Primary cutaneous inoculation blastomycosis occurs less commonly than secondary blastomycosis, in which cutaneous lesions most often originate from a primary pulmonary infection which disseminates through the blood or lymphatics to involve the skin. In secondary cutaneous blastomycosis, the primary pulmonary infection is frequently subclinical at the time cutaneous lesions manifest. Here we report two cases that illustrate the difficulty in distinguishing between primary and secondary cutaneous involvement. We also review the expanding literature on blastomycosis since its identification over a century ago.
Organ transplant recipients (OTRs) are at increased risk of developing non-melanoma skin cancers (NMSC). This has long been thought to be due to immunosuppression and viral infection. However, skin cancer risk among individuals with AIDS or iatrogenic immunodeficiency does not approach the levels seen in OTRs, suggesting other factors play a critical role in oncogenesis. In clinical trials of OTRs, switching from calcineurin inhibitors to mammalian Target of Rapamycin (mTOR) inhibitors consistently led to a significant reduction in the risk of developing new skin cancers. New evidence suggests calcineurin inhibitors interfere with p53 signaling and nucleotide excision repair. These two pathways are associated with NMSC, and squamous cell carcinoma (SCC) in particular. This finding may help explain the predominance of SCC over basal cell carcinoma in this population. mTOR inhibitors do not appear to impact these pathways. Immunosuppression, viral infection, and impaired DNA repair and p53 signaling all interact in OTRs to create a phenotype of extreme risk for NMSC.
BACKGROUND. Surgical defects following the extirpation of cutaneous neoplasia may present challenges to the dermatologic surgeon. There are many repair options for an individual defect, including second-intention healing, primary closure, skin graft, and skin flap closure. The island pedicle flap is a random pattern advancement flap well suited to reconstruct a variety of small-to intermediate-sized soft tissue wounds. OBJECTIVE. To review the utility of the island pedicle flap in reconstructive dermatologic surgery and to detail the operative technique to achieve reproducible functional and esthetic results. METHODS. The method of flap reconstruction is presented. A variety of defects repaired with this technique are reviewed. RESULTS. The subcutaneous island pedicle flap yielded excellent functional and cosmetic repair of the presented defects with minimal operative morbidity. Secondary to a well-preserved central vascular pedicle, complications are infrequent. CONCLUSIONS. The random pattern island pedicle flap is a versatile and robust flap used to repair a variety of soft tissue wounds in a single-stage procedure with reproducible operative outcomes.Figure 1. The design of the island pedicle flap. Arrow indicates direction of the flap movement.
The rate of complications associated with dermatologic surgeons performing interpolated flaps in an outpatient setting under local anesthesia is low. Our complication rates are equal to or lower than published complication rates from other surgical specialties.
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