3D Mohs surgery: a new concept.

Although Mohs surgery is considered a skin-sparing technique, when dealing with aggressive skin tumor that penetrates the deep tissues, the Mohs surgeon usually sacrifices uninvolved skin. We present our technique of 3D Mohs as a new concept for skin-sparing surgery. After raising a skin flap above the residual tumor, Mohs resection was performed on the deep tissues horizontally and simultaneously on the inner plan of the flap vertically. When "clear" borders were achieved, the skin flap was sutured back into place. The results show that the defect was significantly smaller, and the hair on the Mohs-treated vertical flap continue to grow, thus contributing to a more aesthetic outcome. We conclude that careful use of the 3D Mohs technique as we describe spares the healthy uninvolved skin and offers better aesthetic and functional result.

Use of antibiotics in dermatologic surgery.

When skin integrity is disrupted during a surgical procedure, its protective barrier becomes compromised and predisposes the individual to cutaneous infection. Postoperative infection remains a considerable cause of morbidity and mortality. This article briefly reviews the etiology and management of postoperative infections following dermatologic surgery.

The use of photodynamic therapy in dermatology: results of a consensus conference.

Photodynamic therapy (PDT) has significant promise in improving outcomes of patients with a variety of cutaneous conditions. A group of experts met to review the principles, indications, and clinical benefits of PDT with 5-aminolevulinic acid (ALA). They also reviewed PDT with methyl aminolevulinate. The experts established consensus statements for pretreatment, posttreatment, ALA contact time, light sources, and numbers of sessions associated with ALA PDT for actinic keratosis and superficial basal cell carcinoma, photorejuvenation and cosmetic enhancement, acne, sebaceous skin, rosacea, and rhinophyma. They based consensus recommendations on their clinical experience and the medical literature. They also suggested future applications of ALA PDT. Experts concluded that ALA PDT is a safe and effective modality for the treatment of conditions commonly encountered in dermatology. Since downtime is minimal, the technique is suitable for patients of all ages and lifestyles. Appropriate light sources are available in many dermatology offices. The expanding clinical and financial benefits of PDT justify the purchase of an appropriate light source.

Evaluation of a flexible new liquid polymer wound dressing.

Occlusive dressings are the foundation of wound care and have been shown to speed epithelialization and healing of surgical sites. Many different dressings have been introduced over the years including antibacterial ointments with gauze and adhesive, hydrocolloid bandages, and liquid adhesives. All of these have their limitations and advantages. We introduce our experience with a new organic polymer in solvent which when applied to a wound forms a flexible occlusive bandage. The material has been shown to have antimicrobial properties and be well-tolerated by patients.

Therapeutic decision making in the therapy of actinic keratoses.

Actinic keratoses (AKs) represent the second most common reason to visit a dermatologist in the United States and their therapy has become a major portion of most dermatologists' practice. An ever-increasing array of therapeutic options exist for the therapy of actinic keratoses, offering physicians and patients a greater number of choices than ever before. Patient expectations and needs seem to be changing at the same time, thus effecting therapeutic decision-making. While destructive therapies with resultant wounds, time for wound healing, and possible hypopigmentation or scarring were acceptable in the past, many patients from the baby-boom generation are now developing AKs and have little tolerance for any time for wound healing or any cosmetic changes. This paper will raise some fundamental questions regarding AKs and their management.

The ten commandments: what every surgeon should know about performing dermatologic surgery.

The goal of every physician is to render the best medical care to the patient. This article draws on the author's vast surgical experience and provides a list of 'Ten Commandments' for other surgeons to follow in their own practices.

Pulse therapy with 5-FU in eradicating actinic keratoses with less than recommended dosage.

Pulse therapy has been used for many years, but rarely in a clinical setting. This article describes a clinical study designed to determine the efficacy of pulse therapy with 5-FU for patients with multiple actinic keratoses. The results indicated that pulse therapy was indeed effective in eradicating most of the actinic keratoses while causing less discomfort or disfigurement than the FDA recommended dose, especially for patients with less severe and milder forms of actinic keratoses.

Generalized eruptive keratoacanthoma of Grzybowski.

We describe the case of a 71-year-old woman with a six-year history of generalized eruptive keratoacanthomas on the extremities. We review the diagnostic clinical and histologic features of the rare Grzybowski variant of generalized eruptive keratoacanthoma. The course of this disease is chronic and often demonstrates a poor response to therapy.

The use of topical fluorouracil to treat actinic keratosis.

Actinic keratosis (AK) is a lesion induced by UV radiation, affecting predominantly fair-skinned individuals with a history of excessive sun exposure. Because AKs are potentially cancerous, management of AKs is important for dermatologists. The most frequently performed procedure for AKs is excision or destruction of the lesion, followed by biopsy. Topical fluorouracil creams are an efficient, effective treatment, especially for large quantities of widespread lesions. However, fluorouracil can produce an inflammatory facial reaction that is associated with the destruction of AKs. A new formulation, 0.5% fluorouracil cream, is indicated for once-daily use with a duration of treatment of up to 4 weeks. This regimen may be more cost-effective than the higher concentrations of fluorouracil creams (5% and 1%, respectively), which specify twice-daily application. Less frequent applications also may improve patient compliance with topical fluorouracil treatment. The use of 0.5% fluorouracil cream may provide an effective, safe, and economical option to augment the available treatments of AK, which include liquid nitrogen cryotherapy and 5% and 1% fluorouracil creams.

Matching patients with therapy.

Multiple options are available for the treatment of actinic keratosis (AK). Each therapy has its own idiosyncrasies and risks, and not every modality is appropriate for every patient. Physician experience and clinical factors such as patient demographics, concerns, reason for the office visit, and lifestyle, as well as the pros and cons of each treatment modality, must be considered when developing customized rational treatment programs.

Treatment options in the management of actinic keratosis.

Successful treatment of actinic keratosis (AK) requires an understanding of available treatments and matching those treatments with each patient's disease severity, lifestyle, insurance coverage, and primary reason for the physician visit. Cryotherapy and other destructive strategies are optimal for hypertrophic and clearly delineated lesions, but they may not address subclinical lesions and are associated with risk of scarring, infection, and pigmentary changes. Topical therapies such as the fluorouracil creams are appropriate for treating large regions of affected skin but are associated with application-site irritation. A combination of destructive and topical approaches may benefit patients with multiple lesion pathologies.

Fluorouracil 5% and 0.5% creams for the treatment of actinic keratosis: equivalent efficacy with a lower concentration and more convenient dosing schedule.

Several formulations and concentrations of topical fluorouracil have received US Food and Drug Administration (FDA) approval for the treatment of actinic keratosis (AK). The most commonly used are the fluorouracil 5% and 0.5% creams. In clinical trials, these formulations have demonstrated a marked ability to partially and completely eradicate AK lesions. Application site irritation, erythema, and burning are common side effects of both formulations, but comparative data suggest that the fluorouracil 0.5% cream is more cost-effective and may be safer, more tolerable, and as efficacious as fluorouracil 5% cream.

Generalized eruptive keratoacanthomas.

We describe the case of a 71-year-old-woman with a 6-year history of generalized eruptive keratoacanthomas on the extremities. We review the diagnostic clinical and histologic features of the rare Grzybowski variant of generalized eruptive keratoacanthoma. The course of this disease is chronic and often demonstrates a poor response to therapy.