Guidelines for the management of basal cell carcinoma.

This article represents a planned regular updating of the previous British Association of Dermatologists guidelines for the management of basal cell carcinoma. These guidelines present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Discordance between facial wrinkling and the presence of basal cell carcinoma.

BACKGROUND: During routine surgical treatment of basal cell carcinomas (BCCs), we observed an apparent inverse relationship between the presence of a BCC and significant wrinkling of the face. To ascertain the veracity of this observation, we performed a clinical and questionnaire-based case-referent study. OBSERVATION: One hundred eighteen successive white patients (mean +/- SD age, 71.9 +/- 9.5 years) attending the hospital for surgical treatment of a BCC and 121 control (no skin cancer) patients (mean +/- SD age, 69.1 +/- 10.8 years) were assessed for grade of facial wrinkling using a previously validated photonumeric scale of photoaging and completed a questionnaire about sun exposure. Despite being older (P =.03), patients with a BCC were found to have a lower mean grade of wrinkling than controls (P =.001). Using logistic regression, increasing grade of wrinkling was associated with a progressive reduction in risk of developing a BCC. CONCLUSION: Mechanisms responsible for the production of facial wrinkles may either be separate to or mitigate against the development of a BCC of the face.

Guidelines for the management of basal cell carcinoma. British Association of Dermatologists.

These guidelines on the management of basal cell carcinoma have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

An open study of tissue adhesive in full-thickness skin grafting.

BACKGROUND: Securing full-thickness skin grafts (FTSG) by suturing is a time-consuming procedure, even in experienced hands. The advent of tissue adhesives has led to their use in a variety of surgical procedures, providing an acceptable alternative to conventional suturing. OBJECTIVE: Our purpose was to identify whether the tissue adhesive n-butyl-2-cyanoacrylate (NBCA) can be used to secure FTSG and to compare the outcome with conventional suturing. METHODS: Twenty-one patients with defects after Mohs micrographic surgery were enrolled into the study. An initial pilot study of 8 patients compared NBCA and sutures within individual grafts; the subsequent 13 patients had grafts secured with between 4 and 8 cardinal sutures and NBCA alone. RESULTS: No differences in healing, complications, or cosmetic appearance were observed between the sides secured with NBCA and with sutures in the pilot study. Of the grafts in the subsequent 13 patients, 2 patients experienced superficial necrosis with subsequent healing and a good cosmetic outcome, the remainder healed in place without complications, with excellent cosmetic outcome. CONCLUSION: NBCA is suitable for securing selected FTSG and provides a significant time-saving over the traditional approach of suturing such grafts into place.

Oculoplastic reconstruction following Mohs surgery.

PURPOSE: Mohs micrographic surgery has been advocated as the optimal management of nonmelanoma skin cancer in the periocular region. It is a technique that is ideally suited to the removal of skin tumours with a contiguous growth pattern such as basal cell carcinoma and squamous cell carcinoma, allowing examination of 100% of the surgical margin. As a result of this total margin control, the technique offers an unsurpassed curve rate combined with maximal preservation of normal tissue. Following excision of a periocular tumour by a Mohs surgeon, the resulting defect usually requires reconstruction. Our objective was to determine whether the size of defect produced by Mohs surgery and the type of reconstruction required differed from the results we would have expected from standard surgery with a 3 mm excision margin. METHODS: A Mohs surgery service with a combined dermatological and oculoplastic approach was set up in Manchester in 1994. We reviewed 60 of our patients who underwent Mohs surgery and compared the size of defect produced as well as the type of reconstruction required with the results we would have predicted for standard excisional surgery with a 3 mm margin. RESULTS: Although a minority of patients required larger reconstructions than would have been anticipated (20%), many had smaller reconstructions than we had predicted (37%). This latter group often had important structures preserved, and therefore had the benefit of less extensive reconstructive surgery. CONCLUSIONS: Excision of a periocular tumour by Mohs surgery may occasionally identify extensive subclinical tumour extension and so produce an unexpectedly large defect for reconstruction. Many patients, however, require less extensive reconstructive surgery than would have been predicted. This produces benefits in terms not only of improved cosmesis and eyelid function, but also reduced operating theatre costs.

Drug and nutrient aspects of wound healing.

An understanding of the major factors that influence wound healing enables the clinician to better prepare patients for surgery and to identify and correct the effects of either drugs or nutritional imbalances in patients whose wounds fail to heal. Ideally, factors that enhance wound healing should be optimized, and detrimental influences minimized whenever possible. Among the major factors influencing wound healing are the state of general health, drugs, and nutritional status. Nutritional assessment prior to surgery, following injury, and during recovery is an important part of management of patients with extensive wounds. In dermatologic surgical practice, nutritional support is not indicated; however, subclinical nutritional deficiencies may not be uncommon and may become relevant if wound healing is significantly impaired. Dermatologic surgeons must be aware of the potential for many drugs to interfere with wound healing and interrupt therapy prior to surgery whenever possible. Some drugs cannot be stopped and surgery should be performed only when absolutely necessary when patients are receiving antineoplastic, anticoagulant, and high-dose steroid therapy.

Wound care after office procedures.

A knowledge of wound healing physiology and how it is influenced by wound dressings is valuable information for all dermatologists. Such knowledge enables the dermatologist to give authoritative advice on postoperative wound care and more importantly, to use wound dressings as a complement to good planning and surgical technique in order to optimize the conditions for rapid healing following office surgical procedures.

The role of streptococcal infection in the initiation of guttate psoriasis.

BACKGROUND AND DESIGN: Although the association between streptococcal infection and guttate psoriasis is well known, to date there has been little information on whether only limited groups and/or serotypes of beta-hemolytic streptococci are involved. One hundred eleven patients with a sudden onset or deterioration of psoriasis were investigated for evidence of streptococcal infection. Of these patients, 34 had acute guttate psoriasis, 30 had a guttate flare of chronic psoriasis, 37 had chronic plaque psoriasis, and 10 had other types of psoriasis. RESULTS: Serologic evidence of recent streptococcal infection was present in 19 (58%) of 33 patients with acute guttate psoriasis compared with seven (26%) of 27 patients with guttate exacerbations of chronic psoriasis. Streptococcus pyogenes was isolated from 19 (17%) of all 111 patients (9 [26%] of 34 with acute guttate psoriasis, four [13%] of 30 with guttate exacerbations of chronic psoriasis, and five [14%] of 37 patients with chronic psoriasis) compared with seven (7%) of 101 of a control population of patients being seen for treatment of viral warts. Other beta-hemolytic streptococci were found with equal frequency in the study and control populations. Thirteen isolates of 10 different streptococcal serotypes were obtained from the 64 patients with guttate psoriasis. These serotypes were similar in distribution and prevalence to those present in the local community. CONCLUSIONS: This study confirms the strong association between prior infection with S pyogenes and guttate psoriasis but suggests that the ability to trigger guttate psoriasis is not serotype specific.

Congenital and hereditary nail disorders.

An accurate description of nail changes in congenital and hereditary conditions is complicated both by vague terminology and by errors introduced by the effects of trauma. This article attempts to identify primary developmental abnormalities in the nails and divides them into those caused by defects in the nail matrix, the nail field, or the nail bed and those originating from combined ectodermal and mesodermal defects. Attempting to identify underlying embryological defects may allow a more logical approach to both description and classification of congenital and hereditary nail abnormalities.

Tufted folliculitis. A specific bacterial disease?

Residual groups of hair follicles and unusual "tufts" of multiple hairs emerging from single follicular openings have been described in scarring alopecia associated with staphylococcal infection. Various mechanisms have been proposed to explain these findings. Histological study of four cases suggests that retention of telogen hairs through several hair cycles may be responsible for this phenomenon.