was also the most common antiseptic used on the head and neck, excluding the periocular area, and on the torso or extremities (70.0% and 75.5%, respectively) (Table 2). The majority of responders have not recently changed their scrub preparation (92.3%). Keratitis was reported as a side effect associated with Hibiclens by 2 responders. One responder reported keratitis associated with ChloraPrep (CareFusion, El Paso, TX). Nine responders reported hypersensitivity with Hibiclens and 5 with 7.5% to 10% povidone– iodine. The use of perioperative intralesional antibiotic injections was reported by 6.5% of the responders. The type of antiseptic used significantly differed by practice type only. Single-specialty groups were more likely than others to use 70% isopropyl alcohol instead of Hibiclens (head and neck, p = .004; and torso, p = .005).

and during defect reconstruction for all locations excluding the periocular area. Povidone–iodine of 7.5% to 10% is safely being used in the periocular area both when taking a Mohs layer and during defect reconstruction. The most commonly reported side effect associated with the use of Hibiclens was hypersensitivity, and the most serious side effect was keratitis. Similarly, hypersensitivity was the most common side effect associated with povidone–iodine. Acknowledgments The authors thank Emily Scherer, PhD, for her assistance in the statistical analysis.

Reference 1. Eisen D, Warshawski L, Zloty D, Azari R. Results of a survey regarding perioperative antiseptic practices. J Cutan Med Surg 2009; 13:134–9.

Discussion Several trends regarding the use of antiseptics by Mohs surgeons are evident. Although there are a variety of antiseptic techniques available, the majority of members of the ACMS who responded to the survey are safely using Hibiclens when taking a Mohs layer

Lindsey K. Collins, MD Thomas J. Knackstedt, MD Faramarz H. Samie, MD, PhD Section of Dermatology Dartmouth–Hitchcock Medical Center Lebanon, New Hampshire

Myxoid Neurofibroma Treated With Mohs Micrographic Surgery Myxoid neurofibroma is a rare variant of neurofibromas. Myxoid neurofibroma commonly presents as a solitary flesh-colored to pink or blue nodule.1 Lesions typically occur in adults with a predilection for the face, shoulders, and arms.1 Histologically, myxoid neurofibromas are composed mainly of S100 positive Schwann cells in a myxoid-rich matrix with focal delicate collagen fibers.2 Myxoid neurofibromas are usually treated with a standard excision. The authors report the first case treated with Mohs micrographic surgery (MMS).

The patient denied any pain or sensitivity. Over this 10-year course, the patient underwent 2 excisions of the lesion but had recurrences after

History and Course A 72-year-old man presented with a 10-year history of a slow-growing lesion on his dorsal nose.


Figure 1. Myxoid neurofibroma. Preoperative photograph.


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Figure 2. Myxoid neurofibroma. (A) Spindle cells surrounded by myxoid (mucinous) stroma. (B) Staining positive for S100 (A, H&E stain original magnification ·400; B, S100 stain original magnification ·400).

approximately 1 year on both occasions. Previous biopsies were consistent with a myxoid neurofibroma. The patient denied any past medical problems and denied a family history of neurofibromatosis. On examination, the lesion appeared as a well circumscribed flesh-colored nodule measuring 1.4 · 1.2 cm (Figure 1). The patient was treated with MMS and underwent 2 stages to have the lesion completely removed. The first stage was performed using the elliptical Mohs technique3 with the layer taken in the shape of an ellipse. The peripheral margin was unexpectedly focally positive, so a second layer was taken for complete clearance. The final postoperative defect was 5.0 · 2.0 cm. The defect was closed, as a linear repair with the final defect measuring 5.5 cm. The postoperative course was without complications. The patient is doing well 10 months after surgery. Microscopic examination demonstrated a lesion in the dermis and subcutaneous tissue composed of a hypocellular proliferation of bland spindled cells associated with abundant myxoid-rich stroma (Figure 2A). No increased mitotic activity or nuclear pleomorphism was seen. There was weakly positive immunohistochemical staining for S100 in the spindle-cell component, supportive of neurogenic differentiation (Figure 2B). There was negative immunohistochemical staining for neurofilament, epithelial membrane antigen, and CD10.

Discussion Myxoid neurofibroma is a rare benign tumor derived from Schwann cells. Myxoid neurofibromas are slow growing and typically asymptomatic. They occur as solitary lesions and are rarely associated with neurofibromatosis. The pathogenesis of myxoid neurofibromas remains unknown. Histologically, myxoid neurofibromas are composed of spindle-shaped cells in a mucinous stroma with collagen fibers. They are well circumscribed and are typically unencapsulated. Associated perineural cells, fibroblasts, axons, and mast cells may be present in the tumor.4,5 Despite their benign nature, myxoid neurofibromas can cause complications by enlarging and compressing local structures. Although standard excisions have been the mainstay of treatment for myxoid neurofibromas, the authors suggest considering MMS as a treatment option to reduce the likelihood of recurrences. Our patient had 2 recurrences after standard excision alone, and the authors believe that this could have been prevented with MMS as the initial treatment of choice. Conclusion The authors suggest considering MMS as a treatment option for myxoid neurofibromas in cosmetically or functionally sensitive areas.

References 1. Gmyrek R, Beer R, Silvers DN, Reiffel R, et al. Periungual myxoid neurofibroma. Cutis 2002;69:54–6. 2. Megahed M. Histopathological variants of neurofibroma. Am J Dermatopathol 1994;16:486–95.

41:1:JANUARY 2015


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3. Kimyai-Asadi A, Goldberg LH, Nemeth A, Friedman PM, et al. Mohs micrographic surgery for elliptical excision of skin tumors: a surgical and histologic study. Dermatol Surg 2004;30:1310–8. 4. Rodriguez FJ, Folpe AL, Giannini C, Perry A. Pathology of peripheral nerve sheath tumors: diagnostic overview and update on selected diagnostic problems. Acta Neuropathol 2012;123: 295–319. 5. Patrizi A, Medri M, Affolter Orlowski F, Misciali C, et al. Myxoid neurofibroma in a child. An asymptomatic nodule on the finger. Eur J Dermatol 2011;21:267–8.

Diane Trieu, MD Anna Drosou, MD Mary R. Schwartz, MD Leonard H. Goldberg, MD Department of Dermatology Department of Pathology and Genomic Medicine Houston Methodist Houston, Texas

Aneurysmal Dermatofibroma Successfully Treated With Mohs Micrographic Surgery Aneurysmal dermatofibroma (ADF, also referred to as aneurysmal fibrous histiocytoma) is a rare soft-tissue tumor with a local recurrence rate as high as 20% after traditional surgical excision (TSE).1,2 This tumor is also believed to have malignant potential, as there have been several reports of metastasis in the literature.1,3,4 The authors present a case of ADF excised using Mohs Micrographic Surgery (MMS) with 47 months of recurrence-free follow-up.

Case Report A 58-year-old woman was noted to have a 5-mm pink-purple papule on her posterior right calf during a routine skin examination. The patient believed that the lesion had been present for several years but had come to her attention recently because she thought it abruptly became darker. The lesion had bled in the past but was not painful. A 6-mm punch excisional biopsy was taken during the initial encounter.

Figure 1. Aneurysmal dermatofibroma. (A) A 1.5-cm biopsy scar and residual tumor on the posterior right calf before MMS. (B) After Mohs defect. (C) Complex primary closure after MMS.



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Myxoid neurofibroma treated with Mohs micrographic surgery.

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