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Sclerodermatous graft versus host disease (sclGVHD) is a debilitating complication of hematopoietic stem cell transplant and is characterized by skin thickening and fibrosis that can result in severe contractures. While immunosuppressive therapy remains a mainstay of treatment, the disease course often progresses and, in severe cases, renders patients immobile and wheelchair-bound. Lasers that can target sclerotic lesions to improve tissue pliability and restore range of motion are a promising potential treatment for sclGVHD. Fractional CO2 lasers promote selective collagen remodeling by creating microcolumns of thermal injury that stimulate a wound healing response. Here, we present 2 patients with sclGVHD who underwent treatment with fractional ablative CO2 laser. In this pilot case series demonstrating the novel use of CO2 laser for severe, refractory sclGVHD, two patients were treated with fractional ablative CO2 laser to a focal area of sclerosis. One patient also received clobetasol ointment under occlusion in between treatments. Both patients reported marked subjective improvement in pain and mobility. Objective measurements were recorded for patient 2 who gained roughly 10 degrees of extension and 2 degrees of flexion, as well as a 10% reduction in skin thickness in the treated area. CO2 laser therapy with or without clobetasol ointment under occlusion is a promising treatment modality for sclGVHD.

Dermatologic surgery procedures have low but non-negligible infection rates. This review summarizes current understanding of the risk of post-operative wound infections after cutaneous surgery, the diagnosis and management of post-operative infections, and appropriate use of antibiotic prophylaxis in dermatologic surgery. Aside from specific situations associated with risk for infective endocarditis, prosthetic joint infections, and high-risk cutaneous surgeries, routine prophylactic, or post-operative antibiotic use is no longer the standard of care. Preliminary data suggests that post-operative infections may be more related to patient factors such as microbial colonization than technique-related factors. Several recent studies have suggested that outcomes may be equivalent between clean and sterile surgical technique for office-based cutaneous surgery. The past decade has seen a shift away from routine use of prophylactic and post-operative antibiotics in dermatologic surgery. Clinicians should be aware of the indications for prophylaxis and avoid unnecessary prescribing of antibiotics.

Morphea and scleroderma are a spectrum of autoimmune connective tissue disorders hallmarked by tissue fibrosis. Morphea is localized to the skin, subcutaneous tissues, and occasionally, deeper, directly underlying structures such as muscle and bone. In contrast, scleroderma is characterized by systemic involvement, including the vasculature and internal organs (1a) (Fett, Clin Dermatol 31:432–437, 2013). Treatment largely depends upon the extent of disease, with minor cases of morphea requiring observation and systemic sclerosis requiring potent immunosuppressive medications. Although an exhaustive discussion of medical therapies for this spectrum of diseases is beyond the scope of this chapter, surgeries and laser therapy are important components of comprehensive care of these patients. The cosmetic and functional sequelae of morphea and scleroderma can be extensive, and the procedural dermatologist is in a unique position to reverse some of the manifestations of these debilitating diseases.