Optimizing Parameters for Smoke Evacuation.

BACKGROUND: Current literature lacks recommendations regarding the ideal organization of the smoke evacuation system to minimize inhalation of surgical smoke. OBJECTIVE: This study determines optimal parameters of the smoke evacuation system with respect to the surgical field. MATERIALS AND METHODS: This study was conducted in an outpatient surgical facility at a tertiary care center. After 30 seconds of continuous electrocautery of tissue, particulate measurements were recorded using the TSI DustTrak Aerosol Monitor 8520 (>2.5 µm particles) and the TSI P-Trak Ultrafine Particle Counter 8525 (<1 µm particles) while changing the angle and distance of the smoke evacuation system. RESULTS: Particulate matter measurements were lower when suction angle was at 45° than at 90°. For both small-sized and large-sized particles, the lowest particulate matter was recorded when the evacuator was maintained at a 45° angle, 2 to 4 inches away from the cauterizing procedure. Particulate matters dramatically increased after increasing the distance of the smoke evacuator beyond 8 inches from the procedural site. CONCLUSION: In an effort to reduce smoke inhalation, the authors recommend that smoke evacuation should be placed at a 45° suction angle, no further than 8 inches away from the surgical site, while preserving the surgeon's field of vision.

A Split-Scar Study Investigating the Effectiveness of Early Intervention With Electroabrasion on Improving the Cosmetic Appearance of Postsurgical Scars.

BACKGROUND: Electroabrasion, which uses an in-office electrosurgical device, is a method of surgical planning that ablates the skin to the papillary dermis. Several reports demonstrate that intraoperative ablative interventions with lasers or dermabrasion can modulate scar formation more effectively. This investigation uses electroabrasion intraoperatively to mitigate scar formation. OBJECTIVE: To evaluate the effectiveness of intraoperative electroabrasion for scar revision. MATERIALS AND METHODS: This was a prospective, randomized, observer-blinded, split-scar study with 24 linear scar segments resulting from primary closures in patients undergoing Mohs micrographic surgery. After placement of dermal sutures, half of the wound was randomly treated with electroabrasion. The other half was used as the control. Scar appearance was assessed by a blinded observer and by the patient using the Patient and Observer Scar Assessment Scale at 1 to 2 weeks, 1 month, and 3 months after surgery. RESULTS: At the 3-month follow-up, both patient and observer variables measuring scar contour improved on the treated side, whereas erythema was worse. Overall, no difference was seen in total scores between the 2 sides. CONCLUSION: Based on this pilot study, scars treated with electroabrasion revealed improved surface topography but worsened erythema. Future studies with more refined electrosurgical settings are needed for further evaluation.

Cutaneous Complications of Targeted Melanoma Therapy.

OPINION STATEMENT: The landscape of advanced and metastatic melanoma therapy has shifted dramatically in recent years. Since 2011, eight drugs (ipilimumab, vemurafenib, dabrafenib, trametinib, cometinib, pembrolizumab, nivolumab, and talimogene laherparepvec) have received FDA approval for the treatment of advanced or metastatic melanoma, including combination regimens of both small molecule kinase and immune checkpoint inhibitors. These therapies have revolutionized the management of unresectable regional nodal and distant melanoma, providing hope of extended survival to patients. As the use of novel agents has increased, so have the cutaneous toxicities associated with these medications. While most skin reactions are low-grade and can be managed conservatively with topical therapies, malignant lesions and more serious or life-threatening drug reactions can arise during therapy, requiring prompt dermatologic recognition and treatment in order to improve patient outcome. Given the survival benefit attributed to these new agents, treating skin toxicity and maintaining patient quality of life is of paramount importance. Oncologists should be aware of the common cutaneous toxicities associated with these medications and should be encouraged to involve dermatologists in the collaborative care of advanced melanoma patients. Close communication between oncologists and dermatologists can help to avoid unnecessary dose reduction or treatment discontinuation and identify situations when treatment cessation is truly warranted.

Medicolegal issues.

The legal landscape in dermatology is constantly evolving. Dermatologists should nurture strong physician-patient relationships with proper informed consent and stay abreast of legal issues as they pertain to today's practice of medicine. Medicolegal issues that have risen to the forefront include wrong-site surgery, delegation of procedures to nonphysician operators, and compounding of medications. Additionally, although the marriage of health care and technology has facilitated our practice of medicine, it has opened doors to new medicolegal pitfalls associated with the use of electronic medical records, teledermatology, and even social media. This contribution will highlight some of the common medicolegal issues in dermatology along with recommendations to minimize exposure to litigation.

Lichenoid drug reaction following influenza vaccination in an HIV-positive patient: a case report and literature review.

Lichenoid drug reactions to vaccinations are rare but well-documented events. The vast majority of these reported reactions have been triggered by Hepatitis B vaccination (HBV). We describe an impressive generalized lichenoid drug reaction following the influenza vaccination. A 46-year-old African-American woman with a history of treated human immunodeficiency virus (HIV) disease developed a diffuse, pruritic rash one day following vaccination against the influenza virus. Physical exam and histopathology were consistent with a lichenoid drug eruption. This is only the fifth reported case of lichenoid drug reaction, and only the second generalized case, following influenza vaccination. The patient's underlying HIV disease, known to be a risk factor for both cutaneous drug reactions and more severe manifestations of lichen planus, likely predisposed her to this generalized hypersensitivity phenomenon.

Linear atrophoderma of Moulin: a distinct entity?

Linear atrophoderma of Moulin (LAM) is a rare dermatologic disorder characterized by a hyperpigmented atrophoderma that consistently follows the lines of Blaschko. There are many clinical and histologic similarities between LAM, atrophoderma of Pasini and Pierini (APP), and morphea, and whether LAM represents part of a disease spectrum or its own distinct entity is debated. This case of a 16-year-old boy with LAM supports the hypothesis that LAM, APP, and morphea are a spectrum of disorders rather than unique entities. Although the patient's overall clinical picture supports a diagnosis of LAM with hyperpigmented, depressed lesions following the lines of Blaschko and perivascular lymphocytic infiltrate on biopsy, the bilateral presentation typical of APP, collagen entrapment of eccrine ducts typical of morphea, and changes in dermal collagen illustrate features spanning all three disorders, suggesting a relationship between these conditions that represents a spectrum of disease. Furthermore, a review of all reported cases of LAM in the literature suggests an evolving definition beyond what Moulin and colleagues originally described, including features related to those of APP and morphea.