Surgical pearl: double-trephine punch biopsy technique for sampling subcutaneous tissue

Cutaneous vasculitis in rheumatologic disease: Current concepts of skin and systemic manifestations

Cutaneous vasculitis may be limited to the skin, a manifestation of systemic vasculitis, or a sign of an important underlying disease state. A thorough and systematic approach is required for accurate diagnosis and evaluation of such patients to enable appropriate management of the vasculitis and any associated condition. Occasionally, cutaneous vasculitis is a manifestation or presenting sign of connective tissue disease, such as systemic lupus erythematosus, Sjögren syndrome, or another condition. Such patients are at risk for poor outcomes related to systemic manifestations of vasculitis, as well as increased severity of the underlying disease. Recognition of this important subset of patients with skin vasculitis enables appropriate workup and successful management.

Unilateral Erythema Nodosum following Norethindrone Acetate, Ethinyl Estradiol, and Ferrous Fumarate Combination Therapy

Erythema nodosum is a septal panniculitis that typically presents as symmetric, tender nodules on the anterior aspects of bilateral lower extremities. Nearly half of cases are due to secondary causes, with oral contraceptive pills being the leading pharmaceutical cause. However, to our knowledge, there has yet to be a published association with norethindrone acetate, ethinyl estradiol, and ferrous fumarate. We report our experience with a 30-year-old woman who developed unilateral tender nodules within a month of starting 1 mg norethindrone acetate and 20 mcg ethinyl estradiol daily. Of note, she had previously taken oral contraceptives with the same estrogen agent but different progesterone, without problems. We conclude that systemically triggered erythema nodosum can present with lesions localized to one extremity. When a patient presents with tender, firm nodules, clinicians should consider the possibility of erythema nodosum and its triggers, such as oral contraceptives. Additionally, should a patient on hormonal therapy develop erythema nodosum, changing the progesterone agent may allow the patient to continue similar therapy without developing symptoms.

Novel uses of skin biopsy punches in dermatosurgery

The skin punch or surgical punch is an instrument which is used almost exclusively by dermatologists. It is a circular hollow blade attached to a pencil-like handle ranging in size from 0.5 to 10 mm. It is available as a disposable, reusable, and automated instrument. The punch can be used as a diagnostic, therapeutic, and cosmetic tool in dermatology. We have used punch as a diagnostic, therapeutic, and cosmetic tool in our dermatosurgery practice in our hospital. Various original research articles, text book publications, and review articles were studied and compiled. Techniques used by various authors and our own experiences with punch have been described. This article aims at providing the novel usefulness of skin biopsy punch in dermatology as the basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal.

Versatile punch surgery

BACKGROUND

Punch instrument is a circular blade that can be used for many diagnostic and therapeutic purposes in different medical and surgical specialties. Punch surgery (or biopsy) is achieved by using this versatile punch blade under local anesthesia. Basic punch surgery is quick and easy to learn. Complications such as bleeding and infection are minimal. Diagnostic punch surgery can obtain a part of or whole skin lesion for histologic examination. In addition to the skin, nail and mucous membrane tissue can be obtained by punch biopsy. Interestingly, punch biopsy can be used as an adjunctive to fine-needle aspiration to establish the diagnosis of tumors of solid organ such as the breast. Diagnostic punch surgery can be modified to overcome certain problems. The split-punch technique helps avoid crushing the tissue punch when trying to divide it for different examinations. The double-trephine punch facilitates obtaining subcutaneous tissue without the need for full elliptical excision. The string-of-beads technique obviates the need for dissection of tissue into pieces. In other nondermatology and dermatology conditions, such as nerve pathology, arteriosclerosis, melanoma mapping, and eyelid tumors, the diagnosis can be enhanced with the use of punch surgery.Therapeutic punch surgery can be used for excision of unwanted lesions such as nevi, as well as pathologic bone and cartilage tissues. Punch grafting is used in vitiligo surgery and hair transplantion. Punch evacuative surgery can help in the evacuation of unwanted tissue or materials such as lipoma, subungual hematoma, scrotal calcinosis, pseudocyst of the auricle, pilar cyst, and others.Reconstructive punch surgery includes correction of ear lobe defects and acne scars. Enhancement of wound healing can be achieved by use of the punch; therefore, it can help nonhealing ulcers.

Cutaneous Vasculitis Update: Diagnostic Criteria, Classification, Epidemiology, Etiology, Pathogenesis, Evaluation and Prognosis

Vasculitis, inflammation of the vessel wall, can result in mural destruction with hemorrhage, aneurysm formation, and infarction, or intimal-medial hyperplasia and subsequent stenosis leading to tissue ischemia. The skin, in part due to its large vascular bed, exposure to cold temperatures, and frequent presence of stasis, is involved in many distinct as well as un-named vasculitic syndromes that vary from localized and self-limited to generalized and life-threatening with multi-organ disease. To exclude mimics of vasculitis, diagnosis of cutaneous vasculitis requires biopsy confirmation where its acute signs (fibrinoid necrosis), chronic signs (endarteritis obliterans), or past signs (acellular scar of healed arteritis) must be recognized and presence of extravascular findings such as patterned fibrosis or collagenolytic granulomas noted. Although vasculitis can be classified by etiology, many cases have no identifiable cause, and a single etiologic agent can elicit several distinct clinicopathologic expressions of vasculitis. Therefore, the classification of cutaneous vasculitis is best approached morphologically by determining vessel size and principal inflammatory response. These histologic patterns roughly correlate with pathogenic mechanisms that, when coupled with direct immunofluorescent examination, anti-neutrophil cytoplasmic antibody (ANCA) status, and findings from work-up for systemic disease, allow for specific diagnosis, and ultimately, more effective therapy. Herein, we review cutaneous vasculitis focusing on diagnostic criteria, classification, epidemiology, etiology, pathogenesis, and evaluation of the cutaneous vasculitis patient.