Incisional biopsy critical in obtaining definitive diagnosis in a clinically challenging case.

Tissue-sparing biopsy techniques are frequently used in clinical practice but can result in misdiagnosis of large, clinically challenging lesions. We present a case of a 70-year-old man with hidradenocarcinoma of the left chin, a diagnosis that was delayed owing to repeated superficial biopsies that were negative for disease. Diagnosis was ultimately obtained via an incisional biopsy. We discuss the clinical features of hidradenocarcinoma and why this diagnosis can be easily missed with superficial biopsies. It is important that dermatologists consider incisional biopsies in the workup of clinically challenging lesions for which malignancy is considered.

Safety of Prefilled Buffered Lidocaine Syringes With and Without Epinephrine.

BACKGROUND: Lidocaine is often used in conjunction with epinephrine and sodium bicarbonate for local anesthesia. Compounding lidocaine as needed can be highly disruptive to clinic flow, which has led many dermatology clinics to prefill syringes with these solutions, but current regulations recommend the disposal of these preparations within 12 hours, creating medical waste. OBJECTIVE: To evaluate the safety of buffered lidocaine with and without epinephrine drawn from multiuse vials and stored for up to 4 weeks. METHODS: Syringes were filled with lidocaine 1%, lidocaine 1% with 1:100,000 epinephrine, lidocaine 1% with bicarbonate (10:1 ratio), or lidocaine 1% with 1:100,000 epinephrine with bicarbonate (10:1 ratio). The samples were stored for 4 weeks either at controlled room or controlled cold temperature. They were then centrifuged and cultured for anaerobic bacteria, aerobic bacteria, and fungus. RESULTS: Prefilled lidocaine syringes are not subject to bacterial or fungal growth after being stored for 4 weeks. CONCLUSION: Prefilled syringes of lidocaine remain safe to use for up to 4 weeks, and the current regulations placed on the disposal of these solutions should be revisited.

Cutaneous alternariosis in an immunocompetent patient.

Alternaria species are a type of dematiaceous fungi that cause a wide spectrum of disease with cutaneous infections being the most common. These infections are most common in immunocompromised individuals. However, only a few cases of primary cutaneous alternariosis have been reported in immunocompetent patients. We present a case of an otherwise healthy 13-year-old male who presented with primary cutaneous alternariosis on his left ankle that responded to the use of topical econazole and oral itraconazole. We also provide a review of previously described cases of primary cutaneous alternariosis in the literature.

Review of digital image security in Dermatology.

The inherently visual nature of dermatology naturally lends itself to photography. As technology has evolved, smartphone cameras have become ubiquitous and have the potential to improve education and patient care in dermatology. Although patients and physicians may agree that photography can improve patient care, there are certain risks involved with smartphone photography in the medical field. Perhaps most concerning is the number of dermatologists using smartphones to take unsecured images in their daily practice. A recent study revealed that 22% of surveyed dermatologists used smartphone cameras multiple times per day in their practice. Dermatologists may also overestimate patient comfort with smartphone use in clinical photography. We present a review of the use of smartphones in dermatology and address the potential lack of security and accompanying ethical dilemmas.

A 7-year-old with indurated skin and unilateral progressive joint immobility: A case of stiff skin syndrome.

Stiff skin syndrome is a rare sclerotic condition that presents during infancy or early childhood. It has an insidious chronic course and may lead to significant co-morbidity and reduced quality of life. Often, affected individuals experience impaired ambulation and immobilization related to joint involvement. Clinically, it may resemble other sclerotic diseases, so histopathological evaluation is necessary to establish a diagnosis. As it is a condition with limited treatment options, prompt diagnosis and early initiation of physical therapy is crucial to prevent joint restriction and maintain quality of life. We describe a case of a 7-year-old with stiff skin syndrome, and review the literature to discuss the clinical presentation, histological findings, and management of this condition.

Evaluation of nerves in Mohs micrographic surgery: histologic mimickers of perineural invasion and nervous tissue on frozen section.

BACKGROUND: Perineural invasion (PNI) is an important histologic finding and may be a negative prognostic factor for squamous cell carcinoma (SCC). It may be associated with more-aggressive tumor behavior. Mohs surgeons encounter microscopic PNI regularly and must be able to diagnose it accurately to guide care decisions. OBJECTIVE: To describe benign histologic mimickers of PNI and neural structures in SCC commonly encountered on frozen, hematoxylin and eosin-stained sections and to review how to differentiate them from PNI. METHODS AND MATERIALS: Review of the literature regarding histologic mimickers of PNI and additional contributions to frozen section PNI and nerve tissue mimickers. RESULTS: We describe benign findings, including arrector pili muscles, eccrine muscles, vessels, granulomatous inflammation, and eddies of SCC, that may each be mistaken for nerves or PNI. We discuss the ways in which they may be distinguished on frozen sections and review other commonly encountered entities that resemble PNI. CONCLUSION: Perineural inflammation and peritumoral fibrosis are common mimickers of PNI on frozen section, although other mimickers exist on permanent sections. Normal structures may appear "neural" by way of frozen tissue orientation, processing, or inflammation and thus must be differentiated from nerve tissue and PNI during Mohs surgery.

Life expectancy after Mohs micrographic surgery in patients aged 90 years and older.

BACKGROUND: The population of people aged 90 years and older is expected to more than triple by 2050. The incidence of skin cancers is increasing. OBJECTIVE: We sought to determine whether treatment of patients aged 90 years and older with skin cancer by Mohs micrographic surgery (MMS) changed their survival. METHODS: A group of 214 patients aged 90 years and older who underwent MMS from July 1997 to May 2006 was identified. Patient gender, age, tumor type, size, site, defect size, number of MMS stages, and surgical repair were recorded. Comorbid medical conditions were assessed using the Charlson index. Actual survival was compared with expected length of survival using life tables. Data were analyzed by the Kaplan-Meier method with log rank significance tests. RESULTS: Average patient age was 92.3 years. All patients tolerated the procedures well with no deaths within 1 month after surgery. Median survival after surgery was 36.9 months. Tumor characteristics, defect size, number of surgical stages, and closure type did not affect survival. There was no significant difference in survival based on comorbidities according to Charlson scores. Instantaneous mortality hazard was highest 2 to 3 years after surgery. LIMITATIONS: Specific causes of death were not accessible. CONCLUSION: This growing section of the population may safely undergo MMS.

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.

Combination repair of nasal ala and nasolabial fold defects following Mohs micrographic surgery.

BACKGROUND: Repair of excisional defects involving the nose and cheek requires thoughtful planning to maintain the natural contour of the anatomical sites and optimize cosmetic outcomes. We aim to demonstrate that a combination repair of defects involving the ala and nasolabial fold with a full-thickness skin graft and a local flap can be used with good cosmesis and minimal complications. METHODS: This is a case report of a patient with skin cancer on the left ala and left nasolabial fold who underwent Mohs micrographic surgery for tumor extirpation. RESULTS: The patient and the Mohs surgeon reported satisfaction with the cosmetic and functional outcomes at the 6-month postoperative follow-up with no complications. CONCLUSION: The use of a full-thickness skin graft from a standing tissue cone and a cheek crescentic advancement flap is a viable repair option for Mohs micrographic surgery defects involving the ala and nasolabial fold.

Failure of Nasal Defect Closures Following the Use of Continuous Positive Airway Pressure.

In this paper, we report a case series of three patients who developed nasal tip necrosis following Mohs micrographic surgery (MMS), complicated by the concomitant use of a continuous positive airway pressure (CPAP) machine for sleep apnea.