Burn Shock and Resuscitation: Many Priorities, One Goal

Burn injuries come in a wide variety of presentations, depending on the size and depth of the thermal insult, concurrent traumatic or inhalation injury, as well as the associated physiological response of the burn victim. To minimize patient morbidity and reduce mortality, prompt recognition and tailored treatment strategies are critically important. As the percentage of total body surface area (TBSA) burned increases so do the body’s physiologic response and the associated complexity of management. Understanding the pathophysiology of burn injury allows the practitioner to optimize and individualize burn patient management—a component of care critical to limiting wound progression and improving outcomes. Burn patient care starts with an accurate and thorough burn patient evaluation conducted in person by an experienced provider. For burns >10–15% TBSA, prompt initiation of fluid resuscitation greatly impacts clinical outcomes. Several formulae have been published to guide crystalloid and/or colloid fluid resuscitation in the setting of burn shock. Other important considerations include ambient temperature control, early enteral nutritional support, vitamin and mineral supplementation, assessment for inhalation injury, glycemic control, early recognition of potential complications of large volume resuscitation, potential need for cardiovascular support, and early wound excision and coverage. Burn patients often require multidisciplinary teams to manage the physical, social, and psychological effects associated with their injury. Dedicated burn centers are the ideal places for meeting the complex needs of each burn patient

The Role of Biosurgical Agents in Dermatologic Surgery

Performed in an outpatient, office-based setting, dermatologic surgery reduces healthcare costs of hospitalization while maintaining low rates of surgical complications such as infection, dehiscence, and hematoma formation. However, the potential for complications requiring hospitalization or IV antibiotic therapy still exists and varies depending on patient risk factors, such as the use of antiplatelet and anticoagulant medications. Furthermore, measured outcomes in dermatologic surgery expand beyond surgical wound complications to include optimization of wound healing and reduction of scar formation, especially in cosmetically sensitive areas of the body. Biosurgical agents are increasingly being used in surgical fields to achieve hemostasis and to optimize wound healing. This chapter reviews the typical methods to achieve hemostasis in dermatologic surgery and examines the current and future role of biosurgical agents in procedural dermatology

Transient lingual papillitis associated with confirmed herpes simplex virus 1 in a patient with kawasaki disease.

We present a case of transient lingual papillitis associated with confirmed herpes simplex virus 1 that developed after a child received intravenous immunoglobulin and infliximab for acute Kawasaki disease

Laser-Induced Neocollagenesis in Focal Dermal Hypoplasia Associated With Goltz Syndrome in a Girl

Importance: Current models of Goltz syndrome cannot estimate the overall neocollagenesis and marked shift in collagen types after ablative fractional laser resurfacing (AFR) within treated areas of focal dermal hypoplasia (FDH). Objectives: To clinically improve FDH by using AFR to characterize the specific ratio of collagen types associated with observed clinical changes. Design, Setting, and Participants: This case report of a girl with Goltz syndrome used extensive laboratory evaluation and multiple observers blinded to the patient\u27s clinical status. Serial samples of clinically unaffected skin constituted internal control specimens, with clinical and histologic evaluations performed as part of a multicenter investigation. The analysis tested the hypothesis that thermal microtrauma caused by AFR created a unique environment that activated latent genes, inducing neocollagenesis and allowing the patient to adaptively produce the collagen subtype that was specifically deficient at baseline. Interventions: Two AFR treatments were administered within an area of FDH. Histologic comparison of the pretreatment and posttreatment skin was performed using serial internal controls. Main Outcomes and Measures: Histologic changes, including Herovici collagen staining to differentiate between types I and III collagen, within a treated area of mosaically affected FDH compared with clinically unaffected skin. Results: This female patient presented in the second decade of life with self-described red, itchy skin within a large plaque of FDH on her left posterior thigh and calf. After AFR, skin tightening and symptomatic relief were reported. Histologic findings demonstrated objective thickening of the dermal collagen. A marked shift in collagen predominance from type III (fetal/early wound) to type I (adult/mature) was observed. Conclusions and Relevance: Although further study is needed, this report shows promising results and raises important questions about gene expression and the epigenetics of Goltz syndrome-associated mutations and the local effects of AFR. Coupled with more rigorous investigation, this novel technique may help reveal molecular workarounds permitting innovative therapies that take advantage of the subtly different collagens that exist within the skin

Laser-Induced Neocollagenesis in Focal Dermal Hypoplasia Associated With Goltz Syndrome in a Girl

Importance: Current models of Goltz syndrome cannot estimate the overall neocollagenesis and marked shift in collagen types after ablative fractional laser resurfacing (AFR) within treated areas of focal dermal hypoplasia (FDH). Objectives: To clinically improve FDH by using AFR to characterize the specific ratio of collagen types associated with observed clinical changes. Design, Setting, and Participants: This case report of a girl with Goltz syndrome used extensive laboratory evaluation and multiple observers blinded to the patient\u27s clinical status. Serial samples of clinically unaffected skin constituted internal control specimens, with clinical and histologic evaluations performed as part of a multicenter investigation. The analysis tested the hypothesis that thermal microtrauma caused by AFR created a unique environment that activated latent genes, inducing neocollagenesis and allowing the patient to adaptively produce the collagen subtype that was specifically deficient at baseline. Interventions: Two AFR treatments were administered within an area of FDH. Histologic comparison of the pretreatment and posttreatment skin was performed using serial internal controls. Main Outcomes and Measures: Histologic changes, including Herovici collagen staining to differentiate between types I and III collagen, within a treated area of mosaically affected FDH compared with clinically unaffected skin. Results: This female patient presented in the second decade of life with self-described red, itchy skin within a large plaque of FDH on her left posterior thigh and calf. After AFR, skin tightening and symptomatic relief were reported. Histologic findings demonstrated objective thickening of the dermal collagen. A marked shift in collagen predominance from type III (fetal/early wound) to type I (adult/mature) was observed. Conclusions and Relevance: Although further study is needed, this report shows promising results and raises important questions about gene expression and the epigenetics of Goltz syndrome-associated mutations and the local effects of AFR. Coupled with more rigorous investigation, this novel technique may help reveal molecular workarounds permitting innovative therapies that take advantage of the subtly different collagens that exist within the skin

Light-based treatment of pediatric port-wine birthmarks.

Port-wine birthmarks (PWBs) are progressive vascular malformations with significant disfigurement and psychosocial morbidity; early light-based treatment has shown improved outcomes in the pediatric population. Somatic mosaic mutations underly the progressive nature of PWBs and explain the significant differences in response and heterogeneity of vessel architecture in the pediatric population when compared to the adult cohort. Here, we summarize a review of pediatric specific literature on the various light-based treatment modalities, including pulsed dye laser, near-infrared lasers, and intense pulsed light, providing the various indications, tips, advantages, and disadvantages for the pediatric dermatologist