Preoperative methicillin-resistant Staphylococcus aureus screening in Mohs surgery appears to decrease postoperative infections.

BACKGROUND: Colonization with methicillin-resistant Staphylococcus aureus (MRSA) places patients at risk for postoperative MRSA wound infections. OBJECTIVE: To determine the effect of a decontamination and prophylaxis protocol on postoperative MRSA wound infections in patients with nasal MRSA. METHODS & MATERIALS: Wound cultures over a 23-month period were reviewed before and 11 months after implementation of a screening and decontamination protocol. After preoperative MRSA screening with nasal swabs, carriers were instructed to use intranasal mupirocin for 5 to 7 days before surgery and 5 to 7 days of trimethoprim-sulfamethoxazole starting the day before surgery. RESULTS: During the 23 months before prescreening evaluation, we performed 3,633 Mohs surgical cases, and 12 postoperative MRSA wound infections (0.3%) occurred. Subsequently, 963 patients underwent screening for MRSA, and 23 MRSA carriers were identified (2.4%). Of the 22 who underwent the decontamination and treatment protocol, none developed postoperative wound infections. One MRSA carrier did not receive preoperative treatment and subsequently developed a MRSA wound infection. There were no other MRSA infections. CONCLUSION: Preoperative MRSA screening and implementation of a decontamination protocol appears to decrease postoperative MRSA wound infections after Mohs surgery. Although an interesting observation, controlled studies of clinical and cost effectiveness are required before general implementation. The authors have indicated no significant interest with commercial supporters.

Midline/paramedian longitudinal matrix excision with flap reconstruction: alternative surgical techniques for evaluation of longitudinal melanonychia.

BACKGROUND: Surgical evaluation of longitudinal melanonychia requires biopsy of the nail matrix. Previous publications have presented detailed surgical approaches to this problem. However, discussion of longitudinal excision with local matrix flap reconstruction is documented sparsely in the literature. OBJECTIVE: To describe the indications for and technique of performing a longitudinal, full-thickness excision for longitudinal melanonychia; as this surgery poses a high risk of postoperative split nail, reconstruction is essential. Three local matrix flaps are detailed to maximize functional and cosmetic results. METHODS: The authors detail the different procedures, with several illustrations and clinical photographs highlighting the techniques. RESULTS: These techniques provide the surgeon with additional approaches to excise lesions of longitudinal melanonychia and reconstruct the surgical defects. LIMITATIONS: All surgeries of the nail matrix pose a risk of postoperative nail dystrophy and/or split nail. CONCLUSION: The different flaps provide elegant local alternatives to second-intention healing and maximize cosmetic and functional results after matrix excision with narrow margins for longitudinal melanonychia.

Dermatologic conditions seen in end-stage renal disease.

The skin changes reported in patients with end-stage renal disease (ESRD) are diverse and manifold. In this article we focus on a collection of specific cutaneous entities seen most frequently in the setting of ESRD, each presenting with distinctive and unique morphology. These include perforating disorders, porphyria cutanea tarda, pseudoporphyria, calcinosis cutis, calciphylaxis, and nephrogenic systemic fibrosis. The clinical features, histopathology, pathophysiology, differential diagnosis, and management of each entity are reviewed.