Treatment of lipedema by low-volume micro-cannular liposuction in tumescent anesthesia: Results in 111 patients.

Lipedema is a painful disease of subcutaneous adipose tissue leading to bilateral increase of leg and/or arm volume, but sparing hands and feet. Although conservative treatment with complex decongestive therapy has been considered as the fundamental treatment, micro-cannular liposuction in tumescent anesthesia has become a surgical option. We report on 111 patients mostly with advanced lipedema treated by this technique in our center between 2007 and 2018. The median age of the patients was 44 years. Eighty percent of patients had at least one comorbidity. There was an association of longstanding and advanced disease to obesity and diseases of the metabolic syndrome-spectrum. The median total amount of lipoaspirate was 4,700 ml, with a range of 950-14,250 ml. The median reduction of limb circumference was 6 cm. The median pain level before treatment was 7.8 and 2.2 at the end of the treatment. An improvement of mobility could be achieved in all patients. Bruising was also reduced. Serious adverse events were observed in 1.2% of procedures, the infection rate was 0% and the bleeding rate was 0.3%. Liposuction is an effective treatment for painful lipedema. The procedure should be performed in specialized centers.

Acute edema induced by toluidine blue extravasation-first report.

Methemoglobinemia is characterized by an increased level of methemoglobin (MetHb) in the peripheral blood. MetHb levels increase after tumescent anesthesia and need to be monitored. If a patient becomes symptomatic and/or the MetHb levels increase >10%, intravenous injection of an antidote is recommended. Toluidine blue is twice as effective as methylene blue in this respect.A 27-year-old woman with advanced lipedema underwent her third liposuction under tumescent anesthesia. After surgery, her MetHb levels increased and needed injection of toluidine blue. She developed an acute and painful edema after extravasation of some toluidine blue due to a bursting vein. This is the first report in the recent medical literature. Clinical presentation, course, and treatment are described.

Palmar hyperhidrosis treated by noninvasive ultrasound stellate ganglion block.

Focal palmar hyperhidrosis is a common and often debilitating eccrine sweat gland disorder with negative impact on quality of life and self-esteem. For treatment of recalcitrant cases, a stellate ganglion block is a nonsurgical alternative. Although this method has only a temporary effect, surgical risks can be avoided. The usual way to perform the block is by ultrasound-guided injection of local anesthetics. Here we describe the use of therapeutic ultrasound at 0.8 MHz for stellate ganglion block. Ultrasound was applied for 1 min unilaterally every other day for 6 days. The efficacy was monitored by video capillaroscopy and Minor's iodine starch test. Treatment was well tolerated and no adverse effects were noted. Sweating was stopped and capillary blood flow increased. The effect lasted for several weeks.

Rare association of cystic squamous cell carcinoma and small lymphocytic B cell lymphoma: successful surgical approach.

Non-melanoma skin cancer is the most common type of cutaneous neoplasm worldwide. While basal cell carcinoma is the most common tumor, squamous cell carcinoma (SCC) causes higher morbidity and has a risk of metastatic spread, depending on immune status, tumor size, and desmoplastic growth. We reported the case of a 77 year old male patient with retroauricular tumor, which started growing 3 years ago and was excised, buth relapsed three times. The initial diagnosis was infundibular cyst. Delayed Mohs surgery was performed, as was an additional open lymph node biopsy of the patient's right groin, on the occasion of an indolent swelling of the same which developed within 3 months. The first histopathological report confirmed the diagnosis of a cystic squamous cell carcinoma. The histopathologic evaluation of the groin tumor revealed a small lymphocytic B cell lymphoma (BCL). The patient fulfilled the following criteria for high-risk SCC: tumor size ≥2 cm (or 1 cm on the head and 6 mm on the genitals, hands, and feet), tumor thickness ≥4 mm, recurrent tumor, rapid growth. Therefore, lymph node metastasis had to be considered. High-risk SCC has a propensity to metastasize. In cases of primary tumor, Mohs surgery is the most effective treatment, particularly in relapsing tumors. The combination of cystic SCC with a small-sized BCL is very rare. The differential diagnosis and treatment may be challenging. In high-risk SCC, lymph node enlargement warrants histologic evaluation. However, not all suspicious lymph node lesions corroborate as metastatic.

Juxta-articular adiposis dolorosa (Dercum's disease type IV): report of four cases and treatment by dermolipectomy.

Juxta-articular adiposis dolorosa is a rare subtype of Dercum's disease. It manifests mainly on the medial parts of the knees. Pain and impaired mobility are common symptoms. We report on four females (aged between 52 and 83 years) who suffered from juxta-articular adiposis dolorosa for more than 10 years. These patients were successfully treated by dermolipectomy resulting in dramatically improved pain and mobility. Adverse effects and complications were minor with a lymph fistula in a single patient which was treated by surgery.

Classification of vascular disorders in the skin and selected data on new evaluation and treatment.

Cutaneous vascular disorders are common. They include arteries, veins, and lymphatic vessels, or a mixture of them. In this review, we discuss classification, new developments in understanding and treatment of vascular diseases. We focus on infantile hemangiomas and drug therapy, vasculitides with new vasculitic syndromes, yellow nail syndrome and localized lymphatic malformations. Benign cutaneous vascular lesions may be a sign of severe internal diseases. In many cases multidisciplinary treatment is important. The dermatologist can often act as a pilot for these patients.

Management of severe anogenital acne inversa (hidradenitis suppurativa).

BACKGROUND: Severe anogenital acne inversa (AI) is a debilitating chronic inflammatory disease with a major negative effect on quality of life. OBJECTIVES: To evaluate the role of surgery in the treatment of severe anogenital AI. METHODS: We analyzed the records of patients with anogenital AI from 2000 to 2010. Assessment was done using the Hidradenitis Suppurativa Lesion, Area, and Severity Index (HS-LASI), pain visual analogue scale, physician global assessment (PhGA), and patient global assessment (PaGA). Comorbidities and adverse events were analyzed. RESULTS: Sixty-seven patients with a Hurley score of 3 were identified. Mean follow-up was 56.9 ± 41.3 months. A number of comorbidities were observed. After surgery, mean pain scores decreased from 6.3 ± 1.5 to 0.8 ± 0.7, PhGA improved from 6.8 ± 1.2 to 0.9 ± 0.6, PaGA improved from 7.3 ± 1.2 to 1.1 ± 0.5, and HS-LASI decreased from 41.8 ± 21.3 to 2.4 ± 2.8. Adverse reactions were seen in 10.4%. The total relapse rate was 6% (5 patients) with only one case with healing by secondary intention (2% of 49 patients). CONCLUSIONS: Surgery is the cornerstone of treatment for advanced AI. Healing by secondary intention results in significant reduction of complaints and achieves satisfying body contouring.

Psoriatic arthritis.

Psoriatic arthritis (PSA) is an entity of inflammatory joint disease associated with psoriasis. PSA belongs to the heterogeneous group of seronegative spondylarthropathies. Both peripheral joints and axial skeleton can be affected in a characteristic pattern. In addition to that, enthesitis and dactylitis are important extracutaneous manifestations. Uveitis anterior is temporarily seen in about one quarter of PSA patients. There is a closer relationship of nail and joint disease. This review provides data on drug and physical treatment options. In particular DMARDS and inhibitors of tumor necrosis factor alpha are established therapies with importance for quality of life and long term outcome. New drugs are tested in various trials.

Dystrophic calcification in chronic leg ulcers--a clinicopathologic study.

BACKGROUND: Dystrophic calcification (DC) is a risk factor for conservative treatment failure in chronic leg ulcers of various pathologies. PATIENTS AND METHODS: We performed a retrospective noncontrolled trial of 212 patients with 362 chronic leg ulcers who underwent ulcer shave excision with subsequent skin grafting. The ulcers existed for at least 3 months, and no healing was achieved with good ulcer care. Tissue was subjected to histopathology (hematoxylin-eosin and van Kossa stains). RESULTS: DC was evident in 39 patients (18%). Metaplastic subcutaneous bone formation was observed in 15 patients (7%). Clinical symptoms associated with DC were resistance to good ulcer care, pain, and ineffective effects of compression therapy (in venous ulcers). Ulcers were treated with deep dermatome shaving of the ulcer bed and surgical removal of DC. In the same setting, defects were closed using mesh graft transplantation. The procedure achieved a complete take rate in 80% and a significant decrease of pain in 95% of cases. When comparing the take rates in patients with and without DC, DC had a negative effect on outcome (take rate: 91% without DC vs 80% with DC, p<.05). CONCLUSIONS: DC is resistant to conservative treatment. The first-line treatment is deep ulcer dermatome shaving and complete removal of calcifications whenever possible.

Wells Syndrome - An Odyssey.

BACKGROUND: Wells syndrome is a rare idiopathic dermatosis of the eosinophilic spectrum. Diagnostic criteria include cutaneous eruptions of variable morphology with eosinophilic infiltrates, peripheral blood eosinophilia, a relapsing, remitting course, and exclusion of systemic disease. Diagnosis is often delayed. CASE PRESENTATION: We present a 28-year older man with recently developed pruritic and sometimes painful erythema. His medical history was positive for coughing in the evening that started in November 2012. Later, a pansinusitis developed. Early diagnosis improves the outcome. CONCLUSION: Standardized treatment has yet to be developed. In our case, systemic corticosteroids were of limited value only.

Advanced Ulcerated Squamous Cell Carcinoma of the Hand with Locoregional Axillary Lymph Node Metastasis - Case Report and Literature Review.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) of the hand is the most common soft-tissue malignancy in this particular region. A literature survey suggested a higher rate of metastases in advanced SCC of the hand compared to head-and-neck cutaneous SCC. CASE REPORT: An 84-year-old man presented with an ulcerated firm tumour on the dorsum of his right hand. A diagnostic biopsy confirmed the diagnosis SCC. Imaging suggested an involvement of the tendons of digits 3 and 4. A diagnostic ultrasound suggested a loco-regional axillary lymph node metastasis. After discussion in the interdisciplinary tumour board, amputation of the affected digits followed by lymph node excision was recommended. CONCLUSIONS: Advanced SCC of the hand requires interdisciplinary management. Amputation is part of the surgical spectrum in advanced cases.

Eosinophilic Fasciitis - Report of Three Cases and Review of the Literature.

BACKGROUND: Eosinophilic fasciitis is a rare fibrosing disorder of muscle fascia with rapid onset of erythema, induration, oedema and tenderness affecting extremities bilaterally. CASE REPORT: We report three cases of eosinophilic fasciitis in 3 females aged 64, 65 and 73 years, in two of them in association with morphea. They fulfilled the proposed diagnostic criteria. Associated malignancies could be excluded in all of them. They were treated by systemic corticosteroids. In the two females with associated morphea higher prednisolone dosages and a combination with methotrexate was necessary. CONCLUSIONS: Eosinophilic fasciitis is a differential diagnosis of systemic scleroderma. Response to treatment is often delayed. Systemic corticosteroids are the first line therapy. Patients with associated morphea need combined drug therapy, in our patients with methotrexate. There is no close correlation between laboratory signs of inflammation and clinical response to treatment.

Segmental Erythema Multiforme-Like Drug Eruption by Aromatase Inhibitor Anastrozole - First Case Report and another Example of an Immunocompromised District.

Anastrozole is a non-selective aromatase inhibitor for adjuvant breast cancer therapy in postmenopausal women. Cutaneous adverse events have been reported. We observed a 64-year-old female patient with a medical history of locally advanced breast cancer of her right breast that was treated with radiotherapy and adjuvant drug therapy with anastrozole. She developed a segmental bullous eruption limited to the cancer-affected breast. Cessation of the aromatase inhibitor and systemic therapy with prednisolone cleared the lesions completely. This is the first report of a segmental erythema multiforme like drug eruption by anastrozole and another example of the concept of the immunocompromised district of skin.

Unilateral Palmar Callus and Irritant Hand Eczema - Underreported Signs of Dependency on Crutches.

Leg amputees who can't use prostheses and patients with arthritis are often dependent on crutches. Their chronic use can exert significant friction forces. The palmar skin will respond by forming a hyperkeratotic callus. We report for the first time unilateral palmar callus formation caused by friction from using crutches. Another possible adverse effect is the triggering of irritant contact dermatitis by the handholes of crutches. We report two cases with hand dermatitis due to the chronic dependence on crutches and discuss treatment options.

Cutaneous Microembolism of Fingers and Toes.

A macro vascular embolism is a well-known emergency. In contrast, cutaneous microembolism is a lesser known symptom. However, cutaneous microembolism of fingers and toes is a red flag symptom for vascular emergencies. The underlying cause may involve infectious, immunological, metabolic and physical disorders, coagulation disorders and malignancies. Early recognition can help to live safe.

The Role of Complex Treatment in Mixed Leg Ulcers - A Case Report of Vascular, Surgical and Physical Therapy.

BACKGROUND: Leg ulcers are a burden to patients, their families and society. The second most common cause of chronic leg ulcers is the mixed arterio-venous type. An 80-year-old female patient presented to our department due to painful enlarging chronic leg ulcer of mixed arteriovenous origin on her left lower leg. She suffered from peripheral arterial occlusive disease stage I and chronic venous insufficiency Widmer grade IIIa, and a number of comorbidities. AIM: The aim of our ulcer treatment was a complete and stable wound closure that was hampered by arterial occlusion, exposed tendon, and renal insiffuciency. CASE REPORT: To improve the prognosis for ulcer surgery, we performed percutaneous transluminal angioplasty, transcutaneous CO2 and deep ulcer shaving. The wound was closed by sandwich transplantation using elastin-collagen dermal template and meshed split skin graft. She had a 100% graft take with rapid reduction of severe wound pain. CONCLUSION: Complex approaches are necessary, to gain optimum results in leg ulcer therapy in mixed leg ulcers. Therapeutic nihilism should be abandonend.

Ulcerating Lichen Planopilaris - Successful Treatment by Surgery.

Lichen planus is a T-cell mediated autoimmune disorder affecting the skin and mucous membranes. Ulcerating lichen planus is uncommon mostly on oral and genital mucosa but not skin. Lichen planopilaris, however, is a subtype of lichen planus affection hair follicles and leading to permanent scarring alopecia. We report a case of lichen planopilaris of the scalp with multiple alopecic patches ulceration - a hitherto unreported clinical feature. The patient was treated surgically, and the defect could be closed by combined tissue advancement and extension.

Acrocyanosis - A Symptom with Many Facettes.

Acrocyanosis is an uncommon complaint belonging to the acro-syndromes. It typically presents with coolness and bluish discolourations of hands, feet, ears, nose, lips and nipple. The most frequently affected parts of the body are the hands. This review discusses physical factors, vascular disorders, infectious diseases, haematological disorders, solid tumours genetic disorders, drugs, eating disorders, and spinal disease presenting as or leading to acrocyanosis.

Painful ANA-positive scleroderma-like disease with acral ulcerations: a case of chronic gangrenous ergotism.

Chronic ergotism is a rare cause of limb ischemia. In this case report, the authors present a 62-year-old woman with history of long-term use of ergotamine alkaloids for the treatment of menstrual pain, who developed a severe painful disease initially misdiagnosed as systemic sclerosis (scleroderma) for 3 decades. She presented with a combination of acral gangrene, foot ulcer, renal obstruction, mild pulmonary fibrosis, and reduced esophageal motility. Right-sided renal obstruction was evident. The condition was extremely painful and had led to muscular contractions and immobility, drug abuse, and anemia. After establishing the diagnosis of chronic gangrenous ergotism, changing drug therapy, mobilization, and treatment of chronic wounds, she showed a remarkable recovery. Eventually the foot ulcer was closed successfully using a mesh graft transplantation, and the patient was able to walk alone. Chronic ergotism is rare but has to be taken into account when presented with painful chronic digital and foot ulcers.