Ramon Pigem

Patterns of distribution of giant congenital melanocytic nevi (GCMN): The 6B rule

Background Garment‐related terms have been used to describe the pattern of distribution of giant congenital melanocytic nevi (GCMN). Objective We sought to describe patterns of distribution of GCMN and propose a classification scheme. Methods Photographic records of patients with GCMN from the Hospital Clinic of Barcelona were analyzed and a classification based on observed GCMN distribution patterns was created. The classification was independently applied by 8 observers to cases found in the literature. The interobserver agreement was assessed. Results Among 22 patients we observed 6 repeatable patterns of distribution of GCMN, which we termed the “6B”: bolero (involving the upper aspect of the back, including the neck), back (on the back, without involvement of the buttocks or shoulders), bathing trunk (involving the genital region and buttocks), breast/belly (isolated to the chest or abdomen without involvement of bolero or bathing trunk distributions), body extremity (isolated to extremity), and body (both bolero and bathing trunk involvement). Our literature search found 113 cases of GCMN, which we were able to classify into 1 of the 6B patterns with an overall kappa of 0.89. Limitations Some patterns occur infrequently with a dearth of images available for analysis. Conclusions The anatomic distribution of GCMN occurs in 6 recognizable and repeatable patterns.

Utility of polypropylene templates for delayed delimitation of margins from ill-defined tumors

We recommend that traction with counter-traction be first attempted in an initial orientation followed by firm blotting and assessment of wound edge blood flow. If the original orientation is not deemed adequate, orientation can be rotated by 90° and, if necessary, again by 45°, confirming the most effective orientation. Stretch followed by blotting allows targeting of the vessels with heavier blood flow which are either electrocoagulated or ligated to achieve lasting haemostasis. The magnitude of stretch can then be gradually reduced to visualize any remaining vessels with more moderate or minor bleeding. This process of traction followed by blotting and electrocoagulation is repeated until sufficient haemostasis is obtained. If bleeding is excessive, traction combined with compression can be employed centrally within the wound bed, shifting peripherally once lasting haemostasis is obtained centrally. Traction haemostasis is a novel and effective haemostatic manoeuvre with unique advantages that can easily be integrated into any cutaneous surgical procedure in collaboration with other haemostatic techniques.

Bird beak drape technique for nose and lips ambulatory procedures

Dermatologists perform most of their surgical and aesthetic procedures in office-based facilities. A significant number of these procedures are located in the peri-oral area and the nasal pyramid. Proper sterility in the central face area is not always easy to achieve nor is it to maintain. Moreover, face drapes are usually time-consuming and uncomfortable, as they slip away from the site as they cannot be easily fixed. We propose a simple technique for draping the nasal and peri-oral area for dermatologic surgery. It consists of making a notch with straight-bladed Mayo scissors on the nasal side of a disposable fenestrated drape (Fig. 1). When the drape is cut out in the precise way, the resulting notch fits the patient’s nose perfectly (Fig. 2). This technique has many advantages over traditional face drapes. It is easy to perform, cheap and adjustable. Furthermore, the size of the notch can be adjusted to fit the patient’s nose. This simple technique maintains the sterility of surgical field and patient comfort during the whole procedure.

Multiple inflammatory lesions in an oncology patient.

Figure 1 Multiple erythematous papules. Notice that the inflammation is well limited. The most affected areas were the chest, upper back, forearms, and lower legs. It is important to note that the face and scalp (not shown) were completely spared Figure 2 A punch biopsy specimen from the trunk shows an atrophic epidermis with keratinocytes atypia, dyskeratosis, and a dense lymphocytic inflammatory infiltrate (hematoxylin–eosin stain, original magnification 940) Figure 3 At higher magnification, the lichenoid infiltrate and epidermal changes may be observed. Epidermal dysmaturation consistent in disruption of keratinocyte maturation, apoptotic cells, and irregular nucleus is present (hematoxylin–eosin stain, original magnification 9100)

Remission Time after Rituximab Treatment for Autoimmune Bullous Disease: A Proposed Update Definition

A therapeutic endpoint is a very important tool to evaluate response in clinical trials. In 2005, a consensus statement identified two late endpoints of disease activity in pemphigus: complete remission off therapy and complete remission on therapy, both definitions applying to patients without lesions for at least 2 months. The same period of time was considered for partial remission off/on therapy. These definitions were later applied to bullous pemphigoid and are considered in most studies on autoimmune bullous disease. These endpoints were established for different adjuvant agents, but at that moment, rituximab was not considered. Rituximab is known for the long duration of its effect, and in most studies relapses have been reported later than 6 months after treatment. In our opinion, time to remission after rituximab treatment should be redefined.

Vitiliginous alopecia masquerading as frontal fibrosing alopecia

A 73‐year‐old female presented at the Dermatology Department with a white shiny band‐like patch on the temporal and forehead zones [Figure 1]. She had a 4‐year history of vulvar lichen scleroatrophicus (LSA) [Figure 2]. Polarized dermoscopy examination revealed follicular ostium preservation, yellow dots and poliosis of vellus hair [Figure 3]. A biopsy specimen was obtained, and histopathological examination revealed no inflammatory cells, with preservation of the hair follicle and almost no melanocytes were present [Figure 4]. Vitiliginous Alopecia Masquerading as Frontal Fibrosing Alopecia

Residents’corner June 2015. sQUIZ your knowledge!: Papulonecrotic febrile rash in a young man

A previously healthy 28-year-old man presented with a 1-month-history of persistent fever accompanied by the progressive appearance of widespread asymptomatic cutaneous lesions during the previous week. Physical examination revealed the presence of multiple erythematous papulonodular lesions with a crusted necrotic core, on the face, upper trunk and extremities (figures 1A-B).What is your diagnosis (figure 1)?Microscopy of a punch-biopsy specimen showed acanthosis and irregular epithelial hyperplasia, [...]