An Update and Review of Clinical Outcomes Using Immunohistochemical Stains in Mohs Micrographic Surgery for Melanoma.

BACKGROUND: Mohs micrographic surgery (MMS) provides optimal margin control through complete peripheral and deep margin assessment. The treatment of melanoma using MMS has historically been limited by difficulty in interpreting melanocytes using frozen sections. Immunohistochemical (IHC) staining, a technique whereby chromogen-tagged antibodies are used to detect antigens of interest, has revolutionized the surgical treatment of melanoma. OBJECTIVES: This article provides an update and literature review of current IHC stains used in MMS for melanoma, their sensitivities and specificities, and clinical outcomes. MATERIALS AND METHODS: A PubMed search was performed using keywords including "immunohistochemistry," "staining," and "Mohs surgery." Articles related to the use of IHC staining for the treatment of melanoma with MMS were included. RESULTS: Six IHC stains met the criteria for the review including melanoma antigen recognized by T cells (MART-1), SRY-related HMG-box (SOX10), microphthalmia-associated transcription factor, HMB-45, MEL-5, S-100, and preferentially expressed antigen in melanoma. CONCLUSION: The adaptation of IHC methods to frozen sections has enabled MMS to become a preferred treatment option for melanoma in special-site areas. Future studies are needed to standardize IHC techniques and to define best practices when using frozen section in the treatment of melanoma.

Refractory focal epithelial hyperplasia successfully treated with novel use of nano-pulse stimulation technology.

Focal epithelial hyperplasia (FEH), or Heck's disease, is an uncommon HPV-related dermatosis that presents with multiple discrete papules or nodules on the lips, tongue, and gingival or oral mucosa. Treatment is often sought due to cosmesis, social stigma, and functional impairment. Treatment is challenging and a variety of treatment modalities have been attempted with varying degrees of success. This report describes the novel use of nano-pulse stimulation in the successful treatment of recalcitrant FEH of the upper and lower vermillion lip.

Hidden in plain sight: Considerations for an ulcer of the scalp.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare inflammatory skin condition characterized by painful, irregularly shaped skin ulcers mainly affecting the lower extremities. PG rarely affects the head and neck, making the diagnosis of this condition even more challenging. A high index of suspicion is paramount in the diagnosis of PG, especially after surgical procedures. METHODS: We describe a clinical case of a patient with initially undiagnosed PG of the scalp who underwent surgical excision and full thickness skin graft with subsequent graft necrosis as initial clue for the diagnosis. RESULTS: Twenty months after initial presentation, this patient healed with a multimodal medical approach of immunosuppressive therapy and wound care. CONCLUSION: Prompt recognition of PG by physicians assessing any surgical wounds is vital in reducing misdiagnosis and improving patient outcomes.

EATING AND GLYCEMIC CONTROL AMONG CRITICALLY ILL PATIENTS RECEIVING CONTINUOUS INTRAVENOUS INSULIN.

Objective: Consensus guidelines recommend that intensive care unit (ICU) patients with blood glucose (BG) levels >180 mg/dL receive continuous intravenous insulin (CII). The effectiveness of CII at controlling BG levels among patients who are eating relative to those who are eating nothing by mouth (nil per os; NPO) has not been described. Methods: We conducted a retrospective cohort study of 260 adult patients (156 eating, 104 NPO) admitted to an ICU between January 1, 2014, and December 31, 2014, who received CII. Patients were excluded for a diagnosis of diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic syndrome, admission to an obstetrics service, or receiving continuous enteral or parenteral nutrition. Results: Among 22 baseline characteristics, the proportion of patients receiving glucocorticoid treatment (GCTx) (17.3% eating, 37.5% NPO; P<.001) and APACHE II score (15.0 ± 7.5 eating, 17.9 ± 7.9 NPO; P = .004) were significantly different between eating and NPO patients. There was no significant difference in the primary outcome of patient-day weighted mean BG overall (153 ± 8 mg/dL eating, 156 ± 7 mg/dL NPO; P = .73), or day-by-day BG (P = .37) adjusted for GCTx and APACHE score. Surprisingly, there was a significant difference in the distribution of BG values, with eating patients having a higher percentage of BG readings in the recommended range of 140 to 180 mg/dL. However, eating patients showed greater glucose variability (coefficient of variation 23.1 ± 1.0 eating, 21.2 ± 1.0 NPO; P = .034). Conclusion: Eating may not adversely affect BG levels of ICU patients receiving CII. Whether or not prandial insulin improves glycemic control in this setting should be studied. Abbreviations: BG = blood glucose; CII = continuous insulin infusion; CV = coefficient of variation; HbA1c = hemoglobin A1c; ICU = intensive care unit; NPO = nil per os; PDWMBG = patient day weighted mean blood glucose.

Seborrheic Dermatitis in Skin of Color: Clinical Considerations

Seborrheic dermatitis is a common, relapsing, inflammatory skin condition of unclear etiology. The Malassezia yeast genus are believed to play a role. Seborrheic dermatitis commonly affects areas of the skin with high sebum production, including the scalp, nasolabial folds, glabella, eyebrows, beard, ears, retroauricular skin, sternum, and other skin folds. Seborrheic dermatitis may present differently in individuals with skin of color. Darker-skinned individuals may present with scaly, hypopigmented macules and patches in typical areas of involvement. Arcuate or petal-like patches may be seen, specifically termed petaloid seborrheic dermatitis. Children of color often do not experience the classic "cradle cap" appearance of seborrheic dermatitis, and have erythema, flaking, and hypopigmentation of the affected areas and folds of skin. Seborrheic dermatitis tends to respond well to conventional treatments, although it tends to recur. Skin of color patients may require a modified treatment approach which takes into account differences in hair texture and hair washing frequency. This paper aims to highlight these differences to help reduce disparities in the management of seborrheic dermatitis in patients of color. J Drugs Dermatol. 2019;18(1):24-27.