Skin Ulcers: Prevention and Diagnosis of Pressure, Venous Leg, and Arterial Ulcers.

Pressure, venous leg, and arterial ulcers are common and costly skin conditions that affect patients in all clinical settings. Clinical features can help differentiate these ulcers. Pressure ulcers are associated with restricted mobility, poor perfusion, and compromised skin status. Venous leg ulcers (VLUs) are attributed to chronic venous hypertension resulting from venous insufficiency or obstruction. Risk factors for a first VLU include previous nonvenous leg ulcer, male sex, chronic venous hypertension, and older age. Arterial ulcers result from skin and soft tissue ischemia due to arterio-occlusive disease. They are associated with hypertension, diabetes, chronic kidney disease, and smoking. Various methods of pressure offloading have strong evidence of effectiveness in prevention of pressure ulcers. Clinical practice guidelines support the use of compression therapy in patients with previous VLUs to prevent ulcer recurrence. For patients with chronic lower extremity ulcers, a crucial step in evaluation is measurement of the ankle-brachial index, which can identify decreased perfusion and indicate the need for referral to a vascular surgeon. The likelihood of bone involvement should be determined. Skin and soft tissue infections often complicate wound care and should be addressed at each patient evaluation. Various factors can predict likelihood of wound healing.

Skin Ulcers: Surgical Management.

Surgical debridement refers to the use of sharp instruments to remove devitalized tissue from wounds. Skin grafting is an adjunctive therapy that uses human (autograft or allograft), nonhuman (xenograft), or artificial (synthetic graft) skin to cover nonhealing ulcers. Bilayer artificial skin plus compression is more effective for venous leg ulcers (VLUs) than standard dressings plus compression. Reconstructive surgery provides options for coverage of deep, refractory pressure ulcers; however, no randomized trials have compared these techniques with standard care. For patients with VLUs with superficial venous reflux, early endovenous ablation plus compression heals VLUs more quickly than compression with deferred ablation. Revascularization restores in-line arterial flow to ischemic extremities, facilitating wound healing and pain resolution. Bypass surgery has been shown to result in better luminal patency at 1 year than percutaneous transluminal angioplasty (PTA), but PTA is associated with fewer perioperative complications and shorter hospitalizations. PTA with and without stenting are comparable in terms of rates of perioperative complications and major amputation and mortality in patients with infrapopliteal arterio-occlusive disease. Amputation is the last option for patients with critical limb ischemia who are not candidates for or have not benefited from revascularization attempts.

Common Skin Conditions in Children: Noninfectious Rashes.

Cutaneous adverse drug reactions are among the most common noninfectious rashes of childhood. Cutaneous adverse drug reactions are classified as morbilliform, urticarial, bullous, pustular, or psoriasiform. Atopic dermatitis is one of the most common inflammatory cutaneous eruptions, and is characterized by pruritus and flexural distribution. Emollients and topical corticosteroids are first-line therapies. Topical calcineurin inhibitors are second-line, steroid-sparing drugs for certain conditions, such as face and eyelid eczema. Systemic and immunologic conditions have mucocutaneous features, such as malar rash, discoid lupus, and photosensitivity in systemic lupus erythematosus; lip, oral, and extremity changes as well as polymorphous rash in Kawasaki disease; erythematous, scaly plaques in psoriasis; and xerosis and face, hand, and leg skin changes in type 1 diabetes. Genetic conditions that manifest as changes in skin pigmentation are important to recognize because of the thorough diagnostic evaluation they warrant, the often challenging interventions they necessitate, and the permanent disability that frequently accompanies them. These conditions include neurofibromatosis, LEOPARD syndrome, incontinentia pigmenti, congenital hemidysplasia with ichthyosiform erythroderma and limb defects syndrome, hypomelanosis of Ito, and acanthosis nigricans. Childhood dermatologic emergencies often are associated with infection and drugs and require early recognition and intervention.

Common Skin Conditions in Children: Congenital Melanocytic Nevi and Infantile Hemangiomas.

Congenital melanocytic nevi (CMN) are hamartomas present at birth that are composed of nevomelanocytes and thought to originate from faulty migration of precursor melanocytes in the neural crest. Classification is based on projected adult size of the lesion. CMN size correlates positively with risk of melanoma and neurocutaneous melanocytosis. Management requires a patient-centered approach that weighs the risks and benefits of and alternatives to complete removal. All children with large and giant CMN, regardless of surgical status, should be monitored closely and undergo periodic skin examination. Infantile hemangiomas (IHs) are vascular neoplasms arising from endothelial cell hyperplasia that go through proliferative (growth) and involutional phases. Large, segmental IHs carry a higher risk of bleeding, and patients with these IHs may benefit from imaging. Small, focal IHs in noncritical areas do not require treatment. In contrast, early referral and treatment should be considered for patients with large, extensive, deep, segmental, or syndromic IHs. Systemic and topical beta blockers have the strongest efficacy data and have replaced systemic and intralesional corticosteroids as first-line treatment for IHs in the United States. Surgical therapies are second-line modalities, with laser treatment being used most widely.

9 tips to help prevent derm biopsy mistakes.

The authors--with expertise in dermatology and pathology--provide pointers that can help you improve your approach to skin biopsy.

Common questions about vasectomy.

Vasectomy offers a safe, effective, and permanent method of male contraception, with an overall failure rate of less than 1% in pooled studies. Men older than 30 years in a stable, committed relationship appear to be the best candidates for vasectomy. The no-scalpel technique reduces operative complications, shortens operative time, and hastens resumption of sexual activity. Use of a jet injector instead of a needle to provide local anesthesia (no-needle vasectomy) may reduce pain. Bleeding and infection are short-term complications of vasectomy; long-term complications include sperm granuloma and postvasectomy pain syndrome. One postvasectomy semen analysis demonstrating azoospermia performed after three months and 20 ejaculations is sufficient to establish sterility. Vasectomy reversal is more likely to be successful if performed less than 15 years after vasectomy and in men whose female partner is younger than 40 years.