Recurrent disseminated herpes zoster and cytomegalic perianal ulcer: a case report and review of the literature.

We describe a patient with lymphocytic leukemia who developed multiple, disseminated, vesiculopustular eruptions in combination with perianal ulcer. Four years earlier, she had a herpes zoster (HZ) infection involving the ophthalmic division of her left trigeminal nerve with subsequent postherpetic neuralgia that was treated with steroids. After the studies, we concluded that the patient had a recurrent disseminated HZ infection and perianal ulcer caused by cytomegalovirus (CMV).

Quantitative comparison of inflammatory infiltrate and linear contraction in human skin treated with 90-microsecond pulsed and 900-microsecond dwell time carbon dioxide lasers.

BACKGROUND: Skin resurfacing with 90-microsecond pulse duration carbon dioxide (CO2) resurfacing lasers has been reported to have shorter duration of erythema compared with skin resurfacing with 900-microsecond dwell time lasers. The presence of inflammatory infiltrate following resurfacing may correlate with the persistence of this erythema. Furthermore, skin treated with the 90-microsecond pulse duration laser and the 900-microsecond dwell time lasers both result in equivalent improvement of rhytids in the treated skin. OBJECTIVE: To quantitative the inflammatory cell infiltrate and linear contraction of skin treated with the 90-microsecond pulsed and 900-microsecond dwell time CO2 lasers at intervals of 2 and 4 weeks after treatment. MATERIALS AND METHODS: Volunteers were recruited from patients who were planning to undergo full face laser resurfacing under general anesthesia. Informed consent was obtained from all volunteers. In the posterior auricular areas of all volunteers, four separate rectangular areas were marked using a skin marking pen and a template. Two rectangular areas behind the right ear were treated with 6 passes of the 90-microsecond laser and two rectangular areas behind the left ear were treated with the 900-microsecond dwell time laser. The resurfaced areas were wiped with a moist cotton swab and then patted dry with dry gauze between passes. Contraction measurements of the resurfaced areas were taken before and immediately after laser treatment and again at 2 and 4 weeks following treatment. Punch biopsies were also performed at 2 and 4 weeks after treatment in an area of skin different from where contraction measurements were taken. RESULTS: The number of inflammatory cells present in the skin at 2 and 4 weeks after laser resurfacing are greater for skin resurfaced with a 900-microsecond dwell time laser than a 90-microsecond pulse time laser. Linear contraction of skin immediately after treatment was 18% greater with the 900-microsecond dwell time laser than with the 90-microsecond pulsed laser. The difference in the amount of contraction produced by the lasers tended to decrease over time. At 4 weeks there was a 10% difference in mean linear contraction between the two laser types. CONCLUSION: Increased numbers of inflammatory cells in skin resurfaced with the 900-microsecond dwell time laser may explain the observed persistence of erythema associated with the 900-microsecond dwell time laser. Measurable linear contraction produced by the 900-microsecond dwell time laser was initially 18% greater than the 90-microsecond pulse laser. This difference tends to decrease over time.

Skin resurfacing of facial rhytides and scars with the 90-microsecond short pulse CO2 laser. Comparison to the 900-microsecond dwell time CO2 lasers and clinical experience.

BACKGROUND: Carbon dioxide lasers that produce either short pulses or scanned continuous beams have been used for skin resurfacing to improve wrinkles or scars. Using a high peak power, short pulse CO2 laser can produce clinically effective results with minimal thermal damage. OBJECTIVE: To evaluate the effectiveness of skin resurfacing using the 90-microsecond pulse duration CO2 laser compared to other laser systems. Erythema, healing time, complications, and histological measurement of the depth of ablation and thermal damage per pass with this system were also assessed. METHODS: Forty-one patients with facial rhytides and scars underwent resurfacing with a 90 microseconds pulse duration CO2 laser. Using patient survey, patients were evaluated for effectiveness of therapy, healing time, and complication rates. Comparisons of histologic and clinical findings were made with different short pulse CO2 lasers. RESULTS: Healing time, duration of erythema, and post-operative pain were less with the 90 microseconds pulse CO2 laser than with the 900-microsecond dwell time and 950-microsecond pulse duration lasers, while effectiveness was comparable. Complications were few with the 90-microsecond pulse laser, including three patients (9.1%) developing hyperpigmentation. One pass with the 90-microsecond pulse duration CO2 laser produced 100 microns of ablation with 17 microns of thermal damage. Ablation and damage were additive so that, by six passes, ablation depth was 350 microns and depth of thermal damage was 63 microns. This thermal damage is less than that reported with lasers having a longer pulse duration or dwell time with comparable depths of vaporization. CONCLUSION: Treatment with the 90-microsecond pulse duration laser results in a more rapid healing time and shorter duration erythema. The clinical improvements in wrinkles and sun damage were comparable. The 90-microsecond pulse duration laser provides an effective, predictable, and safe means of improving facial rhytides and scars.

Comparison of skin anesthetic effect of liposomal lidocaine, nonliposomal lidocaine, and EMLA using 30-minute application time.

BACKGROUND: Liposomes are microscopic phospholipid vessels that have been utilized to extend the action of topical medications. Previous studies have demonstrated that liposomal vehicles can prolong the action of a variety of medications, including antifungals, anesthetics, interferon, and antineoplastic agents. OBJECTIVE: The purpose of this study was to examine the degree and duration of anesthesia produced by lidocaine in a liposomal vehicle compared with lidocaine in a nonliposomal vehicle and compared with EMLA. The topical preparations in this study were allowed to contact the skin for a 30-minute period prior to evaluation of anesthetic effectiveness. Unoccluded and Tegaderm-occluded topical preparations were evaluated in two separate arms of the study. MATERIALS AND METHODS: Thirteen healthy volunteers (three male, 10 female) were recruited for the nonocclusion arm of the study. Six healthy volunteers (two male, four female) were recruited for the occlusion arm of the study. Subjects with a history of allergy to lidocaine, a history of seizures, cardiac or respiratory difficulty, pregnant patients, and patients less than 18 years old were excluded. Written informed consent was obtained from all patients prior to testing. The volar forearms of the volunteers were swabbed with isopropyl alcohol and allowed to dry. A template was then utilized to mark 2 x 2-cm squares with a skin marker on both volar forearms. In total, nine squares corresponding to nine test areas were marked. The nine test preparations were applied to the test areas in a double-blinded fashion using a clean swab stick. The test preparations were then allowed to remain on the skin for 30 minutes in either occluded or nonoccluded from depending upon the arm of the study. Following the 30-minute application period, the test preparations were wiped off with clean gauze. Testing for anesthesia was performed by following a previously published method utilizing gentle pinpricks. A new pinprick apparatus was used for each patient. Pinprick testing was performed at 0, 15, 30, 60, and 90 minutes following the end of the 30-minute application period. Patients' responses to the pinprick were recorded in a binary fashion, as being either: 1) totally painless or 0) painfully sharp to any degree. Ten applications of the pinprick were applied randomly across each 2 x 2-cm test area. The number of painless applications of the pinprick out of a total of 10 applications of the pinprick was then recorded for each test area at every particular test time. In total, nine test preparations were evaluated. Analysis of the data was performed by a PhD statistical faculty consultant from the UCLA Mathematics Department. RESULTS: Liposomal lidocaine preparations evidenced longer durations of anesthesia than lidocaine preparations in nonliposomal vehicles. Five percent liposomal lidocaine preparations were statistically equivalent to EMLA in anesthetic effectiveness. CONCLUSION: Five percent liposomal lidocaine is an effective alternative topical agent for use in the attainment of temporary local anesthesia of the skin.

Topical anesthetic agents in dermatologic surgery. A review.

BACKGROUND: The ideal topical anesthetic agent is one that provides 100% anesthesia in a short period of time, work on intact skin without systemic side effects, and invokes neither pain nor discomfort. The quest to find such an agent continues today. Because a topical anesthetic agent will induce anesthesia painlessly, the need for an effective agent is clear. This will serve to eliminate painful injections with lidocaine prior to many dermatologic procedures. OBJECTIVE: To provide a review of topical agents used in the past, to present products that are being used today, and to look to the future of topical anesthesia. CONCLUSIVE: During the last three decades a variety of methods have been employed to administer topical anesthesia. Presently, EMLA (eutectic mixture of local anesthetics) is the most often used method among practicing dermatologists. However, iontophoresis and the anesthetic patch are equally effective with a few notable advantages over EMLA. Liposomal agents show promise as we enter into a new millennium.

Photoelastic models of wound closure stress.

BACKGROUND: Areas of high stress in surgical closures are known to have adverse effects on wound healing. OBJECTIVE: To create a surgical model that will predict areas of high stress and allow for quantitative comparison of stress distributions in different closure geometries. METHODS: Surgical models were constructed consisting of soft polyurethane plastic. Surgical defects corresponding to A to T and O to T closures were cut in the plastic and then closed with silk interrupted sutures. The models were transilluminated with polarized light, photographed, and compared. RESULTS: The A to T closure showed much less total stress than the O to T closure. The color-coded stress patterns indicate that each closure has its own distinct stress characteristics. CONCLUSION: Photoelastic surgical models allow rapid and easy comparison of stress concentrations in different closure geometries. Such detailed information may allow the surgeon to avoid the adverse consequences of stress.

Topical use of human recombinant epidermal growth factor (h-EGF) in venous ulcers.

A great deal of interest has been focused recently on the potential use of synthetic polypeptide growth factors to stimulate healing of chronic wounds. In this pilot double-blind randomized study conducted at a single center, we used human recombinant epidermal growth factor (h-EGF) to treat 44 patients with venous ulceration of the lower extremities. An aqueous solution (10 micrograms/mL) of h-EGF was applied topically to the ulcers twice a day until healing occurred or for a maximum of 10 weeks. Patients were evaluated weekly for measurements of ulcer size and for the formation of granulation tissue suitable for grafting. Nine patients were excluded from efficacy evaluation because of protocol violations. Therefore, 35 patients (17 h-EGF, 18 placebo) were evaluable for efficacy, and 44 patients (22 h-EGF, 22 placebo) were available for safety. The median baseline ulcer size for all patients was 18.5 cm2, and was not significantly different between h-EGF and placebo group (12.9 cm2 versus 19.2 cm2, respectively, P = .27). By study end, six (35%) of h-EGF treated patients and two (11%) in the placebo group had healed completely (P = .10). Another 6 patients (2 of 17 h-EGF, 4 of 18 placebo; P = .50) developed healthy granulation tissue that was suitable for grafting. The median ulcer size reduction was 7% for h-EGF versus 3% for placebo per week (P = .29), and 73% versus 33% at study end (P = .32). No untoward side effects were related to the application of h-EGF. We conclude that topical application of h-EGF, in the dose and manner used in this study, was safe but failed to significantly enhance re-epithelialization of venous ulcers. However, a greater reduction in ulcer size and a larger number of healed ulcers with the use of h-EGF are encouraging results.