Nasal tip rotation flap for reconstruction of surgical defects on the distal nose.

BACKGROUND: The nose is a common site for the development of skin cancers. Mohs micrographic surgery (MMS) is a highly curative treatment for skin cancer of the nose. Reconstruction of MMS defects on the nose, especially on the distal aspect, can be challenging given the proximity of multiple subunits and limited adjacent tissue reservoirs. Our goal was to describe our experience using a nasal tip rotation flap (NTRF) for MMS defects on the distal nose. METHODS: A retrospective review of all MMS cases at multiple institutions between June 2018 and June 2022 was undertaken. Cases that used an NTRF to repair the MMS defect(s) were selected, and data were collected on patient demographics, tumor type, anatomical location of the tumor, preoperative and postoperative size, number of stages needed to clear the tumor, repair dimensions, and any postoperative complications. RESULTS: A total of 66 cases that utilized an NTRF for reconstruction were included. The mean preoperative tumor size was 0.8 cm (range: 0.3-1.6 cm), and the mean defect size was 1.2 cm (range: 0.7-1.9 cm). The defects were most commonly on the nasal tip. There were no significant complications observed. CONCLUSIONS: The nasal tip rotation flap is a reliable reconstruction option for MMS defects of the distal nose. This flap can be used for defects that involve the nasal tip, soft triangle, and/or portions of the ala, including the alar rim.

Pernio (Chilblains), SARS-CoV-2, and COVID Toes Unified Through Cutaneous and Systemic Mechanisms.

Pernio or chilblains is characterized by erythema and swelling at acral sites (eg, toes and fingers), typically triggered by cold exposure. Clinical and histopathologic features of pernio are well described, but the pathogenesis is not entirely understood; vasospasm and a type I interferon (IFN-I) immune response are likely involved. During the coronavirus disease 2019 (COVID-19) pandemic, dermatologists have observed an increase in pernio-like acral eruptions. Direct causality of pernio due to COVID-19 has not been established in many cases because of inconsistent testing methods (often negative results) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, a form of COVID-19‒associated pernio (also called COVID toes) is probable because of increased occurrence, frequently in young patients with no cold exposure or a history of pernio, and reports of skin biopsies with positive SARS-CoV-2 immunohistochemistry. PubMed was searched between January 1, 2020, and December 31, 2020 for publications using the following keywords: pernio, chilblain, and acral COVID-19. On the basis of our review of the published literature, we speculate that several unifying cutaneous and systemic mechanisms may explain COVID-19‒associated pernio: (1) SARS-CoV-2 cell infection occurs through the cellular receptor angiotensin-converting enzyme 2 mediated by transmembrane protease serine 2, subsequently affecting the renin-angiotensin-aldosterone system with an increase in the vasoconstricting, pro-inflammatory, and prothrombotic angiotensin II pathway. (2) Severe acute respiratory syndrome coronavirus 2 cell infection triggers an immune response with robust IFN-I release in patients predisposed to COVID-19‒associated pernio. (3) Age and sex discrepancies correlated with COVID-19 severity and manifestations, including pernio as a sign of mild disease, are likely explained by age-related immune and vascular differences influenced by sex hormones and genetics, which affect susceptibility to viral cellular infection, the renin-angiotensin-aldosterone system balance, and the IFN-I response.

Conservative thickness layers in Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is used to treat cutaneous malignancies in locations to maximize tissue sparing. The authors' aim is to demonstrate the utility of conservative thickness layers (CTL) in MMS and review patient and tumor characteristics and the potential anatomic locations where this technique may be most useful. METHODS: We performed a retrospective chart review of patients with tumors treated with CTL in MMS of 339 tumors, recording patient demographics, tumor characteristics, MMS stages for clearance, repairs, complications, and follow-up. RESULTS: A total of 339 tumors were treated with CTL. The most common site was the leg (28.6%), with 77.4% of these being female. The next most common sites were nose (24.5%), scalp (13.9%), and back (11.5%). Most tumors were cleared with one layer (269), but some required two layers (42), three layers (11), and four layers (1). A total of 264 tumors were left to granulate, while 75 of the nasal tumors had immediate dermabrasion. CONCLUSION: In the properly selected patient and anatomic location, CTL taken as the first stage in MMS can be an effective and time-saving technique, leaving wounds in optimal condition for granulation with a low complication rate. Tissue sparing may allow for more reconstructive options.

Pediatric Pyoderma Gangrenosum: A Retrospective Review of Clinical Features, Etiologic Associations, and Treatment.

BACKGROUND/OBJECTIVES: Pyoderma gangrenosum (PG) is a neutrophilic dermatosis rarely seen in children. Its features have not been well characterized in children. We sought to characterize the clinical features, etiologic associations, and treatment of PG in children younger than 18 years. METHODS: We performed a retrospective review of children younger than 18 years with PG at the Mayo Clinic from January 1976 to August 2013. RESULTS: Thirteen children with PG were identified (n = 8; 62% female). All had ulcerations, with 62% having pustular lesions. Sites of involvement included the trunk (77%), lower extremities (77%), upper extremities (38%), and head and neck (38%). Nine (69%) had an underlying comorbidity, including seven with Crohn's disease (54%), one with juvenile idiopathic arthritis (8%), and one with pyogenic arthritis, pyoderma gangrenosum, and acne syndrome (8%). Treatments included topical or local care (92%) and systemic therapies (85%) such as oral corticosteroids (62%) and sulfasalazine or related 5-aminosalicylate drugs (46%). The clinical course did not correlate with that of the underlying systemic disease and response to treatment varied. CONCLUSION: Pediatric PG has a more varied anatomic distribution and a greater predominance of pustular lesions than PG in adults and a strong association with inflammatory bowel disease.

Vasospasm Is a Consistent Finding in Pernio (Chilblains) and a Possible Clue to Pathogenesis.

BACKGROUND/AIMS: Pernio (chilblains) is an inflammatory condition classically characterized by localized erythema and swelling of acral sites upon exposure to cool and damp conditions. We sought to determine whether cold-induced vasospasm has a role in the development of pernio. METHODS: We retrospectively reviewed 5 patients with pernio who were seen at our institution between January 1, 2000 and December 31, 2011, and had undergone a noninvasive arterial vascular study of the upper extremities that corresponded to a site of clinical involvement of pernio and who had also undergone vasospastic testing and ice water immersion as part of the noninvasive arterial vascular study protocol. RESULTS: Vascular testing in all patients (mean age 37.8 years; 4 women) demonstrated vasospasm with ice water immersion. CONCLUSION: Our findings suggest that vasospasm likely has a role in the pathophysiology of pernio and may also provide a rationale for the pharmacological treatment of vasospasm in patients with pernio.

Clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of 104 patients at Mayo Clinic, 2000 to 2011.

OBJECTIVE: To further characterize the clinical features, etiologic associations, laboratory findings, and treatment of pernio. PATIENTS AND METHODS: This is a retrospective review of patients with pernio seen at our institution between January 1, 2000, and December 31, 2011. RESULTS: Of 104 patients with pernio (mean age at diagnosis, 38.3 years), 82 (79%) were women. Pernio affected the toes in 85 patients (82%) and the fingers in 31 (30%). Thirty-eight patients (37%) had at least 1 abnormal laboratory test result, and test results were positive for cold agglutinins in 11 (55%) of 20 tested patients. Results were negative for cryoglobulins in all tested patients (n=53). Four patients (4%) had connective tissue disease (nonlupus) associated with pernio; 3 patients (3%) had an associated hematologic malignant disease. Conservative treatments (eg, warming, drying, and smoking cessation) provided complete response in 23 (82%) of 28 patients with follow-up data. CONCLUSION: To our knowledge, this study represents one of the largest single-center case series of pernio to date. Most of the patients did not have an underlying systemic association with pernio, although a few patients had pernio in association with connective tissue disease or hematologic malignant disease.