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Ming H. Jih, MD, PhD; Paul M. Friedman, MD; Arash Kimyai-Asadi, MD; Edward S. Friedman, MD; Sharon R. Hymes, MD; Leonard H. Goldberg, MD; DermSurgery Associates (Drs Jih, P. M. Friedman, Kimyai-Asadi, and Goldberg), The University of Texas School of Medicine (Dr P. M. Friedman), Baylor College of Medicine (Dr E. S. Friedman), and The University of Texas M. D. Anderson Cancer Center (Drs Hymes and Goldberg), Houston

Background The elliptical (fusiform) excision is a basic tool of cutaneous surgery. Objective To assess the design, functionality, ease of construction, and aesthetic outcomes of the ellipse. Design A systematic review of elliptical designs and their site-specific benefits and limitations. In particular, we consider the (1) context of prevailing relaxed skin tension lines and tissue laxity; and (2) removal of the smallest possible amount of tissue around the lesion and in the "dog-ears." Attention is focused on intuitive methods that can be reproducibly planned and executed. Results Elliptical variations are easily designed and can be adapted to many situations. The eccentric parallelogram excision is offered as a new technique that minimizes notching and focal tension in the center of an elliptical closure. Conclusion The elliptical (fusiform) excision is an efficient, elegant, and versatile technique that will remain a mainstay of the cutaneous surgical armamentarium.

Background Reconstruction of nasal alar defects is difficult because of the complex anatomy of the region. A frequent challenge in this area is repair of small cutaneous defects involving the lateral nasal supratip and the superior alar groove. Observations An oblique advancement flap that uses laxity from the nasal sidewall is described. Its benefits and limitations are compared with those of alternative closures. Overall, the oblique advancement flap preserves the superior alar groove, while minimizing tissue contortion. It is technically similar to a primary closure but functionally and aesthetically superior. Conclusions For selected small lateral nasal supratip defects impinging on the superior alar groove, the oblique advancement flap offers a simple, visually pleasing repair that preserves the alar architecture.

Background Odontogenic keratocysts of the jaw are a central feature of basal cell nevus syndrome (BCNS) and arise from the basal cell layer of the surface epithelium. Although they are benign, they tend to be aggressive, with local invasion of bony structures, extensive growth, and potential for substantial disfigurement and speech dysfunction. Complete surgical resection is the current standard of care; however, the procedures are often technically challenging and are followed by high recurrence rates. Observations We report the case of a 55-year-old man with a long-standing history of BCNS. Over a 25-year period, this patient had been treated for many basal cell carcinomas (BCCs). He also had multiple large odontogenic keratocysts in the mandible that had previously been treated using surgical, chemotherapeutic, and radiation treatment techniques. He had also undergone a right inguinal lymph node dissection after BCC metastasis was diagnosed within a lymph node. Owing to the recalcitrant nature of his condition and his history of BCC metastasis, the patient was started on a daily regimen of a new oral drug, GDC-0449, which inhibits the hedgehog signaling pathway, a key genetic contributor in the oncogenesis of BCCs. In addition to complete resolution of all his BCCs at 12-week follow-up, nearly complete resolution of 3 odontogenic keratocysts was documented by serial dental radiographs after 2 years of therapy. Conclusions We report the nearly complete regression of multiple BCNS-associated odontogenic keratocysts following nonsurgical treatment with GDC-0449. This novel drug, useful for the treatment of BCC, also appears to be effective for treatment of odontogenic keratocysts.

Xanthelasma of the eyelid is an asymptomatic and not uncommon disease with cosmetic consequences that drive the patient to seek medical treatment. tic acid cauterization, carbon dioxide laser ablation, erbium :YAG laser treatment, pulsed-dye laser treatment, and Q-switched Nd:YAG laser treatment. 1-7 .

REPORT OF A CASE A 35-year-old white man with a 5-year history of slowly progressing nail dystrophy of the left index finger presented when his nail bed became tender. The patient denied a history of trauma to the finger. Physical examination revealed a vertical pigmented band, vertical ridging, and distortion of the lunula (Figure 1). A radiograph revealed a 5×5-mm, well-demarcated cyst in the midshaft of the distal phalanx (Figure 2). A total nail avulsion was performed. The proximal nail fold was reflected back to expose the tumor. Gross examination revealed a white, smooth, firm, well-circumscribed tumor that abutted on but was not attached to the underlying cortical bone (Figure 3). After blunt excision of the tumor, the base was curetted and the proximal nail fold was repaired. A normal nail plate regrew. Histopathologic examination of the tumor revealed mature lobules of cartilage with focal ossification around the periphery (Figure

REPORT OF A CASE A 53-year-old white woman presented with a primary nodular basal cell carcinoma on the right nasal ala adjacent to the nasolabial fold (Figure 1). The suspected clinical extent of the tumor was 0.5×0.4 cm. Mohs micrographic surgery was performed. The resulting surgical defect measured 0.8×0.6 cm with the deep margin involving the subcutaneous fat. The defect extended to the melolabial junction but spared the free margin of the nasal rim (Figure 2). THERAPEUTIC CHALLENGE The patient had a surgical defect of the nasal ala involving the melolabial junction but sparing the free margin of the nasal rim. Healing by second intention was considered, but distortion of the free edge of the nasal ala would probably occur. A full-thickness skin graft was a viable option, but a flap would give better skin texture match. Various flap designs were considered. Our challenge was to design an inferiorly

• Background and Design.— This multicenter trial (19 sites) was initiated in 1984 in more than 1100 immunocompetent individuals with a history of frequently recurring genital herpes (mean, ≥12 episodes per year). The first year of this suppressive therapy trial was placebo controlled, with acyclovir being provided for episodic treatment in both groups. Thereafter, patients were treated with open-label acyclovir suppressive therapy on a long-term basis (400 mg twice daily) to continue to assess its long-term safety and efficacy. Complete data are available on 389 of the 430 patients who began the fifth year of the study. Results.— Patients were seen quarterly for review of diaries and clinical laboratory evaluations. The percentage of patients recurrence free for any 3-month quarter of the fifth year ranged from 86% to 90%. The mean annual number of recurrences per patient declined from 1.7 during the first year to 0.8 during the fifth year of suppressive therapy. The frequency of false prodromes has also decreased over time. More than 20% of the patients receiving suppressive therapy for 5 years have been recurrence free the entire time. The duration of herpetic outbreaks during suppressive therapy has not changed. Conclusion.— This study extends the safety and efficacy profile of oral acyclovir in the suppression of genital herpes to 5 years. The majority of the patients were recurrence free on an annual basis during suppressive therapy. Therapy was well tolerated. Acyclovir usage was not associated with serious side effects or cumulative toxicity. ( Arch Dermatol. 1993;129:582-587)

Keratosis lichenoides chronica may be seen clinically and histologically as a variant of lichen planus. One in three patients have nail involvement with changes that may superficially resemble psoriasis, but pitting and pustulosis do not occur. Hyperkeratotic hypertrophy of the periungual tissues is a distinctive feature. Psoralens and UV-A therapy as well as etretinate have improved some cases.

To the Editor.— In the February issue of theArchives, Franz 1 described the percutaneous absorption of minoxidil labeled with carbon 14 following the application to the scalp in 12 healthy adult male subjects. Based on the amount of radioactivity excreted in the urine and feces, he concluded that only a small fraction of the total dose of applied minoxidil was absorbed. We found the study to be very interesting and informative. However, two questions were raised in our minds that require further clarification: What is the metabolic fate, distribution, and tissue binding of minoxidil or its metabolites following percutaneous absorption? The skin is known to be a viable membrane capable of metabolizing a wide variety of drugs. 2 Measurement of urinary radioactivity following percutaneous application does not account for metabolism by the skin, nor does it account for any tissue binding of minoxidil and/or its metabolites. Since 53% to 57% of the applied minoxidil dose was not recovered, it would have been helpful if the author had determined or cited a reference as to the distribution and metabolic fate of minoxidil following percutaneous absorption. This issue becomes relevant if the drug is bound to tissue.

• We investigated the number and morphology of Langerhans' cells in the epidermal component of squamous cell carcinomas located on the sun-exposed skin of 10 patients. Using adenosine triphosphatase-stained epidermis from the tumors, we compared the Langerhans' cells in squamous cell carcinoma with those in nontumorous skin specimens from the same patient. The nontumorous skin specimen was obtained from either sun-exposed perilesional or non-sun-exposed sites. In three patients a normal number and almost normal morphology of Langerhans' cells were observed within the epidermal component of the tumor. One patient showed a normal number but a profound alteration of the morphology of the cells. In the remaining six patients, a significant decrease in the number of Langerhans' cells was observed. Langerhans' cells within the epidermal component of the tumors of these patients exhibited morphologic alterations in that they were mainly round or oval rather than highly dendritic. In none of our patients was the number of Langerhans' cells in the tumor increased. We conclude that a decreased number and altered morphology of Langerhans' cells occur in some, but not all, squamous cell carcinomas of the skin, and that there is no apparent difference between the number of Langerhans' cells in sun-exposed vs unexposed skin from the same individual. ( Arch Dermatol. 1989;125:917-920)

• Fourteen patients with chronic plaque-type psoriasis involving the palms and soles and 14 patients with palmoplantar vesiculopustular dermatosis, including three cases of localized pustular psoriasis, were treated with topical application of methoxsalen, followed by exposure to long-wave ultraviolet energy (topical PUVA). Approximately two thirds of the patients with palmoplantar plaque-type psoriasis and half of those with vesiculopustular dermatosis responded with considerable improvement, as evidenced by flattening of plaques, decreased scaling and erythema, and decreased vesicle and pustule formation after 15 to 40 treatments. Complete clearing of the treated areas was achieved in five patients with palmoplantar psoriasis, three of whom had the pustular variety. Most patients required continued maintenance therapy with topical PUVA. The condition of the patients with palmoplantar vesiculopustular dermatosis, especially those with severe involvement, was more labile and more difficult to control with PUVA therapy than in those with chronic scaling plaques. ( Arch Dermatol 116:1257-1261, 1980)

To the Editor.— Papillon-Lefevre syndrome is a rare autosomal recessive genodermatosis characterized by keratosis palmaris et plantaris and periodontosis, which leads to premature loss of both the deciduous and permanent teeth. An increased susceptibility to infections has been described that includes furunculosis, abscesses of the skin and liver, and hidradenitis suppurativa in 21% of the patients. In some patients, arachnodactyly has also been reported. In a comprehensive review by Haneke 1 in 1979 of 120 cases reported in the literature, no cases of malignant neoplasms were observed. We describe herein a patient with the Papillon-Lefevre syndrome in whom malignant melanoma developed. Report of a Case.— A 31-year-old man had had the Papillon-Lefevre syndrome since infancy, with severe dorsal keratosis palmaris et plantaris, periodontosis, abscesses of the skin, furunculosis, and arachnodactyly (proved by roentgenograms). The patient had noticed a lesion present on one finger for almost eight months and had observed