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EditorPyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative skin disease. 1 Fewer than 50% of the patients achieve wound healing after 6 months of immunosuppressive therapy and relapses occur in 30% to 60% of the cases. 2,3 Progression of existing lesions or development of new lesions after surgery or minor trauma is reported in up to 30% of PG patients (pathergy phenomenon). 3,4 Therefore, the role of surgical interventions such as split thickness skin grafting (STSG) and negative pressure wound therapy (NPWT) is controversially discussed, as these procedures might pose a trigger and further aggravate the condition, especially if performed without immunosuppression. 5 A broad search of the PubMed, Medline, EBSCO Biomedical Reference Collection and Cochrane databases was performed and a total of 61 relevant articles describing 94 patients could be retrieved and complemented with our personal multicentre experience of 21 patients (see Table 1). A total of 115 patients with PG (69% females, median age 53) were identified. Ulcers were mainly situated on the lower extremities (n = 90; 78%), followed by breasts (n = 11; 10%), abdomen (n = 7; 6%) and other localizations (12; 10%). Surgical treatment consisted of split thickness skin grafts (STSG) alone (n = 53; 46%), STSG together with NPWT (n = 35; 30%), NPWT alone (12; 10%) or other forms of skin grafting (cultured cells, suction blisters, full thickness skin grafts, pinch grafts n = 15, 13%). Systemic immunosuppression consisted mainly of systemic corticosteroids (n = 107; 93%), supplemented with cyclosporine (21; 19%), dapsone (12; 9%), TNF-alpha antibodies (11; 9%), mycophenolate mofetil (9; 8%), azathioprine (7, 6%) and others used in less than five patients. Treatment was successful in 84 cases (73%), 18 patients healed but had a recurrence (16%), eight improved (7%), treatment failed in three patients and two patients died due to sepsis. The lower relapse rates observed in this review is probably due to the short follow-up in the many single patients reported. No case of pathergy was observed, neither at the side of PG nor at the skin graft donor sites.On the basis of the literature review and personal experience, we developed a surgical treatment algorithm with proposed immunosuppressive and adjuvant measures shown in Fig. 1. The basic immunosuppression consists of CS. As a second step, we prefer dapsone as anti-inflammatory steroid sparing agent over cyclosporine, as it does not affect renal function or blood pressure and for its well-known additional antimicrobial properties. 6 Indeed, mortality rates from 11% to 17% have been reported for PG and were mostly related to sepsis 3,7 and septical complications were the cause of death in the two deceased patients from the literature review. 3,8 As a third step, if necessary, the anti-TNF-alpha antibody infliximab is used as the sole biologic with a positive randomized, double-blinded, placebocontrolled trial for PG. We further suggest the use of pentoxyphylline as adjuvant treatment for its known rheolo...

SummaryBackgroundDrug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DIHS/DRESS) is a rare and severe adverse drug reaction with an associated mortality of 10–20%. Clinical worsening despite discontinuation of the culprit drug is considered a characteristic feature of DIHS/DRESS. Besides the early recognition of the syndrome and discontinuation of its causative drug, the mainstay of treatment is systemic corticosteroids. Nevertheless, treatment of severe DIHS/DRESS is not well defined, as corticosteroids may sometimes not be effective, and decreasing the dose may be associated with flaring of the disease.Case ReportA 38-year-old woman with high fever, malaise, abdominal pain, rash, and elevated liver enzymes received immediate high-dose N-acetylcysteine, because acetaminophen hepatotoxicity was suspected. N-acetylcysteine administration was associated with a significant clinical improvement. However, within the next week DIHS/DRESS syndrome was diagnosed, which explained all the symptoms, and which was subsequently treated with prednisone and valganciclovir.ConclusionsNew options necessary to improve treatment of severe DIHD/DRESS have to consider its sequential pathogenetic mechanisms. N-acetylcysteine might neutralize the drug-derived reactive metabolites, which are responsible for protein adduct formation and specific T cell stimulation, and replete the glutathione stores that counterbalance oxidative stress. Prednisone might inhibit lymphoproliferation and valganciclovir might prevent complications related to HHV-6 reactivation. We therefore propose the unprecedented combination of N-acetylcysteine, prednisone and valganciclovir as a treatment option for DIHS/DRESS.

The modified "reading man flap" is a good option for the closure of larger rectangular facial skin defects especially in elderly patients, and the use of at least 40 ml of tumescent solution is suggested to achieve optimal pain control.

STSGs are a valid option for closing large auricular skin defects. Even large cutaneous tumors of the external ear do not necessarily infiltrate the cartilage. Thus, cartilage-sparing tumor resection with subsequent defect closure using a STSG is an excellent and quick method associated with high patient satisfaction.

Reconstructions of large surgical defects of the central part of the nose pose a challenge for the surgeon due to its cosmetically prominent location. Treatment options include second intention healing, full-thickness skin grafts and various local flaps. In the present case the "Peng flap" was used for the reconstruction of a 3.1 × 7 cm sized deep defect of the convex curve of the central nasal area in a 66-year-old woman. The Peng flap was performed as single-stage procedure without complications. Good cosmetic outcome was provided by the use of adjacent skin from the lax perinasal area, the placement of the scar lines between facial cosmetic units, and the excellent tissue match for the sebaceous nasal skin. Considering the few complications of a single-stage procedure associated with an excellent aesthetic outcome, the Peng flap should be considered not only as an effective choice for reconstruction of the cosmetically complex midline nasal tip but also the convex curve of the central nose.

We confirm the histological difficulties in the diagnosis of this tumor entity and the large extension of MAC due to delay in diagnosis and treatment. Deep tumor removal including the periostium might be necessary to achieve tumor free margins. Fast granulation tissue above the frontal bone might be achieved by applying hyaluronic acid products. The combination an AT flap with transplantation of the adjacent Burow's triangles gives optimal skin texture and color matching and seems to be a good option to close even large defects of the front especially for supra brow defects.

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