Letters to the Editor
532
Brazilian porcupines quills have the following distinct regions: a conical black tip containing a layer of microscopic barbs oriented towards its base and a cylindrical yellow base without such barbs.2,9 These microscopic structures facilitate penetration of the skin and lodging of the quill in the tissues. In some cases, quill removal requires sedation or anaesthesia.9 One of the major concerns regarding quill wounds is the potential risk of infection.10 The removal of the quills and fragments from the patient’s hand and the follow-up visits led to a successful treatment that allowed the patient to return to work promptly. Porcupine encounters are somewhat seasonal,4 and it might be useful to develop public education and awareness programs to avoid animal-human conflicts. Managing accidents such as this porcupine injury could present a challenge because they are quite rare. Public information and instructions regarding safe management should be displayed in emergency rooms, veterinary clinics and frequently used offleash parks.
Funding sources None. F. Bernardes Filho,1,2,* J.C. Andrade,2 D.L.G. Queiroz,2,3 O. Lupi4,5 1
Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da rdia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro (RJ), Miserico ^ncia Ma rio Brazil, 2Emergency Room, Unidade Municipal de Urge i (RJ), Brazil, 3Department of Plastic Surgery, Santa Casa Monteiro, Nitero rdia do Rio de Janeiro, Rio de Janeiro (RJ), Brazil, da Miserico 4 Department of Dermatology, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro (RJ), Brazil, 5Department of Dermatology, Policlınica Geral do Rio de Janeiro (PGRJ), Rio de Janeiro (RJ), Brazil *Correspondence: F. Bernardes Filho. E-mail: f9fi[email protected]
8 Weishaupt J, Kolb-M€aurer A, Lempert S et al. A different kind of hedgehog pathway: tinea manus due to Trichophyton erinacei transmitted by an African pygmy hedgehog (Atelerix albiventris). Mycoses 2014; 57: 125–127. 9 Cho WK, Ankrum JA, Guo D et al. Microstructured barbs on the North American porcupine quill enable easy tissue penetration and difficult removal. Proc Natl Acad Sci U S A 2012; 109: 21289–21294. 10 Ghanem E, Heppert V, Spangehl M et al. Wound management. J Orthop Res 2014; 32: S108–S119. DOI: 10.1111/jdv.12928
A case of ectopic cilia Sir Ectopic cilia are rare congenital anomalies in which abnormal placement of the eyelashes that are normally aliened at the edge of the eyelid, appear on the anterior or conjunctival surface of the eyelid.1,2 Ectopic cilia have been extremely rarely reported in the dermatology literature.1–5 A 4-year-old boy was referred for evaluation of an asymptomatic hair cluster on left upper eyelid that had been present since birth. He had no other eyelid or ocular abnormalities. His mother denied complicated pregnancy and delivery or drug use. There was no family history of similar lesions. Dermatological examination showed a protruded hair tuft composed of approximately 20 hairs on the left eyelid which was 3 mm above the lateral eyelid margin (Fig. 1). Eversion of the eyelid showed normal tarsal conjunctiva. The lesion was diagnosed as anterior ectopic cilia and surgical excision was suggested. The parents did not accept surgical operation because the patient did not have any complaint. Developmental anomalies of eyelashes such as cilial row duplication, agenesis and ectopic placements have been rarely
References 1 de Ara ujo MR, Luppi MM, Malta Mde C, Assumpcß~ao AL, Langohr IM, Ecco R. Disseminated T-cell lymphoma in a Brazilian porcupine (Coendou prehensilis). J Vet Diagn Invest 2011; 23: 132–135. 2 Leite YLR, Caldara V Junior, Loss AC et al. Designation of a neotype for the Brazilian porcupine, Coendou prehensilis (Linnaeus, 1758). Zootaxa 2011; 2791: 30–40. 3 Freitas MA, Francßa DPF, Verıssimo D. First record of the bicolouredspined Porcupine Coendou bicolor (Tschudi, 1844) for Brazil. CheckList 2013; 9: 94–96. 4 Johnson MD, Magnusson KD, Shmon CL, Waldner C. Porcupine quill injuries in dogs: a retrospective of 296 cases (1998–2002). Can Vet J 2006; 47: 677–682. 5 Mulon PY, Achard D, Babkine M. Ultrasonographic diagnosis of porcupine quill foreign bodies in the plantar flexor tendon sheath region in a heifer. Can Vet J 2010; 51: 888–990. 6 Fairley JA, Suchniak J, Paller AS. Hedgehog hives. Arch Dermatol 1999; 135: 561–563. 7 Philpot CM, Bowen RG. Hazards from hedgehogs: two case reports with a survey of the epidemiology of hedgehog ringworm. Clin Exp Dermatol 1992; 17: 156–158.
JEADV 2016, 30, 446–556
Figure 1 Protruded hair tuft on the lateral left upper eyelid.
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
533
reported. To our knowledge, only about 16 cases with ectopic cilia on the anterior surface of the eyelids have been reported in the literature.5 Ectopic cilia are divided into two categories according to the origination region of cilia; in the anterior type, cilia stem from anterior of the tarsal plate and protrude through the eyelid skin. In the posterior type, cilia originates from the posterior of the tarsal plate and protrude either from the eyelid margin or through the palpebral conjunctiva.1–3 Ectopic cilia are mostly localized on upper lateral quadrant of the anterior surface of the upper eyelid. They may show a variable degree of vertical separation from the lid margin. Ectopic cilia may consist of one or more lash follicles.1,3 The present case is an anterior type of ectopic cilia which is localized on the lateral upper eyelid, at 3 mm distance from eyelid margin and it contained approximately 20 hairs. The cause of ectopic cilia is still unknown. While anterior ectopic cilia are congenital, posterior ectopic cilia may be acquired due to the chronic inflammation.4 There are several hypotheses to explain the development of congenital ectopic cilia. Firstly, it was suggested that cilia replaced and substituted meibomian glands. However, a new hypothesis suggesting that, this anomaly is likely due to inappropriate differentiation during embryogenesis, has becoming to be more accepted.1–3 Ectopic cilia are isolated congenital anomaly but it can be associated with congenital distichiasis, a complex choristoma, cutaneous features of atopic eczema in the periorbital region, pre-septal cellulitis and hypocromic naevus.1–3,5 The present case did not have another pathology. Surgical excision suggested for cosmetical reason in asymptomatic anterior ectopic cilia cases but recurrences may be seen particularly after incomplete excision. The present case has been reported because ectopic cilia are a very rarely seen entity in dermatological practice. € nu €l H. Benar,* M. Go Dermatology Department, Dısßkapı YıldırımBeyazıt Education and Research Hospital, Dısßkapı, Ankara, Turkey *Correspondence: H. Benar. E-mail: [email protected]
References 1 Baghestani S, Banihashemi SA. Ectopic cilia in a 14-year-old boy. Pediatr Dermatol 2011; 28: 55–56. 2 Nakra T, Blaydon SM, Durairaj VD, Shinder R. Congenital upper eyelid ectopic cilia. J Pediatr Ophthalmol Strabismus 2011; 48: e16–e18. 3 Dinc E, Yildirim O. A rare case of ectopic cilia. Can J Ophthalmol 2014; 49: e 8–e 9. 4 Hase K, Kase S, Noda M, Ohashi T, Shinkuma S, Ishida S. Ectopic cilia: a histopathological study. Case Rep Dermatol 2012; 4: 37–40. 5 da Fonseca FL, Yamanaka PK, Lima PP, Matayoshi S. A 6-year-old girl with ectopic cilia and hypochromic nevus. Clin Ophthalmol 2014; 8: 1259–1261. DOI: 10.1111/jdv.12930
JEADV 2016, 30, 446–556
Subcutaneous non-absorbable polypropylene (SNAP) sutures in serial excision of congenital naevi: A new time-saving technique reducing dehiscence with optimized aesthetic results Editor Congenital naevi (CN) are benign lesions that can be detected in newborns with a frequency of 1–3%.1 Besides an aesthetic and consequent psychological stress, the development of melanoma in these patients plays an important role. Due to this risk, the removal of the CN is recommended if possible. Medium- and large-sized congenital naevi may be treated by serial excisions or the use of subcutaneous skin expanders, external tissue expanders (e.g. DermaCloseTM RC, Wound Care Technologies, Inc., Chanhassen, MN, US), or intra-operative rapid stretching with small volume expanders. Usually, serial excisions are performed at 12–16 week intervals. We here introduce the use of subcutaneous non-absorbable polypropylene (SNAP) sutures, as an effective advancement in serial excision of CN, reducing the tendency of dehiscence and hypertrophic spreading scar formation. An 8-year-old girl with a medium-sized congenital naevus on her left shoulder underwent the first serial excision to minimize the risk of malignant transformation. Polyglactin 910 (e.g. Vicrylâ, Ethicon, Norderstedt, Germany) and polydioxanone (e.g. PDSâ II, Ethicon, Norderstedt, Germany) were used as subcutaneous sutures. After the first excision, the ensuing dehiszent scar resulted in the naevus enlarging to its original size (Fig. 1a). To reduce the risk of scar dehiscence and hypertrophic spreading scar formation in the subsequent procedures, we used SNAP sutures (e.g. Proleneâ, Ethicon, Norderstedt, Germany Fig. 1b) resulting in perfect wound healing without dehiscence and scarring. These observations are consistent with our long-term experience of using SNAP sutures in the serial excision of naevi and benign tumours. An 8-month-old girl with a dark-pigmented, medium-sized congenital naevus on the left lower leg was operated by serial excisions (Fig. 2a). Altogether, three procedures were performed until complete removal of the naevus (Fig. 2b). Subcutaneously we used SNAP sutures and cutaneous horizontal mattress sutures. Five years after the last excision, only an unobtrusive scar was left (Fig. 2c). In all procedures, the SNAP sutures were removed completely during the subsequent procedure. The use of SNAP sutures to advance the closure of serial elliptical excisions has not yet been described. Unlike polyglactin 910, which loses 50% of its tensile strength in 21 days, and
© 2014 European Academy of Dermatology and Venereology
532
Brazilian porcupines quills have the following distinct regions: a conical black tip containing a layer of microscopic barbs oriented towards its base and a cylindrical yellow base without such barbs.2,9 These microscopic structures facilitate penetration of the skin and lodging of the quill in the tissues. In some cases, quill removal requires sedation or anaesthesia.9 One of the major concerns regarding quill wounds is the potential risk of infection.10 The removal of the quills and fragments from the patient’s hand and the follow-up visits led to a successful treatment that allowed the patient to return to work promptly. Porcupine encounters are somewhat seasonal,4 and it might be useful to develop public education and awareness programs to avoid animal-human conflicts. Managing accidents such as this porcupine injury could present a challenge because they are quite rare. Public information and instructions regarding safe management should be displayed in emergency rooms, veterinary clinics and frequently used offleash parks.
Funding sources None. F. Bernardes Filho,1,2,* J.C. Andrade,2 D.L.G. Queiroz,2,3 O. Lupi4,5 1
Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da rdia do Rio de Janeiro (IDPRDA/SCMRJ), Rio de Janeiro (RJ), Miserico ^ncia Ma rio Brazil, 2Emergency Room, Unidade Municipal de Urge i (RJ), Brazil, 3Department of Plastic Surgery, Santa Casa Monteiro, Nitero rdia do Rio de Janeiro, Rio de Janeiro (RJ), Brazil, da Miserico 4 Department of Dermatology, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro (RJ), Brazil, 5Department of Dermatology, Policlınica Geral do Rio de Janeiro (PGRJ), Rio de Janeiro (RJ), Brazil *Correspondence: F. Bernardes Filho. E-mail: f9fi[email protected]
8 Weishaupt J, Kolb-M€aurer A, Lempert S et al. A different kind of hedgehog pathway: tinea manus due to Trichophyton erinacei transmitted by an African pygmy hedgehog (Atelerix albiventris). Mycoses 2014; 57: 125–127. 9 Cho WK, Ankrum JA, Guo D et al. Microstructured barbs on the North American porcupine quill enable easy tissue penetration and difficult removal. Proc Natl Acad Sci U S A 2012; 109: 21289–21294. 10 Ghanem E, Heppert V, Spangehl M et al. Wound management. J Orthop Res 2014; 32: S108–S119. DOI: 10.1111/jdv.12928
A case of ectopic cilia Sir Ectopic cilia are rare congenital anomalies in which abnormal placement of the eyelashes that are normally aliened at the edge of the eyelid, appear on the anterior or conjunctival surface of the eyelid.1,2 Ectopic cilia have been extremely rarely reported in the dermatology literature.1–5 A 4-year-old boy was referred for evaluation of an asymptomatic hair cluster on left upper eyelid that had been present since birth. He had no other eyelid or ocular abnormalities. His mother denied complicated pregnancy and delivery or drug use. There was no family history of similar lesions. Dermatological examination showed a protruded hair tuft composed of approximately 20 hairs on the left eyelid which was 3 mm above the lateral eyelid margin (Fig. 1). Eversion of the eyelid showed normal tarsal conjunctiva. The lesion was diagnosed as anterior ectopic cilia and surgical excision was suggested. The parents did not accept surgical operation because the patient did not have any complaint. Developmental anomalies of eyelashes such as cilial row duplication, agenesis and ectopic placements have been rarely
References 1 de Ara ujo MR, Luppi MM, Malta Mde C, Assumpcß~ao AL, Langohr IM, Ecco R. Disseminated T-cell lymphoma in a Brazilian porcupine (Coendou prehensilis). J Vet Diagn Invest 2011; 23: 132–135. 2 Leite YLR, Caldara V Junior, Loss AC et al. Designation of a neotype for the Brazilian porcupine, Coendou prehensilis (Linnaeus, 1758). Zootaxa 2011; 2791: 30–40. 3 Freitas MA, Francßa DPF, Verıssimo D. First record of the bicolouredspined Porcupine Coendou bicolor (Tschudi, 1844) for Brazil. CheckList 2013; 9: 94–96. 4 Johnson MD, Magnusson KD, Shmon CL, Waldner C. Porcupine quill injuries in dogs: a retrospective of 296 cases (1998–2002). Can Vet J 2006; 47: 677–682. 5 Mulon PY, Achard D, Babkine M. Ultrasonographic diagnosis of porcupine quill foreign bodies in the plantar flexor tendon sheath region in a heifer. Can Vet J 2010; 51: 888–990. 6 Fairley JA, Suchniak J, Paller AS. Hedgehog hives. Arch Dermatol 1999; 135: 561–563. 7 Philpot CM, Bowen RG. Hazards from hedgehogs: two case reports with a survey of the epidemiology of hedgehog ringworm. Clin Exp Dermatol 1992; 17: 156–158.
JEADV 2016, 30, 446–556
Figure 1 Protruded hair tuft on the lateral left upper eyelid.
© 2014 European Academy of Dermatology and Venereology
Letters to the Editor
533
reported. To our knowledge, only about 16 cases with ectopic cilia on the anterior surface of the eyelids have been reported in the literature.5 Ectopic cilia are divided into two categories according to the origination region of cilia; in the anterior type, cilia stem from anterior of the tarsal plate and protrude through the eyelid skin. In the posterior type, cilia originates from the posterior of the tarsal plate and protrude either from the eyelid margin or through the palpebral conjunctiva.1–3 Ectopic cilia are mostly localized on upper lateral quadrant of the anterior surface of the upper eyelid. They may show a variable degree of vertical separation from the lid margin. Ectopic cilia may consist of one or more lash follicles.1,3 The present case is an anterior type of ectopic cilia which is localized on the lateral upper eyelid, at 3 mm distance from eyelid margin and it contained approximately 20 hairs. The cause of ectopic cilia is still unknown. While anterior ectopic cilia are congenital, posterior ectopic cilia may be acquired due to the chronic inflammation.4 There are several hypotheses to explain the development of congenital ectopic cilia. Firstly, it was suggested that cilia replaced and substituted meibomian glands. However, a new hypothesis suggesting that, this anomaly is likely due to inappropriate differentiation during embryogenesis, has becoming to be more accepted.1–3 Ectopic cilia are isolated congenital anomaly but it can be associated with congenital distichiasis, a complex choristoma, cutaneous features of atopic eczema in the periorbital region, pre-septal cellulitis and hypocromic naevus.1–3,5 The present case did not have another pathology. Surgical excision suggested for cosmetical reason in asymptomatic anterior ectopic cilia cases but recurrences may be seen particularly after incomplete excision. The present case has been reported because ectopic cilia are a very rarely seen entity in dermatological practice. € nu €l H. Benar,* M. Go Dermatology Department, Dısßkapı YıldırımBeyazıt Education and Research Hospital, Dısßkapı, Ankara, Turkey *Correspondence: H. Benar. E-mail: [email protected]
References 1 Baghestani S, Banihashemi SA. Ectopic cilia in a 14-year-old boy. Pediatr Dermatol 2011; 28: 55–56. 2 Nakra T, Blaydon SM, Durairaj VD, Shinder R. Congenital upper eyelid ectopic cilia. J Pediatr Ophthalmol Strabismus 2011; 48: e16–e18. 3 Dinc E, Yildirim O. A rare case of ectopic cilia. Can J Ophthalmol 2014; 49: e 8–e 9. 4 Hase K, Kase S, Noda M, Ohashi T, Shinkuma S, Ishida S. Ectopic cilia: a histopathological study. Case Rep Dermatol 2012; 4: 37–40. 5 da Fonseca FL, Yamanaka PK, Lima PP, Matayoshi S. A 6-year-old girl with ectopic cilia and hypochromic nevus. Clin Ophthalmol 2014; 8: 1259–1261. DOI: 10.1111/jdv.12930
JEADV 2016, 30, 446–556
Subcutaneous non-absorbable polypropylene (SNAP) sutures in serial excision of congenital naevi: A new time-saving technique reducing dehiscence with optimized aesthetic results Editor Congenital naevi (CN) are benign lesions that can be detected in newborns with a frequency of 1–3%.1 Besides an aesthetic and consequent psychological stress, the development of melanoma in these patients plays an important role. Due to this risk, the removal of the CN is recommended if possible. Medium- and large-sized congenital naevi may be treated by serial excisions or the use of subcutaneous skin expanders, external tissue expanders (e.g. DermaCloseTM RC, Wound Care Technologies, Inc., Chanhassen, MN, US), or intra-operative rapid stretching with small volume expanders. Usually, serial excisions are performed at 12–16 week intervals. We here introduce the use of subcutaneous non-absorbable polypropylene (SNAP) sutures, as an effective advancement in serial excision of CN, reducing the tendency of dehiscence and hypertrophic spreading scar formation. An 8-year-old girl with a medium-sized congenital naevus on her left shoulder underwent the first serial excision to minimize the risk of malignant transformation. Polyglactin 910 (e.g. Vicrylâ, Ethicon, Norderstedt, Germany) and polydioxanone (e.g. PDSâ II, Ethicon, Norderstedt, Germany) were used as subcutaneous sutures. After the first excision, the ensuing dehiszent scar resulted in the naevus enlarging to its original size (Fig. 1a). To reduce the risk of scar dehiscence and hypertrophic spreading scar formation in the subsequent procedures, we used SNAP sutures (e.g. Proleneâ, Ethicon, Norderstedt, Germany Fig. 1b) resulting in perfect wound healing without dehiscence and scarring. These observations are consistent with our long-term experience of using SNAP sutures in the serial excision of naevi and benign tumours. An 8-month-old girl with a dark-pigmented, medium-sized congenital naevus on the left lower leg was operated by serial excisions (Fig. 2a). Altogether, three procedures were performed until complete removal of the naevus (Fig. 2b). Subcutaneously we used SNAP sutures and cutaneous horizontal mattress sutures. Five years after the last excision, only an unobtrusive scar was left (Fig. 2c). In all procedures, the SNAP sutures were removed completely during the subsequent procedure. The use of SNAP sutures to advance the closure of serial elliptical excisions has not yet been described. Unlike polyglactin 910, which loses 50% of its tensile strength in 21 days, and
© 2014 European Academy of Dermatology and Venereology
