Jacob S. Lo

DRESSING THE PART

Wound care after cutaneous surgery can play an integral role in wound healing. Wound care regimens have changed dramatically over the last 35 years as the physiology of wound healing has become better understood. Foremost is the improvement in wound healing achieved by keeping the wound occluded and moist. This observation has led to an explosion of a whole new category of occlusive dressings at the surgeons disposal in healing postoperative wounds. These dressings have numerous applications as discussed previously. Generally, for acute surgical wounds, occlusive dressings are most useful for split-thickness wounds, such as graft donor sites and after dermabrasion, chemical peel, or laser treatment, and full-thickness wounds allowed to heal by secondary intention. Occlusive dressings may have greater benefit for the treatment of chronic ulcers of varying etiologies. The different categories of dressings share the common disadvantage of being relatively expensive. For routine sutured wounds, the authors prefer the readily available and inexpensive Telfa-type dressing combined with a topical antibiotic ointment. Topical antiseptics are useful for reducing bacterial counts on intact skin in preparation for surgery. Povidone-iodine (Betadine) and chlorhexidine gluconate (Hibiclens) have emerged as the two agents of choice. However, antiseptics have been shown to be toxic to healing tissue, and should not be used on open wounds. In contrast, topical antibiotic ointments are safe to use on open wounds, effective in preventing wound infections, and promote wound healing by maintaining a moist wound environment. The authors prefer the combination antibiotic ointment Polysporin for routine postoperative wound care. Antibiotic prophylaxis in dermatologic surgery to prevent wound infection is appropriate in certain cases. Surgery performed on grossly contaminated or infected skin requires a full 7 to 10 day course of antibiotics. Procedures in anatomic areas considered contaminated as well as in clean areas with significant environmental or patient risk factors may benefit from antibiotic prophylaxis. The choice of antibiotics should be based on the organism most likely to cause wound infection at the particular surgical site. Evidence supports giving a single preoperative dose 1 hour before surgery with a second dose possible 6 hours later if the procedure is prolonged or delayed. The risk of bacterial endocarditis after dermatologic surgery is not known. Antibiotics are indicated for any procedure on obviously infected skin, but are not routinely required for very minor procedures, such as small biopsies, on intact skin. Antibiotic prophylaxis may be prudent for those patients classified as high risk by the (AHA). The antibiotic chosen should again cover the organism most likely to cause infection. One dose can be given 1 hour before surgery and repeated 6 hours postoperatively. Finally, wound healing can be greatly impacted by what the patient does or does not do after leaving the office. Therefore, wound care instructions should be clear, detailed, and provided in both oral and written form. Information should also be provided about what to expect as the wound heals.

Transepidermal potassium ion, chloride ion, and water flux across delipidized and cellophane tape-stripped skin

The skin barrier was evaluated as a function of transepidermal water loss (TEWL) and electrolyte loss. Combination electrodes for chloride and pH determinations and a potassium ion electrode were utilized. Delipidization of the skin did not impair the electrolyte barrier, but did damage the epidermal water barrier. Cellophane tape stripping of normal stratum corneum resulted in an increase in outward transepidermal potassium and chloride ion flux, an increase in skin surface pH, and an increase in TEWL. It appears that damage to the epidermal water barrier does not necessarily result in damage to the epidermal electrolyte barrier. We found the potassium electrode facile to use and believe that a combination potassium electrode would be useful for investigating and assessing the epidermal electrolyte barrier.

Metastatic basal cell carcinoma

Background. Metastatic basal cell carcinoma (MBCC) is rare. Risk factors for the development of MBCC include a history of persistent basal cell carcinoma (BCC) for many years, refractory to conventional methods of treatment and previous radiation treatment either in early adulthood or for localized cancer. Most MBCC originate from large tumors. Methods. The authors report five patients with basal cell carcinomas (BCC) of the ear (two patients), scalp, inner canthus, and nasolabial fold that metastasized to the regional lymph nodes, skin, and submandibular gland. In addition, the authors reviewed more than 40 reports of MBCC (n = 65) from 1981 to 1991 and tabulated the primary tumors by size and depth of invasion according to TNM classification, a classification that previously has not been used for BCC. Results. The authors tabulated the size distribution of tumors of 45 patients with MBCC. The overall mean and median diameters of the primary BCC were 8.7 and 7.0 cm, respectively. The mean area of the primary MBCC lesion that originated on the face and trunk was 62 and 217 cm, respectively. Using the TNM classification, approximately 9% of MBCC originate from tumors smaller than 10 cm. In addition, the authors found that large (T2 and T3) and deep (T4) BCC account for approximately 75% of the metastatic tumors. Metastatic BCC from pri-

Syringomas on the Penis

An elderly gentleman with pemhigus vulgaris was noted to have multiple Beaus lines. The lines were associated with each acute exacerbation of this disease. Beaus lines are transverse furrows that begin proximal to the lunula beneath the proximal nail fold and progress distally with nail growth. They are ascribed to the temporary arrest of function of the nail matrix associated with systemic diseases, local trauma, drugs, and infection. When the process is intermittent, the nail becomes grooved,

Granuloma Annulare Associated with Metastatic Adenocarcinoma

• A 59-year-old man with a history of metastatic adenocarcinoma from the cecum and ascending colon was referred to us for evaluation of asymptomatic, red, minimally raised plaques on the elbows and knees. The lesions had been present for a month prior to our evaluation. The patient had no history of psoriasis, diabetes mellitus, or trauma. His family history was noncontributory, and his medical history was significant only for hypertension. He underwent a laparotomy in January, 1988, at which time a right colectomy was also performed. Omental and hepatic metastases were noted at that time. He had no history of bone pain, cough, hemoptysis, or weight loss. He has no known drug allergies and he was only on verapamil at the time of evaluation. A computed tomography (CT) scan of the abdomen on July 13, 1988 showed para-aortic adenopathy and progression of hepatic metastases. The lesions were increased in size when compared to the previous CT scan obtained on May 2, 1988. The adrenal glands appeared to be normal in size and there was no evidence of retroperitoneal lymphadenopathy. Review ofthe slides obtained at the time of laparotomy showed adenocarcinoma ofthe cecum and ascending colon. A lymph node obtained from the region ofthe cecum and ascending colon also showed metastatic adenocarcinoma. The adenocarcinoma was moderately differentiated and deeply infiltrating, extending through the muscular wall ofthe colon into the pedcolic adipose tissue. The tumor appeared to infiltrate at the serosal surface. Portions of five lymph nodes were available for examination. All showed metastatic adenocarcinoma. Carcinoembryonic antigen (CEA) was elevated at 18.8 ng/ml (normal less than 2.3) on September 13, 1988. Results of complete blood count and SMA-17 profile were within normal limits.

RETICULATE NONMELANOCYTIC HYPERPIGMENTATION ANOMALY : A PROBABLE VARIANT OF DOWLING-DEGOS DISEASE

ABSTRACT: A 26‐year‐old white woman had reticulate nonmelanocytic hyperpigmentation anomaly characterized by partially blanching red‐brown papules and macules and a histologic picture of digitate epithelial budding proliferation with lightly pigmented rete ridges. Except for the classically described hyperpigmentation at the rete ridge tips, the patient has Dowling‐Degos disease. This case of a reticulate nonmelanocytic hyperpigmentation anomaly is probably a variant of Dowling‐Degos disease.

Kaposi's sarcoma, angioimmunoblastic lymphadenopathy, and antibody to HIV-1 p24 antigen in a patient nonreactive for HIV-1 with use of ELISA

1. Biro L, Price E, Brand A. Cryosurgery for basal cellcarcinoma of the eyelids and nose: five-year experience. J AM ACAD DERMATOL 1982;6:1042-7. 2. Domonkos AN. Treatment of eyelid carcinoma. Arch DermatoI1965;91:364-71. 3. Zacarian SA. Cryosurgeryfor skin cancer and cutaneous disorders. St Louis: CV Mosby, 1985:96-102. 4. Kuflik EG. Cryosurgery forcarcinomaof the eyelids: a 12year experience. J DermatolSurg Oncol 1985;11 :243-6.