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Dear Editor, Growing evidence suggests that SARS‐CoV‐2 vaccination is associated with a variety of cutaneous reactions, also including autoimmune‐mediated conditions such as autoimmune blistering diseases such as bullous pemphigoid (BP).1,2 We report new‐onset BP in two patients following the first SARS‐CoV‐2 vaccination.

There exist relatively sparse and conflicting data on high-level microsatellite instability (MSI-H) and deficient mismatch repair (dMMR) in cutaneous malignancies. We aimed to determine the expression profiles of MMR proteins (MSH2, MSH6, MLH1, and PMS2) in different progression stages of cutaneous squamous cell carcinoma (cSCC, 102 patients in total) by immunohistochemistry, and search for MSI-H in patients with low-level MMR or dMMR using multiplex-PCR. Low-level MMR protein expression was observed in five patients: One patient with primary cSCC &lt, 2 mm thickness and low-level MLH1, three patients with primary cSCC &gt, 6 mm (including one with low-level MSH2, as well as MSH6 expression, and two with low-level PMS2), and one patient with a cSCC metastasis showing low-level MSH2 as well as MSH6. Intergroup protein expression analysis revealed that MLH1 and MSH2 expression in actinic keratosis was significantly decreased when compared to Bowen’s disease, cSCC &lt, 2 mm, cSCC &gt, 6 mm, and cSCC metastasis. In cases with low-level MMR, we performed MSI-H tests revealing three cases with MSI-H and one with low-level MSI-L. We found low-level MMR expression in a small subset of patients with invasive or metastatic cSCC. Hence, loss of MMR expression may be associated with tumour progression in a small subgroup of patients with non-melanoma skin cancer.

Hidradenitis suppurativa/Acne inversa (HS/AI) ist eine chronisch-entzundliche Hauterkrankung, deren Behandlung sowohl konservative als auch chirurgische Behandlungsmoglichkeiten umfasst. In den Hurley-Stadien II und III ist die chirurgische Resektion irreversibel zerstorten Gewebes anzustreben. Hierzu existieren verschiedene Resektionstechniken, die sich vor allem in ihrer Invasivitat und Rezidivneigung unterscheiden. Bis heute gibt es keinen allgemein akzeptierten Konsens hinsichtlich verschiedener Resektions- und Rekonstruktionstechniken sowie der Einbeziehung medikamentoser Therapien in das therapeutische Gesamtkonzept.

Die Befunde der vereinzelten durchgefuhrten Studien legen nahe, dass v. a. Depressionen und Angststorungen als haufigste psychiatrische Komorbiditaten bei Patienten mit einer Hidradenitis suppurativa/Acne inversa (HS/AI) vorkommen. Im Rahmen einer prospektiven Studie wurden 51 Patienten mit einer HS/AI hinsichtlich einer psychiatrischen Komorbiditat mittels eines standardisierten Interviews und Fragebogen naher untersucht. Bei der fachpsychiatrischen Untersuchung fand sich bei 29,4 % der HS/AI-Patienten eine zusatzliche psychische Symptomatik, die sich v. a. in Form einer depressiven Storung manifestierte. Die HS/AI-Patienten waren eher jung, eher Frauen und wiesen ein haufiges Vorkommen von Nikotin- und Alkoholkonsum und eine positive Familienanamnese fur eine paternale Alkoholabhangigkeit auf. Daruber hinaus bestanden bei den HS/AI-Patienten deutlicher psychosoziale Einschrankungen in Form von fehlender Partnerschaft und eine durch die vorhandenen Symptome deutliche psychische Belastung. Die Acne inversa ist eine schwere chronische entzundliche Hauterkrankung, die ahnlich wie andere inflammatorische Dermatosen mit psychischer Komorbiditat und psychosozialen Beeintrachtigungen einhergeht. Da v. a. junge Patienten betroffenen sind, sollte fruhzeitig eine psychiatrisch-psychotherapeutische Mitbehandlung erwogen werden.

Background In a small number of kindreds with familial hidradenitis suppurativa (HS) different mutations of NCSTN (nicastrin) have been identified. Blocking of NCSTN leads to impairment of the Notch and PI3K/AKT signalling pathway, which is assumed to play a pathogenic role in HS. However, very limited data are available concerning expression levels of these pathway components in HS skin. Objectives To analyse the mRNA and protein expression of NCSTN, Notch1-3, PIK3R3 and AKT3 in HS. Methods Skin samples from healthy controls, lesional and perilesional skin of HS patients with and without a positive family history were analysed by quantitative real-time RT-PCR and immunohistochemistry. Univariate statistical analyses were conducted regarding association between expression levels and patient's characteristics. Results Expression levels of all investigated genes showed significantly higher levels in lesional HS skin compared with healthy controls. Univariate analysis showed no association between a positive family history and mRNA expression levels. Perilesional HS skin of patients with mild disease severity (Hurley I) showed significant higher mRNA expression levels of the investigated pathway components compared to moderate (Hurley II) and severe disease (Hurley III). Conclusion We found no evidence for diminished expression levels of the Notch signalling. In contrast, the NCSTN, Notch and PI3K/AKT signalling components are overexpressed in HS. Future research is needed to investigate a possible pathogenetic role or to reveal a coactivation of these overexpressed components during inflammatory response in HS.

The findings of most studies suggest that depression and anxiety disorders are the most common psychiatric comorbidities in patients with hidradenitis suppurativa/acne inversa (HS/AI).In a prospective study, 51 patients with HS/AI were further examined for psychiatric comorbidity using a standardized interview and questionnaires.In psychiatric examination, 29.4% of HS/AI patients had additional mental symptoms, mainly manifested as depressive disorder. The HS/AI patients were rather young and female, and they showed a high incidence of nicotine and alcohol use, and a positive family history of paternal alcohol dependence. In addition, HS/AI patients experienced more severe psychosocial impairments in the form of lack of partnership and lower school attainment.Acne inversa is a severe chronic inflammatory skin disease that, like other inflammatory dermatoses, is associated with mental comorbidity and psychosocial impairments. Since especially young patients are affected, a psychiatric-psychotherapeutic cotreatment should be considered already at an early stage.HINTERGRUND: Die Befunde der vereinzelten durchgeführten Studien legen nahe, dass v. a. Depressionen und Angststörungen als häufigste psychiatrische Komorbiditäten bei Patienten mit einer Hidradenitis suppurativa/Acne inversa (HS/AI) vorkommen.Im Rahmen einer prospektiven Studie wurden 51 Patienten mit einer HS/AI hinsichtlich einer psychiatrischen Komorbidität mittels eines standardisierten Interviews und Fragebögen näher untersucht.Bei der fachpsychiatrischen Untersuchung fand sich bei 29,4 % der HS/AI-Patienten eine zusätzliche psychische Symptomatik, die sich v. a. in Form einer depressiven Störung manifestierte. Die HS/AI-Patienten waren eher jung, eher Frauen und wiesen ein häufiges Vorkommen von Nikotin- und Alkoholkonsum und eine positive Familienanamnese für eine paternale Alkoholabhängigkeit auf. Darüber hinaus bestanden bei den HS/AI-Patienten deutlicher psychosoziale Einschränkungen in Form von fehlender Partnerschaft und eine durch die vorhandenen Symptome deutliche psychische Belastung.Die Acne inversa ist eine schwere chronische entzündliche Hauterkrankung, die ähnlich wie andere inflammatorische Dermatosen mit psychischer Komorbidität und psychosozialen Beeinträchtigungen einhergeht. Da v. a. junge Patienten betroffenen sind, sollte frühzeitig eine psychiatrisch-psychotherapeutische Mitbehandlung erwogen werden.

BackgroundRhinophyma surgery is commonly associated with prolonged wound healing and the need for multiple wound dressings.ObjectivesTo evaluate clinical outcome with a porcine extracellular matrix (ECM) after shave excision of rhinophyma compared with common wound care procedure.Materials and methodsRetrospective analysis of patients with common dressings (CD) compared with patients with additional ECM (OASIS) application. Clinical findings were assessed prior to treatment and at follow-up visit using the Patient and Observer Scar Assessment Scale (POSAS), Vancouver Scar Scale (VSS), and Rhinophyma Severity Index (RHISI).ResultsOverall, 28 patients (67.5 ±9.0 years) with a mean wound area of 33.9 (±8.5) cm² were included. After a mean follow-up period of 132 (±73) days, scales of POSAS, VSS, and RHISI showed significant ( P< .0001) reductions of 47.0% (±11.1), 56.0% (±12.0), and 62.3% (±14.3), respectively. Subgroup analysis showed no significant differences of aforementioned parameters between the ECM group ( n= 17) and CD group ( n= 11). In contrast, the number of dressing changes were significantly ( P< .006) less in the ECM group (1.4 ±0.8) compared with CD group (4.1 ±2.6). The ECM group showed a significant ( P< .017) shorter time to re-epithelization (10.5 ±1.7 days) than the CD group (13.1 ±2.2 days).ConclusionsThe application of porcine ECM is practicable and reduces the number of dressing changes and time to re-epithelization clearly. Crusts are scaling off spontaneously without any aggressive action needed. Our findings indicate that ECM application is a promising approach for rhinophyma wound care.

Argon plasma coagulation (APC) is an electrosurgical technique which can be used to ablate skin lesions with limited invasion depth into dermal tissue. Hence, APC might be well suited for the removal of epithelial tumours. However, there are no data on the effects of APC on human skin tissue. Thus, the aim of this study was to determine the extent of epidermal and dermal damage after APC of human skin. We performed APC ex-vivo on 91 freshly resected human skin samples, which were obtained after reconstructive surgical closures in actinically damaged areas. Tissue effects were evaluated histologically and compared across different power settings. Using 15, 30, and 45 W, median (interquartile range; IQR) coagulation depths were 110.0 µm (91.7-130.0), 113.3 µm (85.8-135.0), and 130.0 µm (100.0-153.3.0), respectively. Median (IQR) thickness of necrosis zone was 30.0 µm (23.3-40.0) at 15 W, 26.7 µm (20.0-41.6) at 30 W, and 43.3 µm (30.8-57.5) at 45 W. The Kruskal-Wallis test showed significant differences between 15 and 30 W versus 45 W for coagulation depth (P = 0.0414), necrosis zone (P = 0.0017), and necrosis according to overlaying epidermal thickness (P = 0.0467). In summary, APC is a simple and controllable electrosurgical technique to remove epidermal tissue with limited penetration to the dermis. Thus, APC is particularly suited for the ablation of epithelial skin lesions and, therefore, may serve as possible treatment approach for intraepithelial neoplasms such as actinic keratosis.

Hidradenitis suppurativa/acne inversa (HS/AI) is a chronic inflammatory skin disease. Therapy consists of conservative and surgical treatment options. In Hurley stages II and III, surgical intervention is regarded as the method of choice for areas with irreversible tissue destruction. Resection techniques with different grades of invasiveness are described in the literature. Nevertheless, there is no generally accepted concept regarding resection and reconstruction techniques or specific postoperative care. Due to lack of definitions of recurrence after surgery and poor study quality, recurrence rates are difficult to determine.

Die chronische Veneninsuffizienz ist ein haufig auftretendes Krankheitsbild, bestehend aus einem charakteristischen Symptomkomplex und Hautveranderungen. Haufig sind varikos veranderte Venen mit Refluxen und/oder Obstruktion vorhanden. Auch ohne diese konnen bei adiposen Patienten durch funktionelle Beeintrachtigungen des venosen (und lymphatischen) Abfluss chronische Veneninsuffizienz-artige Beschwerden und Hautveranderungen bis hin zu Ulzerationen auftreten. Ziel dieser Arbeit war es, Patienten mit Ulzerationen bei Adipositas-assoziierter chronischer Veneninsuffizienz darzustellen und typische Merkmale herauszuarbeiten. Es wurden 7 Patienten mit Ulzerationen der Unterschenkel bei Adipositas-assoziierter chronischer Veneninsuffizienz untersucht. Neben der klinischen Untersuchung, die auch die Beweglichkeit im Sprunggelenk beurteilte, erfolgten eine digitale Photoplethysmographie, eine Duplexsonographie zum Ausschluss von Refluxen oder Stenosen der Bein- und Beckenvenen sowie eine arterielle Verschlussdruckmessung zum Ausschluss einer peripheren arteriellen Verschlusskrankheit. Bei allen 7 Patienten lag eine Adipositas Grad I–III vor. Es zeigten sich teils multiple Ulzerationen am proximalen oder ventrolateralen Unterschenkel. Die Umgebung zeigte Rotung, Schuppung und Hyperpigmentierung, die als Zeichen einer chronischen Veneninsuffizienz zu werten sind. Haufig traten die Ulzerationen posttraumatisch oder nach Insektenstichen auf. Die Ursache der Adipositas-assoziierten chronischen Veneninsuffizienz wird in der Erhohung des intraabdominellen Drucks durch abdominelle Fettmassen gesehen. Diese fuhrt zu einer messbaren venosen Hypertonie. Die Therapie erfolgt durch eine konsequente Kompressionstherapie und eine leitliniengerechte Behandlung der Adipositas.

Hidradenitis suppurativa (HS) is often a therapeutic challenge with relapses and chronicity which can severely impact patients' quality of life.To evaluate the efficacy of anti-inflammatory oral zinc gluconate, 90mg/day, combined with topical triclosan, 2% twice daily.We retrospectively evaluated the medical records of HS patients in our HS Center of the Department of Dermatology, Venereology, and Allergology, Ruhr-University Bochum, regarding change of disease severity and quality of life. Secondary outcome measures were the number of nodules and fistulas, the number of boils or flair-ups, and the intensity of pain.Sixty-six patients in Hurley stage I and II were included. After 3 months of combination therapy, the modified HS Score and the Dermatology Life Quality Index improved significantly (p0.0001 and p=0.0386, respectively). The number of inflammatory nodules, new boils or flare-ups, and erythema scores decreased significantly. Fistula count and the visual analogue scale score showed no significant difference. Side-effects (mostly abdominal pain and nausea) were reported by 12 (22.2%) patients.The combination therapy of zinc gluconate and topical triclosan can be considered as an anti-inflammatory treatment for HS patients in Hurley stage I and initial Hurley stage II.

Background The long-term outcome of patients with melanoma who had recurrence after negative sentinel lymph node (SLN) biopsy has rarely been evaluated systematically. Methods We searched our databases for melanoma patients with SLN biopsy from the end of 1999 and the beginning of 2011. Data was analyzed using uni- and multivariate statistics as well as Kaplan–Meier curves. Results Data of 651 patients with melanoma was available for statistics. We observed 451 (69.3%) patients with negative SLN who had no evidence of disease recurrence during follow-up. Recurrence in SLN negative patients was found in 50 (7.7%) cases. Tumor subtypes such as invasive lentigo maligna melanoma and acral melanoma (odds ratio 15.2, P = 0.015) and tumor thickness > 2 mm (odds ratio 3.1, P = 0.0017) were independent predictors for recurrence in patients with negative SLN. Patients with negative SLN and subsequent recurrence had a significantly (P = 0.036) reduced 5-year melanoma-specific survival (MSS) when compared with positive SLN patients. Recurrence of disease in positive SLN patients was observed after a median of 39 months when compared to patients with negative SLN and recurrence (28 months, P = 0.0079). Negative SLN with recurrence was an independent predictor for worse recurrence free and melanoma-related survival. Conclusions Patients with negative SLN and recurrence experience earlier disease relapses and poorer MSS when compared to patients with positive SLN status implicating that more stringent follow-up procedures are warranted in patients with higher tumor thickness and invasive lentigo maligna and acral melanoma, despite a negative SLN.

As environmental factors appear to predispose patients to hidradenitis suppurativa (HS), studying epigenetic modifications is of interest to further understand the pathogenesis of HS. To study the expression of DNA hydroxymethylation regulators, namely the ten-eleven translocation (TET) and isocitrate dehydrogenase (IDH) family, in the skin of HS patients. Twenty patients with HS and 12 healthy subjects were recruited.We analysed the expression of TET1, TET2, TET3, IDH1, IDH2, IDH3a, and IDH3b in lesional and perilesional HS tissue as well as tissue from healthy controls by quantitative real-time reverse transcription polymerase chain reaction (RT-PCR). In addition, immunohistochemistrywas performed for TET1, TET2, and TET3. RT-PCR analysis showed that mRNA of all the studied genes was significantly under-expressed in lesional HS skin compared to healthy skin. IDH1 and IDH2 mRNA expression was also significantly lower in perilesional HS skin compared to healthy skin, and TET3 mRNA expression was significantly lower in lesional HS skin compared to perilesional HS skin. RT-PCR analysis for TET1, TET2, and TET3 mRNA expression was confirmed by immunohistochemical analysis. Correlation analysis revealed a significant positive correlation between TET and IDH gene expression in perilesional and lesional HS skin. Our results suggest that epigenetic changes occur in HS tissue and that aberrant expression of the DNA hydroxymethylation regulators may play a role in the pathogenesis of HS. As epigenetic modifications are reversible, further research into the cause of these aberrant expression patterns is warranted in order to develop possible novel therapeutic approaches.

Multinational corporations increasingly establish corporate incubators to combine their own resources with complementary resources of nascent ventures. In order to fulfill their parent's strategic objectives, corporate incubators need to turn into highly efficient resource brokers. The cross-regional embeddedness of incubation hubs leads to a high diversity of involved stakeholders and a complex resource flow among them, which requires a particular organizational design of the corporate incubator. In this context, results of this paper incorporate the recommendation of striking a critical balance between autonomy and integration that might shift depending on the parent's strategic orientation. Furthermore, this research contributes to existing literature by providing an understanding of corporate incubators as a multinational phenomenon, which has been neglected so far. Therefore, the study applies a multiple case study approach including 18 semi-structured interviews with incubation managers.

Actinic keratoses (AKs) can progress into invasive squamous cell carcinoma and thus may become a life threatening disease. Argon plasma coagulation (APC) might complement the therapeutic armamentarium in particular for AK lesions. However, there is no data on APC-induced micromorphological changes following the treatment of AKs. We aimed to determine in vivo APC-induced effects on the epidermis and dermoepidermal junction (DEJ) zone in AK lesions. We performed APC in 108 AKs using the spray mode with a power setting of 15 W and a flow rate of 2.0 L/min. Before and after the intervention, optical coherence tomography (OCT) was performed. After APC, 74.2% (46/62) lesions presented with clearly demarcated DEJ and without any epidermal tissue left, 25.8% (16/62) of treated lesions showed residual epidermal tissue left. In 19.4% (12/62), parts of the DEJ and in 6.5% (4/62), the entire DEJ could not be discriminated. The χ2 test showed a significant (P = 0.0025) association between the presence of hyperkeratosis prior to APC and intact DEJ after APC. In conclusion, APC as shown by OCT is a well controllable treatment modality for AKs causing only limited damage to dermal tissue. Further studies are needed to evaluate clinical outcome as well as recurrence rates.

Importance The variation in both clinical appearance and responses to diverse treatment options emphasize the importance of an accurate, clinically relevant, yet easy-to-use scoring system in hidradenitis suppurativa. Objective To propose and provide validation data for the newly designed Severity Assessment of Hidradenitis Suppurativa score. Design, Setting, and Participants We prospectively assessed disease severity using Hurley staging and the modified Hidradenitis Suppurativa Score in 355 patients referred to Ruhr-University Bochum Department of Dermatology between March 2016 and June 2017. We also assessed disease severity via the Severity Assessment of Hidradenitis Suppurativa score. Main Outcomes and Measures Evaluation and assessment of convergent validity and responsiveness to treatment of the Severity Assessment of Hidradenitis Suppurativa score. Results Eighty-eight of the 355 patients (134 [37.7%] men and 221 [62.3%] women with a median [IQR] age of 40 [30-49] years) were classified as Hurley stage I, 221 were Hurley stage II, and 46 were Hurley stage III, with an overall median modified Hidradenitis Suppurativa Score of 31 (interquartile range [IQR], 19.3-53). The median total Severity Assessment of Hidradenitis Suppurativa score was 6 (IQR, 4-9), significantly different among the 3 Hurley groups. The median SAHS score for patients in Hurley stage I was 5 (IQR, 3-6), 6 (IQR, 5-9) for patients in Hurley stage II, and 9 (IQR, 7-12) for patients in Hurley stage III (P Conclusions and Relevance Our validation data demonstrated that the Severity Assessment of Hidradenitis Suppurativa score is a disease severity instrument that significantly correlates with Hurley staging and the modified Hidradenitis Suppurativa Score, and is responsive enough to measure treatment outcome.

Background: The pathogenesis of hidradenitis suppurativa (HS), with its complex inflammatory network, is still elusive. Imbalances in DNA methylation can lead to genome destabilization and have been assumed to play a role in inflammatory diseases. Global DNA methylation and hydroxymethylation have not been studied in HS yet. Objective: We conducted this study to investigate the global DNA methylation and hydroxymethylation status in lesional and perilesional HS skin compared to healthy controls. Methods: Immunohistochemical analysis was performed for 5-methylcytosine (5-mC) and 5-hydroxymethylcytosine (5-hmC) in 30 lesional and 30 corresponding healthy-appearing perilesional HS tissue samples. We included 30 healthy subjects as an interindividual control group. Results: 5-hmC levels were significantly lower in healthy-appearing perilesional (p < 0.0001) and lesional HS skin (p < 0.0001) when compared to healthy controls. There was no significant difference between lesional HS skin and perilesional HS skin regarding 5-hmC levels (p = 0.6654). In contrast to 5-hmC, 5-mC staining showed no significant changes between the 3 groups. Univariate analysis revealed no significant association between patients' characteristics, disease severity, and the levels of 5-mC and 5-hmC. Conclusion: Our findings indicate that imbalances in DNA hydroxymethylation may play a role in the pathogenesis of HS rather than DNA methylation. Further studies are warranted to investigate the significance of DNA hydroxymethylation and the regulating enzymes in HS in order to advance our knowledge of the inflammatory network in this disease.

Histopathologic differentiation of nevus cell aggregates and metastatic melanoma in lymph nodes is challenging. Patients with melanoma who had undergone sentinel lymph node (SLN) biopsy were evaluated using univariate and multivariate analyses as well as Kaplan-Meier statistics. Of the 651 patients, 50 (7.7%) had a nodal nevus in the SLN. In the logistic regression model, primary melanoma on the lower extremities proved to be the strongest independent negative predictor of nodal nevi with an odds ratio of 0.11 (95% confidence interval, 0.034–0.36; P = .0002). Overall 5-year survival (P = .17) and 5-year disease-free survival (P = .45) of patients with nodal nevi did not significantly differ from that of patients with negative SLNs. The frequency and anatomic localization of nodal nevi observed in the present study are in line with previous studies. Our 5-year survival data clearly demonstrate that nevus cell aggregates in lymph nodes have to be considered a benign condition even though it occurs in patients with melanoma. This study provides an indirect proof of validity and accuracy of current histopathologic methods for differentiation between nodal nevi and melanoma metastasis.

BACKGROUND Bim having strong pro-apoptotic effects belongs to the BH3-only proteins of the Bcl-2 protein family and contributes to survival pathways in cancer cells. OBJECTIVES We aimed to investigate Bim protein expression in cutaneous melanoma (CM). METHODS Bim protein expression was assessed by immunohistochemistry in primary and metastatic melanomas and correlated with clinical and histopathological features. RESULTS The Bim immunoreactivity score of the primary melanomas investigated (4.6 ± 1.5) was significantly (P < 0.0001) higher than that observed in metastases (2.8 ± 1.1). Low Bim expression was significantly associated with primary nodular melanoma type (P = 0.005). Moreover, Bim expression was significantly inversely correlated with tumour thickness (r = -0.36; P = 0.0035), advanced stage of disease (stage III and IV; r = -0.60; P < 0.0001), disease relapse (r = -0.18; P = 0.034) and disease-related death (r = -0.19; P = 0.026). Advanced stage of disease was independently predicted by low Bim expression (P = 0.0010, odds ratio: 0.22, 95% CI: 0.10-0.56) on multivariate analysis; however, Bim was not shown to be an independent predictor for disease relapse (P = 0.40) and disease-related death (P = 0.77). CONCLUSIONS Our data demonstrate that Bim protein expression is significantly inversely correlated with melanoma features that are associated with worse prognosis. We have shown that Bim protein expression in CM is an independent predictor for advanced disease confirming that this pro-apoptotic BH3-only protein might be a potent biomarker and promising therapeutic target.

The main aspects that play a role in the prevention of ultraviolet (UV)-induced skin cancer and photodermatoses by means of clothing are discussed. In vitro and in vivo test methods are reviewed. Furthermore, we describe various fabric parameters (e.g., composition, construction, dye) and other factors that have an influence on the UV-blocking properties of clothing. Standards on sun protective clothing are briefly introduced as well.

SOLUTION A simple and reliable way to reduce the number of staged excisions and risk of wound dehiscence is the so-called presuturing technique (Figs 1, A and 2, A). Under local anesthesia, multiple nonresorbable sutures (eg, with Ethilon) are placed across the lesion, pulling the edges and folding the adjacent skin over the area that is to be excised (Figs 1, B and 2, B). The sutures should be placed at least 24 hours up to 5 days before excision. The principle behind this technique is the stretching of adjacent skin beyond its inherent extensibility to reach sufficient skin laxity. Thus, reduction of the number of staged excisions or a complete 1-stage excision of the lesion with a standard primary closure technique can be achieved.