Carl Vinciullo

Assessment and management of chemical exposure in the Mohs laboratory.

BACKGROUND The correct handling, storage, and disposal of chemicals used in the processing of tissue for Mohs micrographic surgery are essential. OBJECTIVES To identify the chemicals involved in the preparation of Mohs frozen sections and assess the associated occupational health risks. To quantify exposure levels of hazardous chemicals and ensure that they are minimized. METHODS A risk assessment form was completed for each chemical. Atmospheric sampling was performed at our previous laboratory for formaldehyde and volatile organic compounds. These data were used in the design of our new facility, where testing was repeated. RESULTS Twenty‐five chemicals were identified. Ten were classified as hazardous substances, 10 were flammable, six had specific disposal requirements, four were potential carcinogens, and three were potential teratogens. Formaldehyde readings at our previous laboratory were up to eight times the national exposure standard. Testing at the new laboratory produced levels well below the exposure standards. CONCLUSION Chemical exposure within the Mohs laboratory can present a significant occupational hazard. Acutely toxic and potentially carcinogenic formaldehyde was found at high levels in a relatively standard laboratory configuration. A laboratory can be designed with a combination of physical environment and operational protocols that minimizes hazards and creates a safe working environment. The authors have indicated no significant interest with commercial supporters.

Erdheim-Chester disease.

A 38‐year‐old man presented with numerous dermal nodules, similar to xanthoma disseminatum, that were histologically consistent with his diagnosis of Erdheim–Chester disease, a non‐Langerhans cell histiocytosis. Other cutaneous manifestations of this disease include eyelid xanthelasma, pretibial dermopathy and pigmented lesions of the lips and buccal mucosa. The histological diagnosis of Erdheim–Chester disease was originally made on the patients retroperitoneal tissue, obtained at a laparotomy for surgical treatment of a presumed phaeochromocytoma, and confirmed by the pathognomonic long bone X‐ray findings of this disease.

Nasal carriage of Staphylococcus aureus in patients undergoing Mohs micrographic surgery is an important risk factor for postoperative surgical site infection: A prospective randomised study

Surgical site infection (SSI) can be a problematic complication of Mohs micrographic surgery (MMS). Previous reports have cited nasal Staphylococcus aureus (S. aureus) carriage as a risk factor for SSI, but none thus far in dermatologic surgery.

Pulsed dye laser treatment of spider telangiectasia

Spider telangiectasia is a common benign vascular malformation which can be a source of cosmetic concern for the patient A retrospective review of 30 adults and children with spider telangiectasia treated by the flashlamp‐pumped pulsed dye laser was undertaken. There was complete clearance of treated spider telangiectasia in 93% of patients after a single treatment There were no reported permanent adverse effects with purpura being the only transient problem. Most patients were satisfied with the eventual results of treatment and would recommend treatment to other people with a similar problem. This laser should be considered as the treatment of choice for spider telangiectasia.

Oral Antibiotics Versus Topical Decolonization to Prevent Surgical Site Infection After Mohs Micrographic Surgery—a Randomized, Controlled Trial

BACKGROUND The optimal method of reducing the risk of surgical site infection (SSI) after dermatologic surgery is unclear. Empiric, preoperative antibiotic use is common practice but lacks supporting evidence for its efficacy in preventing SSI. Risk stratification for patients at high risk of postoperative SSI based on a nasal swab is a viable strategy when coupled with topical decolonization for positive carriers. We compared the rates of infection in patients undergoing Mohs micrographic surgery (MMS) with nasal carriage of Staphylococcus aureus who received oral antibiotics or topical decolonization. METHODS A randomized, controlled trial with 693 patients was conducted over a 30‐week period at a single surgical practice. Patients were stratified into nasal carriers or noncarriers of S. aureus based on a preoperative nasal swab. Nasal carriers of S. aureus were randomized to receive topical decolonization with intranasal mupirocin twice daily plus 4% chlorhexidine gluconate body wash daily for 5 consecutive days before surgery or statim pre‐ and postoperative doses of oral cephalexin. RESULTS One hundred seventy‐nine patients (25.8%) were identified as carriers of S. aureus. Ninety received topical decolonization, and 89 received oral antibiotics. These groups were compared with a swab‐negative Mohs surgical cohort over the same time period. There were no significant differences between the groups in terms of demographic characteristics or comorbidities. Nine percent of patients receiving oral antibiotic prophylaxis and 0% receiving topical decolonization developed early SSI (p = .003). CONCLUSION In patients with demonstrable carriage of S. aureus, topical decolonization resulted in fewer SSI than in patients receiving perioperative oral antibiotics. Antibiotics should be reserved for clinically suspected and swab‐proven infections rather than being prescribed empirically. Further efforts should be directed toward optimizing endogenous risk factor control for all patients presenting for MMS.

HYPERTROPHIC LUPUS ERYTHEMATOSUS: DIFFERENTIATION FROM SQUAMOUS CELL CARCINOMA

Hypertrophic lupus erythematosus (HLE) may be more common as a variant of discoid lupus erythematosus (DLE) than is reported in the literature. Differentiation from neoplastic transformation of a lesion of DLE to squamous cell carcinoma (SCC) is crucial because of the metastatic potential of this type of SCC. A man is described in whom hypertrophic lesions of LE accompanying lesions of classic DLE were interpreted histopathologically as SCC. The problem of differentiating true HLE from SCC arising within DLE is discussed with a review of the relevant literature.

Sclerosing lipogranuloma of the penis.

We present a case of sclerosing lipogranuloma of the penis in a 25‐year‐old man of Burmese origin complicating injection of an unknown non‐biodegradable oily foreign material into his external genitalia. Despite frequent complications, penile augmentation with exogenous paraffin material is still practised in some parts of the world. Sclerosing lipogranuloma is a rare condition in Australia that dermatologists need to consider in the differential of a genital ulcer or indurated penile mass, particularly in young men from South‐East Asia. A causal relationship between the procedure and adverse events may not be made because complications are frequently delayed for many years. A high degree of clinical suspicion and a skin biopsy is essential, as a history of injection may not be disclosed.

Combination carbon dioxide laser vermilionectomy and wedge excision of the lip

Dermatologic surgeons are very familiar with the use of the carbon dioxide (CO2) laser for treating actinic cheilitis. When squamous cell carcinoma is proven or suspected in the affected lip, then combined CO2 laser vermilionectomy and wedge excision as a one stage procedure has significant advantages for the patient.

Allopurinol hypersensitivity: a potentially life threatening reaction.

Allopurinol is a frequently used drug for the treatment of gout and hyperuricaemia. It has been estimated that as many as 60% of patients receive the drug for asymptomatic hyperuricaemia. Often little thought is given to the patients renal function, the correct dosage of allopurinol or to the concomitant use of other drugs, e.g. thiazides. Approximately 10% of patients develop a mild reaction of a cutaneous or gastrointestinal nature. Severe life‐threatening hypersensitivity reactions can and do occur, as will be described in an illustrative case report. Details of the different reactions of a cutaneous or other type are given and treatment and recommendations for allopurinol use are discussed.

Mohs surgery in Australia: A survey of work practices

Background:  Mohs micrographic surgery is the preferred treatment for certain skin cancers. It had already been considerably refined prior to its introduction into Australia in 1978, refinement has continued since. Documenting the work practices of Australian Mohs surgeons serves to clarify the current role of Mohs surgery and may help tailor future Mohs fellowship programs.