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Classes of drugs in wound healingDrugs can inhibit or assist wound healing. The effect of a speci®c drug depends on its mechanism of action, dosage, route, and administration in relation to the speci®c phase of wound healing. A discussion of the major classes of drugs that impact wound healing follows, with Tables 1±8 summarizing the effects of major classes of drugs. Generic and trade names used in this paper are summarized in Table 9. Table 1 lists the effects of anti-in¯ammatory agents on wound healing. Anti-in¯ammatory agents CorticosteroidsCorticosteroids affect almost every phase of wound healing because of their inhibitory effect on gene expression in various cells. The in¯ammatory phase of wound healing is affected as corticosteroids inhibit prostaglandin synthesis. 1±4 The recruitment and phagocytic properties of neutrophils 5 and macrophages 6 are decreased causing delayed removal of bacteria and foreign bodies. 7 Lymphocyte recruitment and antibody formation by B lymphocytes is reduced. 2 The antimitotic activity 8 causes decreased epithelial regeneration 4 and granulation tissue formation 4,9 affecting the tissue formation phase. A thinned epidermis occurs due to a reduced rate of keratinocyte proliferation and an increased rate of differentiation. 9,10 Granulation tissue formation is reduced due to decreased ®broblast proliferation, 9 resulting in less collagen, 11 proteoglycans, and glycosaminoglycans. 12±14 A decreased oxygen and reduced nutrient supply 14 may result from steroid-induced vasoconstriction caused by the inhibition of the potent vasodilator prostaglandin E 2 (PGE 2 ) 15 and by the enhanced smooth muscle contraction of vessel walls. 14 As the number of macrophages in the tissue is decreased under the in¯uence of steroids, cytokine stimulation provided by macrophages for normal ®broplasia and angiogenesis is diminished. 6 The tissue remodeling phase is affected by decreased collagen and ground substance synthesis. Decreased numbers of ®broblasts are seen and wound contraction is reduced. 16 Steroid atrophy leads to a thinned dermis and the development of striae 17 (Fig. 1). Interestingly, corticosteroids also decrease collagen degradation by decreasing collagenase production. 18 The most pronounced effects are noted when steroids are administered during the early in¯ammatory phase. 19±21 The suppression of macrophage-orchestrated events by steroids in early in¯ammation is thought to play a role. 22 While oral doses of prednisone (above 10 mg per day) adversely affect wound healing during the ®rst 3 days, high-dose prednisone (at or above 40 mg per day) is needed to effect ®broplasia and collagen remodeling during subsequent days. 21 Inhibition of wound contracture in open wounds occurs regardless of the timing of corticosteroid administration. 20 Steroids affect cells by altering gene expression after they cross cell membranes, bind to cytoplasmic receptors, and translocate into the nucleus. 23,24 The degree of inhibition of gene expression is related to the potency of the steroid. 2...

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The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

A report is presented on the use of the carbon dioxide (CO2) laser for the removal of recalcitrant warts of hands and feet of 27 patients. Of the 27 patients 22 (81%) required only one laser treatment to eradicate warts and remain free of lesions at the 6-month follow-up visit. The other patients required up to 3 retreatments with the laser during the first 6 months to remain free of lesions at a 6-month follow-up. The CO2 laser provided a bloodless surgical field, accurate control, minimal postoperative pain, and decreased postoperative infection. The authors conclude that, while the CO2 laser is not without its disadvantages, it should be considered an important adjunct in the treatment of difficult, widespread, or recalcitrant verrucae.