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Background: Clinical improvement in photodamaged skin after carbon dioxide (CO2) laser resurfacing is thought to result in part from thermal collagen shrinkage. The presence of such collagen has not been unequivocally demonstrated. To identify and characterize the morphological features of collagen after CO2 laser exposure, we irradiated ex vivo human facial skin and bovine calcaneus tendon with microsecond domain pulsed CO2 laser energy and examined specimens for histopathological and ultrastructural changes in collagen., Observations: In dermis and tendon, 3 zones of collagen structure were apparent on electron microscopy. The first, most superficial zone demonstrated loss of collagen structure. The second zone consisted of admixed normal collagen fibers and thickened collagen fibers. Zone 3 consisted of normal-appearing collagen fibers., Conclusions: Ultrastructural examination of irradiated collagen revealed distinct morphological zones of denatured collagen fibers. Partially denatured fibers had an increased diameter consistent with lineal shrinkage. Zonal distinction was undetectable by light microscopy. Ultrastructurally, the zones of denatured collagen located above the normal fibers correlated with the zone of altered material seen on light microscopy. These findings suggest that collagen fiber shrinkage does occur after pulsed CO2 laser irradiation and that this phenomenon contributed, at least in part, to the immediate tissue contraction observed clinically.

Background: Placental site trophoblastic tumor (PSTT) is a rare neoplasm of intermediate trophoblastic cells of the placenta. There is a wide range of biologic behavior, with metastases occurring in about 15% of cases. Cases with metastases have all presented with abnormal vaginal bleeding or gynecological symptoms., Methods: We describe a 31-year-old G3P3003 woman who presented with several alopecic patches resembling alopecia areata, which on biopsy proved to be metastatic, previously unsuspected, PSTT., Conclusions: This represents the first case in which PSTT presented initially with metastases, and specifically, with cutaneous metastases. A new primary tumor source of alopecia neoplastica is presented. The role of mitotic counts in predicting prognosis in PSTT is supported. Alopecia areata was mimicked very closely. Dermatologists should be alert to any features atypical of alopecia areata, including erythema, induration, or palpability, and maintain a low threshold for biopsy in atypical cases.

Background: Anti-human epithelial antigen (Dako-Ber-EP4) is an antibody raised in mice that reacts with two glycoproteins of 34 and 49 kD. These glycoproteins are present on the cell surface and in the cytoplasm of basal cell carcinoma (BCC) cells, sweat glands, and some hair follicles in the skin., Methods: We selected 27 BCCs (15 nodular, 11 morpheic/infiltrative, and one adenoid) and one trichoblastoma and performed rapid immunohistochemical studies with Ber-EP4 and a labeled streptavidin biotin alkaline phosphatase system., Results: Twenty-seven of 27 BCCs and one of one trichoblastoma were positive for Ber-EP4. Thirteen of 27 BCCs stained with Ber-EP4 showed areas of BCC in dense inflammation that were better defined by the Ber-EP4 immunostain than by the H&E stain. In two cases persistent infiltrative BCC was found in the final Mohs margins while appearing negative with routine H&E. Several instances occurred where negative Ber-EP4 in inflammatory fields resulted in tissue sparing with the avoidance of a further Mohs (insurance) layer., Conclusion: In conclusion, we found mouse anti-human Ber-EP4 a useful and reliable marker for BCC. This antibody helps to locate latent BCC tumor in inflammatory Mohs margins.

Background and Design: In this study we developed an in vitro model of nodular basal cell carcinoma (BCC). We obtained pure cultures of BCC cells and compared the morphologic characteristics, ultrastructure, immunophenotype, and behavior of cultured tumor cells with those of their in vivo counterparts. Tumors were excised from patients undergoing Mohs micrographic surgery. We established 69 primary cell cultures from 32 patients with nodular BCC., Results: Three cell types grew in primary cultures: fibroblasts, normal-appearing keratinocytes, and cells with dual (spindle and epithelioid) morphologic characteristics. Contaminating fibroblasts were removed using 0.125% trypsin-0.02% edetic acid, and normal-appearing keratinocytes were cornified and eliminated by temporarily increasing the concentration of calcium in the growth medium. The cells with dual morphologic characteristics remained intact and exhibited relentless growth in pure cultures. That these seemingly immortal cell strains represent true nodular BCC was demonstrated by (1) their biphasic morphologic characteristics and very slow cell growth rate, (2) their capability for anchorage-independent growth in soft agar, (3) their ultrastructural similarities to freshly excised nodular BCC, (4) their ability to generate antibodies selectively labeling nodular BCC tumor nests in vivo, and (5) their immunophenotypic similarities to BCC in vivo on more than 20 different cell markers., Conclusions: This study provides a simple technique for establishing pure cell cultures of nodular BCC and describes extensively the in vitro parameters of tumor cell growth. The striking differences in behavior of cultured tumor cells in the presence or absence of normal-appearing keratinocytes suggest that normal human epidermal keratinocytes can suppress the growth of BCC cells.

Background: Adequate preparation of the skin is necessary for a successful chemical peel. Little detailed attention has been given to the effect of degreasing on the efficacy of the peel., Objective: To assess the influence of degreasers on the peel, compare their flammabilities, and discuss alternatives., Methods: Six patients with androgenetic alopecia and widespread actinic keratoses of the scalp were treated with 35% trichloroacetic acid. Scalps were divided into sections and degreased with acetone, rubbing alcohol, Freon Skin Degreaser, or Hibiclens. The influence of these degreasers on trichloroacetic acid peels was assessed by clinical and histologic examination., Conclusion: Acetone was not found to be superior to the other agents. Furthermore, the flashpoint of acetone is markedly lower than the others, making it more flammable and hazardous in the workplace. The use of alternative degreasers may lessen or eliminate this hazard.

Background: Prior studies have demonstrated reduced wounding with trichloracetic acid (TCA) peels after tape occlusion. It is therefore reasonable to question whether or not other types of occlusion may have similar effects, particularly those used in routine postoperative care., Objective: To reevaluate the effect of occlusion after TCA peels in multiple human models using various forms of dressings, at various times postoperatively, and to make recommendations regarding wound care that will not adversely affect the efficacy of the peel., Methods: Equal-sized sections of anterior alopecic scalps of four patients were peeled with 50% TCA, occluded with bacitracin, Vigilon, or Tegaderm at various times postoperatively, and biopsied 1 day later. Depths of necrosis were measured and compared with nonoccluded controls., Results: Bacitracin ointment and Vigilon did not lessen TCA wounding, and sometimes actually enhanced it. Conversely, Tegaderm lessened the degree of the TCA wound. Timing of application played a role in the case of occlusion with Vigilon., Conclusion: Occlusives used in conjunction with TCA peels do not have a uniform effect on depth of necrosis. Ointments and Vigilon can be used without reducing the efficacy of the TCA peel. Multiple subjects and rigid control of variables are necessary in studies of TCA-induced necrosis.

Background: Recurrence of squamous cell carcinoma (SCC) following Mohs micrographic surgery is uncommon. However, such cases do exist, presumably because of incomplete excision. Identification of single cells or small clumps of SCC tumor may be extremely difficult and can be compromised by inflammatory reaction., Objective: The purpose of this study was to evaluate the benefits of incorporating rapid cytokeratin (CK) stains into Mohs technique., Methods: Simple modification of standard immunoenzyme techniques allows keratin-specific staining to be achieved in less than 90 minutes on Mohs cryostat sections. We used the rapid labeled streptavidin biotin anticytokeratin method at the stage when no tumor was apparent by hematoxylin and eosin staining in 20 patients with large, aggressive, or recurrent invasive SCCs., Results: In eight cases, single cells or small clumps of SCC tumor were identified utilizing AE-1 monoclonal antibody. These patients subsequently underwent further surgery, including wider tumor resection, superficial parotidectomy, or postoperative radiation therapy., Conclusion: The rapid CK antibody staining technique enhances the sensitivity of tumor identification in Mohs micrographic surgery, and should reduce tumor recurrence rates.

Extensive extramammary Paget's (EMPD) disease of the perineum in a 68-year-old man was treated by Mohs surgery. To facilitate identification of involved tissue a rapid staining carcinoembryonic antigen was used. This technique proved a useful adjunct to conventional hemotoxylin-eosin (H&E) stains. It was especially useful in highlighting involvement in areas of marked dysplasia/artifact where discrimination is often difficult. It is recommended that such a technique offers considerable benefits over H&E staining when confronted by such tissue morphology.

Background: Pseudocyst of the auricle is characterized by an asymptomatic swelling caused by an intra-cartilaginous accumulation of fluid. Treatments include aspiration, steroid injection, and surgical intervention., Objective: To present two cases of pseudocyst of the auricle treated surgically with an open, deroofing technique., Methods: Two cases are presented and the relevant literature is reviewed., Conclusion: Optimal treatment for pseudocyst of the ear involves removal of the anterior cartilaginous leaflet of the pseudocyst with repositioning of the overlying flap of skin. This results in a normal-appearing auricle with minimal scarring or recurrence of the pseudocyst.

In the routine handling of Mohs specimens the curetted first layer is integral to the process of tumor identification. Small specimens may be smeared inadvertently on filter paper or gauze or even lost between the operating room and laboratory. An efficient method for processing small curetted specimens has been devised that bypasses the use of a tissue tray. This method improves tissue morphology and saves time.

Local anesthetics are perhaps the most important drugs used in dermatologic surgery. They allow a variety of procedures to be performed safely and comfortably. Although generally well-tolerated, patients frequently report adverse reactions to these agents and may be labeled as "caine sensitive". In this review we will discuss the approach to the patient with possible local anesthetic sensitivity and in particular will focus on the role of skin testing and challenge in evaluating these patients.

We have studied eight cases of an acquired lymphatic endothelial lesion for which we propose the name "benign lymphangioendothelioma." The lesions developed as solitary, slowly extending, erythematous macules and plaques, usually occurring on the extremities or the shoulders in adolescents or adults. The characteristic histopathologic feature is permeation of the dermal collagen by flattened, endothelium-lined channels and spaces. Hemorrhage, iron deposition, and inflammation were not part of the lesion. Ulex europaeus agglutinin I labeled the lesional endothelial cells consistently, but factor VIII-related antigen labeling was negative. This histologic pattern and the special studies suggested a lymphatic lesion. Surgical excision, performed in six patients, was not followed by recurrence.

Rhinophyma, the end stage in the development of rosacea, is characterized by sebaceous hyperplasia, fibrosis, follicular plugging and telangiectasia. Although it is commonly considered a cosmetic problem, it can result in gross distortion of soft tissue and in airway obstruction. Previously, basal-cell carcinoma (BCC) has been reported in association with rhinophyma. We are reporting an additional case in which the patient had been delaying treatment because of the 'cosmetic nature' of this condition.

The fingernails of twenty-four patients with classical adult (type 1) pityriasis rubra pilaris were examined for changes in nail morphology and a comparison was made with the fingernail morphology of twenty-seven consecutive psoriatic patients with nail changes. Distal yellow-brown discoloration, subungual hyperkeratosis, nail plate thickening, and splinter hemorrhages indicate a diagnosis of type 1 pityriasis rubra pilaris rather than psoriasis, while onycholysis (particularly marginal), salmon patches, small pits, and larger indentations of the nail plate indicate a diagnosis of psoriasis. Histology demonstrated that a nail biopsy would be a useful diagnostic procedure if nails were involved in isolation but provided no additional diagnostic features to those found from biopsy specimens of involved skin in the two conditions. The similarity in nail morphology between the type 1 pityriasis rubra pilaris patients and five patients with chronic erythroderma resulting from Sézary syndrome indicated that these changes may represent a nonspecific reaction pattern that may result from prolonged erythema of the proximal nail bed and matrix. The rough nails (trachyonychia) described in advanced Sézary syndrome were not observed in any of our patients.

We describe a case of centrifugal lipodystrophy occurring in a young English girl, and compare the clinical and histopathological features with previous reports from Japan.

Precise identification and localization of tumor is the key to success in Mohs micrographic surgery. In a pilot study, we demonstrated improvement in tumor definition and staining characteristics after formalin fixation of cryostat sections (postfixation) when compared with unfixed specimens. We further investigated the benefits of postfixation with a series of tissue fixatives and with varying fixation times. In all cases, postfixation was found to be beneficial. No improvement was noted by extending the postfixation time beyond 1 minute.

Bovine collagen implants are in widespread use for the correction of soft tissue deficiencies. A small portion of the population responds adversely to these implants, evidenced by either positive skin tests or treatment site reactions. Antibodies against bovine collagen implants have been detected in the sera of virtually all patients with adverse treatment reactions and in small percentages of untreated individuals and treated individuals without adverse reactions. In this study we examined the levels of anti-bovine collagen implant antibodies in 150 individuals prior to bovine collagen implant therapy and then monitored these patients for adverse reactions to skin tests and bovine collagen implant treatments. Statistical analyses were performed to determine the value of pretreatment serology in predicting positive skin tests or adverse reactions. It was determined that individuals with greatly elevated levels (greater than 2 standard deviations [SDs] above the mean reactivity of pretreatment sera) of anti-bovine collagen implant antibodies prior to treatment were approximately sixfold more likely to suffer adverse reactions than patients with no elevation of antibodies prior to treatment.

An analysis of T-lymphocyte subpopulations was performed on thirty-eight consecutive patients with atopic eczema, using monoclonal antibodies and flow cytofluorimetry. The total T-lymphocyte and helper T-cell numbers did not differ significantly from those of a matched control group, but there was a highly significant reduction in suppressor T-cell numbers among the atopic group. Both suppressor T-cell deficiency and circulating IgE elevation were found to correlate positively with disease activity. Food specific IgE levels to milk and egg were ascertained by radioallergosorbent (RAST) studies. These proved positive in seven out of thirty-five atopics (20%).

Genital tumors represent a special group requiring effective and curative treatment while functional and cosmetic demands require tissue sparing techniques. For these reasons, micrographic surgery is indicated. Over the past 5 years we have treated 24 such patients utilizing standard techniques for micrographic surgery. The patient population included twenty male and four female patients with ages ranging from 27 to 80 years. Histologically confirmed diagnoses included squamous cell carcinoma, Bowen's disease, verrucous carcinoma, basal cell carcinoma, Paget's disease, and leiomyosarcoma. These were located on the penis, scrotum, perineum, and buttocks. Seven of these patients were considered to have recurrent tumors. Preexisting conditions existed in 6 patients, including balantis xerotica obliterans, trauma, decubitus ulcer, and hidradenitis suppurativa. All surgery was performed under local anesthesia in the cutaneous surgery unit. Average pretreatment tumor size was 2.0 X 1.9 cm. Average postoperative defect size was 4.5 X 3.7 cm. Tumors were excised with an average of three stages and 18 sections. Most defects (65%) were allowed to heal by secondary intention, five (21%) were closed primarily, and three were referred for closure. After surgery five patients developed metastases in their regional lymphatic system. No patients developed local recurrence. Micrographic surgery is a most useful treatment modality in patients with genital tumors for control of local disease. However, patients with squamous cell carcinoma should be considered for elective regional lymph node biopsy and/or dissection in conjunction with micrographically controlled excision of the primary tumor.

Twenty-two adults with persistent, symptomatic viral warts on the hands or feet which had failed to respond to conventional therapy were treated by carbon dioxide (CO2) laser ablation under local anaesthesia. Four patients did not return for follow-up treatment. Of the remaining 18 patients, 12 had plantar warts, the other six had warts on the hands that were mainly periungual. The median duration of the warts prior to laser treatment was 5 years. The areas treated were solitary in eight and multiple in 10 cases. After an average follow-up period of 10 months (minimum 6 months), all of the treated areas were clear of warts in 10 patients (56%), some had cleared in three, and all the treated warts had relapsed in the other five patients. Side-effects were commonly observed, especially post-operative pain, temporary loss of function of the treated part and scarring. The use of the CO2 laser may clear otherwise resistant viral warts but a significant morbidity may occur with this method of treatment.

A new method has been used to measure tissue levels of amiodarone and its major metabolite desethylamiodarone. Amiodarone-pigmented skin has a drug and metabolite concentration ten times that of non-pigmented skin. Iodine-rich amiodarone and its metabolite have been detected in secondary lysosomes by energy dispersive analysis of X-rays. Amiodarone induces a phototoxic reaction with an action spectrum in both the UV-B and UV-A wavelengths.

Tissue from the acute, non-infected eruption of sixteen atopic eczema subjects was subjected to an indirect immunoperoxidase technique using monoclonal antibodies recognizing T-lymphocyte subsets, Langerhans cells and natural killer cells. Over half the cells infiltrating the dermis were T lymphocytes, including a large majority of helper T cells and relatively few suppressor T cells. Langerhans cells were present in significant proportions in the dermis and probably reflected increased antigen presentation within the affected skin. There was no evidence of increased natural killer cell presence. This study suggests that type IV hypersensitivity may be implicated in the aetiology of atopic eczema.

Penile tumors represent a difficult group of neoplasms requiring effective and curative treatment while minimizing tissue loss to prevent cosmetic and functional deformity. Over the past 6 years, we have treated 20 patients with penile cancer utilizing the fresh tissue technique of Mohs micrographic surgery. Tumors were excised with an average of 2.25 stages. Most defects (80%) were allowed to heal by second intention. Since surgery, four patients have developed metastatic disease in their regional lymphatic system, and one patient has died from metastatic spread. One patient has developed local recurrence. Micrographic surgery is a very useful treatment modality for patients with penile tumors. Patients with SCC of the penis should be considered for elective regional lymph node biopsy and/or dissection in conjunction with micrographically controlled excision of the primary tumor.