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Background The population of people aged 90 years and older is expected to more than triple by 2050. The incidence of skin cancers is increasing. Objective We sought to determine whether treatment of patients aged 90 years and older with skin cancer by Mohs micrographic surgery (MMS) changed their survival. Methods A group of 214 patients aged 90 years and older who underwent MMS from July 1997 to May 2006 was identified. Patient gender, age, tumor type, size, site, defect size, number of MMS stages, and surgical repair were recorded. Comorbid medical conditions were assessed using the Charlson index. Actual survival was compared with expected length of survival using life tables. Data were analyzed by the Kaplan-Meier method with log rank significance tests. Results Average patient age was 92.3 years. All patients tolerated the procedures well with no deaths within 1 month after surgery. Median survival after surgery was 36.9 months. Tumor characteristics, defect size, number of surgical stages, and closure type did not affect survival. There was no significant difference in survival based on comorbidities according to Charlson scores. Instantaneous mortality hazard was highest 2 to 3 years after surgery. Limitations Specific causes of death were not accessible. Conclusion This growing section of the population may safely undergo MMS.

Background Patients may delay treatment for skin cancer for various reasons. Prior research on treatment delay has focused on melanoma rather than nonmelanoma skin cancer (NMSC), which is much more common. Objective We sought to clarify the reasons for delay in the presentation for diagnosis and treatment of NMSC. Methods This was a prospective cohort study in a Mohs micrographic surgery private practice in an urban setting. Eligible subjects were 982 consecutive patients presenting for Mohs micrographic surgery for NMSC between March and December 2005. No enrolled subjects were withdrawn for adverse effects. The survey was a 4-page written self-administered questionnaire, eliciting patient medical history, skin cancer history, demographic information, initial and subsequent lesion size, and reasons for delay in presentation for evaluation and management. Outcome analyses addressed the: (1) frequency of specific reasons for delayed presentation, as provided by self-report; (2) association between reasons for delay with demographic or other patient-specific factors; and (3) change in lesion diameter from the time of detection by the patient to the time of presentation to the doctor. Results Among the reasons for waiting, denial (including: thought it would go away, thought it wasn't important, too busy, thought they could self-treat, afraid it might be something dangerous) was the most frequent, accounting for 71% of cases; difficulty scheduling was associated with 10% of the instances of delay. Older patients (age >64 years) were more likely to wait to seek care than younger patients (odd ratio [OR] = 0.5; 95% confidence interval [CI] 0.4-0.7). Patients with a prior skin cancer were more likely to wait (OR = 1.4; 95% CI 1.1-2.0), as were patients with major life problems (OR = 2.6; 95% CI 1.6-4.3) and patients with a history of any cancer (OR = 1.8; 95% CI 1.3-2.4). Weighted kappa analysis comparing tumor size at the two time points yielded a kappa of 0.72 (SE = .02; 95% CI 0.68-0.77). When the data were separated into two groups, one including those tumors that had decreased in size or remained the same (698 patients), and those that had increased in size (120 patients), the median delay-to-presentation intervals associated with these two groups (2.5 vs 6.0 months, respectively) were found to be significantly different ( P Limitations This study may have limited generalizability to the extent that it reflects the characteristics only of the subpopulation of patients with skin cancer who eventually received treatment at a referral-based, urban, dermatology private practice. Overall, these patients may have been better insured and be more affluent than the general population. Conclusions Denial is the most common patient-specific factor accounting for delayed presentation for NMSC diagnosis and treatment. Patients younger than 65 years, with a skin cancer history, with major life problems, and with a history of any cancer were most likely to wait to see a doctor. There was a significant increase in tumor size from the time when tumors were noticed by patients to the time when patients presented to a physician. Increased delay was associated with increased tumor growth.

Hypertrophic scars and keloids are a therapeutic challenge because of the low response to treatment and recurrences after treatment. A variety of treatment regimens have been used with different degrees of success, with no universally accepted treatment protocol resulting in their complete and permanent resolution. We offer this case to demonstrate a combination approach for the treatment of hypertrophic scarring. A 75-year-old woman (with Fitzpatrick skin type II) presented with a 4-month history of scarring, which had developed following a phenol peel for perioral rhytides. The patient underwent 10 treatment sessions with the 595-nm long-pulsed dye laser followed immediately by the 1450-nm diode laser in combination with intralesional triamcinolone and 5-fluorouracil. After the fifth treatment session, about 90% improvement was noted; at the last treatment session, greater than 95% overall improvement was noted. Two and a half years after the last treatment session, the patient and treating physician noted no regression. A limitation of this therapy is that the combination approach makes it difficult to determine what individual contributions each treatment modality had on the final result. We have illustrated a successful multifaceted treatment regimen for hypertrophic scars and keloids using a combination approach.

Background Several specialties and textbooks continue to advocate that local anesthesia using epinephrine should not be used during surgery involving the digits. Objective We sought to assess the association between local anesthesia (buffered 0.5% lidocaine and 1:200,000 epinephrine) injected into digits, comorbid patient conditions, and postoperative complications including ischemia or necrosis. Methods A retrospective review of all patients presenting for Mohs micrographic surgery in a private practice ambulatory surgery center was performed between October 2002 and January 2009. Patient factors including amount of anesthesia injected; preoperative vitals; history of hypertension, stroke, or circulatory disorders; and presence of anticoagulation were assessed. Results Three Mohs surgeons' patients were included in the study. No digital blocks were performed; local anesthesia was infiltrated directly into the tumor site. Patients received buffered 0.5% lidocaine plus epinephrine 1:200,000. Of 63 patients presenting for surgery (59 fingers and 4 toes), there were no cases of digital ischemia or necrosis. Approximately one-third had a circulatory disorder or diabetes, and more than half had a diagnosis of hypertension or were taking anticoagulation. The average amount of anesthesia injected was 6.92 mL, with the greatest amount being 25 mL. Limitations This was a retrospective review with possible overestimation of adverse effects as a result of referral bias of complicated patients to an ambulatory surgery center for treatment. Conclusion There is no evidence that buffered 0.5% lidocaine with epinephrine 1:200,000 causes ischemia or necrosis when injected into digits. This is true despite a history of circulatory disorders, thrombosis, diabetes, smoking, anticoagulation, or significant preoperative hypertension.

The 1450-nm diode laser has been known to thermally alter sebaceous glands and has been found to be effective for the treatment of inflammatory facial acne.Our aim was to evaluate the dose response of a 1450-nm diode laser for treatment of facial acne, sebum production, and acne scarring utilizing two laser fluences and to determine long-term remission after laser treatment.Twenty patients (Fitzpatrick skin phototypes II-VI) received 3 treatments using the 1450 nm diode laser (3-4 week intervals). Split face comparisons were performed by randomizing patients to one of two fluences (14 or 16 J/cm(2)) on the right or left side of the face. Clinical photographs, lesion counts, and sebum measurements were obtained at baseline and after each treatment. Investigators' and patients' subjective evaluations of response to treatment were assessed.Percentage reductions in mean acne lesion counts from baseline were 42.9% (14 J/cm(2)) and 33.9% (16 J/cm(2)) after one treatment and 75.1% (14 J/cm(2)) and 70.6% (16 J/cm(2)) after 3 treatments. There was persistent reduction of 76.1% (14 J/cm(2)) and 70.5% (16 J/cm(2)) at the 12-month follow-up (P.01). Both objective and subjective improvements in acne scarring and sebum production were noted. Treatment-related pain was well tolerated, and adverse effects were limited to transient erythema and edema at treatment sites.This was a small study and comparison was limited to two laser fluences.The 1450-nm diode laser reduced inflammatory facial acne lesions even in Fitzpatrick skin phototypes IV-VI with minimal side effects. Significant improvement in acne lesion counts were noted after the first treatment and was maintained 12 months after the third treatment, indicating significant long-term clinical remission after laser treatment.

Background There has been no previously published study on skin cancers on the scalp of women. Objectives To better elucidate the characteristics of skin cancers that develop on the female scalp. Methods A retrospective review of 13,885 biopsy-proven skin cancers treated by Mohs micrographic surgery was performed. We identified 197 tumors on the scalp of women. Demographic features and tumor characteristics were compiled and analyzed. Results The average age of women with scalp tumors was 61.8 ± 16.9, which was significantly lower than that of men with scalp tumors. The age followed a bimodal distribution with peaks in the fifth and eighth decades. Overall, 77% of female scalp tumors were basal cell carcinomas (BCCs), 17% were squamous cell carcinomas (SCCs), and 6% were a variety of other tumors. This contrasts with men in whom 53% of tumors were squamous cell carcinomas. Basal cell carcinomas were significantly more common in women under age 50. Conclusion Skin cancers of the female scalp tend to be basal cell carcinomas, many of which occur at a relatively young age as compared to other skin cancers. The exact role of ultraviolet radiation in the development of some of these tumors is unclear.

Background Keratoacanthomas usually occur spontaneously as a single rapidly growing tumor on sun-exposed skin. Multiple keratoacanthomas are rarely seen. Keratoacanthomas may also develop after trauma, laser resurfacing, radiation therapy, and at the donor site after skin grafting. Objective We report 6 cases of keratoacanthomas that developed in and around healing and healed surgical sites after treatment of skin cancer. These tumors developed 1 to 3 months after surgery and were sometimes multiple. Methods We performed follow-up examinations of patients' wounds after the treatment of skin cancer. Histological examination of nodules developing in the margins of healing wound sites and in the scars of healed wound sites after Mohs micrographic surgery revealed keratoacanthomas. Results The tumors presented as a rapidly growing nodule or nodules, with the typical morphology and pathology of keratoacanthoma. One patient developed multiple keratoacanthomas at surgical and nonsurgical sites. These nodules were treated by a combination of excision, curettage and electrodesiccation, and oral isotretinoin, 4 mg/d. Conclusion Keratoacanthoma must be considered in the differential diagnosis of a rapidly growing nodule within or around the surgical site after skin cancer surgery.

Background Vismodegib is approved for treatment of advanced basal cell carcinoma. Objective We sought to characterize vismodegib efficacy and safety in operable basal cell carcinoma. Methods Patients with new, operable, nodular basal cell carcinoma received vismodegib (150 mg/d) followed by excision and Mohs micrographic surgery to ensure clear margins. Cohort 1 received vismodegib for 12 weeks; cohort 2 received vismodegib for 12 weeks, then 24 weeks of observation before excision; and cohort 3 received vismodegib for 8 weeks on/4 weeks off/8 weeks on. Results In all, 24 patients enrolled in cohort 1, and 25 in cohorts 2 and 3. Complete histologic clearance was achieved by 42%, 16%, and 44% of patients in cohorts 1, 2, and 3, respectively. Muscle spasms (76%), alopecia (58%), and dysgeusia (50%) were the most frequent adverse events (AEs). Five (7%) patients discontinued treatment because of an AE. AE reversibility was evaluated in cohort 2 with 24 weeks of observation after treatment discontinuation. Limitations Nonrandomized, small cohort sizes, and short observation durations for some patients are limitations. Conclusion Primary efficacy end points were not met (predefined complete histologic clearance rate: >50% in cohorts 1 and 3; >30% in cohort 2). Safety was comparable when dosed continuously versus intermittently. Posttreatment reversibility of vismodegib-related AEs was demonstrated.

T umescent local anesthesia was first described by Klein in 1987 when he detailed the infiltration of large volumes of a diluted solution of lidocaine with epinephrine into fat before liposuction. The tumescent technique revolutionized liposuction by eliminating the necessity of general anesthesia or intravenous sedation and the copious bleeding that had been associated with liposuction procedures. Since that time, the use of the tumescent technique has been expanded to include other dermatologic surgical procedures such as hair transplantation, laser surgery, face-lifts, abdominoplasty, brachioplasty, and breast augmentation. The benefits of the tumescent technique detailed by Klein are numerous: optimizing biochemical drug efficacy, targeting drug effects in local tissue compartments, maximizing drug concentration locally, delaying systemic drug absorption, prolonging local and systemic drug effects, decreasing systemic drug toxicity, increasing the safe upper limit of drug dosage, mechanically expanding a targeted compartment, and benefiting from augmented local hydrostatic pressure to reduce bleeding. In this report, we aim to describe the use of dermal tumescent anesthesia in cutaneous surgical procedures. It is the authors’ experience that dermal tumescent anesthesia produces superior local anesthesia by directly injecting larger amounts of diluted anesthetic solution into the dermis, and also a reduced amount of bleeding intraoperatively and postoperatively.

Basal cell nevus syndrome is a genetically determined disease characterized by 5 major manifestations (multiple basal cell carcinomas, jaw cysts, skeletal abnormalities, pits of the hands and feet, and ectopic calcification) and a variety of developmental anomalies. We present a case of basal cell nevus syndrome in which the patient had adenoid cystic carcinoma of the minor salivary glands develop in the soft palate resulting in distant pulmonary metastases. The patient died at the age of 44 years of respiratory complications. To our knowledge, this is the first simultaneous occurrence of basal cell nevus syndrome with adenoid cystic carcinoma of salivary gland. (J Am Acad Dermatol 2003;48:S64-6.)

Pain characteristics and analgesia in patients undergoing Mohs micrographic surgery have not been systematically studied. It is important to know about pain after Mohs micrographic surgery to better serve patient needs.We sought to measure pain in patients after Mohs micrographic surgery, and to investigate the relationship among postoperative pain, surgical characteristics, patient characteristics, and analgesics used.The Wong-Baker 0-to-10 pain scale was prospectively administered postoperatively to all patients presenting for Mohs micrographic surgery in a private practice setting between October 1, 2007, and December 31, 2008. Patients recorded their pain level from the day of surgery through postoperative day 4. The age, sex, location of surgery, number of lesions operated on, postoperative size, type of repair, severity of pain, and oral analgesics consumed and dosages used were recorded.A total of 433 patients were included in the final analysis. The highest pain scores were found on the day of surgery and steadily declined until postoperative day 4 (P.000). In all, 52% of patients took pain medication on the day of surgery, which declined successively with each postoperative day. The highest mean pain scores were statistically significantly associated with repair type (flaps), age (66 years), number of lesions, and consumption of narcotics for pain relief. No statistically significant differences existed for sex or postoperative defect size.The instrument used to measure pain relied on patient self-report in a private practice surgery center. Only the validated Wong-Baker pain scale was used to assess pain in this study.Approximately half of the patients after Mohs micrographic surgery take medication for pain control. Type of closure, location of surgery, age, and type of pain medication taken were significantly associated with postoperative pain.

Background Primary cutaneous mucinous carcinoma is a rare neoplasm derived from the sweat glands. It is usually located in the head and neck region, with the eyelids being the most common site of presentation. Recurrence following primary excision is common but metastasis is rare. Case report We report a patient presenting with rapidly progressive cutaneous mucinous carcinoma on the right parietal scalp. Systemic work-up failed to reveal an occult primary source. The tumor was treated with Mohs micrographic surgery with clear margins. However, within two months, the patient developed new lesions on the scalp both adjacent to and separate from the original previously excised area, as well as metastasis to the right parotid gland. The patient received adjuvant radiation therapy both to the scalp lesions and to the parotid gland with apparent control of locoregional disease. However, two weeks after completing radiation therapy, the patient was found to have developed pulmonary metastases and died soon thereafter. Conclusion Primary mucinous carcinoma arising in the skin is rare and usually follows an indolent course. We report the rare occurrence of a mucinous carcinoma of the scalp that developed multiple cutaneous tumors caused by in-transit metastases, as well as parotid gland metastases and eventual fatal pulmonary metastases.

REFERENCES 1. Haustein UF. Bacterial skin flora, host defense and skin infections. Dermatol Monatsschr 1989;175:665-80. 2. Brook I. Secondary bacterial infections complicating skin lesions. J Med Microbiol 2002;51:808-12. 3. Galili D, Donitza A, Garfunkel A, Sela MN. Gram-negative enteric bacteria in the oral cavity of leukemia patients. Oral Surg Oral Med Oral Pathol 1992;74:459-62. 4. Flagothier C, Pierard-Franchimont C, Pierard GE. How I explore . . . diaper dermatitis. Rev Med Liege 2004;59:106-9. French. 5. Silvestre JF, Betlloch MI. Cutaneous manifestations due to Pseudomonas infection. Int J Dermatol 1999;38:419-31. 6. Lau GW, Hassett DJ, Ran H, Kong F. The role of pyocyanin in Pseudomonas aeruginosa infection. Trends Mol Med 2004; 10:599-606. 7. Meyer JM. Pyoverdines: pigments, siderophores and potential taxonomic markers of fluorescent Pseudomonas species. Arch Microbiol 2000;174:35-42. 8. Gilmore DS, Montgomerie JZ, Graham IE, Schick DG, Jimenez EM. Effect of antiseptic agents on skin flora of the perineum of men with spinal cord injury. Infect Control 1984;5:431-4. J AM ACAD DERMATOL VOLUME 53, NUMBER 5 Pearls 871

It is typically recommended that linear surgical closures follow a relaxed skin tension line (RSTL). In the temple, these lines generally run parallel to the orbital rim. However, closures parallel to RSTLs are not feasible for many medium and large surgical defects because of anatomic constraints.We sought to describe our method of repairing temple defects and assess the cosmetic outcome of temple defects repaired perpendicular to the RSTLs.We performed a two-phase study of temple closures. In the first phase, a retrospective analysis was performed to assess the defect size and type of closure used for 99 consecutive temple defects. In the second phase, 27 of 86 patients who previously underwent linear surgical repairs in the temple that were designed perpendicular to the RSTLs were evaluated 12 to 24 months postoperatively to assess the cosmetic outcome. Results In the first phase of the study, there was an inverse correlation between the width of the postoperative defect and the ability to close the defect parallel to the RSTLs. The percentage of defects that could be repaired parallel to the RSTLs for defects up to 1 cm in width, 1.1 to 2 cm in width, and greater than 2 cm in width was 46%, 28%, and 8%, respectively. In the second phase of the study, 27 patients with temple defects repaired perpendicular to the RSTLs were evaluated an average of 1.7 years after operation. Most scars (83%) were clinically invisible or barely visible. There were no cases with residual standing cones (dog-ears) or hypertrophic scars.The vast majority of temple defects can be repaired in a linear fashion. Smaller defects (width1 cm) can be repaired parallel to the RSTL. Those that are larger (width 1-3 cm) or more medially located can be repaired perpendicular to the RSTL, using loose cheek skin for the closure. Very large defects (width3-5 cm) or those with limited cheek mobility may require flaps or skin grafts for closure.

A ccurate tissue orientation and precise mapping of tissue specimens are fundamental to the technique of Mohs micrographic surgery. The ideal method for tissuemappingwould allow for precise replication of both the surgical defect and the excised tissue specimens in a reliable, rapid and reproducible manner. The most commonly utilized mapping technique is a hand-drawn sketch of the tissue specimens, which can be used to map and orient the tissue. Themain drawback to hand-drawn maps is the difficulty in replicating the exact size, shape, orientation, and anatomic context of the excised tissue specimens. This is particularly problematic for complex tumors requiring multiple stages or those resulting in large, irregular surgical defects with multiple tissue specimens. In recent years, digital photography has been utilized for Mohs tissue mapping. However, these digital systems are more complicated to incorporate into a practice, are more time consuming and expensive, and do not produce a 1:1 image. Polaroid photography was invented in 1947 by Edwin Land, an American physicist who devised a one-step process for taking, developing, and printing instant photographs. The point-and-shoot Polaroid camera is both easy to master and rapid to use, producing, in less than one minute, vivid color prints that retain theirqualityover time.Usingamacro feature, the Polaroid camera can recreate a 1:1 exact scale replica of a subject. This not only allows accurate and anatomically correct mapping and orientation of tissue specimens, but also makes

A 4-mm surgical margin of clinically normal skin is the current standard for elliptical excision of basal cell carcinomas (BCCs). However, a 4-mm surgical margin is often not feasible on the face because of cosmetic and functional concerns. As such, facial excisions of BCCs are typically performed with the appropriate margin determined by the surgeon based on clinical features of the tumor.We designed a study to test the efficacy of narrow-margin elliptical excisions for the treatment of small, well-demarcated facial BCCs.A total of 134 primary, small (1 cm), well-demarcated, facial nodular BCCs were excised as an ellipse with 1-, 2-, or 3-mm margins around the visible border of the tumor. The margin used was decided by the dermatologic surgeon based on cosmetic, anatomic, and functional factors, with the goal of clearing the tumor in a single excision. Using the Mohs technique for elliptical specimens, frozen sections were prepared and examined microscopically to provide complete histologic margin control.In all, 134 facial BCCs were included in the study. On average, the tumors measured 0.6 x 0.5 cm. Of these, 27 (20.1%) had positive margins, requiring additional excision. Excisions with 1-, 2-, and 3-mm margins were associated with positive margins in 16%, 24%, and 13% of tumors, respectively. There was no statistically significant difference in the occurrence of positive margins based on tumor size, anatomic location, or the measured margin used.Narrow margins (1-3 mm) are inadequate for the excision of small, well-demarcated, primary nodular BCCs of the face. To avoid repetitive operations and the risk of recurrence in anatomically sensitive areas, these tumors should be treated with standard wide margins (eg, 4 mm), or have Mohs micrographic surgery for histologic margin control.

M edial canthal defects resulting from cancer resection after Mohs micrographic surgery present challenging reconstruction dilemmas. In fact, medial canthal reconstruction has been controversial because of the time-honored method of second-intention healing in wound management of this area. Yet, small flaps and grafts for repair of cutaneous medial canthal defects may result in a quicker healing process with excellent cosmetic results. The main difficulties of reconstruction of the medial canthal region are the lack of local availability of similar thin eyelid skin, and the concavity of the defect to be repaired. The area of the medial canthus includes the free tissue margins of the upper and lower eyelids, the bony attachments of the medial canthal tendon, the lacrimal puncta, and arteriovenous and neural bundles that supply and innervate the region. The literature describes a multitude of surgically complex and intricate reconstruction methods including eyelid myocutaneous transposition flaps, glabellar flaps, cheek flaps, V-Y advancement flaps, and skin grafts for repair of defects of the medial canthus. Although these reconstructive options represent tested and widely used choices for medial canthal restoration, they are limited in that these techniques often provide a less than ideal color or texture match, provide tissue that is either too thick or too thin, or place incisions that cross aesthetic units and boundaries. We describe a novel flap that is conceptually simple to design and execute for the repair of medial

Background Diffuse epidermal and periadnexal squamous cell carcinoma in situ (DEPS) is a condition in which large areas of skin are affected by atypical keratinocytes that grow beneath the epidermis and encase adnexal epithelia. Normal differentiation of the overlying epidermis and adnexal epithelium is seen. Objective Our aim was to describe the clinical features of DEPS. Methods We undertook a retrospective case series of 13 patients with DEPS. Results All 13 patients were fair-skinned men older than 50 years with a history of significant sun exposure. The lesions were present on the scalp, face, and neck. Histologic examination showed a growth of atypical keratinocytes in the lower epidermis with encasement of adnexal structures by atypical neoplastic keratinocytes. In the 52 cumulative patient-years of follow-up, we treated 80 invasive squamous cell and 48 basal cell carcinomas in these patients. Despite improvement of DEPS with aggressive topical and destructive therapy, multifocal recurrence would typically develop within a few months. Conclusion DEPS is characterized by diffuse involvement of chronically sun-exposed skin with atypical keratinocytes that grow along the inferior portion of the basal layer of the epidermis and around adnexal structures. The treatment of DEPS is challenging because of its widespread nature and deeper periadnexal involvement. DEPS is also associated with the development of invasive squamous cell and basal cell carcinomas.

There has been no published study estimating the proportion of positive surgical margins that is missed when serial transverse cross-sectioning (bread-loafing) is used to histologically evaluate the surgical margins.Our purpose was to estimate the accuracy of serial transverse cross-sectioning (bread-loafing) at 4-mm intervals in detecting the presence of residual tumor at the margins of well-defined facial basal cell carcinomas excised as an ellipse with 2-mm surgical margins.Forty-two small (1 cm), well-defined, primary, nonmorpheaform facial basal cell carcinomas that had been excised as an ellipse with 2-mm margins and that had positive surgical margins utilizing en-face Mohs sections were included. After longitudinal bisection of each ellipse, frozen sections were prepared encompassing the entire surgical margin. Transparencies with parallel lines spaced at 4-mm intervals were superimposed on the histologic slides with the lines perpendicular to the epidermal surface. Areas in which the lines intersected tumor at the surgical margin were noted. The percentage of tumors that would be detected by serial cross sections was calculated on the basis of the percentage of these parallel lines that intersected tumor.The 42 tumors had a total of 50 positive surgical margins. Overall, the cross-sectional lines intersected tumor 44% of the time (95% confidence interval, 37%-51%). Only 5 (10%) of the residual tumors at the surgical margins exceeded 4 mm in their longitudinal dimension. In the 9 sections containing tumor in the deep margin, tumor intersected the lines 39% of the time.Bread-loafing at 4-mm intervals of elliptical excision specimens from facial basal cell carcinomas excised with 2-mm surgical margins is only 44% sensitive in detecting residual tumor at the surgical margins. We recommend complete histologic margin control by using en face tissue orientation (Mohs technique) to identify residual tumor and reduce the risk of tumor recurrence after elliptical excision of facial basal cell carcinomas.

BACKGROUND We describe the use of tumescent anesthesia before laser hair removal in the axilla to improve patient comfort during treatment. Our modified tumescent technique provides more extensive anesthesia than standard intradermal injections of local anesthetic agents and is less painful to administer. Compared with topical anesthetic creams, tumescent anesthesia has a quicker onset and delivers more complete anesthesia. Hair removal by laser or intense pulsed light sources is a painful procedure, especially in sensitive areas such as the beard, axilla, and groin. Recent trends in laser hair removal (longer pulse durations and wavelengths) offer better treatment of dark skin, 1 but are even more painful. Topical anesthetic creams are commonly used to decrease discomfort, butareslow toactandcan bemessy. 2 Wehavefound that axillary injection of tumescent anesthesia is extremely effective for reducing the discomfort of laser hair removal. In addition, the pain of injection into the subcutaneous fat is minimal (compared with thedermis)and,therefore,welltolerated bypatients. The technique is quick, safe, and cost-effective, making it an important tool in our practice for a wide variety of procedures, including laser hair removal.

Background Deep absorbable stitches should provide a firm closure, hemostasis, and good wound-edge eversion, but this is not always achieved with standard techniques. Objective We sought to investigate alternative techniques that can rapidly and reliably achieve these results. Methods We evaluated the fully buried horizontal mattress suture. We compared this technique with the previously described fully buried vertical mattress, partially buried mattresses, and standard reticular dermal and subcutaneous sutures. Results The fully buried horizontal mattress can provide excellent wound-edge approximation and eversion. It is particularly useful for shallow defects and narrow spaces where a deep stitch is required but technically difficult to insert. Overall, this method offers excellent final cosmesis, and individual sutures can be quickly and reproducibly placed with minimal practice. For very deep defects that require dead-space closure, the fully buried vertical mattress may be preferable. Conclusions The buried horizontal mattress suture has wide applicability as the buried stitch in a bilayer repair.

Background Aesthetic repair of small cutaneous defects of the nose is a common challenge for the dermatologic surgeon because nonmelanoma cancers occur frequently in this location. Objective Our aim was to devise a simple flap for repair of small to medium-sized defects of the lateral nasal supratip. Methods The mechanics of the proposed horizontal advancement ("east-west") flap are described. Patient selection, flap design, and flap mechanics are discussed. The benefits and limitations of this repair are compared with those of alternative closures. Results The horizontal-advancement flap is an easily visualized, constructed, and executed flap that permits repair of small to moderately sized lateral nasal supratip defects without inducing asymmetry of the nasal architecture. The flap is well camouflaged in skin lines, the ala and nares are not distorted, and the large, untwisted pedicle contributes to flap viability. Large defects and defects far lateral to the midline may not be amenable to this repair. Conclusions In selected patients with small to medium-sized lateral nasal supratip defects, the horizontal advancement flap is a simple, reliable, and aesthetically pleasing reconstruction option.

We present a case report of a patient with basal cell nevus syndrome (BCNS) who developed multiple polypoid basal cell carcinomas (PBCC) in the perineum. PBCC is a rare variant of nodular BCCs. Clinically, PBCCs mimic acrochordons. We recommend that the perineum, perianal, and genital areas should be included in the routine exam of patients with BCNS.

Background Controversy exists over the rate of malignant transformation of actinic keratoses (AKs) and, therefore, which treatment is indicated. Furthermore, it is not known to what degree each of the separate clinical subtypes of AKs become malignant. Objective Our purpose was to examine clinically diagnosed hyperkeratotic AKs and classify them histologically. Methods Fifty papular hyperkeratotic AKs on the dorsum of the hand, wrist, and arm, less than 1 cm in diameter, were identified in 43 patients. Histologic evaluation was conducted in a blinded fashion by two observers. Results Histologic examination showed 18 lesions (36%) to be invasive squamous cell carcinoma, whereas another seven (14%) were squamous cell carcinoma in situ. Proliferative AKs were the next most common lesion identified (26%), followed by hypertrophic (10%) and lichenoid (4%) AKs. Basal cell carcinomas (4%) and other benign lesions (6%) comprised the rest of the biopsy specimens. Conclusion It is possible to predict clinically, with greater certainty than previously realized, which AKs have a greater tendency toward malignant change. Clinical hyperkeratotic AKs less than 1 cm in diameter on the dorsum of the hand, wrist, or forearms of white patients have a malignancy rate of 50%. Lesions with this clinical description should be removed by shave biopsy, then by 35% trichloroacetic acid, then liquid nitrogen to a width and depth of 3 mm.

I ssues pertaining to the disposal of surgical waste are seldom discussed in the dermatologic surgery literature. Management of surgical waste as pertaining to the surgeon includes proper disposal of sharps in appropriate containers as well as proper handling and disposal of infectious nonsharp materials. Attention should be paid to two particular issues. First and foremost is to minimize the risk of exposure of patients, health care workers, office or operating room staff, and employees collecting or processing surgical waste to infectious materials through proper disposal of sharp and infectious waste. Although one may assume that these procedures are routinely adhered to in clinical practice, one study in New Zealand discovered that 56% of dental practices disposed of bloody swabs into the waste paper bin, and 24% disposed of contaminated sharp items into the general household refuse collection.1 Second is to minimize aberrant introduction of non-sharp waste into sharp waste disposal containers or of non-infectious waste into infectious waste bags. This is to minimize the financial and environmental costs associated with the processing of sharp and infectious waste. One study of university sharp boxes discovered that the full boxes contained only 14% appropriate sharps by weight and less than 50% appropriate sharps by volume.2 Moreover, the implementation of a waste segregation program in one hospital resulted in a 65% reduction in infectious

I n most dermatologic surgery, hematomas and infection can be avoided by careful patient selection, hemostatic control, and meticulous surgical technique. On rare occasions, postoperative hematomas or abscesses require drainage. Herein, we describe an alternative to the Penrose drain commonly used in such situations. Penrose1 first reported placing a common rubber condom to drain excess fluid collection after abdominal surgery. Today, with millions used yearly, the Penrose drain is the most widely used drain.2 Whereas the cost of the Penrose drain is not prohibitive, it is not routinely used by all dermatologic surgeons nor kept in supply in the office. However, all dermatology offices do have sterile surgical gloves that can be modified and used as a surgical drain. To make this drain, first cut the appropriate length finger from a nonpowdered, sterile glove (Fig 1). This “finger” can then be fenestrated to allow greater drainage along the lateral aspects of the wound that need fluid removal (Fig 2). The fenestrations are discarded, and the drain is placed within the wound bed with the exposed portion allowed to drain inferiorly. The length of drain required will dictate the size of glove needed and which digit to remove from the body of the

This multicenter double-blind study of 157 patients was designed to evaluate the safety and efficacy of a new dosage regimen of oral acyclovir (800 mg twice a day for 5 days) for the treatment of recurrent genital herpes. The new regimen was compared with the standard dosage of 200 mg given five times a day to patients treated for three consecutive episodes (one episode with physician-initiated therapy and two with patient-initiated therapy) and followed up for three untreated episodes. The new regimen was well tolerated and effective. In male patients it may be more effective than the standard regimen of 200 mg given five times a day to treat vesicles that are already present.

The occurrence of cutaneous carcinoma in black patients is an unusual phenomenon, with basal cell carcinoma being particularly uncommon. We present five cases of basal cell epithelioma in black patients collected from the Texas Medical Center to graphically illustrate the varied and often atypical clinical presentations of such tumors. This report supports recent series of basal cell epithelioma in black patients derived from retrospective chart reviews.

Background Vismodegib, a first-in-class Hedgehog pathway inhibitor, was US Food and Drug Administration (FDA) approved for advanced basal cell carcinomas (BCCs) based on a single, nonrandomized, phase-II trial. Consequently, additional clinical data are critical to confirm the efficacy and safety of vismodegib. Objective We sought to assess efficacy and safety of vismodegib, while providing early drug access to patients with advanced BCC and limited treatment options. Methods This was an open-label, multicenter study in patients with advanced BCC inappropriate for radiotherapy or surgery. Patients received 150 mg vismodegib daily until disease progression or intolerable toxicity. Tumor response was assessed via Response Evaluation Criteria in Solid Tumors version 1.0. Results A total of 119 patients with advanced BCC took vismodegib for a median of 5.5 months. Objective responses occurred in 46.4% of locally advanced BCC and 30.8% of patients with metastatic BCC. Response was negatively associated with prior systemic therapy in patients with locally advanced BCC ( P = .002). Mean follow-up for safety was 6.5 months, with muscle spasms (70.6%), dysgeusia (70.6%), alopecia (58.0%), and diarrhea (25.2%) as the most common adverse events. Limitations Abbreviated follow-up time because of study termination upon FDA approval was a limitation. Conclusion This study provides important clinical data supporting the efficacy and safety of vismodegib. Larger studies are underway to assess predictors of response and long-term outcomes.

Fig. 1. Number of lesions in identical twins with basal cell nevus syndrome during isotretinoin therapy. REFERENCES 1. Haustein UF, Herrmann K, Bohme HJ. Pathogenesis of progressive systemic sclerosis. Int J Dermatol 1986;25:28693. 2. Cipoletti HF, Buckingham RB, Barnes EL, et al. Sjogren's syndrome in progressive systemic sclerosis. Ann Intern Med 1977;87:535-41. 3. Fong PH, Chan HL. Systemic lupus erythematosus with pemphigus vulgaris. Arch Dermato1 1985;121:26-7. 4. Vetters JM, Saikia NK, Wood J, et al. Pemphigus vulgaris and myasthenia gravis. Br J Derrnatol 1973;88:437-41. 5. Katz AL, Nashel DJ, Goard PG, et al. Pemphigus vulgaris and lymphoma in a patient with scleroderma. South Med J 1979;72:1463-6. 6. Heyden W. Pemphigus Seborrheicus bei progressiver Sklerodermie. Z Hautkr 1984;59:1336-9. pathogenetic mechanisms, or the association might be merely a coincidence. A larger series of patients should be reported and more should be learned about the pathogenetic mechanisms of these diseases before further conclusions are reached.

The development of skin cancer in black persons is rare, and basal cell epitheliomas are the most uncommon. Eight tumors were evaluated by routine histochemistry examination and irnmunoperoxidase staining for carcinoembryonic antigen (CEA). Our results demonstrate that half these tumors showed a positive reaction to this antigen, supporting the adn-exal origin/differentiation of these lesions. Sixteen (16/18) similar tumors from white patients failed to show equivalent features. In addition, some of these CEA-positive tumors seem to demonstrate less aggressive behavior.