Clinical Pearl: Topical Timolol for Refractory Hypergranulation

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Clinical Pearl: Topical Timolol for Refractory Hypergranulation

 

Practice Gap

Hypergranulation is a frequent complication of dermatologic surgery, especially when surgical defects are left to heal by secondary intention (eg, after electrodesiccation and curettage). Although management of postoperative hypergranulation with routine wound care, superpotent topical corticosteroids, and/or topical silver nitrate often is effective, refractory cases pose a difficult challenge given the paucity of treatment options. Effective management of these cases is important because hypergranulation can delay wound healing, cause patient discomfort, and lead to poor wound cosmesis.

The Technique

If refractory hypergranulation fails to respond to treatment with routine wound care and topical silver nitrate, we prescribe twice-daily application of timolol maleate ophthalmic gel forming solution 0.5% for up to 14 days or until complete resolution of the hypergranulation is achieved. We counsel patients to continue routine wound care with daily dressing changes in conjunction with topical timolol application.

We initiated treatment with topical timolol in a patient who developed hypergranulation at 2 separate electrodesiccation and curettage sites that was refractory to 6 weeks of routine wound care with white petrolatum under nonadherent sterile gauze dressings and 2 subsequent topical silver nitrate applications (Figure 1). After 2 weeks of treatment with topical timolol, resolution of the hypergranulation and re-epithelialization of the surgical sites was observed (Figure 2). Another patient presented with hypergranulation that developed following a traumatic injury on the left upper arm and had been treated unsuccessfully for several months at a wound care clinic with daily nonadherent sterile gauze dressings and both topical and oral antibiotics (Figure 3A). After treatment for 9 days with topical timolol, resolution of the hypergranulation and re-epithelialization of the surgical sites was observed (Figure 3B).

Figure 1. A and B, Electrodesiccation and curettage sites on the left side of the upper back and left forearm with hypergranulation that was refractory to routine wound care and topical silver nitrate application.

Figure 2. A and B, Re-epithelialized electrodesiccation and curettage sites on the left side of the upper back and left forearm following twice-daily treatment with timolol ophthalmic gel forming solution for 2 weeks.

Figure 3. A, Traumatic injury of the left upper arm complicated by hypergranulation. B, Re-epithelialized wound on the left upper arm following twice-daily treatment with timolol ophthalmic gel forming solution for 9 days.

Practice Implications

Beta-blockers are increasingly being used for management of chronic nonhealing wounds since the 1990s when oral administration of propranolol initially was reported to be an effective adjuvant therapy for managing severe burns.1 Since then, topical beta-blockers have been reported to be effective for management of ulcerated hemangiomas, venous stasis ulcers, chronic diabetic ulcers, and chronic nonhealing surgical wounds; however, there are no known reports of using topical beta-blockers for management of hypergranulation.2-5 We found timolol ophthalmic gel to be an excellent second-line therapy for management of postoperative hypergranulation if prior treatment with routine wound care and superpotent topical corticosteroids has failed. To date, we have found no reported adverse effects from the use of topical timolol for this indication that have required discontinuation of the medication. Use of this simple and safe intervention can be effective as a solution to a common postoperative condition.

References
  1. Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. 2001;345:1223-1229.
  2. Pope E, Chakkittakandiyil A. Topical timolol gel for infantile hemangiomas: a pilot study. Arch Dermatol. 2010;146:564-565.
  3. Braun L, Lamel S, Richmond N, et al. Topical timolol for recalcitrant wounds. JAMA Dermatol. 2013;149:1400-1402.
  4. Thomas B, Kurien J, Jose T, et al. Topical timolol promotes healing of chronic leg ulcer. J Vasc Surg. 2017;5:844-850.
  5. Tang J, Dosal J, Kirsner RS. Topical timolol for a refractory wound. Dermatol Surg. 2012;38:135-138.
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From the Dermatology Department, University of Connecticut Health Center, Farmington.

The authors report no conflict of interest.

Correspondence: Brett Sloan, MD, UConn Health Dermatology Department, 21 South Rd, Farmington, CT 06032 (steven.sloan@va.gov).

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From the Dermatology Department, University of Connecticut Health Center, Farmington.

The authors report no conflict of interest.

Correspondence: Brett Sloan, MD, UConn Health Dermatology Department, 21 South Rd, Farmington, CT 06032 (steven.sloan@va.gov).

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From the Dermatology Department, University of Connecticut Health Center, Farmington.

The authors report no conflict of interest.

Correspondence: Brett Sloan, MD, UConn Health Dermatology Department, 21 South Rd, Farmington, CT 06032 (steven.sloan@va.gov).

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Practice Gap

Hypergranulation is a frequent complication of dermatologic surgery, especially when surgical defects are left to heal by secondary intention (eg, after electrodesiccation and curettage). Although management of postoperative hypergranulation with routine wound care, superpotent topical corticosteroids, and/or topical silver nitrate often is effective, refractory cases pose a difficult challenge given the paucity of treatment options. Effective management of these cases is important because hypergranulation can delay wound healing, cause patient discomfort, and lead to poor wound cosmesis.

The Technique

If refractory hypergranulation fails to respond to treatment with routine wound care and topical silver nitrate, we prescribe twice-daily application of timolol maleate ophthalmic gel forming solution 0.5% for up to 14 days or until complete resolution of the hypergranulation is achieved. We counsel patients to continue routine wound care with daily dressing changes in conjunction with topical timolol application.

We initiated treatment with topical timolol in a patient who developed hypergranulation at 2 separate electrodesiccation and curettage sites that was refractory to 6 weeks of routine wound care with white petrolatum under nonadherent sterile gauze dressings and 2 subsequent topical silver nitrate applications (Figure 1). After 2 weeks of treatment with topical timolol, resolution of the hypergranulation and re-epithelialization of the surgical sites was observed (Figure 2). Another patient presented with hypergranulation that developed following a traumatic injury on the left upper arm and had been treated unsuccessfully for several months at a wound care clinic with daily nonadherent sterile gauze dressings and both topical and oral antibiotics (Figure 3A). After treatment for 9 days with topical timolol, resolution of the hypergranulation and re-epithelialization of the surgical sites was observed (Figure 3B).

Figure 1. A and B, Electrodesiccation and curettage sites on the left side of the upper back and left forearm with hypergranulation that was refractory to routine wound care and topical silver nitrate application.

Figure 2. A and B, Re-epithelialized electrodesiccation and curettage sites on the left side of the upper back and left forearm following twice-daily treatment with timolol ophthalmic gel forming solution for 2 weeks.

Figure 3. A, Traumatic injury of the left upper arm complicated by hypergranulation. B, Re-epithelialized wound on the left upper arm following twice-daily treatment with timolol ophthalmic gel forming solution for 9 days.

Practice Implications

Beta-blockers are increasingly being used for management of chronic nonhealing wounds since the 1990s when oral administration of propranolol initially was reported to be an effective adjuvant therapy for managing severe burns.1 Since then, topical beta-blockers have been reported to be effective for management of ulcerated hemangiomas, venous stasis ulcers, chronic diabetic ulcers, and chronic nonhealing surgical wounds; however, there are no known reports of using topical beta-blockers for management of hypergranulation.2-5 We found timolol ophthalmic gel to be an excellent second-line therapy for management of postoperative hypergranulation if prior treatment with routine wound care and superpotent topical corticosteroids has failed. To date, we have found no reported adverse effects from the use of topical timolol for this indication that have required discontinuation of the medication. Use of this simple and safe intervention can be effective as a solution to a common postoperative condition.

 

Practice Gap

Hypergranulation is a frequent complication of dermatologic surgery, especially when surgical defects are left to heal by secondary intention (eg, after electrodesiccation and curettage). Although management of postoperative hypergranulation with routine wound care, superpotent topical corticosteroids, and/or topical silver nitrate often is effective, refractory cases pose a difficult challenge given the paucity of treatment options. Effective management of these cases is important because hypergranulation can delay wound healing, cause patient discomfort, and lead to poor wound cosmesis.

The Technique

If refractory hypergranulation fails to respond to treatment with routine wound care and topical silver nitrate, we prescribe twice-daily application of timolol maleate ophthalmic gel forming solution 0.5% for up to 14 days or until complete resolution of the hypergranulation is achieved. We counsel patients to continue routine wound care with daily dressing changes in conjunction with topical timolol application.

We initiated treatment with topical timolol in a patient who developed hypergranulation at 2 separate electrodesiccation and curettage sites that was refractory to 6 weeks of routine wound care with white petrolatum under nonadherent sterile gauze dressings and 2 subsequent topical silver nitrate applications (Figure 1). After 2 weeks of treatment with topical timolol, resolution of the hypergranulation and re-epithelialization of the surgical sites was observed (Figure 2). Another patient presented with hypergranulation that developed following a traumatic injury on the left upper arm and had been treated unsuccessfully for several months at a wound care clinic with daily nonadherent sterile gauze dressings and both topical and oral antibiotics (Figure 3A). After treatment for 9 days with topical timolol, resolution of the hypergranulation and re-epithelialization of the surgical sites was observed (Figure 3B).

Figure 1. A and B, Electrodesiccation and curettage sites on the left side of the upper back and left forearm with hypergranulation that was refractory to routine wound care and topical silver nitrate application.

Figure 2. A and B, Re-epithelialized electrodesiccation and curettage sites on the left side of the upper back and left forearm following twice-daily treatment with timolol ophthalmic gel forming solution for 2 weeks.

Figure 3. A, Traumatic injury of the left upper arm complicated by hypergranulation. B, Re-epithelialized wound on the left upper arm following twice-daily treatment with timolol ophthalmic gel forming solution for 9 days.

Practice Implications

Beta-blockers are increasingly being used for management of chronic nonhealing wounds since the 1990s when oral administration of propranolol initially was reported to be an effective adjuvant therapy for managing severe burns.1 Since then, topical beta-blockers have been reported to be effective for management of ulcerated hemangiomas, venous stasis ulcers, chronic diabetic ulcers, and chronic nonhealing surgical wounds; however, there are no known reports of using topical beta-blockers for management of hypergranulation.2-5 We found timolol ophthalmic gel to be an excellent second-line therapy for management of postoperative hypergranulation if prior treatment with routine wound care and superpotent topical corticosteroids has failed. To date, we have found no reported adverse effects from the use of topical timolol for this indication that have required discontinuation of the medication. Use of this simple and safe intervention can be effective as a solution to a common postoperative condition.

References
  1. Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. 2001;345:1223-1229.
  2. Pope E, Chakkittakandiyil A. Topical timolol gel for infantile hemangiomas: a pilot study. Arch Dermatol. 2010;146:564-565.
  3. Braun L, Lamel S, Richmond N, et al. Topical timolol for recalcitrant wounds. JAMA Dermatol. 2013;149:1400-1402.
  4. Thomas B, Kurien J, Jose T, et al. Topical timolol promotes healing of chronic leg ulcer. J Vasc Surg. 2017;5:844-850.
  5. Tang J, Dosal J, Kirsner RS. Topical timolol for a refractory wound. Dermatol Surg. 2012;38:135-138.
References
  1. Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. 2001;345:1223-1229.
  2. Pope E, Chakkittakandiyil A. Topical timolol gel for infantile hemangiomas: a pilot study. Arch Dermatol. 2010;146:564-565.
  3. Braun L, Lamel S, Richmond N, et al. Topical timolol for recalcitrant wounds. JAMA Dermatol. 2013;149:1400-1402.
  4. Thomas B, Kurien J, Jose T, et al. Topical timolol promotes healing of chronic leg ulcer. J Vasc Surg. 2017;5:844-850.
  5. Tang J, Dosal J, Kirsner RS. Topical timolol for a refractory wound. Dermatol Surg. 2012;38:135-138.
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Solitary Nodule on the Proximal Nail Fold

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Solitary Nodule on the Proximal Nail Fold

The Diagnosis: Superficial Acral Fibromyxoma

A shave biopsy revealed an uninvolved grenz zone and mildly cellular spindle cell dermal proliferation in a collagenous and myxoid background (Figure 1). Spindle cells were seen in a myxoid background among dense coarse collagen (Figure 2A). Spindle cells also were seen in a myxoid background with mast cells and capillary network (Figure 2B). Histopathologic examination of the biopsy specimen revealed spindle cells that were diffusely positive for CD34 (Figure 3); focally positive for epithelial membrane antigen; and negative for melanocytic markers, smooth muscle markers, and cytokeratin. A diagnosis of superficial acral fibromyxoma (SAFM) was made based on clinical, histopathologic, and immunohistochemical findings.

Figure1
Figure 1. Superficial acral fibromyxoma with an uninvolved grenz zone and mildly cellular spindle cell dermal proliferation in a collagenous and myxoid background (H&E, original magnification ×40).

Figure2
Figure 2. Superficial acral fibromyxoma with spindle cells seen in a myxoid background among dense coarse collagen (A) as well as with mast cells and capillary network (B)(H&E, original magnifications ×200 and ×400).

Figure3
Figure 3. Superficial acral fibromyxoma immunohistochemical staining showed spindle cells that were diffusely positive for CD34 (original magnification ×40).

Superficial acral fibromyxomas, also known as digital fibromyxomas, are soft, slow-growing tumors that have a predilection for subungual or periungual regions of the hands and feet. Superficial acral fibromyxomas most frequently occur on the hallux and rarely occur on the ankle or leg. They can present as nodular, dome-shaped, polyploid, or verrucous masses. They can be soft to firm, gelatinous or solid, off-white to gray-white and can have fasciculate cut surfaces. Superficial acral fibromyxomas can be either painful or painless and present with a deformed nail in 9% of cases. Superficial acral fibromyxoma is a superficial lesion with frequent infiltration of the dermal collagen and subcutaneous tissue and may even erode or infiltrate into the underlying bone in rare cases.1-4 Although SAFMs are rare tumors, documented cases of SAFM have been reported at an increasing rate since the first published report by Fetsch et al2 in 2001.

Patients often delay seeking medical treatment and present with a solitary mass that has been slowly growing for months to years. In a study of 124 patients, Hollmann et al1 found that symptoms exist for a mean of 35 months and present with a small mass with a mean tumor size of 1.7 cm before biopsy or excision. Although the age range is broad, SAFM mostly affects middle-aged adults (median age, 49 years).1 Hollmann et al1 also reported a male predominance (1.3:1 ratio), and preexisting local trauma is reported in 25% of cases.2-4

The differential for SAFM should include dermatofibroma, keloid, dermatofibrosarcoma protuberans, acquired digital fibrokeratoma, infantile digital fibromatosis, neurolemmoma, sclerosing perineurioma, superficial angiomyxoma, low-grade fibromyxoid sarcoma, and acral myxoinflammatory fibroblastic sarcoma.1-4

Superficial acral fibromyxomas are composed of CD34+ spindle or stellate-shaped cells that are embedded in a myxoid and/or dense hyalinized collagenous stroma in a random or loosely fascicular growth pattern. The spindle or stellate-shaped cells in SAFMs also have been found to be focally positive for epithelial membrane antigen and CD99. Lesions have accentuated microvasculature and increased mast cells.5-8

Conservative management is reasonable, but patients presenting with persistent pain and/or local deformity should be definitively treated with complete excision and follow-up. Hollmann et al1 found that 24% of tumors recurred locally upon incomplete excision after a mean interval of 27 months. All recurrent tumors had positive margins at excision or initial biopsy.1 To date, no reports of tumors metastasizing have been documented.1-4

References
  1. Hollmann TJ, Bovée JV, Fletcher CD. Digital fibromyxoma (superficial acral fibromyxoma): a detailed characterization of 124 cases. Am J Surg Pathol. 2012;36:789-798.
  2. Fetsch JF, Laskin WB, Miettinen M. Superficial acral fibromyxoma: a clinicopathologic and immunohistochemical analysis of 37 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes. Hum Pathol. 2001;32:704-714.
  3. Al-Daraji WI, Miettinen M. Superficial acral fibromyxoma: a clinicopathological analysis of 32 tumors including 4 in the heel. J Cutan Pathol. 2008;35:1020-1026.
  4. Ashby-Richardson H, Rogers GS, Stadecker MJ. Superficial acral fibromyxoma: an overview. Arch Pathol Lab Med. 2011;135:1064-1066.
  5. Quaba O, Evans A, Al-Nafussi AA, et al. Superficial acral fibromyxoma. Br J Plast Surg. 2005;58:561-564.
  6. Oteo-Alvaro A, Meizoso T, Scarpellini A, et al. Superficial acral fibromyxoma of the toe, with erosion of the distal phalanx: a clinical report. Arch Orthop Trauma Surg. 2008;128:271-274.
  7. Meyerle J, Keller RA, Krivda SJ. Superficial acral fibromyxoma of the index finger. J Am Acad Dermatol. 2004;50:134-136.
  8. Kazakov DV, Mentzel T, Buro G, et al. Superficial acral fibromyxoma: report of two cases. Dermatology. 2002;205:285-288.
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The authors report no conflict of interest.

Correspondence: David E. Choi, MD (David.Choi2@med.usc.edu).

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The authors report no conflict of interest.

Correspondence: David E. Choi, MD (David.Choi2@med.usc.edu).

Author and Disclosure Information

Dr. Choi was from and Dr. Fernandez is from the Yale School of Medicine, New Haven, Connecticut. Dr. Choi currently is from the University of Southern California Keck School of Medicine, Los Angeles. Dr. Sloan is from the University of Connecticut School of Medicine, Farmington.

The authors report no conflict of interest.

Correspondence: David E. Choi, MD (David.Choi2@med.usc.edu).

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The Diagnosis: Superficial Acral Fibromyxoma

A shave biopsy revealed an uninvolved grenz zone and mildly cellular spindle cell dermal proliferation in a collagenous and myxoid background (Figure 1). Spindle cells were seen in a myxoid background among dense coarse collagen (Figure 2A). Spindle cells also were seen in a myxoid background with mast cells and capillary network (Figure 2B). Histopathologic examination of the biopsy specimen revealed spindle cells that were diffusely positive for CD34 (Figure 3); focally positive for epithelial membrane antigen; and negative for melanocytic markers, smooth muscle markers, and cytokeratin. A diagnosis of superficial acral fibromyxoma (SAFM) was made based on clinical, histopathologic, and immunohistochemical findings.

Figure1
Figure 1. Superficial acral fibromyxoma with an uninvolved grenz zone and mildly cellular spindle cell dermal proliferation in a collagenous and myxoid background (H&E, original magnification ×40).

Figure2
Figure 2. Superficial acral fibromyxoma with spindle cells seen in a myxoid background among dense coarse collagen (A) as well as with mast cells and capillary network (B)(H&E, original magnifications ×200 and ×400).

Figure3
Figure 3. Superficial acral fibromyxoma immunohistochemical staining showed spindle cells that were diffusely positive for CD34 (original magnification ×40).

Superficial acral fibromyxomas, also known as digital fibromyxomas, are soft, slow-growing tumors that have a predilection for subungual or periungual regions of the hands and feet. Superficial acral fibromyxomas most frequently occur on the hallux and rarely occur on the ankle or leg. They can present as nodular, dome-shaped, polyploid, or verrucous masses. They can be soft to firm, gelatinous or solid, off-white to gray-white and can have fasciculate cut surfaces. Superficial acral fibromyxomas can be either painful or painless and present with a deformed nail in 9% of cases. Superficial acral fibromyxoma is a superficial lesion with frequent infiltration of the dermal collagen and subcutaneous tissue and may even erode or infiltrate into the underlying bone in rare cases.1-4 Although SAFMs are rare tumors, documented cases of SAFM have been reported at an increasing rate since the first published report by Fetsch et al2 in 2001.

Patients often delay seeking medical treatment and present with a solitary mass that has been slowly growing for months to years. In a study of 124 patients, Hollmann et al1 found that symptoms exist for a mean of 35 months and present with a small mass with a mean tumor size of 1.7 cm before biopsy or excision. Although the age range is broad, SAFM mostly affects middle-aged adults (median age, 49 years).1 Hollmann et al1 also reported a male predominance (1.3:1 ratio), and preexisting local trauma is reported in 25% of cases.2-4

The differential for SAFM should include dermatofibroma, keloid, dermatofibrosarcoma protuberans, acquired digital fibrokeratoma, infantile digital fibromatosis, neurolemmoma, sclerosing perineurioma, superficial angiomyxoma, low-grade fibromyxoid sarcoma, and acral myxoinflammatory fibroblastic sarcoma.1-4

Superficial acral fibromyxomas are composed of CD34+ spindle or stellate-shaped cells that are embedded in a myxoid and/or dense hyalinized collagenous stroma in a random or loosely fascicular growth pattern. The spindle or stellate-shaped cells in SAFMs also have been found to be focally positive for epithelial membrane antigen and CD99. Lesions have accentuated microvasculature and increased mast cells.5-8

Conservative management is reasonable, but patients presenting with persistent pain and/or local deformity should be definitively treated with complete excision and follow-up. Hollmann et al1 found that 24% of tumors recurred locally upon incomplete excision after a mean interval of 27 months. All recurrent tumors had positive margins at excision or initial biopsy.1 To date, no reports of tumors metastasizing have been documented.1-4

The Diagnosis: Superficial Acral Fibromyxoma

A shave biopsy revealed an uninvolved grenz zone and mildly cellular spindle cell dermal proliferation in a collagenous and myxoid background (Figure 1). Spindle cells were seen in a myxoid background among dense coarse collagen (Figure 2A). Spindle cells also were seen in a myxoid background with mast cells and capillary network (Figure 2B). Histopathologic examination of the biopsy specimen revealed spindle cells that were diffusely positive for CD34 (Figure 3); focally positive for epithelial membrane antigen; and negative for melanocytic markers, smooth muscle markers, and cytokeratin. A diagnosis of superficial acral fibromyxoma (SAFM) was made based on clinical, histopathologic, and immunohistochemical findings.

Figure1
Figure 1. Superficial acral fibromyxoma with an uninvolved grenz zone and mildly cellular spindle cell dermal proliferation in a collagenous and myxoid background (H&E, original magnification ×40).

Figure2
Figure 2. Superficial acral fibromyxoma with spindle cells seen in a myxoid background among dense coarse collagen (A) as well as with mast cells and capillary network (B)(H&E, original magnifications ×200 and ×400).

Figure3
Figure 3. Superficial acral fibromyxoma immunohistochemical staining showed spindle cells that were diffusely positive for CD34 (original magnification ×40).

Superficial acral fibromyxomas, also known as digital fibromyxomas, are soft, slow-growing tumors that have a predilection for subungual or periungual regions of the hands and feet. Superficial acral fibromyxomas most frequently occur on the hallux and rarely occur on the ankle or leg. They can present as nodular, dome-shaped, polyploid, or verrucous masses. They can be soft to firm, gelatinous or solid, off-white to gray-white and can have fasciculate cut surfaces. Superficial acral fibromyxomas can be either painful or painless and present with a deformed nail in 9% of cases. Superficial acral fibromyxoma is a superficial lesion with frequent infiltration of the dermal collagen and subcutaneous tissue and may even erode or infiltrate into the underlying bone in rare cases.1-4 Although SAFMs are rare tumors, documented cases of SAFM have been reported at an increasing rate since the first published report by Fetsch et al2 in 2001.

Patients often delay seeking medical treatment and present with a solitary mass that has been slowly growing for months to years. In a study of 124 patients, Hollmann et al1 found that symptoms exist for a mean of 35 months and present with a small mass with a mean tumor size of 1.7 cm before biopsy or excision. Although the age range is broad, SAFM mostly affects middle-aged adults (median age, 49 years).1 Hollmann et al1 also reported a male predominance (1.3:1 ratio), and preexisting local trauma is reported in 25% of cases.2-4

The differential for SAFM should include dermatofibroma, keloid, dermatofibrosarcoma protuberans, acquired digital fibrokeratoma, infantile digital fibromatosis, neurolemmoma, sclerosing perineurioma, superficial angiomyxoma, low-grade fibromyxoid sarcoma, and acral myxoinflammatory fibroblastic sarcoma.1-4

Superficial acral fibromyxomas are composed of CD34+ spindle or stellate-shaped cells that are embedded in a myxoid and/or dense hyalinized collagenous stroma in a random or loosely fascicular growth pattern. The spindle or stellate-shaped cells in SAFMs also have been found to be focally positive for epithelial membrane antigen and CD99. Lesions have accentuated microvasculature and increased mast cells.5-8

Conservative management is reasonable, but patients presenting with persistent pain and/or local deformity should be definitively treated with complete excision and follow-up. Hollmann et al1 found that 24% of tumors recurred locally upon incomplete excision after a mean interval of 27 months. All recurrent tumors had positive margins at excision or initial biopsy.1 To date, no reports of tumors metastasizing have been documented.1-4

References
  1. Hollmann TJ, Bovée JV, Fletcher CD. Digital fibromyxoma (superficial acral fibromyxoma): a detailed characterization of 124 cases. Am J Surg Pathol. 2012;36:789-798.
  2. Fetsch JF, Laskin WB, Miettinen M. Superficial acral fibromyxoma: a clinicopathologic and immunohistochemical analysis of 37 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes. Hum Pathol. 2001;32:704-714.
  3. Al-Daraji WI, Miettinen M. Superficial acral fibromyxoma: a clinicopathological analysis of 32 tumors including 4 in the heel. J Cutan Pathol. 2008;35:1020-1026.
  4. Ashby-Richardson H, Rogers GS, Stadecker MJ. Superficial acral fibromyxoma: an overview. Arch Pathol Lab Med. 2011;135:1064-1066.
  5. Quaba O, Evans A, Al-Nafussi AA, et al. Superficial acral fibromyxoma. Br J Plast Surg. 2005;58:561-564.
  6. Oteo-Alvaro A, Meizoso T, Scarpellini A, et al. Superficial acral fibromyxoma of the toe, with erosion of the distal phalanx: a clinical report. Arch Orthop Trauma Surg. 2008;128:271-274.
  7. Meyerle J, Keller RA, Krivda SJ. Superficial acral fibromyxoma of the index finger. J Am Acad Dermatol. 2004;50:134-136.
  8. Kazakov DV, Mentzel T, Buro G, et al. Superficial acral fibromyxoma: report of two cases. Dermatology. 2002;205:285-288.
References
  1. Hollmann TJ, Bovée JV, Fletcher CD. Digital fibromyxoma (superficial acral fibromyxoma): a detailed characterization of 124 cases. Am J Surg Pathol. 2012;36:789-798.
  2. Fetsch JF, Laskin WB, Miettinen M. Superficial acral fibromyxoma: a clinicopathologic and immunohistochemical analysis of 37 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes. Hum Pathol. 2001;32:704-714.
  3. Al-Daraji WI, Miettinen M. Superficial acral fibromyxoma: a clinicopathological analysis of 32 tumors including 4 in the heel. J Cutan Pathol. 2008;35:1020-1026.
  4. Ashby-Richardson H, Rogers GS, Stadecker MJ. Superficial acral fibromyxoma: an overview. Arch Pathol Lab Med. 2011;135:1064-1066.
  5. Quaba O, Evans A, Al-Nafussi AA, et al. Superficial acral fibromyxoma. Br J Plast Surg. 2005;58:561-564.
  6. Oteo-Alvaro A, Meizoso T, Scarpellini A, et al. Superficial acral fibromyxoma of the toe, with erosion of the distal phalanx: a clinical report. Arch Orthop Trauma Surg. 2008;128:271-274.
  7. Meyerle J, Keller RA, Krivda SJ. Superficial acral fibromyxoma of the index finger. J Am Acad Dermatol. 2004;50:134-136.
  8. Kazakov DV, Mentzel T, Buro G, et al. Superficial acral fibromyxoma: report of two cases. Dermatology. 2002;205:285-288.
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A 62-year-old man presented for evaluation of a slowly growing, nonpainful nodule on the first proximal toenail fold of the right foot of 6 years' duration. He reported that the nail plate of the affected toe was thickened and malaligned. He denied a history of trauma. Physical examination revealed a 2.0×1.6-cm, flesh-colored, nontender, well-defined, rubbery nodule with prominent overlying tortuous telangiectases on the medial aspect of the first proximal toenail fold of the right foot. The associated nail plate was yellow, thickened, and angled laterally into the second toe. Radiograph of the right hallux identified a soft tissue density contiguous with the dorsal aspect of the distal portion of the phalanx. There was no evidence of bony involvement. A shave saucerization biopsy specimen was obtained and sent for hematoxylin and eosin and immunohistochemical staining. The spindle cells were diffusely positive for CD34.

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Clinical Pearl: A Simple and Effective Technique for Improving Surgical Closures for the Early-Learning Resident

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Clinical Pearl: A Simple and Effective Technique for Improving Surgical Closures for the Early-Learning Resident

Practice Gap

For first-year dermatology residents, dermatologic surgeries can present many challenges. Although approximation of wound edges following excision may be intuitive for the experienced surgeon, an early trainee may need some guidance. Infusion of anesthetics can distort the normal skin field or it may be difficult for the patient to remain in the same position for the required period of time; for example, an elderly patient who requires an excision on the posterior aspect of the neck may be unable to assume the same position for the full duration of the procedure. We offer a simple and effective technique for early-learning dermatology residents to improve surgical closures.

The Technique

We propose drawing straight lines using a sterile marking pen perpendicular to the fusiform plane laid out for any simple, intermediate, or complex linear closure (Figure 1). These lines can then be used as scaffolding for the surgical closure (Figure 2). We recommend drawing the lines at the time of initial planning when the site of excision is in the normal anatomic position.

Figure 1. A typical preexcisional fusiform sketch (A) with added perpendicular markings indicating the approximated wound edges (B) for removal of a melanoma in situ with a 5-mm margin of normal skin.

Figure 2. Surgical site after removal of a melanoma in situ (A). The perpendicular markings were utilized to assist in approximation of the wound edges with buried deep sutures, and the wound was closed using 3-0 poliglecaprone 25 sutures (B). 4-0 Polypropylene sutures in a simple running fashion were used for the final closure (C).

Practice Implications

By creating a sketch with perpendicular lines, approximation of skin edges and surgical closures may become easier for the learning resident. Patients also can rest more comfortably during the procedure, and the overall cosmesis, healing, and outcome of the procedure may improve. The addition of a sterile marking pen to the surgical tray may aide in highlighting faded pen markings for easier visualization after cleansing of the surgical site.

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From the Department of Dermatology, University of Connecticut Health Center, Farmington.

The authors report no conflict of interest.

Correspondence: Sonal A. Parikh, MD, 263 Farmington Ave, MC 6231, Farmington, CT 06030 (sparikh@uchc.edu)

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From the Department of Dermatology, University of Connecticut Health Center, Farmington.

The authors report no conflict of interest.

Correspondence: Sonal A. Parikh, MD, 263 Farmington Ave, MC 6231, Farmington, CT 06030 (sparikh@uchc.edu)

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From the Department of Dermatology, University of Connecticut Health Center, Farmington.

The authors report no conflict of interest.

Correspondence: Sonal A. Parikh, MD, 263 Farmington Ave, MC 6231, Farmington, CT 06030 (sparikh@uchc.edu)

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Practice Gap

For first-year dermatology residents, dermatologic surgeries can present many challenges. Although approximation of wound edges following excision may be intuitive for the experienced surgeon, an early trainee may need some guidance. Infusion of anesthetics can distort the normal skin field or it may be difficult for the patient to remain in the same position for the required period of time; for example, an elderly patient who requires an excision on the posterior aspect of the neck may be unable to assume the same position for the full duration of the procedure. We offer a simple and effective technique for early-learning dermatology residents to improve surgical closures.

The Technique

We propose drawing straight lines using a sterile marking pen perpendicular to the fusiform plane laid out for any simple, intermediate, or complex linear closure (Figure 1). These lines can then be used as scaffolding for the surgical closure (Figure 2). We recommend drawing the lines at the time of initial planning when the site of excision is in the normal anatomic position.

Figure 1. A typical preexcisional fusiform sketch (A) with added perpendicular markings indicating the approximated wound edges (B) for removal of a melanoma in situ with a 5-mm margin of normal skin.

Figure 2. Surgical site after removal of a melanoma in situ (A). The perpendicular markings were utilized to assist in approximation of the wound edges with buried deep sutures, and the wound was closed using 3-0 poliglecaprone 25 sutures (B). 4-0 Polypropylene sutures in a simple running fashion were used for the final closure (C).

Practice Implications

By creating a sketch with perpendicular lines, approximation of skin edges and surgical closures may become easier for the learning resident. Patients also can rest more comfortably during the procedure, and the overall cosmesis, healing, and outcome of the procedure may improve. The addition of a sterile marking pen to the surgical tray may aide in highlighting faded pen markings for easier visualization after cleansing of the surgical site.

Practice Gap

For first-year dermatology residents, dermatologic surgeries can present many challenges. Although approximation of wound edges following excision may be intuitive for the experienced surgeon, an early trainee may need some guidance. Infusion of anesthetics can distort the normal skin field or it may be difficult for the patient to remain in the same position for the required period of time; for example, an elderly patient who requires an excision on the posterior aspect of the neck may be unable to assume the same position for the full duration of the procedure. We offer a simple and effective technique for early-learning dermatology residents to improve surgical closures.

The Technique

We propose drawing straight lines using a sterile marking pen perpendicular to the fusiform plane laid out for any simple, intermediate, or complex linear closure (Figure 1). These lines can then be used as scaffolding for the surgical closure (Figure 2). We recommend drawing the lines at the time of initial planning when the site of excision is in the normal anatomic position.

Figure 1. A typical preexcisional fusiform sketch (A) with added perpendicular markings indicating the approximated wound edges (B) for removal of a melanoma in situ with a 5-mm margin of normal skin.

Figure 2. Surgical site after removal of a melanoma in situ (A). The perpendicular markings were utilized to assist in approximation of the wound edges with buried deep sutures, and the wound was closed using 3-0 poliglecaprone 25 sutures (B). 4-0 Polypropylene sutures in a simple running fashion were used for the final closure (C).

Practice Implications

By creating a sketch with perpendicular lines, approximation of skin edges and surgical closures may become easier for the learning resident. Patients also can rest more comfortably during the procedure, and the overall cosmesis, healing, and outcome of the procedure may improve. The addition of a sterile marking pen to the surgical tray may aide in highlighting faded pen markings for easier visualization after cleansing of the surgical site.

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Cutis - 100(5)
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Clinical Pearl: A Simple and Effective Technique for Improving Surgical Closures for the Early-Learning Resident
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