorded and analyzed. RESULTS: Twenty-nine patients with calciphylaxis (mean age, 57 years; 21 [72%] women) were identified. Mean age at diagnosis was 57 years (range, 36-75 years). Compared with those of controls, plain radiographs of patients with calciphylaxis had more vascular calcifications, more small-vessel calcifications, and a netlike pattern of calcifications. A netlike pattern of calcifications had considerable strength of association with calciphylaxis (odds ratio, 9.4) and a specificity of nearly 90%. These findings were preserved even if only one image was used per patient. LIMITATIONS: This was a retrospective study. CONCLUSION: A netlike pattern of calcifications on plain radiographs was more common in patients with calciphylaxis and may aid in diagnosis.

Melanocytes in nonlesional sun-exposed skin: a multicenter comparative study.

BACKGROUND: There are limited data regarding melanocyte density and distribution on sun-exposed skin of the head and neck, in particular, comparing morphology (hematoxylin-eosin [H&E] staining) and immunohistochemistry (Melan-A staining) on formalin-fixed tissue. Furthermore, comparisons of melanocyte density between distinct geographic populations have not been made using these methods. This information would be useful for physicians who use histologic criteria to diagnose and treat lentigo maligna. OBJECTIVE: We aimed to characterize the density and distribution of melanocytes using Melan-A and H&E stains on nonlesional sun-exposed skin of the face and neck, and compare the results between patients seen in Florida and Minnesota. We also aimed to quantify the presence and extent of features considered characteristic of melanoma in these noncancerous specimens of sun-damaged skin. The overall goal was to be able to provide this information to physicians who perform histopathologic interpretations of skin biopsy specimens to potentially prevent the overdiagnosis of melanoma. METHODS: In all, 100 patients undergoing Mohs micrographic and reconstructive surgery for basal cell and squamous cell carcinoma were enrolled, 50 each at the two sites. Permanent tissue sections were prepared from sun-exposed skin without clinical lesions. Melanocyte density and distribution were quantified. RESULTS: The overall median and 90th percentile, respectively, of melanocytes per high-power field was 9 and 14 on the H&E-stained sections and 11 and 19 on the Melan-A-stained sections. The means were 9.3 and 12.0, respectively (P < .001). There was evidence that melanocyte densities were higher in patients in Florida than in Minnesota, at least using H&E staining. There was evidence of lower melanocyte densities with increasing age, more so for Melan-A than H&E staining, and higher densities in men using Melan-A. Confluence was noted in 24% of cases using H&E and 45% using Melan-A. More than two thirds of these were classified as having mild confluence, whereas the others demonstrated higher amounts of confluence (3-8 melanocytes). Only 37 patients had a follicle present; of these, 7 patients had follicular extension although this did not extend beyond 1 mm in depth. Cytologic atypia was noted in 19 of the 100 patients; pagetoid spread was found in 3. LIMITATIONS: This was a selected population of patients; results may not be generalizable to the wider population. Variables such as contours of the epidermis (rete density), density of hair follicles, and epidermal thickness may affect the reproducibility of the results. Melanomas were not included for comparison. CONCLUSION: Relatively high melanocyte density, mild to moderate confluence of melanocytes, focal pagetosis, superficial follicular extension (<1.0 mm), and mild or moderate cytologic atypia may be observed in the absence of a melanocytic neoplasm. It is important for physicians to be aware of these findings so that such features are interpreted appropriately when making a histologic assessment that may ultimately influence therapy and outcome.

Survey of regional laser centers: a Minnesota perspective.

BACKGROUND: Laser use in medicine is rapidly expanding as patients seek treatment for medical and cosmetic purposes. Concern is mounting about the unsupervised use of lasers and similar devices by nonphysician personnel. Minnesota is currently one of the few states with no legislation regarding the uses of lasers. OBJECTIVE: To determine whether laser centers in Minnesota meet professional standards and guidelines for patient safety. METHODS AND MATERIALS: Public resources were used to identify all businesses with laser services in Minnesota cities with a population of at least 1,000 people. Each laser center was contacted, and a "secret shopper," a person who posed as a potential patient administered a telephone survey. RESULTS: A wide range of physicians and nonphysician personnel offer laser services in Minnesota. Supervision was not standardized and varied widely across the laser centers. CONCLUSIONS: As the demand for laser services increases, the use of lasers must be clearly defined and regulated to prevent patient injury. The authors have indicated no significant interest with commercial supporters.

Clinical outcome of cutaneous flaps versus full-thickness skin grafts after Mohs surgery on the nose.

BACKGROUND: A large proportion of facial skin cancers occur on the nose, and defects after Mohs surgery in this location often present a reconstructive challenge. For intermediate-sized defects, the choice of reconstruction is usually between skin flap and full-thickness skin graft. Ongoing debate exists, and limited data are available to determine which of these methods is more satisfactory. OBJECTIVE: To evaluate and compare the clinical appearance of wound healing after surgical repair with a skin graft versus a skin flap for Mohs defects on the nose. METHOD: In this study, 43 flaps and 24 grafts were evaluated using a modified Hollander Wound Evaluation Scale and a visual analogue scale. RESULTS: The mean visual analogue scale score was significantly better for flap repairs than for graft repairs. In addition, 100% of flaps had an acceptable overall cosmetic appearance on the basis of the Hollander Wound Evaluation Scale, compared with only 75% of skin grafts. CONCLUSIONS: For defects on the nose where flap and graft repair may both be technically possible, a flap may be more likely to result in superior cosmetic outcome.

Incidence of and risk factors for skin cancer after heart transplant.

OBJECTIVE: To examine the incidence, tumor burden, and risk factors for nonmelanoma and other skin cancer types in this heart transplant cohort. DESIGN: Retrospective review of patient medical records. SETTING: Tertiary care center. Patients All heart transplant recipients at Mayo Clinic from 1988 to 2006. MAIN OUTCOME MEASURES: Cumulative incidence of skin cancer and tumor burden, with Cox proportional hazards regression models used to evaluate risk factors for posttransplant primary and secondary nonmelanoma skin cancer. RESULTS: In total, 312 heart transplant patients had 1395 new skin cancers in 2097 person-years (mean, 0.43 per year per patient) with a range of 0 to 306 for squamous cell carcinoma (SCC) and 0 to 17 for basal cell carcinoma (BCC). The cumulative incidence rates of any skin cancer were 20.4%, 37.5%, and 46.4% at 5, 10, and 15 years after heart transplant, respectively. Cumulative incidence of SCC after the first BCC was 98.1% within 7 years. Multivariate analysis showed that posttransplant nonskin cancer, increased age, and heart failure etiologic factors other than idiopathic disease were associated with increased risk of SCC. Posttransplant herpes simplex viral infection, increased age, and use of mycophenolate mofetil for immunosuppression were associated with increased risk of BCC. CONCLUSIONS: With prolonged survival, many heart transplant patients have numerous skin cancers. Vigilant sun protection practices, skin cancer education, and regular skin examination are appropriate interventions in these high-risk patients.

Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008.

BACKGROUND: Antibiotic prophylaxis is an important component of dermatologic surgery, and recommendations in this area should reflect the updated 2007 guidelines of the American Heart Association, the American Dental Association with the American Academy of Orthopaedic Surgeons guidelines, and recent prospective studies on surgical site infection. OBJECTIVE: To provide an update on the indications for antibiotic prophylaxis in dermatologic surgery for the prevention of infective endocarditis, hematogenous total joint infection, and surgical site infection. METHODS: A literature review was performed, expert consensus was obtained, and updated recommendations were created, consistent with the most current authoritative guidelines from the American Heart Association and the American Dental Association with the American Academy of Orthopaedic Surgeons. RESULTS: For patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, prophylactic antibiotics are recommended when the surgical site is infected or when the procedure involves breach of the oral mucosa. For the prevention of surgical site infections, antibiotics may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease. LIMITATIONS: These recommendations are not based on multiple, large-scale, prospective trials. CONCLUSIONS: There is a strong shift away from administration of prophylactic antibiotics in many dermatologic surgery settings, based on updated authoritative guidelines. These recommendations provide guidance to comply with the most current guidelines, modified to address dermatology-specific considerations. Managing physicians may utilize these guidelines while individualizing their approach based on all clinical considerations.

Combined folliculotropic/syringotropic cutaneous T-cell lymphoma without epidermal involvement: report of 2 cases and pathogenic implications.

Exclusive involvement of skin appendages in cutaneous T-cell lymphoma (CTCL) is rare, poses significant problems in diagnosis, and may provide insight into mechanisms of T-cell epitheliotropism. We report 2 cases of combined adnexal (folliculotropic/syringotropic) CTCL in which lesions developed only in chronically sun-damaged skin. Although the epidermal layer in both cases was devoid histologically of significant epidermotropism, immunohistochemistry and polymerase chain reaction analyses of deeper samples that included involved adnexae confirmed aberrant antigen expression (dominant CD4 populations with apparent loss of CD7 and/or CD5) and T cell clonality, respectively. It is diagnostically important to recognize adnexal CTCL as a disorder that may be clinically and histologically protean. Additionally, its occurrence in sun-damaged skin in some patients may provide insight into mechanisms of selective epitheliotropism by malignant T cells.