Plaque-like CD34-positive dermal fibromas, also known as medallion-like dermal dendrocyte hamartomas (MDDHs), are a recently recognized group of congenital and acquired spindle cell neoplasms that may appear histologically similar to dermatofibrosarcoma protuberans. Recognizing the clinical heterogeneity of this neoplasm and the subtle pathologic differences are crucial to making the correct diagnosis and avoiding the aggressive surgical intervention required to treat a dermatofibrosarcoma protuberans. We present the case of a 9-year-old girl with an acquired variant of a plaque-like CD34-positive dermal fibroma without clinical epidermal change. Our case expands the clinical spectrum to include an acquired variant of a plaque-like CD34-positive dermal fibroma without clinical epidermal change. Examination of more cases is needed to determine whether all clinical variants are truly subtypes of the same neoplasm or represent distinct CD34-positive spindle cell proliferations.

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BACKGROUND Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS). OBJECTIVE We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS. MATERIALS AND METHODS A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls. RESULTS Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm2) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure. CONCLUSION This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.

Disseminated superficial actinic porokeratosis (DSAP) is the most common variant of porokeratosis with a potential for malignant transformation. Its association with malignant melanoma, however, is exceedingly rare. Treatment of DSAP is often ineffective. We report a unique case of amelanotic melanoma arising within a lesion of DSAP. The melanoma was managed surgically, and her DSAP were treated successfully with a novel approach utilizing 5-fluorouracil chemowraps. melanoma. Given the extent of her lesions, their hyperkeratotic nature, and the known treatment challenges associated with this condition, we opted to treat with 5-FU chemowraps. This treatment has been used successfully to treat multiple hypertrophic actinic keratoses on the legs (Tallon & Turnbull, 2013). Twenty grams of 5% 5-FU was applied to each leg, and then occluded with a zinc oxide impregnated bandage. This in turn was covered with a cotton conforming bandage and a selfadhering 3M Coban bandage. The wraps were removed 1 week later, and the area gently washed using an antiseptic solution. The chemowrap was then reapplied for a total of 3 months. We monitored closely for rare signs of systemic absorption; neutropenia, diarrhea, and mucositis. The patient tolerated the treatment well and achieved satisfactory results without any side effects (Figure 3). | DI SCUSSIONThe etiology of PK remains unclear, though a genetic predisposition together with additional factors such as immune suppression and ultraviolet exposure have been implicated (Sertznig et al., 2012). DSAP, the most common variant, typically occurs on sun-exposed areas, affecting females more commonly than males. Clinically it is characterized by asymptomatic to mildly pruritic, keratotic papules that spread centrifugally leaving annular patches with atrophic centers and raised keratotic rims. Malignant transformation can occur, and though its exact cause remains unknown, it may be related to chromosomal instability. FIG URE 1 (a) Typical lesions of PK on the legs. (b) The inset shows a nodule within a lesion of PK at the time of biopsy FIG URE 2 (a) Low power showing malignant melanoma arising in a lesion of PK (H&E, 403). (b) A higher power showing the cornoid lamella (H&E, 1003). (c,d) High power view of the malignant melanoma, which was clinically amelanotic (H&E, 4003) FIG URE 3 Appearance of PK before (a) and after (b) chemowraps. Note the decrease in leg swelling and improvement in appearance of the lesions AL-HASENI ET AL.