Combination of Autologous Fat Grafting and Negative-Pressure Wound Therapy for the Treatment of Scalp Linear Scleroderma.

ABSTRACT: Scalp linear scleroderma (LSc) is a subtype of localized scleroderma which typically affects young patients and which can be severely disfiguring. Traditional treatment options include bone grafting or tissue expansion. in this report, we present the case of a patient with scalp LSc successfully treated with scar release, autologous fat grafting, and negative-pressure wound therapy (NPWT). A 55-year-old female, with a history of craniectomy for a benign sellar tumor 10 years previously, developed LSc over the frontal scalp with exposure of titanium plates and screws. She was treated with removal of metalwork, scar release, autologous fat grafting from the abdominal wall and immediate application of NPWT. At 3-month postoperative follow-up, the appearance of the depressed lesion and of its margins had significantly improved. Our experience suggests that the combination of autologous fat grafting and NPWT is an effective treatment modality for scalp LSc.

Long-Term Utility of Follicular Unit Excision in Lichen Planopilaris-Correlation of Graft Survival With Histopathological and Ultrasound Biomicroscopic Parameters.

BACKGROUND: Hair transplantation in scarring alopecia is challenging and transplant surgeons are hesitant due to fear of poor graft survival apart from the risk of reactivating the disease. OBJECTIVE: Survival rate of hair follicles transplanted in cases of lichen planopilaris (LPP). To correlate histopathological and ultrasonography findings and their impact on graft survival. METHODS: In 32 patients of inactive LPP included, a 5-cm2 recipient area was tattooed. The follicular unit density of the transplanted area was 20 to 25 FU/cm2. Postoperative follow-up was conducted at 6, 12, and 24 months. The recipient area density and ultrasound biomicroscopic parameters were assessed at each follow-up visit. RESULTS: The survival of grafts was 78.62% at 12 months, and 79.96% at 24 months. Histopathology variables studied at the time of transplantation such as epidermal atrophy, fibrosis, and inflammatory infiltrate were not found to have any effect on the graft survival. Ultrasonography parameters of the involved scalp skin were found to be markedly improved on follow-up. This suggests that the overall health of the scalp improved after hair transplantation. CONCLUSION: Follicular unit excision is a ray of hope for cases of primary cicatricial alopecia such as LPP because the result is satisfying to both the patient as well as the doctor.

Severe dissecting scalp cellulitis successfully treated with serial excisions in combination with anti-TNF therapy.

The management of dissecting scalp cellulitis involves medical treatment with oral antibiotics and isotretinoin, as well as surgical input in more severe cases. In extensive disease, a full scalpectomy with reconstruction can be required. We report a case of severe dissecting scalp cellulitis in a 34-year-old man who underwent serial scalp excisions over three years, with wounds being left to heal by secondary intention. Initially, the excisions helped to control symptoms but, once the patient was on concurrent anti-TNF therapy, further excisions were successful in reducing disease load and inducing remission. He remained disease free at the 20 months follow-up. This case is the first of its kind to be described in the literature and it highlights how a conservative, staged surgical approach, in combination with anti-TNF therapy, can be effective in the management of severe dissecting scalp cellulitis. In doing so, it offers an alternative to full scalpectomy with reconstruction.

Syringocystadenoma papilliferum of the scalp.

Syringocystadenoma papilliferum is a rare, benign adnexal tumor of eccrine or apocrine origin that typically presents at birth or before puberty. Syringocystadenoma papilliferum is associated with a nevus sebaceus in about 40% of cases. We present a 50-year old woman with a pink-orange plaque and nodule on the scalp, consistent with syringocystadenoma papilliferum that arose within a nevus sebaceus.

Approach to treatment of refractory dissecting cellulitis of the scalp: a systematic review.

BACKGROUND: Dissecting cellulitis is a chronic inflammatory dermatosis that results in disfiguring and painful, purulent lesions. Treatment of patients with disease resistant to standard therapies, including intralesional or topical steroids or antibiotics, can be a dilemma for clinicians. METHODS: We performed a systematic review of the literature in November 2018 to find articles which presented treatment options and outcomes of patients who failed prior treatment with standard therapies. RESULTS: We identified 57 articles of interest, with 53 being case studies or series. Isotretinoin was the most often reported, but the response was limited. Biologics and laser therapy were used less often but demonstrated a better chance of remission. X-ray epilation and surgical excision demonstrated the best remission rates but can be complicated by serious morbidity. CONCLUSION: We propose a regimen for the treatment of recalcitrant cases of dissecting cellulitis. In the future, more robust studies including randomized control trials are needed to identify the preferred treatment options for refractory dissecting cellulitis.

Trichilemmal Cysts With Divergent Ductal Differentiation: A Series of 4 Cases.

ABSTRACT: Trichilemmal cysts are common clonal tumors with a predilection for the scalp. They are composed of an outer epithelial wall resembling the outer root sheath in the isthmus of the hair follicle and a central core of compact keratin. Sweat duct differentiation is exceptional with only one convincing case reported to date. Here, we sought to characterize the clinicopathological characteristics of sweat duct differentiation in trichilemmal cysts. We reviewed all cases of trichilemmal cyst diagnosed at our institution between 2008 and 2019. Ductal structures were found in 4 of 411 cases (0.97%). Subjects included 2 male and 2 female patients with a median age of 37.5 years (range 34-55). The ducts were lined by attenuated epithelial cells and immunoreactive for polyclonal carcinoembryonic antigen and cytokeratin 7. Ductal differentiation involved a median of 7.5% (range 1%-50%) of the cyst wall. All 4 cases were from the scalp and treated with local excision. No recurrence was identified with a median follow-up period of 1.5 years (range 1-12 years). In summary, sweat duct differentiation in trichilemmal cysts is rare but likely under recognized. Conceptually, we suggest it represents a type of divergent cellular differentiation within a clonal neoplasm rather than a retention cyst or hybrid cyst.

Beare-Stevenson Syndrome With Blepharoptosis as a Complication of Front-Orbital Advancement and Remodeling.

Beare-Stevenson syndrome (BSS) is an extremely rare genetic disorder characterized by a broad range of congenital malformations including craniosynostosis, cutis gyrata, facial deformities, and abnormal genitalia. The authors report a case of a 7 month old female who developed a mechanical ptosis secondary to dermatochalasis as a complication of fronto-orbital advancement and remodeling (FOAR) surgery which subsequently required multiple lid surgeries to reverse ptosis. This is the first report of blepharoptosis correction in a child with BSS as a complication of FOAR.

Pseudomycetoma of the scalp caused by Microsporum canis

Abstract Pseudomycetoma is an extremely rare deep mycosis, caused by dermatophytic fungi that penetrate the tissue from infected follicles of tinea capitis. Both clinically and histopathology are similar to eumycetoma, being distinguished through the isolation of the fungus, which in the case of pseudomycetoma can be Microsporum spp. or Trichophyton spp. genre. We present a 24-year-old man with an exuberant tumor in the occipital region with fistula, whose histopathological examination evidenced grains composed of hyaline hyphae and the culture for fungi isolated the agent Microsporum canis. Combined treatment of surgical excision followed by oral griseofulvin for two years was performed, with resolution of the condition.

Osteonevus of Nanta: a case report in a combined melanocytic nevus

Abstract Secondary osteoma cutis is a phenomenon that may occur in several conditions. When it occurs in a melanocytic nevus it is named osteonevus of Nanta, an event considered uncommon and characterized by the presence of bone formation adjacent or interposed with melanocytic cells. There are reports of its occurrence in various melanocytic lesions, being more frequently associated with intradermal nevus. We report a case of osteonevus of Nanta in combined nevus, possibly the first description of this association.

Photodynamic therapy combined with dermatosurgical approach for Perifolliculitis Capitis Abscedens et Suffodiens.

Perifolliculitis capitis abscedens et suffodiens (PCAS) is a rare, chronic, suppurative and inflammatory scalp disease with aetiology and pathogenesis not completely understood. The treatment of PCAS usually represents a challenging problem with frustrating outcome (1). Photodynamic therapy (PDT) is an approach considered to be useful to treat tumors, bacterial and fungal infections (2-4). We report 9 cases of patients who suffered from PCAS in varying degrees. Photodynamic therapy combined with surgery were used in these cases and the results were satisfactory. In conclusion, photodynamic therapy may provide a new way to treat PCAS.

Pseudomycetoma of the scalp caused by Microsporum canis.

Pseudomycetoma is an extremely rare deep mycosis, caused by dermatophytic fungi that penetrate the tissue from infected follicles of tinea capitis. Both clinically and histopathology are similar to eumycetoma, being distinguished through the isolation of the fungus, which in the case of pseudomycetoma can be Microsporum spp. or Trichophyton spp. genre. We present a 24-year-old man with an exuberant tumor in the occipital region with fistula, whose histopathological examination evidenced grains composed of hyaline hyphae and the culture for fungi isolated the agent Microsporum canis. Combined treatment of surgical excision followed by oral griseofulvin for two years was performed, with resolution of the condition.

Osteonevus of Nanta: a case report in a combined melanocytic nevus.

Secondary osteoma cutis is a phenomenon that may occur in several conditions. When it occurs in a melanocytic nevus it is named osteonevus of Nanta, an event considered uncommon and characterized by the presence of bone formation adjacent or interposed with melanocytic cells. There are reports of its occurrence in various melanocytic lesions, being more frequently associated with intradermal nevus. We report a case of osteonevus of Nanta in combined nevus, possibly the first description of this association.

Pilar Cyst Pigmented Epithelial Remnants: A Potential Diagnostic Pitfall.

Pilar cysts are common cutaneous cysts of follicular origin. They are easy to diagnose clinically and pathologically. Histologic diagnostic difficulties might arise in certain situations, however. Acute inflammation with total destruction of the cyst wall due to rupture with replacement by an abscess formation, foreign body giant cell reaction, and fibrosis could obscure their recognition. Cysts with hybrid lining epithelium could be confused with other cutaneous cysts. Epithelial remnants of the basal layer with loss of the squamous epithelium and shelled out cyst contents might mimic other epithelial cysts and vascular lesions. Few studies focused on the phenomenon of epithelial remnants or epithelial separation of pilar cysts. We report a case of a scalp cyst composed of a single layer of pigmented cuboidal lining epithelium. The initial differential diagnosis was hidrocystoma, solid-cystic hidradenoma, arteriovenous malformation, and lymphangioma. The intraepithelial pigment was melanin. The lining epithelium was positive for cytokeratin cocktail, CK5/6, CK8, CK19, p63, and D2-40 with scattered S-100 protein and melan-A positive melanocytes. Being unaware of the phenomenon of epithelial split in pilar cysts, it was mislabeled as a melanin-pigmented eccrine hidrocystoma. Surgical pathologists should be aware of pilar cysts' epithelial remnants to avoid potential diagnostic pitfalls. An attention to certain histologic hints and knowledge of the immunoprofile of the basal layer should help pathologists avoid this pitfall.

Acute otitis externa because of negative pressure wound therapy applied over the head and ear canal for scalping treatment.

Scalping is considered a complex wound with difficult treatment, requiring early surgical intervention, reconstructive plastic surgery, and a multidisciplinary team. The reconstruction of the scalp frequently requires a combination of therapies, including temporary coverage, such as negative pressure wound therapy (NPWT). Complications of NPWT, such as bleeding, infection, and pain, have been described. However, there is no report of acute otitis externa (AOE) because of NPWT. In this article, we present an unprecedented clinical case - a female patient who developed AOE after scalping treatment with NPWT applied over the head and ear canal. We consider that it may be a result of the direct physical action of subatmospheric pressure, the presence of dressing covering the external meatus, and alteration of the bacterial population.

Posterior Distraction First or Fronto-Orbital Advancement First for Severe Syndromic Craniosynostosis.

PURPOSE: Posterior calvarial vault expansion using distraction osteogenesis is performed for syndromic craniosynostosis as the first choice. This procedure allows far greater intracranial volume than fronto-orbital advancement (FOA). This study aimed to determine the most suitable timing of posterior distraction or FOA to sufficiently increase the intracranial volume and remodel the skull shape. PATIENTS AND METHODS: From 2014 to 2017, the authors performed posterior distraction in 13 patients with syndromic craniosynostosis. Data on premature suture fusion, age at first visit, age at surgery, skull thickness, and complications were collected. RESULTS: Five patients underwent posterior distraction at approximately 12 months of age and had no complications, including cerebrospinal fluid leakage or gull wing deformity. However, during the waiting period for the operation, the skull deformity continues to extend upward (turribrachycephaly). To prevent progress of the skull deformity, the authors performed the operation at approximately 6 months of age in 7 patients. However, in 3 of 7 patients whose lambdoid sutures were opening, gull wing deformity occurred. From these results, in a patient with severe Beare-Stevenson syndrome, the authors performed FOA first at 5 months of age, followed by posterior distraction at 12 months of age, and achieved favorable results. CONCLUSIONS: Treatment patterns are patient specific and should be tailored to premature suture fusion, specific skull deformity, and required intracranial volume of each patient.