Mariah Brown

Identifying and Managing Local Anesthetic Allergy in Dermatologic Surgery.

BACKGROUND Local anesthetic (LA) allergy is a concern for dermatologic surgeons given the large number of procedures performed yearly with LAs. Many patients also have anxiety about past or potential anesthesia allergy. OBJECTIVE This article will review the symptoms of IgE-mediated allergic reactions, the prevalence of IgE-mediated LA allergy, discuss common mimics of LA, and propose a practical approach for diagnostic and therapeutic options for LA allergy for the dermatologic surgeon in practice. MATERIALS AND METHODS A literature search of Pubmed using keywords “lidocaine,” “local anesthetic,” “hypersensitivity,” and “allergy” was performed. RESULTS Amide anesthetics result in the most reports of true local anesthetic immediate hypersensitivity. CONCLUSION True IgE-mediated anaphylaxis to local anesthesia is very rare. Dermatologic surgeons should be aware of the symptoms of anesthetic allergy and its mimickers, as well as how to manage allergic reactions in their clinical practice.

Small Molecule Inhibitors of the Hedgehog Pathway in the Treatment of Basal Cell Carcinoma of the Skin

Basal cell carcinoma (BCC) is the most common type of skin cancer, with rising incidence rates primarily attributed to an aging population and ultraviolet radiation exposure. While the majority of BCCs are localized and respond to standard therapies, a very small minority of these tumors become locally destructive or metastasize. These advanced BCCs may not be amenable to localized treatment with surgery and/or radiation therapy. Most BCCs result from mutations in key receptors in the Hedgehog (HH) signaling pathway. As a result, identification of drugs that inhibit the receptor Smoothened (SMO) in the HH pathway has resulted in novel therapeutic approaches to treating patients with advanced BCC. These HH-pathway inhibiting medications have shown efficacy in clinical trials, and two medications, vismodegib and sonidegib, have received FDA approval. However, several limitations of these drugs have been identified, including treatment-limiting adverse events, drug resistance, and the formation of additional malignancies. This paper aims to summarize the clinical trials leading to the approval of SMO inhibitors, as well as reviewing potential mechanisms driving tumor resistance and the formation of cutaneous squamous cell carcinomas. Strategies to overcome some of these challenges, including the development of drugs that inhibit other downstream targets in the HH pathway, are the subject of ongoing clinical trials.

Cutaneous spindle cell carcinoma misdiagnosed as atypical fibroxanthoma based on immunohistochemical stains

Poorly differentiated spindle cell neoplasms pose a diagnostic challenge for dermatopathologists because of a lack of specific morphologic features on standard histopathology. Further characterization with immunohistochemical (IHC) studies is frequently required. We present a fatal case of spindle cell squamous cell carcinoma (SCC) misdiagnosed as atypical fibroxanthoma (AFX) based on a limited panel of IHC markers.

Tattoo reactions in an HIV patient: Autoeczematization and progressive allergic reaction to red ink after antiretroviral therapy initiation

Complications of tattoos are a growing concern, especially because more than 21% of American adults now have at least 1 tattoo.1 Overall, few tattoo reactions have been described in HIV patients, and all of the cases reported occurred after antiretroviral therapy (ART) initiation, attributed either to immune reconstitution syndrome (IRS) or leishmaniasis infiltration.2, 3, 4, 5, 6, 7 To our knowledge, there are no reported cases of tattoo reaction in HIV patients not on ART. We describe an HIV patient with an allergic tattoo reaction at baseline that dramatically worsened after ART initiation, which was further complicated by a severe id reaction.

Breast carcinoma masquerading as basal cell carcinoma of the nipple

Basal cell carcinoma (BCC) is the most common type of skin cancer and is seen rarely on the nipple-areolar complex (NAC) in men and women. We present a case of a 47-year-old woman referred for Mohs micrographic surgery (MMS) for BCC on the nipple. Close examination of frozen section specimens during MMS and rebiopsy led to the correct diagnosis of invasive breast cancer. This case emphasizes the histologic importance of remaining vigilant when interpreting Mohs pathology and the importance of understanding immunohistochemical stains.

Undermining and Hemostasis.

BACKGROUND Undermining and hemostasis are basic surgical techniques that can have a significant impact on surgical outcomes. OBJECTIVE To review the mechanisms and techniques of undermining and hemostasis, with an emphasis on the advantages and limitations of each modality. MATERIALS AND METHODS The PubMed database was searched for articles with the keywords “undermining,” “hemostasis,” and “electrosurgery.” RESULTS Whether performing blunt, sharp, or electrosurgical techniques, undermining at the appropriate depth and width is necessary for tissue movement during closures. Both excessive and inadequate undermining can compromise surgical healing. Surgical hemostasis techniques include pressure, suture ligation, topical hemostatic agents, and electrosurgery. Dermatologic surgeons should select the appropriate amount and type of hemostasis for each procedure. Particular care should be taken in performing electrosurgery, given the potential for complications. CONCLUSION Understanding and optimizing hemostasis and undermining will allow dermatologic surgeons to execute complex closures with minimal complications.

Second Intention Healing for Large Surgical Defects of the Foot.

Reconstructive options are limited for surgical defects on the plantar aspect of the foot. Primary or local flap closures are restricted by a lack of tissue mobility and local tissue reservoirs. Free flaps or complex pedicled flaps based on named arteries require specialized knowledge of anatomy and microvascular surgery. As a result, dermatologic surgeons frequently use splitor full-thickness skin grafts on the plantar surface of the foot. Skin grafts on the feet have several disadvantages, including cost, creation of a second surgical site, and the need for the patient to be completely non–weight bearing or even casted during healing to allow for graft take.

ASDS Cosmetic Dermatologic Surgery Fellowship Milestones

BACKGROUND The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of “milestones,” standard levels of achievement keyed to particular time points, to assess trainee performance during residency. OBJECTIVE To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. METHODS An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. RESULTS Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. CONCLUSION Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.

Advanced acral melanoma.

In the United States, the incidence of melanoma is increasing faster than any other preventable cancer. Acral melanoma is the fourth most common type of cutaneous melanoma and is frequently diagnosed later in its course compared with melanoma in other anatomic locations. Here we describe a case of highly advanced acral melanoma.

Immunobiology and Immune Based Therapies of Melanoma

Despite efforts in preventative care, the incidence and mortality rate of melanoma have continued to rise. However, in the past decade, an increasing understanding of melanoma immunology has resulted in tremendous bench to bedside advancements in melanoma therapies. Many of these new treatment modalities have proven efficacious, leading to seven new melanoma therapies receiving FDA approval within the past 5 years. This chapter explores our current understanding of melanoma immunology, with an emphasis on tumor microenvironment and the ability of melanoma to evade immune surveillance. The remainder of the chapter focuses on how this understanding of melanoma immunology has been translated into clinical therapies. These agents include cytokines such as interleukin-2 and interferons, checkpoint inhibitors such as anti-CTLA4 and anti-PD1 antibodies, and vaccines. For each melanoma therapy, mechanism of action, efficacy, side effects, dosing strategy and future directions will be discussed.