Paul G. Hazen

Hidradenitis Suppurativa: Successful Treatment Using Carbon Dioxide Laser Excision and Marsupialization

BACKGROUND Hidradenitis suppurativa (HS) is a disease associated with significant patient morbidity and less‐than‐ideal therapies. OBJECTIVES To determine the long‐ and short‐term benefits of carbon dioxide (CO2) laser excision and marsupialization in the management of persisent lesions of HS. METHODS Patients with long‐standing lesions of HS were treated using a CO2 laser to excise inflammatory and draining masses. RESULTS One hundred eighty‐five areas were treated in 61 patients using the CO2 laser excision and marsupialization technique in 154 sessions. Local anesthesia was used for all but three sessions. Healing occurred primarily through secondary intention. In follow‐up from 1 to 19 years, acceptable to excellent qualities of healing occurred. Recurrence within the treated area occurred in two of 185 sites treated. CONCLUSION CO2 laser excision and marsupialization appears to be an effective therapy for management of persisent or late‐stage HS. There was good patient comfort during and after treatment, lower costs than with inpatient modalities, good healing, and minimal risk of recurrence within the treated areas. The authors have indicated no significant interest with commercial supporters.

The superficial mycoses and the dermatophytes

More than 100,000 species of fungi have been identified worldwide, but only a few dozen are of medical significance. Because of the opportunistic nature of these organisms and the prevalence of immunodeficient conditions, the number of medically important fungi is increasing. Identification of the causative organism is of value in the choice of correct therapy. The development of new antifungal drugs has made it increasingly important to be able to distinguish one fungus from another. This article reviews the laboratory diagnosis of the fungi generally classified as the superficial mycoses and the dermatophytes.

Isotretinoin treatment of Darier's disease

A total of 104 patients with Dariers disease were treated with 13- cis -retinoic acid (isotretinoin) at nineteen medical centers. Clinical evaluation by both physicians and patients indicated that the drug is very effective in alleviating Dariers disease but does not produce prolonged remissions.

Itraconazole in the prevention and management of dermatophytosis in competitive wrestlers

12. Merman JS, Sober AJ, Merman GS. Immunosuppression: a cause of porokeratosis. J Am Acad Dermatol 1985; 13:75-9. 13. Inamato N, Watanabe T, Nakamura K. Porokeratosis of Mibelli: benzylhy~ochlorthiazide induced new lesions accompanied by eosinophilic spongiosis. J Am Acad Dermatol 1984; 11:357-61. 14. James WD, Rodman OG. Squamous cell carcinoma arising in porokeratosis of Mibelli. Int J Dermatol 1986;25: 389-91. 15. MacMillan AL, Roberts SOB. Porokeratosis of Mibelli after renal transplantation. Br J Dermatol t974;90:45-51. 16. Goertfler EA, Jung EG. Pamkeratosis Mibelli and skin carcinoma. Humangenetik 1975;26:291-6. 17. Otsuka F, Iwata M, Watanabe R, et al. Porokeratosis: clinical and cellular characterization of its cancer-prone nature. J Dermatol 1992;19:702-6.

Angiosarcoma of the Head and Neck Managed by a Combination of Multiple Biopsies to Determine Tumor Margin and Radiation Therapy: Report of Three Cases and Review of the Literature

background. Cutaneous angiosarcoma (AS) is a rare, often multicentric vascular tumor of the head and neck region with a rather poor prognosis. The original clinical size of the tumor rarely correlates to the degree of microscopic tissue invasion. Treatment by surgical excision sometimes requires very wide excision. Treatment by radiation or electron beam appears less mutilating but its efficacy is not well documented. objective. To present our experience with a combined surgical delineation of tumor margins followed by radiation treatment. methods. We treated three patients with extensive AS of the scalp and face. Prior to radiation, in two cases the tumor margins were determined by grid‐pattern punch biopsies. In the third patient, the tumor margins were determined by Mohs mapping system. All three patients then received radiation either by rotational arc electron beam (n = 2) and standard radiation. results. One patient developed two local recurrences in non‐irradiated areas plus a metastatic cervical node, all of which responded to additional electron beam. The patient has no evidence of disease (NED) after 30 months of observation. The other two patients were treated by electron beam and radiation have NED at 5 and 1 years follow‐up, respectively. conclusions. Local control of AS of the scalp may be achieved by assessment of the tumor margin by peripheral biopsies or Mohs technique followed by electron beam and radiation.

Keratitis, ichthyosis, and deafness (KID) syndrome: management with chronic oral ketoconazole therapy.

Extensive cutaneous mycoses have been described in patients with the keratitis, ichthyosis, and deafness (KID) syndrome. We present a case occurring in a 48‐year‐old woman where improvement in the ichthyosiform dermatosis, stabilization of her ocular disease, and apparent partial prevention of further cutaneous malignancies occurred in association with ketoconazole therapy.

Prenatal diagnosis for keratin mutations to exclude transmission of epidermolytic hyperkeratosis.

Epidermolytic hyperkeratosis (bullous congenital ichthyosiform erythroderma) is an autosomal dominant skin disorder caused by mutations in keratins 1 and 10. We have used direct gene sequencing to ascertain the status of a 15 week fetus of parents whose first child was affected with this disorder. The parents show no clinical signs of epidermolytic hyperkeratosis but were concerned about the possibility of transmitting the disorder due to germline mosaicism. Molecular analysis of the affected son revealed a G to A mutation in codon 156 of keratin 10, resulting in an arginine to histidine substitution within the highly conserved 1A region. Codon 156 has been previously identified as a mutational hot spot and substitutions of this arginine residue are very common in epidermolytic hyperkeratosis patients. Analysis of genomic DNA isolated from amniotic cells showed that the fetus did not harbour this mutation and a healthy infant was eventually born that was unaffected by this disorder.

New and traditional surgical approaches to hidradenitis suppurativa.

When the prevention of new lesions fails and when medical therapy of established and growing lesions is ineffective, surgery is the accepted method of dealing with hidradenitis suppurativa/acne inversa. The rationale and preferred techniques of mini-unroofing using a biopsy punch, deroofing using scissors, electrosurgery or laser, and classical wide excision and closure are discussed. The situation in which incision and drainage is considered for temporary pain relief would be best considered an opportunity for deroofing, as illustrated in the accompanying online videos.

Acanthosis nigricans presenting as hyperkeratosis of the palms and soles.

A patient with an unusual form of palmoplantar hyperkeratosis is described. On thorough physical examination, widespread acanthosis nigricans was discovered. We believe this patients distinctive keratoderma represents acanthosis nigricans.

Basal Cell Nevus Syndrome

A single patient with basal cell nevus syndrome is presented. Prolonged application of 5% 5-fluorouracil and dinitrochlorobenzene was unsuccessful in inducing regression or clearing of his cutaneous l