Paul T. Martinelli

The purse-string suture revisited: a useful technique for the closure of cutaneous surgical wounds

The purse‐string suture provides complete or partial closure of round postoperative skin defects. It is a rapid and simple procedure to perform. Tension placed on the suture uniformly advances the skin from the entire periphery of the wound, resulting in a significant reduction of the defect size and enhancement of hemostasis at the wound edge. The history, modifications of the technique, advantages, and potential complications of the purse‐string suture are reviewed. It is not only useful following the removal of nonmelanoma skin cancer but also after the local excision of melanoma. In addition, this technique is especially suitable for the repair of round surgical wounds for patients who are unable to modify their active lifestyles during the week following surgery, individuals concurrently being treated with anticoagulants, antiplatelet agents or both, and people with extensive postoperative defects that would otherwise require either a skin graft or a large cutaneous flap. Typically, the site of the surgical wound following partial or complete closure with the purse‐string suture demonstrates excellent long‐term cosmetic and functional results.

The cuticular purse string suture : a modified purse string suture for the partial closure of round postoperative wounds

Background  The purse string suture can be used to provide primary closure for small skin defects or as a partial closure for larger round wounds. The size of the defect is reduced secondary to the tension placed on the suture, which uniformly advances the skin from the entire periphery of the wound.

Trigeminal trophic syndrome

Ulceration of the nose may be inadvertently induced by the patient. Although trigeminal trophic syndrome is an uncommon cause of chronic ulcers, healthcare providers should consider the possibility of this disorder when encountering a patient with nasal ulcerations. Trigeminal trophic syndrome most commonly occurs in older women following therapy for trigeminal neuralgia. The ulcers usually involve the nasal ala and paranasal areas. The clinical vignette of a man with a self-induced nasal ulcer secondary to trigeminal trophic syndrome, which was initially suspected to be skin cancer, is presented. Since nasal ulcerations can be secondary to other conditions, a lesional biopsy should be performed to exclude other diagnoses when trigeminal trophic syndrome is entertained. In addition to trigeminal trophic syndrome, the differential diagnosis of conditions that can cause nasal ulcers include factitial disorders with self-induced ulcerations (such as dermatitis artifacta and neurotic excoriations), granulomatous conditions, infectious diseases, malignancy, and pyoderma gangrenosum. Treatment of trigeminal trophic syndrome requires prevention of digital manipulation of the lesion—either by occluding contact with the ulcer, initiating psychotropic medication, or both. Psychiatric and/or pharmacologic intervention should be considered to reduce or resolve further habitual self-inflicted injury before surgical intervention.

Mohs micrographic surgery for tubular apocrine adenoma

5 Hay RJ, Moore M. Mycology. In: Champion RH, Burton JL, Burns DA, et al., eds. Textbook of Dermatology, 6th edn. Oxford: Blackwell Science, 1998: 1277–1376. 6 Arenas R, Toussaint S, Isa-Isa R. Kerion and dermatophytic granuloma. Mycological and histopathological findings in 19 children with inflammatory tinea capitis of the scalp. Int J Dermatol 2006; 45: 215–219. 7 Aste N, Pau M, Biggio P. Kerion celsi: a clinical epidemiological study. Mycoses 1998; 41: 169–173. 8 Sehgal VN, Saxena AK, Kumari S. Tinea capitis. A clinicoetiologic correlation. Int J Dermatol 1985; 24: 116–119. 9 Honig PJ, Caputo GL, Leyden JJ, et al. Microbiology of kerions. J Pediatr 1993; 123: 422–424.

Coincidental consort clear cell cutaneous carcinoma: facial squamous cell carcinoma in situ containing human papillomavirus and cancer cells with clear cytoplasm in an octogenarian couple.

Clear cell squamous cell carcinoma in situ, also referred to as pagetoid or clear cell Bowen disease, is a rare pathologic variant of this neoplasm. It is characterized by neoplastic cells with clear or pale cytoplasm. An octogenarian husband and wife concurrently developed new facial skin lesions which demonstrated squamous cell carcinoma in situ consisting of cancer cells with clear cytoplasm. Cutaneous human papillomavirus (HPV) typing detected HPV Type 5 and HPV Type 21 in the tumors of the husband and wife, respectively. HPV is a potential etiologic factor in the oncogenesis of nonmelanoma skin cancer, and HPV DNA has been demonstrated in extragenital squamous cell carcinoma in situ. The detection of DNA from different HPV types in the tumors of our patients suggests that the concurrent occurrence of their skin cancers may have been coincidental. However, the presence of HPV DNA in their tumors introduces the possibility of a viral-associated oncogenesis for clear cell squamous cell carcinoma in situ.

Detection of human papillomavirus in cutaneous clear cell squamous cell carcinoma in situ: viral-associated oncogenesis may contribute to the development of this pathologic variant of skin cancer

To the Editor, We read with interest the excellent study by AlArashi and Byers which adds to the clinical, morphological, histological and immunohistochemical characteristics of clear cell squamous cell carcinoma in situ (SCCIS) and clear cell change in SCCIS. Their findings support outer root sheath differentiation in these tumors. Our recent detection of human papillomavirus (HPV) in clear cell SCCIS adds further to the characterization of this tumor and suggests that a viral-associated oncogenesis may contribute to the development of this pathologic variant of skin cancer. We evaluated and treated new tumors that had concurrently developed on the faces of an octogenarian husband and wife. The discovery that both cancers were the rare clear cell variant of SCCIS and that both tumors were located on exposed skin of potential contact between the spouses prompted us to consider the possibility that the cancers had a viral-induced etiology and that one spouse may have acquired the tumor-associated virus from the other partner. Cutaneous HPV typing by polymerase chain reaction and sequencing confirmed the presence of HPV in both tumors. However, HPV type 5 was detected in the husband’s clear cell SCCIS and HPV type 21 was detected in the wife’s tumor. Therefore, in summary, although our findings did not show contact transmission of a single tumorassociated etiologic virus, they did confirm the presence of HPV DNA in the clear cell SCCIS from both spouses. We consider it unlikely that the detection of HPV DNA in both of our immunocompetent patient’s clear cell SCCIS merely represents the coincidental ubiquitous presence of viral DNA in the tumor-containing (lesional) skin and normal appearing (nonlesional) adjacent skin. However, we cannot exclude this possibility with absolute certainty because we were not able to evaluate the normal appearing skin adjacent to our patients’ tumors for the presence of commensal, subclinical, skin HPV infection. A viral etiology may be a factor in the cutaneous oncogenesis of nonmelanoma skin cancer. Indeed, HPV has been identified in squamous cell carcinomas from both immunosuppressed patients and immunocompetent individuals. The detection of HPV types in the clear cell SCCIS from two people raises the possibility that this unusual variant of SCCIS is associated with an infectious etiology. If the presence of HPV DNA can be confirmed in additional clear cell SCCIS, it would support the hypothesis that a viral-associated oncogenesis plays a role in the induction of this pathologic variant of skin cancer.