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Surgical dermatologic procedures in children pose unique challenges that differ from those in adults. Child and parental anxiety, along with procedural anxiety in adults, necessitate different approaches. Special considerations are reviewed in the application of topical anesthesia and administration of local anesthesia in children as opposed to adults, and the use and safety of general anesthesia in children is highlighted. In addition, management of postprocedural analgesia differs in children, largely due to concern for safety of opioids in children.

The incidence of nonmelanoma skin cancer is increasing every year. Basal cell carcinoma and squamous cell carcinoma are the two major types of nonmelanoma skin cancer. Among other factors, understanding the potential role of nutrients in the development, progression, and treatment of nonmelanoma skin cancer is critical. This contribution provides a review of the nutrients that have been more extensively investigated in the literature with regard to nonmelanoma skin cancer, including dietary fats, retinol, carotenoids, vitamin C, vitamin D, vitamin E, selenium, copper, iron, zinc, green tea, and black tea.

Mohs micrographic surgery (MMS) is very successful in the treatment of nonmelanoma skin cancer. Examining 100% of the margin using MMS improves cure rates. This method has obvious appeal in treating melanoma. Evaluating the lateral margins of melanomas using frozen tissue sections is complicated. Some studies have shown that basic frozen sections can be accurate in margin evaluation, but others have shown that they are unreliable. The use of immunostains on frozen sections is one method that may make the analysis of frozen sections more accurate. Other modifications, including the use of rush paraffin sections in lieu of frozen sections, "slow Mohs," have also been reported. Although the role of MMS in the treatment of melanoma has been controversial, multiple reports using all of the above-mentioned methods have shown great success. Mohs micrographic surgery has a role in the management of melanoma, especially for lesions with poorly defined margins or for those located in areas where tissue conservation is critical.

Merkel cell carcinoma (MCC) is an uncommon, potentially lethal, cutaneous tumor that mainly occurs in sun-exposed skin of the head and neck area of the elderly. We report a case of MCC presenting as a 2-mm crusted erosion on the nose of an elderly patient, the smallest MCC reported thus far in the literature. The optimal management of MCC has not been clearly established. In view of its high local recurrence rate, predilection to metastasis, and significant mortality, aggressive treatment has been advocated. Identification of this tumor at such a small size posed a management dilemma because of lack of prospective treatment data involving biologic markers of prognostic significance for MCC.

Dermatologic surgery presents a unique set of ethical dilemmas not frequently discussed within the medical literature. This contribution presents a few cases commonly encountered by dermatologic surgeons. The case-based discussion follows a principles-based framework for analysis and seeks to identify the central moral conflict and exemplify the development of sound reasoning for subsequent decision making through the consideration of multiple viewpoints and the weighing of potential consequences. Additional cases are provided in concise format to encourage further analysis and discourse on the distinct ethical dilemmas encountered within dermatologic surgery.

To compare the cost and margin adequacy of Mohs micrographic surgery (Mohs) and traditional surgical excision (TSE) for the treatment of facial and auricular nonmelanoma skin cancer (NMSC).Prospective cost analysis with each patient serving as his or her own control.Study was performed from 1999 to 2001 at the University of Connecticut dermatology clinic, a tertiary care referral center.A total of 98 consecutive patients with a primary diagnosis of NMSC on the face and ears.The average cost of Mohs and TSE per patient for the treatment and repair of NMSC; adequacy of TSE margins after the initial procedure(because this outcome affects overall cost).Mohs was cost comparable to TSE when the subsequent procedure for inadequate TSE margins after permanent section was Mohs (937 vs 1029 US dollars; P =.16) or a subsequent TSE (937 vs 944 US dollars; P =.53). When facility-based frozen sections were requested for TSE, Mohs was significantly less costly (956 vs 1399 US dollars; P.001). The cost difference between Mohs and TSE was sensitive to the type of repair chosen.If the end point is clear margins, Mohs is cost comparable to TSE performed by otolaryngologic surgeons. Some caution is needed when evaluating the cost of facial and auricular NMSC treatment because the choice of repair can significantly affect the cost conclusions.

Peptide growth factors produced by platelets, macrophages, epidermal, and dermal cells may play key roles in regulating healing of partial-thickness skin wounds. We examined the effects of recombinant transforming growth factor beta (TGF-beta) on cultures of epidermal and dermal cells in vitro and on healing of partial-thickness injuries in vivo. Increasing concentrations of TGF-beta (0.1, 1, and 10 ng/ml) progressively inhibited serum-stimulated DNA synthesis by up to 95% in cultures of adult human keratinocytes during 48 hr of exposure to TGF-beta. In contrast, TGF-beta (10 and 100 ng/ml) in serum-free media stimulated DNA synthesis by up to 80% compared to serum-free control cultures of adult human dermal fibroblasts. To evaluate the effects of TGF-beta on healing of partial-thickness injuries in vivo, wounds (20 x 20 x 0.6 mm) were created on the dorsal thoracolumbar region of adult pigs by an electrokeratome and were treated daily for 5 days after injury with vehicle or vehicle containing 0.1 or 1 microgram/ml TGF-beta and covered with occlusive dressing. Computerized planimetry of wound photographs demonstrated that TGF-beta treatment stimulated statistically significantly increases in the area of regenerated epidermis compared to wounds treated with saline vehicle on Days 3, 4, 5, and 7 after injury probably due to TGF-beta increasing the rate of epidermal cell migration. In addition, morphometry of biopsy specimens showed that TGF-beta treatment stimulated statistically significant increases in the cross-sectional depths of regenerated dermis compared to wounds treated with saline or Silvadene vehicles on Days 5, 6, and 8 after injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Local anesthetics (LAs) are used by nearly all dermatologists and most physicians. Physicians frequently encounter patients who report a previous allergic reaction to LAs. Allergic reactions to LAs are well documented, but most patients are not truly allergic despite their histories. Every physician who uses LAs needs an organized approach to these patients. Report of a Case. A 76-year-old white woman presented for treatment of a squamous cell carcinoma of the right hand. Her medical history included mild arthritis mepivacaine, etidocaine hydrochloride, and prilocaine hydrochloride. Lidocaine is the most commonly used LA for cutaneous surgery. Adverse reactions to LAs include toxic responses, drug-unrelated responses, and idiosyncratic and allergic reactions. 1 Most reactions occur soon after the use of the LA. 2 Immunologically mediated allergic reactions account for about 1% of these adverse reactions. 3 The DTH reaction is uncommon. Most of the DTH reactions to amide anesthetics occur after topical

BACKGROUND Toxic exposure to xylene may occur during routine histopathologic staining procedures. Safer xylene substitutes have been available for over a decade, however, a 1991 survey of 25 Mohs training programs revealed that only 56% were using xylene substitutes. OBJECTIVE The purpose of this study was to compare xylene to xylene substitutes in the histologic preparation of frozen sections with respect to staining quality, clarity, cellular detail, and tissue distortion. METHODS Xylene and xylene substitutes were used as the final clearing agent in the routine histologic preparation of fresh frozen horizontal sections. The slides were evaluated by a dermatopathologist and a Mohs surgeon in a blinded manner. RESULTS No difference between xylene and the xylene substitutes were noted. CONCLUSION In light of the improved safety profile and efficacy of the xylene substitutes, they should replace xylene in the Molis laboratory.