Superpulsed carbon dioxide lasers emit a controlled train of short duration, high-power pulses which minimize the protein coagulation effects of the laser. Very high irradiances can be used with superb control of vaporization without significant peripheral heating. In incisional work, superpulsing permits the surgeon to advance the hand piece as slowly and as accurately as desired, while experiencing a fraction of the necrosis attendant to conventional continuous-wave lasers. In vaporizational applications, target tissue volumes are flash vaporized before significant heat can be transferred to surrounding tissue, promoting faster wound healing and reduced scarring. The superpulse feature may significantly change the way in which the carbon dioxide laser is used in cutaneous surgery.

Ten patients with dermatofibrosarcoma protuberans, all of whom had been treated previously by conventional excisional surgery without success, were treated with Mohs micrographic surgery. A team approach utilizing margin control by Mohs-trained physicians and reconstruction by surgical specialists was employed. Average follow-up exceeds 3 1/2 years, with no recurrences. Microscopically controlled excision appears to be the treatment of choice for dermatofibrosarcoma protuberans.

No abstract

Although rapid population growth in the Southwestern United States and travel to and through the area are increasing the potential for exposure to Coccidioides immitis, prevalence rates have declined in some endemic areas, probably because of environmental factors. With the iatrogenic immunosuppression of organ transplantation and the immunosuppression inherent in AIDS, more opportunistic infections with this organism are to be expected. The variety of cutaneous manifestations continues to challenge the dermatologist's acumen. Spherule-derived coccidioidin is an improved epidemiologic tool, and serodiagnostic techniques are easier to perform and are useful in the management of dissemination. While amphotericin B remains the standard, ketoconazole has found a definite role in the treatment of this disease in many patients. Itraconazole, now under investigation, appears very promising. Morbidity and mortality from disseminated disease appear to be declining. With current diagnostic and therapeutic methods, the prognosis for survival in immunocompetent patients is excellent.