Dermatology

Homemade, borax-containing “slime” can contribute to hand dermatitis.

A young, otherwise healthy 9-year-old girl was evaluated for pruritic hand dermatitis which lasted 5 months after exposure to homemade slime. Physical exam revealed erythematous, scaly plaques on the palmar surfaces of her hands; her fingernails had onychomadesis and longitudinal ridging. Despite frequent emolliation, her dermatitis persisted. She was then treated empirically for scabies and for culture-positive Staphylococcus aureus infection, which required a full round of cephalexin and mupirocin ointment. This also did not alleviate the dermatitis. A combination of homemade borax-containing slime avoidance, brief course of high-dose corticosteroids, and frequent bland emollients was prescribed because the dermatitis was assumed to be caused by an irritant.

ilacy@mdedge.com

SOURCE: Gittler JK et al. J Pediatr. 2018 May 3. doi: 10.1016/j.jpeds.2018.03.064 .

Homemade, borax-containing “slime” can contribute to hand dermatitis.

A young, otherwise healthy 9-year-old girl was evaluated for pruritic hand dermatitis which lasted 5 months after exposure to homemade slime. Physical exam revealed erythematous, scaly plaques on the palmar surfaces of her hands; her fingernails had onychomadesis and longitudinal ridging. Despite frequent emolliation, her dermatitis persisted. She was then treated empirically for scabies and for culture-positive Staphylococcus aureus infection, which required a full round of cephalexin and mupirocin ointment. This also did not alleviate the dermatitis. A combination of homemade borax-containing slime avoidance, brief course of high-dose corticosteroids, and frequent bland emollients was prescribed because the dermatitis was assumed to be caused by an irritant.

ilacy@mdedge.com

SOURCE: Gittler JK et al. J Pediatr. 2018 May 3. doi: 10.1016/j.jpeds.2018.03.064 .

Homemade, borax-containing “slime” can contribute to hand dermatitis.

A young, otherwise healthy 9-year-old girl was evaluated for pruritic hand dermatitis which lasted 5 months after exposure to homemade slime. Physical exam revealed erythematous, scaly plaques on the palmar surfaces of her hands; her fingernails had onychomadesis and longitudinal ridging. Despite frequent emolliation, her dermatitis persisted. She was then treated empirically for scabies and for culture-positive Staphylococcus aureus infection, which required a full round of cephalexin and mupirocin ointment. This also did not alleviate the dermatitis. A combination of homemade borax-containing slime avoidance, brief course of high-dose corticosteroids, and frequent bland emollients was prescribed because the dermatitis was assumed to be caused by an irritant.

ilacy@mdedge.com

SOURCE: Gittler JK et al. J Pediatr. 2018 May 3. doi: 10.1016/j.jpeds.2018.03.064 .

DALLAS – Fractional ablative laser treatment combined with poly-L-lactic acid (PLLA) in a patient with recessive dystrophic epidermolysis bullosa (RDEB) led to considerable clinical improvement, including thickening of the dermis, results from a case report showed.

“We have so much more to learn about how the laser treatments are modifying these intricate pathways,” lead study author Samantha Schneider, MD, said in an interview following the annual conference of the American Society for Laser Medicine and Surgery. “But, our project suggests that patients with genetic blistering diseases may benefit from fractional laser therapy in combination with topical PLLA. This may be a good option, particularly for patients who are looking for more therapeutic options for slowly healing wounds and have exhausted other more conventional treatment modalities.”

dbrunk@mdedge.com

DALLAS – Fractional ablative laser treatment combined with poly-L-lactic acid (PLLA) in a patient with recessive dystrophic epidermolysis bullosa (RDEB) led to considerable clinical improvement, including thickening of the dermis, results from a case report showed.

“We have so much more to learn about how the laser treatments are modifying these intricate pathways,” lead study author Samantha Schneider, MD, said in an interview following the annual conference of the American Society for Laser Medicine and Surgery. “But, our project suggests that patients with genetic blistering diseases may benefit from fractional laser therapy in combination with topical PLLA. This may be a good option, particularly for patients who are looking for more therapeutic options for slowly healing wounds and have exhausted other more conventional treatment modalities.”

dbrunk@mdedge.com

DALLAS – Fractional ablative laser treatment combined with poly-L-lactic acid (PLLA) in a patient with recessive dystrophic epidermolysis bullosa (RDEB) led to considerable clinical improvement, including thickening of the dermis, results from a case report showed.

“We have so much more to learn about how the laser treatments are modifying these intricate pathways,” lead study author Samantha Schneider, MD, said in an interview following the annual conference of the American Society for Laser Medicine and Surgery. “But, our project suggests that patients with genetic blistering diseases may benefit from fractional laser therapy in combination with topical PLLA. This may be a good option, particularly for patients who are looking for more therapeutic options for slowly healing wounds and have exhausted other more conventional treatment modalities.”

dbrunk@mdedge.com

The combination of a topical corticosteroid and a topical retinoid for the treatment of plaque psoriasis resulted in significant improvements in clinical signs, in two multicenter, double-blind, vehicle-controlled phase 3 studies.

In the two studies, investigators randomized a total of 418 adults with moderate to severe plaque psoriasis to a lotion containing halobetasol propionate (0.01%) and tazarotene (0.045%) or vehicle lotion, applied once a day to affected areas. After 8 weeks of treatment, 35.8% of adults in the first study and 45.3% of those in the second study had achieved the primary outcome of at least a two-grade improvement in the Investigator’s Global Assessment score and reaching “clear” or “almost clear,” compared with 7.0% and 12.5%, respectively, of patients treated with the vehicle (P less than .001). The report was published online in the Journal of the American Academy of Dermatology.

At 8 weeks, reduction in erythema was achieved by 44.2% and 49.6% of patients in the treatment arms, compared with 10% and 18.7% of patients in the control arms. Plaque elevation was reduced in 59.3% and 59.7% of patients in the treatment arms, compared with 17.9% and 21.3% of patients in the control arms; and scaling was reduced in 59.4% and 62.9% of those on treatment, compared with 20.6% and 21.0%, respectively. All differences between the treatment and control groups were statistically significant (P less than .001).

Participants who received the treatment also reported significantly lower scores for itching, dryness, and burning or stinging compared with those who received the vehicle lotion.

Dr. Linda Stein Gold of Henry Ford Hospital in Detroit, and her coauthors, wrote that while clinical studies have established the benefit of using a topical corticosteroid as an adjunct to tazarotene for plaque psoriasis, data on their combined use was limited. This combination “was consistently more effective than vehicle in achieving treatment success; effectively reducing affected area and psoriasis signs at the target lesion, and improving QoL [quality of life],” they wrote.

Most patients maintained these improvements over the 4-week posttreatment period.

Patients who received the halobetasol propionate/tazarotene lotion reported more adverse events than did those who received the control lotion, but most were mild to moderate and included contact dermatitis (6.3%), pruritus (2.2%) and application site pain (2.6%). Three serious adverse events were not related to treatment.

The studies were funded by Dow Pharmaceutical Sciences, a division of Valeant Pharmaceuticals North America. Four authors disclosed advisory, consultancy and speaking positions and other funding from the pharmaceutical industry, including with Valeant Pharmaceuticals. Five authors are employees of the company.

SOURCE: Gold L et al. J Am Acad Dermatol. 2018 Mar 31. pii: S0190-9622(18)30494-8. doi: 10.1016/j.jaad.2018.03.040.

The combination of a topical corticosteroid and a topical retinoid for the treatment of plaque psoriasis resulted in significant improvements in clinical signs, in two multicenter, double-blind, vehicle-controlled phase 3 studies.

In the two studies, investigators randomized a total of 418 adults with moderate to severe plaque psoriasis to a lotion containing halobetasol propionate (0.01%) and tazarotene (0.045%) or vehicle lotion, applied once a day to affected areas. After 8 weeks of treatment, 35.8% of adults in the first study and 45.3% of those in the second study had achieved the primary outcome of at least a two-grade improvement in the Investigator’s Global Assessment score and reaching “clear” or “almost clear,” compared with 7.0% and 12.5%, respectively, of patients treated with the vehicle (P less than .001). The report was published online in the Journal of the American Academy of Dermatology.

At 8 weeks, reduction in erythema was achieved by 44.2% and 49.6% of patients in the treatment arms, compared with 10% and 18.7% of patients in the control arms. Plaque elevation was reduced in 59.3% and 59.7% of patients in the treatment arms, compared with 17.9% and 21.3% of patients in the control arms; and scaling was reduced in 59.4% and 62.9% of those on treatment, compared with 20.6% and 21.0%, respectively. All differences between the treatment and control groups were statistically significant (P less than .001).

Participants who received the treatment also reported significantly lower scores for itching, dryness, and burning or stinging compared with those who received the vehicle lotion.

Dr. Linda Stein Gold of Henry Ford Hospital in Detroit, and her coauthors, wrote that while clinical studies have established the benefit of using a topical corticosteroid as an adjunct to tazarotene for plaque psoriasis, data on their combined use was limited. This combination “was consistently more effective than vehicle in achieving treatment success; effectively reducing affected area and psoriasis signs at the target lesion, and improving QoL [quality of life],” they wrote.

Most patients maintained these improvements over the 4-week posttreatment period.

Patients who received the halobetasol propionate/tazarotene lotion reported more adverse events than did those who received the control lotion, but most were mild to moderate and included contact dermatitis (6.3%), pruritus (2.2%) and application site pain (2.6%). Three serious adverse events were not related to treatment.

The studies were funded by Dow Pharmaceutical Sciences, a division of Valeant Pharmaceuticals North America. Four authors disclosed advisory, consultancy and speaking positions and other funding from the pharmaceutical industry, including with Valeant Pharmaceuticals. Five authors are employees of the company.

SOURCE: Gold L et al. J Am Acad Dermatol. 2018 Mar 31. pii: S0190-9622(18)30494-8. doi: 10.1016/j.jaad.2018.03.040.

The combination of a topical corticosteroid and a topical retinoid for the treatment of plaque psoriasis resulted in significant improvements in clinical signs, in two multicenter, double-blind, vehicle-controlled phase 3 studies.

In the two studies, investigators randomized a total of 418 adults with moderate to severe plaque psoriasis to a lotion containing halobetasol propionate (0.01%) and tazarotene (0.045%) or vehicle lotion, applied once a day to affected areas. After 8 weeks of treatment, 35.8% of adults in the first study and 45.3% of those in the second study had achieved the primary outcome of at least a two-grade improvement in the Investigator’s Global Assessment score and reaching “clear” or “almost clear,” compared with 7.0% and 12.5%, respectively, of patients treated with the vehicle (P less than .001). The report was published online in the Journal of the American Academy of Dermatology.

At 8 weeks, reduction in erythema was achieved by 44.2% and 49.6% of patients in the treatment arms, compared with 10% and 18.7% of patients in the control arms. Plaque elevation was reduced in 59.3% and 59.7% of patients in the treatment arms, compared with 17.9% and 21.3% of patients in the control arms; and scaling was reduced in 59.4% and 62.9% of those on treatment, compared with 20.6% and 21.0%, respectively. All differences between the treatment and control groups were statistically significant (P less than .001).

Participants who received the treatment also reported significantly lower scores for itching, dryness, and burning or stinging compared with those who received the vehicle lotion.

Dr. Linda Stein Gold of Henry Ford Hospital in Detroit, and her coauthors, wrote that while clinical studies have established the benefit of using a topical corticosteroid as an adjunct to tazarotene for plaque psoriasis, data on their combined use was limited. This combination “was consistently more effective than vehicle in achieving treatment success; effectively reducing affected area and psoriasis signs at the target lesion, and improving QoL [quality of life],” they wrote.

Most patients maintained these improvements over the 4-week posttreatment period.

Patients who received the halobetasol propionate/tazarotene lotion reported more adverse events than did those who received the control lotion, but most were mild to moderate and included contact dermatitis (6.3%), pruritus (2.2%) and application site pain (2.6%). Three serious adverse events were not related to treatment.

The studies were funded by Dow Pharmaceutical Sciences, a division of Valeant Pharmaceuticals North America. Four authors disclosed advisory, consultancy and speaking positions and other funding from the pharmaceutical industry, including with Valeant Pharmaceuticals. Five authors are employees of the company.

SOURCE: Gold L et al. J Am Acad Dermatol. 2018 Mar 31. pii: S0190-9622(18)30494-8. doi: 10.1016/j.jaad.2018.03.040.

How to handle opioid constipation. Bath emollients are a washout for childhood eczema. Does warfarin cause acute kidney injury? And there may be a new option for postpartum depression.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

How to handle opioid constipation. Bath emollients are a washout for childhood eczema. Does warfarin cause acute kidney injury? And there may be a new option for postpartum depression.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

How to handle opioid constipation. Bath emollients are a washout for childhood eczema. Does warfarin cause acute kidney injury? And there may be a new option for postpartum depression.

Listen to the MDedge Daily News podcast for all the details on today’s top news.


 

The FP recognized this as a benign congenital nevus.

While most congenital nevi are visible at birth, there are some that appear in the first year of life and are known as tardive congenital nevi. The FP used a dermatoscope to look at this nevus and found that its features were benign.

The parents wondered whether this needed to be removed to prevent it from becoming skin cancer in the future. The FP reassured them that the risk of melanoma from this one nevus was too small to warrant a prophylactic surgical excision. The parents agreed to the standard 6-month immunizations.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith, M. Congenital nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:953-957.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized this as a benign congenital nevus.

While most congenital nevi are visible at birth, there are some that appear in the first year of life and are known as tardive congenital nevi. The FP used a dermatoscope to look at this nevus and found that its features were benign.

The parents wondered whether this needed to be removed to prevent it from becoming skin cancer in the future. The FP reassured them that the risk of melanoma from this one nevus was too small to warrant a prophylactic surgical excision. The parents agreed to the standard 6-month immunizations.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith, M. Congenital nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:953-957.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized this as a benign congenital nevus.

While most congenital nevi are visible at birth, there are some that appear in the first year of life and are known as tardive congenital nevi. The FP used a dermatoscope to look at this nevus and found that its features were benign.

The parents wondered whether this needed to be removed to prevent it from becoming skin cancer in the future. The FP reassured them that the risk of melanoma from this one nevus was too small to warrant a prophylactic surgical excision. The parents agreed to the standard 6-month immunizations.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith, M. Congenital nevi. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:953-957.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Emollient bath additives do not appear to offer any clinical benefit for childhood eczema, according to an open-label randomized trial.

In a trial of 482 children with atopic dermatitis who were randomized to either use of prescribed emollient bath additives regularly for 12 months or no additives, in addition to usual care, there was no significant difference between the two groups in the patient-oriented eczema measure (POEM) – a score of symptoms in the previous week – for the first 16 weeks of treatment, reported Miriam Santer, MD, of the University of Southampton, England, and her coauthors. The mean POEM score was 7.5 in the bath additives group and 8.4 in the no bath additives group.

LucaLorenzelli/Thinkstock

SOURCE: Santer M et al. BMJ 2018 May 2. doi: 10.1136/bmj.k1332
 

Emollient bath additives do not appear to offer any clinical benefit for childhood eczema, according to an open-label randomized trial.

In a trial of 482 children with atopic dermatitis who were randomized to either use of prescribed emollient bath additives regularly for 12 months or no additives, in addition to usual care, there was no significant difference between the two groups in the patient-oriented eczema measure (POEM) – a score of symptoms in the previous week – for the first 16 weeks of treatment, reported Miriam Santer, MD, of the University of Southampton, England, and her coauthors. The mean POEM score was 7.5 in the bath additives group and 8.4 in the no bath additives group.

LucaLorenzelli/Thinkstock

SOURCE: Santer M et al. BMJ 2018 May 2. doi: 10.1136/bmj.k1332
 

Emollient bath additives do not appear to offer any clinical benefit for childhood eczema, according to an open-label randomized trial.

In a trial of 482 children with atopic dermatitis who were randomized to either use of prescribed emollient bath additives regularly for 12 months or no additives, in addition to usual care, there was no significant difference between the two groups in the patient-oriented eczema measure (POEM) – a score of symptoms in the previous week – for the first 16 weeks of treatment, reported Miriam Santer, MD, of the University of Southampton, England, and her coauthors. The mean POEM score was 7.5 in the bath additives group and 8.4 in the no bath additives group.

LucaLorenzelli/Thinkstock

SOURCE: Santer M et al. BMJ 2018 May 2. doi: 10.1136/bmj.k1332
 

Hidradenitis suppurativa, which occurs in only 28 per 100,000 U.S. children and teens, is most common in African American and biracial girls aged 15-17 years, a study has found.

“The relatively low disease burden must not overshadow the extreme quality of life impact this disease has on those afflicted with it,” noted Amit Garg, MD, and associates at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hyde Park, N.Y.

Elsevier

• HS appears most likely to be a post-adrenarche disease; children with the disease more frequently present with a hormonal imbalance compared with adults. In fact, HS in children may be a marker of precocious puberty, as noted in those presenting with adrenal hyperplasia and premature adrenarche.
• A separate population-based analysis revealed an association between HS and polycystic ovary syndrome.
• Pediatric patients diagnosed with HS are more likely to present with a family history of the condition, and those experiencing early onset appear likely to develop more widespread HS.
• A fivefold likelihood of HS in pediatric Down syndrome patients is also attributed to genetic mutations.

The higher incidence of HS among adults (0.1%) is likely due to largely postpubertal disease onset, the authors speculated. They acknowledged that delays in diagnosing adolescent HS could account for the difference in prevalence between pediatric and adult populations. According to one study cited by Dr. Garg and his colleagues, adults with HS may have symptoms as many as 7 years prior to receiving a diagnosis.

Findings in Dr. Garg’s study serve to reinforce those of previous studies on adult HS populations, which also cited higher prevalence among females, especially African American females.

The research was funded by an unrestricted educational grant from AbbVie. Dr. Garg has served as an adviser for and received honoraria from AbbVie; the remaining researchers had no relevant financial disclosures.

SOURCE: Garg A et al. J Investig Dermatol. 2018 Apr 2. doi: 10.1016/j.jid.2018.04.001.

Hidradenitis suppurativa, which occurs in only 28 per 100,000 U.S. children and teens, is most common in African American and biracial girls aged 15-17 years, a study has found.

“The relatively low disease burden must not overshadow the extreme quality of life impact this disease has on those afflicted with it,” noted Amit Garg, MD, and associates at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hyde Park, N.Y.

Elsevier

• HS appears most likely to be a post-adrenarche disease; children with the disease more frequently present with a hormonal imbalance compared with adults. In fact, HS in children may be a marker of precocious puberty, as noted in those presenting with adrenal hyperplasia and premature adrenarche.
• A separate population-based analysis revealed an association between HS and polycystic ovary syndrome.
• Pediatric patients diagnosed with HS are more likely to present with a family history of the condition, and those experiencing early onset appear likely to develop more widespread HS.
• A fivefold likelihood of HS in pediatric Down syndrome patients is also attributed to genetic mutations.

The higher incidence of HS among adults (0.1%) is likely due to largely postpubertal disease onset, the authors speculated. They acknowledged that delays in diagnosing adolescent HS could account for the difference in prevalence between pediatric and adult populations. According to one study cited by Dr. Garg and his colleagues, adults with HS may have symptoms as many as 7 years prior to receiving a diagnosis.

Findings in Dr. Garg’s study serve to reinforce those of previous studies on adult HS populations, which also cited higher prevalence among females, especially African American females.

The research was funded by an unrestricted educational grant from AbbVie. Dr. Garg has served as an adviser for and received honoraria from AbbVie; the remaining researchers had no relevant financial disclosures.

SOURCE: Garg A et al. J Investig Dermatol. 2018 Apr 2. doi: 10.1016/j.jid.2018.04.001.

Hidradenitis suppurativa, which occurs in only 28 per 100,000 U.S. children and teens, is most common in African American and biracial girls aged 15-17 years, a study has found.

“The relatively low disease burden must not overshadow the extreme quality of life impact this disease has on those afflicted with it,” noted Amit Garg, MD, and associates at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hyde Park, N.Y.

Elsevier

• HS appears most likely to be a post-adrenarche disease; children with the disease more frequently present with a hormonal imbalance compared with adults. In fact, HS in children may be a marker of precocious puberty, as noted in those presenting with adrenal hyperplasia and premature adrenarche.
• A separate population-based analysis revealed an association between HS and polycystic ovary syndrome.
• Pediatric patients diagnosed with HS are more likely to present with a family history of the condition, and those experiencing early onset appear likely to develop more widespread HS.
• A fivefold likelihood of HS in pediatric Down syndrome patients is also attributed to genetic mutations.

The higher incidence of HS among adults (0.1%) is likely due to largely postpubertal disease onset, the authors speculated. They acknowledged that delays in diagnosing adolescent HS could account for the difference in prevalence between pediatric and adult populations. According to one study cited by Dr. Garg and his colleagues, adults with HS may have symptoms as many as 7 years prior to receiving a diagnosis.

Findings in Dr. Garg’s study serve to reinforce those of previous studies on adult HS populations, which also cited higher prevalence among females, especially African American females.

The research was funded by an unrestricted educational grant from AbbVie. Dr. Garg has served as an adviser for and received honoraria from AbbVie; the remaining researchers had no relevant financial disclosures.

SOURCE: Garg A et al. J Investig Dermatol. 2018 Apr 2. doi: 10.1016/j.jid.2018.04.001.

A total of 34% of children who underwent solid organ transplantation subsequently developed eczema, food allergy, rhinitis, eosinophilic gastrointestinal disease, or asthma, according to the results of a single-center retrospective cohort study.

Another 6.6% of patients developed autoimmunity, usually autoimmune cytopenia, inflammatory bowel disease, or vasculitis, wrote Nufar Marcus, MD, of the University of Toronto, and her associates.

Posttransplant allergy, autoimmunity, and immune-mediated disorders (PTAA) likely share a common pathogenesis “and may represent a unique state of post-transplant immune-dysregulation,” they wrote. The report was published in the Journal of Pediatrics.

The study included 273 children who underwent solid organ transplantation and were followed for a median 3.6 years (range, 1.7-6.3 years). None had immune-mediated conditions or allergies diagnosed at baseline. Posttransplantation allergies most commonly included eczema (51%), asthma (32%), food allergy (25%, including 5% with associated anaphylaxis), rhinitis (17%), and eosinophilic esophagitis, gastritis, or enteritis (13%).

aniaostudio/Thinkstock.com

SOURCE: Marcus N et al. J Pediatr. 2018;196:154-60.

A total of 34% of children who underwent solid organ transplantation subsequently developed eczema, food allergy, rhinitis, eosinophilic gastrointestinal disease, or asthma, according to the results of a single-center retrospective cohort study.

Another 6.6% of patients developed autoimmunity, usually autoimmune cytopenia, inflammatory bowel disease, or vasculitis, wrote Nufar Marcus, MD, of the University of Toronto, and her associates.

Posttransplant allergy, autoimmunity, and immune-mediated disorders (PTAA) likely share a common pathogenesis “and may represent a unique state of post-transplant immune-dysregulation,” they wrote. The report was published in the Journal of Pediatrics.

The study included 273 children who underwent solid organ transplantation and were followed for a median 3.6 years (range, 1.7-6.3 years). None had immune-mediated conditions or allergies diagnosed at baseline. Posttransplantation allergies most commonly included eczema (51%), asthma (32%), food allergy (25%, including 5% with associated anaphylaxis), rhinitis (17%), and eosinophilic esophagitis, gastritis, or enteritis (13%).

aniaostudio/Thinkstock.com

SOURCE: Marcus N et al. J Pediatr. 2018;196:154-60.

A total of 34% of children who underwent solid organ transplantation subsequently developed eczema, food allergy, rhinitis, eosinophilic gastrointestinal disease, or asthma, according to the results of a single-center retrospective cohort study.

Another 6.6% of patients developed autoimmunity, usually autoimmune cytopenia, inflammatory bowel disease, or vasculitis, wrote Nufar Marcus, MD, of the University of Toronto, and her associates.

Posttransplant allergy, autoimmunity, and immune-mediated disorders (PTAA) likely share a common pathogenesis “and may represent a unique state of post-transplant immune-dysregulation,” they wrote. The report was published in the Journal of Pediatrics.

The study included 273 children who underwent solid organ transplantation and were followed for a median 3.6 years (range, 1.7-6.3 years). None had immune-mediated conditions or allergies diagnosed at baseline. Posttransplantation allergies most commonly included eczema (51%), asthma (32%), food allergy (25%, including 5% with associated anaphylaxis), rhinitis (17%), and eosinophilic esophagitis, gastritis, or enteritis (13%).

aniaostudio/Thinkstock.com

SOURCE: Marcus N et al. J Pediatr. 2018;196:154-60.

A 38-year-old man sought care in the emergency department for an acute, pruritic, generalized cutaneous eruption that manifested in the intertriginous areas of the inner thighs, antecubital fossae, and axilla (FIGURE 1A). He reported associated chills, a 15-pound weight gain, and swelling of his inner thighs. Two weeks before presentation, he had received azithromycin for an upper respiratory tract infection. He was unsure if the rash developed prior to or after taking the medication. He was not taking any other medications and had no history of skin conditions.

On examination, the patient was afebrile and had bilateral thigh edema. Skin examination revealed background erythema with morbilliform papules, plaques, and patches on the bilateral flanks, back, buttocks, arms, legs, and central neck. Pinpoint pustules were present in the intertriginous sites and on the low back and buttocks. The laboratory evaluation revealed leukocytosis (11.0 × 10⁹ cells/L), increased levels of neutrophils and eosinophils, and an elevated C-reactive protein level (12.8 mg/L). The remaining laboratory results were unremarkable. The patient was referred to Dermatology.

An examination by the dermatologist 3 days later revealed small areas of annular desquamation with a few pinpoint pustules, mostly located on the inner thighs and buttocks (FIGURE 1B). Skin biopsies were taken from the anterior hip region. The histopathology revealed subacute dermatitis with mixed dermal inflammatory cells, including neutrophils and eosinophils, and discrete subcorneal spongiform pustules.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Acute generalized exanthematous pustulosis (AGEP)

The acute rash with minute pustules and associated leukocytosis with neutrophilia and eosinophilia led to an early diagnosis of AGEP, which may have been triggered by azithromycin—the patient’s only recent medication. AGEP is a severe cutaneous eruption that may be associated with systemic involvement. Medications are usually implicated, and patients often seek urgent evaluation.

The development of pustules on an erythematous base in intertriginous areas should raise suspicion for acute generalized exanthematous pustulosis—particularly in patients taking medication.

AGEP typically begins as an acute eruption in the intertriginous sites of the axilla, groin, and neck, but often becomes more generalized.^1,2 The diagnosis is strongly suggested by the condition’s key features: fever (97% of cases) and leukocytosis (87%) with neutrophilia (91%) and eosinophilia (30%); leukocytosis peaks 4 days after pustulosis occurs and lasts for about 12 days.¹ Although common, fever is not always documented in patients with AGEP. ³ (Our patient was a case in point.) While not a key characteristic of AGEP, our patient’s weight gain was likely explained by the severe edema secondary to his inflammatory skin eruption.

Medications are implicated, but pathophysiology is unknown

In approximately 90% of AGEP cases, medications such as antibiotics and calcium channel blockers are implicated; however, the lack of such an association does not preclude the diagnosis.^1,4 In cases of drug reactions, the eruption typically develops 1 to 2 days after a medication is begun, and the pustules typically resolve in fewer than 15 days.⁵ In 17% of patients, systemic involvement can occur and can include the liver, kidneys, bone marrow, and lungs.⁶ A physical exam, review of systems, and a laboratory evaluation can help rule out systemic involvement and guide additional testing.

AGEP has an incidence of 1 to 5 cases per million people per year, affecting women slightly more frequently than men.⁷ While the pathophysiology is not well understood, AGEP and its differential diagnoses are categorized as T cell-related inflammatory responses.^4,7

Distinguishing AGEP from some look-alikes

There are at least 4 severe cutaneous eruptions that might be confused with AGEP, all of which may be associated with fever. They include: drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome; Stevens-Johnson syndrome (SJS); toxic epidermal necrolysis (TEN); and pustular psoriasis.^8-10 The clinical features that may help differentiate these conditions from AGEP include timeline, mucocutaneous features, organ system involvement, and histopathologic findings.^4,8

DRESS occurs 2 to 6 weeks after drug exposure, rather than a few days, as is seen with AGEP. It often involves morbilliform erythema and facial edema with substantial eosinophilia and possible nephritis, pneumonitis, myocarditis, and thyroiditis.⁹ Unlike AGEP, DRESS does not have a predilection for intertriginous anatomic locations.

SJS and TEN occur 1 to 3 weeks after drug exposure. These conditions manifest with the development of bullae, atypical targetoid lesions, painful dusky erythema, epidermal necrosis, and mucosal involvement at multiple sites. Tubular nephritis, tracheobronchial necrosis, and multisystem organ failure can occur, with reported mortality rates of 5% to 35%.^8,11

Pustular psoriasis is frequently confused with AGEP. However, AGEP usually develops fewer than 2 days after drug exposure, with pustules that begin in intertriginous sites, and there is associated neutrophilia and possible organ involvement.^1,8 Patients who have AGEP typically do not have a history of psoriasis, while patients with pustular psoriasis often do.⁷ A history of drug reaction is uncommon with pustular psoriasis (although rapid tapering of systemic corticosteroids in patients with psoriasis can trigger the development of pustular psoriasis), whereas a previous history of drug reaction is common in AGEP.^3,7

Patients who have acute generalized exanthematous pustulosis are not likely to have a history of psoriasis.

Discontinue medication, treat with corticosteroids

Patients who have AGEP, including those with systemic involvement, generally improve after the offending drug is discontinued and treatment with topical corticosteroids is initiated.⁶ A brief course of systemic corticosteroids can also be considered for patients with severe skin involvement or systemic involvement.³

Our patient was prescribed topical corticosteroid wet dressing treatments twice daily for 2 weeks. At the 2-week follow-up visit, the rash had completely cleared, and only minimal residual erythema was noted (FIGURE 2). The patient was instructed to avoid azithromycin.

CORRESPONDENCE
David A. Wetter, MD, Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; wetter.david@mayo.edu.

A 38-year-old man sought care in the emergency department for an acute, pruritic, generalized cutaneous eruption that manifested in the intertriginous areas of the inner thighs, antecubital fossae, and axilla (FIGURE 1A). He reported associated chills, a 15-pound weight gain, and swelling of his inner thighs. Two weeks before presentation, he had received azithromycin for an upper respiratory tract infection. He was unsure if the rash developed prior to or after taking the medication. He was not taking any other medications and had no history of skin conditions.

On examination, the patient was afebrile and had bilateral thigh edema. Skin examination revealed background erythema with morbilliform papules, plaques, and patches on the bilateral flanks, back, buttocks, arms, legs, and central neck. Pinpoint pustules were present in the intertriginous sites and on the low back and buttocks. The laboratory evaluation revealed leukocytosis (11.0 × 10⁹ cells/L), increased levels of neutrophils and eosinophils, and an elevated C-reactive protein level (12.8 mg/L). The remaining laboratory results were unremarkable. The patient was referred to Dermatology.

An examination by the dermatologist 3 days later revealed small areas of annular desquamation with a few pinpoint pustules, mostly located on the inner thighs and buttocks (FIGURE 1B). Skin biopsies were taken from the anterior hip region. The histopathology revealed subacute dermatitis with mixed dermal inflammatory cells, including neutrophils and eosinophils, and discrete subcorneal spongiform pustules.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Acute generalized exanthematous pustulosis (AGEP)

The acute rash with minute pustules and associated leukocytosis with neutrophilia and eosinophilia led to an early diagnosis of AGEP, which may have been triggered by azithromycin—the patient’s only recent medication. AGEP is a severe cutaneous eruption that may be associated with systemic involvement. Medications are usually implicated, and patients often seek urgent evaluation.

The development of pustules on an erythematous base in intertriginous areas should raise suspicion for acute generalized exanthematous pustulosis—particularly in patients taking medication.

AGEP typically begins as an acute eruption in the intertriginous sites of the axilla, groin, and neck, but often becomes more generalized.^1,2 The diagnosis is strongly suggested by the condition’s key features: fever (97% of cases) and leukocytosis (87%) with neutrophilia (91%) and eosinophilia (30%); leukocytosis peaks 4 days after pustulosis occurs and lasts for about 12 days.¹ Although common, fever is not always documented in patients with AGEP. ³ (Our patient was a case in point.) While not a key characteristic of AGEP, our patient’s weight gain was likely explained by the severe edema secondary to his inflammatory skin eruption.

Medications are implicated, but pathophysiology is unknown

In approximately 90% of AGEP cases, medications such as antibiotics and calcium channel blockers are implicated; however, the lack of such an association does not preclude the diagnosis.^1,4 In cases of drug reactions, the eruption typically develops 1 to 2 days after a medication is begun, and the pustules typically resolve in fewer than 15 days.⁵ In 17% of patients, systemic involvement can occur and can include the liver, kidneys, bone marrow, and lungs.⁶ A physical exam, review of systems, and a laboratory evaluation can help rule out systemic involvement and guide additional testing.

AGEP has an incidence of 1 to 5 cases per million people per year, affecting women slightly more frequently than men.⁷ While the pathophysiology is not well understood, AGEP and its differential diagnoses are categorized as T cell-related inflammatory responses.^4,7

Distinguishing AGEP from some look-alikes

There are at least 4 severe cutaneous eruptions that might be confused with AGEP, all of which may be associated with fever. They include: drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome; Stevens-Johnson syndrome (SJS); toxic epidermal necrolysis (TEN); and pustular psoriasis.^8-10 The clinical features that may help differentiate these conditions from AGEP include timeline, mucocutaneous features, organ system involvement, and histopathologic findings.^4,8

DRESS occurs 2 to 6 weeks after drug exposure, rather than a few days, as is seen with AGEP. It often involves morbilliform erythema and facial edema with substantial eosinophilia and possible nephritis, pneumonitis, myocarditis, and thyroiditis.⁹ Unlike AGEP, DRESS does not have a predilection for intertriginous anatomic locations.

SJS and TEN occur 1 to 3 weeks after drug exposure. These conditions manifest with the development of bullae, atypical targetoid lesions, painful dusky erythema, epidermal necrosis, and mucosal involvement at multiple sites. Tubular nephritis, tracheobronchial necrosis, and multisystem organ failure can occur, with reported mortality rates of 5% to 35%.^8,11

Pustular psoriasis is frequently confused with AGEP. However, AGEP usually develops fewer than 2 days after drug exposure, with pustules that begin in intertriginous sites, and there is associated neutrophilia and possible organ involvement.^1,8 Patients who have AGEP typically do not have a history of psoriasis, while patients with pustular psoriasis often do.⁷ A history of drug reaction is uncommon with pustular psoriasis (although rapid tapering of systemic corticosteroids in patients with psoriasis can trigger the development of pustular psoriasis), whereas a previous history of drug reaction is common in AGEP.^3,7

Patients who have acute generalized exanthematous pustulosis are not likely to have a history of psoriasis.

Discontinue medication, treat with corticosteroids

Patients who have AGEP, including those with systemic involvement, generally improve after the offending drug is discontinued and treatment with topical corticosteroids is initiated.⁶ A brief course of systemic corticosteroids can also be considered for patients with severe skin involvement or systemic involvement.³

Our patient was prescribed topical corticosteroid wet dressing treatments twice daily for 2 weeks. At the 2-week follow-up visit, the rash had completely cleared, and only minimal residual erythema was noted (FIGURE 2). The patient was instructed to avoid azithromycin.

CORRESPONDENCE
David A. Wetter, MD, Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; wetter.david@mayo.edu.

A 38-year-old man sought care in the emergency department for an acute, pruritic, generalized cutaneous eruption that manifested in the intertriginous areas of the inner thighs, antecubital fossae, and axilla (FIGURE 1A). He reported associated chills, a 15-pound weight gain, and swelling of his inner thighs. Two weeks before presentation, he had received azithromycin for an upper respiratory tract infection. He was unsure if the rash developed prior to or after taking the medication. He was not taking any other medications and had no history of skin conditions.

On examination, the patient was afebrile and had bilateral thigh edema. Skin examination revealed background erythema with morbilliform papules, plaques, and patches on the bilateral flanks, back, buttocks, arms, legs, and central neck. Pinpoint pustules were present in the intertriginous sites and on the low back and buttocks. The laboratory evaluation revealed leukocytosis (11.0 × 10⁹ cells/L), increased levels of neutrophils and eosinophils, and an elevated C-reactive protein level (12.8 mg/L). The remaining laboratory results were unremarkable. The patient was referred to Dermatology.

An examination by the dermatologist 3 days later revealed small areas of annular desquamation with a few pinpoint pustules, mostly located on the inner thighs and buttocks (FIGURE 1B). Skin biopsies were taken from the anterior hip region. The histopathology revealed subacute dermatitis with mixed dermal inflammatory cells, including neutrophils and eosinophils, and discrete subcorneal spongiform pustules.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Acute generalized exanthematous pustulosis (AGEP)

The acute rash with minute pustules and associated leukocytosis with neutrophilia and eosinophilia led to an early diagnosis of AGEP, which may have been triggered by azithromycin—the patient’s only recent medication. AGEP is a severe cutaneous eruption that may be associated with systemic involvement. Medications are usually implicated, and patients often seek urgent evaluation.

The development of pustules on an erythematous base in intertriginous areas should raise suspicion for acute generalized exanthematous pustulosis—particularly in patients taking medication.

AGEP typically begins as an acute eruption in the intertriginous sites of the axilla, groin, and neck, but often becomes more generalized.^1,2 The diagnosis is strongly suggested by the condition’s key features: fever (97% of cases) and leukocytosis (87%) with neutrophilia (91%) and eosinophilia (30%); leukocytosis peaks 4 days after pustulosis occurs and lasts for about 12 days.¹ Although common, fever is not always documented in patients with AGEP. ³ (Our patient was a case in point.) While not a key characteristic of AGEP, our patient’s weight gain was likely explained by the severe edema secondary to his inflammatory skin eruption.

Medications are implicated, but pathophysiology is unknown

In approximately 90% of AGEP cases, medications such as antibiotics and calcium channel blockers are implicated; however, the lack of such an association does not preclude the diagnosis.^1,4 In cases of drug reactions, the eruption typically develops 1 to 2 days after a medication is begun, and the pustules typically resolve in fewer than 15 days.⁵ In 17% of patients, systemic involvement can occur and can include the liver, kidneys, bone marrow, and lungs.⁶ A physical exam, review of systems, and a laboratory evaluation can help rule out systemic involvement and guide additional testing.

AGEP has an incidence of 1 to 5 cases per million people per year, affecting women slightly more frequently than men.⁷ While the pathophysiology is not well understood, AGEP and its differential diagnoses are categorized as T cell-related inflammatory responses.^4,7

Distinguishing AGEP from some look-alikes

There are at least 4 severe cutaneous eruptions that might be confused with AGEP, all of which may be associated with fever. They include: drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome; Stevens-Johnson syndrome (SJS); toxic epidermal necrolysis (TEN); and pustular psoriasis.^8-10 The clinical features that may help differentiate these conditions from AGEP include timeline, mucocutaneous features, organ system involvement, and histopathologic findings.^4,8

DRESS occurs 2 to 6 weeks after drug exposure, rather than a few days, as is seen with AGEP. It often involves morbilliform erythema and facial edema with substantial eosinophilia and possible nephritis, pneumonitis, myocarditis, and thyroiditis.⁹ Unlike AGEP, DRESS does not have a predilection for intertriginous anatomic locations.

SJS and TEN occur 1 to 3 weeks after drug exposure. These conditions manifest with the development of bullae, atypical targetoid lesions, painful dusky erythema, epidermal necrosis, and mucosal involvement at multiple sites. Tubular nephritis, tracheobronchial necrosis, and multisystem organ failure can occur, with reported mortality rates of 5% to 35%.^8,11

Pustular psoriasis is frequently confused with AGEP. However, AGEP usually develops fewer than 2 days after drug exposure, with pustules that begin in intertriginous sites, and there is associated neutrophilia and possible organ involvement.^1,8 Patients who have AGEP typically do not have a history of psoriasis, while patients with pustular psoriasis often do.⁷ A history of drug reaction is uncommon with pustular psoriasis (although rapid tapering of systemic corticosteroids in patients with psoriasis can trigger the development of pustular psoriasis), whereas a previous history of drug reaction is common in AGEP.^3,7

Patients who have acute generalized exanthematous pustulosis are not likely to have a history of psoriasis.

Discontinue medication, treat with corticosteroids

Patients who have AGEP, including those with systemic involvement, generally improve after the offending drug is discontinued and treatment with topical corticosteroids is initiated.⁶ A brief course of systemic corticosteroids can also be considered for patients with severe skin involvement or systemic involvement.³

Our patient was prescribed topical corticosteroid wet dressing treatments twice daily for 2 weeks. At the 2-week follow-up visit, the rash had completely cleared, and only minimal residual erythema was noted (FIGURE 2). The patient was instructed to avoid azithromycin.

CORRESPONDENCE
David A. Wetter, MD, Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; wetter.david@mayo.edu.

Skin disease accounts for up to 15% of primary care visits,¹ with family physicians (FPs) frequently in the important position of determining if a growth requires a biopsy or referral.

Once it’s determined that a growth requires a biopsy, there is often uncertainty about which type of biopsy to perform. Insufficient knowledge of, and/or experience with, the various biopsy modalities may deter FPs from performing skin biopsies when they are indicated. To help fill the knowledge gaps and better position FPs to tackle skin cancer in its earliest stages, this article identifies and dispels 5 of the most common myths surrounding skin biopsies for the detection of basal and squamous cell carcinoma and melanoma.

MYTH #1

A punch biopsy is always preferred for suspected melanoma because it gets full depth.

A deep shave biopsy (saucerization)—not a punch biopsy—is usually the procedure of choice when biopsying a lesion suspected to be melanoma.² The National Comprehensive Cancer Network (NCCN) "Melanoma Clinical Practice Guidelines in Oncology" state that an excisional biopsy (elliptical, punch, or saucerization) with a 1- to 3-mm margin is the preferred method of biopsy for suspected melanoma.³ However, a punch biopsy should be performed only if a 1- to 3-mm margin all around a suspected melanoma can be obtained. Otherwise, a saucerization or elliptical excision is preferred.³

The saucerization technique generally permits optimal sampling in terms of both the breadth and depth of the growth, providing the pathologist with sufficient tissue from both the epidermis and dermis (FIGURE 1).

Why are breadth/depth important? Breadth is important because showing the pathologist the epidermis (especially the edge) of a suspected melanocytic tumor allows for detection of pagetoid spread (upward movement through the epidermis) of melanocytes and of single melanocytes at the edge of a tumor. Single melanocytes at the edge of a tumor and pagetoid spread are histologic features of melanoma that help to distinguish these lesions from nevi, which tend to have nested melanocytes.²

Depth is important because it predicts prognosis and impacts management. For tumors 0.8 mm to 1 mm deep, a sentinel lymph node biopsy (SLNB) should be considered.^3,4 Although the tumor depth threshold for a SLNB is still debated, most skin cancer experts in the United States agree that a melanoma thicker than 1 mm qualifies for this procedure. Some melanomas with high-risk features (such as ulceration) qualify for an SNLB even if they are <1 mm in depth.⁵ An SLNB provides prognostic information, and a positive SLNB directly affects staging.

[polldaddy:9990508]

Avoid partial biopsies. For tumors that have been partially biopsied with a punch or shallow shave biopsy, evaluation of the remaining neoplasm after subsequent excision leads to tumor upstaging in 21% of patients, with 10% qualifying for an SLNB.⁶ Thus, the goal should always be to obtain the entire depth of the tumor with the initial biopsy.

In addition, surgical margins are determined by primary tumor depth. To ensure a depth greater than 1 mm, aim to obtain a tissue specimen that is at least as thick as a dime (1.3 mm).

Because the goal is to avoid partial sampling, a challenge exists when the suspicious growth is large. Many melanomas are broader than a centimeter. And while punch biopsies ensure a depth of 1 mm or more, they risk missing the thickest portion of the tumor.⁷

Partial sampling of large melanocytic tumors with punch biopsies can lead to sampling error.⁸ Ng et al⁹ found there was a significant increase in histopathologic misdiagnosis with a punch biopsy of part of a melanoma (odds ratio [OR]=16.6; 95% confidence interval [CI], 10-27; P<.001) and with shallow shave biopsy (OR=2.6; 95% CI, 1.2-5.7; P=.02) compared with excisional biopsy (including saucerization).⁹ Punch biopsy of part of a melanoma was also associated with increased odds of misdiagnosis with an adverse outcome (OR=20; 95% CI, 10-41; P<.001).

Punch biopsies do, however, offer a reasonable alternative when the melanoma is too broad for a complete saucerization. In these cases, consider multiple 4- to 6-mm punch biopsies to reduce the risk of sampling error.

Avoid performing punch biopsies <4 mm, as the breadth of tissue is inadequate. For example, even with dermoscopy, facial lentigo maligna melanoma is often difficult to differentiate from pigmented actinic keratosis and solar lentigines. (See JFP’s Watch and Learn Video on dermoscopy.) A broad shave biopsy is the preferred method of biopsy for lentigo maligna melanoma in situ according to the NCCN.³ And there have been several reports showing that the results of shave biopsies of melanocytic lesions are cosmetically acceptable to patients.^10,11

If the biopsy confirms malignancy, a larger surgery with suturing will be needed. The most important issue to keep in mind is that if partial sampling leads to a benign diagnosis of a suspicious lesion, then the remainder of the lesion must be excised and sent for pathology.

Saucerization is also the preferred biopsy type for basal cell and squamous cell carcinomas (SCCs). Studies have shown tumor depth is the most important factor in predicting metastasis of SCC, as well as tumor relapse rate, making accurate identification of the depth of the tumor important for both management and prognosis.^12,13 Determining the thickness of the SCC is important for guiding management. SCC in situ is more amenable than invasive SCC to topical therapy or electrodesiccation and curettage.

What you’ll need. FPs can perform saucerization quickly and easily in the office during a standard 15-minute visit. Of course, it is essential to have all the necessary materials available. The key materials needed are lidocaine and epinephrine, a sharp razor blade such as a DermaBlade, and something for hemostasis (aluminum chloride and/or an electrosurgical instrument). Cotton-tipped applicators to apply the aluminum chloride and needles and syringes to administer the local anesthetic are also needed. (See JFP’s Watch and Learn Video on shave biopsy.) A quick saucerization eliminates the need for the patient to return for an elliptical excision and prevents a delayed diagnosis that can occur as a result of a long wait to see a dermatologist.

As a final note, the pathology order form should be completed with information on biopsy type, clinical presentation, differential diagnosis, and whether or not the full lesion was excised.

MYTH #2

A wide excisional biopsy is required for a suspected melanoma.

While complete excision of the entire tumor does allow the pathologist to evaluate the entire growth, wide (>3 mm) margins on the initial biopsy are not necessary. In fact, there are potential disadvantages to full excisional biopsy.

For example, seborrheic keratoses and other benign growths can mimic melanoma. Neither the physician nor the patient wants to learn that a large elliptical wound was created for a growth that turned out to be a benign seborrheic keratosis. Saucerization provides the pathologist with the entire lesion, and the resulting shallow wound heals as a round scar that is most often acceptable to patients.^10,11,14 In addition, excisional biopsies carry a higher risk of infection than does saucerization.

Even when the index of suspicion is high for melanoma, a wide margin is not indicated. NCCN guidelines suggest that the margins around a suspected melanoma on initial biopsy not exceed 3 mm to avoid disrupting the accuracy of an SLNB (FIGURE 2).³

In addition, time constraints (elliptical excisional biopsies can take up to one hour, especially when a layered closure is performed) and a lack of surgical training may prohibit FPs from performing excisions.

One study found that while dermatologists prefer shave biopsies (80.5%), surgeons prefer excisional biopsies (46.3%) and primary care physicians prefer punch biopsies (44%) for biopsy of a growth suspicious for melanoma.⁷ In fact, of the biopsies FPs perform, only 29% are of the shave variety.⁷

However, deep shave biopsies can be performed quickly, with the whole process taking less than 5 minutes. We advocate performing them at the time of presentation, as the evidence shows that deep shave biopsies of suspected melanoma are reliable and accurate in 97% of cases.¹⁵

MYTH #3

A partial biopsy can make the cancer spread.

There is no evidence to support that a partial biopsy has any effect on the local recurrence or metastatic potential of malignant melanoma.¹⁶ In fact, a biopsy elicits an inflammatory response that activates the patient’s immune system and often causes tumor lysis. Some tumors may even resolve after biopsy. In our clinical practice, we have had several cases of basal cell carcinoma resolve after a biopsy without additional treatment.

MYTH #4

If after performing a deep shave biopsy, tumor or pigment remains, you must leave it because a second biopsy specimen can’t be added to the first.

If pigment is visible after an initial shave or punch biopsy, it is reasonable to obtain additional tissue from the base of the biopsy site. While the deeper tissue cannot be added to the initial specimen for the purposes of Breslow’s depth, it is still helpful for the pathologist to have the sample so that he or she can analyze the tumor cells in the dermis. (Melanoma tumor depth is measured as the maximum distance between malignant cells and the top of the granular layer.¹⁷) In these situations, be sure to let the pathologist know that there are 2 specimens in the container.

In general, it is valuable to get as much of the tissue as possible at the time of the initial biopsy. One way to avoid leaving tumor at the base of the biopsy is to look at the base of the biopsy halfway through the saucerization (FIGURE 3). Aluminum chloride can be used for hemostasis if needed to have a clear view. If you see pigment below, angle the blade deeper for the remainder of the biopsy. This method is made easier if you wait at least 10 minutes after injecting lidocaine with epinephrine, which allows the epinephrine to take maximum effect. Management changes when a growth has a depth >1 mm, as it suggests the need for an SNLB, as well as larger margins at the time of definitive surgery (2 cm rather than 1 cm).³

 

 

MYTH #5

Epinephrine cannot be used for biopsies on the fingers, toes, nose, or penis.

Lidocaine with epinephrine is safe to use in areas with end-arteries, such as the fingers, toes, nose (FIGURE 4), and penis. There is no evidence to support the notion that local anesthesia with vasoconstriction can cause necrosis in these areas, and no case of necrosis has been reported since the introduction of commercial lidocaine with epinephrine in 1948.¹⁸

In addition to an absence of complications, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia, as a study of more than 10,000 ear and nose surgeries using epinephrine-supplemented local anesthetics showed.¹⁹ The relative absence of blood in the operating field significantly reduces the duration of surgery and increases the healing rate because less electrocautery is needed.¹⁹

Similarly, the addition of epinephrine in digital blocks minimizes the need for tourniquets and large volumes of anesthetic and provides better and longer pain control during procedures.²⁰ This topic was addressed by Prabhakar et al in a Cochrane Review in 2015.²¹ While digital surgeries are common, there were only 4 randomized controlled studies addressing the use of epinephrine in digital blocks. In these studies, there were no reports of adverse events, such as ischemia distal to the injection site. Evidence suggests that epinephrine in digital blocks can even be used safely in patients with vascular disease.²²

And while the use of epinephrine with lidocaine in sites with end-arteries is beneficial for hemostasis and does not seem to pose a risk of ischemia, it is prudent to use the smallest volume of epinephrine (with lidocaine) needed to achieve anesthesia for the site.

CORRESPONDENCE
Elizabeth V. Seiverling, MD, 300 Southborough Drive, Suite 201, South Portland, ME 04106; vseiverling@gmail.com.

Skin disease accounts for up to 15% of primary care visits,¹ with family physicians (FPs) frequently in the important position of determining if a growth requires a biopsy or referral.

Once it’s determined that a growth requires a biopsy, there is often uncertainty about which type of biopsy to perform. Insufficient knowledge of, and/or experience with, the various biopsy modalities may deter FPs from performing skin biopsies when they are indicated. To help fill the knowledge gaps and better position FPs to tackle skin cancer in its earliest stages, this article identifies and dispels 5 of the most common myths surrounding skin biopsies for the detection of basal and squamous cell carcinoma and melanoma.

MYTH #1

A punch biopsy is always preferred for suspected melanoma because it gets full depth.

A deep shave biopsy (saucerization)—not a punch biopsy—is usually the procedure of choice when biopsying a lesion suspected to be melanoma.² The National Comprehensive Cancer Network (NCCN) "Melanoma Clinical Practice Guidelines in Oncology" state that an excisional biopsy (elliptical, punch, or saucerization) with a 1- to 3-mm margin is the preferred method of biopsy for suspected melanoma.³ However, a punch biopsy should be performed only if a 1- to 3-mm margin all around a suspected melanoma can be obtained. Otherwise, a saucerization or elliptical excision is preferred.³

The saucerization technique generally permits optimal sampling in terms of both the breadth and depth of the growth, providing the pathologist with sufficient tissue from both the epidermis and dermis (FIGURE 1).

Why are breadth/depth important? Breadth is important because showing the pathologist the epidermis (especially the edge) of a suspected melanocytic tumor allows for detection of pagetoid spread (upward movement through the epidermis) of melanocytes and of single melanocytes at the edge of a tumor. Single melanocytes at the edge of a tumor and pagetoid spread are histologic features of melanoma that help to distinguish these lesions from nevi, which tend to have nested melanocytes.²

Depth is important because it predicts prognosis and impacts management. For tumors 0.8 mm to 1 mm deep, a sentinel lymph node biopsy (SLNB) should be considered.^3,4 Although the tumor depth threshold for a SLNB is still debated, most skin cancer experts in the United States agree that a melanoma thicker than 1 mm qualifies for this procedure. Some melanomas with high-risk features (such as ulceration) qualify for an SNLB even if they are <1 mm in depth.⁵ An SLNB provides prognostic information, and a positive SLNB directly affects staging.

[polldaddy:9990508]

Avoid partial biopsies. For tumors that have been partially biopsied with a punch or shallow shave biopsy, evaluation of the remaining neoplasm after subsequent excision leads to tumor upstaging in 21% of patients, with 10% qualifying for an SLNB.⁶ Thus, the goal should always be to obtain the entire depth of the tumor with the initial biopsy.

In addition, surgical margins are determined by primary tumor depth. To ensure a depth greater than 1 mm, aim to obtain a tissue specimen that is at least as thick as a dime (1.3 mm).

Because the goal is to avoid partial sampling, a challenge exists when the suspicious growth is large. Many melanomas are broader than a centimeter. And while punch biopsies ensure a depth of 1 mm or more, they risk missing the thickest portion of the tumor.⁷

Partial sampling of large melanocytic tumors with punch biopsies can lead to sampling error.⁸ Ng et al⁹ found there was a significant increase in histopathologic misdiagnosis with a punch biopsy of part of a melanoma (odds ratio [OR]=16.6; 95% confidence interval [CI], 10-27; P<.001) and with shallow shave biopsy (OR=2.6; 95% CI, 1.2-5.7; P=.02) compared with excisional biopsy (including saucerization).⁹ Punch biopsy of part of a melanoma was also associated with increased odds of misdiagnosis with an adverse outcome (OR=20; 95% CI, 10-41; P<.001).

Punch biopsies do, however, offer a reasonable alternative when the melanoma is too broad for a complete saucerization. In these cases, consider multiple 4- to 6-mm punch biopsies to reduce the risk of sampling error.

Avoid performing punch biopsies <4 mm, as the breadth of tissue is inadequate. For example, even with dermoscopy, facial lentigo maligna melanoma is often difficult to differentiate from pigmented actinic keratosis and solar lentigines. (See JFP’s Watch and Learn Video on dermoscopy.) A broad shave biopsy is the preferred method of biopsy for lentigo maligna melanoma in situ according to the NCCN.³ And there have been several reports showing that the results of shave biopsies of melanocytic lesions are cosmetically acceptable to patients.^10,11

If the biopsy confirms malignancy, a larger surgery with suturing will be needed. The most important issue to keep in mind is that if partial sampling leads to a benign diagnosis of a suspicious lesion, then the remainder of the lesion must be excised and sent for pathology.

Saucerization is also the preferred biopsy type for basal cell and squamous cell carcinomas (SCCs). Studies have shown tumor depth is the most important factor in predicting metastasis of SCC, as well as tumor relapse rate, making accurate identification of the depth of the tumor important for both management and prognosis.^12,13 Determining the thickness of the SCC is important for guiding management. SCC in situ is more amenable than invasive SCC to topical therapy or electrodesiccation and curettage.

What you’ll need. FPs can perform saucerization quickly and easily in the office during a standard 15-minute visit. Of course, it is essential to have all the necessary materials available. The key materials needed are lidocaine and epinephrine, a sharp razor blade such as a DermaBlade, and something for hemostasis (aluminum chloride and/or an electrosurgical instrument). Cotton-tipped applicators to apply the aluminum chloride and needles and syringes to administer the local anesthetic are also needed. (See JFP’s Watch and Learn Video on shave biopsy.) A quick saucerization eliminates the need for the patient to return for an elliptical excision and prevents a delayed diagnosis that can occur as a result of a long wait to see a dermatologist.

As a final note, the pathology order form should be completed with information on biopsy type, clinical presentation, differential diagnosis, and whether or not the full lesion was excised.

MYTH #2

A wide excisional biopsy is required for a suspected melanoma.

While complete excision of the entire tumor does allow the pathologist to evaluate the entire growth, wide (>3 mm) margins on the initial biopsy are not necessary. In fact, there are potential disadvantages to full excisional biopsy.

For example, seborrheic keratoses and other benign growths can mimic melanoma. Neither the physician nor the patient wants to learn that a large elliptical wound was created for a growth that turned out to be a benign seborrheic keratosis. Saucerization provides the pathologist with the entire lesion, and the resulting shallow wound heals as a round scar that is most often acceptable to patients.^10,11,14 In addition, excisional biopsies carry a higher risk of infection than does saucerization.

Even when the index of suspicion is high for melanoma, a wide margin is not indicated. NCCN guidelines suggest that the margins around a suspected melanoma on initial biopsy not exceed 3 mm to avoid disrupting the accuracy of an SLNB (FIGURE 2).³

In addition, time constraints (elliptical excisional biopsies can take up to one hour, especially when a layered closure is performed) and a lack of surgical training may prohibit FPs from performing excisions.

One study found that while dermatologists prefer shave biopsies (80.5%), surgeons prefer excisional biopsies (46.3%) and primary care physicians prefer punch biopsies (44%) for biopsy of a growth suspicious for melanoma.⁷ In fact, of the biopsies FPs perform, only 29% are of the shave variety.⁷

However, deep shave biopsies can be performed quickly, with the whole process taking less than 5 minutes. We advocate performing them at the time of presentation, as the evidence shows that deep shave biopsies of suspected melanoma are reliable and accurate in 97% of cases.¹⁵

MYTH #3

A partial biopsy can make the cancer spread.

There is no evidence to support that a partial biopsy has any effect on the local recurrence or metastatic potential of malignant melanoma.¹⁶ In fact, a biopsy elicits an inflammatory response that activates the patient’s immune system and often causes tumor lysis. Some tumors may even resolve after biopsy. In our clinical practice, we have had several cases of basal cell carcinoma resolve after a biopsy without additional treatment.

MYTH #4

If after performing a deep shave biopsy, tumor or pigment remains, you must leave it because a second biopsy specimen can’t be added to the first.

If pigment is visible after an initial shave or punch biopsy, it is reasonable to obtain additional tissue from the base of the biopsy site. While the deeper tissue cannot be added to the initial specimen for the purposes of Breslow’s depth, it is still helpful for the pathologist to have the sample so that he or she can analyze the tumor cells in the dermis. (Melanoma tumor depth is measured as the maximum distance between malignant cells and the top of the granular layer.¹⁷) In these situations, be sure to let the pathologist know that there are 2 specimens in the container.

In general, it is valuable to get as much of the tissue as possible at the time of the initial biopsy. One way to avoid leaving tumor at the base of the biopsy is to look at the base of the biopsy halfway through the saucerization (FIGURE 3). Aluminum chloride can be used for hemostasis if needed to have a clear view. If you see pigment below, angle the blade deeper for the remainder of the biopsy. This method is made easier if you wait at least 10 minutes after injecting lidocaine with epinephrine, which allows the epinephrine to take maximum effect. Management changes when a growth has a depth >1 mm, as it suggests the need for an SNLB, as well as larger margins at the time of definitive surgery (2 cm rather than 1 cm).³

 

 

MYTH #5

Epinephrine cannot be used for biopsies on the fingers, toes, nose, or penis.

Lidocaine with epinephrine is safe to use in areas with end-arteries, such as the fingers, toes, nose (FIGURE 4), and penis. There is no evidence to support the notion that local anesthesia with vasoconstriction can cause necrosis in these areas, and no case of necrosis has been reported since the introduction of commercial lidocaine with epinephrine in 1948.¹⁸

In addition to an absence of complications, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia, as a study of more than 10,000 ear and nose surgeries using epinephrine-supplemented local anesthetics showed.¹⁹ The relative absence of blood in the operating field significantly reduces the duration of surgery and increases the healing rate because less electrocautery is needed.¹⁹

Similarly, the addition of epinephrine in digital blocks minimizes the need for tourniquets and large volumes of anesthetic and provides better and longer pain control during procedures.²⁰ This topic was addressed by Prabhakar et al in a Cochrane Review in 2015.²¹ While digital surgeries are common, there were only 4 randomized controlled studies addressing the use of epinephrine in digital blocks. In these studies, there were no reports of adverse events, such as ischemia distal to the injection site. Evidence suggests that epinephrine in digital blocks can even be used safely in patients with vascular disease.²²

And while the use of epinephrine with lidocaine in sites with end-arteries is beneficial for hemostasis and does not seem to pose a risk of ischemia, it is prudent to use the smallest volume of epinephrine (with lidocaine) needed to achieve anesthesia for the site.

CORRESPONDENCE
Elizabeth V. Seiverling, MD, 300 Southborough Drive, Suite 201, South Portland, ME 04106; vseiverling@gmail.com.

Skin disease accounts for up to 15% of primary care visits,¹ with family physicians (FPs) frequently in the important position of determining if a growth requires a biopsy or referral.

Once it’s determined that a growth requires a biopsy, there is often uncertainty about which type of biopsy to perform. Insufficient knowledge of, and/or experience with, the various biopsy modalities may deter FPs from performing skin biopsies when they are indicated. To help fill the knowledge gaps and better position FPs to tackle skin cancer in its earliest stages, this article identifies and dispels 5 of the most common myths surrounding skin biopsies for the detection of basal and squamous cell carcinoma and melanoma.

MYTH #1

A punch biopsy is always preferred for suspected melanoma because it gets full depth.

A deep shave biopsy (saucerization)—not a punch biopsy—is usually the procedure of choice when biopsying a lesion suspected to be melanoma.² The National Comprehensive Cancer Network (NCCN) "Melanoma Clinical Practice Guidelines in Oncology" state that an excisional biopsy (elliptical, punch, or saucerization) with a 1- to 3-mm margin is the preferred method of biopsy for suspected melanoma.³ However, a punch biopsy should be performed only if a 1- to 3-mm margin all around a suspected melanoma can be obtained. Otherwise, a saucerization or elliptical excision is preferred.³

The saucerization technique generally permits optimal sampling in terms of both the breadth and depth of the growth, providing the pathologist with sufficient tissue from both the epidermis and dermis (FIGURE 1).

Why are breadth/depth important? Breadth is important because showing the pathologist the epidermis (especially the edge) of a suspected melanocytic tumor allows for detection of pagetoid spread (upward movement through the epidermis) of melanocytes and of single melanocytes at the edge of a tumor. Single melanocytes at the edge of a tumor and pagetoid spread are histologic features of melanoma that help to distinguish these lesions from nevi, which tend to have nested melanocytes.²

Depth is important because it predicts prognosis and impacts management. For tumors 0.8 mm to 1 mm deep, a sentinel lymph node biopsy (SLNB) should be considered.^3,4 Although the tumor depth threshold for a SLNB is still debated, most skin cancer experts in the United States agree that a melanoma thicker than 1 mm qualifies for this procedure. Some melanomas with high-risk features (such as ulceration) qualify for an SNLB even if they are <1 mm in depth.⁵ An SLNB provides prognostic information, and a positive SLNB directly affects staging.

[polldaddy:9990508]

Avoid partial biopsies. For tumors that have been partially biopsied with a punch or shallow shave biopsy, evaluation of the remaining neoplasm after subsequent excision leads to tumor upstaging in 21% of patients, with 10% qualifying for an SLNB.⁶ Thus, the goal should always be to obtain the entire depth of the tumor with the initial biopsy.

In addition, surgical margins are determined by primary tumor depth. To ensure a depth greater than 1 mm, aim to obtain a tissue specimen that is at least as thick as a dime (1.3 mm).

Because the goal is to avoid partial sampling, a challenge exists when the suspicious growth is large. Many melanomas are broader than a centimeter. And while punch biopsies ensure a depth of 1 mm or more, they risk missing the thickest portion of the tumor.⁷

Partial sampling of large melanocytic tumors with punch biopsies can lead to sampling error.⁸ Ng et al⁹ found there was a significant increase in histopathologic misdiagnosis with a punch biopsy of part of a melanoma (odds ratio [OR]=16.6; 95% confidence interval [CI], 10-27; P<.001) and with shallow shave biopsy (OR=2.6; 95% CI, 1.2-5.7; P=.02) compared with excisional biopsy (including saucerization).⁹ Punch biopsy of part of a melanoma was also associated with increased odds of misdiagnosis with an adverse outcome (OR=20; 95% CI, 10-41; P<.001).

Punch biopsies do, however, offer a reasonable alternative when the melanoma is too broad for a complete saucerization. In these cases, consider multiple 4- to 6-mm punch biopsies to reduce the risk of sampling error.

Avoid performing punch biopsies <4 mm, as the breadth of tissue is inadequate. For example, even with dermoscopy, facial lentigo maligna melanoma is often difficult to differentiate from pigmented actinic keratosis and solar lentigines. (See JFP’s Watch and Learn Video on dermoscopy.) A broad shave biopsy is the preferred method of biopsy for lentigo maligna melanoma in situ according to the NCCN.³ And there have been several reports showing that the results of shave biopsies of melanocytic lesions are cosmetically acceptable to patients.^10,11

If the biopsy confirms malignancy, a larger surgery with suturing will be needed. The most important issue to keep in mind is that if partial sampling leads to a benign diagnosis of a suspicious lesion, then the remainder of the lesion must be excised and sent for pathology.

Saucerization is also the preferred biopsy type for basal cell and squamous cell carcinomas (SCCs). Studies have shown tumor depth is the most important factor in predicting metastasis of SCC, as well as tumor relapse rate, making accurate identification of the depth of the tumor important for both management and prognosis.^12,13 Determining the thickness of the SCC is important for guiding management. SCC in situ is more amenable than invasive SCC to topical therapy or electrodesiccation and curettage.

What you’ll need. FPs can perform saucerization quickly and easily in the office during a standard 15-minute visit. Of course, it is essential to have all the necessary materials available. The key materials needed are lidocaine and epinephrine, a sharp razor blade such as a DermaBlade, and something for hemostasis (aluminum chloride and/or an electrosurgical instrument). Cotton-tipped applicators to apply the aluminum chloride and needles and syringes to administer the local anesthetic are also needed. (See JFP’s Watch and Learn Video on shave biopsy.) A quick saucerization eliminates the need for the patient to return for an elliptical excision and prevents a delayed diagnosis that can occur as a result of a long wait to see a dermatologist.

As a final note, the pathology order form should be completed with information on biopsy type, clinical presentation, differential diagnosis, and whether or not the full lesion was excised.

MYTH #2

A wide excisional biopsy is required for a suspected melanoma.

While complete excision of the entire tumor does allow the pathologist to evaluate the entire growth, wide (>3 mm) margins on the initial biopsy are not necessary. In fact, there are potential disadvantages to full excisional biopsy.

For example, seborrheic keratoses and other benign growths can mimic melanoma. Neither the physician nor the patient wants to learn that a large elliptical wound was created for a growth that turned out to be a benign seborrheic keratosis. Saucerization provides the pathologist with the entire lesion, and the resulting shallow wound heals as a round scar that is most often acceptable to patients.^10,11,14 In addition, excisional biopsies carry a higher risk of infection than does saucerization.

Even when the index of suspicion is high for melanoma, a wide margin is not indicated. NCCN guidelines suggest that the margins around a suspected melanoma on initial biopsy not exceed 3 mm to avoid disrupting the accuracy of an SLNB (FIGURE 2).³

In addition, time constraints (elliptical excisional biopsies can take up to one hour, especially when a layered closure is performed) and a lack of surgical training may prohibit FPs from performing excisions.

One study found that while dermatologists prefer shave biopsies (80.5%), surgeons prefer excisional biopsies (46.3%) and primary care physicians prefer punch biopsies (44%) for biopsy of a growth suspicious for melanoma.⁷ In fact, of the biopsies FPs perform, only 29% are of the shave variety.⁷

However, deep shave biopsies can be performed quickly, with the whole process taking less than 5 minutes. We advocate performing them at the time of presentation, as the evidence shows that deep shave biopsies of suspected melanoma are reliable and accurate in 97% of cases.¹⁵

MYTH #3

A partial biopsy can make the cancer spread.

There is no evidence to support that a partial biopsy has any effect on the local recurrence or metastatic potential of malignant melanoma.¹⁶ In fact, a biopsy elicits an inflammatory response that activates the patient’s immune system and often causes tumor lysis. Some tumors may even resolve after biopsy. In our clinical practice, we have had several cases of basal cell carcinoma resolve after a biopsy without additional treatment.

MYTH #4

If after performing a deep shave biopsy, tumor or pigment remains, you must leave it because a second biopsy specimen can’t be added to the first.

If pigment is visible after an initial shave or punch biopsy, it is reasonable to obtain additional tissue from the base of the biopsy site. While the deeper tissue cannot be added to the initial specimen for the purposes of Breslow’s depth, it is still helpful for the pathologist to have the sample so that he or she can analyze the tumor cells in the dermis. (Melanoma tumor depth is measured as the maximum distance between malignant cells and the top of the granular layer.¹⁷) In these situations, be sure to let the pathologist know that there are 2 specimens in the container.

In general, it is valuable to get as much of the tissue as possible at the time of the initial biopsy. One way to avoid leaving tumor at the base of the biopsy is to look at the base of the biopsy halfway through the saucerization (FIGURE 3). Aluminum chloride can be used for hemostasis if needed to have a clear view. If you see pigment below, angle the blade deeper for the remainder of the biopsy. This method is made easier if you wait at least 10 minutes after injecting lidocaine with epinephrine, which allows the epinephrine to take maximum effect. Management changes when a growth has a depth >1 mm, as it suggests the need for an SNLB, as well as larger margins at the time of definitive surgery (2 cm rather than 1 cm).³

 

 

MYTH #5

Epinephrine cannot be used for biopsies on the fingers, toes, nose, or penis.

Lidocaine with epinephrine is safe to use in areas with end-arteries, such as the fingers, toes, nose (FIGURE 4), and penis. There is no evidence to support the notion that local anesthesia with vasoconstriction can cause necrosis in these areas, and no case of necrosis has been reported since the introduction of commercial lidocaine with epinephrine in 1948.¹⁸

In addition to an absence of complications, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia, as a study of more than 10,000 ear and nose surgeries using epinephrine-supplemented local anesthetics showed.¹⁹ The relative absence of blood in the operating field significantly reduces the duration of surgery and increases the healing rate because less electrocautery is needed.¹⁹

Similarly, the addition of epinephrine in digital blocks minimizes the need for tourniquets and large volumes of anesthetic and provides better and longer pain control during procedures.²⁰ This topic was addressed by Prabhakar et al in a Cochrane Review in 2015.²¹ While digital surgeries are common, there were only 4 randomized controlled studies addressing the use of epinephrine in digital blocks. In these studies, there were no reports of adverse events, such as ischemia distal to the injection site. Evidence suggests that epinephrine in digital blocks can even be used safely in patients with vascular disease.²²

And while the use of epinephrine with lidocaine in sites with end-arteries is beneficial for hemostasis and does not seem to pose a risk of ischemia, it is prudent to use the smallest volume of epinephrine (with lidocaine) needed to achieve anesthesia for the site.

CORRESPONDENCE
Elizabeth V. Seiverling, MD, 300 Southborough Drive, Suite 201, South Portland, ME 04106; vseiverling@gmail.com.