Rhinophyma: A Treatment Review.

BACKGROUND: Rhinophyma is the overgrowth of sebaceous glands in nasal tissue and its etiology unclear. Without treatment, rhinophyma can be progressive and cause concern both with respect to function and cosmesis. OBJECTIVE: The objective of this work is to describe treatment options for rhinophyma and their respective risks and benefits. MATERIALS AND METHODS: A PubMed search was performed to include the terms "rhinophyma" and "treatment." RESULTS: Numerous physically destructive modalities exist for treatment of rhinophyma, falling primarily into 3 categories: mechanical destruction, directed electrical energy/radiofrequency, and directed laser energy. CONCLUSION: There are multiple treatment modalities available to dermatologists for the treatment of rhinophyma. To the best of our knowledge, there are no randomized, prospective, control studies for any treatment, which makes it difficult to recommend a single treatment over another. Nonetheless, it is important to recognize that scarring and hypopigmentation most often occur on or near the nasal ala. Moreover, risks may increase if tissue destruction extends to the papillary dermis or pilosebaceous units are ablated.

Asymptomatic petechial eruption on the lower legs.

The authors report an unusual case of Rocky Mountain spotted fever that presented as an asymptomatic petechial eruption on the lower legs. Rocky Mountain spotted fever is rare in New England and, as such, is typically not on the differential diagnosis when presented with such patients. What began as an asymptomatic eruption progressed to more classic signs of the disease, including a positive Rocky Mountain spotted fever titer. The patient was successfully treated with doxycydine and within a short period of time, was completely back at baseline.

Low-grade myxofibrosarcoma presenting at the site of prior high-grade disease.

Myxofibrosarcoma is one of the most common soft tissue sarcomas occurring in older adults. It can arise de novo or can be radiation induced, and the term myxofibrosarcoma was originally devised to encompass a spectrum of myxoid tumors with characteristics similar to malignant fibrous histiocytoma (MFH). Confusion exists, however, regarding the distinction between microscopic grade and characteristics of myxofibrosarcoma and MFH. Correct classification is vital to prognosis, as the degree of myxoid change is inversely related to the incidence of metastasis. We present a case of a 76-year-old man with a history of high-grade MFH of the left lower extremity, status post excision and radiation therapy, who presented 2 years later with a regional metastatic recurrence of high-grade MFH to the left groin as well as new nodules adjacent to and within his prior excision and radiation site. These new nodules were determined to represent low-grade myxofibrosarcoma. These new low-grade lesions either represent a low-grade recurrence of high-grade sarcoma or a new, radiation-induced soft tissue sarcoma occurring at the same site. Radiotherapy, however, is an unlikely cause; specific postradiation sarcoma criteria have not been fulfilled. This article discusses both the nosology and histopathological spectrum of these important soft tissue sarcomas, their aggressive and recurrent nature and their association with radiation therapy.

A direct comparison of visual inspection, curettage, and epiluminescence microscopy in determining tumor extent before the initial margins are determined for Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is a tissue-sparing technique for the removal of cutaneous malignancies. There is no standardized procedure for determining tumor extent before taking the initial margins during the first stage of Mohs. OBJECTIVE: To compare visual inspection, curettage, and dermoscopy in determining tumor extent before initial margins are taken for MMS. METHODS: Fifty-four patients were randomized into three groups (visual inspection, curettage, or dermoscopy) before MMS for basal cell carcinomas on the nose. One of these three methods was used to delineate the biopsy site or residual tumor. The final number of stages and postoperative defect sizes were recorded. RESULTS: There was no statistically significant differences for the final number of stages (p=.20) or the final defect sizes (p=.47) between the three arms. CONCLUSION: There has been controversy as to whether presurgical curettage is appropriate before MMS. Some feel that curettage better delineates the tumor, leading to fewer stages, whereas others feel that curettage may falsely increase the final defect size, negating any tissue-sparing advantages of the procedure. Our study did not demonstrate any differences in the final number of stages or postoperative defect sizes between the three test groups.

Do pulsed lasers produce an effective photodynamic therapy response?

BACKGROUND: Photodynamic therapy (PDT) in dermatology is traditionally performed with topical aminolevulinic acid (ALA) and continuous-wave (CW) illumination with blue or red light. Recently, several authors have reported success with laser and other pulsed-light sources for PDT. While the clinical benefits on sun-exposed skin are apparent, no study has demonstrated that the pulsed light sources are responsible for the observed response. STUDY DESIGN: A placebo-controlled study of two pulsed light sources previously reported for PDT: the pulsed dye laser (PDL) or broadband flashlamp filtered intense pulsed light (IPL). Sun-hidden skin was prepared with microdermabrasion and acetone scrub followed by ALA under occlusion. Laser or IPL was delivered under conditions previously reported to produce a clinical response. Control areas were exposed to standardized CW blue light or to no light. A second control area was prepared and received light and the ALA vehicle. RESULTS: IPL and PDL demonstrated a faint dose-response effect on PDT activation, but were less potent than a smaller fluence of CW blue light. Ambient light activated ALA-treated skin. CONCLUSION: Both IPL and PDL are capable of activation of PDT but produce dramatically less PDT reaction than the standard CW blue-light broadband source. Physicians desiring a robust PDT response might select CW sources over pulsed sources. Ambient light may activate a PDT reaction.

Massive exophytic abscesses and fibrotic masses of the chin: a variant of the follicular occlusion triad.

We present a patient with an extensive cluster of exophytic nodules that developed on his chin. These nodules consisted of abscesses and fibrotic areas. Lesion morphology, histology, and microbiology support a follicular occlusion triad entity. However, the distribution is striking and does not fit the entities described in the triad. We present the case to show that follicular occlusion was the inciting factor in our patient's eruption and to broaden our concept of clinical manifestations that can arise from this pathologic process.

Excision of head and neck basal cell carcinoma with a rapid, cross-sectional, frozen-section technique.

OBJECTIVES: To compare a rapid, cross-sectional frozen-section technique with Mohs micrographic surgery, using recurrence rate and cost of treatment for excision of basal cell carcinoma as indicators to validate our indications for Mohs surgery. DESIGN: Retrospective study of 557 head and neck basal cell carcinomas excised over 10 years. MAIN OUTCOME MEASURES: Recurrence rates; tumor comparisons by size, location, and subtype; a life table, and a patient satisfaction survey. RESULTS: Recurrence rate for the cross-sectional technique was 2.1% at 5 years. Recurrent tumors had an average diameter of 1.56 cm (vs 1.04 cm for nonrecurrent tumors). Recurrences were in the cheek (30%), nose (20%), temple (20%), forehead/brow (10%), conchal bowl (10%), and postauricular crease (10%). Recurrences were nodular cystic (40%), micronodular (20%), multifocal (10%), and infiltrating (30%). A total of 86.6% of patients surveyed rated the aesthetic outcome of their surgery favorably. The cost compared with the cost of Mohs excision varied depending on the Current Procedural Terminology coding technique. CONCLUSIONS: Cross-sectional frozen-section recurrence rates can compare favorably with Mohs micrographic surgery. The cross-sectional frozen-section technique generated a cost savings over Mohs surgery that may not hold true for all practice settings. Margin size did not adversely affect aesthetic results. Loupe magnification x2.5 is important in our technique. We also offer a useful definition for recurrence.