Application of dermal regenerative template in reconstructing skin defects after plantar malignant melanoma excision

PURPOSE

The excision of plantar malignant melanoma frequently leads to wide skin defects on the plantar surface. This study aimed to investigate the advantages and feasibility of dermal regenerative template reconstructing plantar blemishes caused by malignant melanoma.

METHODS

28 patients identified with plantar malignant melanoma were included in this retrospective article. Eighteen patients received immediate skin grafts after wide excision skin graft (SG) group), whereas the remaining 10 patients were treated with dermal regenerative template (DRT) (Lando ®, Shenzhen TsingCare Medical Co. Ltd) 14 days before skin grafts (DRT group) and the postoperative survival rate in the two groups was analyzed. During the 6-month follow-up, we compared the scar index, plantar pain, and recurrent skin graft ulcer incidence on the skin grafts area.

RESULTS

Postoperative survival rate in the DRT group (91.75% ± 7.64%) was higher than in the SG group (80.51% ± 7.17%). The DRT group showed less scar formation on Vancouver scar scale (VSS index): 3.40 ± 1.07 than the SG group (VSS index: 6.33 ± 0.68). The dermal regenerative template alleviated plantar pain and decreased the incidence of ulcer on the skin grafts area.

CONCLUSIONS

The dermal regenerative template not only improves the survival rate of skin grafts but also alleviates scar condition, plantar pain and recurrent skin graft ulcer. This study provides a new reconstructive strategy in plantar skin defects after the excision of malignant melanoma.

Electrosurgical debulking of pretibial myxedema of the foot

Pretibial myxedema or thyroid dermopathy constitutes dermal deposition of mucin, primarily hyaluronic acid and chondroitin sulfate. It is a manifestation of autoimmune thyroiditis, seen more in Graves disease than in Hashimoto thyroiditis. The time delay from treatment of hyperthyroidism to appearance of localized myxedema varies from one month to 16 years (mean 5.13 years). Despite a variety of therapeutic options, failure and relapse rates are high. Therapeutic options reported in the literature include compression, topical and intralesional corticosteroids, oral pentoxifylline, octreotide, rituximab, plasmapheresis, and high-dose intravenous immunoglobulin. We share our experience in two patients who were treated with electrosurgical debulking of selected longstanding myxedematous lesions, with one positive result and one negative result.

A pedunculated lesion on the foot: acquired fibrokeratoma

Acquired fibrokeratomas are benign and uncommon lesions consisting of collagenous papules and nodules covered by hyperkeratotic epidermis. These tumors occur mainly on the fingers and toes and infrequently on the palms and soles. They may possibly be triggered by a reaction to a trauma and presents as small and solitary dome-shaped lesions with a collarete of slightly raised skin at the base. Several case reports have been published of this rare lesion, with only a few investigators describing lesions of the feet.

[Contribution of histopathology in the diagnosis of mycetoma in a Cameroonian trader and possibility of an urban contamination]

BACKGROUND

Mycetoma are rare cutaneous affections caused by pathogens such as fungi or bacteria. They settle preferentially on limb extremities. We are going to talk about an original case of mycetoma in a young Cameroonian trader.

OBSERVATION

A cutaneous mass with multiple draining sinuses was received at the anatomy and cytopathology laboratory. That mass was from a 30-year-old male trader, with no particular medical history and living in Yaounde, who was received for a lesion at the sole of the foot, which appeared some months before. This lesion started like a tough and painless nodule, which later showed draining sinuses to the skin. The surgical resection of the tissue mass was performed. The histopathological analysis with special staining procedures, which was later on performed, revealed mycetoma caused by fungi.

DISCUSSION

This observation describes an original case of fungal mycetoma, which occured in a Cameroonian trader living in an urban milieu away from any mycetoma endemic zone. This case confirms the undeniable or undisputable contribution of histopathology in diagnosis of certainty. To our knowledge and according to available data, it is a premiere to find a case of mycetoma described in an urban milieu in Cameroon.

[Mycetoma of the foot: a case report]

Mycetoma is a chronic inflammatory cutaneous and subcutaneous pathology caused by either a fongic (eumycetoma) or bacterial (actinomycetoma) infection, which lead to a granulomatous tumefaction with multiple sinuses. When localized in the foot this infection is named "Madura foot". This infection is endemic to tropical and subtropical regions and rarely occurs in western countries. A historical case in Europe of a foot mycetoma evolving since 20 years without any treatment is presented. A histopathologic diagnosis of actinomycetoma has been done in 1987. The patient presented a severe Staphylococcus aureus chronic osteitis leading to a trans-tibial amputation. This case allows to present this infection which, even if rarely presented in France, can be meet especially among a migrant's population.

Severe plantar hyperhidrosis: an effective surgical solution

Severe palmoplantar hyperhidrosis both affects activities of daily living and diminishes quality of life. This study evaluated overall safety and efficacy of endoscopic lumbar sympathectomy (ELS) using a clamping method in a large series of consecutive patients. Patient data were routinely entered into a prospectively designed database. Plantar sweating was graded as cured, improved, or unchanged. ELS (using 5-mm titanium clips) was performed in 154 patients, 68.2 per cent at the third lumbar vertebrae and 31.8 per cent at the fourth lumbar vertebrae. Follow-up averaged 15 months and ranged up to 4.7 years. Anhidrosis was achieved in 97.4 per cent of patients with the remainder reporting major reduction in symptoms. All patients were discharged home within 24 hours of surgery, requiring only oral analgesics, if any. There were two surgical complications (lymphatic leak and misidentification of genitofemoral nerve for sympathetic nerve). Six early patients required conversion to an open surgical procedure. Partial recurrence, usually mild, occurred in 4.5 per cent with 2.6 per cent requiring revision surgery. Severe plantar hyperhidrosis can be safely and effectively treated by endoscopic lumbar sympathectomy using the clamping method. It can be accomplished on an outpatient basis with low morbidity, complete resolution of symptoms, and a significant improvement in quality of life.

Management of mycetomas in France

OBJECTIVE OF THE STUDY

Mycetomas are chronic sub-cutaneous tropical infections in which exogenous causative agents, fungal (eumycetes) or bacterial (actinomycetes), generate grains. The typical presentation is multi-fistulized pseudotumors. This disease, particularly eumycetoma, is difficult to treat. It is a major health problem in tropical and subtropical countries. In France, the disease is rare, but patients have access to a broader range of treatments. The authors had for objective to present the cases of mycetomas diagnosed in developed country and their management.

PATIENTS AND METHODS

A retrospective study was made on the clinical presentation and management of mycetomas from 1995 to 2011, in the Bobigny Avicenne teaching hospital.

RESULTS

Six patient files were studied. The patients were men with a median age of 31 years (16-70). Five patients were from Sub Saharan Africa, one from Sri Lanka. The etiologies were one actinomycetoma and five eumycetomas. There was bone involvement in five cases. There was one atypical presentation: a primary intra-osseous mycetoma. Three patients were cured including two by surgical management and one by medical treatment (actinomycetoma). Antifungal therapy failed (four patients) in every case (voriconazole, itraconazole, ketoconazole, terbinafine, caspofungin).

CONCLUSION

The results of this study made in a non-epidemic zone revealed that despite a typical clinical presentation, the diagnosis and management were delayed because this imported disease is rare in France. The patients received new broad-spectrum triazole and caspofungin, but none were cured with antifungal therapy alone.

Punch grafting of chronic ulcers in patients with laminin-332-deficient, non-Herlitz junctional epidermolysis bullosa

BACKGROUND

Epidermolysis bullosa (EB) is a genetic, heterogeneous, trauma-induced blistering disease. Patients with laminin-332-deficient non-Herlitz junctional EB (JEB-nH) can have impaired wound healing witnessed by persistent, small, deep ulcers on the hands and feet that adversely affect the quality of life.

OBJECTIVE

We sought to present the results of punch grafting in patients with laminin-332-deficient JEB-nH, and to discuss its therapeutic value.

METHODS

Retrospective analysis of the Dutch EB Registry revealed 4 patients with laminin-332-deficient JEB-nH who were treated with punch grafting. Punch grafting was performed according to protocol, and the patients were followed up.

RESULTS

In the past 10 years we have treated 23 ulcers in 4 patients with JEB-nH using punch grafting without any complications or adverse effects. The ulcers had on average persisted 6 years before treatment. Healing rate after punch grafting was 70% (n = 16), with a mean healing time of 2 months. Thirty percent (n = 7) of the treated ulcers did not completely heal, but did show improvement. The recurrence rate after 3 months was 13% (n = 2), and was a result of renewed blistering.

LIMITATIONS

Limitations of the study are the retrospective design, small number of patients, absence of a control group, and follow-up and ulcer measurement that were not standardized.

CONCLUSIONS

Punch grafting can be used as a first-line treatment in small persistent ulcers in patients with JEB-nH. The method is easy, is inexpensive, has little risk of complications, and results in significant healing rates and improvement in quality of life.

Treating onychomycoses of the toenail: clinical efficacy of the sub-millisecond 1,064 nm Nd: YAG laser using a 5 mm spot diameter

BACKGROUND

Onychomycosis is a relatively common fungal infection. Current treatments have limited applicability and low cure rates. Recently introduced laser therapy has shown to be a safe and effective treatment for onychomycosis. In this study, we evaluate a submillisecond Nd:YAG 1,064 nm laser for treating onychomycoses of the tonail.

METHODS

Thirteen subjects (9 female, 4 male) with 37 affected toenails received 1 to 3 treatments 4 and/or 8 weeks apart with a sub-millisecond 1,064 nm Nd:YAG laser. Diagnosis of onychomycosis was confirmed with microscopy. Average follow-up time was 16 weeks post-final treatment. Photos were taken and degree of turbidity was determined using a turbidity scale (ranging from "0 = clear nail" to "10 = completely turbid nail") at each visit. Improvement in turbidity was determined by comparison of turbidity scores at baseline and 16-week follow-up on average. Efficacy was assessed by an overall improvement scale (0 to 4), which combined improvement in turbidity scores and microscopic examination. Overall improvement was classified as "4 = complete clearance" if the turbidity score indicated "0 = clear nail" accompanied by a negative microscopic result. No microscopic examination was performed unless the turbidity score showed "0 = clear nail."

RESULTS

Treatments were well tolerated by all subjects and there were no adverse events. Of the 37 toenails treated, 30 (81%) had "moderate" to "complete" clearance average of 16 weeks post-final treatment. Nineteen toenails (51%) were completely clear and all tested negative for fungal infection on direct microscopic analysis. Seven (19%) toenails had significant clearance and four (11%) had moderate clearance.

CONCLUSIONS

The preliminary results of this study show this treatment modality is safe and effective for the treatment of onychomycosis in the short term. Additional studies are needed to more fully assess the clinical and mycological benefits as well as optimize the treatment protocol and parameters.

Endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis: outcomes and complications during a 10-year period

OBJECTIVE

To review surgical results of endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis during the past decade.

PATIENTS AND METHODS

We retrospectively reviewed 155 consecutive patients who underwent surgery from June 30, 2000, through December 31, 2009, for medically refractory palmar-plantar hyperhidrosis using a technique of T1-T2 sympathotomy disconnection, designed for successful palmar response and minimization of complications.

RESULTS

Of the 155 patients, 44 (28.4%) were male, and 111 (71.6%) were female; operative times averaged 38 minutes. No patient experienced Horner syndrome, intercostal neuralgia, or pneumothorax. The only surgical complication was hemothorax in 2 patients (1.3%); in 1 patient, it occurred immediately postoperatively and in the other patient, 10 days postoperatively; treatment in both patients was successful. All 155 patients had successful (warm and dry) palmar responses at discharge. Long-term follow-up (>3 months; mean, 40.2 months) was obtained for 148 patients (95.5%) with the following responses to surgery: 96.6% of patients experienced successful control of palmar sweating; 69.2% of patients experienced decreased axillary sweating; and 39.8% of patients experienced decreased plantar sweating. At follow-up, 5 patients had palmar sweating (3 patients, <3 months; 1 patient, 10-12 months; 1 patient, 16-18 months). Compensatory hyperhidrosis did not occur in 47 patients (31.7%); it was mild in 92 patients (62.2%), moderate in 7 patients (4.7%), and severe in 2 patients (1.3%).

CONCLUSION

In this series, a small-diameter uniportal approach has eliminated intercostal neuralgia. Selecting a T1-T2 sympathotomy yields an excellent palmar response, with a very low severe compensatory hyperhidrosis complication rate. The low failure rate was noted during 18 months of follow-up and suggests that longer follow-up is necessary in these patients.

Acquired fibrokeratoma presenting as multiple plantar nodules

Acquired digital fibrokeratoma is a rare benign fibroepithelial tumor that typically presents as a solitary asymptomatic nodule on the finger or toe. Middle-aged adults are most commonly affected. Here we discuss an unusual case of acquired digital fibrokeratoma presenting as a cluster of multiple nodules on the sole of a 15-year-old boy.

The impact of aggressive debridement used as an adjunct therapy with terbinafine on perceptions of patients undergoing treatment for toenail onychomycosis

OBJECTIVE

To determine whether adding aggressive debridement to oral terbinafine for treating toenail onychomycosis impacts patient-reported outcomes (PROs).

MATERIALS AND METHODS

A total of 504 patients were randomized to receive 12 weeks of terbinafine 250 mg/day with or without debridement, with an additional 36-week follow-up. The OnyCOE-t, a validated disease-specific PRO questionnaire, was completed at baseline and weeks 6, 12, 24, and 48. It included six multi-item scales (symptom frequency, appearance problems, physical activities problems, stigma, and treatment satisfaction), and one single-item scale: overall problem. Longitudinal analysis of change was conducted to assess treatment effect. Repeated-measures models adjusted for visit, age, sex, baseline scores, severity and duration of infection; treatment interactions were also tested.

RESULTS

Symptom frequency and treatment satisfaction significantly improved in the terbinafine + debridement group compared with terbinafine alone (p = 0.0395 and p = 0.0077, respectively). Age and sex were often significant explanatory variables, and further analysis of change scores at 12 weeks revealed that females treated with terbinafine + debridement reported significantly less improvement in the physical activities problems (p = 0.0021) and overall problem (p = 0.0112) scores.

CONCLUSIONS

Aggressive debridement, when used as an adjunct therapy with oral terbinafine, improved treatment satisfaction and reduced symptom frequency. The observed sex differences warrant further investigation.

Sonography of plantar warts: role in diagnosis and treatment

OBJECTIVE

The purpose of this presentation is to show the sonographic morphologic characteristics of plantar warts and the scope of sonography in the treatment of these lesions.

METHODS

We retrospectively reviewed 27 sonographic examinations of the plantar region; 17 corresponded to plantar warts diagnosed by dermatologists in which the diagnoses were medically derived from sonographic examinations after failure of their treatments. The remaining group consisted of 10 healthy individuals. Sonograms were compared with standard histologic findings.

RESULTS

The sonographic features of normal plantar skin and plantar warts are described, including the shape, echogenicity, pattern of growth, involvement of skin layers, and blood flow in the lesions.

CONCLUSIONS

Sonography may be considered as reliable support for plantar wart diagnosis and may have a role in the evaluation of plantar wart treatment modalities, allowing monitoring of therapeutic responses, especially in recurrent and difficult cases with persistent symptoms such as pain.

Amelanotic malignant melanoma in an acral location

We present the case of a 74-year-old white female admitted to the Department of Dermatology because of a tumor in the IV-V interdigital area of her right foot. A crimson, dome-shaped tumor with a granular, spongy surface (diameter 4 cm) had developed over a period of about 3 months. The biopsy, stained with H and E, revealed an anaplastic malignant tumor. Additional immunochemical staining with Melan A allowed us to make the final diagnosis: amelanotic malignant melanoma (MM). The melanoma was removed by amputation of digits IV and V, with partial removal of the metatarsal bones (Clark degree 5, Breslow thickness 9 mm). Sentinel node biopsy was done using Tc99; it revealed no neoplastic alteration. The patient is still under oncological observation.

Eruptive acral lentigines--a new paraneoplastic sign?

Cutaneous signs may be the first indications of an internal disease. Any definitive sign of a neoplastic disease is of special importance since early diagnosis and early treatment may make a telling difference in improving prognosis. Presented is a 68-year-old patient with advanced stage melanoma that was associated with the appearance of multiple acral lentigines. The exact time-course of onset of the lentigines in relation to the formation of the melanoma could not be established. However, from the information we could take out of our patient, it is clear that the lentigines had appeared either shortly before or after the appearance of the melanoma. In conclusion we suggest that the present case represents a new paraneoplastic sign.

Geometric analysis of the Weil osteotomy

BACKGROUND

The Weil osteotomy has been reported to be a clinically effective treatment of metatarsalgia and intractable plantar keratosis. The plantar inclination of the metatarsal influences the effect of the osteotomy but has never been studied in detail.

METHODS

This study examined five fresh or fresh-frozen cadaver specimens. The data obtained from the specimens was used to model the geometry of the Weil osteotomy. The effect of thick saw blades on the Weil osteotomy was determined.

RESULTS

The inclination of the second metatarsal averaged 24.6 (range 19 to 31) degrees. The displacement of the capital fragment in the plantar direction was dependent on the angle of the osteotomy and the inclination of the metatarsal. A 5-mm proximal displacement along a 25-degree osteotomy displaced the capital fragment in a plantar direction if the inclination of the metatarsal was 19 degrees and displaced it dorsally if the inclination was 25 degrees or more.

CONCLUSIONS

The results of this study showed that a thick saw blade could offset a portion of the plantar displacement of the capital segment that can occur with the Weil osteotomy. A 1-mm thick saw blade is recommended for most osteotomies, and a 2-mm thick saw blade is recommended for shortening of more than 5 mm or with plantar inclination of the lesser metatarsal of less than 19 degrees. A thicker saw blade should be considered for the treatment of plantar keratosis.

Subcutaneous hyalohyphomycosis due to Cephalotheca foveolata in an immunocompetent host

We report the first case of subcutaneous hyalohyphomycosis caused by the genus Cephalotheca, which has not been reported to cause human infection. A 67-year-old immunocompetent farmer presented with a 10-year history of verrucous erythematous plaques on the right foot dorsum, great toe, heel and sole. Histopathology of the lesions revealed chronic granulomatous inflammation with numerous nonpigmented fungal spores in the dermis. Cultures of biopsy specimens on Sabouraud's dextrose agar for 2 weeks developed into yellowish brown, velvety colonies that subsequently turned black after 8 weeks because of the production of black cleistothecia indicating the teleomorph. On the basis of mycological features, scanning electron microscopic morphology and molecular analysis data, a new species of Cephalotheca was identified and designated Cephalotheca foveolata. Because there was no response to the antifungal agents administered, the patient was successfully treated by surgical excision with skin graft.

[Clinical and microbiological study of mycetomas at the Muñiz hospital of Buenos Aires between 1989 and 2004]

This work presents clinical, microbiological and outcome data collected from 76 patients with mycetomas at the Muñiz Hospital from 1989 to 2004. Forty-nine patients were male and 27 female; the mean age was 43.4 years. The majority of the patients acquired the infection in Argentina: the most affected provinces were Santiago del Estero with 31 cases, and Chaco with 11; 8 cases came from other countries (Bolivia 6 and Paraguay 2). The mean evolution of the disease was 9.2 years. The most frequently observed sites were: feet 63 cases, ankles 3, and knees 2. Forty-eight patients had bone lesions and 5, adenomegalies. The following etiological agents were identified: Madurella grisea 29 cases, Actinomadura madurae 26, Scedosporium apiospermum 5, Nocardia brasiliensis 5, Acremonium spp. 4 (Acremonium falciforme 2, Acremonium kiliense 1, Acremonium recifei 1), Madurella mycetomatis 3, Fusarium solani 2, Nocardia asteroides 1 and Streptomyces somaliensis 1. The main drugs used in the treatments were ketoconazole and itraconazole for maduromycotic mycetomas, and cotrimoxazole associated with ciprofloxacin or amikacin for actinomycetic mycetoma. Six patients had to undergo amputation, 25 cases achieved complete clinical remission and 34 showed remarkable improvement.

Treatment of digital myxoid cysts with infrared coagulation: a retrospective case series

BACKGROUND

Digital myxoid cysts (DMC) are often unsightly; they may cause nail dystrophy and are sometimes painful. There is a multitude of existing therapies and recurrences are not uncommon; some treatments may be painful or result in scarring. Infrared coagulation (IRC) produces predictable thermal injury with relative sparing of superficial tissues and represents an alternative treatment modality in DMC.

OBJECTIVES

To assess the outcome of treatment of DMC with IRC.

METHODS

Twenty-two patients with DMC treated with IRC were identified retrospectively (23 DMC: 18 finger and five toe). IRC was delivered to the area of the cyst under local anaesthesia.

RESULTS

Of the 23 lesions treated with IRC 86% responded; these included 73% that resolved after a single treatment, one lesion that relapsed after 3 years, one lesion that was reduced in size and one lesion that required three treatments over 18 months but has not recurred over the subsequent 9 years. There were three early recurrences that required treatment with other modalities: two were successfully treated with surgery and one responded to a single treatment with cryotherapy. One patient was excluded from the analysis because it was not possible to assess her adequately.

CONCLUSIONS

We present long-term follow-up data (mean follow-up 4.8 years, range 10 months-10.5 years) of the treatment of DMC with IRC. Treatment was well tolerated, with few side-effects, and cosmetic outcome was excellent. While recurrence rates were similar to many existing therapies, the ease of delivery, tolerability and cosmetic results make IRC a favourable option for the treatment of DMC.

[Successful treatment of a case of extense verrucous chromoblastomychosis with surgical exeresis associated with the use of ketoconazole]

The case of a 56-year-old man with an extense verrucous chromoblastomycosis of long evolution, with lesions in the right foot that had not been cured with previous treatment, and that was successfully treated by surgical exeresis of all the lesions together with oral ketoconazole, is presented. Literature was reviewed to conclude that the treatment of chromoblastomycosis is still a challenge and that it should be selected for each case in particular.

The treatment of common warts with infrared coagulation

Treatment of warts can involve medical and surgical methods. Infrared coagulation is a surgical method very rarely used in the treatment of warts. We planned an open-labeled prospective study to research the effect of infrared coagulation in the treatment of common warts, comparing it with electrocoagulation, and discussing its applicability as an alternative therapy regimen. Eighteen patients with common warts were included in this study. There were 49 warts of various sizes (1 mm to 1 cm) in these 18 patients. Twenty-seven warts were treated with infrared coagulation, and 22 warts were treated with electrocoagulation. Sixteen patients were treated with both infrared coagulation and electrocoagulation; two patients were treated with only infrared coagulation. The patients were followed-up for six months after treatment. Changes in sizes of warts, healing times, and cure rates were compared by Mann-Whitney U test. The mean healing time was 35.5 +/- 5.7 days with infrared coagulation and 32.9 +/- 4.0 days with electrocoagulation. There was not any significant difference between healing times (p > 0.05). Bacterial infection was seen on seven (31.8%) warts treated with electrocoagulation, but no side effects were seen with infrared coagulation. There was a significant difference between side effect rates in two groups (p < 0.01). Nine (33.3%) of the warts treated with infrared coagulation and seven (31.8%) of the warts treated with electrocoagulation recurred in the six-month follow-up period. The overall cure rates at the end of the follow-up period were 66.7% and 68.2% respectively. There was not any significant difference between the cure rates in the two groups (P > 0.05). We conclude that infrared coagulation is a safe and cheap method and should be kept in mind as an alternative modality for the treatment of common warts.

A clinical trial to assess the use of sodium hypochlorite and oxytetracycline on the healing of digital dermatitis lesions in cattle

The increased frequency of diseases, especially those of the hoof, cause economic losses, such as premature culling of affected animals, decreased milk production, weight loss, reduced fertility, and the high costs of treatment. A great variety of hoof conditions may affect cattle, one of them is digital dermatitis. These conditions are probably due to multiple factorial diseases and present with similar clinical signs. Bovine lameness is typically treated by foot trimming and debridment of the lesions, coupled when necessary with systemic antibiotics and therapeutic footbaths, which results in a clinical cure in the majority of the cases. The objective of this study was to evaluate the topical action of sodium hypochlorite associated with the systemic use of oxytetracycline for the treatment of wounds clinically diagnosed as bovine digital dermatitis. One hundred and twenty Holstein cattle varying ages from 1 to 9 y and presenting the clinical signs of digital dermatitis, were used in this study. Group 1 (G1) received topical treatment with a 1% sodium hypochlorite footbath twice a day for 30 d and 4 treatments of parenteral oxytetracycline (10 mg/kg bodyweight, IM, q48h). Group 2 (G2) received only the topical treatment with 1% sodium hypochlorite, as described for G1. Group 3 (G3) received only with parenteral oxytetracycline, as described for G1. Group 4 (G4) was treated exclusively with a dicloro divynil pirrolidona, ortoiododimetil, para-nitofenil-fosforotioato in a vegetal tar-based ointment, immediately after the surgery. After 45 d, the recovery rates were as follows: G1, 86.67%; G2, 73.33%; G3, 56.67%; and G4, 50%. The surgical treatment of digital dermatitis with subsequent treatment with oxytetracycline systemically and 1% sodium hypochlorite topically was the most effective for the convalescence of cattle bearing wounds similar to digital dermatitis.

Debridement of plantar callosities in rheumatoid arthritis: a randomized controlled trial

OBJECTIVE

To compare forefoot pain, pressure and function before and after normal and sham callus treatment in rheumatoid arthritis (RA).

PATIENTS AND METHODS

Thirty-eight RA patients were randomly assigned to normal (NCT group) or sham (SCT) scalpel debridement. The sham procedure comprised blunt-edged scalpel paring of the callus which delivered a physical stimulus but left the hyperkeratotic tissue intact, the procedure being partially obscured from the patient. Forefoot pain was assessed using a 100 mm visual analogue scale (VAS), pressure using a high-resolution foot pressure scanner and function using the spatial-temporal gait parameters measured on an instrumented walkway. Radiographic scores of joint erosion were obtained for metatarsophalangeal (MTP) joints with and without overlying callosities. The trial consisted of a randomized sham-controlled phase evaluating the immediate same-day treatment effect and an unblinded 4-week follow-up phase.

RESULTS

During the sham-controlled phase, forefoot pain improved in both groups by only 3 points on a VAS and no statistically significant between-group difference was found (P = 0.48). When data were pooled during the unblinded phase, the improvement in forefoot pain reached a peak after 2 days and gradually lessened over the next 28 days. Following debridement, peak pressures at the callus sites decreased in the NCT group and increased in the SCT group, but there was no statistically significant between-group difference (P = 0.16). The area of and duration of contact of the callus site on the ground remained unchanged following treatment in both groups. Following debridement, walking speed was increased, the stride-length was longer and the double-support time shorter in both groups; however, between-group differences did not reach levels of statistical significance. MTP joints with overlying callus were significantly more eroded than those without (P = 0.02).

CONCLUSIONS

Treatment of painful plantar callosities in RA using scalpel debridement lessened forefoot pain but the effect was no greater than sham treatment. Localized pressure or gait function was not significantly improved following treatment.

Keratotic disorders of the plantar skin

Keratotic lesions on the plantar aspect of the foot develop beneath an osseous prominence and can result in substantial disability. This occurs because, during normal gait, the metatarsal head area is subjected to more prolonged stress than any other area on the plantar aspect of the foot. In the treatment of this disorder, it is imperative to establish the etiology, among many possibilities, and then address the specific pathology accordingly.

Giant right plantar keloid treated with excision and tissue-engineered allograft

Plantar keloids are a management problem as a result of the pain and mechanic restriction with ambulation. We present the treatment of a patient with a particularly large plantar keloid that was refractory to multiple excisions, adjunctive intralesional steroids, and radiation therapy, who was successfully treated with excision, intralesional steroids, and tissue-engineered allograft placement.

Osteotomies of the fifth metatarsal

Although the literature is limited primarily to retrospective small case series of the operative technique of fifth metatarsal osteotomies with a short follow-up, some important information can be learned. Stabilization of the osteotomy with Kirschner wire fixation appears to decrease dorsal displacement of the distal fragment and distal osteotomies; this leads to decreased incidence of transfer metatarsalgia. Kirschner wire fixation is advocated. The proximal chevron osteotomy of the fifth metatarsal, although stable, has a 20% delayed union rate, most likely resulting from the unique vascular anatomy in this region. The radiographic and clinical results appear to be compatible between distal and proximal osteotomies. Based on this information, primary use of a proximal osteotomy technique is not recommended. The oblique diaphyseal osteotomy technique requires an incision for the osteotomy as well as a distal incision at the metatarsophalangeal joint for correction of this joint. Hardware removal was performed in most patients, and the complications included two cases of delayed union. Time to healing was reported to be 8 weeks, 1.5 times the reported time to healing in distal chevron osteotomies. A significant radiographic correction was noted with the oblique diaphyseal osteotomy; however, radiographic measurements can be altered with foot position and lack of x-ray standardization and technique. Kitaoka et al found no correlation with the degree of radiographic correction and post-operative clinical symptoms. The authors agree with Kitaoka et al that the oblique diaphyseal osteotomy should be reserved for patients who fail an initial distal osteotomy technique. Distal oblique osteotomies appear to have less stability and more complications with malunion, transfer metatarsalgia, and delayed union and should be abandoned for a more stable chevron technique. The distal chevron osteotomy has a small incidence of transfer metatarsalgia; however, it appears to improve the clinical radiographic appearance of [table: see text] the foot with a shortened time to healing (4 to 6 weeks). A biplanar technique can be employed with a distal chevron osteotomy to improve plantar callosity symptoms. More studies are needed to examine critically patient outcomes with uniplanar and biplanar techniques using the distal chevron osteotomy.

Onychogryphosis in elderly persons: an indicator of long-standing poor nursing care? Report of one case and review of the literature

A 92-year-old immobilized white woman under the daily nursing care of a private ambulatory nursing service displayed acquired deformities of the toenails resembling a ram's horn. In light of a rapidly growing elderly population, this case report illustrates the need for close monitoring of the quality of care that nursing services provide to older persons. In addition, it reviews the clinical aspects of onychogryphosis, as well as its pathomechanisms and treatment options.

Liquid nitrogen cryotherapy of common warts: cryo-spray vs. cotton wool bud

BACKGROUND

Viral warts represent a large workload for dermatology departments. Cryotherapy with liquid nitrogen is the most widely used method of treatment by dermatologists and is increasingly used by general practitioners in the U.K. Existing data relating to the response to cryotherapy are virtually all derived from the use of a cotton wool bud as the applicator. There is an increasing trend to use the cryo-spray to freeze warts and it has been assumed that this is equally effective. In view of the workload involved it is important to test this assumption.

OBJECTIVES

This prospective study was undertaken to compare these two methods of liquid nitrogen cryotherapy with regards to cure rate after 3 months of treatment.

METHODS

Patients referred to two hospital dermatology departments with hand or foot warts were allocated to have liquid nitrogen applied with either a cryo-spray or with a cotton wool bud. Using either technique, liquid nitrogen was applied until ice-ball formation had spread from the centre to include a margin of 2 mm around each wart. Treatment was done fortnightly for up to 3 months. Plantar warts were pared and treated with a double freeze-thaw cycle. The endpoint of the study was complete clearance of all warts.

RESULTS

Three hundred and sixty-three patients were enrolled, mean age 21 years (range 3-75), 188 male and 175 female. The mean duration of the warts was 98 weeks (median 78, range 2-936). The number of warts on the hands and feet varied from one to 80 (mean 5). The treatment groups were comparable with regards to baseline demographics. Two hundred and seven patients were evaluable. Cure rates at 3 months were 47% in the cotton wool bud group and 44% in the cryo-spray group (P = 0.8). Warts that had been present for 6 months or less (n = 31) had a greater chance of clearance (84%) compared with warts that had been present for more than 6 months (39%, n = 176) (P < 0.0005).

CONCLUSIONS

Cryotherapy with liquid nitrogen for hand and foot warts in our study was equally effective when applied with a cotton wool bud or by means of a spray.

Isolation of both Sporothrix schenckii and Nocardia asteroides from a mycetoma of the forefoot

Mycetoma is a localized primary subcutaneous infection due to fungi (eumycetoma) or aerobic actinomycetes (actinomycetoma). We report a patient who acquired an implantation infection on the forefoot following a motorcycle accident in Crete. Both Sporothrix schenckii and Nocardia asteroides were isolated simultaneously from the lesion. Under combined therapy with itraconazole and trimethoprim-sulphamethoxazole for 7 months the lesion healed completely. A combination of causative organisms in mycetomas is rare, and the combination of S. schenckii and N. asteroides together has not been reported from one lesion.