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Repair of excisional defects involving the nose and cheek requires thoughtful planning to maintain the natural contour of the anatomical sites and optimize cosmetic outcomes. We aim to demonstrate that a combination repair of defects involving the ala and nasolabial fold with a full-thickness skin graft and a local flap can be used with good cosmesis and minimal complications.This is a case report of a patient with skin cancer on the left ala and left nasolabial fold who underwent Mohs micrographic surgery for tumor extirpation.The patient and the Mohs surgeon reported satisfaction with the cosmetic and functional outcomes at the 6-month postoperative follow-up with no complications.The use of a full-thickness skin graft from a standing tissue cone and a cheek crescentic advancement flap is a viable repair option for Mohs micrographic surgery defects involving the ala and nasolabial fold.

Squamous cell carcinoma (SCC) arising from an epidermal inclusion cyst (EIC) is uncommon. We present a case of a 70-year-old man with a scalp nodule with persistent discharge that was resected based on the clinical impression of an EIC. Histopathologic exam showed an infundibular EIC with an epidermal type of squamous epithelium; however, some of the cyst lining and lumen was replaced by squamous proliferation with malignant features. There are 56 cases of SCC arising in EICs reported in the English literature. Though suspected EICs are commonly benign, a thorough pathologic evaluation is required to rule out malignancy.

Group A β-hemolytic Streptococcal (GAS) cellulitis is an uncommon surgical site infection that presents with rapid onset of pain and swelling in the first few days after a procedure. Unlike staphylococcal cellulitis, GAS cellulitis lacks purulence and spreading erythema. The absence of these classic signs may delay the diagnosis of GAS cellulitis and lead to severe complications. We present the case of an immunosuppressed 49-year-old patient who developed swelling and severe pain at his incision site two days after undergoing Mohs micrographic surgery on his forehead. He was clinically diagnosed with GAS cellulitis and recovered with intravenous antibiotics. Unfortunately, there is a paucity of information about GAS cellulitis in the dermatologic literature and clinicians need to recognize and aggressively treat this rare but serious complication of Mohs micrographic surgery.

We report an 88 year-old male with a history of multiple non-melanoma skin cancers who presented for Mohs micrographic surgery with a biopsy proven infiltrative and nodular basal cell carcinoma located on the right posterior ear. During Mohs surgery, frozen sections revealed a typical nodular BCC on stage 1. However, on stage 2, frozen section showed nodular aggregates of regular cuboidal cells with pale cytoplasm with areas mimicking multi-nucleated giant cells. Deeper permanent sections were consistent with BCC with adnexal differentiation. This histopathological presentation of basal cell carcinoma is uncommon and we sought to report the clinical and pathological features of this case.

Background Lidocaine is often used in conjunction with epinephrine and sodium bicarbonate for local anesthesia. Compounding lidocaine as needed can be highly disruptive to clinic flow, which has led many dermatology clinics to prefill syringes with these solutions, but current regulations recommend the disposal of these preparations within 12 hours, creating medical waste. Objective To evaluate the safety of buffered lidocaine with and without epinephrine drawn from multiuse vials and stored for up to 4 weeks. Methods Syringes were filled with lidocaine 1%, lidocaine 1% with 1:100,000 epinephrine, lidocaine 1% with bicarbonate (10:1 ratio), or lidocaine 1% with 1:100,000 epinephrine with bicarbonate (10:1 ratio). The samples were stored for 4 weeks either at controlled room or controlled cold temperature. They were then centrifuged and cultured for anaerobic bacteria, aerobic bacteria, and fungus. Results Prefilled lidocaine syringes are not subject to bacterial or fungal growth after being stored for 4 weeks. Conclusion Prefilled syringes of lidocaine remain safe to use for up to 4 weeks, and the current regulations placed on the disposal of these solutions should be revisited.

Tissue-sparing biopsy techniques are frequently used in clinical practice but can result in misdiagnosis of large, clinically challenging lesions. We present a case of a 70-year-old man with hidradenocarcinoma of the left chin, a diagnosis that was delayed owing to repeated superficial biopsies that were negative for disease. Diagnosis was ultimately obtained via an incisional biopsy. We discuss the clinical features of hidradenocarcinoma and why this diagnosis can be easily missed with superficial biopsies. It is important that dermatologists consider incisional biopsies in the workup of clinically challenging lesions for which malignancy is considered.

Background Perineural invasion (PNI) is an important histologic finding and may be a negative prognostic factor for squamous cell carcinoma (SCC). It may be associated with more-aggressive tumor behavior. Mohs surgeons encounter microscopic PNI regularly and must be able to diagnose it accurately to guide care decisions. Objective To describe benign histologic mimickers of PNI and neural structures in SCC commonly encountered on frozen, hematoxylin and eosin–stained sections and to review how to differentiate them from PNI. Methods and Materials Review of the literature regarding histologic mimickers of PNI and additional contributions to frozen section PNI and nerve tissue mimickers. Results We describe benign findings, including arrector pili muscles, eccrine muscles, vessels, granulomatous inflammation, and eddies of SCC, that may each be mistaken for nerves or PNI. We discuss the ways in which they may be distinguished on frozen sections and review other commonly encountered entities that resemble PNI. Conclusion Perineural inflammation and peritumoral fibrosis are common mimickers of PNI on frozen section, although other mimickers exist on permanent sections. Normal structures may appear “neural” by way of frozen tissue orientation, processing, or inflammation and thus must be differentiated from nerve tissue and PNI during Mohs surgery.

Background The population of people aged 90 years and older is expected to more than triple by 2050. The incidence of skin cancers is increasing. Objective We sought to determine whether treatment of patients aged 90 years and older with skin cancer by Mohs micrographic surgery (MMS) changed their survival. Methods A group of 214 patients aged 90 years and older who underwent MMS from July 1997 to May 2006 was identified. Patient gender, age, tumor type, size, site, defect size, number of MMS stages, and surgical repair were recorded. Comorbid medical conditions were assessed using the Charlson index. Actual survival was compared with expected length of survival using life tables. Data were analyzed by the Kaplan-Meier method with log rank significance tests. Results Average patient age was 92.3 years. All patients tolerated the procedures well with no deaths within 1 month after surgery. Median survival after surgery was 36.9 months. Tumor characteristics, defect size, number of surgical stages, and closure type did not affect survival. There was no significant difference in survival based on comorbidities according to Charlson scores. Instantaneous mortality hazard was highest 2 to 3 years after surgery. Limitations Specific causes of death were not accessible. Conclusion This growing section of the population may safely undergo MMS.

Background Studies show that holding single antithrombotic agents perioperatively increases the risk of acute thrombotic events and does not significantly decrease the risk of bleeding complications in dermatological surgery. Recent data suggest that selected patients may benefit from combination therapy in preventing acute thrombotic events. Objective We sought to evaluate postoperative bleeding complications in patients who underwent Mohs micrographic surgery while using multiple agents perioperatively compared with patients using a single agent or none at all. Methods We conducted a retrospective chart review of patients treated in one academic Mohs micrographic surgery department during 1 year. Results Patients taking two or more agents at the time of surgery were more likely to bleed than those taking one agent or none at all ( P = .0016, Fisher's exact). Limitations Small sample size and retrospective nature were limitations. Conclusion Perioperative use of more than one antithrombotic agent increases postoperative bleeding risk.

Alternaria species are a type of dematiaceous fungi that cause a wide spectrum of disease with cutaneous infections being the most common. These infections are most common in immunocompromised individuals. However, only a few cases of primary cutaneous alternariosis have been reported in immunocompetent patients. We present a case of an otherwise healthy 13-year-old male who presented with primary cutaneous alternariosis on his left ankle that responded to the use of topical econazole and oral itraconazole. We also provide a review of previously described cases of primary cutaneous alternariosis in the literature.

The inherently visual nature of dermatology naturally lends itself to photography. As technology has evolved, smartphone cameras have become ubiquitous and have the potential to improve education and patient care in dermatology. Although patients and physicians may agree that photography can improve patient care, there are certain risks involved with smartphone photography in the medical field. Perhaps most concerning is the number of dermatologists using smartphones to take unsecured images in their daily practice. A recent study revealed that 22% of surveyed dermatologists used smartphone cameras multiple times per day in their practice. Dermatologists may also overestimate patient comfort with smartphone use in clinical photography. We present a review of the use of smartphones in dermatology and address the potential lack of security and accompanying ethical dilemmas.Keywords: Smartphone, iPhone, digital

Stiff skin syndrome is a rare sclerotic condition that presents during infancy or early childhood. It has an insidious chronic course and may lead to significant co-morbidity and reduced quality of life. Often, affected individuals experience impaired ambulation and immobilization related to joint involvement. Clinically, it may resemble other sclerotic diseases, so histopathological evaluation is necessary to establish a diagnosis. As it is a condition with limited treatment options, prompt diagnosis and early initiation of physical therapy is crucial to prevent joint restriction and maintain quality of life. We describe a case of a 7-year-old with stiff skin syndrome, and review the literature to discuss the clinical presentation, histological findings, and management of this condition.

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a rare, low-grade, cutaneous neoplasm that may be associated with invasive mucinous carcinoma. Tumors typically present as slow-growing, flesh-colored, nonspecific papules or nodules that favor the eyelids in older individuals. Histologic examination usually reveals basaloid nodules composed of cells with eosinophilic cytoplasm, with focal mucin production and occasional glandular structures. Definitive diagnosis requires immunohistochemical staining. Endocrine mucin-producing sweat gland carcinomas have been noted to stain positively with neuroendocrine markers such as synaptophysin and chromogranins as well as cytokeratin 7, cytokeratin CAM 5.2, epithelial membrane antigen, estrogen receptor, and progesterone receptor. Complete excision with close follow-up is important given EMPSGC's association with invasive mucinous carcinoma. Mohs micrographic surgery is an appropriate choice for treatment. We report 2 cases of EMPSGC presenting on the eyelids in a 72-year-old woman and a 74-year-old man.

Squamous cell carcinoma in situ (SCCIS) is thought to be a precursor to squamous cell carcinoma. It should be treated before invasive cancer develops, especially in transplant recipients, who may develop more aggressive skin cancers. Treatment can involve surgical and nonsurgical methods. OBJECTIVE To review the evidence available in the English medical literature for different treatment options of SCCIS on nongenital skin and evaluate the efficacy of each option.A Pubmed search of articles describing the treatment of SCCIS was conducted. Keywords were "treatment," "Bowen's disease," and "squamous cell carcinoma in situ." Articles describing the use of surgical excision, curettage and electrodesiccation, cryotherapy, 5-fluorouracil, imiquimod, radiation, photodynamic therapy, lasers, and rarer methods were reviewed.No single treatment can be said to be superior for any one situation. Most studies are small, limiting the power of each. Further studies are needed to clarify optimal treatment protocols for nonsurgical methods such as cryotherapy, photodynamic therapy, and topical chemotherapy.There are many methods available to treat SCCIS. Physicians should consider each patient's situation while keeping in mind that treatment protocols have not been fully defined for most options. The authors have indicated no significant interest with commercial supporters.

Nursing professionals at health care institutions should be prepared to suspect and identify cases of pulmonary tuberculosis at the earliest possible stage, in view of the risk of their contagion and consequent sickness. The prevention aspects should be valued in the performance of their activities, to the effect of remaining continuously attentive, to adopt safety measures that prevent the intra-hospital transmission of the disease. This study was aimed at identifying the knowledge of nursing team members of protective measures to be deployed in caring for adult patients suspected of having or diagnosed with pulmonary tuberculosis, confined in clinical-surgical and emergency units of a university hospital. This exploratory, transversal onsite study included 280 nursing professionals, comprising nurses (31-11.43%) and nursing assistants (249-88.57%). The material was gathered by applying a questionnaire with closed and open-ended questions. The material gathered was organized and the content analysis was used for the handling of data. The nursing professionals expressed their understanding of the disease and their knowledge of protective measures in the care of patients suspected of having or diagnosed with pulmonary tuberculosis. The study provided means of identifying the needs of nursing professionals focused on biosafety aspects in relation to the performance of their practice, permitting the formulation of subsidies for the continued education service and Hospital Infection Control Service of the Institution (SCIH).

Abstract 4223 Acquired amegakaryocytic thrombocytopenia is a rare disorder in which there is a marked decrease in bone marrow megakaryocytes leading to severe thrombocytopenia with preserved hematopoeisis in the remaining lineages. The clinical course is variable and no standardized treatment exists. Multiple cases in the literature report treatment using immunosuppressive agents including cyclosporine and antithymocyte globulin. In this case report, we describe the first successful use of rituximab in a patient with amegakaryocytic thrombocytopenia in the absence of any underlying autoimmune disorders. Our patient, an 86- year-old woman, presented with epistaxis, ecchymoses, and blood-tinged sputum. She had thrombocytopenia (platelets 6 × 109/L, MPV 8.3) with a normal hemoglobin and white blood cell count. Peripheral blood smear showed no obvious cause for thrombocytopenia. Bone marrow biopsy revealed focal lymphocytic infiltrates and severe megakaryocytic hypoplasia with nearly absent megakaryocytes. Cytogenetic and molecular analyses were normal, revealing no evidence of a clonal myelo- or lymphoproliferative disorder. The diagnosis of amegakaryocytic thrombocytopenia was made. She was started on prednisone 50mg per day. There was no significant improvement in her platelet count and she was then given IVIG without response. Repeat bone marrow biopsy showed persistent severe bone marrow hypoplasia with near absence of megakaryocytes. After 6 weeks of platelet transfusion dependence and steroids, she was tapered off her steroids and was given rituximab 375mg/m2 weekly for 4 doses. Three weeks after starting rituximab, her platelet counts began to recover and by day 37, her platelet counts normalized and remained within normal limits 12 months after treatment. This case demonstrates the possible utility of rituximab in treating patients with isolated acquired amegakaryocytic thrombocytopenia. Disclosures: No relevant conflicts of interest to declare.