A Large Pilar Sheath Acanthoma of the Cheek Successfully Treated With Surgical Excision.

This case report describes an atypically large pilar sheath acanthoma (PSA) presenting on a patient's cheek. Due to the bothersome nature of the lesion, the patient underwent surgical excision, with subsequent histopathological analysis confirming the diagnosis of an unusually large PSA. In addition to a definitive diagnosis, surgical excision provided symptomatic relief for the patient.

Report of Basal Cell Carcinoma Occurring With a Desmoplastic Trichilemmoma Successfully Treated With Mohs Micrographic Surgery.

Desmoplastic trichilemmoma, an uncommon variant of trichilemmoma, is a benign adnexal neoplasm originating from the outer root sheath of a hair follicle, which has rarely been associated with atypical basaloid proliferations, including basal cell carcinoma. In this patient case, a 67-year-old female presented to our dermatology clinic for a skin check. On physical examination, a pearly, pink papule was noted on the vertex scalp, and a biopsy was obtained to rule out malignancy. Histologic examination of the lesion favored a desmoplastic trichilemmoma; however, a basaloid neoplasm could not be ruled out. Subsequently, the patient underwent Mohs micrographic surgery, and upon examination of the Stage I Mohs slides, superficial basal cell carcinoma was identified within the lesion. This case serves to further strengthen the known association between basal cell carcinoma and desmoplastic trichilemmoma. In addition, it demonstrates that the presence of basal cell carcinoma may not be observed on the initial biopsy of these lesions, underscoring the utility of complete surgical excision.

Efficacy of 0.25% Lidocaine Versus 0.5% Lidocaine in Dermatologic Surgery: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Although lidocaine is widely used in dermatologic surgery, no formal standard concentration is established. Previous research indicates that more dilute concentrations may offer equally effective anesthesia while potentially reducing toxicity risks. In addition, diluting commercially available lidocaine conserves supplies-a significant benefit during periods of lidocaine shortage. OBJECTIVE: To evaluate the efficacy of 0.25% lidocaine compared with that of 0.5% lidocaine in achieving anesthesia in cutaneous surgery. MATERIALS AND METHODS: A prospective, double-blind study with 100 patients undergoing cutaneous surgery (Mohs surgery or excision) randomized to receive either 0.25% or 0.5% lidocaine for their percutaneous anesthesia. Patients completed a postoperative survey assessing pain level, satisfaction, and willingness to undergo future dermatologic surgery. RESULTS: This study revealed no statistically significant differences between the 0.25% and 0.5% lidocaine groups regarding pain scores, patient satisfaction, total lidocaine volume, rescue lidocaine volume, or willingness to undergo the procedure again. CONCLUSION: 0.25% lidocaine is a safe and effective option for achieving anesthesia during Mohs surgery and standard excisions. The results suggest that 0.25% lidocaine can be used to optimize high-value care and enhance patient safety in dermatologic surgery.

Squamous Cell Carcinoma With Unusual Benign-Appearing Cystic Features on Histology.

Squamous cell carcinoma (SCC) is a malignancy that arises from keratinocytes of the epidermis. Cystic variants of several types of cutaneous neoplasms have been rarely described in the literature. We report a case of biopsy-proven, well-differentiated invasive SCC treated with Mohs surgery. On frozen sections, the pathology slides showed benign-appearing cystic structures in the margins that persisted after it had appeared that the original malignancy had been cleared. After taking another Mohs stage due to clinical suspicion, additional SCC was found and was subsequently cleared after two more Mohs stages. To the best of our knowledge, this is the first report to histologically demonstrate biopsy-proven invasive SCC with benign-appearing cystic structures on frozen sections.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Tinea Capitis Masquerading as Basal Cell Carcinoma.

A 52-year-old white man with alcoholic cirrhosis presented to the Mohs surgery clinic with a 1-month history of tender "bumps" located diffusely on his scalp. Two biopsies performed at an outside institution were read as "basal cell carcinoma" and "actinic keratosis." The patient was scheduled for a large excision of the scalp for presumed multiple nodules of basal cell carcinoma and desired a second opinion from our Mohs surgery clinic.

Goodness, gracious, great balls of fire: A case of transient lingual papillitis following consumption of an Atomic Fireball.

Transient lingual papillitis is a benign condition characterized by the inflammation of one or more fungiform papillae on the dorsolateral tongue. Although it is a common condition that affects more than half of the population, few cases have been reported in the dermatological literature. Therefore, it is a condition uncommonly recognized by dermatologists though it has a distinct clinical presentation that may be easily diagnosed by clinicians familiar with the entity. We report an interesting case of transient lingual papillitis in a 27 year-old healthy woman following the consumption of the hard candy, Atomic Fireball. We describe treatment and resolution of the condition, and its recurrence following re-exposure to the identified culprit. This report further reviews the literature to illustrate the clinical manifestations, etiology, differential diagnosis, course, and treatment of this condition.

Merkel cell carcinoma in a vein graft donor site.

The development of malignancies in graft donor sites is rare and may be caused by de novo malignancies as well as metastatic and iatrogenic spread. Malignancies in graft donor sites are distinguished from Marjolin ulcers by some investigators because they occur in healed surgical wounds rather than in chronic wounds or unstable scars and tend to occur sooner after injury. We present a unique case of Merkel cell carcinoma (MCC) developing in a vein graft donor site 18 years after vein harvesting.

Bullous lesions in a patient with systemic lupus erythematosus.

Bullous eruptions in patients with lupus erythematosus can be difficult to diagnose as bullous lesions can develop in lupus-specific lesions, and primary blistering disorders can also occur. Additionally, these patients tend to have multiple co-morbidities making them more likely to be on many medications that can lead to bullous drug reactions. A thorough history, the clinical presentation, and histopathological findings along with direct immunofluorescence can be helpful in diagnosing most cases. The authors report the case of a woman with a long history of systemic lupus erythematosus who initially presented in their clinic for diagnosis and management of erythema dyschromicum perstans and one year later developed bullae in atypical targetoid lesions on the extremities and trunk. They discuss several blistering disorders that have been reported in patients with lupus erythematosus with a focus on features that help distinguish erythema multiforme, fixed drug eruption, and lupus erythematosus from Stevens-Johnson syndrome/toxic epidermal necrolysis. In the patient described herein, the authors favor a diagnosis of Stevens-Johnson syndrome, but the classification between erythema multiforme major and Stevens-Johnson syndrome/toxic epidermal necrolysis cannot be made in some cases.

Unilateral presentation of disseminated candidiasis: case report and review of the literature.

Candidiasis is the most common fungal infection in immunocompromised patients who are at greater risk for developing disseminated disease. Renal transplant recipients often are administered immunosuppressants and therefore are at an increased risk for developing disseminated candidal infections. Disseminated candidiasis generally does not present with cutaneous lesions, but when present, lesions usually are generalized or limited to the trunk and limbs. We describe the case of an immunosuppressed renal transplant recipient who developed a disseminated Candida kefyr infection and presented with oral mucosal lesions and cutaneous lesions limited to the left lower extremity. The lesions were localized due to a thrombus that was subsequently found in the patient's left external iliac artery.