OBJECTIVE:

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis are on a spectrum of rare reactions primarily attributable to drugs. Timely diagnosis, cessation of the offending drug and burn center care are associated with favorable outcomes. Acute blistering disease has a wide differential diagnosis, including autoimmune bullous disease and other drug reactions. The aim of our study was to identify the final diagnosis in patients transferred for widespread blistering disease and to identify clinical features at admission predicting final diagnosis.

METHODS:

We performed a 5-year retrospective chart review (2006-2011) of the clinical features at admission of patients transferred to a burn ward with widespread blistering disease. Clinical features at admission were compared between patients.

RESULTS:

12 patients had a final diagnosis of Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis and 7 patients had an alternative final diagnosis. Skin detachment surface area at admission was superior in the Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis group. Presence of tense bullae and pustules was associated with an alternative final diagnosis.

CONCLUSION:

Extensive skin detachment surface and morphological features (tense bullae, pustules) were statistically significant clinical clues to final diagnosis. Patients transferred for widespread blistering disease should be thoroughly evaluated in order to exclude other causes of acute blistering disease.

OBJECTIVE::

To evaluate whether a panel of common biomedical markers can be utilized as trajectories to determine survival in pediatric burn patients.

BACKGROUND::

Despite major advances in clinical care, of the more than 1 million people burned in the United States each year, more than 4500 die as a result of their burn injuries. The ability to predict patient outcome or anticipate clinical trajectories using plasma protein expression would allow personalization of clinical care to optimize the potential for patient survival.

METHODS::

A total of 230 severely burned children with burns exceeding 30% of the total body surface, requiring at least 1 surgical procedure were enrolled in this prospective cohort study. Demographics, clinical outcomes, and inflammatory and acute-phase responses (serum cytokines, hormones, and proteins) were determined at admission and at 11 time points for up to 180 days postburn. Statistical analysis was performed using a 1-way analysis of variance, the Student t test, χ test, and Mann-Whitney test where appropriate.

RESULTS::

Survivors and nonsurvivors exhibited profound differences in critical markers of inflammation and metabolism at each time point. Nonsurvivors had significantly higher serum levels of interleukin (IL)-6, IL-8, granulocyte colony-stimulating factor, monocyte chemoattractant protein-1, C-reactive protein, glucose, insulin, blood urea nitrogen, creatinine, and bilirubin (P < 0.05). Furthermore, nonsurvivors exhibited a vastly increased hypermetabolic response that was associated with increases in organ dysfunction and sepsis when compared with survivors (P < 0.05).

CONCLUSIONS::

Nonsurvivors have different trajectories in inflammatory, metabolic, and acute phase responses allowing differentiation of nonsurvivors from survivors and now possibly allowing novel predictive models to improve and personalize burn outcomes.

INTRODUCTION AND

AIM:

Several studies have demonstrated that ozonated oil is effective on cutaneous wound healing. This in vivo study has been conducted to evaluate the clinical effect of the topical application of ozonated oil for 12 weeks on second-degree skin burns.

METHOD:

A total of 30 patients suffering from second-degree skin burns in the phase of re-epithelisation were included in this study. Every skin burn was subdivided in two symmetrical parts. One part was treated with occlusive application of ozonated oil; the contralateral part of the lesion was treated with topical application of hyaluronic acid gel, once a day for 12 weeks. A clinical evaluation and an intra-vital video-capillaroscopy were performed on every patient at baseline, 6 and 12 weeks after.

RESULTS:

All treated lesions improved regardless of the treatment used. Ozonated oil was as effective as hyaluronic acid in improving erythema, tension, itching and burning sensation reported by patients, and it does not exert a specific anti-angiogenic effect compared to hyaluronic acid. However it seems more effective than hyaluronic acid in reducing post-lesional hyperpigmentation.

CONCLUSION:

Ozonated oil, topically applied for 12 weeks, seems to be as effective as hyaluronic acid in reducing symptoms related to skin burns, but it could be more effective in preventing the post-lesional hyperpigmentation.

A subset of patients with melanoma present in rare and unique clinical circumstances requiring specific considerations with respect to diagnostic and therapeutic interventions. Herein, we present our review of patients with: (1) primary mucosal melanoma of the head and neck, gastrointestinal, and genitourinary tracts; (2) primary melanoma of the eye; (3) desmoplastic melanoma; (4) subungual melanoma; (5) melanoma in special populations: children, nonwhites, as well as a discussion of familial melanoma.

Background  Immunosuppressants used to treat inflammatory bowel disease (IBD) may contribute towards the development of non-melanoma skin cancer (NMSC). Few studies have documented this increase in risk. Methods  A mail-in survey was sent to practicing dermatologists and gastroenterologists in the state of Hawaii, USA. These physicians were asked if they had patients with IBD on immunosuppressants with NMSC and if they were aware of an association between immunosuppressants used in IBD and the occurrence of NMSC. Physicians were located via the Yellow Pages telephone directory and the websites http://www.healthgrades.com and http://www.ucomparehealthcare.com. Results  Of the 96 surveys delivered, 45 were returned for analysis. Overall, 73.3% of responding physicians knew about an association between NMSC and immunosuppressants for IBD, but 26.7% had no knowledge of this association. When respondents were categorized according to specialty, 90.9% of dermatologists reported knowing about this association, but only 46.2% of responding gastroenterologists reported this awareness (P = 0.0034). Of the respondents who did not provide details of their specialty, 70.0% reported knowledge of the association. Conclusions  Immunosuppressants are helpful in controlling IBD symptoms and progression but should only be used after a thorough assessment of their risks and benefits in each patient. After the initiation of immunosuppressants, patients should have access to appropriate preventative and treatment modalities for NMSC.

Complementary and alternative medicine (CAM) is a conservative and increasingly popular approach to treat pruritus for both patients and medical providers. CAM includes natural products, mind-body medicine, and manipulative and body-based practices. In this overview, we summarize current evidence, possible mechanisms and clinical approaches for treating pruritus with CAM techniques. We focus on pruritus associated with atopic dermatitis, herpes zoster, chronic urticaria, burns, and postoperative contexts where the evidence for CAM approaches is promising.

Topical glycopyrrolate (glycopyrronium bromide, 0.5% - 4% cream, solution or pads) is indicated mainly for hyperhydrosis (HH) of the head and neck(1) and gustatory sweating (diabetic(2) and Frey's(3) ). In our experience it is effective and well tolerated at those sites. European Pharmacopeia and US Pharmacopeia grade glycopyrrolate powder can be imported, and the desired formulation prepared by special order manufacturers in a cream formulation with an acidic base, for example Cetomacrogol Cream BP, to reduce drug hydrolysis and extend stability to three months.

Acute blistering and erosion in a newborn is one of the few emergency cases seen in dermatology. It is important to differentiate between infectious causes, congenital abnormalities, autoimmune bullous dermatitis, immunological skin diseases and skin burns within 24 hours. In this clinical lesson, we present a case of acute skin detachment in a newborn caused by staphylococcal scalded skin syndrome (SSSS). Our patient was a six-day-old boy who had developed flaccid blisters around the umbilicus, which ruptured on minimal friction. Generalised superficial erosions on the face, hands and feet arose within hours. Based on the clinical presentation combined with a subcorneal blister found on histopathological examination and a positive culture for Staphylococcus aureus on nasal and umbilical smears, the diagnosis of SSSS was made. Our patient was treated successfully with flucloxacillin and gentamicin; the skin lesions healed without scarring within six days.

Hypertrophic scars and contractures are common following various types of trauma and procedures despite skilled surgical and wound care. Following ample time for healing and scar maturation, many millions of patients are burdened with persistent symptoms and functional impairments. Cutaneous scars can be complex and thus the approach to therapy is often multimodal. Intralesional corticosteroids have long been a staple in the treatment of hypertrophic and restrictive scars. Recent advances in laser technology and applications now provide additional options for improvements in function, symptoms, and cosmesis. Fractional ablative lasers create zones of ablation at variable depths of the skin with the subsequent induction of a wound healing and collagen remodeling response. Recent reports suggest these ablative zones may also be used in the immediate post-operative period to enhance delivery of drugs and other substances. We present a case series evaluating the efficacy of a novel combination therapy that incorporates the use of an ablative fractional laser with topically applied triamcinolone acetonide suspension in the immediate post-operative period.This is a prospective case series including 15 consecutive subjects with hypertrophic scars resulting from burns, surgery or traumatic injuries. Subjects were treated according to typical institutional protocol with three to five treatment sessions at 2- to 3-month intervals consisting of fractional ablative laser treatment and immediate post-operative topical application of triamcinolone acetonide suspension at a concentration of 10 or 20 mg/ml. Three blinded observers evaluated photographs taken at baseline and six months after the final treatment session. Scores were assigned using a modified Manchester quartile score to evaluate enhancements in dyschromia, hypertrophy, texture, and overall improvement.Small sample size and lack of a control arm.Combination same session laser therapy and immediate post-operative corticosteroid delivery resulted in average overall improvement of 2.73/3.0. Dyschromia showed the least amount of improvement while texture showed the most improvement.Combination same-session therapy with ablative fractional laser-assisted delivery of triamcinolone acetonide potentially offers an efficient, safe and effective combination therapy for challenging hypertrophic and restrictive cutaneous scars.

IMPORTANCE Acellular dermal matrices have many current and potential applications, but their long-term safety has not been extensively studied. In particular, limited information exists regarding such materials' resistance to infection.

OBJECTIVE

To assess the resistance to microbial penetration of common acellular dermal matrix materials used in reconstruction after skin cancer excision, treatment of chronic ulcers and burns, breast reconstruction, hernia repairs, and other applications. DESIGN Comparative in vitro study of 4 commercially available dermal substitutes for their ability to act as barriers to penetration by common skin pathogens. SETTING University-based dermatology and plastic surgery departments and a hospital microbiology laboratory. MATERIALS Four commercially available dermal substitutes, including AlloDerm (LifeCell), FlexHD (Musculoskeletal Transplant Foundation), Strattice (LifeCell), and NeoForm (Mentor Corporation). INTERVENTION We tested the 4 dermal matrix materials with the following 4 organisms commonly implicated in wound infections: Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus pyogenes, and Candida albicans. Each material was inoculated with the same concentration of each pathogen. MAIN OUTCOME MEASURE The number of bacterial colonies grown on blood agar plates.

RESULTS

AlloDerm and rehydrated FlexHD were found to be the best barriers to penetration by P aeruginosa. AlloDerm, FlexHD, and Strattice also prevented penetration by S aureus and S pyogenes; NeoForm was less effective in withstanding these organisms. The results of this study were inconclusive with regard to C albicans penetration.

CONCLUSIONS

AND RELEVANCE Three of the 4 commonly used acellular dermal matrix materials are resistant to in vitro penetration by S aureus and S pyogenes and partially resistant to P aeruginosa. Resistance to fungal pathogens is uncertain. Antimicrobial differences across matrix materials may influence their selection for particular uses, such as treatment of refractory leg ulcers or reconstruction after skin cancer excision.