Wound Debridement in Pyoderma Gangrenosum.

BACKGROUND: Wound debridement improves healing in a variety of acute and chronic ulcers. However, there is concern that debridement may trigger pathergy and worsen pyoderma gangrenosum (PG). OBJECTIVE: To determine whether published evidence supports conservative wound debridement for PG. DATA SOURCES: The authors reviewed the literature published in MEDLINE through January 2023 using the search germs "pyoderma gangrenosum" and "debridement." STUDY SELECTION: Articles reporting sharp surgical debridement or maggot debridement for PG were included in the review. The authors also searched the reference sections of the reviewed articles for additional reports on debridement for PG. DATA EXTRACTION: Clinical data regarding patient status, procedures performed, and patient outcomes were extracted from the selected articles. DATA SYNTHESIS: There are multiple reports of uncontrolled, active-phase PG wounds worsening after aggressive excisional debridement of viable inflamed tissues. In contrast, there is no evidence indicating that conservative debridement of nonviable necrotic tissue worsens PG wounds, regardless of the disease activity. There are multiple reports of successful debridement and surgical grafting for PG in remission. CONCLUSIONS: There is no evidence in favor of or against using conservative debridement of nonviable necrotic tissue for a PG wound. Therefore, it should not be considered contraindicated, even in the active phase of the disease.

Intravitreal bevacizumab injection in aggressive posterior retinopathy of prematurity compared with type I retinopathy of prematurity.

PURPOSE: To compare type I retinopathy of prematurity (ROP) with aggressive posterior retinopathy of prematurity (AP-ROP) regarding risk factors, complications and treatment outcomes. METHODS: A prospective cohort approach was applied on premature newborns diagnosed as type I ROP and AP-ROP. An intravitreal injection of bevacizumab (Avastin®) was given to each patient. Demographic features such as gestational age, birth weight, age at the initial injection, involved eye, treatment response, relapses and need to extra interventions were compared. RESULTS: Seventy-seven patients underwent an initial intravitreal injection of bevacizumab (IVB), and 108 eyes were type I ROP and 30 eyes were AP-ROP. There was no significant difference in birth weight and gestational age between two groups. ROP relapsed in eight eyes of four patients with AP-ROP (26.6%), of which six eyes of three patients received re-injection of bevacizumab, and two eyes of one patient underwent a laser treatment. Recurrence occurred in two eyes of one patient with type I ROP (1.8%), which were treated by laser. CONCLUSION: Bilateral eye involvement, relapse and retreatment (IVB, laser and surgical intervention) are more frequent in AP-ROP than type I ROP even when treated with intravitreal bevacizumab injection.

T-Lymphoblastic Leukemia/Lymphoma With Annular Skin Rash and Epidermotropism.

Leukemia cutis is uncommon in patients with acute lymphoblastic leukemia. It typically presents with dermal papules or subcutaneous nodules, with no epidermal or upper papillary dermal involvement on histopathology. We present an unusual clinical presentation of leukemia cutis, with annular plaques and epidermotropism.

How Frequency of Electrosurgical Current and Electrode Size Affect the Depth of Electrocoagulation.

BACKGROUND: Many factors affect the depth of electrocoagulation. OBJECTIVE: To evaluate the effect of current frequency and electrode size on the depth of electrocoagulation. METHODS AND MATERIALS: In this in vitro study, 4 cylindrical electrodes (2, 2.3, 3, and 4 mm) were used to apply 3 electrosurgical currents (0.4, 1.5, and 3 MHz) to bovine liver. Each electrode was placed at different points on the surface of the liver, and energy at various levels and frequencies was delivered to the tissue. Subsequently, cross-sections of the liver were analyzed. RESULTS: Coagulation started at the periphery of the electrode-tissue contact area. With higher energy levels, coagulation spreads to involve the remainder of the contact area. Neither the frequency nor the electrode size had any effect on this coagulation pattern. The frequency of the current also did not show any relation with depth of coagulation; however, there was a direct correlation between the size of the electrode and the depth of coagulation. CONCLUSION: Larger-tip electrodes provided deeper coagulation compared with finer-tip electrodes.

The existence of cords in olecranon bursae.

BACKGROUND: The purpose of this study was to document the existence of transverse cords in olecranon bursae in patients undergoing excision of the bursa and to describe the unique clinical presentation of patients with these cords. METHODS: A retrospective study was performed on 24 patients who had surgery to excise an olecranon bursa between 2006 and 2011. The patient's history, preoperative radiographs, ultrasound images, intraoperative photographs, and findings on histologic analysis were reviewed in all cases. RESULTS: Nine olecranon bursae had cords (cord group) and 15 did not have cords (noncord group). All patients in the cord group were male manual laborers, and nearly all had olecranon enthesophytes (n = 8). Patients in the noncord group had associated medical conditions or an infection. A higher level of satisfaction was reported in the noncord group after surgical excision. CONCLUSION: This study documents the existence of transverse cords oriented at right angles to the long axis of the olecranon. Olecranon bursae with cords have a unique presentation and are found in male manual workers, are nearly always associated with an olecranon enthesophyte, and do not present with infections.

Better Axial Stiffness of a Bicortical Screw Construct Compared to a Cable Construct for Comminuted Vancouver B1 Proximal Femoral Fractures.

The aim of this study was to biomechanically evaluate the Locking attachment plate (LAP) construct in comparison to a Cable plate construct, for the fixation of periprosthetic femoral fractures after cemented total hip arthroplasty. Each construct incorporated a locking compression plate with bi-cortical locking screws for distal fixation. In the Cable construct, 2 cables and 2 uni-cortical locking screws were used for proximal fixation. In the LAP construct, the cables were replaced by a LAP with 4 bi-cortical locking screws. The LAP construct was significantly stiffer than the cable construct under axial load with a bone gap (P=0.01). The LAP construct offers better axial stiffness compared to the cable construct in the fixation of comminuted Vancouver B1 proximal femoral fractures.

The use of endemic Iranian plant, Echium amoenum, against the ethyl methanesulfonate and the recovery of mutagenic effects.

In this study, potential genotoxic effects of ethyl methanesulfonate (EMS) that caused mutagenicity in a variety of organisms were tried to resolve by the methanol and chloroform extract of Echium amoenum (EAmet and EAchl) Fisch. & C.A. Mey. from the family of Boraginaceae, which is an endemic plant, and is used as an alternative treatment among public in Iran. Somatic mutation and recombination test with Drosophila wing was used to determine the genotoxic and antigenotoxic effects in our investigations. For this purpose, 3-day-old transheterozygous larvae of mwh/flr(3) genotype of Drosophila melanogaster were used in all our experiments. The larvae were fed chronically on the Drosophila instant medium (DIM) including 1 ppm EMS. However, in another application group, different concentrations (1, 2 and 4 ppm) of EAmet and EAchl were added to DIM including 1 ppm EMS (EMS + EAmet and EMS + EAchl). Then, for the matured individuals, wing preparates were prepared within the mediums that include control group that has only DIM, negative control group that contains dimethyl sulfoxide and application groups in different concentrations that contain EMS, EMS + EAmet and EMS + EAchl. Clone induction frequency for the normal wing phenotype of EMS application group was observed to be 2.00. In the EMS + EAmet application group, the value of 1 ppm EAmet is 1.49, value of 2 ppm EAmet is 1.08 and value of 4 ppm EAmet is 0.72; in the EMS + EAchl application group, the value of 1 ppm is EAchl 1.33, value of 2 ppm EAchl is 0.67 and value of 4 ppm EAchl is 0.56 were determined. This decrease observed between EMS and all application groups in terms of total induction frequency is statistically significant (p < 0.05). These results concluded that chloroform extracts were more effective than the methanol extracts of E. amoenum.

Electrosurgery: part I. Basics and principles.

The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage is responsible for at least the majority--if not all--of the tissue effects in electrosurgery. Adjacent to the active electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that determines the final tissue effects of a current is the depth and the rate at which heat is produced. Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation. An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which leads to tissue fragmentation and cutting.

Electrosurgery: part II. Technology, applications, and safety of electrosurgical devices.

Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminal modes, with the primary difference between these modes being their safety profiles. A monopolar electrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2 active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is no dispersive electrode connected to the patient's body and instead the earth acts as the return electrode. Biterminal mode uses a dispersive electrode connected to the patient's body, has a higher maximum power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have different technologies for controlling the output power and for providing safety. A thorough understanding of these technologies helps with a better selection of the appropriate surgical generator and modes.

Are topical keratolytic agents needed in the treatment of scalp psoriasis?

BACKGROUND: Topical corticosteroids are the primary treatment for scalp psoriasis. Keratolytic agents are promoted as adjunctive treatments. However, complex treatment regimens may result in poor adherence and outcomes. OBJECTIVE: To evaluate the evidence for the need for use of topical keratolytic agents as opposed to topical corticosteroid monotherapy in the treatment of scalp psoriasis. METHODS: A review of the literature was performed seeking clinical trials using topical keratolytics, topical corticosteroids or the combination for treatment of scalp psoriasis. RESULTS: Complete clearance of scalp psoriasis can be achieved in 10-78% of patients using topical corticosteroids alone, in 3% of patients using topical keratolytics alone, and in up to 84% using a combination of topical keratolytics and topical steroids. Clinical trials comparing the combination of keratolytics and topical corticosteroids versus topical corticosteroids alone found marginally more efficacy using combination regimens. LIMITATIONS: We could not find any long term study evaluating the efficacy of combination therapy in scalp psoriasis and its effect on the patients' adherence. CONCLUSION: High potency topical corticosteroids are usually effective in treating scalp psoriasis in clinical trials. Poor efficacy in clinical practice may be owing to poor adherence to the treatment regimen. Using a keratolytic agent in conjunction with a topical corticosteroid may provide marginal additional benefit in clinical trials, but that benefit is likely outweighed by the downside of complicating treatment and reducing adherence in the clinical setting, unless a single product containing both medications were used.

Top dermatologic diagnoses by age.

BACKGROUND: Although some skin conditions predominate in patients of certain ages, little data exists about the relative prevalence of dermatologic conditions by age. OBJECTIVES: To determine the common skin conditions by age group in the United States, both in dermatologist samples and for all specialties. METHODS: The National Ambulatory Medical Care Survey (NAMCS) was queried for top diagnoses at dermatologist and all skin disease visits from 1993-2010. ICD-9 coding was used for diagnoses. RESULTS: There were 588 million estimated visits to dermatologists in the US from 1993-2010. Atopic dermatitis, acne, and actinic keratosis were the top diagnoses in all age groups. Common diagnoses in all groups included contact dermatitis and benign neoplasm. There were 740 million estimated skin disease visits to all physicians; more of these were acute or infectious. The percent of skin diseases seen by dermatologists gradually increased with age to a maximum of 55% in the 75-84 year age group. CONCLUSION: Dermatologic conditions seen in different age groups and between dermatologists and non-dermatologists vary. With advancing age, Americans increasingly seek a dermatologist rather than a non-dermatologist physician for skin conditions.

Can light-field photography ease focusing on the scalp and oral cavity?

BACKGROUND: Capturing a well-focused image using an autofocus camera can be difficult in oral cavity and on a hairy scalp. Light-field digital cameras capture data regarding the color, intensity, and direction of rays of light. Having information regarding direction of rays of light, computer software can be used to focus on different subjects in the field after the image data have been captured. METHODS: A light-field camera was used to capture the images of the scalp and oral cavity. The related computer software was used to focus on scalp or different parts of oral cavity. The final pictures were compared with pictures taken with conventional, compact, digital cameras. RESULTS: The camera worked well for oral cavity. It also captured the pictures of scalp easily; however, we had to repeat clicking between the hairs on different points to choose the scalp for focusing. A major drawback of the system was the resolution of the resulting pictures that was lower than conventional digital cameras. CONCLUSION: Light-field digital cameras are fast and easy to use. They can capture more information on the full depth of field compared with conventional cameras. However, the resolution of the pictures is relatively low.

Focusing and depth of field in photography: application in dermatology practice.

BACKGROUND: Conventional photography obtains a sharp image of objects within a given 'depth of field'; objects not within the depth of field are out of focus. In recent years, digital photography revolutionized the way pictures are taken, edited, and stored. However, digital photography does not result in a deeper depth of field or better focusing. METHODS: In this article, we briefly review the concept of depth of field and focus in photography as well as new technologies in this area. RESULTS: A deep depth of field is used to have more objects in focus; a shallow depth of field can emphasize a subject by blurring the foreground and background objects. The depth of field can be manipulated by adjusting the aperture size of the camera, with smaller apertures increasing the depth of field at the cost of lower levels of light capture. Light-field cameras are a new generation of digital cameras that offer several new features, including the ability to change the focus on any object in the image after taking the photograph. CONCLUSION: Understanding depth of field and camera technology helps dermatologists to capture their subjects in focus more efficiently.

Tachyphylaxis to topical glucocorticoids; what is the evidence?

BACKGROUND: Common belief holds that as topical glucocorticoids are used over time the less effective they become, a phenomenon called tolerance or tachyphylaxis. OBJECTIVE: To determine what evidence supports the concept of tachyphylaxis to glucocorticoids. METHODS: We searched Medline and Google Scholar for articles on tachyphylaxis to glucocorticoids published through October 2012. RESULTS: Rapid tolerance, tachyphylaxis, to non-clinical effects of glucocorticoids has been reported in literature. However, clinically significant tolerance to topical glucocorticoids has not been identified in clinical trials. We did not identify any evidence that clinical efficacy of glucocorticoids in inflammatory skin diseases significantly diminishes during long term continuous use. LIMITATIONS: Tachyphylaxis or tolerance to clinical effects of topical glucocorticoids in inflammatory skin diseases is not fully characterized or well studied. CONCLUSION: Based on available data in literature, there is no clinical trial supporting the concept that topical glucocorticoids lose effectiveness over time, nor that intermittent use of topical glucocorticoids is more effective than continuous use.

A comparison of three times vs. five times weekly narrowband ultraviolet B phototherapy for the treatment of chronic plaque psoriasis.

BACKGROUND: Narrowband ultraviolet B (NB-UVB) phototherapy is an effective treatment for psoriasis. OBJECTIVES: To compare the effects of three and five times weekly NB-UVB phototherapy in the treatment of chronic plaque psoriasis. METHODS: Sixty-five patients with chronic plaque psoriasis were allocated to receive three or five times weekly NB-UVB, starting at low dose. RESULTS: Among the patients who completed the study, clearance was achieved in 18 out of 23 patients (78%) in the three times weekly group and in 15 out of 22 patients (68%) in the five times weekly group. The difference was not statistically significant (P=0.44). No statistically significant differences were found between the two groups in the number of treatments (P=0.95), cumulative UVB dose (P=0.51), and rate of side-effects. Length of the treatment period was significantly shorter in the five times weekly group (P<0.001). At the end of treatment, the mean psoriasis area and severity index score was lower in the three times weekly group (P=0.02). CONCLUSIONS: We recommend three times weekly NB-UVB for chronic plaque psoriasis; however, the more rapid clearance of psoriasis with five times weekly phototherapy may justify using this method in some patients.

Controlling depth of electrosurgery after curettage of skin tumors-an in vitro study.

BACKGROUND: Depth of tissue injury in electrosurgery depends on generator power, electrode size, speed of electrode movement on tissue, and current delivery method. We sought to evaluate the depth of tissue injury associated with different methods of electrocoagulation in an effort to make electrocoagulation more reproducible. METHODS: A knife-shaped electrode was used to apply an electrosurgical current to the surface of a piece of bovine liver. Different electrosurgical methods were performed. Cross sections of the liver were then studied for tissue effect. RESULTS: Fulguration provided only superficial coagulation. Contact electrocoagulation and electrodesiccation using the flat side of the electrode provided significantly deeper levels of coagulation and were associated with less smoke than fulguration. Desiccation provided the deepest tissue effect. CONCLUSIONS: Electrofulguration can be used for superficial tissue destruction. For deeper coagulation, a relatively larger electrode can be used in contact mode. Slower movement of the electrode on tissue in contact mode is associated with desiccation and the deepest level of tissue destruction.

Management of fluid status and cardiovascular function in patients with diffuse skin inflammation.

Background: Skin inflammation causes vasodilation and increased vascular permeability, which may result in decreased blood pressure and peripheral edema. Patients with erythroderma usually compensate for low blood pressure with fluid retention and increased cardiac output. However, if the heart cannot support increased cardiac output, blood pressure will stay low, resulting in severe compensatory fluid retention, which leads to decompensated congestive heart failure, and pulmonary edema. Treatment for high-output congestive heart failure focuses on the primary pathology, which is skin inflammation. However, aggressive treatment of the inflammation with glucocorticoids may result in rapid resorption of extravascular fluid into the intravascular space and occurrence or aggravation of pulmonary edema. Erythrodermic patients with no clinical heart failure are also at risk for developing pulmonary edema if they receive glucocorticoids and/or intravascular fluids. Most hospitalists and dermatologists are not familiar with fluid administration and ways to manage cardiovascular function and blood pressure in patients with skin inflammation. Objectives and methods: In this article, we discuss the pathophysiology of vascular and fluid changes in the context of diffuse skin inflammation and provide some basic guidelines that can be presented to hospitalists by dermatologists. Limitations: Most of the recommendations and guidelines in the article are based on basic science and on the personal experience of the authors and are not supported by controlled trials. Capsule summary Diffuse skin inflammation causes major changes in the cardiovascular system and in the perfusion of internal organs. We provide guidelines for management of fluid status and cardiovascular function in patients with diffuse skin inflammation. Dermatologists can provide hospitalists or primary care providers with these guidelines to help them with creating better treatment plans.