Dorsal Forearm Research Articles

Xylazine-induced Skin Necrosis, Emerging Public Health Crisis and the Ethical Considerations in Surgical Reconstruction: A Case Report

Xylazine, a non-opioid veterinary sedative, is increasingly being used to adulterate illicit fentanyl. Injection into the extremities causes progressive necrotic wounds, resulting in a compromised limb and life. Managing xylazine-induced skin necrosis may require extensive surgical intervention, including serial debridements and soft tissue reconstruction. Moreover, managing these complex wounds requires a multi-disciplinary approach, including hospital medicine, infectious disease, psychiatry, addiction medicine, pain/palliative care, ethics, wound care, orthopedic surgery, and plastic surgery. A 38-year-old female with a history of intravenous drug use presented with severe bilateral dorsal forearm wounds, and despite initial non-compliance with surgical debridement, she eventually underwent successful skin grafting after extensive treatment, including antibiotics and negative pressure therapy, but was later lost to follow-up. She relapsed into fentanyl use, leading to severe bilateral lower extremity wounds requiring further debridement and skin grafting, and later returned with new forearm wounds, at which point further reconstruction was deemed inappropriate without addressing her addiction; she refused inpatient rehabilitation and ultimately being lost to follow-up again.

Fluorescence Spectroscopy With Temperature Functional Tests in the Assessment of Markers of Intracellular Energy Metabolism: Spatial Heterogeneity and Reproducibility of Measurements.

The fluorescence intensities of the cellular respiratory cofactors NADH (reduced nicotinamide adenine dinucleotide) and FAD++ (oxidized flavin adenine dinucleotide) reflect energy metabolism in skin and other tissues and can be quantified in vivo by fluorescence spectroscopy (FS). However, the variability of physiological parameters largely determines the reproducibility of measurement results and the reliability of the diagnostic test. In this prospective study, we evaluated the interday reproducibility of NADH and FAD++ fluorescence intensity measurements in the skin of 51 healthy volunteers assessed by the FS at baseline, after local cooling (10°C) and heating of the skin (35°C). Results showed that the fluorescence amplitude of NADH (AFNADH) in forearm skin was the most reproducible of the FS parameters studied. Assessment of AFNADH in the dorsal forearm in combination with a thermal functional test is the most promising method for clinical use for assessing energy metabolism in the skin.

Patterns of forearm lymphatic drainage to the epitrochlear lymph nodes in 1400 cutaneous melanoma patients.

Variations of hand and forearm lymphatic drainage to upper-arm lymphatic pathways may impact the route of melanoma metastasis. This study compared rates of lymphatic drainage to epitrochlear nodes between anatomic divisions of the hand and forearm to determine whether the anatomic distribution of hand and forearm melanomas affects the likelihood of drainage to epitrochlear lymph nodes. Using a single-institution lymphoscintigraphy database, we identified all patients with cutaneous melanoma on the hand and forearm. A body-map two-dimensional coordinate system was used to classify cutaneous melanoma sites between radial-ulnar and dorsal-volar divisions. Sentinel lymph nodes (SLNs) visualized on lymphoscintigraphy were recorded. Proportions of patients with epitrochlear SLNs were compared between anatomic divisions using χ2 analysis. Of 3628 upper extremity cutaneous melanoma patients who underwent lymphatic mapping with lymphoscintigraphy, 1400 met inclusion criteria. Twenty-one percent of patients demonstrated epitrochlear SLNs. Epitrochlear SLNs were observed in 27% of dorsal forearm melanomas and 15% of volar forearm melanomas (p < 0.001). Epitrochlear SLNs were observed in 31% of ulnar forearm melanomas and 17% of radial forearm melanomas (p < 0.001). Higher proportions of dorsal and ulnar forearm melanomas have epitrochlear SLNs. Metastasis to epitrochlear SLNs may be more likely from melanomas in these respective forearm regions.

Flexor Injury Rehabilitation Splint Trial (FIRST): protocol for a pragmatic randomised controlled trial comparing three splints for finger flexor tendon repairs

BackgroundWithout surgical repair, flexor tendon injuries do not heal and patients’ ability to bend fingers and grip objects is impaired. However, flexor tendon repair surgery also requires optimal rehabilitation. There are currently three custom-made splints used in the rehabilitation of zone I/II flexor tendon repairs, each with different assumed harm/benefit profiles: the dorsal forearm and hand-based splint (long), the Manchester short splint (short), and the relative motion flexion splint (mini). There is, however, no robust evidence as to which splint, if any, is most clinical or cost effective. The Flexor Injury Rehabilitation Splint Trial (FIRST) was designed to address this evidence gap.MethodsFIRST is a parallel group, superiority, analyst-blind, multi-centre, individual participant-randomised controlled trial. Participants will be assigned 1:1:1 to receive either the long, short, or mini splint. We aim to recruit 429 participants undergoing rehabilitation following zone I/II flexor tendon repair surgery. Potential participants will initially be identified prior to surgery, in NHS hand clinics across the UK, and consented and randomised at their splint fitting appointment post-surgery. The primary outcome will be the mean post-randomisation score on the patient-reported wrist and hand evaluation measure (PRWHE), assessed at 6, 12, 26, and 52 weeks post randomisation. Secondary outcome measures include blinded grip strength and active range of movement (AROM) assessments, adverse events, adherence to the splinting protocol (measured via temperature sensors inserted into the splints), quality of life assessment, and further patient-reported outcomes. An economic evaluation will assess the cost-effectiveness of each splint, and a qualitative sub-study will evaluate participants’ preferences for, and experiences of wearing, the splints. Furthermore, a mediation analysis will determine the relationship between patient preferences, splint adherence, and splint effectiveness.DiscussionFIRST will compare the three splints with respect to clinical efficacy, complications, quality of life and cost-effectiveness. FIRST is a pragmatic trial which will recruit from 26 NHS sites to allow findings to be generalisable to current clinical practice in the UK. It will also provide significant insights into patient experiences of splint wear and how adherence to splinting may impact outcomes.Trial registrationISRCTN: 10236011

Radial nerve palsy in patients presenting with fentanyl/xylazine wounds of the dorsal forearm: A case series

IntroductionThe presence of synthetic compounds like xylazine in the illicit opioid supply of the United States has led to presentations of unique upper extremity wounds in persons who inject drugs. As an alpha-2 adrenergic receptor agonist, xylazine causes local vasoconstriction of blood vessels as well as central nervous system depression. With increased vasoconstriction, patients experience more issues with adequate perfusion which is hypothesized to cause nerve deficiencies near injection sites. MethodsThree patients presenting with a history of deep upper extremity forearm wounds secondary to injection with xylazine and fentanyl had clinically significant radial nerve palsies. Each patient's presentation and clinical course was observed and reported. ResultsIn all three cases, patients presented with chronic necrotic forearm wounds that required repeated surgical debridement and wound care. There was evidence of weakness in the radial nerve distribution, with patients exhibiting dysfunction of the extrinsic digital and wrist extensors. ConclusionProviders should be aware of a common manifestation of radial nerve deficiency in upper extremity wounds in patients with a history of fentanyl-xylazine injections. While surgical management of nerve palsies such as tendon transfers are options for treatment, successful long-term treatment must also rely on multidisciplinary care for addiction and psychosocial support for ideal functional outcomes.

Examining the Forearm Intersection through Palpation and Ultrasonography.

Forearm intersection syndrome causes pain, swelling, and a rub at the dorsal distal forearm where the first extensor compartment muscles intersect with the second compartment tendons. Although primary care settings tend to treat mild cases, high-performance athletes may suffer from severe symptoms that require surgery. This proof-of-concept study aims to help detect the anatomical substrate of forearm intersection syndrome using palpation and ultrasonography when available. Five individuals were studied using independent palpation and ultrasonography to identify the first dorsal compartment muscles and the second dorsal compartment tendons. The distances between the dorsal (Lister's) tubercle of the radius and the ulnar and radial edges of the first dorsal compartment muscles were measured to determine the location and extent of the muscle-tendon intersection. The palpatory and ultrasonographic measurements were compared using descriptive statistics and the paired t-test. The mean distances from the dorsal tubercle of the radius to the ulnar and radial borders of the first dorsal compartment muscles were 4.0 cm (SE 0.42) and 7.7 cm (SE 0.56), respectively, based on palpation. By ultrasonography, the corresponding distances were 3.5 cm (SD 1.05, SE 0.47) and 7.0 cm (SD 1.41, SE 0.63). Both methods showed a similar overlap length. However, ultrasonography revealed a shorter distance between the dorsal tubercle of the radius and the ulnar border of the first compartment than palpation (p = 0.0249). Our findings indicate that a basic knowledge of anatomy should help health professionals diagnose forearm intersection syndrome through palpation and, if available, ultrasonography.

Skin Hydration Measurement: Comparison Between Devices and Clinical Evaluations.

The need for an objective method for measuring skin hydration levels is becoming increasingly important. Various devices with different measuring principles for assessing skin hydration have been developed and are widely used. This study aimed to investigate the reproducibility and correlation between clinical evaluation and skin hydration measurement devices that are the most widely used in the field. A prospective comparative clinical trial was conducted on 184 healthy volunteers. Skin hydration levels were measured using the Corneometer (CM820) and hydration probe (HP: DermaLab Combo) at 3 points: the ventral forearm, the dorsal forearm, and the shin. We used the intraclass correlation coefficient (ICC) to evaluate the reproducibility and Pearson's correlation coefficient (PCC) to evaluate the correlation of each measurement. Simple linear regression was used to analyze the Corneometer and HP skin hydration value changes according to changes in xerosis severity scale (XSS) values, which were evaluated by clinicians. Both the Corneometer and HP showed significant, excellent reproducibility (ICC for Corneometer: 0.954-0.971, ICC for HP: 0.980-0.986) and significant high positive correlations (PCC: 0.708-0.737) regardless of the measurement site. Both devices showed negative regression coefficients in all measurement sites in XSS analysis, but this was not statistically significant. The Corneometer and HP were both accurate and objective skin hydration measuring devices, regardless of the measurement site. Using reliable and objective devices such as the Corneometer or HP can aid in understanding an individual's skin condition and making more informed decisions for skin care. Clinical Research Information Service Identifier: KCT0005146.

Optimising oral cancer reconstruction: a retrospective cohort study on the modified radial forearm free flap technique to eliminate the need for a secondary donor site

The radial forearm free flap (RFFF) is commonly used in the reconstruction of oral cancer patients. Traditional RFFF (TRFFF) techniques, which often require a secondary donor site to repair the forearm defect, may result in a scar extending to the dorsal hand. This can lead to significant functional and aesthetic concerns in the forearm. We designed a modified RFFF (MRFFF) that incorporates a glasses-shaped flap and features deep venous drainage. To evaluate its effectiveness we conducted a retrospective chart review of 105 patients with oral squamous cell carcinoma who underwent reconstructive surgery between 2018 and 2022. These patients were treated either with a TRFFF (n = 60) or the newly developed MRFFF (n = 45). Our inclusion criteria, guided by preliminary surgical experience prior to initiating the study, stipulated that single oral defects should be no larger than 6 × 6 cm2, and adjacent double defects no larger than 3 × 6 cm2. Flap size, pedicle length, harvesting duration, and anastomosis during the surgical procedure were compared between the two techniques. Preoperative and postoperative oral function, recurrence, mortality, and dorsal scarring were recorded. One-week, one-month, and six-month postoperative subjective aesthetics assessments, and self-reported postoperative donor hand function, were measured using the Michigan hand questionnaire (MHQ). There were no significant differences between the groups in terms of flap size, pedicle length, harvesting time, anastomosis time, postoperative oral function, recurrence, and mortality. However, patients with a MRFFF did not require a second donor graft site and did not have scars extending to the dorsal forearm. They also had significantly improved postoperative aesthetic outcomes (1 week: 70.6%, 1 month: 62.2%) and donor hand function (1 week: 54.6%, 1 month: 40.4%) compared with the TRFFF group (p < 0.001). The MRFFF eliminates the need for secondary donor sites and improves primary donor site outcomes. It is versatile and can be employed for either single or composite oral defects. Through extensive case studies, we have defined its specific scope: it is suitable for single defects measuring no more than 6 × 6 cm2, or for composite defects no larger than 3 × 6 cm2. Furthermore, it does not compromise the functional recovery of the recipient site, and should be widely adopted for all qualifying patients.

Revisiting a classical theory of sensory specificity: assessing consistency and stability of thermosensitive spots.

Thermal sensitivity is not uniform across the skin, and is particularly high in small (∼1 mm2) regions termed "thermosensitive spots." These spots are thought to reflect the anatomical location of specialized thermosensitive nerve endings from single primary afferents. Thermosensitive spots provide foundational support for "labeled line" or specificity theory of sensory perception, which states that different sensory qualities are transmitted by separate and specific neural pathways. This theory predicts a highly stable relation between repetitions of a thermal stimulus and the resulting sensory quality, yet these predictions have rarely been tested systematically. Here, we present the qualitative, spatial, and repeatability properties of 334 thermosensitive spots on the dorsal forearm sampled across four separate sessions. In line with previous literature, we found that spots associated with cold sensations (112 cold spots, 34%) were more frequent than spots associated with warm sensations (41 warm spots, 12%). Still more frequent (165 spots, 49%) were spots that elicited inconsistent sensations when repeatedly stimulated by the same temperature. Remarkably, only 13 spots (4%) conserved their position between sessions. Overall, we show unexpected inconsistency of both the perceptual responses elicited by spot stimulation and of spot locations across time. These observations suggest reappraisals of the traditional view that thermosensitive spots reflect the location of individual thermosensitive, unimodal primary afferents serving as specific labeled lines for corresponding sensory qualities.NEW & NOTEWORTHY Thermosensitive spots are clustered rather than randomly distributed and have the highest density near the wrist. Surprisingly, we found that thermosensitive spots elicit inconsistent sensory qualities and are unstable over time. Our results question the widely believed notion that thermosensitive spots reflect the location of individual thermoreceptive, unimodal primary afferents that serve as labelled lines for corresponding sensory qualities.

Skin maturation from birth to 10 years of age: Structure, function, composition and microbiome.

Infant and adult skin physiology differ in many ways; however, limited data exist for older children. To further investigate the maturation processes of healthy skin during childhood. Skin parameters were recorded in 80 participants of four age groups: babies (0-2 years), young children (3-6 years), older children (7-<10 years) and adults (25-40 years). Overall, skin barrier function continues to mature, reaching adult levels of transepidermal water loss (TEWL), lipid compactness, stratum corneum (SC) thickness and corneocyte size by the age of about 6 years. Higher levels of lactic acid and lower levels of total amino acids in the SC of babies and young children further indicate higher cell turnover rates. In all age groups, TEWL and skin surface hydration values remain higher on the face compared with the arm. Skin becomes darker and contains higher levels of melanin with increasing age. The composition of skin microbiome of the dorsal forearm in all children groups is distinct from that in adults, with Firmicutes predominating in the former and Proteobacteria in the latter. Skin physiology, along with the skin microbiome, continues to mature during early childhood in a site-specific manner.

Interrater reproducibility of the Myoton and durometer devices to quantify sclerotic chronic graft-versus-host disease.

Chronic graft-versus-host disease (cGVHD) is a severe complication in long-term survivors of allogeneic hematopoietic stem cell transplantation. This disease is challenging to manage clinically due to a lack of validated tools to quantitatively measure skin sclerosis. The current gold standard for measuring skin sclerosis is the NIH Skin Score which has only moderate agreement among clinicians and experts. To more accurately assess skin sclerosis in cGVHD, the Myoton and durometer devices can be used to directly measure biomechanical parameters of the skin. However, the reproducibility of these devices is not known in patients with cGVHD. To determine this reproducibility, three observers independently measured 10 anatomic sites in each of seven patients with sclerotic cGVHD using the Myoton and durometer. Clinical reproducibility was measured by mean pairwise differences (U-statistic) and intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs). Mean pairwise differences, expressed in true physical units, were used to report typical errors for each anatomic site and device. Mean pairwise differences were less than 11% of the average overall values for all five Myoton parameters and durometer hardness. These were lower for Myoton creep (4.1%), relaxation time (4.7%), and frequency (5.1%) than decrement (9.0%), stiffness (10.4%), and durometer hardness (9.0%). Myoton parameters creep, relaxation time, and frequency showed promise for capturing skin biomechanics more accurately than Myoton stiffness, decrement, or durometer hardness. Mean pairwise differences trended highest in the shin and volar forearm and lowest in the dorsal forearm. The interobserver ICC for overall (averaged across all measured body sites of a patient) creep (0.94; 95% CI 0.87-1.00), relaxation time (0.96; 95% CI 0.90-1.00), and frequency (0.95; 95% CI 0.88-1.00), trended higher than that for decrement (0.43; 95% CI 0.00-0.88), stiffness (0.92; 95% CI 0.81-1.00), and durometer hardness (0.82; 95% CI 0.61-1.00). Similar trends were observed in healthy participants. These findings can help clinicians design better studies to assess therapeutic response to new cGVHD treatments and support the interpretation of future measurements.

Seasonal Tanning-Induced Increases in Skin Pigmentation Do Not Affect Nitric Oxide-Mediated Vasodilation of the Cutaneous Microvasculature

Acute ultraviolet radiation (UVR) exposure reduces nitric oxide (NO)-dependent cutaneous vasodilation. Additionally, increased constitutive skin melanin concentrations are associated with reduced NO-dependent cutaneous vasodilation. However, the impact of seasonal tanning-induced increases in skin melanin concentration on NO-dependent cutaneous vasodilation has not been investigated. PURPOSE: To investigate the effect of seasonal tanning-induced increases in skin melanin on the NO-dependent cutaneous vasodilation response to local heating. We hypothesized that NO-dependent cutaneous vasodilation would be reduced in tanned skin relative to untanned skin. METHODS: Three intradermal microdialysis fibers were placed in the ventral upper arm (least sun exposed), ventral forearm (moderately sun exposed), and dorsal forearm (most sun exposed) of seven adults (33 ± 14 yrs; 4M/3F) with light-to-moderate constitutive skin pigmentation. Differences in sun exposure among the sites was confirmed using the melanin-index (M-index; an index of skin pigmentation), measured via skin reflectance spectrophotometry. Lactated Ringer’s solution was perfused through the microdialysis fibers while local heating to 42°C induced cutaneous vasodilation. After attaining a stable plateau in cutaneous blood flow, 15mM NG-nitro-L-arginine methyl ester (L-NAME; NO synthase inhibitor) was perfused at all sites to quantify NO-mediated vasodilation. Red cell flux was measured using laser-Doppler flowmetry (LDF). Cutaneous vascular conductance (CVC=LDF/mean arterial pressure) was calculated for each phase of the local heating response (i.e., baseline, initial peak, local heating plateau, post L-NAME plateau) and expressed as percent maximum (%CVCmax; 28mM sodium nitroprusside + 43°C local heating). RESULTS: M-index was highest (i.e., skin pigmentation was darkest) in the dorsal forearm (50.5 ± 11.8 a.u.) compared to the ventral forearm (37.5 ± 7.4 a.u.; p ≤ 0.03) and upper arm (30.2 ± 5.1 a.u.; p ≤ 0.001). There were no baseline (p ≥ 0.37), initial peak (p ≥ 0.22), post L-NAME plateau (p ≥ 0.12), or maximal CVC (p ≥ 0.23) differences among the three sites. Likewise, the magnitude of the local heating plateau was not different among the three sites (dorsal: 88±17%; ventral: 81±20%; upper: 90±12%; p ≥ 0.16), nor was NO-mediated vasodilation (dorsal: 59±15%; ventral: 54±13%; upper: 55±11.0%; p ≥ 0.79). CONCLUSION: These data suggest that, in contrast to the effects of acute UVR exposure or a constitutively dark skin pigmentation, seasonal tanning-induced increases in skin pigmentation do not alter NO-dependent cutaneous vasodilation responses to local heating. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

The anatomic relationship of dorsal arterial perforators of the distal forearm, wrist, and dorsum of the hand with conclusions for the clinic

Extended soft tissue defects of the fingers are often challenging to treat, and therefore, we performed cadaver dissections to elucidate the anatomic relationship between dorsal arterial perforators of the distal upper extremities to support the development of new local flaps. Ten fixated cadaveric distal dorsal lower forearms were dissected to their arterial perforators down to 0.1mm diameter in size with identification of their relationship. Dorsal distal fascia piercing perforators of the lower forearm come in two distinct rows, radial and ulnar, of the fourth extensor compartment. These were interconnected by subfascial axial arteries in line. The most proximal perforator is usually located 8-10cm from the dorsal wrist, the most distal about 1-2cm, and on average, only three subcutaneous bridging vessels connect both axial systems. The number of less reliable subcutaneous arterial connecting vessels between the dorsal wrist and forearm is also fairly limited to only one or two. More constant bridging arteries interconnect at the level of the dorsal retinaculum between the axial systems of the hand and lower forearm. At the level of the dorsum of the hand perforators reaching the skin, they interconnect in an arcuate fashion. This unique distribution pattern could be used for freestyle perforator propellor flaps of the hand, as we demonstrated in a case directly derived from our recent research. In our opinion, a super-extended perforator flap should be possible with the inclusion of the bridging arteries in flap design at the level of the dorsal retinaculum.

Congenital Atrophic Dermatofibrosarcoma Protuberans: A Case Report and Review of the Literature

Dermatofibrosarcoma protuberans (DFSP) is a rare mesenchymal tumor of intermediate malignant potential. The neoplasm is locally aggressive with a high rate of recurrence. It typically presents in adults. Atrophic congenital DFSP is extremely rare. The few reported cases have presented as a morphea-like plaque that persists for years, before progressing into a nodular form. To our knowledge, congenital atrophic DFSP has been only reported fourteen times, and of those, only nine were confirmed by molecular studies. Herein we report a congenital case of atrophic DFSP, which initially presented as a bruise-like atrophic plaque on the dorsal forearm, initially mistaken for child abuse. The clinical appearance, histopathology, and molecular features of this rare form of DFSP are reviewed. Our case highlights the importance of early detection and adequate sampling of congenital DFSP; early treatment allows for treating small lesions without large, disfiguring, and potentially disabling excisions.

Regional and time course differences in sweat cortisol, glucose, and select cytokine concentrations during exercise

IntroductionThe use of sweat as a biofluid for non-invasive sampling and diagnostics is a popular area of research. However, concentrations of cortisol, glucose, and cytokines have not been described across anatomical regions or as time progresses throughout exercise.PurposeTo determine regional and time course differences in sweat cortisol, glucose, and select cytokines (EGF, IFN-γ, IL-1β, IL-1α, IL-1ra, TNF-α, IL-6, IL-8, and IL-10).MethodsSweat was collected with absorbent patches from eight subjects (24–44 y; 80.2 ± 10.2 kg) on the forehead (FH), right dorsal forearm (RDF), right scapula (RS), and right triceps (RT) at 0–25 min, 30–55 min, and 60–85 min during 90 min of cycling (~ 82% HRmax) in a heated chamber (32 °C, 50% rh). ANOVA was used to determine the effect of site and time on outcomes. Data are reported as LS means ± SE.ResultsThere was a significant effect of location on sweat analyte concentrations with FH having higher values than most other regions for cortisol (FH: 1.15 ± 0.08 ng/mL > RDF: 0.62 ± 0.09 ng/mL and RT: 0.65 ± 0.12 ng/mL, P = 0.02), IL-1ra (P < 0.0001), and IL-8 (P < 0.0001), but lower concentrations for glucose (P = 0.01), IL-1α (P < 0.0001), and IL-10 (P = 0.02). Sweat IL-1β concentration was higher on the RS than RT (P < 0.0001). Sweat cortisol concentration increased (25 min: 0.34 ± 0.10 ng/mL < 55 min: 0.89 ± 0.07 ng/mL < 85 min: 1.27 ± 0.07 ng/mL; P < 0.0001), while EGF (P < 0.0001), IL-1ra (P < 0.0001), and IL-6 (P = 0.02) concentrations decreased over time.ConclusionSweat analyte concentrations varied with time of sampling and anatomical region, which is essential information to consider when conducting future work in this area.Clinical trial identifierNCT04240951 registered January 27, 2020.

Quantitative morphometric analysis of intrinsic and extrinsic skin ageing in individuals with Fitzpatrick skin types II-III.

Skin ageing is an intricate physiological process affected by intrinsic and extrinsic factors. There is a demand to understand how the skin changes with age and photoexposure in individuals with Fitzpatrick skin types I-III due to accelerated photoageing and the risk of cutaneous malignancies. To assess the structural impact of intrinsic and extrinsic ageing, we analysed 14 skin parameters from the photoprotected buttock and photoexposed dorsal forearm of young and ageing females with Fitzpatrick skin types II-III (n=20) using histomorphic techniques. Whilst the minimum viable epidermis (Emin ) remained constant (Q > 0.05), the maximum viable epidermis (Emax ) was decreased by both age and photoexposure (Q ≤ 0.05), which suggests that differences in epidermal thickness are attributed to changes in the dermal-epidermal junction (DEJ). Changes in Emax were not affected by epidermal cell proliferation. For the first time, we investigated the basal keratinocyte morphology with age and photoexposure. Basal keratinocytes had an increased cell size, cellular height and a more columnar phenotype in photoexposed sites of young and ageing individuals (Q ≤ 0.05), however no significant differences were observed with age. Some of the most striking changes were observed in the DEJ, and a decrease in the interdigitation index was observed with both age and photoexposure (Q ≤ 0.001), accompanied by a decreased height of rête ridges and dermal papilla. Interestingly, young photoexposed skin was comparable to ageing skin across many parameters, and we hypothesise that this is due to accelerated photoageing. This study highlights the importance of skin care education and photoprotection from an early age.

Angioinvasive mucormycosis in a patient with aplastic anemia

A 9-year-old boy with no past medical history was admitted for severe epistaxis and aplastic anemia of unknown etiology with hospital course complicated by bacteremia and the development of a tender plaque on the forearm. Exam revealed a violaceous plaque with peripheral erythema and central necrosis on the left dorsal forearm (Fig 1). Punch biopsies for frozen section and tissue cultures were obtained. Histopathologic exam showed epidermal and dermal necrosis with numerous fungal hyphae in the dermis and within small vessels (Fig 2, black arrow).

Decision-making in the treatment of radial head fractures: Delphi methodology

The treatment of partially displaced radial head fractures is determined not only by the type of fracture but also by patient characteristics such as age, occupation, hand dominance, mechanism of injury, and concomitant injuries and comorbidities. The goal of this study was to employ the Delphi method to achieve consensus on the management of patients with radial head fractures, utilizing the experience of the ASES Elbow Fracture-Dislocation Multicenter Study Group and Mayo Elbow Club surgeons. The initial survey was sent to participants, which included consent to participate in the study and questions about their experience, knowledge, and interest in participating in the Delphi method. We used both open-ended and category-based questions. The second questionnaire generated 76 variables, and individual questions with mean Likert ratings of <2.0 or >4.0 were deemed significant and merged to form multifactorial clinical scenarios relating to both nonoperative and operative management, respectively. Of the surgeons who responded to the questionnaire, 64% were from the United States, while the remainder were from overseas practices. Years in practice on average were 12.4years (range, 1-40). Seven of the 76 factors met the criteria of a mean Likert score of <2.0 or >4.0. These factors were as follows: age, block to the range of motion (ROM) after aspiration/injection, crepitation with ROM, tenderness over the distal radioulnar joint and/or interosseous membrane (dorsal forearm), gap and/or displacement >2mm on imaging, complete loss of contact of the head with the rest of the radius on imaging, and fracture head involvement 30% on imaging. Twenty-two (46%) of the 96 clinical scenarios gained >90% consensus in favor of surgical treatment, whereas 8 (17%) reached >90% consensus in favor of nonoperative treatment. Obtaining expert consensus on the treatment of radial head fractures remains challenging. Certain factors such as gap/displacement ≥2mm without complete loss of contact, ≥30% head involvement with a block to an ROM regardless of tenderness over distal radioulnar joint or interosseous membrane (dorsal forearm), or crepitation when the patient was <80years of age led to a recommendation of operative treatment in 100% of the surveyed surgeons. Patients older than 80years with no block to ROM after aspiration/injection, no crepitation with ROM, and no tenderness on distal radioulnar joint/interosseous membrane (dorsal forearm) were recommended for nonoperative treatment regardless of the size of the radial head involvement on imaging.

MOMMY RN DERMATITIS

<h3>Introduction</h3> The COVID-19 pandemic has highlighted the importance of hand hygiene and led to the increased use of sanitizing gels and wipes. Here we describe a case of contact dermatitis due to sanitizing gels and wipes which was misdiagnosed as eczema for 3 years. <h3>Case Description</h3> A 40-year-old Guyanese female presented for evaluation of pruritic rash. She has seen several dermatologists and diagnosed with eczematous dermatitis. She has been prescribed topical 0.1% triamcinolone and a course of oral steroids with temporary improvement in symptoms. She had tried oral antihistamines with no improvement. On interview, she reported a rash predominantly on her hands which began in early 2020 and had worsened in the past year. Social history is significant for working as a registered nurse and having a baby 9 months ago. She admitted to frequent use of Clorox wipes without gloves at home since her baby was born. On exam she had numerous small papules with flare on bilateral dorsal hand, forearm, right orbit, and upper back. Patch testing was done and positive for benzyl alcohol. We recommended she use soap and water to clean her hands, avoid alcohol gels, and use gloves when using antiseptic wipes. She had abrupt improvement in symptoms. <h3>Discussion</h3> This case emphasizes the importance of cleaning gels and wipes as a cause of contact dermatitis. It particularly important to remember in the context of healthcare workers who frequently clean their hands, new parents who may using sanitizing wipes more often, and people with darker colored skin.

Scaly forearm plaque

A 62-year-old woman with a history of type 2 diabetes presented to Dermatology with a nonhealing, nonpainful wound on her left dorsal forearm that had been present for 6 months. She had tried over-the-counter moisturizers, but they had not led to any improvement in the appearance of her skin.What’s your diagnosis?