The Bilateral Dufourmentel Flap for Repair of Nasal Dorsum Defects After Mohs Micrographic Surgery.

BACKGROUND: Single-stage repairs of large nasal dorsum defects risk introducing lower nasal distortion. OBJECTIVE: To describe the authors experience with the "birhombic" flap, a bilateral Dufourmentel rhomboid flap, for repair of nasal surgical defects after Mohs micrographic surgery. MATERIALS AND METHODS: The authors performed a retrospective chart review of patients who underwent birhombic flap repair of the nose by a single physician after Mohs micrographic surgery from 2008 to 2013 at the Medical University of South Carolina. RESULTS: Thirty-eight patients were identified on whom the birhombic flap repair was performed on the nasal dorsum over a 6-year period. There were no significant complications. Alar position remained neutral and nasal profile remained unaltered in all cases. Postoperatively, pulsed dye laser was performed in 8 patients (21%) and dermabrasion in 11 patients (29%). All patients achieved very good or excellent final aesthetic results. CONCLUSION: The birhombic flap is a reproducible, one-stage flap for small to large defects of the nasal dorsum that consistently produces topographic restoration with minimal risk of aesthetic or functional complication. The use of 2 opposing flaps redistributes the secondary defect, thus minimizing the potential for lower nasal distortion when closing the flaps' donor sites.

The importance of dedicated dermoscopy training during residency: a survey of US dermatology chief residents.

BACKGROUND: Studies have shown low satisfaction levels among dermatology residents with respect to dermoscopy training. Many desire additional instruction. OBJECTIVE: We surveyed graduating chief residents to assess current education practices among US dermatology training programs with respect to the role of dermoscopy as an aid in the management of pigmented lesions. METHODS: An online survey was sent to 139 chief residents of US dermatology training programs. RESULTS: A 59% response rate was achieved. Of responding chief residents, 94% use dermoscopy. Although 92% of chief residents received dermoscopy training, only 48% trained with a pigmented lesion specialist. Among those training without a specialist, less than half received classroom or bedside teaching compared with 77% of those who trained with a specialist. Of those who trained with a specialist, 77% were satisfied with their training compared with only 30% who trained without a specialist (P < .0001). Those who trained with a specialist were more likely to agree that dermoscopy can help differentiate melanoma from benign lesions (77% vs 47%; P = .0065). LIMITATIONS: Response bias and limiting the survey to chief residents potentially limits our ability to generalize these results to all US dermatology trainees. CONCLUSION: Although many residents use dermoscopy as a diagnostic tool, the lack of dedicated dermoscopy training remains a potential barrier to increasing residents' diagnostic confidence in the management of pigmented lesions. Increasing the amount of dedicated instruction on this topic is one possible approach to enhance resident satisfaction, potentially increasing their competency in the management of atypical nevi.

Safety of staged interpolation flaps after Mohs micrographic surgery in an outpatient setting: a single-center experience.

OBJECTIVE: To establish the safety of staged interpolation flaps performed in an outpatient dermatologic clinic setting. METHODS: A retrospective chart review was performed of patients who underwent staged interpolation flap reconstruction by a single dermatologic surgeon after tumor clearance using Mohs micrographic surgery from 2000 to 2012 at the Department of Dermatology, Medical University of South Carolina. RESULTS: Six hundred fifty-three staged flaps were performed in 639 patients (mean age 65) between June 2000 and November 2012. Types of flaps included paramedian forehead flaps (n = 291, 45%), two-stage melolabial flaps (n = 256, 39%), retroauricular flaps (n = 58, 9%), interpolated paranasal flaps (n = 40, 6%), and Abbe or Abbe-Estlander flaps (n = 8, 1%). No major complications were observed. Of the minor complications, problems related to bleeding were the most prevalent; active bleeding requiring physician intervention was seen in 8.4% and hematoma formation in 0.4% of flaps. Postoperative infections were seen in 1.7% of patients after the initial surgery and 3.4% after division of the pedicle. Primary or secondary dehiscence was seen in 0.5%. Partial full-thickness flap necrosis was seen in 2.3% and total flap necrosis in 0.6%. CONCLUSION: The rate of complications associated with dermatologic surgeons performing interpolated flaps in an outpatient setting under local anesthesia is low. Our complication rates are equal to or lower than published complication rates from other surgical specialties.

Investigation into optimal treatment intervals of facial port-wine stains using the pulsed dye laser.

BACKGROUND: Port-wine stains (PWS) affect 0.3% to 0.5% of newborns and pulsed dye laser (PDL) remains the treatment of choice. Optimal treatment intervals have not been established. OBJECTIVE: We sought to validate the optimal treatment intervals for the management of facial PWS with PDL. METHODS: In all, 24 infants with facial PWS who received at least 5 treatments with the PDL at 2-, 3-, and 4-week intervals at a private laser and skin surgery center from 2009 to 2010 were identified by a retrospective chart review. Safety and efficacy were compared by blinded investigators. RESULTS: Side effects were equivalent in all interval groups and included only expected short-term erythema, edema, purpura, and mild postinflammatory hyperpigmentation. No patient developed hypopigmentation, scarring, or infection. All interval groups showed 50% to 100% clearance of their PWS after 5 treatments. Complete or near-complete clearance was seen in 6 of 8 (75%) and 7 of 8 (87.5%) patients in the 2- and 3-week interval groups, respectively, as compared with 3 of 8 (37.5%) patients in the 4-week interval group. LIMITATIONS: This was a retrospective chart review from a single institution. Long-term side effects and recurrence rates were not assessed. CONCLUSION: We conclude that PDL treatments at 2-, 3-, and 4-week intervals are effective for the management of facial PWS in infants with minimal short-term side effects. Shorter treatment intervals may allow for relatively more rapid and more effective treatment.

Minocycline-induced hyperpigmentation in multibacillary leprosy.

Minocycline has been used in the treatment of leprosy since the demonstration of its efficacy in inhibiting Mycobacterium leprae growth in 1987. Hyperpigmentation, a well-documented adverse effect, classically shows 3 clinical and histological patterns: type I consists of blue-black pigmentation in areas of current or previous inflammation, type II consists of blue-gray pigmentation of normal skin, often seen on the legs, and type III consists of diffuse muddy-brown pigmentation accentuated on sun-exposed sites. Whereas type I hyperpigmentation stains positively for hemosiderin and type III hyperpigmentation stains positively for melanin, type II hyperpigmentation stains positively for both. We describe 2 patients with leprosy on minocycline therapy who developed multiple patches of blue-gray pigmentation within preexisting leprosy lesions. Biopsies from both patients demonstrated deposition of brownish-black pigment granules within the cytoplasm of foamy histiocytes that was highlighted by both Perls and Fontana-Masson stains. Given the clinical and histological findings in our patients, it is as yet unclear whether this coexistent type I clinical pattern and type II histopathologic pattern of pigmentation is unique to multibacillary leprosy. These findings provide support for the existence of additional subtypes of minocycline-induced hyperpigmentation that do not adhere to the classic 3-type model described.

Pityriasis rubra pilaris.

Pityriasis rubra pilaris (PRP) is an inflammatory condition of uncertain etiology. We present a case of PRP that demonstrates acantholysis on histopathologic examination, which is a characteristic feature that increasingly is recognized to aid in the diagnosis. We also review the clinical presentations and treatment options for this condition.

Papillary dermal elastosis.

There are numerous acquired disorders of elastic tissue that are distinguished by a combination of clinical appearance, location, gender, age of onset, and characteristic histopathologic findings. We present a case of a 36-year-old man with multiple confluent, hypopigmented papules that coalesced into plaques with prominent follicular ostia over the dorsal aspects of the forearms, shoulders, upper chest, and upper back. Histologically there was selective loss of papillary dermal elastic fibers. The clinical and histopathologic findings in this case are consistent with an acquired disorder of elastic tissue which we believe represents the second reported case of papillary dermal elastosis.

Pustular pyoderma gangrenosum.

A 79-year-old woman was admitted to our hospital with pustular pyoderma gangrenosum and an associated IgG kappa monoclonal gammopathy. The patient is currently being evaluated for possible multiple myeloma. IgG multiple myeloma and IgG monoclonal gammopathies are very rare in patients with pyoderma gangrenosum. The skin lesions are improving with the use of prednisone.

Graham-Little-Piccardi-Lassueur syndrome.

Graham-Little-Piccardi-Lassueur syndrome (GLPLS) traditionally describes patients with a triad of a multifocal cicatricial alopecia of the scalp, noncicatricial alopecia of the axillae and groin, and a lichenoid follicular eruption. The entity has caused much controversy with respect to both etiology and clinical definition. We present a patient with lichen planopilaris, lichen planus pigmentosus, and nonscarring alopecia of the genitals, who is reminiscent of GLPLS. Recent work shows evidence for autoimmunity in GLPLS. Further elucidation of underlying mechanisms can improve categorization and treatment options in this rare and controversial syndrome.

Primary cutaneous anaplastic large-cell lymphoma.

Primary cutaneous anaplastic large-cell lymphoma (ALCL) is a form of cutaneous T-cell lymphoma that is characterized by solitary or localized nodules or plaques. Histopathologic features include a diffuse, non-epidermotropic infiltrate with cohesive sheets of large anaplastic CD30+ tumor cells. This entity must be distinguished from systemic ALCL with cutaneous involvement and lymphomatoid papulosis. Treatment modalities include clinical monitoring, radiation therapy, and surgical excision, with systemic chemotherapy reserved for disseminated or extracutaneous disease.

Secondary structure switching in Cro protein evolution.

We report the solution structure of the Cro protein from bacteriophage P22. Comparisons of its sequence and structure to those of lambda Cro strongly suggest an alpha-to-beta secondary structure switching event during Cro evolution. The folds of P22 Cro and lambda Cro share a three alpha helix fragment comprising the N-terminal half of the domain. However, P22 Cro's C terminus folds as two helices, while lambda Cro's folds as a beta hairpin. The all-alpha fold found for P22 Cro appears to be ancestral, since it also occurs in cI proteins, which are anciently duplicated paralogues of Cro. PSI-BLAST and transitive homology analyses strongly suggest that the sequences of P22 Cro and lambda Cro are globally homologous despite encoding different folds. The alpha+beta fold of lambda Cro therefore likely evolved from its all-alpha ancestor by homologous secondary structure switching, rather than by nonhomologous replacement of both sequence and structure.

Antihelminthic therapy and antimony in cutaneous leishmaniasis: a randomized, double-blind, placebo-controlled trial in patients co-infected with helminths and Leishmania braziliensis.

Helminth infections influence the clinical response to certain diseases and are associated with delayed healing time of patients with cutaneous leishmaniasis (CL) caused by Leishmania braziliensis. We conducted a randomized, double-blind, placebo-controlled clinical trial to examine the role of early versus deferred treatment of intestinal helminth infection on the clinical course of patients with CL treated with pentavalent antimony. (Clinicaltrials.gov number NCT00469495). A total of 90 patients were enrolled, 51.1% (N = 23) of control patients had persistent lesions at Day 90, compared with 62.2% (N = 28) in the treatment group (difference 11.1%, 95% confidence interval = -9.1-30.0%). There was no statistically significant difference in overall time to cure between groups, although there was a tendency for shorter cure times in the control group. This study shows that early introduction of antihelminthic therapy does not improve clinical outcome in patients co-infected with helminths and L. braziliensis.

Relationship between sequence determinants of stability for two natural homologous proteins with different folds.

In the Cro protein family, an evolutionary change in secondary structure has converted an alpha-helical fold to a mixture of alpha-helix and beta-sheet. P22 Cro and lambda Cro represent the ancestral all-alpha and descendant alpha+beta folds, respectively. The major structural differences between these proteins are at the C-terminal end of the domain (residues 34-56), where two alpha-helices in P22 Cro align with two beta-strands in lambda Cro. We sought to assess the possibility that smooth evolutionary transitions could have converted the all-alpha structure to the alpha+beta structure through sequences that could adopt both folds. First, we used scanning mutagenesis to identify and compare patterns of key stabilizing residues in the C-terminal regions of both P22 Cro and lambda Cro. These patterns exhibited little similarity to each other, with structurally important residues in the two proteins most often occurring at different sequence positions. Second, "hybrid scanning" studies, involving replacement of each wild-type residue in P22 Cro with the aligned wild-type residue in lambda Cro and vice versa, revealed five or six residues in each protein that strongly destabilized the other. These results suggest that key stability determinants for each Cro fold are quite different and that the P22 Cro sequence strongly favors the all-alpha structure while the lambda Cro sequence strongly favors the alpha+beta structure. Nonetheless, we were able to design a "structurally ambivalent" sequence fragment (SASF1), which corresponded to residues 39-56 and simultaneously incorporated most key stabilizing residues for both P22 Cro and lambda Cro. NMR experiments showed SASF1 to stably fold as a beta-hairpin when incorporated into the lambda Cro sequence but as a pair of alpha-helices when incorporated into P22 Cro.

A trade between similar but nonequivalent intrasubunit and intersubunit contacts in Cro dimer evolution.

The homodimeric lambda Cro protein has a "ball-and-socket" interface that includes insertion of an aromatic side chain, Phe 58, from each subunit into a cavity in the hydrophobic core of the other subunit. This overlap between the subunit core and dimer interface hypothetically explains the strong dimerization and weak monomer stability of lambda Cro in comparison to homologues. According to a model developed here and in a previous study [LeFevre, K. R., and Cordes, M. H. (2003) Proc. Natl. Acad. Sci. U.S.A. 100, 2345-2350], the socket cavity evolved in part by replacement of a buried tryptophan in an ancestral stable monomer with a smaller side chain (Ala 33 in lambda Cro). The resulting core defect was in effect repaired by insertion of a different side chain (Phe 58) from a second subunit, generating the ball and socket. Consistent with such an evolutionary trade between intrasubunit and intersubunit interactions, we showed in the previous study that restoration of the ancestral Trp 33 in lambda Cro stabilized the monomer and reduced the extent of dimerization. Here, we report the solution structure of a stable lambda Cro monomer containing the Ala33Trp mutation, which confirms that the restored tryptophan fulfills its ancestral role as a core side chain, filling part of the socket cavity occupied by Phe 58 in the wild-type dimer. The structure also reveals, however, that the cavity is not completely filled by Trp 33, suggesting that its formation could have involved multiple mutations that reduced side chain volume. We offer suggestive evidence of a role of mutations at a second position.