Christopher J. Arpey

Aggressive basal cell carcinoma: Presentation, pathogenesis, and management

Basal cell carcinoma (BCC) is the most common cutaneous skin malignancy. BCC generally has a clinical course characterized by slow growth, minimal soft tissue invasiveness, and a high cure rate. Occasionally, however, BCC behaves aggressively with deep invasion, recurrence, and potential regional and distant metastasis. Several factors, including tumor size, duration, histology, and perineural spread, have been postulated as markers of the aggressive BCC phenotype. It is undetermined whether intrinsic biological factors within certain subsets of BCC predispose these tumors toward an inherently aggressive behavior, or whether any BCC with inadequate early management may assume this phenotype. Review of the pertinent literature on this topic suggests that both intrinsic biological factors and extrinsic management factors play a role in the development and progression of aggressive BCC.

Treatment of multiple cutaneous leiomyomas with CO2 laser ablation.

Background. Cutaneous leiomyomas are benign tumors that can be exquisitely painful. Symptomatic lesions often necessitate treatment, but many options are inadequate or create substantial morbidity. Without a definitive therapy of first choice, the search continues for alternative methods to alleviate discomfort in affected patients. Objective. To describe the use of CO2 laser ablation for the symptomatic treatment of a 73‐year‐old woman with multiple cutaneous leiomyomas in whom pharmacologic therapy was contraindicated and surgical excision was impractical. Methods. CO2 laser ablation of six symptomatic cutaneous leiomyomas was performed under local anesthesia. After initial success, all remaining symptomatic lesions were treated. Results. There was complete pain relief in the originally treated lesions 9 months postoperatively, and in all remaining treated lesions 3 months postoperatively. Conclusion. CO2 laser ablation may be an effective alternative treatment for symptomatic cutaneous leiomyomas.

Biologic Dressings: Current Applications and Limitations in Dermatologic Surgery

BACKGROUND Various biologic dressings have been developed in an effort to find the ideal skin substitute for use in acute and chronic wounds. There are many potential uses for such dressings, but no panaceas exist. Because millions of health care dollars are spent each year on wound care, and a great deal of patient morbidity occurs from these wounds, the search for new and better dressings is likely to continue. OBJECTIVE To review the current evidence regarding the utility, outcomes, and adverse effects of the available biologic dressings, with a particular focus on use in acute surgical wounds and applicability to dermatologic surgery. MATERIALS AND METHODS PubMed literature search and review of data on biologic dressings with particular attention to the past 2 decades. Emphasis was placed on peer‐reviewed manuscripts and larger series. CONCLUSIONS There is extensive literature regarding the use of biologic dressings in chronic wounds, such as venous leg ulcers and burns, but studies evaluating these dressings in acute surgical wounds and dermatologic surgery have been limited. There appear to be specific surgical settings in which such dressings may be of particular use, in addition to limitations of their use. Additional studies, particularly randomized and comparative trials, would be highly desirable.

Differential Effect of Capsaicin Treatment on Pain-Related Behaviors After Plantar Incision

UNLABELLED We evaluated the effect of infiltration of dilute solutions of capsaicin, administered before plantar incision, on 3 pain-related behaviors: guarding pain, heat-withdrawal latency, and mechanical-withdrawal threshold. Perineural application of capsaicin was also studied and the appearance of the wound was also evaluated. Dilute solutions of capsaicin .025% and .10% were infiltrated in the plantar region 1 day before incision. In another group of rats, perineural capsaicin (1%) was applied to the nerves innervating the plantar aspect of the rat hindpaw. Rats were then tested for pain-related behaviors before and after plantar incision and then daily thereafter. Wound appearance was graded and histopathology was evaluated. Infiltration with capsaicin reduced guarding pain and heat hyperalgesia after plantar incision; there were minimal effects on mechanical responses. Perineural-capsaicin application produced a similar result. Both capsaicin infiltration and perineural-capsaicin application impaired wound apposition. Histologic evaluation also confirmed impaired wound apposition after capsaicin infiltration. In conclusion, dilute solutions of capsaicin have differential effects on pain-related behaviors after plantar incision. Based on the antinociception produced by capsaicin both via infiltration and perineural injection, the effect on wound appearance was likely related to its inhibitory effects on pain behaviors and was not necessarily a local effect of the drug. PERSPECTIVE This study demonstrated that capsaicin infiltration before plantar incision produced an analgesic effect that depended upon the stimulus modality tested. When evaluating novel treatments for postoperative pain, studies using a single stimulus modality may overlook an analgesic effect by not examining a variety of stimuli.

Consensus for Nonmelanoma Skin Cancer Treatment, Part II: Squamous Cell Carcinoma, Including a Cost Analysis of Treatment Methods

BACKGROUND Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer in the United States. Cutaneous squamous cell carcinoma has an estimated incidence of more than 700,000 new cases per year and a 5% risk of metastasis. OBJECTIVE To provide clinicians with guidelines for the management of cSCC based on evidence from a comprehensive literature review and consensus among the authors. MATERIALS AND METHODS The authors conducted an extensive review of the medical literature on treatment methods for cSCC, taking into consideration cure rates, recurrence and metastatic rates, aesthetic and functional outcomes, and cost effectiveness of the procedures. RESULTS Surgical treatments provide the best outcomes for cSCC. Mohs micrographic surgery is a cost-effective procedure that affords the highest cure rate, maximal tissue preservation, and superior cosmetic outcomes. Nonsurgical methods may be used as a primary treatment for low-risk squamous cell carcinomas, but the cure rates are lower. CONCLUSION The cure rate remains the most important consideration in choosing the treatment method, but additional factors, such as the patients general medical condition, psychosocial circumstances, the location of the tumor and cost effectiveness of the therapy should be considered. Mohs micrographic surgery remains the preferred treatment for high-risk tumors and tumors located in cosmetically sensitive areas.

Porcine Heterografts in Dermatologic Surgery and Reconstruction

Background. Porcine heterografting is a method that can be used to reestablish the protective integrity of skin after cutaneous injury. These grafts may be used in an assortment of clinical situations for chronic and acute wounds, burn injury, and partial‐ or full‐thickness areas of skin loss. Objective. The purpose of this article is to address the indications for using porcine heterografts in dermatologic surgery, the advantages and disadvantages of their use, and the technique of graft application. Methods. Indications for porcine heterografts and the methodology of graft application are discussed. Results. Porcine heterografts serve as a valuable tool in a variety of reconstruction settings in dermatologic surgery. Conclusions. Heterografts provide an inexpensive method to facilitate wound care and promote healing, and serve as an effective repair option for a variety of surgical defects.

Wound hypoxia in deep tissue after incision in rats.

Our previous studies using rat models of incisional pain have shown that tissue lactate levels increase and pH decreases for several days after incision, suggesting the presence of an ischemic‐like condition. The purpose of this study was to evaluate the time course and the extent of tissue hypoxia that develops in incised muscle and skin. We directly measured oxygen tension at several time points after incisions of the gastrocnemius muscle, the paraspinal skin, and the plantar hindpaw in anesthetized rats using an oxygen‐sensitive microelectrode. In vivo hypoxia of the incised tissues was also evaluated immunohistochemically using a hypoxia marker, pimonidazole hydrochloride. To minimize intersubject variability, unincised contralateral tissues were used as a control. Tissue oxygen tension was decreased in both skeletal muscle and skin compared with control, for several days after incision. When measured directly, oxygen tension decreased immediately and remained low for several days after incisions. Pimonidazole immunostaining revealed hypoxic areas in incised muscle and skin for several days. By postoperative day 10, tissue oxygen tension recovered to that of control tissue. These results support the evidence that a hypoxic condition is present in deep tissue after incisions and that an ischemic‐like mechanism may contribute to postoperative pain.

Treatment of Atrophoderma of Pasini and Pierini-associated hyperpigmentation with the Q-switched alexandrite laser : A clinical, histologic, and ultrastructural appraisal

Atrophoderma of Pasini and Pierini (APP) is an uncommon cutaneous disorder, with no known effective treatment, manifested by hyperpigmented patches that appear to be depressed compared with surrounding skin. This study investigated the effectiveness of the Q‐switched alexandrite laser on a patient with extensive APP, and evaluated histopathologic and ultrastructural changes.

Persistent Keratoacantoma: Challenges in Management

background. Keratoacanthoma is a common cutaneous neoplasm, although the persistent form is less common and often more difficult to manage. Multiple treatment approaches have been attempted with variable efficacy. Establishing the diagnosis and selecting a treatment plan for persistent keratoacanthoma is often challenging. objective. Our purpose is to describe the difficulty one may encounter in the diagnosis and treatment of persistent keratoacanthoma. Hopefully, review of this clinical conundrum may facilitate the management of the readers future patients. methods. We describe a case of persistent keratoacanthoma where the diagnosis was initially elusive and the management challenging. Our thought process during each stage of diagnosis and management is described in the form of “issues” with references to the appropriate literature. results. After several diagnostic and therapeutic interventions, successful treatment was achieved with administration of oral isotretinoin. Long‐term remission continued as the dosage was tapered. conclusion. Persistent keratoacanthoma may be challenging to diagnose and manage, presenting a clinical conundrum. Careful review of the clinicopathologic presentation and an understanding of the various treatment options may result in a successful outcome.

Fordyce spots of the lip responding to electrodesiccation and curettage.

Fordyce spots are heterotopic sebaceous glands typically located on the vermilion lip or oral mucosa. They are characterized by asymptomatic white or yellow 1to 3-mm, occasionally lobulated, papules. These occur in both genders in up to 80% of the population and usually are not seen before puberty. The most common oropharyngeal locations are the buccal mucosa and retromolar regions. While a benign finding, treatment may be sought by patients who have prominent Fordyce spots for improved appearance. There are few beneficial treatment approaches reported, including CO2 laser ablation and oral isotretinoin. Treatment with 5-aminolevulinic acid (ALA) photodynamic therapy has recently been reported to produce poor outcomes with significant side effects. Here, we report a case responding to electrodesiccation and gentle curettage, a widely available, safe, and well-tolerated treatment modality.