S Verykiou

Survey of dermatologists demonstrates widely varying approach to perioperative antibiotic use ‐ time for a randomized trial?

post-operative wound infection rate following dermatological surgery ranges between 0.5%-8%.(1-3) Factors reported to increase the risk of surgical site infection (SSI) include procedure type (e.g. wedge excision, full thickness skin grafts); anatomic location (e.g. lower limb, groin); tumour ulceration; and patient-associated factors, such as immunodeficiency, diabetes and smoking.(4-6) A survey of UK Dermatologists demonstrated significant variation in the use of peri-operative oral antibiotics dependent upon various factors; presence of ulceration; diabetes; lower limb surgery; immunosuppression and flap / graft repairs.(7-8) These findings likely reflect a paucity of data in the literature. This article is protected by copyright. All rights reserved.

Assessing the In Vivo Epidermal Barrier in Mice: Dye Penetration Assays

INTRODUCTION The formation of a properly functioning epidermal barrier is a prerequisite for terrestrial life. The epidermis not only protects from external influences such as pathogens, chemicals, and UV light, but also prevents dehydration. To maintain proper barrier function, the epidermis undergoes a dynamic turnover driven by proliferating keratinocytes in the basal layer that, upon induction of differentiation, will move upward through the stratum spinosum and stratum granulosum while undergoing a terminal differentiation process to ultimately form the stratum corneum (SC). This layer is in direct contact with the outside environment and provides important structural and innate immune barrier properties. Barrier function is initiated when stratum granulosum keratinocytes start secreting and crosslinking specific proteins and lipids into the intercellular space and at the same time transform their membrane into a so-called cornified envelope (e.g., by linking different structural proteins such as loricrin to the inner side of the cell membrane). Consequently, keratinocytes shed their nucleus to become corneocytes forming the SC. In recent years it has become clear that the SC is not the sole structure providing barrier properties to the epidermis. It is now clear that specialized intercellular junctions, called tight junctions (TJs), are present between cells of the granular layer, where they ensure proper barrier function (Furuse et al., 2002; Tunggal et al., 2005). TJs have been well characterized in simple epithelia where they form a paracellular sizeand ion-specific barrier to separate tissue compartments. The size and ion selectivity of TJs is mainly based on which members of the claudin family of transmembrane proteins are located in the TJs of different tissues. The epidermis expresses several claudins, and loss of claudin-1 in mice results in perinatal lethality attributable to rapid dehydration (Furuse et al., 2002). In addition, TJs are crucial for immune surveillance by Langerhans cells (Kubo et al., 2009). The importance of the two barriers is further confirmed by observations that mutations in SC proteins such as filaggrin are linked to diseases characterized by an impaired skin barrier, such as atopic dermatitis and ichthyosis vulgaris (Palmer et al., 2006; Smith et al., 2006). In addition, human claudin-1 mutations are associated with neonatal sclerosing cholangitis associated with ichthyosis (Hadj-Rabia et al., 2004). However, the exact molecular mechanisms of how TJs and the SC contribute to the formation, maintenance, and restoration of the skin barrier are not well understood. In addition, it is not known whether and how TJs and the SC cooperate to form a fully functional skin barrier. Transgenic mouse models have been helpful tools to investigate how proteins implicated in epidermal barrier function contribute to the formation and maintenance of skin barrier function. Next to assessing whether such mice have a BENEFITS OF DYE PENETRATION ASSAYS

Legionella feelei i: An unusual organism associated with cutaneous infection in an immunocompromised patient

We report a 23‐year‐old immunocompromised woman who, following cardiac transplantation, presented with an unusual cutaneous eruption. She developed a widespread pustular rash, systemic symptoms and a high temperature with raised inflammatory markers. The diagnosis was reached when a skin biopsy was cultured onto Legionella agar (buffered charcoal yeast extract) and Legionella feeleii was isolated. The patient was treated with 6 weeks of moxifloxacin and her cutaneous lesions gradually resolved. Cutaneous Legionella infections are uncommon and usually affect immunocompromised patients.

Cutaneous manifestations of phosphate solution extravasation

Extravasation injuries are common in patients receiving multiple intravenous infusions. Although such injuries are closely associated with the infusion of cytotoxic chemotherapy, they have also been been associated with extravasation of noncytotoxic drugs. Extravasation injuries can lead to skin ulceration and nerve and tendon damage, and therefore to permanent disability. We report three cases of phosphate solution extravasation leading to unusual cutaneous manifestations.

Do perioperative antibiotics reduce the risk of surgical‐site infections following excision of ulcerated skin cancers? A Critically Appraised Topic

To review the efficacy of perioperative antibiotics in reducing the risk of surgical‐site infections (SSIs) following excision of ulcerated skin cancers.

Diagnostic biopsy before Mohs micrographic surgery, frequency of change in diagnosis and impact on management.

DEAR EDITOR, Mohs micrographic surgery (MMS) is the most effective surgical method for complete removal of skin tumours. In the majority of cases the referring physicians rely on either the clinical characteristics of a tumour or a diagnostic biopsy, which provides histological confirmation of the diagnosis and may inform about the growth pattern of a tumour. We usually undertake debulk excision of the tumour before the first Mohs stage. A piece of the debulk specimen may be removed and placed ‘side on’ on a slide next to one of the blocks of the first Mohs stage to allow histological examination of vertical sections of the Mohs debulk specimen. The purpose of this study was to investigate the frequency of change in histological diagnosis in a group of patients undergoing MMS and to investigate whether a diagnostic biopsy prior to MMS would have led to a change in the patients’ management. A ‘change in diagnosis’ was recorded when a different diagnosis was reported on the Mohs debulk specimen following histological examination by a dermatopathologist. We performed a retrospective study of our consecutive MMS data over a period of 18 months (January 2011 to June 2012). Patient identification and all relevant information were collected from the Mohs maps, which are completed by the Mohs surgeon during MMS. The histological results of the Mohs debulk specimens were collected from the hospital’s electronic results system. In total 873 consecutive unselected cases of MMS were included in the study. The mean age of patients was 68 years (range 30–100). In 23 of 873 patients (2 6%) the histological diagnosis changed after MMS. The initial diagnosis at the time of referral for MMS was basal cell carcinoma (BCC) in 819 of 873 cases (94%). Other diagnoses included squamous cell carcinoma (SCC) (32 patients), dermatofibrosarcoma protuberans (n = 6), atypical fibroxanthoma (n = 3), desmoplastic trichoepithelioma (n = 5), lentigo maligna (n = 2), sebaceous carcinoma (n = 2), eccrine spiradenoma (n = 2), desmoid fibromatosis (n = 1) and primary mucinous carcinoma (n = 1). In 395 of 873 patients (45%) this diagnosis was reached following a diagnostic biopsy. Only 28 of 873 patients (3 2%) had incomplete excision of a BCC prior to MMS. No pre-MMS biopsy was done in 450 of 873 patients (52%). In 23 of 873 patients the diagnosis changed following examination of the MMS debulk specimen. Ten of the 23 patients had a diagnostic biopsy prior to referral for MMS, whereas 13 had no diagnostic biopsy performed. The clinical

Perioperative antibiotics for patients with ulcerated skin cancers undergoing dermatological surgery in the UK: a nationwide survey of current clinical practice

DS01 Proposal for National Dermatology Surgery Safety Standards: development of a dermatology surgery standard operating policy with mandatory training of staff may be an important tool to prevent wrong-site surgery R. Bhutani, C. Machin, G. Stables, V. Goulden and A. Mitra Chapel Allerton Hospital, Leeds, U.K. Wrong-site surgery (WSS) is the second most common reported adverse event, and accounts for 20% of National Health Service dermatology legal claims. WSS is more of a risk in dermatology because of the difficulties in identifying skin biopsy sites, including variance of individual documentation; time lag between initial consultation and surgical procedure, often by different clinicians; and multiple lesions in close proximity confounded by background secondary changes. It has been shown that up to one-third of dermatology patients are unable accurately to identify their own initial skin biopsy site. We reported two cases of WSS in 2012 at our centre, where 5200 local-anaesthetic skin surgeries are performed per year. Our initial written local surgical standard operating procedure (SOP) was produced in 2013 with introduction of a surgical checklist and the development of triplicate carbon copies of a combined surgery/photography booking form, which included large body maps to facilitate transmission of correct site identification and documentation across all multiprocedural teams. Despite this we experienced two further cases of WSS in 2014. We present the subsequent procedural changes made through our clinical governance processes to prevent further WSS and improve our patient safety and quality standards. This includes the introduction of a ‘double check policy for lesion marking’, where photographers are instructed to send patients back to the clinician if the site is not properly marked with an arrow. Use of a mirror is mandatory to reconfirm the site with the patient prior to photography and surgery, and there is a final ‘surgical pause’ where the assistant calls out and reconfirms the site and procedure with the patient and surgeon. Human factor training is being organized. Our trust has now mandated annual training in our SOP for all multidisciplinary staff involved. Specific educational intervention using a training session has been associated with reduction in WSS in a dental outpatient setting. Following our first training in 2015, improvement in lesion marking was demonstrated from a photography audit. We have also developed an interactive, scenario based e-learning dermatology SOP module to ensure that training is updated and maintained in a robust manner. This will also generate measurable evaluation outcomes that can be linked to appraisals. In 2015 National Safety Standards for Interventional Procedures were produced, but these are not specific to dermatology. We propose that our speciality produces National Safety Standards for Dermatology Surgery with standardization of local SOPs and consideration of mandatory SOP training, which could reduce WSS and deliver a safer consistent patient service across the U.K.

Atypical presentation of Rothmund-Thomson syndrome with cafe au lait patches

S BJD British Journal of Dermatology 28th Annual Meeting of the British Society for Paediatric Dermatology, London, 8–9 November 2013

Life-threatening complications of a large rapidly involuting congenital haemangioma

S BJD British Journal of Dermatology 28th Annual Meeting of the British Society for Paediatric Dermatology, London, 8–9 November 2013