David F. Butler

Nodular (keloidal) scleroderma

Two patients with progressive systemic sclerosis (PSS) developed keloidal-like nodules within areas of thickened skin. This extremely unusual event is most likely a keloidal response to the early inflammatory component of scleroderma in patients who are either genetically at risk for keloid formation or in areas of the skin that have a high predilection for keloid formation such as the chest.

Imiquimod 5% Cream as Adjunctive Therapy For Primary, Solitary, Nodular Nasal Basal Cell Carcinomas Before Mohs Micrographic Surgery: A Randomized, Double Blind, Vehicle-Controlled Study

BACKGROUND Imiquimod 5% cream is currently approved for treatment of nonfacial, superficial basal cell carcinomas (BCCs). Topical imiquimod might be a reasonable candidate for adjunctive therapy of nodular, nasal BCCs before Mohs surgery. OBJECTIVE To observe the effectiveness of imiquimod 5% cream in reducing the number of Mohs stages, defect size, cost of Mohs surgery, and reconstruction. METHODS Patients applied the study medication nightly for 6 weeks with occlusion followed by a 4-week rest period before Mohs surgery was performed. RESULTS No differences were demonstrated in the number of Mohs stages, defect sizes, or costs between the two groups, possibly because of our small sample size. Only five of 12 patients (42%) in the treatment group were found histologically clear of tumor (complete responders). CONCLUSION Imiquimod 5% cream was not helpful as an adjunctive treatment of nodular, nasal BCCs before Mohs surgery, but a larger study might show a benefit. Clearance of nodular, nasal BCCs treated with imiquimod prior to Mohs surgery was less than described in previous studies. Nasal BCCs may be more resistant to imiquimod treatment. Local inflammatory reactions limit imiquimods usefulness in this setting. Histologic assessment of nasal BCCs treated with imiquimod is recommended.

Cutaneous Collision Cancers: A Report of Two Squamomelanocytic Malignancies and Review of the Literature

A ‘‘collision tumor’’ has been described as the coexistence of two different neoplasms within the same tumor. Many benign collision tumors occur serendipitously and may have limited clinical significance, but the occurrence of two cutaneous malignancies within the same tumor, each having the potential to metastasize, may pose a considerable health risk. Several authors have reported the collision of squamous cell carcinoma (SCC) and melanoma. Other authors have described similar tumors as ‘‘squamomelanocytic’’ neoplasms and postulate that they may have a unique histogenesis with unknown biologic behavior. Many terms have been used interchangeably, each having slightly different meanings. In the strictest sense, a ‘‘collision’’ tumor is defined as the occurrence of two neoplastic cell populations in close proximity to each other while maintaining sharp separate boundaries. In contrast, a ‘‘biphasic’’ tumor demonstrates two or more phenotypically distinct neoplastic cell populations merging within the same space. Confusion in the nomenclature exists, and previously reported cases have been referred to variously under both designations. We report two patients with squamomelanocytic tumors, describe their clinical and histopathologic findings, and review and compare the reports of this entity in the literature. Case One

Excisional surgery (scalpectomy) for dissecting cellulitis of the scalp.

The scalp condition was nonresponsive to trials of oral prednisone and topical and oral clindamycin before presentation to our clinic. Local incision and drainage of lesions and intralesional steroids provided temporary symptomatic relief. He completed two courses of systemic isotretinoin with minimal improvement and failed several months of etanercept, an anti-tumor necrosis factor alpha (TNF-a) inhibitor. Radiation-induced epilation was considered, but his insurance carrier did not approve it. Because the scalp disorder was progressing, disfiguring, and a social stigma for him, he underwent total scalp excision (Figures 1 and 2) followed by split-thickness skin grafting (Figure 3) for definitive therapy. He tolerated the procedure well, experienced relief of symptoms, and was pleased with his final outcome (Figure 4).

Face-Down Cryoembedding of Tissue Specimens for Mohs Micrographic Surgery Using Stainless Steel Embedding Wells

Conforming the tissue specimen to a shape that will allow sectioning of the peripheral (epidermal) and deep margin in a single plane is an essential aspect of Mohs micrographic surgery. A sectioning plane that encompasses the complete margin will help to ensure adequate clearance of the tumor being treated. A variety of methods are currently employed to conform, freeze, embed, and mount tissue specimens to cut sections in the proper plane. A survey of Mohs surgeons published in 2003 showed a great deal of variation in the devices and techniques used to flatten specimens and obtain an epidermal edge, use of a heat extractor (22.6%), relaxing incisions (16.1%), heat extractor and relaxing incisions (14.2%), freezing on a glass slide (10.3%), relaxing incision and glass slide (9.4%), and mechanical flattening (Miami special) with liquid nitrogen (3.9%) being the most commonly used. Two additional devices, the Davidson Cryocup (Bradley Products Inc., Bloomington, MN) and the CryoHist (Cryo Histology, Inc., Shawnee, KS), have been described that allow for more rapid and efficient embedding of Mohs specimens. The CryoHistprepared blocks required less time to prepare and far fewer sections to obtain a complete margin than the Cryocup. Disadvantages of the CryoHist included cost of the machine (

Imiquimod 5% Cream: A Review of Its Safety and Efficacy in the Management of Superficial Basal Cell Carcinoma

20,000), cost of consumables (cellophane

Periorbital Granulomatous Plaque

120/y), external power source, space requirements, and an additional source of cryogen (liquid nitrogen 5L/d). We describe a simple, efficient, durable, inexpensive, one-step, easily maintained, space-conserving system that uses stainless steel bars with embedding wells that reside within the cryostat for embedding and mounting tissue during Mohs micrographic surgery.

Oscillating Electric Dermatome Use for Harvesting Split-Thickness Skin Grafts

Imiquimod 5% cream (Aldara) was approved by the Food and Drug Administration for the treatment of non-facial superficial basal cell carcinomas (sBCC) in 2004 and has become one of the most commonly used topical treatments for this variant of basal cell carcinoma. Application of the cream once a day, 5 days per week for 6 weeks has demonstrated a clinical and histological cure rate approximating 80% for non-facial sBCCs. Erythema, erosions, and crusting are common local adverse events; but systemic side effects are much less common. The clinical use of imiqimod for nodular or facial basal cell carcinomas, particularly on the nose, has not been as successful. Cure rates range from 42%–76%, depending on the frequency and duration of use. Several reports have described the usefulness of imiquimod cream as an adjunctive therapy of basal cell carcinomas when combined with a surgical modality. However, most of these “adjunctive” studies were neither blinded nor controlled. We review the safety and efficacy of imiquimod 5% cream in the treatment of sBCC, report on its effectiveness in the treatment of nodular and facial basal cell carcinomas, and comment on its role as an adjunctive therapy.

Dapsone-responsive histiocytoid Sweet's syndrome associated with Crohn's disease

Case Presentation A healthy, 9-year-old boy presented with a 6-week history of an enlarging, nontender, erythematous plaque in the right periorbital region. It had commenced as a small pink papule near the right lateral canthus after a cat scratch. Previous treatment had included topical mupirocin, several courses of systemic antibiotics, and acyclovir without improvement. The patient had continued to feel well without any fevers or chills, changes in activity level, or ophthalmologic symptoms. Physical examination revealed an indurated, erythematous, slightly crusted plaque at the right periorbital region (Fig. 1). Several small, nontender, mobile, subcutaneous nodules were palpated radially along the right cheek. A skin biopsy specimen was obtained for histopathological evaluation (Figs. 2 and 3) and tissue culture.

Multiple mucinous (myxoid) cysts of a single finger.

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