Venous ulcers: A reappraisal analyzing the effects of neuropathy, muscle involvement, and range of motion upon gait and calf muscle function.

Chronic venous insufficiency is a complex disease that can result in severe sequelae including venous ulceration. Though the exact progression from chronic venous insufficiency to venous ulcer remains unclear, the high cost and burden of this disease on patients and society is quite clear. Sustained ambulatory venous pressures or venous hypertension plays an integral role in the development of venous ulceration and involves the failure of the calf muscle pump system. Standard of care involves compression therapy to assist the calf muscle pump. However, several cofactors may contribute to or exacerbate this disease and understanding their impact may provide insight into new treatment modalities. Nerve involvement, which may result in neuropathic pain and muscle dysfunction, alterations in mobility and a decrease in range of motion may lead to gait alterations all affecting calf muscle pump function. In this paper, we analyze these cofactors and discuss possible treatment options to target them. Physicians treating this disease should be aware of the numerous factors involved in its development. Exploring new treatment options may 1 day lessen the burden and suffering caused by venous insufficiency.

Voriconazole-induced phototoxicity masquerading as chronic graft-versus-host disease of the skin in allogeneic hematopoietic cell transplant recipients.

Systemic fungal infections pose a significant risk to patients following allogeneic hematopoietic cell transplantation (alloHCT). Voriconazole (Vfend, Pfizer) is an oral second-generation triazole antifungal agent that offers a broad spectrum of coverage against fungal species and is frequently utilized in the post-HCT setting. Herein, we describe 5 patients who were initially believed to be experiencing a flare of cutaneous chronic graft-versus-host disease (cGVHD), but who were actually exhibiting phototoxicity caused by voriconazole. A high index of suspicion for this adverse reaction in the post-alloHCT setting will prevent misdiagnosis and avoid inappropriate therapy for cGVHD.

Herpes simplex virus: a histopathologic study of the depth of herpetic wounds.

BACKGROUND: Herpes is a prevalent, infectious disease that can occur anywhere on the body; it is found primarily on the face and genitalia. Herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2) are the DNA viruses that cause human herpes. Clinically, HSV-1 and HSV-2 infections produce lesions generally located on the mucocutaneous junctions of the face and genitalia. At times, vesicular lesions may ulcerate, leaving recalcitrant wounds that are challenging to treat. Until now, the basis of treatment has been related to the eradication of the viral infection. Little attention has focused on the consequence of the viral infection and the resulting wounds, specifically whether this represents an epidermal or dermal injury. METHODS: Using 10 herpetic lesions from different individuals, we studied the depth of the injury via routine hematoxylin and eosin stains, as well as periodic acid-Schiff (PAS) and type IV collagen stains, which demonstrate the presence of the basement membrane. RESULTS: In all cases, we found an inflammatory infiltrate in the dermis and selective disruption of the basement membrane. CONCLUSION: This suggests that herpetic lesions involve the dermis and are best classified as partial-thickness wounds.

Treatment of herpes simplex virus infection: rationale for occlusion.

Orofacial herpes is a widespread benign malady that is also commonly known as herpes labialis or cold sores. Herpes of this type is generally caused by herpes simplex virus type 1 (HSV-1) and, to a lesser degree, herpes simplex virus type 2 (HSV-2), both of which are DNA viruses. The clinical presentation of herpetic lesions is normally located on mucocutaneous areas of the face and may eventually erode and ulcerate, leaving wounds that are known to be difficult to successfully treat. Focus of treatment has been related to treatment of the viral infection, and limited attention has focused on the resultant wounds. Clinical observation and recent histologic evaluation has demonstrated these wounds to extend through a disrupted cutaneous basement membrane into the dermis, suggesting that HSV is capable of causing partial-thickness wounds. This observation suggests a role for occlusion in the treatment of herpetic-induced partial-thickness wounds because occlusion is well recognized as the treatment of choice for other types of partial-thickness wounds.

Clinical pearl: the evaluation of the surface area of small pigmented lesions.

The ability to calculate the surface area of small pigmented lesions is an important assessment tool, especially if one is suspicious for malignancy. Calculation of the surface area can be an arduous task if one does not have a standard technique. This article is in regards to the inexpensive and relatively easy technique of calculating the surface area of small pigmented lesions. This technique is a unique method, not described in the literature before, and may be utilized by any dermatologist at any level of experience. Our method is presented because the calculation of small pigmented lesions is an important tool to utilize, especially in cases of skin carcinoma. This technique can also be modified to calculate the surface area of much larger lesions and therefore may have a broad clinical application in the field of dermatology and cutaneous surgery.

Use of the Vectra polyetherurethaneurea graft for dialysis access in HIV-positive patients with end-stage renal disease.

The primary objective of this study was to establish the safety, efficacy, infection rate, and patency of the Vectra graft (polyetherurethaneurea) for dialysis access in patients diagnosed with human immunodeficiency virus (HIV) and end-stage renal disease. The Vectra graft has a unique self-sealing property; therefore we hypothesize that these patients will have fewer infections. A Vectra graft was implanted in 30 consecutive HIV-positive patients without sufficient veins for an autologous fistula. These surgeries were carried out over a 2.5-year period. Primary graft patency was 42% at 12 months and 3 (10%) of the grafts developed infection. This rate of graft infection was less (10% vs 45%) than both our prior experience and published reports using polytetrafluorothene bridge grafts. The unique self-sealing property of the Vectra graft minimizes the development of perigraft hematoma with repetitive needle cannulation and in the immunosuppressed HIV-positive patient, may account for the observed decrease in dialysis access infection.

Basal cell carcinoma of the nail unit treated with Mohs micrographic surgery: superficial multicentric BCC with jagged borders--a histopathological hallmark for nail unit BCC.

We present a case of basal cell carcinoma (BCC) of the nail unit with a special emphasis on superficial multicentric histopathologic type with jagged borders that was treated with Mohs micrographic surgery. Nail unit BCCs may not be as rare as previously believed and jagged borders in the superficial neoplastic buds may be a hallmark for superficial BCCs of the nail unit.