Polyurethane dressing assisted epidermal suturing minimizes postoperative wound care.

An exact vertical approximation of epidermal edges during wound suturing allows rapid reepithelialization of the sutured wound and may reduce scar formation. Over 20 patients have been treated with a unique suturing technique for wound-edge approximation using a sterile polyurethane adhesive dressing as an epidermal scaffolding, Some of these procedures and results were documented using intraoperative and postoperative photos to help evaluate potential benefits to wound healing. The polyurethane dressing acts as a barrier to microbes, water, and irritants. Postoperative wound care was found to be cost-effective and virtually maintenance-free, as the wound does not require daily dressing changes. The patients treated with this technique demonstrated well-approximated wound edges and excellent cosmesis. The authors have not found cases of contact dermatitis or wound infection as a result of treatment using this suturing technique.

Recurrent nodule on the nasal columella: a good reason to re-biopsy.

BACKGROUND: A 15-year-old Caucasian male presented with 9-month history of a recurrent nodule on the nasal columella. The previous biopsy was reported as a neurofibroma. METHODS: Frozen sections revealed a spindle cell neoplasm. Permanent section immunohistochemistry sections stained positive for vimentin and smooth muscle actin and negative for S100 and CD34, confirming the diagnosis of leiomyosarcoma. RESULTS: The tumor was removed using Mohs micrographic surgery. Radiological work-up revealed no distant metastasis. There has been no local recurrence to date. CONCLUSIONS: Leiomyosarcoma is a difficult diagnosis to make clinically and requires histological confirmation. Re-biopsy of a "benign" growth may be necessary if clinicopathological correlation does not match with the clinical behavior of the tumor in question. Finally, Mohs micrographic surgery is a useful treatment modality for leiomyosarcomas, particularly those located in cosmetically-sensitive regions of the body such as the nose.

The 20-minute rapid MART-1 immunostain for malignant melanoma frozen sections.

BACKGROUND: Immunohistochemical staining has been used to help detect malignant melanoma on Mohs surgery frozen sections. Previous investigators have developed protocols for reliable MART-1 immunostaining of frozen sections, but these protocols are time-consuming. OBJECTIVE: The objective was to report a rapid 20-minute MART-1 immunostaining protocol for frozen sections. METHODS: The protocol was utilized on 30 melanomas treated with Mohs micrographic surgery. RESULTS: The stain clearly highlighted normal background melanocytes, as well as melanocytic hyperplasia and malignant melanoma. CONCLUSIONS: The 20-minute protocol provides a rapid and reliable method for immunostaining of malignant melanoma. The availability of more rapid immunostaining methods improves efficiency of the Mohs laboratory and significantly reduces patient and physician waiting time. The authors have indicated no significant interest with commercial supporters.

Margin involvement after the excision of melanoma in situ: the need for complete en face examination of the surgical margins.

BACKGROUND: The standard treatment for cutaneous melanoma in situ is surgical excision followed by standard pathologic evaluation. Serial cross-sectioning (bread-loafing) may result in false negative margin examination and higher local recurrence rates than Mohs micrographic surgery, which histologically evaluates the entire surgical margin. OBJECTIVE: To estimate the sensitivity of bread-loafing in detecting residual melanoma in situ at surgical margins. METHODS: A retrospective study was performed including 36 cases of melanoma in situ treated with Mohs surgery with positive margins after initial excision with 5 mm margins. The length of the margin involved with melanoma was measured. The ability of bread-loafing to detect residual tumor was calculated. RESULTS: The average linear extent of tumor at the surgical margin was 1.4 mm. Bread-loafing at 1, 2, 4, and 10 mm intervals would have a 58, 37, 19, and 7% chance of detecting positive margins, respectively. In order to detect 100% of positive margins, bread-loafing would have to be performed every 0.1 mm. CONCLUSION: Bread-loaf cross-sections through excised melanoma specimens are inherently unreliable for detecting residual melanoma at the surgical margins. We recommend complete histologic margin control of the entire surgical margin using en-face tissue orientation (Mohs technique) to reduce the risk of recurrence.

Repair of partial and complete earlobe clefts: a review of 21 methods.

BACKGROUND: Partially or completely spilt earlobes are a common reason for patient presentation to the cosmetic surgeon. METHODS: In this article, we review the different techniques of repairing both partial and complete cleft earlobes. RESULTS: We review and illustrate 4 methods to repair a partial cleft earlobe and 17 methods to correct a complete cleft earlobe. In addition, preoperative, intraoperative, and follow-up photographs are shown on several examples. CONCLUSIONS: Earlobe clefts may be repaired by various techniques. While advantages and disadvantages exist for each method, the surgeon should be familiar with categorizing the cleft, choosing a repair, and deciding whether to repierce the earlobe intra- or postoperatively.

Treatment of severe, recalcitrant, major aphthous stomatitis with adalimumab.

We describe an 18-year-old man with a 7-year history of severe major aphthous stomatitis refractory to multiple standard therapies who responded completely to therapy with adalimumab, a fully humanized monoclonal antibody against tumor necrosis factor alpha (TNF-alpha).

Open-label pilot study of alitretinoin gel 0.1% in the treatment of photoaging.

Alitretinoin (9-cis-retinoic acid) is an FDA-approved topical therapy for the treatment of Kaposi sarcoma. Alitretinoin is a naturally occurring endogenous retinoid that binds to and activates all known intracellular retinoic acid receptor (RAR) subtypes alpha, beta, and gamma and retinoic X receptor (RXR) subtypes alpha, beta, and gamma. Photoaging of the skin is the result of accumulated exposure to solar UV radiation. Several topically applied retinoids have been proven clinically effective for treating the appearance of photoaging. Tretinoin and tazarotene, which have been shown to improve photodamaged skin, bind RAR subtypes only. The theoretic benefit of alitretinoin gel 0.1% (Panretin) in the treatment of photoaged skin stems from the binding and activation of both RARs and RXRs, which promote the repair mechanisms in damaged skin. The objective of this study was to evaluate the safety and efficacy of topical alitretinoin gel 0.1% in the treatment of photodamaged skin. The treatment was well tolerated by participants (N=20) and subjectively showed improvement of benign skin lesions (eg, seborrheic keratoses) and precancerous lesions (eg, actinic keratoses). Larger, blinded, controlled trials are needed to investigate the role of this novel retinoid in the treatment of photoaging.

Pilot study of the safety and efficacy of Myobloc (botulinum toxin type B) for treatment of axillary hyperhidrosis.

BACKGROUND: Botulinum toxin type B (BTX-B, Myobloc, San Francisco, CA, USA) was FDA-approved for the treatment of cervical dystonia in December 2000. It has since been used off-label for the treatment of axillary hyperhidrosis. However, there are sparse data in the medical literature evaluating the safety and efficacy of Myobloc (botulinum toxin type B) for this indication. OBJECTIVE: To assess the safety, efficacy and duration of action of Myobloc (botulinum toxin type B) in the treatment of bilateral axillary hyperhidrosis. METHODS: This study was a double-blinded, randomized, pilot study conducted in an outpatient office setting at a private academic medical center beginning in November 2001. Twenty-three male and female volunteers between the ages of 18 and 80 were screened for participation; 20 participants with primary axillary hyperhidrosis were enrolled. Participants were injected subcutaneously with either Myobloc (botulinum toxin type B) (2500 U, or 0.5 ml, per axilla) or 0.5 ml vehicle (100 mM NaCl, 10 mM succinate, and 0.5 mg/ml human albumin) into bilateral axillae. Participants who received placebo were rolled over and received Myobloc (botulinum toxin type B) at subsequent visits. All participants were followed until sweating returned to baseline levels. This trial was initially conceived as a placebo-controlled study; however, owing to the insufficient size of the placebo group, the placebo arm of this trial was dropped during data analysis. The main outcome measures were safety, efficacy, and duration of effect. RESULTS: According to participant assessment of axillary hyperhidrosis improvement (A-HI) and quality of life (A-HQOL) scores and the physician assessment scores, a significant difference was observed in treatment response at Day 30 in the participants receiving Myobloc (botulinum toxin type B) injections. Duration of action ranged from 2.2 to 8.1 months (mean 5.0 months). The adverse event profile included bruising, flu-like symptoms, and dry eyes. CONCLUSION: Myobloc (botulinum toxin type B) proved to be safe and efficacious for the treatment of bilateral axillary hyperhidrosis. More studies are needed to assess the duration of response using different doses of Myobloc (botulinum toxin type B).

Double-blind, randomized, placebo-controlled pilot study of the safety and efficacy of Myobloc (botulinum toxin type B) for the treatment of palmar hyperhidrosis.

BACKGROUND: Palmar hyperhidrosis is a problem of unknown etiology that affects patients both socially and professionally. Botulinum toxin type B (Myobloc), approved by the Food and Drug Administration for use in the treatment of cervical dystonia in the United States in December 2000, has subsequently been used effectively in an off-label indication to treat hyperhidrosis. There are sparse data, however, in the literature evaluating the safety and efficacy of BTX-B for the treatment of palmar hyperhidrosis. OBJECTIVE: We evaluated the safety and efficacy of Myobloc in the treatment of bilateral palmar hyperhidrosis. This was a double-blind, randomized, placebo-controlled study to report on the safety and efficacy of Myobloc. METHODS: Twenty participants (10 men, 10 women) diagnosed with palmar hyperhidrosis were injected with either Myobloc (5,000 U per palm) or a 1.0 mL vehicle (100 mM NaCl, 10 mM succinate, and 0.5 mg/mL human albumin) into bilateral palms (15 Myobloc, 5 placebo). The participants were followed until sweating returned to baseline levels. The main outcome measures were safety, efficacy versus placebo, and duration of effect. RESULTS: A significant difference was found in treatment response at day 30, as determined by participant assessments, between 15 participants injected with Myobloc and 3 participants injected with placebo. The duration of action, calculated in the 17 participants who received Myobloc injections and completed the study, ranged from 2.3 to 4.9 months, with a mean duration of 3.8 months. The single most reported adverse event was dry mouth or throat, which was reported by 18 of 20 participants. The adverse event profile also included indigestion or heartburn (60%), excessively dry hands (60%), muscle weakness (60%), and decreased grip strength (50%). CONCLUSION: Myobloc proved to be efficacious for the treatment of palmar hyperhidrosis. Myobloc had a rapid onset, with most participants responding within 1 week. The duration of action ranged from 2.3 to 4.9 months, with a mean of 3.8 months. The adverse event profile included dry mouth, indigestion or heartburn, excessively dry hands, muscle weakness, and decreased grip strength.

The epidermal nevus syndromes: multisystem disorders.

The epidermal nevus syndromes are a group of congenital syndromes comprising epidermal nevi in conjunction with central nervous system (CNS), ocular, musculoskeletal, and other organ anomalies. We describe a patient with epidermal nevi and multiple organ abnormalities, highlighting the wide spectrum of involvement in epidermal nevus syndromes, and briefly summarize the literature on these rare syndromes.