Rhombic Flap: A Useful Flap for Small-to-Medium Defects of the Medial Canthus.

BACKGROUND: Medial canthal defects are frequently encountered yet present specific challenges for the reconstructive surgeon. Surgical repair in this area may inadvertently lead to canthal webbing, ectropion, and/or epiphora. The rhombic flap is a versatile workhorse in the reconstructive armamentarium for canthal defects. OBJECTIVE: To describe the use of the inferiorly based rhombic flap for reconstructing defects on the medial canthus. METHODS: A retrospective analysis of the Mohs micrographic surgery cases was performed. All cases in which an inferiorly based rhombic flap was used for canthal reconstruction between 2012 and 2017 were identified. Defect size, location, and any postoperative complications were noted. Surgical scars were scored using the Vancouver Scar Scale. RESULTS: There were 34 cases (17 men and 17 women). Age ranged from 38 to 86 (mean 69). Defect size varied from 0.6 to 2.1 cm in diameter. Postoperative complications were uncommon and minor. CONCLUSION: The rhombic flap is a versatile and useful option for reconstructing surgical defects of the medial canthus.

The Effects of Primary Defect Characteristics on Reconstruction Type and Adjunctive Intervention in Mohs Micrographic Surgery: A Retrospective Review.

BACKGROUND: Cosmetic concerns following Mohs Micrographic surgery (MMS) are significant and may require adjunctive treatments for unsatisfactory appearance. OBJECTIVE: To determine factors associated with adjunctive cosmetic intervention for facial defects following MMS. METHODS AND MATERIALS: A retrospective review of 699 patients undergoing repair of facial defects after MMS from 2008-2018 was performed. Tumor types, defect sizes, patient demographics, repair methods, complications, and post-operative cosmetic interventions were examined. RESULTS: 666 Mohs cases and resultant defects were analyzed. The most common method of repair following MMS was primary closure (52.3%), and the most common post-operative intervention was steroid injection (18.3%). The lip subunit was more than twice as likely as other locations to be treated with steroid injections (P<.001). The lip subunit also had the highest frequency of scar revision (13%; P<0.001). Patients who had primary closure were less likely to require scar revision (P=0.003) or dermabrasion (P=0.042), and there was no significant association between skin graft repair and cosmetic intervention. CONCLUSIONS: Both defect subunit and closure type were independently associated with adjunctive cosmetic intervention following MMS. Defect size was not significantly associated with an adjunctive intervention in our study. Understanding the factors affecting the need for adjunctive cosmetic interventions may improve patient counseling prior to Mohs repair. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4701.

Stoma care products represent a common and previously underreported source of peristomal contact dermatitis.

BACKGROUND: Peristomal dermatitis is a common complication for the >700 000 patients in the United States with an ostomy. The role of stoma skin care products in peristomal dermatitis is poorly understood. OBJECTIVE: To evaluate stoma skin care products as a cause of peristomal dermatitis. METHODS: A retrospective chart review of patients with peristomal dermatitis at four academic hospitals from January 2010 to March 2014 was performed. Patient demographics, clinical information and use test and patch test results were documented. RESULTS: Eighteen patients identified as having peristomal dermatitis were tested. Twelve of these had peristomal contact dermatitis. We identified numerous stoma skin care products as triggers of irritant and/or allergic contact dermatitis. The most common stoma skin care product used and/or involved in dermatitis was Cavilon™ No Sting Barrier Film. CONCLUSIONS: Our data support a paradigm shift whereby healthcare workers treating patients with peristomal dermatitis, which is currently considered to be a reaction mainly to bodily fluids, must consider those products used to protect the skin as potential triggers for this disease. Therefore, patients with peristomal dermatitis should be tested with their stoma skin care agents to determine the need for removal or change of these products. Additionally, full ingredient labelling by manufacturers would help identify new allergens and irritants.

Squamomelanocytic tumor: a case report and further insights into its possible histogenesis.

We report a case of combined squamomelanocytic tumor of the skin. Clinically, the lesion was felt to be a squamous cell carcinoma. Histologically, it was characterized by large epithelioid cells admixed with basaloid cells with central squamous differentiation. Immunohistochemical staining showed both cell populations to be reactive with Melan A, BEREP4, and Pan Keratins. Ultrastructural studies revealed simultaneous features of squamous differentiation (dense cytoplasmic tonofilaments with well-developed desmosomes) and melanocytic differentiation (mature/pigmented melanosomes) in the same cell population. This is the second reported case in the English literature with documented biphenotypic or divergent differentiation at the ultrastructural level. The behavior of squamomelanocytic tumor is uncertain given the rarity of reported cases.

Dermatitis linearis: vesicating dermatosis caused by paederus species (coleoptera: staphylinidae). Case series and review.

OBJECTIVE: Outbreaks of dermatitis linearis have been documented worldwide. We present a case series of dermatitis linearis from Latin America to highlight the importance of this clinical entity. Clinical, historical, epidemiological, and pathological aspects of the condition are discussed, and a concise current approach to the management and treatment of this morbidity is presented. METHODS: We present a series of 4 selected cases reflecting the clinical spectrum exhibited in dermatitis linearis by Paederus along with a review of the literature. RESULTS: In this review we demonstrate the need for awareness of dermatitis linearis as a clinical entity that must be considered in the broad list of differential diagnosis embracing vesicating linear lesions. CONCLUSIONS: Capture of the insect, epidemiologic features, and a high clinical suspicion can aid in making the correct diagnosis. Primary prevention through public awareness, decreased use of artificial lighting, and mosquito nets can limit the extent and severity of outbreaks.

Subungual Hematoma with Feline Resemblance.

A 54-year-old woman was found to have an incidental pigmented lesion on her right thumbnail. Interestingly, this lesion was in the shape of a cat and she also had a cat tattoo. We briefly review how coincidences have been known to occur in dermatology. We also highlight how dermoscopy can aid in differentiating pigmented lesions from trauma-induced changes.

Papulonodular Secondary Syphilis Presenting as Multiple Distinct Cutaneous Lesions in an HIV-Positive Transgender Woman.

We present the first reported case of papulonodular secondary syphilis in an HIV-positive transgender female. Syphilis is classified into primary, secondary, latent, and tertiary stages, with secondary syphilis having notably diverse cutaneous manifestations. Our patient presented with diverse lesions throughout her body, all pathologically consistent with papulonodular secondary syphilis. Proper identification of the multiple presentations of syphilis is crucial to early diagnosis and treatment. This report seeks to broaden the scope of dermatological manifestations that arise secondary to papulonodular syphilis in HIV-positive patients.

Long-term safety of ustekinumab for psoriasis.

INTRODUCTION: The biologic, Ustekinumab (Stelara®, Centocor, Inc., Malvern, PA, USA), is a fully human monoclonal antibody with a high affinity for the shared p40 subunit of interleukins 12 and 23 (IL-12 and IL-23). Approved for use in treating moderate-to-severe psoriasis in 2009, there has been considerable interest in the long-term safety of ustekinumab. AREAS COVERED: This review discusses the use of ustekinumab in the treatment of psoriasis and its potential to be an effective and well-tolerated therapy. A literature search was performed for articles published through April 2013 to identify any safety concerns. EXPERT OPINION: Our results indicate that ustekinumab has demonstrated higher efficacy rates as compared to traditional therapies; and with a favorable dosing schedule and stable safety profile, patients with recalcitrant disease will now have another option for treatment.

Contact allergy to sorbitans: a follow-up study.

BACKGROUND: Sorbitan sesquioleate (SSO), an emulsifier in many corticosteroids, was previously found positive in 8.9% of 112 dermatitis patients. OBJECTIVE: The objective of this study was to present data on 24 of 591 dermatitis patients with reactions to SSO and/or sorbitan monooleate (SMO) on patch testing. METHODS: A retrospective chart review was conducted on 591 consecutive dermatitis patients patch tested from November 2008 to May 2010. In addition to being tested to a modified North American Contact Dermatitis Group standard series, all patients were tested to a cosmetic series. RESULTS: Of the 591 patients tested, 24 reacted to SSO and/or SMO (4.1%), 19 (3.2%) reacted to SSO alone, 1 (0.17%) to SMO alone, and 4 (0.68%) reacted to both. Of the 24 sorbitan-allergic patients, 2 (8.3%) reacted to any of 4 corticosteroid screening chemicals tested. CONCLUSIONS: In this follow-up study, 4.1% of 591 dermatitis patients reacted to SSO and/or SMO. Given the presence of SSO in many popular topical corticosteroid formulations, clinicians should consider allergy to sorbitans when patients do not improve with topical corticosteroid therapy.

Monitoring universal protocol compliance through real-time clandestine observation by medical students results in performance improvement.

OBJECTIVE: To measure universal protocol compliance through real-time, clandestine observation by medical students compared with chart audit reviews, and to enable medical students the opportunity to become conscious of the importance of medical errors and safety initiatives. DESIGN: With endorsement from Tufts Medical Center's (TMC's) Chief Medical Officer and Surgeon-in-Chief, 8 medical students performed clandestine observation audits of 98 cases from April to August 2009. A compliance checklist was based on TMC's presurgical checklist. Our initial results led to interventions to improve our universal protocol procedures, including modifications to the operating room white board and presurgical checklist, and specific feedback to surgical departments. One year later, 6 medical students performed observations of 100 cases from June to August 2010. SETTING: Tufts Medical Center, Boston, Massachusetts, which is an academic medical center and the principal teaching hospital for Tufts University School of Medicine. PARTICIPANTS: An operating room coordinator placed the medical students into 1 of our 25 operating rooms with students entering under the premise of observing the anesthesiologist for clinical education. The observations were performed Monday to Friday between 7 am and 4 pm. Although observations were not randomized, no single service or type of surgery was targeted for observation. RESULTS: A broad range of departments was observed. In 8.2% of cases, the surgical site was unmarked. A Time Out occurred in 89.7% of cases. The entire surgical team was attentive during the time out in 82% of cases. The presurgical checklist was incomplete before incision in 13 cases. Images were displayed in 82% of cases. The operating room "white board" was filled out completely in 49% of cases. Team introductions occurred in 13 cases. One year later, compliance increased in all Universal Protocol dimensions. CONCLUSIONS: Direct, real-time observation by medical students provides an accurate and granular assessment of compliance with specific components of the universal protocol and engages medical students in the quality improvement process, raises their awareness of the gravity of medical errors, and ensures appreciation of the importance of quality and safety initiatives.