A randomized controlled trial comparing acetaminophen, acetaminophen and ibuprofen, and acetaminophen and codeine for postoperative pain relief after Mohs surgery and cutaneous reconstruction.

BACKGROUND: There are no population-based data comparing analgesics after Mohs micrographic surgery (MMS) and reconstruction. OBJECTIVE To compare the efficacy in pain management of three analgesic combinations. METHODS: In a randomized, double-blind, controlled study, patients undergoing MMS and reconstruction for head and neck skin cancers received 1,000 mg of acetaminophen (Ac), 1,000 mg Ac plus 400 mg ibuprofen (Ib), or 325 mg Ac plus 30 mg codeine (Co) immediately after surgery and every 4 hours for up to four doses. Patients rated their pain on a visual analog scale (VAS) 0, 2, 4, 8, and 12 hours after surgery and recorded medication-related side effects. RESULTS: The Ac+Ib group had the lowest pain scores (mean change from baseline/immeditely prior to surgery) at each postoperative recorded time interval and a significantly smaller change from baseline pain scores than the Ac+Co group at 4 hours (p=.005) and the Ac group at 8 hours (p=.02). Ac+Ib was also superior in pain control for patients with surgical areas smaller than 10 cm(2) . Complications in the Ib+Ac group were significantly lower than in the Ac+Co group but not the Ac group. CONCLUSIONS: The combination of Ac+Ib is superior to Ac alone or Ac+Co in controlling postoperative pain after MMS and cutaneous reconstruction.

A randomized controlled trial of high-viscosity 2-octyl cyanoacrylate tissue adhesive versus sutures in repairing facial wounds following Mohs micrographic surgery.

BACKGROUND: High-viscosity 2-octyl cyanoacrylate (HVOCA) is a rapidly polymerizing liquid topical adhesive indicated for epidermal approximation of superficial lacerations and surgical wounds. Use of HVOCA in repair of facial wounds after Mohs micrographic surgery (MMS) has not been reported. OBJECTIVE: To compare aesthetic outcome of HVOCA versus sutured epidermal closure of linearly repaired facial wounds following MMS. METHODS: Patients undergoing MMS for facial tumors with postoperative wounds >3 cm appropriate for linear closure were recruited. After placement of dermal sutures, half the wound was randomly selected for closure with HVOCA and the other half was closed with 5-0 polypropylene suture. RESULTS: Fourteen patients (13 men and 1 woman; mean age, 72+/-8.8 years; range, 52-81 years) with basal cell or squamous cell carcinoma of the face (n=12) or neck (n=2) were enrolled. The mean wound length was 4.9+/-1.9 cm (range, 3.1-10 cm). No postoperative complications, including bleeding, infection, or dehiscence, occurred. Using photographs obtained 3 months postoperatively, five dermatologists (including two Mohs surgeons) blinded to the intervention rated cosmesis using a visual analog scale from 1 (worst) to 10 (best). The mean ratings for HVOCA half (6.64+/-1.55) versus sutured half (6.77+/-1.88) were not significantly different (p=.35). Paired comparisons of rater preferences similarly showed no cosmetic differences. All 14 patients preferred OCA for ease of postoperative care. CONCLUSION: HVOCA tissue adhesive is cosmetically equivalent to epidermal sutures in the linear repair of facial wounds following MMS. This technique represents an additional option for Mohs surgeons.

Rickettsia parkeri infection after tick bite, Virginia.

We describe a man with a febrile illness and an eschar that developed at the site of a tick bite. Rickettsia parkeri was detected and isolated from the eschar. This report represents the second documented case of R. parkeri rickettsiosis in a US serviceman in eastern Virginia.

Distribution of toenail dystrophy predicts histologic diagnosis of onychomycosis.

BACKGROUND: Onychomycosis (OM) affects up to 10% of the general population and is associated with functional impairment. Clinically, OM can mimic nail psoriasis, trauma, lichen planus, oncyhogryphosis, and other disorders. Laboratory methods for diagnosing OM vary in accuracy and predictive value. Clinical clues to OM would help guide laboratory testing and decrease improper empiric antifungal therapy. OBJECTIVE: The goal of this study was to determine whether particular distribution patterns of toenail dystrophy are associated with fungal infection of the nail. METHODS: We retrospectively reviewed toenail clippings submitted over a 5-year period to our pathology department for periodic acid-Schiff (PAS) staining for diagnosis of OM. RESULTS: Specimens from a total of 311 patients (130 men, 181 women; mean age: 48.3 yrs; range: 19-97 yrs) were included. Overall, 150 specimens (48.2%) were histologically positive for OM. OM was significantly more likely to be diagnosed in men (P < .01), in persons over the age of 64 (P < .02), and in the context of tinea pedis (P < .001). Involvement of the third (41/65; 63.1%) or fifth (27/41; 65.9%) toenails of either foot significantly correlated with OM (P < .025). Dystrophy of the great toenail was seen in 257/311 (82.6%) and was associated with OM in about half of cases (128/257; 49.8%). Dystrophy of first and fifth nails on the same foot was predictive of OM (23/32; P < .01). Unilateral dystrophy correlated positively with OM (79/142; 55.6%; P < .02), with a stronger correlation when 2 or more nails were dystrophic (33/42; P < .001). Dystrophy of the second or fourth nails, a single nail, or all 10 nails did not support or contradict of OM. Female gender was a negative predictor for OM (P < .001). LIMITATIONS: Potassium hydroxide and culture results were not available to correlate with histology. PAS staining of nail clippings has inherent diagnostic limitations. CONCLUSIONS: Dystrophy of the third or fifth toenails, of the first and fifth nails on the same foot, unilateral dystrophy, male gender, an age over 64, and the presence of tinea pedis are all independent predictive factors of OM. Presence of these patterns of dystrophy may help to clinically distinguish OM and guide laboratory testing.

Stevens-Johnson syndrome induced by doxycycline.

Stevens-Johnson syndrome (SJS) is an acute mucocutaneous eruption nosologically related to erythema multiforme (EM) and toxic epidermal necrolysis (TEN). Medications are the most common triggering factors for SJS, with anticonvulsants, sulfonamides, penicillins, allopurinol, and nonsteroidal anti-inflammatory drugs (NSAIDs) most commonly implicated. SJS is very rarely associated with tetracyclines. We report a case of doxycycline-induced SJS in a 46-year-old man.

Treatment of granuloma annulare with the 585 nm pulsed dye laser.

BACKGROUND: Granuloma annulare is a chronic asymptomatic dermatosis that is typically manifested by annular papules arising on the dorsa of the hands, feet, elbows, and knees. Multiple treatment modalities have been used with variable efficacy, but no known cure exists. Obtaining long-term resolution of involved areas is often a therapeutic challenge. OBJECTIVE: We report the results of treatment of a patient with localized erythematous granuloma annulare with a 585 nm flashlamp-pumped pulsed dye laser. METHODS: A single granuloma annulare plaque present on the left wrist for 3 years was treated on three occasions with a 585 nm flashlamp-pumped pulsed dye laser initially and repeated at months 5 and 13. RESULTS: After initial pulsed dye laser treatment, significant flattening and reduction of erythema were evident within the treated area. After a second treatment at month 5 and a third treatment at month 13, further improvement was evident, and long-term remission was achieved. CONCLUSION: Localized granuloma annulare may be difficult to manage, presenting a therapeutic challenge. Thorough understanding of available treatment options, their relative efficacies, and risks of complication can facilitate successful management of this chronic disease. Pulsed dye laser therapy may be an effective and relatively safe treatment option for erythematous granuloma annulare, although prospective studies in additional patients would be desirable. Improvement of the condition in a single patient does not imply that others might improve, and variability in response is more likely.

Guiding sutures to promote optimal contraction of a large surgical defect prior to delayed grafting.

BACKGROUND: Large surgical defects on the face are often challenging to repair. OBJECTIVE: To describe a method to reduce wound area and promote wound contraction. MATERIALS AND METHODS: Case report. Mohs' excision of a neglected basal cell carcinoma on the cheek left a large defect of 54 cm2. Delayed grafting was selected for the repair due to the size of the wound and the presence of multiple foci of perineural, muscle and parotid invasion. Two 4-0 polyglactin guiding sutures were placed across the inferior half of the wound; the superior half of the wound was allowed to granulate. RESULTS: At the time of split-thickness skin grafting 17 days later, the entire wound was 42% smaller than the original defect. The superior half of the wound was reduced by 29%, attributable to granulation. The inferior half of the wound was reduced by 55%, attributable to granulation and the contractile effect of guiding sutures. CONCLUSIONS: The placement of guiding sutures across large defects is a quick and simple technique that promotes optimal wound contraction with substantial reduction in the size of a wound, improving the final surgical result.

Rapidly growing mycobacterial infections after pedicures.

BACKGROUND: Rapidly growing mycobacteria (RGM) can cause a variety of cutaneous and systemic diseases. The causative organisms are typically Mycobacterium fortuitum or Mycobacterium chelonae (also known as Mycobacterium abscessus). Primary cutaneous lesions may develop after a variable latent period, from weeks to several months, and usually result from direct inoculation after trauma, from injections, or during surgery via contaminated medical instruments. Recently, investigators from the Centers for Disease Control and Prevention, Atlanta, Ga, and the California Department of Health Services, Berkeley, documented a large, unprecedented outbreak of community-acquired RGM infection, during which more than 100 patrons of a northern California nail salon contracted furunculosis in their legs as a result of exposure to whirlpool footbaths that were contaminated with M fortuitum. OBSERVATIONS: We report the clinical and epidemiological findings in 3 cases of lower extremity RGM infections that occurred after similar whirlpool footbath exposure at several different nail salons in southern California. These infections typically presented as recurrent furunculosis, causing considerable morbidity as a result of scarring, delayed diagnosis, and the need for long-term polymicrobial therapy. CONCLUSIONS: Rapidly growing mycobacterial infections related to pedicures may continue to occur in a sporadic fashion. Clinicians should consider the possibility of RGM infection and inquire about recent pedicures in a patient with recurrent lower extremity furunculosis and abscesses that are unresponsive to conventional antibiotic therapy.