Complications of ambulatory major dermatological surgery in patients older than 85 years.

BACKGROUND: During the last decades, the progressive ageing of the population has resulted in a rising skin cancer incidence. Although previous studies detected no higher morbidity for dermatological surgery in senior patients, their exclusion from optimal surgical treatment remains as a common clinical practice. OBJECTIVE: The aim of this study was to determine the diseases treated with ambulatory major dermatological surgery, the surgical morbidity and the associated variables in ≥ 85 year-old patients. PATIENTS/METHODS: This is an observational study on 247 successive patients older than 85 years of age who underwent dermatological surgery in a single Ambulatory Mayor Surgery unit. Studied variables were age, gender, tobacco-alcohol exposure, co-morbid medical conditions, blood-thinning medication, antibiotic prophylaxis, number of lesions, location, histopathological diagnosis, area of skin removed, surgical technique, type of flap, length of surgery, entrance order, suture thread, surgical complications and need of post-operative admission. RESULTS: The most common site was head and neck (82.7%). The most frequent tumour was basal cell carcinoma (45.1%), followed by squamous cell carcinoma (38.7%) and melanoma (8.3%). Direct closure was the most frequent procedure (55.6%). Of the total number of patients, 7.9% of patients suffered complications; necrosis followed by cellulitis were the most frequent. Length of surgical procedure, area of skin removed and reconstruction with skin-graft were significantly related to higher risk of post-operative complications. CONCLUSIONS: No intra or post-surgical mortality or life-threatening local complications were detected. Most post-surgical local complications appeared after wide excisions and complex reconstruction techniques that prolonged the length of the surgery.

[Flexural psoriasis induced by infliximab and adalimumab in a patient with Crohn's disease]. / Psoriasis secundaria al tratamiento con infliximab y adalimumab en la enfermedad de Crohn.

Anti-TNF drugs are used increasingly in several diseases with immune-mediated inflammation, not only in rheumatological conditions, but also in inflammatory bowel disease and psoriasis. Different side effects have been described over the last few years, including the development of psoriasis or psoriasiform exanthemas. These drugs began to be used in paediatrics during the 90's, therefore paediatricians need to be aware of the adverse effects that may occur. We describe here a flexural psoriasis induced by both infliximab and adalimumab in a paediatric patient with Crohn's Disease. To the best of our knowledge, this is the first reported paediatric case of psoriasis triggered by an anti-TNF drug, as well as the first case of psoriasis induced by adalimumab in patients with inflammatory bowel disease.

Cutaneous ulceration as a sign of methotrexate toxicity.

Methotrexate (MTX) inhibits DNA synthesis by competition with dihydrofolate reductase. Adverse cutaneous reactions to MTX are usually dose-related and have been mainly reported in patients receiving extremely large doses of chemotherapy. Painful erosion of psoriatic plaques has been often reported as an early sign of MTX toxicity, but cutaneous ulceration as a sign of MTX toxicity in patients without psoriasis has only been described in one case. We report a patient with rheumatoid arthritis and without psoriasis who developed cutaneous ulceration on the knuckles as a sign of MTX toxicity. Cutaneous ulceration by MTX toxicity is an exclusion diagnosis and its pathogenic mechanism may be multifactorial, including direct toxicity of the drug in addition to local factors.

Altered expression of immunoreactive involucrin in lamellar ichthyosis.

In some cases of lamellar ichthyosis, mutations in the epidermal transglutaminase gene and a reduction in the thickness of the cornified envelope have been documented. Involucrin is a major component of the cornified envelope and a substrate for epidermal transglutaminase. The aim of the present work was to analyse the expression of involucrin in lamellar ichthyosis. An ultrastructural study and/or immunohistochemical and biochemical techniques with anti-involucrin antibody were carried out on the epidermis of fifteen patients (12 families) suffering from lamellar ichthyosis. The effect of in vivo retinoid treatment on the involucrin epidermal expression was also investigated. Four cases with normal skin, seventeen cases of other ichthyoses and ten cases of psoriasis were used as controls. In all these cases of lamellar ichthyosis, a thin or absent cornified envelope, electron-dense granules inside corneocytes and a decrease of the epidermal involucrin expression were observed. In the patients receiving treatment with retinoids, western blot and ELISA revealed an increase in the involucrin expression. The decreased expression of involucrin in lamellar ichthyosis could contribute to the altered desquamation process accompanying the disease, since the clinical improvement associated with retinoid treatment is accompanied by an increase in the expression of involucrin.

Multiple apocrine hidrocystomas: treatment with carbon dioxide laser vaporization.

BACKGROUND: Apocrine hidrocystoma is a benign cystic tumour with apocrine differentiation. Although most cases are solitary tumours, multiple tumours may occur. Surgical removal is the usual treatment for apocrine hidrocystoma, but it may be troublesome and disfiguring in cases with multiple tumours. OBJECTIVE: To determine the efficacy and cosmetic outcome of carbon dioxide laser vaporization in the treatment of multiple apocrine hidrocystomas. PATIENTS AND METHODS: A total of 11 lesions in three adult patients were treated with carbon dioxide laser vaporization using a continuous and defocused mode, with a power density of 5 J/cm(2). The lesions were localized lateral to the outer canthus, on the free edge of the eyelids, and on the ear. Only a single session of treatment was performed for each lesion. Photographic controls were taken before and after treatment. RESULTS: The lesions cleared after laser treatment without residual changes, and a successful cosmetic result was obtained. CONCLUSION: Carbon dioxide laser is an efficient method of the treatment for multiple apocrine hidrocystomas.

[Atypical cutaneous sporotrichosis. The response to itraconazole and surgery]. / Esporotricosis cutánea atípica. Respuesta a itraconazol y cirugía.

Sporotrichosis is a subcutaneous (rarely extracutaneous) fungal disease caused by Sporothrix schenckii. Cutaneous sporotrichosis has two well-defined forms: lymphocutaneous and stable. In lymphocutaneous sporotrichosis, lesions arise along lymphatic vessels, generally in limbs. The stable form is rarer and consists of a single, generally facial, lesion. We report the case of a 70-year-old male farmer with a single lesion on the right nostril that had been removed repeatedly. After 5 years, new, linearly distributed lesions appeared. Fungal cultures of biopsy tissues revealed S. schenckii. The evolution and response to treatment with itraconazole, potassium iodide, terbinafine, and surgery is discussed.

[Chronic graft-versus-host disease presenting as bullous lesions]. / Lesiones ampollosas como forma de presentación de una enfermedad de injerto contra huésped crónica.

Graft-vs-host disease is still the leading cause of morbidity and mortality in patients undergoing bone marrow transplantation. It is important to start treatment early to reduce the severity and consequences of this complication. Cutaneous lesions are often the presenting compliant of graft-vs-host disease and presage visceral involvement. We present the case of a 45-year-old woman with multiple myeloma who underwent autologous and subsequently allogeneic bone marrow transplantation with hematopoietic precursors. She developed bullous lesions with fluid elimination on the abdomen and legs. Biopsy findings were compatible with graft-vs-host disease and immunosuppressive therapy was increased. She subsequently presented oral lichenoid lesions and sicca syndrome. The bullous lesions progressed to painful ulcers that healed leaving highly sclerodermatous skin with substantial hyperpigmentation. Bullous lesions are a rare form of presentation of chronic graft-vs-host disease. In such cases, the diagnosis may not be suspected initially, particularly when the lesions are isolated and internal organs are not involved.

Outpatient dermatology major surgery: a 1-year experience in a Spanish tertiary hospital.

INTRODUCTION: The constant increase in the incidence of skin cancer together with the requirement for maximum exploitation of available medical resources has meant that dermatological major surgery on an outpatient basis has greatly increased in recent years. OBJECTIVE: This article reviews the practice of dermatological surgery in an outpatient setting over a 1-year period. Its purpose is to analyse the number of surgical procedures, the type of cutaneous processes treated and the kind of surgical intervention and anaesthesia used. We also assessed the percentage of cancellations, postsurgical hospital admission and postsurgical complications. Clinicopathological correlation and complete tumour removal were also evaluated. MATERIAL AND METHODS: Our clinical experience of major surgery of outpatients at the dermatology department of the Hospital Juan Canalejo in A Coruña (Spain), analysing 565 patients in a non-randomized pilot study running from January to December 2003, is presented. RESULTS: Six hundred and forty-four surgical procedures were performed on a total of 565 patients. The three main cutaneous processes treated were basal cell carcinoma (240), squamous cell carcinoma (117) and melanoma (77). The most frequent type of procedure was direct closure (346), followed by exeresis and flap (133) and partial- or full-thickness skin graft (29), nail apparatus surgery (56) and lip surgery (33). Twelve patients were admitted to hospital after surgery owing to the complexity of their operations or to complications arising during surgery. Five hundred and fifty-three patients were discharged after being kept under observation for a few hours. Seventeen patients (3%) suffered complications following surgery, which consisted of partial implant failure (six cases), infection of the surgical wound (six cases), intense pain (four cases) and haemorrhage (one case). There was a good clinicopathological correlation in 90.78% of non-melanoma skin cancers, of which 92.03% were completely removed. CONCLUSIONS: Medium and high complexity operations for dermatological processes, traditionally performed on hospitalized patients, can be conducted on an outpatient basis. This allows hospitalization costs and waiting lists to be reduced and affords the possibility of achieving better morbidity rates and medical care than in the standard hospital setting.

Acne is not a stigma of HIV infection: a review of 36 patients.

INTRODUCTION: Several diseases with follicular occlusion have been described in HIV-infected patients and can appear isolated or associated with each other in an independent disease named 'HIV-associated follicular syndrome'. Worsening of cutaneous lesions during the course of infection in patients with previous acne vulgaris, late onset or severe forms of acne have been reported in HIV-infected patients. PATIENTS AND METHODS: A prospective study of 335 HIV-infected patients was performed in our hospital. A meticulous dermatological exploration in all patients was made, and multiple data were stored into a Microsoft Access 97 program. Patients diagnosed as having acne were considered separately, and we studied their characteristics. A statistical analysis with SPSS 9.0 (Statistical Package for the Social Sciences) was performed. RESULTS: Thirty-six patients (10.8%) were diagnosed as having acne. Papulopustular lesions were the most frequent clinical presentation. Most lesions were localized on the face or on the back, and 80% of patients had mild to moderate acne; 40% of them required no treatment and the remainder was treated with topical measures, oral antibiotics and isotretinoin. 85% of cases reported the onset of acne during adolescence or before HIV infection and without any relationship with this disease. No relation between acne intensity and stage of HIV infection was observed. A multivariate analysis showed that the most important variable was age. DISCUSSION: In contrast to previous reports, no greater intensity or modifications in acne lesions were observed in our HIV-infected patients during the course of the disease. In the majority of cases, cutaneous lesions started before HIV infection, during adolescence, and the most important factor for suffering from acne was young age. In contrast to data reported in the literature, no relation of acne lesions to CD4 lymphocyte count or AIDS case criteria was found in our patients. CONCLUSIONS: Acne in HIV-infected patients has characteristics similar to those in non-HIV-infected patients. The age is the most important factor for the appearance of lesions that usually develop during adolescence. Acne lesions are not modified by HIV infection, and no relationship with the severity of HIV infection has been observed.

Basal cell carcinoma in a girl after cobalt irradiation to the cranium for acute lymphoblastic leukemia: case report and literature review.

A 12-year-old girl had a lesion located on the upper part of the scalp that was clinically interpreted as a melanocytic nevus and corresponded histologically to a basal cell carcinoma. At age 2 years she had been diagnosed as having acute lymphoblastic leukemia L1, for which she was treated with systemic chemotherapy. She also received telecobalt therapy to the whole cranium for prophylaxis of meningeal leukosis. Having rejected other possible causes that can favor the appearance of basal cell carcinoma during childhood (basal cell nevus syndrome, nevus sebaceus, albinism, etc.), we believe that this case should be added to the five previously reported in the literature as basal cell carcinoma developing at an early age in cranial radiation portals with megavoltage radiotherapy. We draw attention to the need to explore radiated areas of skin as part of the long-term follow-up of these patients, and to the advisability of obtaining a biopsy from any persistent lesion in these areas.

Superficial white onychomycosis in a 3-year-old human immunodeficiency virus-infected child.

BACKGROUND: Superficial white onychomycosis is exceptional in children, although a few anecdotal cases have been reported in the literature. On the other hand, superficial white onychomycosis and proximal subungual onychomycosis, while unusual in the general population, often appear in adult human immunodeficiency virus (HlV)-infected persons. CASE REPORT: A 3-year-old girl with vertically acquired HIV-1 infection presented superficial white onychomycosis involving the second, third, fourth and fifth toes of her left foot, caused by Trichophyton rubrum. She was treated with topical amorolfine once a week, with a good response within 4 weeks. CONCLUSIONS: We report a case of superficial white onychomycosis associated with HIV infection in a 3-year-old girl. To our knowledge, this type of onychomycosis has not been previously reported in HIV-infected prepubertal children.

Benign cephalic histiocytosis: case report and literature review.

A 3-year-old boy had maculopapules on his face and neck since age 6 months. These were yellow-brown, asymptomatic, and clinically similar to flat warts. Histopathologic study revealed a fibrohistiocytic infiltrate in the superficial dermis. Ultrastructurally, comma-shaped bodies, desmosome-like junctions, and coated vesicles were seen; there were no lipid droplets or Birbeck granules. With these data, a diagnosis of benign cephalic histiocytosis was made. Twenty-five cases are reported in the literature: 17 males and 8 females (male:female ratio 2:1). Sixteen patients had lesions on parts of the body other than the head, neck, and shoulders.

Primary syphilis with multiple chancres and porphyria cutanea tarda in an HIV-infected patient.

A 51-year-old promiscuous heterosexual man with no history of venereal diseases or porphyria had a large genital chancre and deep erosions on the hands. The HIV serology was positive; the CD4 lymphocyte count was 187/mm3, but the patient did not fulfill the CDC criteria for AIDS. Five months later he developed a clinical and biochemically typical porphyria cutanea tarda.