Sarcomatoid carcinoma of the hand: a clinical case with an aggressive and uncommon presentation.

Cutaneous sarcomatoid carcinoma is a high-grade malignancy. We describe a clinical case of an aggressive sarcomatoid carcinoma in an 87-year-old woman, who presented to the outpatients department with a haemorrhagic nodule on the dorsum of her right hand. By the time of excision 3 weeks later, the nodule had enlarged to 100 × 90 × 65 mm in size. On histological examination, a poorly differentiated carcinoma was seen, with both carcinomatous and sarcomatous elements, in keeping with a sarcomatoid carcinoma. The tumour was positive for cytokeratin, epithelial, smooth-muscle actin, and vimentin stains. Two months later, the patient presented with a recurrent growth on the excised scar along with numerous large right axillary lymph nodes. A right axillary dissection along with excision of the growth confirmed tumour recurrence with metastasis to lymph nodes. Soon after, the patient developed cerebral metastasis, which proved fatal. This case thus highlights the aggressive potential of sarcomatoid carcinoma.

Interventions to reduce Staphylococcus aureus in the management of atopic eczema: an updated Cochrane review.

BACKGROUND: An association between the bacterium Staphylococcus aureus and atopic eczema has been recognized for many years. Although few would dispute the benefit of systemic antibiotics in people with overtly clinically infected eczema, the clinical role of S. aureus in causing inflammatory flares in clinically uninfected eczema is less clear. OBJECTIVES/METHODS: To see if atopic eczema can be improved by antistaphylococcal agents, we performed a systematic review of randomized controlled trials (RCTs) using Cochrane Skin Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE (from 2000), EMBASE (from 1980), the metaRegister of Current Controlled Trials (to March 2009), plus manual searching of references and conference proceedings. RCTs that compared interventions to reduce S. aureus in people with atopic eczema with no treatment, vehicle, or another active compound were included. Publication status and language were not barriers to inclusion. RESULTS: Twenty-six studies involving 1229 participants were included. The studies were generally short term and of poor quality. There was no significant difference in global outcome for clinically infected eczema when oral antibiotics were compared with placebo [one study, relative risk (RR) 0.40, 95% confidence interval (CI) 0.13-1.24] or when topical steroid antibiotic combinations were compared with steroid alone (two studies, RR 0.52, 95% CI 0.23-1.16). One study of children with infected eczema that added bleach to bathwater showed a significant improvement in eczema severity when compared with bathwater alone, although the difference could have been explained by regression to the mean. Although antistaphylococcal interventions reduced S. aureus numbers in people with clinically uninfected eczema, none of the studies showed any clinical benefit. CONCLUSIONS: We failed to find any evidence that commonly used antistaphylococcal interventions are clinically helpful in people with eczema that is not clinically infected. Their continued use should be questioned in such situations, until better and longer-term studies show clear evidence of clinical benefit.

Should eye protection be worn during dermatological surgery: prospective observational study.

BACKGROUND: There is a potential risk of infection with blood-borne viruses if a doctor receives a blood splash to a mucous membrane. The quantification of facial contamination with blood has never been documented in the context of dermatological surgery. OBJECTIVES: (i) To identify the number of facial blood splashes that occur during skin surgery and to identify the procedures that present higher risks for the operator and assistant. (ii) To assess the provision of eye protection and attitudes to its use in dermatological surgery in the U.K. METHODS: (i) Prospective, observational study in the skin surgery suite of a U.K. teaching hospital assessing 100 consecutive dermatological surgery procedures, plus 100 consecutive operations in which an assistant was present. PRIMARY OUTCOME: number of face-mask visors with at least one blood splash. SECONDARY OUTCOMES: to identify if any of the following variables influenced the occurrence of a blood splash: grade of operator, site and type of procedure, and the use of electrocautery. (ii) A postal survey of all U.K.-based members of the British Society of Dermatological Surgery (BSDS) was conducted assessing facilities available and the attitudes of U.K.-based clinicians to the use of face masks during surgery. RESULTS: (i) In 33% of all surgical procedures there was at least one facial splash to the operator (range 1-75) and in 15% of procedures the assistant received at least one splash (range 1-11). Use of monopolar electrocautery was significantly less likely to result in splashes to the mask compared with bipolar electrocautery [odds ratio (OR) 0.04; 95% confidence interval (CI) 0.01-0.19]. Compared with the head/neck, operations on the body were significantly more likely to result in splashes to the mask (OR 6.52) (95% CI 1.7-25.07). The type of procedure and the status of the operator did not have a bearing on the likelihood of receiving a splash to the mask. (ii) From the survey, 33 of 159 (20.8%) of BSDS members had no face masks available and 54 of 159 (34.0%) did not wear any facial protection while operating. The majority (53.5%) thought they received a splash in

A case of linear IgA disease occurring in a patient with colonic Crohn's disease.

Linear IgA disease has been reported in association with inflammatory bowel disease, in particular ulcerative colitis. We experienced a case of linear IgA disease that occurred simultaneously with colonic Crohn's disease in a 55-year-old woman and rather unusually both skin and bowel disease improved in tandem. We report the presentation, investigations and subsequent improvement of our patient and speculate on possible causes.

Antibiotic prophylaxis in patients with valvular heart defects undergoing dermatological surgery remains a confusing issue despite apparently clear guidelines.

The guidelines pertaining to prescription of prophylactic antibiotics to prevent endocarditis during dermatological surgery appear clear and well-documented. The British Society for Dermatological Surgery, in agreement with the British Society for Antimicrobial Chemotherapy, state that antibiotic prophylaxis for endocarditis is not required for routine dermatological surgery procedures even in the presence of a pre-existing heart lesion. Pre-existing cardiac lesions include prosthetic valves, history of bacterial endocarditis, congenital cardiac malformation, rheumatic or other acquired valvular dysfunction, hypertrophic cardiomyopathy or mitral valve prolapse with regurgitation. It is important to distinguish between antibiotic prophylaxis for wound infection and that for bacterial endocarditis. Routine procedures, such as punches, shaves, curettage and simple excisions, performed on clean intact skin have an extremely low risk of wound infection (1-4%). The risk of wound infection increases to 5-15% with clean-contaminated skin surgery that includes procedures involving eroded or ulcerated skin, respiratory or buccal mucosa, flexural areas and protracted procedures such as Mohs' micrographic surgery. In such cases, antibiotic prophylaxis may be considered in patients with a cardiac lesion because a wound infection may result in bacteraemia and subsequent endocarditis. This should therefore not be considered 'routine' dermatological surgery. In contaminated, dirty and/or infected classes of wounds the risk of wound infection is higher (> 25%). Elective skin surgery should be postponed if possible until the wound infection is treated with therapeutic antibiotics.

Post-operative delayed bleeding from the superficial temporal artery.

We present three patients who experienced late, severe bleeding from the superficial temporal artery (STA) following uncomplicated removal of basal cell carcinoma (BCC) from the temple. This is a common site for BCC and the risk of damage to the temporal branch of the facial nerve and the STA are well known. However, delayed bleeding as described in these individuals is potentially dangerous but poorly reported.