Practical Pearls

Practice Gap

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by inflammatory nodules, abscesses, sinus tracts, fistulae, and scarring, mainly in intertriginous areas. The extent of disease—classified using the Hurley staging system (stages I–III)—helps guide treatment, which includes medical management and surgical intervention in later stages.

First-line treatment of HS includes topical or systemic medications, or both. Surgical therapy typically is reserved for refractory HS in moderate to severe disease (Hurley stages II and III) and is combined with pharmacotherapy. Specifically, clinical management guidelines issued by an expert committee of the United States and Canadian Hidradenitis Suppurativa Foundations recommend excision or deroofing for recurrent nodules and tunnels.¹

Surgical options for HS that are available to the outpatient dermatologist include incision and drainage, electrosurgery, CO₂ laser evaporation, excision, and deroofing (also known as unroofing).² Deroofing is a fairly novel therapy; many dermatologists are unfamiliar with the procedure. A PubMed search of articles indexed for MEDLINE related to HS prior to 2010 revealed only 1 article containing the word deroofing and only 4 articles containing unroofing.

The pathophysiology of HS has important implications for successful treatment. Inflammation of the follicular pilosebaceous unit along with follicular occlusion create challenges with treatment.³ It is postulated that a defect in the glassy membrane of the infra-infundibular wall predisposes the pilosebaceous follicle to lose its structural integrality as pressure builds from plugging of the duct,⁴ which can result in the clinical hallmarks of HS including tunneling tracts, bridging nodules, abscesses, and fistulae that form with lateral expansion of the plugged follicle.

Leaking of the contents of these plugged follicles into surrounding tissue produces an inflammatory response in characteristic HS lesions. Because debris within the lesions moves laterally instead of being able to burst to the surface, the lesions have difficulty fully healing. Unroofing the lesions and removing built-up debris allows them to heal more expediently and quiets the underlying immune response by removing the stimulus.⁴

Herein, we describe the benefits, risks, and surgical process of deroofing for HS.

Technique and Tools

Deroofing is performed under local anesthesia, stepwise as follows:

1. Identify sinus tracts and infiltrate the area with lidocaine (Figure, A).

2. Use a blunt probe to define the borders of the area to be unroofed and to evaluate for any communicating sinus tracts (Figure, B).

3. Remove the roof of underlying abscesses and tracts, using a probe as a guide (Figure, C).

4. Enter through the skin or sinus opening using electrocautery or with a scalpel or scissors; perform blunt dissection.

5. Reflect back the entirety of skin overlying the probed areas and remove the skin to expose the base of the lesion (Figure, D).

6. Explore the exposed base and walls of the lesion with the probe again to assess for hidden tracts; take care not to create false tracts.

7. Debride the surgical wound using curettage or rough gauze grattage to remove remaining inflammatory debris or biofilm. To achieve hemostasis, apply aluminum chloride or ferric chloride. Coat the wound with petroleum jelly and gauze and allow it to heal by secondary intention.

8. Educate the patient on wound care—once-daily gentle cleansing with soap and water, followed by application of a moist dressing—which is similar to wound healing by secondary intention from other causes.^2,4

Practice Implications

A deroofing procedure has many benefits compared to other surgical modalities for the treatment of HS. Deroofing requires only a probe, curette, and electrocautery device, making the procedure more cost-effective than excision, which requires a full tray of equipment and sutures. Furthermore, margins do not need to be taken with deroofing, and no undermining or closure is needed, which saves time during the operation and minimizes the risk for complications, including dehiscence and formation of new sinus tracts.⁴ No specialized equipment, such as a CO₂ laser, is required, which makes deroofing accessible to every clinical dermatologist in any demographic or geographic setting.

Evidence of Benefit—Saylor and colleagues⁵ found that deroofing carries a 12.5% complication rate, which includes postoperative bleeding, hypergranulation tissue, and rarely wound infection. This rate is significantly lower than the 26% complication rate associated with local excision, which includes wound dehiscence, infection, and contracture (P<.001). Deroofing also was found to have an HS recurrence rate of 14.5%, which is significantly less than the 30% recurrence rate seen with local excision (P=.015). Saylor et al⁵ also concluded that incision and drainage was recommended only for immediate relief of HS because of its 100% recurrence rate.

van der Zee² reported on 88 lesions from 44 patients that were treated by surgical deroofing, resulting in an average defect of 3.0 cm in length and a mean healing time of 14 days. The typical outcome was cosmetically acceptable scarring; this finding was supported by a postoperative survey (>1 year), to which 37 of 44 patients responded and assigned an average satisfaction score of 8 (of a possible 10) and a recommendation rate of 90%.²

Procedural Coding—Specific Current Procedural Terminology codes (11450-11471) from the International Classification of Diseases, Tenth Revision, exist for HS deroofing procedures; the applicable code for a given case depends on the final length of the surgical defect. Documentation to support these codes is similar to the note for an excision procedure, taking care to include location, depth, and length of the excision; healing by secondary intention; and the diagnosis of HS.

Final Thoughts

Deroofing is a surgical option that can be beneficial to patients with HS. It is a relatively simple procedure available to any dermatologist, regardless of setting. We encourage dermatologists to consider deroofing, even in patients with Hurley stage II lesions, because it can yield cosmetically acceptable and definitive results, given the variety of therapies available for HS. Deroofing also can be superior to standard excision, especially because of the potential complications with standard excision and quicker operative time with deroofing. As more providers become familiar with the deroofing procedure for HS, further studies can be undertaken to add to the paucity of data about deroofing and how it compares to other surgical treatments.

Practice Gap

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by inflammatory nodules, abscesses, sinus tracts, fistulae, and scarring, mainly in intertriginous areas. The extent of disease—classified using the Hurley staging system (stages I–III)—helps guide treatment, which includes medical management and surgical intervention in later stages.

First-line treatment of HS includes topical or systemic medications, or both. Surgical therapy typically is reserved for refractory HS in moderate to severe disease (Hurley stages II and III) and is combined with pharmacotherapy. Specifically, clinical management guidelines issued by an expert committee of the United States and Canadian Hidradenitis Suppurativa Foundations recommend excision or deroofing for recurrent nodules and tunnels.¹

Surgical options for HS that are available to the outpatient dermatologist include incision and drainage, electrosurgery, CO₂ laser evaporation, excision, and deroofing (also known as unroofing).² Deroofing is a fairly novel therapy; many dermatologists are unfamiliar with the procedure. A PubMed search of articles indexed for MEDLINE related to HS prior to 2010 revealed only 1 article containing the word deroofing and only 4 articles containing unroofing.

The pathophysiology of HS has important implications for successful treatment. Inflammation of the follicular pilosebaceous unit along with follicular occlusion create challenges with treatment.³ It is postulated that a defect in the glassy membrane of the infra-infundibular wall predisposes the pilosebaceous follicle to lose its structural integrality as pressure builds from plugging of the duct,⁴ which can result in the clinical hallmarks of HS including tunneling tracts, bridging nodules, abscesses, and fistulae that form with lateral expansion of the plugged follicle.

Leaking of the contents of these plugged follicles into surrounding tissue produces an inflammatory response in characteristic HS lesions. Because debris within the lesions moves laterally instead of being able to burst to the surface, the lesions have difficulty fully healing. Unroofing the lesions and removing built-up debris allows them to heal more expediently and quiets the underlying immune response by removing the stimulus.⁴

Herein, we describe the benefits, risks, and surgical process of deroofing for HS.

Technique and Tools

Deroofing is performed under local anesthesia, stepwise as follows:

1. Identify sinus tracts and infiltrate the area with lidocaine (Figure, A).

2. Use a blunt probe to define the borders of the area to be unroofed and to evaluate for any communicating sinus tracts (Figure, B).

3. Remove the roof of underlying abscesses and tracts, using a probe as a guide (Figure, C).

4. Enter through the skin or sinus opening using electrocautery or with a scalpel or scissors; perform blunt dissection.

5. Reflect back the entirety of skin overlying the probed areas and remove the skin to expose the base of the lesion (Figure, D).

6. Explore the exposed base and walls of the lesion with the probe again to assess for hidden tracts; take care not to create false tracts.

7. Debride the surgical wound using curettage or rough gauze grattage to remove remaining inflammatory debris or biofilm. To achieve hemostasis, apply aluminum chloride or ferric chloride. Coat the wound with petroleum jelly and gauze and allow it to heal by secondary intention.

8. Educate the patient on wound care—once-daily gentle cleansing with soap and water, followed by application of a moist dressing—which is similar to wound healing by secondary intention from other causes.^2,4

Practice Implications

A deroofing procedure has many benefits compared to other surgical modalities for the treatment of HS. Deroofing requires only a probe, curette, and electrocautery device, making the procedure more cost-effective than excision, which requires a full tray of equipment and sutures. Furthermore, margins do not need to be taken with deroofing, and no undermining or closure is needed, which saves time during the operation and minimizes the risk for complications, including dehiscence and formation of new sinus tracts.⁴ No specialized equipment, such as a CO₂ laser, is required, which makes deroofing accessible to every clinical dermatologist in any demographic or geographic setting.

Evidence of Benefit—Saylor and colleagues⁵ found that deroofing carries a 12.5% complication rate, which includes postoperative bleeding, hypergranulation tissue, and rarely wound infection. This rate is significantly lower than the 26% complication rate associated with local excision, which includes wound dehiscence, infection, and contracture (P<.001). Deroofing also was found to have an HS recurrence rate of 14.5%, which is significantly less than the 30% recurrence rate seen with local excision (P=.015). Saylor et al⁵ also concluded that incision and drainage was recommended only for immediate relief of HS because of its 100% recurrence rate.

van der Zee² reported on 88 lesions from 44 patients that were treated by surgical deroofing, resulting in an average defect of 3.0 cm in length and a mean healing time of 14 days. The typical outcome was cosmetically acceptable scarring; this finding was supported by a postoperative survey (>1 year), to which 37 of 44 patients responded and assigned an average satisfaction score of 8 (of a possible 10) and a recommendation rate of 90%.²

Procedural Coding—Specific Current Procedural Terminology codes (11450-11471) from the International Classification of Diseases, Tenth Revision, exist for HS deroofing procedures; the applicable code for a given case depends on the final length of the surgical defect. Documentation to support these codes is similar to the note for an excision procedure, taking care to include location, depth, and length of the excision; healing by secondary intention; and the diagnosis of HS.

Final Thoughts

Deroofing is a surgical option that can be beneficial to patients with HS. It is a relatively simple procedure available to any dermatologist, regardless of setting. We encourage dermatologists to consider deroofing, even in patients with Hurley stage II lesions, because it can yield cosmetically acceptable and definitive results, given the variety of therapies available for HS. Deroofing also can be superior to standard excision, especially because of the potential complications with standard excision and quicker operative time with deroofing. As more providers become familiar with the deroofing procedure for HS, further studies can be undertaken to add to the paucity of data about deroofing and how it compares to other surgical treatments.

Practice Gap

Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition characterized by inflammatory nodules, abscesses, sinus tracts, fistulae, and scarring, mainly in intertriginous areas. The extent of disease—classified using the Hurley staging system (stages I–III)—helps guide treatment, which includes medical management and surgical intervention in later stages.

First-line treatment of HS includes topical or systemic medications, or both. Surgical therapy typically is reserved for refractory HS in moderate to severe disease (Hurley stages II and III) and is combined with pharmacotherapy. Specifically, clinical management guidelines issued by an expert committee of the United States and Canadian Hidradenitis Suppurativa Foundations recommend excision or deroofing for recurrent nodules and tunnels.¹

Surgical options for HS that are available to the outpatient dermatologist include incision and drainage, electrosurgery, CO₂ laser evaporation, excision, and deroofing (also known as unroofing).² Deroofing is a fairly novel therapy; many dermatologists are unfamiliar with the procedure. A PubMed search of articles indexed for MEDLINE related to HS prior to 2010 revealed only 1 article containing the word deroofing and only 4 articles containing unroofing.

The pathophysiology of HS has important implications for successful treatment. Inflammation of the follicular pilosebaceous unit along with follicular occlusion create challenges with treatment.³ It is postulated that a defect in the glassy membrane of the infra-infundibular wall predisposes the pilosebaceous follicle to lose its structural integrality as pressure builds from plugging of the duct,⁴ which can result in the clinical hallmarks of HS including tunneling tracts, bridging nodules, abscesses, and fistulae that form with lateral expansion of the plugged follicle.

Leaking of the contents of these plugged follicles into surrounding tissue produces an inflammatory response in characteristic HS lesions. Because debris within the lesions moves laterally instead of being able to burst to the surface, the lesions have difficulty fully healing. Unroofing the lesions and removing built-up debris allows them to heal more expediently and quiets the underlying immune response by removing the stimulus.⁴

Herein, we describe the benefits, risks, and surgical process of deroofing for HS.

Technique and Tools

Deroofing is performed under local anesthesia, stepwise as follows:

1. Identify sinus tracts and infiltrate the area with lidocaine (Figure, A).

2. Use a blunt probe to define the borders of the area to be unroofed and to evaluate for any communicating sinus tracts (Figure, B).

3. Remove the roof of underlying abscesses and tracts, using a probe as a guide (Figure, C).

4. Enter through the skin or sinus opening using electrocautery or with a scalpel or scissors; perform blunt dissection.

5. Reflect back the entirety of skin overlying the probed areas and remove the skin to expose the base of the lesion (Figure, D).

6. Explore the exposed base and walls of the lesion with the probe again to assess for hidden tracts; take care not to create false tracts.

7. Debride the surgical wound using curettage or rough gauze grattage to remove remaining inflammatory debris or biofilm. To achieve hemostasis, apply aluminum chloride or ferric chloride. Coat the wound with petroleum jelly and gauze and allow it to heal by secondary intention.

8. Educate the patient on wound care—once-daily gentle cleansing with soap and water, followed by application of a moist dressing—which is similar to wound healing by secondary intention from other causes.^2,4

Practice Implications

A deroofing procedure has many benefits compared to other surgical modalities for the treatment of HS. Deroofing requires only a probe, curette, and electrocautery device, making the procedure more cost-effective than excision, which requires a full tray of equipment and sutures. Furthermore, margins do not need to be taken with deroofing, and no undermining or closure is needed, which saves time during the operation and minimizes the risk for complications, including dehiscence and formation of new sinus tracts.⁴ No specialized equipment, such as a CO₂ laser, is required, which makes deroofing accessible to every clinical dermatologist in any demographic or geographic setting.

Evidence of Benefit—Saylor and colleagues⁵ found that deroofing carries a 12.5% complication rate, which includes postoperative bleeding, hypergranulation tissue, and rarely wound infection. This rate is significantly lower than the 26% complication rate associated with local excision, which includes wound dehiscence, infection, and contracture (P<.001). Deroofing also was found to have an HS recurrence rate of 14.5%, which is significantly less than the 30% recurrence rate seen with local excision (P=.015). Saylor et al⁵ also concluded that incision and drainage was recommended only for immediate relief of HS because of its 100% recurrence rate.

van der Zee² reported on 88 lesions from 44 patients that were treated by surgical deroofing, resulting in an average defect of 3.0 cm in length and a mean healing time of 14 days. The typical outcome was cosmetically acceptable scarring; this finding was supported by a postoperative survey (>1 year), to which 37 of 44 patients responded and assigned an average satisfaction score of 8 (of a possible 10) and a recommendation rate of 90%.²

Procedural Coding—Specific Current Procedural Terminology codes (11450-11471) from the International Classification of Diseases, Tenth Revision, exist for HS deroofing procedures; the applicable code for a given case depends on the final length of the surgical defect. Documentation to support these codes is similar to the note for an excision procedure, taking care to include location, depth, and length of the excision; healing by secondary intention; and the diagnosis of HS.

Final Thoughts

Deroofing is a surgical option that can be beneficial to patients with HS. It is a relatively simple procedure available to any dermatologist, regardless of setting. We encourage dermatologists to consider deroofing, even in patients with Hurley stage II lesions, because it can yield cosmetically acceptable and definitive results, given the variety of therapies available for HS. Deroofing also can be superior to standard excision, especially because of the potential complications with standard excision and quicker operative time with deroofing. As more providers become familiar with the deroofing procedure for HS, further studies can be undertaken to add to the paucity of data about deroofing and how it compares to other surgical treatments.

Practice Gap

Nonmelanoma skin cancer is the most common cancer, typically growing in sun-exposed areas. As such, the nasal area is a common site of onset, constituting approximately 25% of cases. Surgical excision of these cancers generally has a high cure rate.¹

Although complete excision of the tumor is the primary goal of the dermatologic surgeon, achieving a cosmetically satisfactory scar also is important. As a prominent feature of the face, any irregularities to the nose are easily noticeable.² The subsequent scar may exhibit features that are less than ideal and cause notable stress to the patient.

When a scar presents with several complications, using a single surgical technique may not sufficiently address all defects. As a result, it can be challenging for the surgeon to decide which combination of methods among the myriad of nonsurgical and surgical options for scar revision will produce the best cosmetic outcome.

Case and Technique

A 76-year-old man presented 1 year after he underwent Mohs micrographic surgery for squamous cell carcinoma on the nasal dorsum. The tumor cleared after 1 stage and was repaired using a bilateral V-Y advancement flap. Postoperatively, the patient developed pincushioning of the flap, atrophic scarring inferior to the flap, and webbing of the pivotal restraint point at the nasal root (Figures 1A and 1B). We opted to address the pincushioning and nasal root webbing by defatting the flap and performing Z-plasty, respectively.

Pincushioning—Pincushioning of a flap arises due to contraction and lymphedema at the edge of the repair. It is seen more often in nasal repairs due to the limited availability of surrounding skin and changes in skin texture from rhinion to tip.³ To combat this in our patient, an incision was made around the site of the original flap, surrounding tissue was undermined, and the flap was reflected back. Subcutaneous tissue was removed with scissors. The flap was then laid back into the defect, and the subcutaneous tissue and dermis were closed with interrupted buried vertical mattress sutures. The epidermis was closed in a simple running fashion.

Webbing—Webbing of a scar also may develop from the contractile wound-healing process.⁴ Z-plasty commonly is used to camouflage a linear or contracted scar, increase skin availability in an area, or alter scar direction to better align with skin-tension lines.^5,6 In our patient, we incised the webbing of the nasal root along the vertical scar. Two arms were drawn at each end of the scar at a 60° angle (Figure 2); the side arms were drawn equal in length and incised vertically. Full-thickness skin flaps were then undermined at the level of subcutaneous fat, creating 2 triangular flaps. Adequate undermining of the surrounding subcutaneous tissue was performed to achieve proper mobilization of the flaps, which allowed for flap transposition to occur without tension and therefore for proper redirection of the scar.⁶ The flaps were secured using buried vertical mattress sutures and simple running sutures. Using too many buried interrupted sutures can cause vascular compromise of the fragile tips of the Z and should be avoided.³

At 4-month postoperative follow-up, the cosmetic outcome was judged satisfactory (Figure 1C).

Practice Implications

In our patient, pincushioning of the flap was easily addressed by defatting the area. However, doing just this would not have sufficed and necessitated another surgical technique—the Z-plasty—which needed to be designed carefully. The larger the angle between the side arms and central limb, the greater directional change and scar length that is gained (Figure 3). As a result, longer limbs and a greater angle could advantageously break up the scar line but consequently would lengthen the scar considerably. Therefore, if the scar was longer or the skin was inelastic, multiple Z-plasty procedures may have been preferred.

Additionally, for each central limb, both mirror-image options for peripheral arms were considered, with the optimal choice being the one that allowed for final scar lines to mimic relaxed skin-tension lines. Accuracy of the incisions was critical and was assessed by drawing a line between the free ends of the lateral limbs of the Z; this line should pass perpendicularly through the midpoint of the central limb. Last, as with other transposition flap options, Z-plasty has the potential to create a trapdoor or pincushion effect; we reduced this risk by wide undermining to establish an even contraction plate.⁶

When planning the revision, we considered multiple approaches to achieve the best aesthetic outcome in 1 stage. Had there been notable depression in the scar, we may have used a full-thickness skin graft. If the skin surface was lumpy and uneven, dermabrasion or a laser may have been utilized. Another consideration was to avoid using intralesional steroids, which could have made the already atrophied portions of the scar worse.

Overall, the surgical plan that we chose took into consideration the patient’s nasal anatomic structure, the combination of scar defects, the patient’s desires, and the tools available.

Final Thoughts

The ideal scar is inconspicuous, does not impair the function of surrounding structures, and blends well with adjacent skin.⁵ Consequently, the combination of pincushioning and webbing of a scar, especially in the nasal area, can pose a surgical challenge to the surgeon and can cause severe anxiety in the patient. In those circumstances, a single surgical technique is not likely to produce the revision with the best cosmetic outcome. Therefore, the synergy of 2 or more surgical techniques with proper planning and meticulous selection may be necessary. A broad knowledge of various scar revision techniques increases the surgeon’s capability to create the ideal scar.

Acknowledgment—The authors thank the case patient for granting permission to publish this information.

Practice Gap

Nonmelanoma skin cancer is the most common cancer, typically growing in sun-exposed areas. As such, the nasal area is a common site of onset, constituting approximately 25% of cases. Surgical excision of these cancers generally has a high cure rate.¹

Although complete excision of the tumor is the primary goal of the dermatologic surgeon, achieving a cosmetically satisfactory scar also is important. As a prominent feature of the face, any irregularities to the nose are easily noticeable.² The subsequent scar may exhibit features that are less than ideal and cause notable stress to the patient.

When a scar presents with several complications, using a single surgical technique may not sufficiently address all defects. As a result, it can be challenging for the surgeon to decide which combination of methods among the myriad of nonsurgical and surgical options for scar revision will produce the best cosmetic outcome.

Case and Technique

A 76-year-old man presented 1 year after he underwent Mohs micrographic surgery for squamous cell carcinoma on the nasal dorsum. The tumor cleared after 1 stage and was repaired using a bilateral V-Y advancement flap. Postoperatively, the patient developed pincushioning of the flap, atrophic scarring inferior to the flap, and webbing of the pivotal restraint point at the nasal root (Figures 1A and 1B). We opted to address the pincushioning and nasal root webbing by defatting the flap and performing Z-plasty, respectively.

Pincushioning—Pincushioning of a flap arises due to contraction and lymphedema at the edge of the repair. It is seen more often in nasal repairs due to the limited availability of surrounding skin and changes in skin texture from rhinion to tip.³ To combat this in our patient, an incision was made around the site of the original flap, surrounding tissue was undermined, and the flap was reflected back. Subcutaneous tissue was removed with scissors. The flap was then laid back into the defect, and the subcutaneous tissue and dermis were closed with interrupted buried vertical mattress sutures. The epidermis was closed in a simple running fashion.

Webbing—Webbing of a scar also may develop from the contractile wound-healing process.⁴ Z-plasty commonly is used to camouflage a linear or contracted scar, increase skin availability in an area, or alter scar direction to better align with skin-tension lines.^5,6 In our patient, we incised the webbing of the nasal root along the vertical scar. Two arms were drawn at each end of the scar at a 60° angle (Figure 2); the side arms were drawn equal in length and incised vertically. Full-thickness skin flaps were then undermined at the level of subcutaneous fat, creating 2 triangular flaps. Adequate undermining of the surrounding subcutaneous tissue was performed to achieve proper mobilization of the flaps, which allowed for flap transposition to occur without tension and therefore for proper redirection of the scar.⁶ The flaps were secured using buried vertical mattress sutures and simple running sutures. Using too many buried interrupted sutures can cause vascular compromise of the fragile tips of the Z and should be avoided.³

At 4-month postoperative follow-up, the cosmetic outcome was judged satisfactory (Figure 1C).

Practice Implications

In our patient, pincushioning of the flap was easily addressed by defatting the area. However, doing just this would not have sufficed and necessitated another surgical technique—the Z-plasty—which needed to be designed carefully. The larger the angle between the side arms and central limb, the greater directional change and scar length that is gained (Figure 3). As a result, longer limbs and a greater angle could advantageously break up the scar line but consequently would lengthen the scar considerably. Therefore, if the scar was longer or the skin was inelastic, multiple Z-plasty procedures may have been preferred.

Additionally, for each central limb, both mirror-image options for peripheral arms were considered, with the optimal choice being the one that allowed for final scar lines to mimic relaxed skin-tension lines. Accuracy of the incisions was critical and was assessed by drawing a line between the free ends of the lateral limbs of the Z; this line should pass perpendicularly through the midpoint of the central limb. Last, as with other transposition flap options, Z-plasty has the potential to create a trapdoor or pincushion effect; we reduced this risk by wide undermining to establish an even contraction plate.⁶

When planning the revision, we considered multiple approaches to achieve the best aesthetic outcome in 1 stage. Had there been notable depression in the scar, we may have used a full-thickness skin graft. If the skin surface was lumpy and uneven, dermabrasion or a laser may have been utilized. Another consideration was to avoid using intralesional steroids, which could have made the already atrophied portions of the scar worse.

Overall, the surgical plan that we chose took into consideration the patient’s nasal anatomic structure, the combination of scar defects, the patient’s desires, and the tools available.

Final Thoughts

The ideal scar is inconspicuous, does not impair the function of surrounding structures, and blends well with adjacent skin.⁵ Consequently, the combination of pincushioning and webbing of a scar, especially in the nasal area, can pose a surgical challenge to the surgeon and can cause severe anxiety in the patient. In those circumstances, a single surgical technique is not likely to produce the revision with the best cosmetic outcome. Therefore, the synergy of 2 or more surgical techniques with proper planning and meticulous selection may be necessary. A broad knowledge of various scar revision techniques increases the surgeon’s capability to create the ideal scar.

Acknowledgment—The authors thank the case patient for granting permission to publish this information.

Practice Gap

Nonmelanoma skin cancer is the most common cancer, typically growing in sun-exposed areas. As such, the nasal area is a common site of onset, constituting approximately 25% of cases. Surgical excision of these cancers generally has a high cure rate.¹

Although complete excision of the tumor is the primary goal of the dermatologic surgeon, achieving a cosmetically satisfactory scar also is important. As a prominent feature of the face, any irregularities to the nose are easily noticeable.² The subsequent scar may exhibit features that are less than ideal and cause notable stress to the patient.

When a scar presents with several complications, using a single surgical technique may not sufficiently address all defects. As a result, it can be challenging for the surgeon to decide which combination of methods among the myriad of nonsurgical and surgical options for scar revision will produce the best cosmetic outcome.

Case and Technique

A 76-year-old man presented 1 year after he underwent Mohs micrographic surgery for squamous cell carcinoma on the nasal dorsum. The tumor cleared after 1 stage and was repaired using a bilateral V-Y advancement flap. Postoperatively, the patient developed pincushioning of the flap, atrophic scarring inferior to the flap, and webbing of the pivotal restraint point at the nasal root (Figures 1A and 1B). We opted to address the pincushioning and nasal root webbing by defatting the flap and performing Z-plasty, respectively.

Pincushioning—Pincushioning of a flap arises due to contraction and lymphedema at the edge of the repair. It is seen more often in nasal repairs due to the limited availability of surrounding skin and changes in skin texture from rhinion to tip.³ To combat this in our patient, an incision was made around the site of the original flap, surrounding tissue was undermined, and the flap was reflected back. Subcutaneous tissue was removed with scissors. The flap was then laid back into the defect, and the subcutaneous tissue and dermis were closed with interrupted buried vertical mattress sutures. The epidermis was closed in a simple running fashion.

Webbing—Webbing of a scar also may develop from the contractile wound-healing process.⁴ Z-plasty commonly is used to camouflage a linear or contracted scar, increase skin availability in an area, or alter scar direction to better align with skin-tension lines.^5,6 In our patient, we incised the webbing of the nasal root along the vertical scar. Two arms were drawn at each end of the scar at a 60° angle (Figure 2); the side arms were drawn equal in length and incised vertically. Full-thickness skin flaps were then undermined at the level of subcutaneous fat, creating 2 triangular flaps. Adequate undermining of the surrounding subcutaneous tissue was performed to achieve proper mobilization of the flaps, which allowed for flap transposition to occur without tension and therefore for proper redirection of the scar.⁶ The flaps were secured using buried vertical mattress sutures and simple running sutures. Using too many buried interrupted sutures can cause vascular compromise of the fragile tips of the Z and should be avoided.³

At 4-month postoperative follow-up, the cosmetic outcome was judged satisfactory (Figure 1C).

Practice Implications

In our patient, pincushioning of the flap was easily addressed by defatting the area. However, doing just this would not have sufficed and necessitated another surgical technique—the Z-plasty—which needed to be designed carefully. The larger the angle between the side arms and central limb, the greater directional change and scar length that is gained (Figure 3). As a result, longer limbs and a greater angle could advantageously break up the scar line but consequently would lengthen the scar considerably. Therefore, if the scar was longer or the skin was inelastic, multiple Z-plasty procedures may have been preferred.

Additionally, for each central limb, both mirror-image options for peripheral arms were considered, with the optimal choice being the one that allowed for final scar lines to mimic relaxed skin-tension lines. Accuracy of the incisions was critical and was assessed by drawing a line between the free ends of the lateral limbs of the Z; this line should pass perpendicularly through the midpoint of the central limb. Last, as with other transposition flap options, Z-plasty has the potential to create a trapdoor or pincushion effect; we reduced this risk by wide undermining to establish an even contraction plate.⁶

When planning the revision, we considered multiple approaches to achieve the best aesthetic outcome in 1 stage. Had there been notable depression in the scar, we may have used a full-thickness skin graft. If the skin surface was lumpy and uneven, dermabrasion or a laser may have been utilized. Another consideration was to avoid using intralesional steroids, which could have made the already atrophied portions of the scar worse.

Overall, the surgical plan that we chose took into consideration the patient’s nasal anatomic structure, the combination of scar defects, the patient’s desires, and the tools available.

Final Thoughts

The ideal scar is inconspicuous, does not impair the function of surrounding structures, and blends well with adjacent skin.⁵ Consequently, the combination of pincushioning and webbing of a scar, especially in the nasal area, can pose a surgical challenge to the surgeon and can cause severe anxiety in the patient. In those circumstances, a single surgical technique is not likely to produce the revision with the best cosmetic outcome. Therefore, the synergy of 2 or more surgical techniques with proper planning and meticulous selection may be necessary. A broad knowledge of various scar revision techniques increases the surgeon’s capability to create the ideal scar.

Acknowledgment—The authors thank the case patient for granting permission to publish this information.

Practice Gap

Dermatology residents can struggle with surgical closure early in their training years. Although experienced dermatologic surgeons may intuitively be able to align edges for maximal cosmesis, doing so can prove challenging in the context of learning basic surgical techniques for early residents.

Furthermore, local anesthesia can distort cutaneous anatomy and surgical landmarks, requiring the surgeon to reexamine their closure technique. Patients may require position changes or may make involuntary movements, both of which require dynamic thinking and planning on the part of the dermatologic surgeon to achieve optimal outcomes.

The Technique

We propose the use of sutures to intraoperatively guide placement of the dermal needle. This technique can be used for various closure types; here, we demonstrate its use in a standard elliptical excision.

To begin, a standard length to width ellipse ratio of 3:1 is drawn with appropriate margins around a neoplasm.¹ After excision and appropriate undermining of the ellipse, we typically use deep sutures to close the deep space. The first pass of the needle through tissue can be performed in a place of the surgeon’s preference but typically abides by the rule of halves or the zipper method (Figure 1A). To determine optimal placement of the second needle pass through tissue, we recommend applying gentle opposing traction forces to the wound apices to approximate the linear outcome of the wound edges. The surgeon can use a skin hook to guide placement of the needle to the contralateral wound edge in an unassisted method of this technique (Figure 1B). The surgeon’s assistant also can aid in applying cutaneous traction along the length of the excision if the surgeon wishes to free their hands (Figure 1C). Because the risk of needlestick injury at this step is small, it is prudent for the surgeon to advise the assistant to avoid needlestick injury by keeping their hands away from the needle path in the surgical site.

Although traction is being applied to the wound apices, the deep suture should extend across the wound with just enough pressure to leave a serosanguineous notched mark in the contralateral tissue edge (Figure 1D). After releasing traction on the wound edges, the surgeon can effortlessly visualize the target for needle placement and make a throw through the tissue accordingly.

This process can be continued until wound closure is complete (Figure 2). Top sutures or adhesive strips can be placed afterward for completing approximation of the wound edges superficially.

Practice Implications

By using this technique to align wound edges intraoperatively, the surgeon can have a functional guide for needle placement. The technique allows improvement of function and cosmesis of surgical wounds, while also accounting for topographical variations in the patient’s surgical site. Approximation of the wound edges is particularly important at the beginning of closure, as the wound edges align and approximate more with each subsequent stitch, with decreasing tension.²

In addition, when operating on a curvilinear or challenging topographical surface of the body, this technique can provide a clear template for guiding suture placement for approximating wound edges. Furthermore, local biodynamic anatomy might become distorted after excision of the tissue specimen due to release of centripetal tangential forces that were present in the pre-excised skin.¹ Local change in biodynamic forces may be difficult to plan for preoperatively using other techniques.³

Although this technique can be utilized for all suture placements in closure, it is of greatest value when placing the first few sutures and when operating on nonplanar surfaces that might become distorted after excision. To ensure the best outcome, it is important to be certain that the area has been properly cleaned prior to surgery and a sterile technique is used.

Practice Gap

Dermatology residents can struggle with surgical closure early in their training years. Although experienced dermatologic surgeons may intuitively be able to align edges for maximal cosmesis, doing so can prove challenging in the context of learning basic surgical techniques for early residents.

Furthermore, local anesthesia can distort cutaneous anatomy and surgical landmarks, requiring the surgeon to reexamine their closure technique. Patients may require position changes or may make involuntary movements, both of which require dynamic thinking and planning on the part of the dermatologic surgeon to achieve optimal outcomes.

The Technique

We propose the use of sutures to intraoperatively guide placement of the dermal needle. This technique can be used for various closure types; here, we demonstrate its use in a standard elliptical excision.

To begin, a standard length to width ellipse ratio of 3:1 is drawn with appropriate margins around a neoplasm.¹ After excision and appropriate undermining of the ellipse, we typically use deep sutures to close the deep space. The first pass of the needle through tissue can be performed in a place of the surgeon’s preference but typically abides by the rule of halves or the zipper method (Figure 1A). To determine optimal placement of the second needle pass through tissue, we recommend applying gentle opposing traction forces to the wound apices to approximate the linear outcome of the wound edges. The surgeon can use a skin hook to guide placement of the needle to the contralateral wound edge in an unassisted method of this technique (Figure 1B). The surgeon’s assistant also can aid in applying cutaneous traction along the length of the excision if the surgeon wishes to free their hands (Figure 1C). Because the risk of needlestick injury at this step is small, it is prudent for the surgeon to advise the assistant to avoid needlestick injury by keeping their hands away from the needle path in the surgical site.

Although traction is being applied to the wound apices, the deep suture should extend across the wound with just enough pressure to leave a serosanguineous notched mark in the contralateral tissue edge (Figure 1D). After releasing traction on the wound edges, the surgeon can effortlessly visualize the target for needle placement and make a throw through the tissue accordingly.

This process can be continued until wound closure is complete (Figure 2). Top sutures or adhesive strips can be placed afterward for completing approximation of the wound edges superficially.

Practice Implications

By using this technique to align wound edges intraoperatively, the surgeon can have a functional guide for needle placement. The technique allows improvement of function and cosmesis of surgical wounds, while also accounting for topographical variations in the patient’s surgical site. Approximation of the wound edges is particularly important at the beginning of closure, as the wound edges align and approximate more with each subsequent stitch, with decreasing tension.²

In addition, when operating on a curvilinear or challenging topographical surface of the body, this technique can provide a clear template for guiding suture placement for approximating wound edges. Furthermore, local biodynamic anatomy might become distorted after excision of the tissue specimen due to release of centripetal tangential forces that were present in the pre-excised skin.¹ Local change in biodynamic forces may be difficult to plan for preoperatively using other techniques.³

Although this technique can be utilized for all suture placements in closure, it is of greatest value when placing the first few sutures and when operating on nonplanar surfaces that might become distorted after excision. To ensure the best outcome, it is important to be certain that the area has been properly cleaned prior to surgery and a sterile technique is used.

Practice Gap

Dermatology residents can struggle with surgical closure early in their training years. Although experienced dermatologic surgeons may intuitively be able to align edges for maximal cosmesis, doing so can prove challenging in the context of learning basic surgical techniques for early residents.

Furthermore, local anesthesia can distort cutaneous anatomy and surgical landmarks, requiring the surgeon to reexamine their closure technique. Patients may require position changes or may make involuntary movements, both of which require dynamic thinking and planning on the part of the dermatologic surgeon to achieve optimal outcomes.

The Technique

We propose the use of sutures to intraoperatively guide placement of the dermal needle. This technique can be used for various closure types; here, we demonstrate its use in a standard elliptical excision.

To begin, a standard length to width ellipse ratio of 3:1 is drawn with appropriate margins around a neoplasm.¹ After excision and appropriate undermining of the ellipse, we typically use deep sutures to close the deep space. The first pass of the needle through tissue can be performed in a place of the surgeon’s preference but typically abides by the rule of halves or the zipper method (Figure 1A). To determine optimal placement of the second needle pass through tissue, we recommend applying gentle opposing traction forces to the wound apices to approximate the linear outcome of the wound edges. The surgeon can use a skin hook to guide placement of the needle to the contralateral wound edge in an unassisted method of this technique (Figure 1B). The surgeon’s assistant also can aid in applying cutaneous traction along the length of the excision if the surgeon wishes to free their hands (Figure 1C). Because the risk of needlestick injury at this step is small, it is prudent for the surgeon to advise the assistant to avoid needlestick injury by keeping their hands away from the needle path in the surgical site.

Although traction is being applied to the wound apices, the deep suture should extend across the wound with just enough pressure to leave a serosanguineous notched mark in the contralateral tissue edge (Figure 1D). After releasing traction on the wound edges, the surgeon can effortlessly visualize the target for needle placement and make a throw through the tissue accordingly.

This process can be continued until wound closure is complete (Figure 2). Top sutures or adhesive strips can be placed afterward for completing approximation of the wound edges superficially.

Practice Implications

By using this technique to align wound edges intraoperatively, the surgeon can have a functional guide for needle placement. The technique allows improvement of function and cosmesis of surgical wounds, while also accounting for topographical variations in the patient’s surgical site. Approximation of the wound edges is particularly important at the beginning of closure, as the wound edges align and approximate more with each subsequent stitch, with decreasing tension.²

In addition, when operating on a curvilinear or challenging topographical surface of the body, this technique can provide a clear template for guiding suture placement for approximating wound edges. Furthermore, local biodynamic anatomy might become distorted after excision of the tissue specimen due to release of centripetal tangential forces that were present in the pre-excised skin.¹ Local change in biodynamic forces may be difficult to plan for preoperatively using other techniques.³

Although this technique can be utilized for all suture placements in closure, it is of greatest value when placing the first few sutures and when operating on nonplanar surfaces that might become distorted after excision. To ensure the best outcome, it is important to be certain that the area has been properly cleaned prior to surgery and a sterile technique is used.

Practice Gap

Mycologic testing is necessary and cost-effective¹ for appropriate diagnosis and treatment of onychomycosis. Empiric treatment of onychodystrophy for presumed onychomycosis can result in misdiagnosis, treatment failure, or potential adverse effects caused by medications.² Collection of ample subungual debris facilitates the sensitivity and specificity of fungal culture and fungal polymerase chain reaction. However, the naturally pale hue of subungual debris makes specimen estimation challenging, particularly when using a similarly light-colored gauze or piece of paper for collection (Figure, A).

The Technique

A sheet from a black sticky notepad (widely available and cost-effective) can be adapted for making a diagnosis of onychomycosis (Figure, B).

Practical Implication

Use of a dark background that contrasts with light-hued nail debris is valuable to ensure an adequate specimen for fungal culture and polymerase chain reaction.

Practice Gap

Mycologic testing is necessary and cost-effective¹ for appropriate diagnosis and treatment of onychomycosis. Empiric treatment of onychodystrophy for presumed onychomycosis can result in misdiagnosis, treatment failure, or potential adverse effects caused by medications.² Collection of ample subungual debris facilitates the sensitivity and specificity of fungal culture and fungal polymerase chain reaction. However, the naturally pale hue of subungual debris makes specimen estimation challenging, particularly when using a similarly light-colored gauze or piece of paper for collection (Figure, A).

The Technique

A sheet from a black sticky notepad (widely available and cost-effective) can be adapted for making a diagnosis of onychomycosis (Figure, B).

Practical Implication

Use of a dark background that contrasts with light-hued nail debris is valuable to ensure an adequate specimen for fungal culture and polymerase chain reaction.

Practice Gap

Mycologic testing is necessary and cost-effective¹ for appropriate diagnosis and treatment of onychomycosis. Empiric treatment of onychodystrophy for presumed onychomycosis can result in misdiagnosis, treatment failure, or potential adverse effects caused by medications.² Collection of ample subungual debris facilitates the sensitivity and specificity of fungal culture and fungal polymerase chain reaction. However, the naturally pale hue of subungual debris makes specimen estimation challenging, particularly when using a similarly light-colored gauze or piece of paper for collection (Figure, A).

The Technique

A sheet from a black sticky notepad (widely available and cost-effective) can be adapted for making a diagnosis of onychomycosis (Figure, B).

Practical Implication

Use of a dark background that contrasts with light-hued nail debris is valuable to ensure an adequate specimen for fungal culture and polymerase chain reaction.

Practice Gap

Perioperative anxiety is common in patients undergoing nail surgery. Patients might worry about seeing blood; about the procedure itself, including nail avulsion; and about associated pain and disfigurement. Nail surgery causes a high level of anxiety that correlates positively with postoperative pain¹ and overall patient dissatisfaction. Furthermore, surgery-related anxiety is a predictor of increased postoperative analgesic use² and delayed recovery.³

Therefore, implementing strategies that reduce perioperative anxiety may help minimize postoperative pain. Squeezing a stress ball, hand-holding, virtual reality, and music are tools that have been studied to reduce anxiety in the context of Mohs micrographic surgery; these strategies have not been studied for nail surgery.

The Technique

Using a sleep mask is a practical solution to reduce patient anxiety during nail surgery. A minority of patients will choose to watch their surgical procedure; most become unnerved observing their nail surgery. Using a sleep mask diverts visual attention from the surgical field without physically interfering with the nail surgeon. Utilizing a sleep mask is cost-effective, with disposable sleep masks available online for less than $0.30 each. Patients can bring their own mask, or a mask can be offered prior to surgery.

If desired, patients are instructed to wear the sleep mask during the entirety of the procedure, starting from anesthetic infiltration until wound closure and dressing application. Any adjustments can be made with the patient’s free hand. The sleep mask can be offered to patients of all ages undergoing nail surgery under local anesthesia, except babies and young children, who require general anesthesia.

Practical Implications

Distraction is an important strategy to reduce anxiety and pain in patients undergoing surgical procedures. In an observational study of 3087 surgical patients, 36% reported that self-distraction was the most helpful strategy for coping with preoperative anxiety.⁴ In a randomized, open-label clinical trial of 72 patients undergoing peripheral venous catheterization, asking the patients simple questions during the procedure was more effective than local anesthesia in reducing the perception of pain.⁵

It is crucial to implement strategies to reduce anxiety in patients undergoing nail surgery. Using a sleep mask impedes direct visualization of the surgical field, thus distracting the patient’s sight and attention from the procedure. Furthermore, this technique is safe and cost-effective.

Controlled clinical trials are necessary to assess the efficacy of this method in reducing nail surgery–related anxiety in comparison to other techniques.

Practice Gap

Perioperative anxiety is common in patients undergoing nail surgery. Patients might worry about seeing blood; about the procedure itself, including nail avulsion; and about associated pain and disfigurement. Nail surgery causes a high level of anxiety that correlates positively with postoperative pain¹ and overall patient dissatisfaction. Furthermore, surgery-related anxiety is a predictor of increased postoperative analgesic use² and delayed recovery.³

Therefore, implementing strategies that reduce perioperative anxiety may help minimize postoperative pain. Squeezing a stress ball, hand-holding, virtual reality, and music are tools that have been studied to reduce anxiety in the context of Mohs micrographic surgery; these strategies have not been studied for nail surgery.

The Technique

Using a sleep mask is a practical solution to reduce patient anxiety during nail surgery. A minority of patients will choose to watch their surgical procedure; most become unnerved observing their nail surgery. Using a sleep mask diverts visual attention from the surgical field without physically interfering with the nail surgeon. Utilizing a sleep mask is cost-effective, with disposable sleep masks available online for less than $0.30 each. Patients can bring their own mask, or a mask can be offered prior to surgery.

If desired, patients are instructed to wear the sleep mask during the entirety of the procedure, starting from anesthetic infiltration until wound closure and dressing application. Any adjustments can be made with the patient’s free hand. The sleep mask can be offered to patients of all ages undergoing nail surgery under local anesthesia, except babies and young children, who require general anesthesia.

Practical Implications

Distraction is an important strategy to reduce anxiety and pain in patients undergoing surgical procedures. In an observational study of 3087 surgical patients, 36% reported that self-distraction was the most helpful strategy for coping with preoperative anxiety.⁴ In a randomized, open-label clinical trial of 72 patients undergoing peripheral venous catheterization, asking the patients simple questions during the procedure was more effective than local anesthesia in reducing the perception of pain.⁵

It is crucial to implement strategies to reduce anxiety in patients undergoing nail surgery. Using a sleep mask impedes direct visualization of the surgical field, thus distracting the patient’s sight and attention from the procedure. Furthermore, this technique is safe and cost-effective.

Controlled clinical trials are necessary to assess the efficacy of this method in reducing nail surgery–related anxiety in comparison to other techniques.

Practice Gap

Perioperative anxiety is common in patients undergoing nail surgery. Patients might worry about seeing blood; about the procedure itself, including nail avulsion; and about associated pain and disfigurement. Nail surgery causes a high level of anxiety that correlates positively with postoperative pain¹ and overall patient dissatisfaction. Furthermore, surgery-related anxiety is a predictor of increased postoperative analgesic use² and delayed recovery.³

Therefore, implementing strategies that reduce perioperative anxiety may help minimize postoperative pain. Squeezing a stress ball, hand-holding, virtual reality, and music are tools that have been studied to reduce anxiety in the context of Mohs micrographic surgery; these strategies have not been studied for nail surgery.

The Technique

Using a sleep mask is a practical solution to reduce patient anxiety during nail surgery. A minority of patients will choose to watch their surgical procedure; most become unnerved observing their nail surgery. Using a sleep mask diverts visual attention from the surgical field without physically interfering with the nail surgeon. Utilizing a sleep mask is cost-effective, with disposable sleep masks available online for less than $0.30 each. Patients can bring their own mask, or a mask can be offered prior to surgery.

If desired, patients are instructed to wear the sleep mask during the entirety of the procedure, starting from anesthetic infiltration until wound closure and dressing application. Any adjustments can be made with the patient’s free hand. The sleep mask can be offered to patients of all ages undergoing nail surgery under local anesthesia, except babies and young children, who require general anesthesia.

Practical Implications

Distraction is an important strategy to reduce anxiety and pain in patients undergoing surgical procedures. In an observational study of 3087 surgical patients, 36% reported that self-distraction was the most helpful strategy for coping with preoperative anxiety.⁴ In a randomized, open-label clinical trial of 72 patients undergoing peripheral venous catheterization, asking the patients simple questions during the procedure was more effective than local anesthesia in reducing the perception of pain.⁵

It is crucial to implement strategies to reduce anxiety in patients undergoing nail surgery. Using a sleep mask impedes direct visualization of the surgical field, thus distracting the patient’s sight and attention from the procedure. Furthermore, this technique is safe and cost-effective.

Controlled clinical trials are necessary to assess the efficacy of this method in reducing nail surgery–related anxiety in comparison to other techniques.

Practice Gap

Management of surgical wounds is a critical component of postsurgical care for patients during recovery at home.¹ However, postoperative wound care can be troublesome, time consuming, and expensive. Common problems with current standard dressings include an increased risk for infection, pain, and wound damage with frequent dressing changes.^2-4

Patients often are unable to take proper care of wounds themselves and may not have the financial means or social support to have others assist them.^4-6 For these patients, the option of a hassle-free dressing that they can leave on until their follow-up appointment is preferred. In our experience, what we call a 24-7 bandage has been remarkably successful in patients who are vulnerable to wound complications.

We report a comfortable, effective, and simple technique for wound dressings after dermatologic surgery.

The Technique

In Figure 1, we demonstrate a simple dressing technique that can be used to optimize wound healing in patients unable to provide adequate wound care for themselves:

1. The surgical site is covered with mupirocin ointment, followed by bismuth tribromophenate gauze (Figure 1A). The bismuth-impregnated gauze helps make the dressing nonadherent and moderately occlusive. It also adds moisture to the wound bed.

2. The gauze is then covered with excess mupirocin. A nonadherent dressing is applied (Figure 1B).

3. The entire area is covered with gauze and cover-roll nonlatex bandaging tape to ensure maximum adhesion (Figures 1C and 1D).

4. When the surgical site is on an extremity, it is wrapped in a self-adherent wrap or bandage roll to prevent clothing from pulling the tape loose.

Once this dressing technique is performed in the office, the bandage requires no wound care at home other than ensuring that the bandage is kept dry. The 24-7 dressing can be left on the surgical site for 7 days until the follow-up appointment. If necessary, it also can be applied for a second week after bolster removal or for multiple weeks following advanced flap repair.

Our patients find this dressing comfortable and unobtrusive. It is easy for the staff to apply and inexpensive.

Practical Implications

We have treated approximately 200 patients with the 24-7 dressing technique. Our experience is that these patients demonstrated an excellent aesthetic outcome without complications (Figure 2). We have successfully utilized the dressing in several anatomic locations, including the arms, legs, neck, face, and scalp. We use mupirocin for its antimicrobial activity, but we have not performed a study at our clinic looking at the difference between rate of infection and wound healing using mupirocin vs petrolatum. We prefer adding bulk gauze under the tape and leaving the dressing on for 7 days. We seldom have issues with bleeding, and if there is an issue, the patient is told to come back to our clinic so we can change the bandage for them.

This dressing technique is cost-effective to the patient and clinical staff, provides protection from potential injury to the sutures, decreases the risk for infection, and removes the stress and burden on the patient and family of frequent dressing changes. Furthermore, by preventing patient manipulation and frequent removal of the dressing, the wound retains adequate moisture during healing. This technique also can be applied to a variety of outpatient procedures other than Mohs micrographic surgery.

We hope that our colleagues find this 24-7 dressing technique for dressing wounds after dermatologic surgery useful in patient populations vulnerable to wound complications.

Practice Gap

Management of surgical wounds is a critical component of postsurgical care for patients during recovery at home.¹ However, postoperative wound care can be troublesome, time consuming, and expensive. Common problems with current standard dressings include an increased risk for infection, pain, and wound damage with frequent dressing changes.^2-4

Patients often are unable to take proper care of wounds themselves and may not have the financial means or social support to have others assist them.^4-6 For these patients, the option of a hassle-free dressing that they can leave on until their follow-up appointment is preferred. In our experience, what we call a 24-7 bandage has been remarkably successful in patients who are vulnerable to wound complications.

We report a comfortable, effective, and simple technique for wound dressings after dermatologic surgery.

The Technique

In Figure 1, we demonstrate a simple dressing technique that can be used to optimize wound healing in patients unable to provide adequate wound care for themselves:

1. The surgical site is covered with mupirocin ointment, followed by bismuth tribromophenate gauze (Figure 1A). The bismuth-impregnated gauze helps make the dressing nonadherent and moderately occlusive. It also adds moisture to the wound bed.

2. The gauze is then covered with excess mupirocin. A nonadherent dressing is applied (Figure 1B).

3. The entire area is covered with gauze and cover-roll nonlatex bandaging tape to ensure maximum adhesion (Figures 1C and 1D).

4. When the surgical site is on an extremity, it is wrapped in a self-adherent wrap or bandage roll to prevent clothing from pulling the tape loose.

Once this dressing technique is performed in the office, the bandage requires no wound care at home other than ensuring that the bandage is kept dry. The 24-7 dressing can be left on the surgical site for 7 days until the follow-up appointment. If necessary, it also can be applied for a second week after bolster removal or for multiple weeks following advanced flap repair.

Our patients find this dressing comfortable and unobtrusive. It is easy for the staff to apply and inexpensive.

Practical Implications

We have treated approximately 200 patients with the 24-7 dressing technique. Our experience is that these patients demonstrated an excellent aesthetic outcome without complications (Figure 2). We have successfully utilized the dressing in several anatomic locations, including the arms, legs, neck, face, and scalp. We use mupirocin for its antimicrobial activity, but we have not performed a study at our clinic looking at the difference between rate of infection and wound healing using mupirocin vs petrolatum. We prefer adding bulk gauze under the tape and leaving the dressing on for 7 days. We seldom have issues with bleeding, and if there is an issue, the patient is told to come back to our clinic so we can change the bandage for them.

This dressing technique is cost-effective to the patient and clinical staff, provides protection from potential injury to the sutures, decreases the risk for infection, and removes the stress and burden on the patient and family of frequent dressing changes. Furthermore, by preventing patient manipulation and frequent removal of the dressing, the wound retains adequate moisture during healing. This technique also can be applied to a variety of outpatient procedures other than Mohs micrographic surgery.

We hope that our colleagues find this 24-7 dressing technique for dressing wounds after dermatologic surgery useful in patient populations vulnerable to wound complications.

Practice Gap

Management of surgical wounds is a critical component of postsurgical care for patients during recovery at home.¹ However, postoperative wound care can be troublesome, time consuming, and expensive. Common problems with current standard dressings include an increased risk for infection, pain, and wound damage with frequent dressing changes.^2-4

Patients often are unable to take proper care of wounds themselves and may not have the financial means or social support to have others assist them.^4-6 For these patients, the option of a hassle-free dressing that they can leave on until their follow-up appointment is preferred. In our experience, what we call a 24-7 bandage has been remarkably successful in patients who are vulnerable to wound complications.

We report a comfortable, effective, and simple technique for wound dressings after dermatologic surgery.

The Technique

In Figure 1, we demonstrate a simple dressing technique that can be used to optimize wound healing in patients unable to provide adequate wound care for themselves:

1. The surgical site is covered with mupirocin ointment, followed by bismuth tribromophenate gauze (Figure 1A). The bismuth-impregnated gauze helps make the dressing nonadherent and moderately occlusive. It also adds moisture to the wound bed.

2. The gauze is then covered with excess mupirocin. A nonadherent dressing is applied (Figure 1B).

3. The entire area is covered with gauze and cover-roll nonlatex bandaging tape to ensure maximum adhesion (Figures 1C and 1D).

4. When the surgical site is on an extremity, it is wrapped in a self-adherent wrap or bandage roll to prevent clothing from pulling the tape loose.

Once this dressing technique is performed in the office, the bandage requires no wound care at home other than ensuring that the bandage is kept dry. The 24-7 dressing can be left on the surgical site for 7 days until the follow-up appointment. If necessary, it also can be applied for a second week after bolster removal or for multiple weeks following advanced flap repair.

Our patients find this dressing comfortable and unobtrusive. It is easy for the staff to apply and inexpensive.

Practical Implications

We have treated approximately 200 patients with the 24-7 dressing technique. Our experience is that these patients demonstrated an excellent aesthetic outcome without complications (Figure 2). We have successfully utilized the dressing in several anatomic locations, including the arms, legs, neck, face, and scalp. We use mupirocin for its antimicrobial activity, but we have not performed a study at our clinic looking at the difference between rate of infection and wound healing using mupirocin vs petrolatum. We prefer adding bulk gauze under the tape and leaving the dressing on for 7 days. We seldom have issues with bleeding, and if there is an issue, the patient is told to come back to our clinic so we can change the bandage for them.

This dressing technique is cost-effective to the patient and clinical staff, provides protection from potential injury to the sutures, decreases the risk for infection, and removes the stress and burden on the patient and family of frequent dressing changes. Furthermore, by preventing patient manipulation and frequent removal of the dressing, the wound retains adequate moisture during healing. This technique also can be applied to a variety of outpatient procedures other than Mohs micrographic surgery.

We hope that our colleagues find this 24-7 dressing technique for dressing wounds after dermatologic surgery useful in patient populations vulnerable to wound complications.

Practice Gap

Tuberous sclerosis complex (TSC) is an autosomal-dominant genetic disorder resulting in loss-of-function mutations in the TSC1 and TSC2 genes. These mutations lead to constitutive activation of the mitogenic mTOR pathway and release of lymphangiogenic growth factors, causing the formation of hamartomatous tumors throughout multiple organ systems.¹ Facial angiofibromas (FAs) are a common cutaneous manifestation of TSC, affecting up to 80% of patients worldwide.² Aesthetic disfigurement, vision obstruction, and breathing impairment often are associated with FAs. They frequently arise in children with TSC and impose a psychosocial burden that can affect the patient’s overall quality of life.

Cutaneous stigmata of TSC pose a significant therapeutic challenge. Topical sirolimus has become a first-line treatment of FAs by inhibiting the mitogenic mTOR pathway¹; however, thicker, more extensive lesions are less responsive to topical therapy. The entire dermis is involved in TSC, and topical sirolimus alone often is ineffective for large fibrous FAs.³ Likewise, oral mTOR inhibition has shown only 25% to 50% improvement in FAs and has potential side effects that can limit patients’ tolerance and compliance.⁴

The Technique

A 46-year-old man with TSC was referred to dermatology for treatment of numerous facial papules and plaques that had been present since childhood and were consistent with FAs (Figure 1A). The lesions were tender, impaired the patient’s breathing, and caused emotional distress. Dermabrasion was attempted 20 years prior with minimal improvement and subsequent progression of the FAs. Other stigmata of TSC were present, including cutaneous hypopigmented macules and shagreen patches as well as seizures and renal angiomyolipomas. Due to multiorgan involvement, the patient was started on once-daily oral everolimus 2.5 mg; however, the FAs were progressive despite the systemic mTOR inhibition. Furthermore, it was presumed that topical sirolimus monotherapy would be ineffective due to thickness and extent of FAs; therefore, we proposed a novel treatment approach combining initial surgical debulking with subsequent longitudinal use of topical sirolimus to reduce the risk of recurrence.

Local anesthesia with lidocaine 1% and epinephrine 1:100,000 was administered. Larger FAs were removed at the base with a sterile surgical blade. Nasal recontouring subsequently was performed using a combination of shave biopsy and curettage. Extensive electrocautery was performed for hemostasis and destruction of residual FAs. Figure 1B shows the immediate postoperative result.

One month postoperatively, the patient stopped the oral everolimus at his oncologist’s recommendation due to abdominal pain and peripheral edema. Once the abraded skin showed evidence of wound healing, the patient was instructed to initiate sirolimus ointment 1% twice daily to reduce the risk of recurrence.^1,5,6 At 8-week follow-up, the patient was noted to have cosmetic improvement and resolution of breathing impairment (Figure 2A). He continued to show excellent cosmetic results at 1-year follow-up using topical sirolimus monotherapy (Figure 2B).

Practical Implications

Surgical debulking combined with longitudinal use of sirolimus ointment 1% can achieve an optimal therapeutic response for disfiguring phymatous presentation of FAs in the setting of TSC. We believe it is an effective approach for thick disfiguring FAs that are unlikely to respond to mTOR inhibition alone.

Practice Gap

Tuberous sclerosis complex (TSC) is an autosomal-dominant genetic disorder resulting in loss-of-function mutations in the TSC1 and TSC2 genes. These mutations lead to constitutive activation of the mitogenic mTOR pathway and release of lymphangiogenic growth factors, causing the formation of hamartomatous tumors throughout multiple organ systems.¹ Facial angiofibromas (FAs) are a common cutaneous manifestation of TSC, affecting up to 80% of patients worldwide.² Aesthetic disfigurement, vision obstruction, and breathing impairment often are associated with FAs. They frequently arise in children with TSC and impose a psychosocial burden that can affect the patient’s overall quality of life.

Cutaneous stigmata of TSC pose a significant therapeutic challenge. Topical sirolimus has become a first-line treatment of FAs by inhibiting the mitogenic mTOR pathway¹; however, thicker, more extensive lesions are less responsive to topical therapy. The entire dermis is involved in TSC, and topical sirolimus alone often is ineffective for large fibrous FAs.³ Likewise, oral mTOR inhibition has shown only 25% to 50% improvement in FAs and has potential side effects that can limit patients’ tolerance and compliance.⁴

The Technique

A 46-year-old man with TSC was referred to dermatology for treatment of numerous facial papules and plaques that had been present since childhood and were consistent with FAs (Figure 1A). The lesions were tender, impaired the patient’s breathing, and caused emotional distress. Dermabrasion was attempted 20 years prior with minimal improvement and subsequent progression of the FAs. Other stigmata of TSC were present, including cutaneous hypopigmented macules and shagreen patches as well as seizures and renal angiomyolipomas. Due to multiorgan involvement, the patient was started on once-daily oral everolimus 2.5 mg; however, the FAs were progressive despite the systemic mTOR inhibition. Furthermore, it was presumed that topical sirolimus monotherapy would be ineffective due to thickness and extent of FAs; therefore, we proposed a novel treatment approach combining initial surgical debulking with subsequent longitudinal use of topical sirolimus to reduce the risk of recurrence.

Local anesthesia with lidocaine 1% and epinephrine 1:100,000 was administered. Larger FAs were removed at the base with a sterile surgical blade. Nasal recontouring subsequently was performed using a combination of shave biopsy and curettage. Extensive electrocautery was performed for hemostasis and destruction of residual FAs. Figure 1B shows the immediate postoperative result.

One month postoperatively, the patient stopped the oral everolimus at his oncologist’s recommendation due to abdominal pain and peripheral edema. Once the abraded skin showed evidence of wound healing, the patient was instructed to initiate sirolimus ointment 1% twice daily to reduce the risk of recurrence.^1,5,6 At 8-week follow-up, the patient was noted to have cosmetic improvement and resolution of breathing impairment (Figure 2A). He continued to show excellent cosmetic results at 1-year follow-up using topical sirolimus monotherapy (Figure 2B).

Practical Implications

Surgical debulking combined with longitudinal use of sirolimus ointment 1% can achieve an optimal therapeutic response for disfiguring phymatous presentation of FAs in the setting of TSC. We believe it is an effective approach for thick disfiguring FAs that are unlikely to respond to mTOR inhibition alone.

Practice Gap

Tuberous sclerosis complex (TSC) is an autosomal-dominant genetic disorder resulting in loss-of-function mutations in the TSC1 and TSC2 genes. These mutations lead to constitutive activation of the mitogenic mTOR pathway and release of lymphangiogenic growth factors, causing the formation of hamartomatous tumors throughout multiple organ systems.¹ Facial angiofibromas (FAs) are a common cutaneous manifestation of TSC, affecting up to 80% of patients worldwide.² Aesthetic disfigurement, vision obstruction, and breathing impairment often are associated with FAs. They frequently arise in children with TSC and impose a psychosocial burden that can affect the patient’s overall quality of life.

Cutaneous stigmata of TSC pose a significant therapeutic challenge. Topical sirolimus has become a first-line treatment of FAs by inhibiting the mitogenic mTOR pathway¹; however, thicker, more extensive lesions are less responsive to topical therapy. The entire dermis is involved in TSC, and topical sirolimus alone often is ineffective for large fibrous FAs.³ Likewise, oral mTOR inhibition has shown only 25% to 50% improvement in FAs and has potential side effects that can limit patients’ tolerance and compliance.⁴

The Technique

A 46-year-old man with TSC was referred to dermatology for treatment of numerous facial papules and plaques that had been present since childhood and were consistent with FAs (Figure 1A). The lesions were tender, impaired the patient’s breathing, and caused emotional distress. Dermabrasion was attempted 20 years prior with minimal improvement and subsequent progression of the FAs. Other stigmata of TSC were present, including cutaneous hypopigmented macules and shagreen patches as well as seizures and renal angiomyolipomas. Due to multiorgan involvement, the patient was started on once-daily oral everolimus 2.5 mg; however, the FAs were progressive despite the systemic mTOR inhibition. Furthermore, it was presumed that topical sirolimus monotherapy would be ineffective due to thickness and extent of FAs; therefore, we proposed a novel treatment approach combining initial surgical debulking with subsequent longitudinal use of topical sirolimus to reduce the risk of recurrence.

Local anesthesia with lidocaine 1% and epinephrine 1:100,000 was administered. Larger FAs were removed at the base with a sterile surgical blade. Nasal recontouring subsequently was performed using a combination of shave biopsy and curettage. Extensive electrocautery was performed for hemostasis and destruction of residual FAs. Figure 1B shows the immediate postoperative result.

One month postoperatively, the patient stopped the oral everolimus at his oncologist’s recommendation due to abdominal pain and peripheral edema. Once the abraded skin showed evidence of wound healing, the patient was instructed to initiate sirolimus ointment 1% twice daily to reduce the risk of recurrence.^1,5,6 At 8-week follow-up, the patient was noted to have cosmetic improvement and resolution of breathing impairment (Figure 2A). He continued to show excellent cosmetic results at 1-year follow-up using topical sirolimus monotherapy (Figure 2B).

Practical Implications

Surgical debulking combined with longitudinal use of sirolimus ointment 1% can achieve an optimal therapeutic response for disfiguring phymatous presentation of FAs in the setting of TSC. We believe it is an effective approach for thick disfiguring FAs that are unlikely to respond to mTOR inhibition alone.

Clinical Challenge

An odontogenic cutaneous sinus tract (OCST) of dental origin is an uncommon occurrence and is most commonly caused by chronic periodontitis, specifically a periapical abscess due to chronic dental infection.^1,2 Odontogenic cutaneous sinus tract commonly is misdiagnosed due to a lack of symptoms on presentation, location, and variations in clinical appearance mimicking other lesions. Patients with OCSTs typically present with a fixed, erythematous, crusty, and nontender nodule with periodic drainage that easily can be mistaken for a pustule, furuncle, cyst, foreign-body lesion, squamous cell carcinoma (SCC), basal cell carcinoma, or granulomatous disorder.³ It becomes challenging for dermatologists to correctly diagnose these lesions and refer for proper evaluation and treatment.

Practice Gap

It is estimated that half of patients with an extraoral fistula are treated with multiple dermatologic surgical operations, radiotherapy, antibiotic therapy, and chemotherapy before the correct diagnosis is made.¹ Thus, proper identification of these lesions is crucial for prognosis and treatment. The most common locations for OCSTs are the mandibular, submandibular, and cervical skin.^1,2 Given these locations, patients with OCSTs commonly present to the dermatology office for evaluation. Education regarding the clinical presentation, histopathology, and proper evaluation and further referral for treatment is essential for dermatologists.

Tools and Technique for Diagnosis

We present 2 patients with OCSTs who were referred for cutaneous surgery for an SCC and epidermal cyst, but the proper diagnosis was rendered after an index of suspicion and clinicopathologic correlation led to additional testing and eventual referral for imaging.

Patient 1
A 68-year-old woman presented for Mohs micrographic surgery (MMS) of a biopsy-proven SCC on the chin. The tumor cleared after 2 MMS stages (Figure 1A). Due to notable inflammation in each stage, the slides were sent to a pathologist who confirmed clear margins. Within 2 weeks of MMS, the wound began to dehisce (Figure 1B). The patient presented 4 months later with a crusted ulcerated nodule at the MMS site (Figure 1C). A biopsy showed likely recurrence of SCC. Upon presentation to the Mohs surgeon, the nodule felt fixed to the underlying jaw, and the patient was noted to have poor dentition. The patient was sent for computed tomography (CT), which showed focal thinning of the mandible, likely postsurgical, and clear maxillary sinuses. Due to the clinical appearance and anatomic location of the lesion, a request was made for a second read of the CT, specifically looking for an OCST at the prior surgical site. With this information, the radiologist noted an OCST extending from the mandible to the lesion, reported as a periapical lucency (representing a periapical abscess) at a mandibular tooth with a dental sinus draining into the soft tissues. The patient was started on antibiotics and referred to an oral surgeon for OCST excision.

Practice Implications

Odontogenic cutaneous sinus tracts commonly are misdiagnosed due to variations in clinical presentations resembling more common cutaneous diagnoses, nonspecific histopathologic findings, and lack of dental symptoms or concerns about dentition. Clinically, an OCST presents as a fixed, red, crusty, nontender nodule with intermittent draining. With palpation of the involved area, the clinician may feel a cord of tissue connecting the skin lesion intraorally.^2,4 A clinician should have a high index of suspicion for an OCST when evaluating fixed lesions of the lower face, jawline, and neck due to the possibility of a dental origin,¹ which is important because an OCST can have similar clinical findings to lesions such as congenital fistulas, pustules, cysts, osteomyelitis, foreign-body granulomas, pyogenic granulomas, syphilis, metastatic carcinomas, basal cell carcinomas, and SCCs.^2,4 A PubMed search of articles indexed for MEDLINE using the terms Mohs, MMS, chemosurgery, odontogenic sinus, odontogenic cutaneous sinus tract, and dental sinus yielded only 2 OCSTs that were referred for MMS in the last 30 years, both of which were in the nasolabial fold/medial malar cheek.^2,4 Histopathologic findings of an OCST are nonspecific; a mixed or granulomatous inflammatory infiltrate, granulation tissue, and scarring can be seen.¹ Pseudocarcinomatous/pseudoepitheliomatous hyperplasia of the epidermis can be seen and cause histologic misinterpretation for an SCC.² Given that these findings are nonspecific without a clinical context, even with a histopathologic diagnosis of SCC or cyst, a clinical suspicion for an OCST should lead to an intraoral examination. Imaging can be ordered to look for an OCST in the area of interest. Although panoramic or periapical radiography with or without dental probes/radiopaque markers commonly have been used, more recent literature has suggested that CT may be superior to radiographs for making an OCST diagnosis.^1,3 If imaging is not consistent with the clinically suspected OCST, we recommend directly contacting the radiologist to explain the clinical history and even refresh his/her suspicion for this diagnosis.

If a diagnosis of an OCST is made, oral antibiotics can be prescribed, though the use of antibiotics has been controversial. For severe odontogenic infections, typically beta-lactam antibiotics, cephalosporins, metronidazole, clindamycin, moxifloxacin, or erythromycin can be given for 7 days or until 3 days after symptoms have resolved.⁵ Although antibiotics can bring temporary resolution, it is imperative to treat the source of infection to prevent recurrence. It is crucial for these patients to be referred to an oral surgeon for evaluation and treatment of OCST by either a root canal or tooth extraction.

Final Thoughts

We present this pearl on the diagnosis and management of an OCST, also known as a dental sinus, to better assist clinicians in making this diagnosis. With an index of suspicion as well as intraoral and radiologic evaluations, a proper diagnosis may be rendered, potentially avoiding unnecessary cutaneous surgery. In addition, we highlight the importance of communication between the clinician and the radiologist to directly look for OCST in the area of concern and consider a re-read of the images when clinical suspicion does not correlate with the radiology report.

Clinical Challenge

An odontogenic cutaneous sinus tract (OCST) of dental origin is an uncommon occurrence and is most commonly caused by chronic periodontitis, specifically a periapical abscess due to chronic dental infection.^1,2 Odontogenic cutaneous sinus tract commonly is misdiagnosed due to a lack of symptoms on presentation, location, and variations in clinical appearance mimicking other lesions. Patients with OCSTs typically present with a fixed, erythematous, crusty, and nontender nodule with periodic drainage that easily can be mistaken for a pustule, furuncle, cyst, foreign-body lesion, squamous cell carcinoma (SCC), basal cell carcinoma, or granulomatous disorder.³ It becomes challenging for dermatologists to correctly diagnose these lesions and refer for proper evaluation and treatment.

Practice Gap

It is estimated that half of patients with an extraoral fistula are treated with multiple dermatologic surgical operations, radiotherapy, antibiotic therapy, and chemotherapy before the correct diagnosis is made.¹ Thus, proper identification of these lesions is crucial for prognosis and treatment. The most common locations for OCSTs are the mandibular, submandibular, and cervical skin.^1,2 Given these locations, patients with OCSTs commonly present to the dermatology office for evaluation. Education regarding the clinical presentation, histopathology, and proper evaluation and further referral for treatment is essential for dermatologists.

Tools and Technique for Diagnosis

We present 2 patients with OCSTs who were referred for cutaneous surgery for an SCC and epidermal cyst, but the proper diagnosis was rendered after an index of suspicion and clinicopathologic correlation led to additional testing and eventual referral for imaging.

Patient 1
A 68-year-old woman presented for Mohs micrographic surgery (MMS) of a biopsy-proven SCC on the chin. The tumor cleared after 2 MMS stages (Figure 1A). Due to notable inflammation in each stage, the slides were sent to a pathologist who confirmed clear margins. Within 2 weeks of MMS, the wound began to dehisce (Figure 1B). The patient presented 4 months later with a crusted ulcerated nodule at the MMS site (Figure 1C). A biopsy showed likely recurrence of SCC. Upon presentation to the Mohs surgeon, the nodule felt fixed to the underlying jaw, and the patient was noted to have poor dentition. The patient was sent for computed tomography (CT), which showed focal thinning of the mandible, likely postsurgical, and clear maxillary sinuses. Due to the clinical appearance and anatomic location of the lesion, a request was made for a second read of the CT, specifically looking for an OCST at the prior surgical site. With this information, the radiologist noted an OCST extending from the mandible to the lesion, reported as a periapical lucency (representing a periapical abscess) at a mandibular tooth with a dental sinus draining into the soft tissues. The patient was started on antibiotics and referred to an oral surgeon for OCST excision.

Practice Implications

Odontogenic cutaneous sinus tracts commonly are misdiagnosed due to variations in clinical presentations resembling more common cutaneous diagnoses, nonspecific histopathologic findings, and lack of dental symptoms or concerns about dentition. Clinically, an OCST presents as a fixed, red, crusty, nontender nodule with intermittent draining. With palpation of the involved area, the clinician may feel a cord of tissue connecting the skin lesion intraorally.^2,4 A clinician should have a high index of suspicion for an OCST when evaluating fixed lesions of the lower face, jawline, and neck due to the possibility of a dental origin,¹ which is important because an OCST can have similar clinical findings to lesions such as congenital fistulas, pustules, cysts, osteomyelitis, foreign-body granulomas, pyogenic granulomas, syphilis, metastatic carcinomas, basal cell carcinomas, and SCCs.^2,4 A PubMed search of articles indexed for MEDLINE using the terms Mohs, MMS, chemosurgery, odontogenic sinus, odontogenic cutaneous sinus tract, and dental sinus yielded only 2 OCSTs that were referred for MMS in the last 30 years, both of which were in the nasolabial fold/medial malar cheek.^2,4 Histopathologic findings of an OCST are nonspecific; a mixed or granulomatous inflammatory infiltrate, granulation tissue, and scarring can be seen.¹ Pseudocarcinomatous/pseudoepitheliomatous hyperplasia of the epidermis can be seen and cause histologic misinterpretation for an SCC.² Given that these findings are nonspecific without a clinical context, even with a histopathologic diagnosis of SCC or cyst, a clinical suspicion for an OCST should lead to an intraoral examination. Imaging can be ordered to look for an OCST in the area of interest. Although panoramic or periapical radiography with or without dental probes/radiopaque markers commonly have been used, more recent literature has suggested that CT may be superior to radiographs for making an OCST diagnosis.^1,3 If imaging is not consistent with the clinically suspected OCST, we recommend directly contacting the radiologist to explain the clinical history and even refresh his/her suspicion for this diagnosis.

If a diagnosis of an OCST is made, oral antibiotics can be prescribed, though the use of antibiotics has been controversial. For severe odontogenic infections, typically beta-lactam antibiotics, cephalosporins, metronidazole, clindamycin, moxifloxacin, or erythromycin can be given for 7 days or until 3 days after symptoms have resolved.⁵ Although antibiotics can bring temporary resolution, it is imperative to treat the source of infection to prevent recurrence. It is crucial for these patients to be referred to an oral surgeon for evaluation and treatment of OCST by either a root canal or tooth extraction.

Final Thoughts

We present this pearl on the diagnosis and management of an OCST, also known as a dental sinus, to better assist clinicians in making this diagnosis. With an index of suspicion as well as intraoral and radiologic evaluations, a proper diagnosis may be rendered, potentially avoiding unnecessary cutaneous surgery. In addition, we highlight the importance of communication between the clinician and the radiologist to directly look for OCST in the area of concern and consider a re-read of the images when clinical suspicion does not correlate with the radiology report.

Clinical Challenge

An odontogenic cutaneous sinus tract (OCST) of dental origin is an uncommon occurrence and is most commonly caused by chronic periodontitis, specifically a periapical abscess due to chronic dental infection.^1,2 Odontogenic cutaneous sinus tract commonly is misdiagnosed due to a lack of symptoms on presentation, location, and variations in clinical appearance mimicking other lesions. Patients with OCSTs typically present with a fixed, erythematous, crusty, and nontender nodule with periodic drainage that easily can be mistaken for a pustule, furuncle, cyst, foreign-body lesion, squamous cell carcinoma (SCC), basal cell carcinoma, or granulomatous disorder.³ It becomes challenging for dermatologists to correctly diagnose these lesions and refer for proper evaluation and treatment.

Practice Gap

It is estimated that half of patients with an extraoral fistula are treated with multiple dermatologic surgical operations, radiotherapy, antibiotic therapy, and chemotherapy before the correct diagnosis is made.¹ Thus, proper identification of these lesions is crucial for prognosis and treatment. The most common locations for OCSTs are the mandibular, submandibular, and cervical skin.^1,2 Given these locations, patients with OCSTs commonly present to the dermatology office for evaluation. Education regarding the clinical presentation, histopathology, and proper evaluation and further referral for treatment is essential for dermatologists.

Tools and Technique for Diagnosis

We present 2 patients with OCSTs who were referred for cutaneous surgery for an SCC and epidermal cyst, but the proper diagnosis was rendered after an index of suspicion and clinicopathologic correlation led to additional testing and eventual referral for imaging.

Patient 1
A 68-year-old woman presented for Mohs micrographic surgery (MMS) of a biopsy-proven SCC on the chin. The tumor cleared after 2 MMS stages (Figure 1A). Due to notable inflammation in each stage, the slides were sent to a pathologist who confirmed clear margins. Within 2 weeks of MMS, the wound began to dehisce (Figure 1B). The patient presented 4 months later with a crusted ulcerated nodule at the MMS site (Figure 1C). A biopsy showed likely recurrence of SCC. Upon presentation to the Mohs surgeon, the nodule felt fixed to the underlying jaw, and the patient was noted to have poor dentition. The patient was sent for computed tomography (CT), which showed focal thinning of the mandible, likely postsurgical, and clear maxillary sinuses. Due to the clinical appearance and anatomic location of the lesion, a request was made for a second read of the CT, specifically looking for an OCST at the prior surgical site. With this information, the radiologist noted an OCST extending from the mandible to the lesion, reported as a periapical lucency (representing a periapical abscess) at a mandibular tooth with a dental sinus draining into the soft tissues. The patient was started on antibiotics and referred to an oral surgeon for OCST excision.

Practice Implications

Odontogenic cutaneous sinus tracts commonly are misdiagnosed due to variations in clinical presentations resembling more common cutaneous diagnoses, nonspecific histopathologic findings, and lack of dental symptoms or concerns about dentition. Clinically, an OCST presents as a fixed, red, crusty, nontender nodule with intermittent draining. With palpation of the involved area, the clinician may feel a cord of tissue connecting the skin lesion intraorally.^2,4 A clinician should have a high index of suspicion for an OCST when evaluating fixed lesions of the lower face, jawline, and neck due to the possibility of a dental origin,¹ which is important because an OCST can have similar clinical findings to lesions such as congenital fistulas, pustules, cysts, osteomyelitis, foreign-body granulomas, pyogenic granulomas, syphilis, metastatic carcinomas, basal cell carcinomas, and SCCs.^2,4 A PubMed search of articles indexed for MEDLINE using the terms Mohs, MMS, chemosurgery, odontogenic sinus, odontogenic cutaneous sinus tract, and dental sinus yielded only 2 OCSTs that were referred for MMS in the last 30 years, both of which were in the nasolabial fold/medial malar cheek.^2,4 Histopathologic findings of an OCST are nonspecific; a mixed or granulomatous inflammatory infiltrate, granulation tissue, and scarring can be seen.¹ Pseudocarcinomatous/pseudoepitheliomatous hyperplasia of the epidermis can be seen and cause histologic misinterpretation for an SCC.² Given that these findings are nonspecific without a clinical context, even with a histopathologic diagnosis of SCC or cyst, a clinical suspicion for an OCST should lead to an intraoral examination. Imaging can be ordered to look for an OCST in the area of interest. Although panoramic or periapical radiography with or without dental probes/radiopaque markers commonly have been used, more recent literature has suggested that CT may be superior to radiographs for making an OCST diagnosis.^1,3 If imaging is not consistent with the clinically suspected OCST, we recommend directly contacting the radiologist to explain the clinical history and even refresh his/her suspicion for this diagnosis.

If a diagnosis of an OCST is made, oral antibiotics can be prescribed, though the use of antibiotics has been controversial. For severe odontogenic infections, typically beta-lactam antibiotics, cephalosporins, metronidazole, clindamycin, moxifloxacin, or erythromycin can be given for 7 days or until 3 days after symptoms have resolved.⁵ Although antibiotics can bring temporary resolution, it is imperative to treat the source of infection to prevent recurrence. It is crucial for these patients to be referred to an oral surgeon for evaluation and treatment of OCST by either a root canal or tooth extraction.

Final Thoughts

We present this pearl on the diagnosis and management of an OCST, also known as a dental sinus, to better assist clinicians in making this diagnosis. With an index of suspicion as well as intraoral and radiologic evaluations, a proper diagnosis may be rendered, potentially avoiding unnecessary cutaneous surgery. In addition, we highlight the importance of communication between the clinician and the radiologist to directly look for OCST in the area of concern and consider a re-read of the images when clinical suspicion does not correlate with the radiology report.

Practice Gap

Invasive fungal infections are a leading cause of morbidity and mortality among neutropenic, immunocompromised, and critically ill patients. Candida species are the most common cause of fungemia, with portals of entry into the bloodstream including the gastrointestinal tract, contaminated intravascular catheters, and localized foci of infection.¹ Diagnosis of invasive candidiasis remains challenging due to an absence of specific clinical signs and symptoms, varying from a mild fever that is unresponsive to antibiotics to florid sepsis. When present, clinical clues may include chorioretinitis; muscle abscesses; and skin eruptions, characteristically with Candida tropicalis. Cutaneous manifestations of disseminated Candida infections appear in only 13% of affected patients.¹ The lesions typically present as 5- to 10-mm pink dermal papules or painless pustules on an erythematous base and may be singular, localized, or diffuse in distribution. Body regions normally involved are the trunk, arms, and legs, rarely the head and neck.¹ Cutaneous lesions often develop at a time when patients are febrile, are not responding to antibiotics, and are clinically deteriorating.

A 15-year-old adolescent boy with pre–B-cell acute lymphoblastic leukemia was admitted with febrile neutropenia for presumed septic shock secondary to an unknown infectious etiology. The patient was started on broad-spectrum intravenous antibiotics, and blood cultures were obtained. On the second day of hospitalization, he developed approximately 10 to 15 discrete, 3- to 6-mm, pink to violaceous papules scattered on the chest and arms (Figure 1). Over several hours, the number of lesions increased to more than 50 with involvement of the legs (Figure 2). A punch biopsy of lesional skin from the left dorsal wrist demonstrated a circumscribed abscess of yeast in the papillary dermis, which was highlighted by periodic acid–Schiff staining with minimal associated inflammation (Figure 3). Blood and tissue cultures persistently grew C tropicalis. The patient was started on intravenous liposomal amphotericin B but died on day 5 of hospitalization after developing endocarditis.

Early and reliable diagnosis of Candida species fungemia is of critical importance to successful treatment, particularly with the emergence of multidrug-resistant strains such as Candida auris.² In patients with apparent cutaneous manifestations, a lesional punch biopsy for culture and histopathologic evaluation is recommended in addition to blood culture; however, organisms may or may not be present in large numbers, and they may be difficult to identify on routine hematoxylin and eosin–stained tissue sections. To enhance the likelihood of highlighting the fungus within the sample, the pathologist must be made aware of the presumptive diagnosis of disseminated candidiasis so that special techniques can be utilized, such as periodic acid–Schiff stain.

Although positive blood culture is the gold standard for candidemia diagnosis, only 30% to 50% of patients with disseminated candidiasis had positive blood cultures at autopsy.¹ Another study showed the sensitivity of blood culture for the detection of invasive fungal infection to be as low as 8.3%.³ In cases with positive blood cultures, the median time to positivity is 2 to 3 days, but it can take as long as 8 days, thus limiting its clinical utility in acutely ill patients.⁴ Given the low sensitivity and prolonged time required for culture growth of most fungal organisms, novel assays for rapid, non–culture-based diagnosis of systemic fungal infections hold substantial clinical promise moving forward.

The Technique

One of the more promising non–culture-based fungal diagnostic methodologies is an antigen assay based on the detection of serum (1,3)-β-D-glucan (BDG), a major cell wall constituent of most pathogenic fungi. This assay is not specific for Candida species and can be positive for Aspergillosis species, Fusarium species, Coccidioides immitis, Histoplasma capsulatum, and Pneumocystis jirovecii pneumonia, among others; therefore, it functions as a general biomarker for fungi in the bloodstream.^4,5 (1,3)-β-D-glucan assay can be useful as an adjunct for blood cultures and punch biopsy, especially when cultures are negative or the results remain outstanding. The results of the BDG assay are available in less than 24 hours at minimal cost, and the test is approved by the US Food and Drug Administration for use as an aid in invasive fungal disease diagnosis. In a meta-analysis of 11 studies, BDG sensitivity was 75%.⁴ In a study based on autopsy cases from 6 years, BDG specificity was 98.4% with positive and negative predictive values of 86.7% and 97.1%, respectively.³ Optimal results were achieved when 2 consecutive tests were positive.⁴ The serum assay output is based on spectrophotometer readings, which are converted to BDG concentrations (negative, <60 pg/mL; indeterminate, 60–79 pg/mL; positive ≥80 pg/mL).⁵ Although we cannot be certain, utilizing the BDG assay in our patient may have led to earlier treatment and a better outcome.

A disadvantage of the BDG assay is the potential for false-positive results, which have been reported in lung transplant recipients with respiratory mold colonization and patients with other systemic bacterial infections.⁴ False-positive results also have been associated with use of ampicillin-clavulanate and piperacillin-tazobactam antibiotics and human blood products, hemodialysis, and severe mucositis, thus reaffirming the importance of judicious interpretation of BDG assay results by the clinician.^4,6 There also is a potential for false-negative results, as the BDG assay does not detect certain fungal species such as Cryptococcus species and Blastomyces dermatitidis, which produce very low levels of BDG, or zygomycetes (Absidia, Mucor, and Rizopus species), which are not known to produce BDG.⁶

Practice Implications

In the setting of invasive fungal infections, a high degree of clinical suspicion is paramount due to the often subtle nature of cutaneous manifestations. A positive BDG assay can be used to identify high-risk patients for empiric antifungal therapy, prompting early intervention and improved outcomes in these acutely ill patients. The BDG assay’s excellent negative predictive value is useful in ruling out invasive Candida infections and may justify stopping unnecessary empiric antifungal therapy.⁴ For the dermatology hospitalist, incorporation of the BDG assay as a noninvasive screening tool may allow for more rapid initiation of appropriate antifungal therapy while awaiting confirmatory skin biopsy or culture results in disseminated candidemia and other invasive fungal infections.

Practice Gap

Invasive fungal infections are a leading cause of morbidity and mortality among neutropenic, immunocompromised, and critically ill patients. Candida species are the most common cause of fungemia, with portals of entry into the bloodstream including the gastrointestinal tract, contaminated intravascular catheters, and localized foci of infection.¹ Diagnosis of invasive candidiasis remains challenging due to an absence of specific clinical signs and symptoms, varying from a mild fever that is unresponsive to antibiotics to florid sepsis. When present, clinical clues may include chorioretinitis; muscle abscesses; and skin eruptions, characteristically with Candida tropicalis. Cutaneous manifestations of disseminated Candida infections appear in only 13% of affected patients.¹ The lesions typically present as 5- to 10-mm pink dermal papules or painless pustules on an erythematous base and may be singular, localized, or diffuse in distribution. Body regions normally involved are the trunk, arms, and legs, rarely the head and neck.¹ Cutaneous lesions often develop at a time when patients are febrile, are not responding to antibiotics, and are clinically deteriorating.

A 15-year-old adolescent boy with pre–B-cell acute lymphoblastic leukemia was admitted with febrile neutropenia for presumed septic shock secondary to an unknown infectious etiology. The patient was started on broad-spectrum intravenous antibiotics, and blood cultures were obtained. On the second day of hospitalization, he developed approximately 10 to 15 discrete, 3- to 6-mm, pink to violaceous papules scattered on the chest and arms (Figure 1). Over several hours, the number of lesions increased to more than 50 with involvement of the legs (Figure 2). A punch biopsy of lesional skin from the left dorsal wrist demonstrated a circumscribed abscess of yeast in the papillary dermis, which was highlighted by periodic acid–Schiff staining with minimal associated inflammation (Figure 3). Blood and tissue cultures persistently grew C tropicalis. The patient was started on intravenous liposomal amphotericin B but died on day 5 of hospitalization after developing endocarditis.

Early and reliable diagnosis of Candida species fungemia is of critical importance to successful treatment, particularly with the emergence of multidrug-resistant strains such as Candida auris.² In patients with apparent cutaneous manifestations, a lesional punch biopsy for culture and histopathologic evaluation is recommended in addition to blood culture; however, organisms may or may not be present in large numbers, and they may be difficult to identify on routine hematoxylin and eosin–stained tissue sections. To enhance the likelihood of highlighting the fungus within the sample, the pathologist must be made aware of the presumptive diagnosis of disseminated candidiasis so that special techniques can be utilized, such as periodic acid–Schiff stain.

Although positive blood culture is the gold standard for candidemia diagnosis, only 30% to 50% of patients with disseminated candidiasis had positive blood cultures at autopsy.¹ Another study showed the sensitivity of blood culture for the detection of invasive fungal infection to be as low as 8.3%.³ In cases with positive blood cultures, the median time to positivity is 2 to 3 days, but it can take as long as 8 days, thus limiting its clinical utility in acutely ill patients.⁴ Given the low sensitivity and prolonged time required for culture growth of most fungal organisms, novel assays for rapid, non–culture-based diagnosis of systemic fungal infections hold substantial clinical promise moving forward.

The Technique

One of the more promising non–culture-based fungal diagnostic methodologies is an antigen assay based on the detection of serum (1,3)-β-D-glucan (BDG), a major cell wall constituent of most pathogenic fungi. This assay is not specific for Candida species and can be positive for Aspergillosis species, Fusarium species, Coccidioides immitis, Histoplasma capsulatum, and Pneumocystis jirovecii pneumonia, among others; therefore, it functions as a general biomarker for fungi in the bloodstream.^4,5 (1,3)-β-D-glucan assay can be useful as an adjunct for blood cultures and punch biopsy, especially when cultures are negative or the results remain outstanding. The results of the BDG assay are available in less than 24 hours at minimal cost, and the test is approved by the US Food and Drug Administration for use as an aid in invasive fungal disease diagnosis. In a meta-analysis of 11 studies, BDG sensitivity was 75%.⁴ In a study based on autopsy cases from 6 years, BDG specificity was 98.4% with positive and negative predictive values of 86.7% and 97.1%, respectively.³ Optimal results were achieved when 2 consecutive tests were positive.⁴ The serum assay output is based on spectrophotometer readings, which are converted to BDG concentrations (negative, <60 pg/mL; indeterminate, 60–79 pg/mL; positive ≥80 pg/mL).⁵ Although we cannot be certain, utilizing the BDG assay in our patient may have led to earlier treatment and a better outcome.

A disadvantage of the BDG assay is the potential for false-positive results, which have been reported in lung transplant recipients with respiratory mold colonization and patients with other systemic bacterial infections.⁴ False-positive results also have been associated with use of ampicillin-clavulanate and piperacillin-tazobactam antibiotics and human blood products, hemodialysis, and severe mucositis, thus reaffirming the importance of judicious interpretation of BDG assay results by the clinician.^4,6 There also is a potential for false-negative results, as the BDG assay does not detect certain fungal species such as Cryptococcus species and Blastomyces dermatitidis, which produce very low levels of BDG, or zygomycetes (Absidia, Mucor, and Rizopus species), which are not known to produce BDG.⁶

Practice Implications

In the setting of invasive fungal infections, a high degree of clinical suspicion is paramount due to the often subtle nature of cutaneous manifestations. A positive BDG assay can be used to identify high-risk patients for empiric antifungal therapy, prompting early intervention and improved outcomes in these acutely ill patients. The BDG assay’s excellent negative predictive value is useful in ruling out invasive Candida infections and may justify stopping unnecessary empiric antifungal therapy.⁴ For the dermatology hospitalist, incorporation of the BDG assay as a noninvasive screening tool may allow for more rapid initiation of appropriate antifungal therapy while awaiting confirmatory skin biopsy or culture results in disseminated candidemia and other invasive fungal infections.

Practice Gap

Invasive fungal infections are a leading cause of morbidity and mortality among neutropenic, immunocompromised, and critically ill patients. Candida species are the most common cause of fungemia, with portals of entry into the bloodstream including the gastrointestinal tract, contaminated intravascular catheters, and localized foci of infection.¹ Diagnosis of invasive candidiasis remains challenging due to an absence of specific clinical signs and symptoms, varying from a mild fever that is unresponsive to antibiotics to florid sepsis. When present, clinical clues may include chorioretinitis; muscle abscesses; and skin eruptions, characteristically with Candida tropicalis. Cutaneous manifestations of disseminated Candida infections appear in only 13% of affected patients.¹ The lesions typically present as 5- to 10-mm pink dermal papules or painless pustules on an erythematous base and may be singular, localized, or diffuse in distribution. Body regions normally involved are the trunk, arms, and legs, rarely the head and neck.¹ Cutaneous lesions often develop at a time when patients are febrile, are not responding to antibiotics, and are clinically deteriorating.

A 15-year-old adolescent boy with pre–B-cell acute lymphoblastic leukemia was admitted with febrile neutropenia for presumed septic shock secondary to an unknown infectious etiology. The patient was started on broad-spectrum intravenous antibiotics, and blood cultures were obtained. On the second day of hospitalization, he developed approximately 10 to 15 discrete, 3- to 6-mm, pink to violaceous papules scattered on the chest and arms (Figure 1). Over several hours, the number of lesions increased to more than 50 with involvement of the legs (Figure 2). A punch biopsy of lesional skin from the left dorsal wrist demonstrated a circumscribed abscess of yeast in the papillary dermis, which was highlighted by periodic acid–Schiff staining with minimal associated inflammation (Figure 3). Blood and tissue cultures persistently grew C tropicalis. The patient was started on intravenous liposomal amphotericin B but died on day 5 of hospitalization after developing endocarditis.

Early and reliable diagnosis of Candida species fungemia is of critical importance to successful treatment, particularly with the emergence of multidrug-resistant strains such as Candida auris.² In patients with apparent cutaneous manifestations, a lesional punch biopsy for culture and histopathologic evaluation is recommended in addition to blood culture; however, organisms may or may not be present in large numbers, and they may be difficult to identify on routine hematoxylin and eosin–stained tissue sections. To enhance the likelihood of highlighting the fungus within the sample, the pathologist must be made aware of the presumptive diagnosis of disseminated candidiasis so that special techniques can be utilized, such as periodic acid–Schiff stain.

Although positive blood culture is the gold standard for candidemia diagnosis, only 30% to 50% of patients with disseminated candidiasis had positive blood cultures at autopsy.¹ Another study showed the sensitivity of blood culture for the detection of invasive fungal infection to be as low as 8.3%.³ In cases with positive blood cultures, the median time to positivity is 2 to 3 days, but it can take as long as 8 days, thus limiting its clinical utility in acutely ill patients.⁴ Given the low sensitivity and prolonged time required for culture growth of most fungal organisms, novel assays for rapid, non–culture-based diagnosis of systemic fungal infections hold substantial clinical promise moving forward.

The Technique

One of the more promising non–culture-based fungal diagnostic methodologies is an antigen assay based on the detection of serum (1,3)-β-D-glucan (BDG), a major cell wall constituent of most pathogenic fungi. This assay is not specific for Candida species and can be positive for Aspergillosis species, Fusarium species, Coccidioides immitis, Histoplasma capsulatum, and Pneumocystis jirovecii pneumonia, among others; therefore, it functions as a general biomarker for fungi in the bloodstream.^4,5 (1,3)-β-D-glucan assay can be useful as an adjunct for blood cultures and punch biopsy, especially when cultures are negative or the results remain outstanding. The results of the BDG assay are available in less than 24 hours at minimal cost, and the test is approved by the US Food and Drug Administration for use as an aid in invasive fungal disease diagnosis. In a meta-analysis of 11 studies, BDG sensitivity was 75%.⁴ In a study based on autopsy cases from 6 years, BDG specificity was 98.4% with positive and negative predictive values of 86.7% and 97.1%, respectively.³ Optimal results were achieved when 2 consecutive tests were positive.⁴ The serum assay output is based on spectrophotometer readings, which are converted to BDG concentrations (negative, <60 pg/mL; indeterminate, 60–79 pg/mL; positive ≥80 pg/mL).⁵ Although we cannot be certain, utilizing the BDG assay in our patient may have led to earlier treatment and a better outcome.

A disadvantage of the BDG assay is the potential for false-positive results, which have been reported in lung transplant recipients with respiratory mold colonization and patients with other systemic bacterial infections.⁴ False-positive results also have been associated with use of ampicillin-clavulanate and piperacillin-tazobactam antibiotics and human blood products, hemodialysis, and severe mucositis, thus reaffirming the importance of judicious interpretation of BDG assay results by the clinician.^4,6 There also is a potential for false-negative results, as the BDG assay does not detect certain fungal species such as Cryptococcus species and Blastomyces dermatitidis, which produce very low levels of BDG, or zygomycetes (Absidia, Mucor, and Rizopus species), which are not known to produce BDG.⁶

Practice Implications

In the setting of invasive fungal infections, a high degree of clinical suspicion is paramount due to the often subtle nature of cutaneous manifestations. A positive BDG assay can be used to identify high-risk patients for empiric antifungal therapy, prompting early intervention and improved outcomes in these acutely ill patients. The BDG assay’s excellent negative predictive value is useful in ruling out invasive Candida infections and may justify stopping unnecessary empiric antifungal therapy.⁴ For the dermatology hospitalist, incorporation of the BDG assay as a noninvasive screening tool may allow for more rapid initiation of appropriate antifungal therapy while awaiting confirmatory skin biopsy or culture results in disseminated candidemia and other invasive fungal infections.