Michael J. Wells

Linear Morphea Presenting as Acquired Unilateral Edema

Abstract:  We describe a 2‐year‐old African‐American boy with a 4‐month history of gradually worsening unilateral edema that was initially noted on his left hand and then approximately 2 weeks later on his left lower extremity. In addition, linear hypopigmented patches were noted along the left forearm and leg, with no appreciable scarring or induration. The edema on the left‐hand side of his body progressed so that he developed tense bullae on his left hand. Two months later, the hypopigmented patches were indurated and bound‐down, especially over the left groin and thigh. A biopsy specimen from this area showed features characteristic of morphea. In this patient, dilated lymphatic channels secondary to the sclerosis of the morphea caused the bullae. Bullous morphea is a rare condition. We were unable to find any reports its occurrence in children under 18 with associated lymphedema. This entity should be included in the differential for acquired unilateral edema in children.

Mohs Micrographic Surgery for Penoscrotal Malignancy

Mohs micrographic surgery (MMS) has been shown to reduce recurrence rates when used to excise many different mucocutaneous neoplasms, especially of the head and neck. The low recurrence rates are due to careful microscopic evaluation of the horizontal and vertical surgical margins. This article discusses the utility and limitations of MMS in controlling neoplasia of the male genitalia. Specific penoscrotal neoplasias discussed in this article include invasive and in situ squamous cell carcinoma, basal cell carcinoma, extramammary Paget disease, and granular cell tumor.

Irradiated polyglactin 910 (Vicryl Rapide) for placement of full-thickness skin grafts.

Background The “unsuture” technique originally reported with the use of fast-absorbing gut for the placement of full-thickness skin grafts has provided years of successful full-thickness graft placement without the need for suture removal. Objective The objective was to explore another option for successful graft placement and survival using irradiated polyglactin 910 (Vicryl Rapide, Ethicon Inc, Somerville, NJ, USA), with its longer tensile strength of 7 to 10 days. Methods Irradiated polyglactin 910 was used to suture the edges and place basting sutures in full-thickness skin grafts. Results In our experience, we have found that the use of irradiated polyglactin 910 for the placement of full-thickness skin grafts provides an alternative to the “unsuture” technique with fast-absorbing gut. It provides excellent graft survival, easy workability, low inflammation, and good long-term cosmesis, without the need for suture removal. Conclusion Irradiated polyglactin 910 provides another option for the placement of full-thickness skin grafts without the need for suture removal.

Perineural extension of cutaneous desmoplastic melanoma mimicking an intracranial malignant peripheral nerve sheath tumor

The authors present a case illustrating the importance of obtaining a biopsy of any facial skin lesions in a patient presenting with an intracranial tumor involving the facial or trigeminal nerve. Conventional malignant melanoma metastasizes to the brain frequently and does not usually pose diagnostic difficulties. Direct intracranial spread of cutaneous melanoma is rare. In our patient, desmoplastic melanoma with perineural spread to the Meckel cave mimicked a malignant peripheral nerve sheath tumor clinically, radiographically, and histologically.

JAAD Grand Rounds quiz

LEARNING OBJECTIVES At the conclusion of this learning activity, physician participants should be able to assess their own diagnostic and patient management skills and use the results of this exercise to help determine personal learning needs that can be addressed through subsequent CME involvement. Instructions for claiming CME credit appear in the front advertising section. See last page of Contents for page number. Instructions: In answering each question, refer to the specific directions provided. Because it is often necessary to provide information occurring later in a series that gives away answers to earlier questions, please answer the questions in each series in sequence.

Milia-like papules on upper trunk, neck, and left forehead

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The Beveled Edge Technique for Harvesting of Full-Thickness Skin Grafts

Background Mohs surgery often uses the creation of a “beveled edge” of 45 degrees during the staged excision of skin cancers. Reconstruction of these defects frequently requires the use of full-thickness skin grafts. Because most wounds are best repaired with 90-degree edges, the beveled incision technique often used in Mohs micrographic surgery creates a wound that may need to be modified prior to reconstruction. Objective We present a method of harvesting the graft with a similar 45-degree angle beveled incision. Methods After marking, preparing, locally anesthetizing, and draping the donor site, the graft is harvested using a 45-degree angled incision. Any remaining fat is trimmed away from the base of the graft. The graft is then placed directly on the surgical defect without any “freshening” of the wound edges and is sutured into place. Results The graft takes well on the surgically created defect, leaving a cosmetically acceptable result. Conclusion We have found that harvesting the graft with a beveled incision of 45 degrees, similar to taking Mohs stages, hastens the repair process. This obviates the need to remove normal tissue to create a 90-degree angle and allows for better approximation of the dermal surface area of the graft to the base of the defect.

JAAD Grand Rounds quiz∗ : Neonate with extensive papulovesicles

Instructions: In answering each question, refer to the specific directions provided. Because it is often necessary to provide information occurring later in a series that give away answers to earlier questions, please answer the questions in each series in sequence.

Decades of progressive red and yellow nodules

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