Stanislav N. Tolkachjov

Postoperative pyoderma gangrenosum (PG): The Mayo Clinic experience of 20 years from 1994 through 2014

BACKGROUND Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by the development of PG-type lesions within surgical sites. OBJECTIVE We sought to characterize postoperative PG as a distinct subtype of PG for earlier recognition and prevention of improper therapy. METHODS We conducted a retrospective chart review of patients with nonperistomal postoperative PG at Mayo Clinic from 1994 to 2014.x RESULTS Eighteen patients had postoperative PG with an average age of 58 years. Fifteen (83%) were female. Among patients with postoperative PG, 4 (22%) had an associated systemic disease traditionally associated with PG. Sites of postoperative PG included 7 breast (38%), 7 abdomen (38%), 1 back, 1 shoulder, 1 ankle, and 1 scrotum, witxxh breast reconstruction being the most common surgery. The average time to symptoms was 11 days. No patients had a fever. Eight (44%) had documented anemia and 5 (27%) had leukocytosis. Antibiotics and systemic corticosteroids were initiated in 10 (56%) and 14 (83%), respectively. Debridement was done in 11 (61%) patients. LIMITATIONS Small sample size and retrospective study are limitations. CONCLUSION Postoperative PG is a rare surgical complication with predilection for the breast and abdomen of females and has less association with systemic disease than idiopathic PG. Early recognition may prevent unnecessary debridements and morbidity.

Progressive hemifacial atrophy: a review

BackgroundProgressive Hemifacial Atrophy (PHA) is an acquired, typically unilateral, facial distortion with unknown etiology. The true incidence of this disorder has not been reported, but it is often regarded as a subtype of localized scleroderma. Historically, a debate existed whether PHA is a form of linear scleroderma, called morphea en coup de sabre (ECDS), or whether these conditions are inherently different processes or appear on a spectrum (; Adv Exp Med Biol 455:101–4, 1999; J Eur Acad Dermatol Venereol 19:403–4, 2005). Currently, it is generally accepted that both diseases exist on a spectrum of localized scleroderma and often coexist.The pathogenesis of PHA has not been delineated, but trauma, autoimmunity, infection, and autonomic dysregulation have all been suggested. The majority of patients have initial manifestations in the first two decades of life; however, late presentations in 6th and 7th decades are also described [J Am Acad Dermatol 56:257–63, 2007; J Postgrad Med 51:135–6, 2005; Neurology 61:674–6, 2003]. The typical course of PHA is slow progression over 2-20 years and eventually reaching quiescence.Systemic associations of PHA are protean, but neurological manifestations of seizures and headaches are common [J Am Acad Dermatol 56:257–63, 2007; Neurology 48:1013–8, 1997; Semin Arthritis Rheum 43:335–47, 2013]. As in many rare diseases, standard guidelines for imaging, treatment, and follow-up are not defined.MethodsThis review is based on a literature search using PubMed including original articles, reviews, cases and clinical guidelines. The search terms were “idiopathic hemifacial atrophy”, “Parry-Romberg syndrome”, “Romberg’s syndrome”, “progressive hemifacial atrophy”, “progressive facial hemiatrophy”, “juvenile localized scleroderma”, “linear scleroderma”, and “morphea en coup de sabre”. The goal of this review is to summarize clinical findings, theories of pathogenesis, diagnosis, clinical course, and proposed treatments of progressive hemifacial atrophy using a detailed review of literature.Inclusion- and exclusion criteriaReview articles were used to identify primary papers of interest while retrospective cohort studies, case series, case reports, and treatment analyses in the English language literature or available translations of international literature were included.

Treatment of Porocarcinoma With Mohs Micrographic Surgery: The Mayo Clinic Experience.

BACKGROUND Eccrine porocarcinoma (EPC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment. OBJECTIVE This study reviews the clinical characteristics and outcomes of patients with EPC treated with Mohs micrographic surgery (MMS). MATERIALS AND METHODS The authors performed a retrospective chart review of patients with EPC treated by MMS at the Mayo Clinic from 1995 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality. RESULTS A total of 9 patients underwent MMS for EPC in 19 years. The average age was 64.2 years, with 6 males and 3 females. All patients were Caucasian. The head and lower extremity were the most common locations (44% each), with 1 on the forearm. Of the 9 tumors, 8 were located on the right side of the body. The mean preoperative tumor size and postoperative defect were 2.9 and 7.8 cm2, respectively, when 2 outliers were excluded. An average of 1.3 MMS stages was required for clearance. The mean postoperative follow-up was 3.3 years (range: 1–60 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality. CONCLUSION Mohs micrographic surgery seems to be a useful treatment modality for EPC. This is one of the largest single-center series of EPC treated with MMS.

Postoperative Pyoderma Gangrenosum: A Clinical Review of Published Cases

Postoperative pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterized by PG at surgical incisions. It is often misdiagnosed as wound infection, and pathergy may complicate wound debridement. From September 1, 2013, through November 30, 2013, a literature search was conducted of articles published from January 1, 1978, through December 31, 2012. We referenced PubMed, MEDLINE, and Mayo Clinic Libraries using the keywords pyoderma gangrenosum, postoperative pyoderma gangrenosum, postsurgical pyoderma gangrenosum, superficial granulomatous pyoderma, pathergic pyoderma, and pyoderma gangrenosum associated with surgery, incision, breast, and wound dehiscence. In addition, all titles from PubMed with the words pyoderma gangrenosum were reviewed manually for postoperative cases. Of 136 patients, 90 (66%) did not have associated systemic diseases. If a comorbidity was present, hematologic disorders were most common. In addition, 29% (28) of women had predisposing disease vs 53% (19) of men. Women had more frequent breast involvement (P<.001); chest involvement was more common in men (P=.005). Girls and women aged 13 to 64 years had more frequent breast involvement (P=.01). Sites were distributed equally for men regardless of age (P=.40). Antibiotic drug therapy was begun and debridement occurred in 90% (110 of 122 treated patients) and 73% (90 of 123 available patients), respectively. Postoperative PG has less association with systemic disease than its nonpostoperative counterpart. Antibiotic drug therapy is routinely initiated. Affected sites are often debrided, causing additional wound breakdown. Early diagnosis may prevent complications.

Mohs micrographic surgery in the treatment of trichilemmal carcinoma: The Mayo Clinic experience

REFERENCES 1. Accetta P, Accetta J, Kostecki J. The use of digital cameras by US dermatologists. J Am Acad Dermatol. 2013;69:837-838. 2. Hubbard VG, Goddard DJ, Walker SL. An online survey of the use of digital cameras by members of the British Association of Dermatologists. Clin Exp Dermatol. 2009;34:492-494. 3. Kunde L, McMeniman E, Parker M. Clinical photography in dermatology: ethical and medico-legal considerations in the age of digital and smartphone technology. Australas J Dermatol. 2013;54:192-197.

Frontal fibrosing alopecia among men: A clinicopathologic study of 7 cases

Background: Frontal fibrosing alopecia (FFA) is a lichen planopilaris–variant scarring alopecia that has rarely been described in men. Objective: To characterize the clinicopathologic findings of FFA in men by studying a series of 7 male patients. Methods: We conducted a retrospective review of all cases of male patients with FFA at the Mayo Clinic from 1992 to 2016. Results: Seven male patients with FFA were identified. The frontal scalp (in 6 of 7 patients), sideburns (in 4 of 7), and temporal scalp (in 4 of 7) were most frequently involved. Three patients had involvement of the eyebrows. One patient had hair loss of the upper cutaneous lip. All patients had biopsy evidence of lichen planopilaris. None of the patients had associated autoimmune or thyroid disease. Two patients had hypogonadism upon testosterone studies. Limitations: Limitations include small sample size and varied follow‐up. Conclusions: Although most often reported among postmenopausal women, FFA also occurs among men. The clinical and histopathologic characteristics of FFA in men parallel those described in women with FFA. Unique areas of involvement in men include sideburns and facial hair. Concomitant mucocutaneous lichen planus, autoimmune disease, and thyroid disease are infrequent among men with FFA. Distribution of hair loss and associated hormonal abnormalities aid in the recognition of FFA in men.

Incidence and Clinical Features of Rare Cutaneous Malignancies in Olmsted County, Minnesota, 2000 to 2010

BACKGROUND The incidence of rare cutaneous malignancies is unknown. Current estimates of rare cutaneous malignancy incidences are based on broad epidemiologic data or single institution experiences, not population-based data. OBJECTIVE To determine the incidence of several rare nonmelanoma skin cancers. MATERIALS AND METHODS The authors conducted a retrospective chart review of a population-based cohort between the years 2000 and 2010. Residents of Olmsted County, Minnesota, who were diagnosed with a biopsy-proven nonmelanoma skin cancer—excluding basal cell carcinoma and squamous cell carcinoma—were included in this study. The primary outcome was tumor incidence. Additionally, the authors extracted patient demographics, tumor characteristics, treatment modalities, and outcomes. RESULTS The age-adjusted and sex-adjusted incidences per 100,000 persons of multiple rare cutaneous malignancies were: atypical fibroxanthoma (1.8), sebaceous carcinoma (0.8), dermatofibrosarcoma protuberans (0.4), microcystic adnexal carcinoma (0.7), eccrine carcinoma (0.4), eccrine porocarcinoma (0.2), and leiomyosarcoma (0.2). CONCLUSION The authors report population-based incidences and clinical characteristics for these rare cutaneous malignancies. The immune status and smoking status of patients and the treatment and outcomes of these tumors are reported. Additional studies in a broader population are needed to further define the epidemiology and outcomes of these malignancies.

Mohs Micrographic Surgery for the Treatment of Hidradenocarcinoma: The Mayo Clinic Experience From 1993 to 2013

BACKGROUND Hidradenocarcinoma (HAC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment. OBJECTIVE To review clinical characteristics and outcomes of patients with HAC treated with Mohs micrographic surgery (MMS). MATERIALS AND METHODS The authors performed a retrospective chart review of patients with HAC treated by MMS at Mayo Clinic from 1993 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality. RESULTS Ten patients underwent MMS for HAC more than 20 years. The average age was 62.8 years, with 6 females and 4 males. Occipital scalp was the most common location (40%), followed by extremities (30%) and face (20%). In 5 of 7 cases (71%), “cyst” was the working clinical diagnosis. The average preoperative lesion area was 3.18 cm2, with an average of 1.5 MMS stages required for clearance. Mean postoperative follow-up was 7 years (range, 5–205 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality. CONCLUSION Mohs micrographic surgery seems to be a useful treatment modality for HAC. This is the largest reported series of HAC treated with MMS with long-term follow-up.

Oral manifestations of nutritional disorders

Nutritional deficiencies occur when body metabolic requirements are not matched by intake and absorption. Reasons for this discrepancy are numerous, but often social, economic, medical, and even psychiatric factors may play a role. Vitamins and minerals are required for appropriate rapid cell turnover of the oral mucosa. The oral cavity is a unique anatomic environment that may manifest early signs of nutritional disorders as well as other indicators of systemic disease. Knowledge of these oral manifestations and associated findings will allow a practitioner to consider a nutritional disorder when evaluating oral changes and, in turn, initiate appropriate therapy. A systematic approach to examination of the mouth and perioral skin is suggested. A detailed medical and social history complements the physical examination in identifying patients at risk for nutritional disorders and heightening the clinical suspicion to warrant additional nutritional screening. The rising prevalence of anorexia and bulimia, as well as fad diets, add to the population of patients at risk for vitamin and mineral deficiencies that a clinician must now consider.

Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist

&NA; The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high‐risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost‐effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost‐effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.