Management of giant congenital nevi in infants by excision under local anesthesia

The spectrum of melanocytic nevi and their clinical implications

The magnitude of the topic of melanocytic nevi (MN) is directly related to its relevance in everyday clinical work. The different MN have different prognostic significance in regard to comorbidity and possible risk of transformation. In addition to the criteria of the ABCDE rule, relevant criteria in the assessment of an MN are the time of occurrence, the growth tendency, the distribution and the comparison with other MN of the respective individual.

The present CME article provides an overview of the knowledge that has been gained with regard to the development and genetic background of MN and any risk of degeneration that may exist. In addition, certain clinical and/or dermatoscopic features may provide the clinician with a decision‐making aid in the management of different MNs.

Use of local anesthetics with an epinephrine additive on fingers and penis - dogma and reality

Epinephrine supplements in local anesthetics are regularly used for surgery in areas with terminal vessels. According to the pharmaceutical guidelines, the use of epinephrine as an additive to local anesthetics is contraindicated for these areas. This review provides an overview of the current scientific data as well as new clinical developments in various fields. It also reviews the current legal situation. A literature research was carried out to survey the current status of relevant data. Written inquiries to several German institutions (Institute for Quality and Efficiency in Health Care, National Association of Statutory Health Insurance Physicians, Center for Clinical Studies Tübingen, Federal Institute for Drugs and Medical Devices) were made to determine the legal situation. No evidence was found in the literature for a causal relationship between the use of epinephrine as a vasoconstrictor and necrosis of the finger or penis. Studies and reviews show that the use of local anesthetics with epinephrine on the fingers or penis is a safe procedure with many clinical and economic advantages. In routine clinical practice, the WALANT method (Wide Awake Local Anesthesia No Tourniquet) as well as the increasing incidence of skin tumors in acral areas has led to a tendency towards increasing use. However, its use is still legally contraindicated, and the pharmaceutical companies show no interest in supporting a drug study. Further clinical trials - regardless of the strength of the evidence - would not change the current legal contraindication.

Vorteile, Sicherheit und Nebenwirkungen der Tumeszenz‐Lokalanästhesie bei dermatologischen Operationen an Säuglingen

Die Tumeszenz-Lokalanästhesie (TLA) spielt bei dermatochirurgischen Eingriffen eine wichtige Rolle. Die TLA bietet etliche Vorteile, wie lang anhaltende Betäubung, reduzierte Blutung während der Operation und Vermeidung möglicher Komplikationen einer Vollnarkose. Einfache Durchführung, günstiges Risikoprofil und breites Indikationsspektrum sind weitere Gründe dafür, dass TLA zunehmend auch bei Säuglingen eingesetzt wird. Es gibt nicht nur viele Indikationen für chirurgische Exzisionen im Säuglingsalter, wie angeborene Naevi, sondern es hat auch erhebliche Vorteile, wenn diese Exzisionen in einem frühen Alter durchgeführt werden. Dazu zählen die geringere Größe der Läsionen sowie die unproblematische Wundheilung und Geweberegeneration im Säuglingsalter. Dennoch müssen hinsichtlich der Anwendung der TLA bei Säuglingen einige Aspekte berücksichtigt werden, darunter die Dosierung, eine veränderte Plasmaproteinbindung und die Notwendigkeit einer adäquaten und lang anhaltenden Schmerzkontrolle.

Benefits, safety and side effects of tumescent local anesthesia in dermatologic surgery in infants

Tumescent local anesthesia (TLA) plays an important role in dermatosurgical procedures. TLA has several benefits such as long-lasting anesthesia, reduced bleeding during surgery and the avoidance of general anesthesia-associated complications. Convenience and a favorable risk profile along with a broad spectrum of indications are further reasons why TLA is increasingly applied in infants as well. There are not only a variety of indications for surgical excisions in infancy, such as congenital nevi, but also substantial benefits when performing these excisions at an early age. These include the smaller size of the lesions as well as the unproblematic wound healing and tissue regeneration in infancy. Nevertheless, several aspects need to be considered when applying TLA in infants including dosing, altered plasma protein binding and the need for adequate and long-lasting pain control.