Which of the following is the most appropriate management?

(A) Lymphatic massage
(B) Application of a compression bandage and elevation of the extremity
(C) Topical application of an antibiotic
(D) Intravenous administration of an antibiotic
(E) Incision and drainage

The correct response is Option D.

In this patient who has had the spontaneous onset of cellulitis of the arm after undergoing axillary lymph node dissection, the most appropriate management is intravenous administration of an antistreptococcal antibiotic. Fever and leukocytosis are typically associated with cellulitis but are not required to make the diagnosis, as many of these patients will be afebrile and will not have an increased leukocyte count or absolute neutrophil count on serologic testing. Anti-streptolysin O titer may be positive.

Although lymphatic massage and compression and elevation of the extremity are useful in controlling the lymphedema associated with lymph node dissection, these measures will not treat cellulitis. Antibiotic therapy should not be based on the results of blood or tissue aspirate cultures because these often do not yield any growth. Topical application of an antibiotic will not effectively treat cellulitis. Incision and drainage of the affected site is not indicated.

References
1. Calkins ER. Nosocomial infections in hand surgery. Hand Clin. 1998;14:531-545.
2. Simon MS, Cody RL. Cellulitis after axillary lymph node dissection for carcinoma of the breast. Am J Med. 1992;93:543-548.

A 55-year-old woman is scheduled to undergo 30% trichloroacetic acid peeling for eradication of fine perioral rhytids. Which of the following is the most likely complication?

(A) Cardiac arrhythmias
(B) Herpetic reactivation
(C) Hyperpigmentation
(D) Hypertrophic scarring
(E) Loss of sweat glands

The correct response is Option C.

Potential complications of trichloroacetic acid peeling are rare, but include infection, scarring, and changes in skin pigmentation. Pigmentary changes are most common. The optimal chemical peel creates a controlled partial-thickness wound; however, peels that destroy tissue through the entire epidermis are most likely to result in hypopigmentation. Hyperpigmentation, which is typically transient, results from inflammatory changes that are thought to be caused by trauma to melanocytes, resulting in excessive stimulation.

Cardiac arrhythmias are associated with phenol peeling, and herpetic reactivation is usually a complication of laser resurfacing. Trichloroacetic acid peeling provides a superficial peel that would not result in hypertrophic scarring or permanent loss of sweat glands.

References
1. Brody HJ. Complications of chemical resurfacing. Dermatol Clin. 2001;19:427-438.
2. Greenbaum SS. Chemical peeling, injectable collagen, implants, and dermabrasion. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:597-608.

A 52-year-old woman wishes to undergo phenol chemical peeling for improvement of the facial skin surface. She has a history of alcohol abuse and liver disease. Laboratory evaluation shows a prothrombin time of 12 sec and a serum aspartate aminotransferase level of 68 U/L. Which of the following complications is most likely in this patient?

(A) Cardiac arrhythmias
(B) Delayed wound healing
(C) Excessive bleeding
(D) Hypertrophic scarring
(E) Permanent hyperpigmentation

The correct response is Option A.

Phenol (carbolic acid) is an aromatic hydrocarbon derived from coal tar. It is one of the most common agents used in chemical peeling and is often combined with other topical agents to increase absorption and decrease inflammatory skin response. However, patients who undergo phenol peeling should be monitored closely because of the potential for the development of cardiac toxicity associated with increased levels of phenol in the blood. Because phenol is detoxified in the liver, adverse cardiac effects are more likely to occur in this patient who has a history of alcohol abuse and liver disease. In addition, only small areas should be treated at one time; if chemical peeling is performed on more than one half of the face in less than 30 minutes, arrhythmias or other severe cardiac complications can occur. These complications have been noted in as many as 50% of treated patients.

Other, less common complications in patients undergoing phenol peeling include hypopigmentation, transient splotchy hyperpigmentation, prominence of the skin pores, telangiectasias, erythema, and milia. Delayed wound healing and hypertrophic scarring are rare complications of deep peeling. Bleeding does not occur.

References
1. Gross BG. Cardiac arrhythmias during phenol face peeling. Plast Reconstr Surg. 1984;73:590.
2. Truppman ES, Ellenby JD. Major electrocardiographic changes during chemical face peeling. Plast Reconstr Surg. 1979;63:44.

A 65-year-old woman desires correction of fine facial rhytids. Which of the following agents is most effective for skin rejuvenation in this patient?

(A) Ascorbic acid
(B) Glycolic acid
(C) Hyaluronic acid
(D) Retinoic acid
(E) Trichloroacetic acid

The correct response is Option E.

Because trichloroacetic acid produces moderate exfoliation in concentrations of 15% to 35%, it is the most appropriate agent for improvement of facial rhytids. The other agents listed provide only mild or no exfoliation.

Ascorbic acid (vitamin C) has been shown in some clinical studies to improve photoaged skin but is not yet widely used.

Glycolic acid and other alpha-hydroxy acids are used for chemical peeling. These agents provide some improvement of fine rhytids, but overall results in patients with photoaged skin remain controversial.

Hyaluronic acid is used in other countries as a filler substance for lip augmentation, as well as for correction of rhytids. It has also shown promise as an adjunct treatment for depressed scars. However, it is not yet approved for use in the United States.

Retinoic acid is also used for skin rejuvenation but has been shown to provide only moderate improvement in fine rhytids. Clear histologic improvement in photoaging has not been confirmed.

References
1. Clark CP III. New directions in skin care. Clin Plast Surg. 2001;28:745-750.
2. Fusco FJ. The aging face and skin: common signs and treatment. Clin Plast Surg. 2001;28:1-12.

Use of which of the following agents is CONTRAINDICATED prior to dermabrasion?

(A) Alpha-hydroxy acid
(B) Glycolic acid
(C) Hydroquinone 4%
(D) Isotretinoin
(E) Tretinoin

The correct response is Option D.

Isotretinoin (Accutane, also referred to as 13-cis retinoic acid) is contraindicated in a patient who is to undergo dermabrasion. Isotretinoin is an oral retinoid that is used to treat acne by suppressing keratinization and the function of sebaceous glands, thereby diminishing the oiliness of the skin. In patients undergoing isotretinoin therapy, dermabrasion or laser resurfacing should be deferred for at least one year following discontinuation of the drug, because delayed healing and hypertrophic scarring may occur.

Alpha-hydroxy and glycolic acids are mild agents typically found in many over-the-counter skin creams. These agents are not contraindicated in patients undergoing dermabrasion.

Hydroquinones are typically administered preoperatively and postoperatively to prevent hyperpigmentation.

Tretinoin is used for skin preparation in patients scheduled to undergo dermabrasion or laser therapy.

References
1. Greenbaum SS. Chemical peeling, injectable collagen, implants, and dermabrasion. In: Aston SJ, Beasley RW, Thorne CH, eds. Grabb & Smith's Plastic Surgery. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:597-608.
2. Harmon CB. Dermabrasion. Dermatol Clin. 2001;19:439-442.
3. Rubenstein R, Roenigk HH, Stegman SJ, et al. Atypical keloids after dermabrasion of patients taking isotretinoin. J Acad Dermatol Surg Oncol. 1986;15:280.

Which of the following best describes a patient with Fitzpatrick type II skin?

(A) Usually burns, tans with difficulty
(B) Sometimes burns, tans moderately
(C) Rarely burns, tans easily
(D) Never burns, deep pigmentation

The correct response is Option A.

Fitzpatrick's system is used for classifying patients according to skin type in order to assist them in the promotion of skin care and the prevention of solar damage. The classification is also helpful in determining treatment protocols for topical and laser skin care. This method of classification is based on melanin content, inherent pigmentation, and sensitivity to ultraviolet light during an initial, unprotected sun exposure. Patients with a lower Fitzpatrick skin type tend to have less melanin pigmentation within their skin.

A table representing this classification system is shown below.

Reference
1. Fitzpatrick TB. The validity and practicality of sun reactive skin types I-VI. Arch Dermatol. 1988;124:869.