Superimposed type 2 segmental atopic dermatitis: case series and review of the literature.

Generalized acquired dermatoses can seldom manifest more prominently or exclusively along the lines of Blaschko. Six individuals with segmental atopic dermatitis (AD) have been reported to date. We present three additional cases of segmental cutaneous manifestations superimposed on generalized AD, and review the relevant literature.

The "jigsaw puzzle" advancement flap for reconstruction of a retroauricular surgical defect.

Repairing retroauricular defects is quite challenging. Although direct observation of the repaired defect is not possible, choosing the wrong reconstruction might result in serious deformity of the auricle that will be easily noticed. An 89-year-old man presented with a large basal cell carcinoma tumor on his right retroauricular area adjacent to the mastoid-auricle border. The clinical tumor size was 17 × 17 mm. The tumor was excised in one stage, using the Mohs micrographic surgery technique. The final defect size was 20 × 20 mm. The surgical defect was reconstructed by a "jigsaw puzzle"-like flap.

Fluorescence imaging for the demarcation of basal cell carcinoma tumor borders.

BACKGROUND: Basal cell carcinoma (BCC) is a common malignancy accounting for 80% of all nonmelanoma skin cancers. Mohs micrographic surgery (MMS) is considered superior to alternative treatments, but the procedure is time consuming and costly. Alternative simpler techniques to facilitate accurate tumor demarcation are therefore in demand. Fluorescence imaging following application of 5-aminolevulinic acid is a noninvasive diagnostic technique that gives rapid information about the superficial extent of the skin tumor. OBJECTIVE: To ascertain whether fluorescence imaging improves the clinical tumor border assessment by investigating the consistency between tumor size determination by MMS, clinical assessment, and fluorescence imaging. METHODS: Eighteen patients with histologically verified nodular BCCs on the face scheduled for MMS were included in the study. The night before the surgical procedure, 5-aminolevulinic methyl ester cream was applied to the lesion. The following morning, tumor borders were determined clinically (clinical size), after illumination with Wood's light (fluorescence size), and by the tumor defect left on the skin surface following removal of the MMS specimen (Mohs size). RESULTS: The median tumor sizes were 93.05 mm2 (Mohs size), 61.05 mm2 (clinical size), and 72.75 mm2 (fluorescence size). The interclass correlation coefficients between Mohs size and fluorescence size was 0.984 and Mohs size and clinical size was 0.752. CONCLUSION: Tumor border estimation by fluorescence imaging and clinical assessment underestimate the genuine tumor size determined by MMS; however, the fluorescence size showed a higher degree of consistency with the Mohs size than did the clinical size.

Idiopathic basal cell carcinoma in children.

Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer in humans, and is the most common malignant neoplasm among adults in the US. The peak incidence occurs in the seventh decade of life. Childhood onset of BCC is rare and usually associated with genetic disorders such as basal cell nevus syndrome, Bazex syndrome, albinism, and xeroderma pigmentosum or due to radiation therapy. Idiopathic childhood onset is less common. A girl with idiopathic onset of BCC who was treated with Mohs micrographic surgery is reported. A computerized review of the literature was performed. A total of 108 children including this patient were reported with idiopathic de novo BCC. Most of the tumors were nodular and located on the head, the same as in adults. Basal cell carcinoma in children is probably the result of genetic background and intense ultraviolet radiation exposure. The preferred treatment is excision with the Mohs micrographic technique.

Prevalence of Candida on the tongue and intertriginous areas of psoriatic and atopic dermatitis patients.

Data in the literature regarding the prevalence of Candida in psoriatic and atopic dermatitis patients are controversial. We conducted a prospective study to determine the prevalence of Candida on the tongue, axillae and groin of psoriatic patients when compared with atopic dermatitis patients and normal controls. During the period 2003-2005, data were collected from 100 psoriatic patients, 100 patients with atopic dermatitis and 100 normal controls. Fungal test specimens for Candida were collected from the axillae, groin and tongue of each patient. There was no increase in the prevalence of Candida in intertriginous area of either psoriatic or atopic dermatitis patients. However, the prevalence of Candida on the tongue was significantly higher in psoriatic patients (32%) compared with atopic dermatitis (18%) (P = 0.024) and higher, although not significantly, than in normal controls (21%) (P = 0.08). Our study did not reveal higher prevalence of Candida in the axillae and groin of either psoriatic or atopic dermatitis patients. There was a higher prevalence of Candida on the tongue of psoriatic patients. The Candida of the tongue was asymptomatic and did not correlate with age, gender, type of psoriasis or severity of the disease, therefore we conclude that this is clinically irrelevant.

Ultraviolet A-1 as a treatment for ulcerative lichen planus of the feet.

Ulcerative lichen planus of the feet is a rare variant of lichen planus characterized by the constellation of a chronic bullous and ulcerative eruption limited to the feet, atrophy of involved skin and nails, and cicatricial alopecia. Only split-thickness skin grafting has here to been documented to be effective. We here report a case with ulcerative lichen planus of the feet successfully treated with medium-dose ultraviolet A-1.

Plantar verrucous carcinoma treated with Mohs micrographic surgery: a case report and literature review.

BACKGROUND: Verrucous carcinoma of the foot is a slow-growing tumor that is capable of causing vast local destruction. It is a rare tumor and is frequently misdiagnosed as a plantar wart. OBJECTIVE: To describe a patient with verrucous carcinoma of the foot treated by Mohs micrographic surgery and give a review of the literature. RESULTS: A 43-year-old male with plantar verrucous carcinoma was successfully treated with Mohs micrographic surgery. CONCLUSION: Early diagnosis of verrucous carcinoma of the foot and treatment with Mohs micrographic surgery may prevent amputation of the foot.

Controversies in perioperative management of blood thinners in dermatologic surgery: continue or discontinue?

BACKGROUND: The use of blood thinners has increased dramatically in recent years among the general, and especially among the elderly, population. When these patients need to undergo cutaneous surgery, the surgeon encounters the obvious problem of whether to stop these medications before surgery. OBJECTIVE: The objective was to evaluate the risks and benefits associated with the continuation of blood thinners perioperatively in cutaneous and Mohs micrographic surgery. METHODS: The study comprises two parts: a search of the literature in English that examined articles that related to the perioperative use of blood thinners in dermatologic surgery and a presentation of data of continuous warfarin therapy in patients who underwent Mohs surgery in our practice. RESULTS: A total of 15 articles were published in the literature until October 2003. One article showed an increase in complications in patients treated with warfarin, but not with aspirin. All other articles showed no increase in complications during the perioperative period. Data from our practice showed that of a total of 2790 patients, 68 were operated on while taking warfarin (2.4%). Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients. CONCLUSION: Continuous treatment with blood thinners perioperatively in patients undergoing Mohs and cutaneous surgery is not associated with an increase in surgical complications. Discontinuation of these medications may increase the risk of cerebral and cardiovascular complications.

Residual skin cancer after preoperative biopsy: evaluation by Mohs micrographic surgery.

BACKGROUND: Some patients are referred for Mohs surgery with no or minimal clinical evidence of skin cancer at the biopsy site. OBJECTIVE: To determine the incidence of residual skin cancer at biopsy sites during Mohs micrographic surgery. METHODS: We evaluated all patients that underwent Mohs surgery for basal cell and squamous cell carcinomata in one year. The study was carried out prospectively. Debulking was done using a no. 15 blade at the clinical borders of the tumor or biopsy site. All specimens were sectioned at the middle and cut to the periphery at 20- microm intervals. RESULTS: Seven hundred and forty-one patients underwent operations. In 390 patients, a biopsy was performed prior to surgery. A total of 351 patients were biopsied as prestaged (chemocheck) during surgery. Ninety-nine (25%) of the preoperatively biopsied patients showed no residual tumor in the debulking specimen or the first layer. Of these 99 patients, 84 had basal cell carcinoma and 15 had superficial or in situ squamous carcinoma. CONCLUSIONS: In this study, preoperative biopsy for diagnosis of skin cancer of the face was curative in 25% of patients, despite pathologic diagnosis of incompletely excised tumor. However, as the majority of preoperatively biopsied patients showed residual tumor, Mohs micrographic surgery is indicated in all patients with incomplete removal of skin cancer of the head and neck.

Late-onset granulomatous reaction to Artecoll.

BACKGROUND: Artecoll is permanent filler that is used for the correction of facial wrinkles. It has been used mainly in Europe in the last 9 years. It is a suspension of 25% polymethylmethacrylate microspheres of 30 to 40 microns in diameter and 75% athecollagen. OBJECTIVE: To report a side effect of a late-onset granulomatous reaction to Artecoll. METHODS: We report the case of a 54-year-old woman who presented with longitudinal hard nodules with slight overlying erythema in the glabella and nasolabial folds 14 months after she was treated with Artecoll injections to her glabellar and nasolabial wrinkles. An excisional biopsy of a glabellar nodule was performed. RESULTS: Microscopic examination of hematoxylin and eosin-stained specimen revealed histiocytic granulomas with giant cells and vacuoles, a picture of Artecoll granulomas. Treatment with topical steroids showed no improvement. Intralesional injections of Kenalog caused temporary disappearance of the granulomas. A few months later the nodules reappeared. No further treatment was done. CONCLUSION: Artecoll injection to wrinkles of the face can cause delayed granulomatous reaction. This side effect is not reversible and should be addressed in the informed consent.