LETTERS AND COMMUNICATIONS
possible, alternative antifungal therapy should be considered to minimize these patients’ risk of developing aggressive, and possibly life-threatening, SCC. Acknowledgments The authors acknowledge Whitney Tolpinrud, MD, for her help with this case. References 1. Epaulard O, Villier C, Ravaud P, Chosidow O, et al. A multistep voriconazole-related phototoxic pathway may lead to skin carcinoma: results from a French nationwide study. Clin Infect Dis 2013;57: e182–8. 2. Singer JP, Boker A, Metchnikoff C, Binstock M, et al. High cumulative dose exposure to voriconazole is associated with cutaneous squamous cell carcinoma in lung transplant recipients. J Heart Lung Transplant 2012;31:694–9. 3. Feist A, Osborne SL, Thistlethwaite PA. Voriconazole use increases the incidence of skin cancer in lung transplant recipients. J Heart Lung Transplant 2009;28:S5242. 4. Mehrany K, Weenig RH, Lee KK, et al. Increased metastasis and mortality from cutaneous SCC in patients with chronic lymphocytic leukemia. J Am Acad Dermatol 2005;53:1067–71. 5. Rork JF, Margossian SP, Nambudiri VE, Huang JT. Nonmelanoma skin cancer in childhood after hematopoietic stem cell transplant: a report of 4 cases. J Pediatr Hematol Oncol 2014;36:224–7.
Vishal Anil Patel, MD Sonal A. Parikh, BS Mohs Micrographic & Dermatologic Surgery Columbia University Medical Center New York, New York Department of Dermatology Columbia University New York, New York Priya Mahindra Nayyar, MD Department of Dermatology Mohs Micrographic & Dermatologic Surgery North Shore LIJ-Health System Manhasset, New York Desiree Ratner, MD Icahn School of Medicine at Mount Sinai New York, New York The authors have indicated no significant interest with commercial supporters.
Topical Oxymetazoline Hydrochloride 0.05% as a Strategy to Reduce Intraoperative Wound Oozing in Mohs Micrographic Surgery Despite firm pressure dressings and seemingly adequate electrocautery, physicians are routinely called to address persistent slow bleeding between Mohs layers. The waiting time between layers is often accompanied by patient position changes and ambulation. Leakage from under a bandage is both unsettling to patients and family members and suboptimal infection control, as drips tend to make their way onto the chair or floor. In their practice, topical oxymetazoline has been used selectively in small to medium wounds as a hemostatic aid. Based on observation, it appears useful in a subset of patients. On removal of a tissue layer, any particularly brisk bleeding is first addressed with cautery. Thereafter, oxymetazoline HCl 0.05% is applied directly to the wound bed, followed by a standard pressure dressing. Although statistical data have not been collected to date, this
simple intervention has effectively reduced wound leakage without noted adverse reactions. Oxymetazoline, a selective alpha-1 agonist, partial alpha-2 agonist, and potent vasoconstrictor, has long been used as a topical hemostatic agent in managing epistaxis and during sinus surgery.1 It is most commonly used as a sinus decongestant, available over the counter. In their practice, they use over-thecounter oxymetazoline in a regular spray formulation, although it is additionally available as a gel. Numerous studies highlight hemostatic efficacy and an excellent safety profile as compared with other topical vasoconstrictors used for surgical hemostasis (phenylephrine, cocaine, epinephrine).1–4 A systematic review of 42 articles on topical vasoconstrictor use in endoscopic sinus surgery revealed no reported morbidity from oxymetazoline use.2
41:6:JUNE 2015
749
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Certainly, the advantages of local vasoconstriction are well appreciated, given the widespread use of epinephrine in anesthetic agents. It is the authors’ experience that added topical vasoconstriction with oxymetazoline is particularly useful in patients who report intolerance of anesthesia containing epinephrine or who take anticoagulant medications. Further investigation, with reportable statistics, is warranted to fully characterize the apparent benefits, and any untoward effects, as of yet unencountered. To date, it has proved an inexpensive, safe, and efficacious aid in controlling intraoperative wound oozing.
2. Higgins T, et al. Systematic review of topical vasoconstrictors in endoscopic sinus surgery. Laryngoscope 2011;121:422–32. 3. Riegle EV, et al. Comparison of vasoconstrictors for functional endoscopic sinus surgery in children. Laryngoscope 1990;102: 820–3. 4. Katz RI, et al. A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation. J Clin Anesth 1990;2:16–20.
C. Blake Phillips, MD Conway C. Huang, MD Department of Dermatology University of Alabama at Birmingham Birmingham, Alabama
References 1. Krempl GA, Noorily AD. Use of oxymetazoline in the management of epistaxis. Ann Otol Rhinol Laryngol 1995;104(9 Pt 1):704–6.
The authors have indicated no significant interest with commercial supporters.
A Case of Multiple Large Reactive Keratoacanthomas Treated With Serial Zinc Oxide Wraps Keratoacanthomas (KAs) are considered a variant of squamous cell carcinoma (SCC) characterized by rapid growth over 4 to 6 weeks into a firm crateriform nodule, often with a central keratin plug. Although KAs commonly develop spontaneously, they can occur in reaction to a number of conditions including trauma and immunosuppression. The authors describe a patient with multiple large reactive KAs after the use of topical 0.5% 5-fluorouracil (Carac Cream, 0.5%; Valeant Pharmaceuticals, Bridgewater, NJ) for actinic keratoses, who improved significantly with serial treatments of electrodessication and curettage (ED&C) and Unna zinc oxide impregnated wraps. To the authors’ knowledge, this is the first case describing reactive KAs developing after topical 5-fluorouracil and the first to report benefit of therapeutic serial zinc oxide wraps. A 67-year-old white woman with a history of numerous nonmelanoma skin cancers (NMSC) was referred for a 12-month history of multiple enlarging nodules on her lower legs that appeared after a few weeks of applying 0.5% 5-fluorouracil cream to the area for presumed actinic keratoses. She had no history of NMSC on the lower extremities. On examination, numerous large, firm, pink, exophytic nodules were
750
scattered primarily on the anterior shins (Figure 1). Biopsies were consistent with SCC of the KA subtype. Given the large number of KAs in the location of her recent 5-fluorouracil use, these were determined to be clinically consistent with reactive KAs. The patient repeatedly declined 2 well-known treatments, oral acitretin and intralesional methotrexate, because of personal preference to avoid any systemic therapy. Initial treatment consisted of excision of 2 KAs given their size and symptomatology, which resulted in the appearance of reactive KAs along the suture line within 1 week (Figure 2). Consequently, all remaining lesions were treated with shave excision, ED&C, followed by zinc oxide wraps. Over the next 24 months, the patient continued at-home wraps, changing them 1 to 2 times per week. Significant improvement was noted when the patient consistently used the wraps, with complete resolution of many of the lesions and decrease in background erythema. When the wraps were not consistently applied (>1 week without wrapping), some of the previously regressed lesions recurred and new KAs appeared. Of note, intralesional triamcinolone acetonide (40 mg/mL) was injected into a minority of lesions early in the clinical course but did not result in any measurable clinical improvement. Subsequently,
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
possible, alternative antifungal therapy should be considered to minimize these patients’ risk of developing aggressive, and possibly life-threatening, SCC. Acknowledgments The authors acknowledge Whitney Tolpinrud, MD, for her help with this case. References 1. Epaulard O, Villier C, Ravaud P, Chosidow O, et al. A multistep voriconazole-related phototoxic pathway may lead to skin carcinoma: results from a French nationwide study. Clin Infect Dis 2013;57: e182–8. 2. Singer JP, Boker A, Metchnikoff C, Binstock M, et al. High cumulative dose exposure to voriconazole is associated with cutaneous squamous cell carcinoma in lung transplant recipients. J Heart Lung Transplant 2012;31:694–9. 3. Feist A, Osborne SL, Thistlethwaite PA. Voriconazole use increases the incidence of skin cancer in lung transplant recipients. J Heart Lung Transplant 2009;28:S5242. 4. Mehrany K, Weenig RH, Lee KK, et al. Increased metastasis and mortality from cutaneous SCC in patients with chronic lymphocytic leukemia. J Am Acad Dermatol 2005;53:1067–71. 5. Rork JF, Margossian SP, Nambudiri VE, Huang JT. Nonmelanoma skin cancer in childhood after hematopoietic stem cell transplant: a report of 4 cases. J Pediatr Hematol Oncol 2014;36:224–7.
Vishal Anil Patel, MD Sonal A. Parikh, BS Mohs Micrographic & Dermatologic Surgery Columbia University Medical Center New York, New York Department of Dermatology Columbia University New York, New York Priya Mahindra Nayyar, MD Department of Dermatology Mohs Micrographic & Dermatologic Surgery North Shore LIJ-Health System Manhasset, New York Desiree Ratner, MD Icahn School of Medicine at Mount Sinai New York, New York The authors have indicated no significant interest with commercial supporters.
Topical Oxymetazoline Hydrochloride 0.05% as a Strategy to Reduce Intraoperative Wound Oozing in Mohs Micrographic Surgery Despite firm pressure dressings and seemingly adequate electrocautery, physicians are routinely called to address persistent slow bleeding between Mohs layers. The waiting time between layers is often accompanied by patient position changes and ambulation. Leakage from under a bandage is both unsettling to patients and family members and suboptimal infection control, as drips tend to make their way onto the chair or floor. In their practice, topical oxymetazoline has been used selectively in small to medium wounds as a hemostatic aid. Based on observation, it appears useful in a subset of patients. On removal of a tissue layer, any particularly brisk bleeding is first addressed with cautery. Thereafter, oxymetazoline HCl 0.05% is applied directly to the wound bed, followed by a standard pressure dressing. Although statistical data have not been collected to date, this
simple intervention has effectively reduced wound leakage without noted adverse reactions. Oxymetazoline, a selective alpha-1 agonist, partial alpha-2 agonist, and potent vasoconstrictor, has long been used as a topical hemostatic agent in managing epistaxis and during sinus surgery.1 It is most commonly used as a sinus decongestant, available over the counter. In their practice, they use over-thecounter oxymetazoline in a regular spray formulation, although it is additionally available as a gel. Numerous studies highlight hemostatic efficacy and an excellent safety profile as compared with other topical vasoconstrictors used for surgical hemostasis (phenylephrine, cocaine, epinephrine).1–4 A systematic review of 42 articles on topical vasoconstrictor use in endoscopic sinus surgery revealed no reported morbidity from oxymetazoline use.2
41:6:JUNE 2015
749
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Certainly, the advantages of local vasoconstriction are well appreciated, given the widespread use of epinephrine in anesthetic agents. It is the authors’ experience that added topical vasoconstriction with oxymetazoline is particularly useful in patients who report intolerance of anesthesia containing epinephrine or who take anticoagulant medications. Further investigation, with reportable statistics, is warranted to fully characterize the apparent benefits, and any untoward effects, as of yet unencountered. To date, it has proved an inexpensive, safe, and efficacious aid in controlling intraoperative wound oozing.
2. Higgins T, et al. Systematic review of topical vasoconstrictors in endoscopic sinus surgery. Laryngoscope 2011;121:422–32. 3. Riegle EV, et al. Comparison of vasoconstrictors for functional endoscopic sinus surgery in children. Laryngoscope 1990;102: 820–3. 4. Katz RI, et al. A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation. J Clin Anesth 1990;2:16–20.
C. Blake Phillips, MD Conway C. Huang, MD Department of Dermatology University of Alabama at Birmingham Birmingham, Alabama
References 1. Krempl GA, Noorily AD. Use of oxymetazoline in the management of epistaxis. Ann Otol Rhinol Laryngol 1995;104(9 Pt 1):704–6.
The authors have indicated no significant interest with commercial supporters.
A Case of Multiple Large Reactive Keratoacanthomas Treated With Serial Zinc Oxide Wraps Keratoacanthomas (KAs) are considered a variant of squamous cell carcinoma (SCC) characterized by rapid growth over 4 to 6 weeks into a firm crateriform nodule, often with a central keratin plug. Although KAs commonly develop spontaneously, they can occur in reaction to a number of conditions including trauma and immunosuppression. The authors describe a patient with multiple large reactive KAs after the use of topical 0.5% 5-fluorouracil (Carac Cream, 0.5%; Valeant Pharmaceuticals, Bridgewater, NJ) for actinic keratoses, who improved significantly with serial treatments of electrodessication and curettage (ED&C) and Unna zinc oxide impregnated wraps. To the authors’ knowledge, this is the first case describing reactive KAs developing after topical 5-fluorouracil and the first to report benefit of therapeutic serial zinc oxide wraps. A 67-year-old white woman with a history of numerous nonmelanoma skin cancers (NMSC) was referred for a 12-month history of multiple enlarging nodules on her lower legs that appeared after a few weeks of applying 0.5% 5-fluorouracil cream to the area for presumed actinic keratoses. She had no history of NMSC on the lower extremities. On examination, numerous large, firm, pink, exophytic nodules were
750
scattered primarily on the anterior shins (Figure 1). Biopsies were consistent with SCC of the KA subtype. Given the large number of KAs in the location of her recent 5-fluorouracil use, these were determined to be clinically consistent with reactive KAs. The patient repeatedly declined 2 well-known treatments, oral acitretin and intralesional methotrexate, because of personal preference to avoid any systemic therapy. Initial treatment consisted of excision of 2 KAs given their size and symptomatology, which resulted in the appearance of reactive KAs along the suture line within 1 week (Figure 2). Consequently, all remaining lesions were treated with shave excision, ED&C, followed by zinc oxide wraps. Over the next 24 months, the patient continued at-home wraps, changing them 1 to 2 times per week. Significant improvement was noted when the patient consistently used the wraps, with complete resolution of many of the lesions and decrease in background erythema. When the wraps were not consistently applied (>1 week without wrapping), some of the previously regressed lesions recurred and new KAs appeared. Of note, intralesional triamcinolone acetonide (40 mg/mL) was injected into a minority of lesions early in the clinical course but did not result in any measurable clinical improvement. Subsequently,
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
