Hugh M. Gloster

The epidemiology of skin cancer

BACKGROUND The incidence of skin cancer is increasing at an alarming rate. OBJECTIVE To discuss current epidemiologic data concerning the incidence, morbidity, environmental influences, predisposing, host conditions, precursor lesions, and prevention of melanoma and nonmelanoma (basal and squamous cell) skin cancer. METHODS The current literature ions reviewed in order to provide current epidemiologic data for melanoma, basal cell carcinoma (BCC), mid squamous cell carcinoma (SCC). RESULTS Skin cancer is exceedingly common and the incidence is rising rapidly. Although the mortality rate for nonmelanoma skin cancer (NMSC) is decreasing, that of melanoma is increasing. Both NMSC and melanoma are associated with significant morbidity. Whereas chronic sun exposure is the main cause of NMSC, the development of melanoma appears to be related to intense, intermittent sun exposure. Ozone depletion has contributed to rising incidence rates of both NMSC and melanoma. In contrast to NMSC, there is not a direct relationship between ultraviolet radiation and melanoma. Genetic susceptibility significantly increases the lifetime risk of acquiring melanoma. There is no precursor lesion for BCC. Precursor lesions for invasive SCC include actinic keratoses and SCC in situ. Melanoma may arise from benign nevi and dysplastic nevi. Prevention of melanoma and NMSC is extremely important since prognosis improves with early detection. Prevention may be achieved by educating patients and physicians how to detect skin cancers early and by decreasing or eliminating exposure to ultraviolet light. CONCLUSION The incidence of skin cancer has readied epidemic proportions. Only through heroic efforts by health care professionals and the general public to prevent the development or progression of skin cancer will this epidemic be abated. Dermatol Surg 1996;22:217‐226.

Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts

BACKGROUNDnThe documented presence of human papillomavirus DNA in the plume after carbon dioxide laser treatment of warts has raised questions about the risk of transmission of human papillomavirus to laser surgeons.nnnOBJECTIVEnWe sought to define more clearly the risks to surgeons of acquiring warts from the CO2 laser plume.nnnMETHODSnA comparative study was conducted between CO2 laser surgeons and two large groups of population-based control subjects (patients with warts in Olmsted County and at the Mayo Clinic from 1988 to 1992). Conclusions were drawn about the risks to surgeons of acquiring warts from the CO2 laser plume.nnnRESULTSnThere was no significant difference (p = 0.569) between the incidence of CO2 laser surgeons with warts (5.4%) and patients with warts in Olmsted County from 1988 to 1992 (4.9%). There was a significant difference between the incidence of plantar (p = 0.004), nasopharyngeal (p = 0.001), and genital and perianal warts (p = 0.004) in the study group and in patients with warts treated at the Mayo Clinic from 1988 to 1992. No significant difference was found between physicians who had acquired warts and those who were wart free, on the basis of the failure to use gloves (p = 0.418), standard surgical masks (p = 0.748), laser masks (p = 0.418), smoke evacuators (p = 0.564), eye protection (p = 0.196), or full surgical gowns (p = 0.216). Finally, the incidence rates of surgeons with warts per 1000 person-years did not increase significantly (p = 0.951) as the length of time that the CO2 laser was used to treat warts increased.nnnCONCLUSIONnWhen warts are grouped together without specification of anatomic site, CO2 laser surgeons are no more likely to acquire warts than a person in the general population. However, human papillomavirus types that cause genital warts seem to have a predilection for infecting the upper airway mucosa, and laser plume containing these viruses may represent more of a hazard to the surgeon.

Infection with mycobacterium abscessus after Mohs micrographic surgery in an immunocompetent patient.

Background Nontuberculous mycobacterial infections are increasing in incidence. They have been reported following multiple procedures, including dialysis, liposuction, soft tissue augmentation, pedicures, public baths, acupuncture, placement of contaminated foreign devices such as the Norplant (Wyeth Pharmaceuticals, Collegetown, PA, USA), intravenous catheters, and during surgery from contamination of medical instruments. Objective We report a case of Mycobacterium abscessus infection presenting as erythematous papules occurring after Mohs micrographic surgery. We also review the literature on nontuberculous mycobacterial infection to discuss common presentations, diagnosis, and treatment options. Methods/Materials One case presenting to an outpatient dermatology surgery clinic is presented with extensive review of the medical literature on M. abscessus. Results/Conclusion Infection with nontuberculous mycobacteria can present with varied nonspecific morphologies. A high degree of clinical suspicion is necessary to avoid delays in diagnosis and treatment.

Cryptococcal cellulitis in a diabetic, kidney transplant patient

The cutaneous manifestations of disseminated cryptococcosis are variable and include papules, plaques, nodules, draining sinuses, acneiform lesions, tumors, abscesses, ulcers, pustules, bullae, molluscum-like lesions, and cellulitis.8-1 0 Cryptococcal cellulitis has only been seen in patients with severe underlying diseases such as leukemiaf myeloma,8.11 systemic lupus erythematosusj chronic active hepatitis,? intestinal lymphangiectasia and congenital lymphedema.P as well as in kidney transplant recipients. 1-7 These patients had received immunosuppressive therapy, which in all cases included prednisone. Only a few cases of cryptococcal cellulitis in kidney transplant patients have been reported. 1-7 Most lesions occurred on an extremity and appeared abruptly as a single, tender, indurated, erythematous plaque that was initially mistaken for bacterial cellulitis and erroneously treated with antibiotics. Ours is only the third reported case of cryptococcal cellulitis with multiple sites of involvement.: 7 Methods of directly diagnosing cryptococcal cellulitis include Grams stain or india ink preparation of tissue aspirates and cultures of skin specimens. Cryptococcal cellulitis may histologically demonstrate a variable lymphohistiocytic infiltrate in the Hugh M. Gloster, Jr., MD, Robert A. Swerlick, MD, and Alvin R. Solomon, MD Atlanta, Georgia

The use of perichondrial cutaneous grafts to repair defects of the lower third of the nose

The reconstruction of surgical defects on the nasal tip and nasal ala which require both skincoverage and underlying support is often a complex surgical problem. The perichondrial cutaneous graft (PCCG) is a composite graft of skin and perichondrium harvested from the conchal bowl of the ear. It is an excellent alternative to full‐thickness skin grafts and local flaps for reconstructing defects of the lower third of the nose. This composite graft, which is composed of epidermis, dermis, a small amount of subcutaneous tissue, and the underlying perichondrium, yields excellent cosmetic and functional results in a simple, single‐stage, out‐patient procedure. This article describes and illustrates the repair of surgical defects on the nasal tip and nasal ala using the PCCG.

The Use of Full‐Thickness Skin Grafts for the Repair of Defects on the Dorsal Hand and Digits

background The hand is a complex part of the human body and plays an important role in our everyday lives. It is critical to preserve manual function when repairing surgical defects on the dorsum of the hand and digits. objective To demonstrate the effectiveness of the full‐thickness skin graft (FTSG) in the repair of surgical defects on the dorsum of the hand and digits. methods Through a retrospective review of photographic and written records and person‐to‐person interviews, the authors evaluated 19 patients who underwent FTSG repair of 21 defects on the dorsum of the hand and digits after Mohs micrographic surgery. results In all cases, the FTSG was durable, yielded good cosmetic results, and maintained normal function of the hand. conclusion The FTSG is a good option for repairing surgical defects on the dorsum of the hand and digits.

The efficacy of second-intention healing in the management of defects on the dorsal surface of the hands and fingers after Mohs micrographic surgery.

Background The type of repair chosen to manage defects on the dorsal aspects of the hands and fingers can affect overall hand function. Preservation of manual function in these areas is critical. Objective To evaluate the efficacy of second‐intention healing of defects on the dorsal surface of the hands and fingers after Mohs micrographic surgery and to define optimal wound parameters for choosing second‐intention healing. Methods Fifty‐nine patients who had undergone second‐intention healing of a Mohs defect on the dorsum of a hand or finger were contacted and their records obtained; 48 patients completed the study. Healing by second intention was assessed according to self‐evaluation and retrospective review of medical records based on six outcome variables, including functional ability, durability, sensation, and cosmetic result. Results Defects ranged in size from 0.8 to 6.0 cm. Patient records revealed no documented problems with function, durability, sensation, cosmesis, or wound infection. All patients reported excellent or good functional results and normal sensation within the scar, and most reported excellent or good scar durability and cosmesis. Conclusion Second‐intention healing is an effective option for repairing defects on the dorsum of the hand and fingers. Large defect size is not a contraindication for second‐intention healing.

A Malignant Granular Cell Tumor Excised with Mohs Micrographic Surgery

Malignant granular cell tumors are extremely rare, aggressive neoplasms displaying rapid growth and frequent associated metastatic disease. Excision and evaluation for metastatic disease are mandatory. We present a 54-year-old patient with a malignant granular cell tumor, treated with Mohs micrographic surgery. Cutaneous granular cell tumors are uncommon neoplasms, likely of perineural origin. Most follow a benign and uneventful course, with wide local excision being the treatment of choice (Enzinger, 1988). The malignant granular cell tumor is an extremely rare, aggressive variant, which provides a diagnostic challenge and management dilemma, especially with early presentation when it may be mistaken for other entities. There is also controversy regarding surgical management and follow-up of both benign and malignant granular cell tumors.

Combined hinge and nasolabial transposition flap for repair of a full-thickness nasal alar defect.

An otherwise-healthy 53-year-old man was referred for surgical treatment of a micronodular basal cell carcinoma in the left nasal alar groove. Mohs micrographic surgery was performed, with tumor-free margins achieved after three stages. The final defect was an ovoid 1.21.0-cm full-thickness nasal defect centered at the anterior aspect of the left nasal alar groove. How would you reconstruct this surgical defect?

Layered closure versus buried sutures and adhesive strips for cheek defect repair after cutaneous malignancy excision

BACKGROUNDnPrimary closure of surgical defects after excision of cutaneous malignancies has been traditionally accomplished with layered closure.nnnOBJECTIVEnWe sought to compare the cosmetic outcome of cheek defects repaired with layered closure versus buried sutures and adhesive strips.nnnMETHODSnIn all, 38 patients underwent excision of a cutaneous malignancy on the cheek by primary excision or Mohs micrographic surgery. Patients were prospectively randomized to receive layered closure to one half of the repair and buried sutures with adhesive strip closure for the other half of the repair. Follow-up assessment was performed by a blinded evaluator using a visual analog scale.nnnRESULTSnThere were no differences in scar contour, erythema, or overall cosmesis between closure types.nnnLIMITATIONSnAll study participants were Caucasian, with a mean age of 68 years, limiting generalizability of results.nnnCONCLUSIONnLayered closure does not have a cosmetic advantage over buried sutures and adhesive strips for the primary repair of cheek defects.