Perioperative management of and recommendations for antithrombotic medications in dermatological surgery.

With the ever-increasing number of patients on anticoagulant or antiplatelet medications presenting for a dermatological surgical procedure, dermatological surgeons are facing the challenge of managing these drugs in order to balance the bleeding complications against the risk of thromboembolic events. The difficulty arises from the scarce available recommendations, the data in the literature that is in part contradictory and the rate of emergence of newer agents that have not been thoroughly studied and widely used. Although the common approach in the past was to stop any antithrombotic medications, including warfarin and aspirin, several days prior to cutaneous surgery, recent data suggest that this practice should be changed as the relatively low risk of bleeding does not justify the life-threatening nature of a likely thrombosis. For patients on warfarin, surgery should be avoided if the international normalized ratio is > 3·5; aspirin should not be stopped prior to dermatological surgery and in most other circumstances patients taking long-term antithrombotic medication should not stop this prior to dermatological surgery. In more complicated cases liaison with the prescriber is indispensable even when the therapy should be discontinued for a short period of time. This review studies the available data and presents the dermatological surgeon with up-to-date information about all studies concerning the old and new antithrombotic agents in the setting of dermatological surgery procedures. Our aim is to propose our recommendations based on the most recent evidence and our experience and provide a comprehensive approach to the dermatological surgeon without excluding the need for individual assessment of each case.

Metastatic Crohn's disease: a review.

Metastatic Crohn's disease (MCD) indicates the presence of non-caseating granuloma of the skin at sites separated from the gastrointestinal tract by normal tissue and is the least common dermatologic manifestation of CD. In adults, MCD usually appears after the initial diagnosis of CD in 70% of cases, whereas in children, it appears at the same time as CD in almost half of the cases. The most frequent skin lesions in adults are nodules, plaques with or without ulceration on the extremities and ulcers on the genitals. In children, genital swelling with or without erythema is the most frequent presentation of MCD. Simultaneous presence of perianal CD affects more females (60%) and particularly children. Associated gastrointestinal symptoms are present in one third of the cases in adults and in half of the cases in children. Treatment is often unsatisfactory. Randomised controlled trials are lacking. Various chemotherapeutic agents have been used such as oral metronidazole, topical and/or oral steroids, azathioprine, cyclosporine, sulfasalazine, tetracyclines, topical or systemic tacrolimus, infliximab alone or with methotrexate, and surgical treatment with oral zinc sulphate. MCD represents another 'great imitator'. This reviews the most relevant characteristics of this disease, in order to increase awareness and to avoid delay in diagnosis and improve management of the whole CD complex.

The usefulness of a diagnostic biopsy clinic in a genitourinary medicine setting: recent experience and a review of the literature.

Genital diseases include a wide range of lesions e.g. infectious and inflammatory. In most cases a clinical diagnosis is reached without the need for a biopsy. Nonetheless, a genital biopsy is safe and may help to confirm the diagnosis. We established a dedicated diagnostic biopsy clinic in 2003. Our objective was to evaluate the effectiveness of our diagnostic biopsy clinic and compare it with other Genitourinary medicine (GUM) clinics in the UK. A retrospective case-note study was performed on 71 patients referred to the biopsy clinic with persistent genital lesions over a 12-month period. Forty-seven biopsies were performed (71% biopsy rate). 43 specimens (92%) were appropriate for histopathological diagnosis. Of these 15% were lichen planus, 15% lichen sclerosis, 10% psoriasis, 7.5% each: eczema, Zoon's and non-specific balanitis. The remainder represented a variety of other conditions. In 27 cases (68%) the clinical diagnosis was consistent with the histological result. The possibility of self-referral and walk-in nature of our GUM service substantially decrease the waiting times for assessment of anogenital disorders. We had a lower biopsy rate for the diagnosis of non-specific balanitis (7.5%) compared with the average rate (21.5%) in 14 UK GUM clinics and good agreement between clinical and histological diagnosis. An empirical first treatment, with simple emollients before biopsy, appears to be a safe clinical approach for the treatment of non-specific balanitis. A multidisciplinary approach (GUM physicians, dermatologists and urologists/gynaecologists) could help prevent unnecessary biopsies and improve correlation between clinical and histological diagnosis.

Photoaggravated pityriasis rubra pilaris.

Pityriasis rubra pilaris (PRP) is a rare papulosquamous condition with an estimated incidence of one in 35,000 to one in 50,000. Psoralen and ultraviolet A (UVA) therapy has been used in its treatment but some patients are reported to be clinically photosensitive. We describe the photoinvestigation of a patient with PRP in whom sensitivity to broadband UVA was demonstrated.