Jennifer T. Trent

Wounds and malignancy.

Due to the prevalence of skin cancers, health care practitioners involved with wound management are likely to encounter cutaneous malignancies as part of their practice. This article focuses on 2 ways in which malignancies and wounds are related: the malignant degeneration of chronic wounds into cancer and malignancies that present as chronic wounds. The most common scenario in which chronic wounds have been associated with the development of squamous cell carcinoma is in the presence of chronic osteomyelitis. However, wounds secondary to burns, trauma, radiotherapy, and diabetes are also at risk for malignant degeneration. It is often difficult to distinguish malignant transformations from primary malignant ulcers. Given the uncommon nature of degeneration of a chronic wound or a malignancy presenting as a chronic wound, some suggest that only suspicious wounds undergo biopsy. Primary malignancy should be considered if the ulcer has a relatively short duration and the patient does not have a history of prior radiotherapy. Until recently, amputation has been the treatment of choice for squamous cell carcinomas that arose within chronic wounds associated with chronic osteomyelitis; however, other reports have shown that other methods of ensuring complete local excision are also useful.

Leg ulcers in sickle cell disease.

410 WWW.WOUNDCAREJOURNAL.COM Sickle cell disease (SCD) is an inherited blood disorder that causes the bone marrow to produce red blood cells with defective hemoglobin, hemoglobin S (sickled hemoglobin). Leg ulcers are the most common cutaneous manifestation of SCD.1 These ulcers are characterized by an indolent, intractable course, typically healing up to 16 times slower than venous ulcers.2 A patient who experiences his or her first sickle cell ulcer is likely to ulcerate again: Approximately 97% of healed sickle cell ulcers will recur in less than 1 year.3 Due to the recalcitrant nature of these ulcers, patients may experience significant disfigurement, social isolation, and loss of income. The incidence of leg ulcers in patients with SCD ranges from 25.7% to 75%.3,4 Risk factors for the development of ulcers include being older than 20 years, being male, having a lower level of fetal hemoglobin and a hemoglobin level less than 6 g/dL, having antithrombin III deficiency, possessing certain human leukocyte antigens (HLA), having thrombocytosis, and living in certain geographic areas.1,5,6 History of a sickle cell leg ulcer carries a 23-fold increased risk of developing future ulcerations; having 1 active ulcer carries a 146-fold increased risk.1 Prognosis improves in these patients, however, with the presence of sickle/beta-thalassemia and sickle C hemoglobin.5

Hospitalization for severe skin disease improves quality of life in the United Kingdom and the United States: a comparative study

BACKGROUND Financial and managerial constraints have resulted in the rationalization of dermatology inpatient services in the United Kingdom and the United States. Therapeutic regimes may vary locally, regionally, and internationally but the clinical outcome of treatment remains the same. OBJECTIVE We studied 2 inpatient units: the University of Wales College of Medicine, Cardiff, United Kingdom, and the University of Miami School of Medicine, Miami, Florida, to compare the use and effectiveness of the service provided. METHODS Data were collected prospectively from inpatients during a 12-month period. The Dermatology Life Quality Index was administered on admission and after discharge. Data were recorded about the diagnosis, duration of admission, and referring dermatologist. RESULTS In all, 295 patients (Cardiff, UK) and 366 patients (Miami, Fla) participated. The average duration of admission in Miami was 6.7 days compared with 14.2 (P <.0001) in Cardiff. In Miami, the most common reasons necessitating admission were extensive disease (54%), the patient being unwell (18%), photophoresis (14%), outpatient treatment failure (8%), and acute deterioration of disease (4%). In Cardiff, the common reasons were acute deterioration (35%), extensive disease (28%), outpatient treatment failure (22%), and liver biopsy (4%). The most common diagnoses in Cardiff were psoriasis (31%) and eczema (26%). In contrast, the most common diagnoses in Miami, were psoriasis (19%), leg ulcers (17%), and mycosis fungoides (14%). The mean Dermatology Life Quality Index value for all patients decreased after admission in Cardiff (14.9-8.2, P <.0001) and Miami (12.0-8.5, P <.0001). CONCLUSION Despite the differences in the 2 health care systems, inpatient therapy remains an important and effective therapeutic option in the United States and the United Kingdom.

Epidermolysis bullosa: identification and treatment.

284 WWW.WOUNDCAREJOURNAL.COM Epidermolysis bullosa (EB) comprises a group of inherited disorders that are characterized by cutaneous blisters and mucosal erosions, usually resulting from minor trauma and evolving into chronic wounds.1 Genetic defects lead to abnormal protein formation. These abnormal proteins cause skin fragility, blistering, and ulceration.The term epidermolysis bullosa was first used to describe this disorder by Koebner in 1886.1 The incidence of EB ranges from 1:50,000 for the autosomal dominant forms to 1:300,000 for the autosomal recessive forms.2

Mucoepidermoid carcinoma (adenosquamous carcinoma) treated with Mohs micrographic surgery

Background  Mucoepidermoid carcinoma (MEC), sometimes referred to as adenosquamous carcinoma (ASC), is a common malignant tumor of the salivary glands that can also develop from the esophagus, lacrimal passages, lung, upper respiratory tract, pancreas, prostate and thyroid. Rarely, MEC will present primarily in the skin.

Cutaneous manifestations of HIV: a primer.

PURPOSE:To provide physicians and nurses with an overview of the characteristics and treatments for skin lesions associated with HIV/AIDS. TARGET AUDIENCE:This continuing education activity is intended for physicians and nurses with an interest in identifying and managing skin lesions in patients with HIV/AIDS. OBJECTIVES:After reading the article and taking the test, the participant will be able to: 1. Identify the characteristics of skin lesions associated with HIV/AIDS. 2. Identify treatment options for skin lesions associated with HIV/AIDS.

Identifying and Treating Mycotic Skin Infections

PURPOSE To provide physicians and nurses with an overview of mycotic infections and related cutaneous manifestations. TARGET AUDIENCE This continuing-education activity is intended for physicians and nurses with an interest in learning how to recognize and treat mycotic skin infections. OBJECTIVES After reading the article and taking the test, the participant will be able to:1. Identify the cause and clinical presentation of mycotic skin infections.2. Identify diagnostic tests used in evaluating patients with mycotic skin infections.3. Identify appropriate treatment options in patients with mycotic skin infections.

Skin and wound biopsy: when, why, and how.

372 WWW.WOUNDCAREJOURNAL.COM Biopsies are the cornerstone of dermatologic office surgery techniques. They aid in diagnosis and, for certain lesions, are a treatment. Prior to obtaining the biopsy specimen, the clinician must consider the type and location of the lesion and the reason for performing the biopsy.1 The answers to these questions will determine the biopsy technique used, the solution for transport and/or storage, and whether the clinician should suggest certain stains to the dermatopathologist for evaluation.2 To improve the likelihood of a correct diagnosis, lesions chosen for biopsy should be fully developed. An exception to this occurs with vesicles, bullae, and pustules. For these lesion types, a developing lesion should be biopsied, optimally one that has arisen within the prior 24 hours.3 Vesicles, bullae, and pustules should be biopsied as early as possible so that associated inflammation and regeneration of the blistered epithelium do not obscure the original pathology. In all cases, virgin lesions, those lesions that have not been mechanically or chemically manipulated, should be targeted for biopsy.

Dose of intravenous immunoglobulin and patient survival in SJS and toxic epidermal necrolysis

Toxic epidermal necrolysis (TEN) is a rare, life-threatening hypersensitivity reaction to certain medications. Keratinocytes affected by TEN have been found to undergo Fas–FasL-mediated apoptosis. Intravenous immunoglobulin (IVIG) has been shown to inhibit this interaction. However, conflicting reports have led to controversy regarding the use and dosage of IVIG for the treatment of TEN and Stevens–Johnson Syndrome (SJS). The aim of this article is to analyze both our experience and the published literature regarding IVIG treatment of adult patients with SJS and TEN to determine whether a dose response exists. We searched Medline for all studies involving the use of IVIG for TEN or SJS. We categorized total IVIG dose and used Cochran-Armitage Trend Test to examine whether high doses were associated with improved survival. We also performed multivariate logistic regression analysis to evaluate total IVIG dose and mortality after controlling for age and body surface area. There are several limitations to th...

Incorporating laboratory values in chronic wound management.

PURPOSETo provide physicians and nurses with an overview of 3 common chronic wounds and the laboratory values that can be used to assist in accurately diagnosing them. TARGET AUDIENCEThis continuing education activity is intended for physicians and nurses with an interest in tools that can assist in accurately diagnosing chronic wounds. OBJECTIVESAfter reading the article and taking the test, the participant will be able to:Describe the pathophysiology, assessment, and management of pressure, venous, and arterial ulcers.Identify laboratory values that can assist in diagnosing chronic wounds.