Prevalence of acne keloidalis nuchae in football players

BACKGROUND

Acne mechanica (AM) is common in football players. Severe cases of nuchal AM may precede acne keloidalis nuchae (AKN). Factors that may be associated with the progression of nuchal AM to AKN are unknown. The prevalence of AKN in football players has not been reported.

OBJECTIVE

We investigated the frequency of nuchal AM and AKN within a susceptible population and attempted to identify factors that may be associated with AKN.

METHODS

Four hundred fifty-three high school, collegiate, and professional football players were examined for the presence of nuchal AM or AKN. Those with positive findings completed a questionnaire regarding their disease.

RESULTS

Nuchal AM was more prevalent in high school players (15.5%) than older players (1.2%). AKN was more frequent in players beyond the high school level and was found exclusively in blacks. AKN was not associated with a positive family history of AKN nor a positive personal or family history of keloid formation.

CONCLUSION

AKN occurs almost exclusively in blacks. The level of football play may be associated with the development of AKN. Positive family history of AKN and positive family or personal history of keloids is not associated with AKN development.

Current status of melanoma vaccines

BACKGROUND

Malignant melanoma is increasing worldwide faster than any other cancer and the American lifetime risk is estimated to reach 1 in 75 by the year 2000. Active specific immunotherapy with vaccines is evolving as a promising new modality in the treatment of malignant melanoma.

OBJECTIVE

To present a concise and understandable summary of the key molecular and clinical concepts of melanoma vaccines currently under investigation, the history that led to their development, and their anticipated clinical response.

METHODS

The recent advances in the field of melanoma immunobiology and the newest experiment vaccines are reviewed.

RESULTS

There is no effective melanoma vaccine that successfully treats or prevents melanoma. However, their use has been associated with regression or delayed disease progression in some cases. The minority of patients who do have a major clinical response to vaccine therapy experience an improvement in survival. Even in those patients in whom melanoma vaccines cannot improve survival, the paucity of severe side effects has provided a quality of life superior to standard multiagent chemotherapy.

CONCLUSION

Melanoma vaccines are relatively safe immunotherapeutic modalities for the management of malignant melanoma. The clinical effectiveness of melanoma vaccines is unclear and adequately controlled studies need yet to be performed. Current melanoma vaccines manipulate antigen presentation networks and combine the best cellular and antibody antitumor immune response effective in mediating tumor protective immunity; these combination vaccines hold the most promise. The ideal melanoma vaccine will ultimately prevent melanoma.

The medical necessity for treatment of port-wine stains

BACKGROUND

Port-wine stains are congenital vascular malformations that can be disfiguring and may lead to psychosocial as well as medical complications. The 585-nm pulsed dye laser is very effective in treating port-wine stains. Laser treatment is often viewed by insurance companies as a "cosmetic procedure" and not "medically necessary". Consequently many patients are denied coverage for treatment of their disfiguring birthmarks.

OBJECTIVE

To determine variability of insurance coverage for laser treatment of port-wine stains from state to state. Natural history, progression, and potential complications of port-wine stains are reviewed and rationale for consistent insurance coverage for laser treatment of port-wine stains is given.

METHODS

A questionnaire was mailed to 40 dermatologic surgeons in 22 states and the District of Columbia. We reviewed the literature regarding port-wine stains and their potential complications, and health care policy guidelines regarding "medical necessity" and "cosmetic procedures".

RESULTS

Insurance coverage for laser treatment of port-wine stains varies from state to state.

CONCLUSION

Based on current health care policy guidelines, laser treatment of port-wine stains should be regarded, and covered, as a medical necessity by all insurance providers.

The molecular basis of xeroderma pigmentosum

BACKGROUND

Xeroderma pigmentosum is an extremely rare, autosomal recessive disease characterized by a more than 1000-fold increase in nonmelanoma skin cancer. Individuals with this disease can be divided into eight complementation groups: A-G and V for variant. Each one represents a different genetic defect in DNA repair.

OBJECTIVE

To review the molecular basis of xeroderma pigmentosum.

RESULTS

Deficiencies in various gene products in the nucleotide excision repair pathway cause xeroderma pigmentosum in complementation groups A-G. The molecular basis of the variant group remains to be elucidated.

CONCLUSIONS

Research into the genetic defects underlying xeroderma pigmentosum have led to an increased understanding of nucleotide excision repair.

Ignition potential of the 585-nm pulsed-dye laser. Review of the literature and safety recommendations

BACKGROUND

The 585-nm pulsed-dye laser is the treatment of choice for many port-wine stains. The risk of accidental flash fires occurring with the pulsed-dye laser is considered minimal. Recently, however, there have been several reports of unwanted ignitions. These cases all share two features: 1) oxygen delivery by face mask, and 2) the ignition of a hair-bearing surface.

OBJECTIVE

We report a case of a laser-induced fire that occurred on a non-hair-bearing surface in a patient who was receiving oxygen by nasal cannula. The mechanisms, risk factors, and guidelines for the prevention of pulsed-dye laser-induced fires are presented.

METHODS

We reviewed the literature regarding the safety of pulsed-dye laser use.

RESULTS

Pulsed-dye laser-induced fires can occur on non-hair-bearing regions and in patients receiving oxygen by nasal cannula.

CONCLUSION

Precautions should be taken to prevent pulsed-dye laser fires regardless of treated region or method of oxygen delivery.

Current status of tumescent liposuction in the United States. National survey results

BACKGROUND

Tumescent liposuction is an extremely safe method of liposuction that can be performed entirely under local anesthesia.

OBJECTIVE

To determine evolving trends in the current practice of tumescent liposuction in 15,336 patients treated by 66 dermatologic surgeons.

METHODS

A survey questionnaire was sent to 1,778 Fellows of the American Society for Dermatologic Surgery in February 1994. The comprehensive questionnaire requested information on the number of patients treated with tumescent liposuction, complications, and various practice issues.

RESULTS

Sixty-six dermatologic surgeons provided data on 15,336 patients; 44,014 body areas were treated. The complications that developed were infrequent and minor and have been reported previously. The average amount of fat removed per patient was 1,276 cc. An average of 33 cc of blood was lost per patient per procedure. Cannulas of 4.0 mm or less in diameter were commonly used. The abdomen and outer thighs were the most common areas treated in women. The flanks/love handles and abdomen were the most common areas treated in men. Intraoperative monitoring of vital signs was common.

CONCLUSIONS

Tumescent liposuction is an evolving technique that has virtually eliminated blood transfusions and the major complications of liposuction under general anesthesia. Large amounts of fat can be removed using small diameter cannulas. The fat can be safely removed with a minimum risk of minor complications.

LY191704 inhibits type I steroid 5 alpha-reductase in human scalp

Conversion of testosterone to dihydrotestosterone (DHT) has been demonstrated to be catalyzed by two isoforms of steroid 5 alpha-reductase, designated types I and II. Although several classes of steroid-based inhibitors of the type II isoform have been identified, these agents have not demonstrated highly selective pharmacological activity against human type I 5 alpha-reductase. LY191704 is representative of a series of nonsteroidal agents that have potent [apparent inhibitory constant (Ki) = 11.3 nM] inhibitory activity in human scalp skin homogenates (pH 7.5), a source of type I 5 alpha-reductase. [3H]-DHT production in the presence and absence of LY191704 is consistent with a noncompetitive mode of inhibition. In human prostatic homogenates (pH 5.5), a source of type II 5 alpha-reductase, LY191704 is virtually inactive as an inhibitor [concentration of inhibitor producing 50% inhibition of enzymatic activity (IC50) > 1,000 nM] of [3H]-DHT formation. LY191704 does not inhibit the type I or type II isoforms of rat 5 alpha-reductase, nor does the compound compete for binding to the murine androgen receptor expressed in SF9 cells using a baculo virus expression system. The benzoquinolinones, as exemplified by LY191704, possess exquisite pharmacological selectivity and provide a tool to understand the role of human type I 5 alpha-reductase in normal and pathophysiological states. These agents may also find clinical utility in treating androgen-dependent dermatological conditions.

Dermatofibrosarcoma protuberans treated with Mohs micrographic surgery: cure rates and surgical margins

BACKGROUND

Dermatofibrosarcoma protuberans is an uncommon malignant tumor of the skin with a frequent tendency to recur after standard surgical excision. This study assesses the degree of subclinical tumor extension and evaluates the cure rate and tissue conservation abilities of Mohs micrographic surgery.

METHODS

Twenty-four patients with dermatofibrosarcoma protuberans underwent Mohs micrographic surgery. Surgical margins and clinical outcome were evaluated and compared with the results of standard surgical treatment in the medical literature.

RESULTS

Twenty-six Mohs micrographic surgical procedures were performed on 24 patients. Eighty-five percent of the procedures were microscopically cleared with 2.5-cm margins, 69% with 2.0-cm margins, 50% with 1.5-cm margins, and 35% with 1.0-cm margins. Two tumors would have been inadequately excised if standard 3-cm had been used. The assessment of tissue conservation revealed a mean of 43.0 cm(2) of tissue spared in a subset of seven tumors in functionally or cosmetically critical locations. Two tumors were recurrent following MMS and are detailed as case reports.

CONCLUSION

The variability of subclinical tumor extension in dermatofibrosarcoma protuberans is confirmed. The ability of Mohs micrographic surgery to minimize surgical margins, preserve cosmetically and functionally vital tissue, and yield high cure rates is confirmed.

Histologic evaluation of preauricular and postauricular human skin after high-energy, short-pulse carbon dioxide laser

BACKGROUND

Despite its growing use in dermatalogic surgery, the effects of high-energy, short-pulse carbon dioxide laser on human skin have not been well documented.

OBJECTIVES

To study the histologic effects of this high-energy, short-pulse CO2 laser on human skin and to compare these changes with the effects of standard chemexfoliation procedures.

OBSERVATIONS

Twenty-four hours after laser administration, there was extensive epidermal necrosis and coagulative change in the superficial papillary dermis. With increasing doses of laser energy, there was a statistically significant increase in the depth of dermal wounding (P<.001 for days 1 and 3, F-test). Reepithelialization occurred in most specimens by day 3. By day 90, most specimens showed a subepidermal dermal repair zone consisting of compact new collagen fibers overlying collagen with evidence of solar elastosis.

CONCLUSION

This high-energy, short-pulse CO2 laser produces morphologic changes similar to those seen with medium-depth chemical peels. This laser can ablate skin precisely and bloodlessly with little interference in the wound healing process, suggesting that it may serve as an alternative treatment for photoaged skin.

Risk assessment of polymyositis/dermatomyositis after treatment with injectable bovine collagen implants

BACKGROUND

Questions have been raised about a possible relation between injectable collagen and polymyositis and dermatomyositis (PM/DM). Predictions of the prevalence of PM/DM have been based on anecdotal estimates of the duration of follow-up for the collagen-treated population.

OBJECTIVE

Our purpose was to study the duration of follow-up for a large sample of collagen-treated patients.

METHODS

Physicians in North America who purchased collagen implants during fiscal year 1988 were categorized according to collagen practice size; one third were randomly invited to participate in the study.

RESULTS

Review of 2622 patient records yielded an average duration of follow-up of 4 years.

CONCLUSION

Five-year incidence rates were used to estimate the expected number of cases of PM/DM in the collagen-treated population. Through June 1993 the expected number was 30.2. The number of confirmed cases after treatment was seven, less than one fourth of the number of cases expected for a model of the collagen-treated population, matched for age, sex, and race.

Mohs' micrographic surgery and distal urethrectomy with immediate urethral reconstruction for glanular carcinoma in situ with significant urethral extension

OBJECTIVES

To report the use of conservative extirpative surgical techniques to manage glanular carcinoma in situ with significant urethral extension.

METHODS

Over a 5-year period, 2 patients with carcinoma in situ of the glans with significant distal urethral involvement, who refused penectomy, were managed with combined treatment modalities using Mohs' micrographic surgery and distal urethrectomy with immediate urethral reconstruction.

RESULTS

At follow-up of 5 years and of 12 months, there has been no evidence of meatal or proximal urethral recurrence.

CONCLUSIONS

Mohs' micrographic surgical excision and distal urethrectomy with immediate urethral reconstruction offers an acceptable alternative to partial penectomy in patients with perimeatal carcinoma in situ who fail conservative treatment or refuse penectomy.

Safety of tumescent liposuction in 15,336 patients. National survey results

BACKGROUND

Tumescent liposuction is a new method of liposuction under local anesthesia that has been developed by dermatologic surgeons.

OBJECTIVE

To determine the safety of tumescent liposuction in a large group of patients treated by dermatologic surgeons.

METHODS

A survey questionnaire was sent to 1,778 Fellows of the American Society for Dermatologic Surgery in February 1994. The comprehensive questionnaire requested information on numbers of patients treated with tumescent liposuction and complications that occurred.

RESULTS

Sixty-six dermatologic surgeons provided data on 15,336 patients. The complications that were reported were infrequent and minor. There were no serious complications such as death, embolism (pulmonary or fat), hypovolemic shock, perforation of peritoneum or thorax, or thrombophlebitis. Blood transfusions were not required in any of the 15,336 patients and there were no admissions to the hospital for treatment of complications.

CONCLUSIONS

Tumescent liposuction is an exceptionally safe method of liposuction under local anesthesia that eliminates the necessity of general anesthesia and blood transfusions. Tumescent liposuction is safer than liposuction under general anesthesia and results in fewer complications.

Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant

The incidence, clinical presentation, pathophysiology, and possible treatment of two rare but clinically meaningful complications of tissue augmentation with Zyderm and Zyplast Collagen Implant are described. Abscesses as a manifestation of hypersensitivity to bovine collagen occur rarely (4 in 10,000 cases) and may persist for days to weeks. Periods of remission and exacerbation may occur from 1 month to more than 24 months. Localized tissue necrosis also occurs rarely (9 in 10,000 cases) after implantation and is probably the result of local vascular interruption and not hypersensitivity. The incidence varies greatly between the anatomic sites of implantation; more than half the reported cases involve the glabella. Evidence strongly suggests that the increased vulnerability of the glabellar region is due to its unique vascular distribution.