High-risk squamous cell carcinoma and its impact on a 62-year-old male surgeon.

Cutaneous squamous cell carcinoma (cSCC) is a form of non-melanoma skin cancer responsible for more deaths in the USA than all other skin cancers combined. Some features, including anatomic site, are considered high risk in nature and pose a challenge for complete tumour removal. We present a case of a 62-year-old male surgeon with a multiply recurrent cSCC of the right conchal bowl. The tumour described herein was doubly recurrent to excision with a standard margin and could ultimately not be cleared with Mohs micrographic surgery. Ultimately, it necessitated auriculectomy and parotidectomy. This case exemplifies the pitfalls of traditional wide local excision with standard pathologic processing for high-risk cSCC.

Highlights of Skin Disease Education Foundations 42nd Annual Hawaii Dermatology Seminar.

Updates on managing some of the most common dermatologic conditions for which patients seek care illuminated presentations at the Skin Disease Education Foundation's 42nd Annual Hawaii Dermatology Seminar®. This educational supplement summarizes the highlights of clinical sessions presented during this CME/CE conference. Treatment of psoriasis has continued to advance, with three interleukin (IL)-17 antagonists approved by the US Food and Drug Administration (FDA) and a fourth in phase 3 trials. An authority on the use of biologics in psoriasis presents current data on the safety and efficacy of these therapies. Tumor necrosis factor (TNF) inhibitors also retain a place in the management of psoriasis, with records of long-term safety. A fourth TNF inhibitor awaits FDA approval for use in psoriasis, offering data on transmission during pregnancy and lactation. An expert on the use of this drug class presents the evidence. Topical therapies remain the cornerstone of care for many patients with psoriasis as well as those with rosacea. Our faculty update readers about new and investigational topical therapies for moderate or severe psoriasis, as well as for acne and rosacea. The current literature on monitoring patients receiving isotretinoin also is summarized. Aesthetic and cosmetic dermatology services form a sizable portion of some practices. Our faculty review data on safety of topical and procedural therapies for cellulite as well as safe injection of facial fillers.

Amelanotic melanoma: a unique case study and review of the literature.

Amelanotic melanoma (AM) is a rare form of melanoma which lacks visible pigment. Due to the achromic manifestation of this atypical cutaneous malignancy, it has been difficult to establish clinical criteria for diagnosis. Thus, AM often progresses into an invasive disease due to delayed diagnosis. In this report, we describe the case of a 72-year-old Caucasian woman who had been diagnosed with AM after 3 years of failed treatments for what presented as a periorbital dermatitis. Her Clark's level 4, 1.30 mm thick melanoma required nine surgeries for successful resection and reconstruction. This case exemplifies the diagnostic pitfall of AM and the need for new criteria for early detection and management.

New advances in liposuction technology.

Although suction-assisted liposuction under tumescent anesthesia remains the traditional method for body sculpting, newer technologies promise to increase efficiency, decrease surgeon fatigue, and minimize complication. Power-, ultrasound-, and laser-assisted devices are ideal in large volume cases and in areas of fibrous tissues as an adjunct to traditional liposuction. Although skepticism remains chemical lipolysis, more commonly termed mesotherapy or lipodissolve may be an alternative to surgical treatment of localized fat. This article reviews the recent advancements in the field of liposuction and the current literature which support their use.

Nonsurgical treatment modalities for primary cutaneous malignancies.

BACKGROUND: Various modalities have been available to treat primary cutaneous malignancies. Although not indicated for certain aggressive tumors, many of the newest regimens involve noninvasive techniques. It behooves both the nonsurgeon and the surgeon alike to be apprised of all treatment options, their indications, and their efficacy. OBJECTIVE: The objective was to review the indications and published data on various nonsurgical treatment options for primary cutaneous malignancy. METHODS AND MATERIALS: This study is a literature review. CONCLUSIONS: Many nonsurgical treatment options exist for primary cutaneous malignancies. In determining which modalities to implement, consideration must be given to careful patient selection, tumor type, and appropriate expectations. Additionally, adjunctive/combination therapy may be used before or after surgery.

Mohs micrographic surgery for penile cancer: management and long-term followup.

PURPOSE: Mohs micrographic surgery is efficacious for the primary treatment and local recurrence control of nongenital and cutaneous squamous and basal cell cancers. The efficacy of this procedure for squamous cell carcinoma of the penis was reviewed. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients treated with Mohs micrographic surgery for penile cancer at our institution from 1988 to 2006. RESULTS: We identified 33 patients who underwent a total of 41 Mohs procedures. Average +/- SD lesion size was 509 +/- 699 mm(2). An average of 2.6 +/- 1.4 stages were done using Mohs micrographic surgery. Five procedures were terminated with positive margins, including 3 due to urethral involvement and 2 due to defect size. Of the tumors 26 were stage Tis, 4 were T1, 7 were T2 and 4 were T3. A total of 13 defects were reconstructed by primary repair or granulation, 4 were reconstructed by skin grafts and 25 were reconstructed by tissue flaps and urethroplasty. Followup data were available on 25 patients at a mean of 58 +/- 63 months. Eight patients (32%) had recurrence, which was managed by repeat Mohs micrographic surgery in 7 and by penectomy in 1. There were 2 cases of tumor progression, including 1 from T1 to T3 disease (meatal involvement) and 1 from T1 to inguinal lymph node involvement. Two patients died, of whom 1 had no evidence of penile cancer and 1 had metastatic disease. CONCLUSIONS: Mohs micrographic surgery for low stage penile cancer results in a relatively high local recurrence rate. However, with repeat procedures and vigilant followup cancer specific and overall survival rates are excellent and progression rates are low.

Acrochordon-like basal cell carcinomas in patients with basal cell nevus syndrome.

Basal cell nevus syndrome is an autosomal dominant disorder characterized by multiple basal cell carcinomas, along with numerous other documented clinical features. Acrochordons (or skin tags) are common benign neoplasms that are appropriately left untreated in most patients. We describe two patients with known BCNS who were found to have multiple BCCs that clinically resembled acrochordons. Our findings support the biopsy of acrochordon-like growths in patients with basal cell nevus syndrome to rule out basal cell carcinoma.

Earlier detection of patients' second primary basal cell carcinomas: a quantitative analysis.

BACKGROUND: Basal cell carcinoma (BCC) is the most common occurring cancer in humans. No studies to date have compared the size of a patient's first and second primary BCC to determine whether we are detecting and treating second primary cancers at earlier stages of development. OBJECTIVE: The objective was to ascertain whether patients who have had a primary BCC are diagnosed and treated for subsequent BCC at an earlier clinical stage of development. METHODS AND MATERIALS: We performed a 4-year retrospective chart review of all patients presenting for Mohs micrographic surgery for two separate primary BCC. We compared the presenting clinical size of patients' first and second primary BCC. RESULTS: We found a statistically significant decrease in size of the second primary BCC when compared to the first primary BCC (p<.0001). The mean difference was 116.6 mm2 and the median difference was 28.3 mm2. CONCLUSION: Our results provide important quantitative data illustrating our effectiveness in detecting subsequent BCC at an earlier stage of development. Earlier detection of skin cancers can decrease the morbidity and chance of recurrence as well as lead to smaller scars and better cosmetic outcomes and may also allow for various treatment modalities and cost containment.

Larval melanocyte regeneration following laser ablation in zebrafish.

A method to specifically ablate melanocytes in a genetically tractable organism would facilitate the analysis of melanocyte regeneration and regulation. We have demonstrated that a Q-switched neodymium:yttrium-aluminum-garnet dermatology laser kills larval melanocytes in zebrafish. Following melanocyte ablation, new melanocytes regenerate from unpigmented precursors. We show that melanocyte regeneration following laser ablation requires kit receptor tyrosine kinase.

Vitamin B12-associated localized scleroderma and its treatment.

BACKGROUND: Localized drug-induced injection site reactions are rare. Injection site sclerodermoid reactions have been reported as a result of multiple drugs, most commonly vitamin K. Sclerodermoid injection site reactions have also been reported with pentazocine, progestin, and vitamin B12. Little has been written on the efficacious treatment of this complication. OBJECTIVE: The objective was to raise awareness of the potential complication of localized sclerodermoid change secondary to vitamin B12 injections and to present a novel approach to its treatment. METHODS: We report a case and review the English literature for injection site reactions from vitamin B12 as well as treatment options for this complication. RESULTS: We report the first non-European case of localized sclerodermoid reaction secondary to vitamin B12 injections. Our patient presented with disfiguring depression of the left upper arm following vitamin B12 injections for macrocytic anemia secondary to Crohn's disease. Histopathology showed findings similar to those seen in localized scleroderma. The patient was successfully treated with excision of diseased skin, local fat transfer, and complex repair with dramatic improvement at 5 months in contour and overall appearance.

Guidelines for the management of squamous cell carcinoma in organ transplant recipients.

BACKGROUND: Solid-organ transplant recipients have a high incidence of cutaneous squamous cell carcinoma (SCC) and often develop multiple and aggressive tumors. There are few published studies or reviews, which provide guidance to the clinician in the treatment of these patients. OBJECTIVE: The objective was to develop useful clinical guidelines for the treatment of skin cancer in organ transplant recipients (OTRs). METHODS: The members of the Guidelines Committee of the International Transplant-Skin Cancer Collaborative (ITSCC) carried out a computerized search utilizing the databases of the National Library of Medicine for reports in the literature on SCC in OTRs. These reports were collectively examined by the group and combined with experiences from the members' clinical practices in the development of the guidelines. RESULTS: More than 300 articles relating to SCC in OTRs were reviewed. In general, reports concerning the prevention and treatment of SCC in OTRs are of individual cases or small case series. They are retrospective in nature, statistically nonrigorous, and lack the complete epidemiologic data necessary to derive definitive conclusions. Combining these studies and collective clinical experience, however, is at present the best available method for devising guidelines for the treatment of SCC in OTRs. CONCLUSION: Guidelines developed for the treatment of skin cancer in OTRs, supported by the best available data and collective clinical experience, may assist in the management of OTRs with SCC. The development of clinical pathways and complete documentation with rigorous prospective study is necessary to improve and refine future guideline development.

Botulinum toxin A treatment of perioral rhytides.

BACKGROUND: Botulinum toxin A is well documented as a useful therapy for smoothing dynamic facial rhytides of the upper face. Most controlled studies have focused on the treatment of glabellar frown lines, horizontal forehead lines, and crow's feet. Reports of botulinum toxin A use in the lower face are few and anecdotal. OBJECTIVE: We present our experience using botulinum toxin A in the lip as a treatment of vertical perioral rhytides, which resulted in the added cosmetic benefits of lip eversion and enhanced lip fullness. METHODS: Eighteen patients were injected with botulinum toxin A into the vertical lip rhytides. The effect of treatment was evaluated at 2 to 3 weeks after procedure. RESULTS: Smoothening of hyperfunctional lines and upper lip fullness/eversion is observed in patients treated with perioral botulinum toxin A injections; 72% of patients continued treatment. CONCLUSIONS: In select patients, perioral botulinum toxin A results in amelioration of perioral rhytides and enhancement of lip fullness and lip eversion.

Chemical injury to the eye from trichloroacetic Acid.

BACKGROUND: Trichloroacetic acid (TCA) is frequently utilized for chemical peeling by physicians practicing dermatologic surgery. Ocular complications from TCA have not been reported previously. OBJECTIVE: The purpose of this article is to underscore the irritating and corrosive effects of TCA on the eye. METHODS: A patient is described who experienced seepage of 35% TCA into the eye during a chemical peel. RESULTS: The patient developed marked conjunctivitis of the affected eye and abrasions involving 25% of the cornea. CONCLUSION: TCA must be applied carefully around the eyes to avoid ocular complications, which albeit rare, can be quite grave if not addressed in a timely manner.

Standing cone avoidance via advancement flap modification.

BACKGROUND: Tissue redundancy manifesting as a standing cutaneous cone is a common surgical problem. OBJECTIVE: We describe modifications to traditional advancement flap design that allows for standing cutaneous cone avoidance. METHODS: In addition to traditional incisions employed in advancement flaps, an additional curvilinear incision is made along one or more limbs of the flap. By removing tissue along the length of the flap incision, redundant tissue is redistributed along the length of the incision. A standing cutaneous cone is thereby avoided. RESULTS: Use of the technique provides standing cone avoidance without lengthening a surgical scar. There has been no increase in flap failure or other complications with the described technique. CONCLUSION: The modified advancement flap allows for standing cone avoidance. Improved cosmesis can also be achieved when the modified flap limb is placed in a facial line or subunit junction.