- Email: [email protected]
Subcutaneous emphysema resulting from liquid nitrogen spray
J AM ACAD DERMATOL
Letters S95
VOLUME 55, NUMBER 5
REFERENCES 1. Hofmann B, Stege H, Ruzicka T, Lehmann P. Effect of topical tazarotene in the treatment of congenital ichthyoses. Br J Dermatol 1999;141:642-6. 2. Stege H, Hofmann B, Ruzicka T, Lehmann P. Topical application of tazarotene in the treatment of nonerythrodermic lamellar ichthyosis. Arch Dermatol 1998;134:640. 3. Marulli GC, Campione E, Chimenti MS, Terrinoni A, Melino G, Bianchi L. Type I lamellar ichthyosis improved by tazarotene 0.1% gel. Clin Exp Dermatol 2003;28:391-3. doi:10.1016/j.jaad.2005.09.018
Subcutaneous emphysema resulting from liquid nitrogen spray
Fig 2. Improvement in tazarotene-treated areas on back (A) and right shoulder (B) after 3 months.
acetylenic retinoid with selective binding to RARgamma and RAR-beta receptors, and 90% of retinoid receptors in the skin are of the RAR-gamma subtype. RAR-gamma receptor specificity may be one reason tazarotene can be more effective than systemic retinoids that do not demonstrate receptor specificity. Variability in expression of retinoid receptors and in metabolism of prodrug to the active form may account for individual differences in therapeutic response. Although our patient experienced rapid and significant improvement, larger controlled studies are needed to evaluate the efficacy of topical tazarotene in the treatment of lamellar ichthyosis and other ichthyotic disorders. Roopal V. Kundu, MD,a Amit Garg, MD,b and Sophie M. Worobec, MDc Department of Dermatology, Northwestern University Medical School, Chicago, Illinois,a Division of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts,b Department of Dermatology, University of Illinois College of Medicine, Chicago, Illinoisc Reprint requests: Sophie M. Worobec, MD, Department of Dermatology, University of Illinois College of Medicine, 808 S Wood, 376CME, Chicago, IL 60612 E-mail: [email protected]
To the Editor: The presence of gas within subcutaneous tissue, known as subcutaneous emphysema (SE), can be a worrisome finding. It may indicate the presence of serious infection or may result from antecedent trauma or rupture of a visceral organ. SE has been described in conjunction with a variety of causes, including dental procedures, endotracheal procedures, respiratory and gastrointestinal tract disease, loosely sutured wounds, and even hydrogen peroxide irrigation.1-3 We report a case of SE of the forearm caused by liquid nitrogen spray to a curetted hypertrophic actinic keratosis (HAK). A 79-year-old Caucasian woman presented to our clinic for a routine skin check. Multiple actinic keratoses, including an HAK on the left forearm, were noted. The skin over the dorsum of the hands and forearms was also noted to be significantly atrophic. To achieve maximum therapeutic effect from the liquid nitrogen spray, the HAK was curetted to remove much of the dense hyperkeratosis. On administration of the spray, SE instantly appeared throughout the left forearm, involving an area of approximately 10 cm. Soft tissue swelling was readily visible, and crepitus was palpated diffusely (Fig 1). This effect improved modestly over the next 30 minutes, and the patient was sent home with the reassurance that the air infiltration would continue to dissipate. At the time of follow-up, we learned that the SE had resolved by the following day. As already mentioned, several pathological events can give rise to SE. Perhaps the most serious causes are related to soft tissue infection and respiratory tract disease. Notably, the presence of gas in the subcutaneous tissue does not always indicate a serious underlying disorder, such as in the case of our patient. The association between compressed nitrogen gas causing tissue insufflation has been reported as a complication of cutaneous cryotherapy, but it is rare.1,4-6 Specifically, SE has been described with the use of sprayed liquid nitrogen in the periorbital area in two cases. In one case, the
S96 Letters
J AM ACAD DERMATOL NOVEMBER 2006
Funding sources: None. Conflicts of interest: None identified. Correspondence to: Michael J. Wells, MD, Department of Dermatology, Texas Tech University Health Sciences Center, 3601 Fourth St, Stop 9400, Lubbock, TX 79430 E-mail: [email protected]
Fig 1. Soft-tissue swelling after open-spray cryotherapy preceded by curettage of hypertrophic actinic keratosis on an elderly patient’s atrophic extremity. Crepitus was palpated diffusely.
nozzle aperture was placed in direct contact with an actinic keratosis on fragile elderly skin. The swelling resolved without complication after 12 hours.1,5 The other case involved treatment of an ulcerated basal cell carcinoma. The author makes no reference to the time course to resolution or if other complications were noted.6 The same principle has been described with other types of compressed air injuries. The literature states a benign course is expected, but there is the potential for infection if microbes are carried along with the forced injection of compressed air into the subcutaneous tissue.1 Other complications associated with liquid nitrogen are numerous and have been previously described in detail.1,4,6-8 They may be acute, delayed, protracted, or permanent and include changes such as excessive blistering, bleeding, infection, dyspigmentation, hair loss, altered sensation, nerve damage, atrophy, and scarring. Our case further illustrates a rare and seldom reported complication associated with the use of liquid nitrogen spray. Any type of compressed gas has the potential to insufflate tissue. The risk of this complication is significantly enhanced with cutaneous defects from ulcerations, curettage procedures, and freshly closed wounds. We believe that patients with frail, atrophic skin are at particular risk for this cryotherapy complication. Therefore, in these patients, the use of a cotton-tipped applicator or a cryoprobe may be a better choice. Another option would be to utilize pressure rings or cones when spraying open lesions.6 Overall this complication is benign and self-resolving, but it can be startling to the physician and patient. Thomas J. Lambert, BA, Michael J. Wells, MD, and Keith W. Wisniewski, MD Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas
REFERENCES 1. Samlaska CP, Maggio KL. Subcutaneous emphysema. Adv Dermatol 1996;11:117-51; discussion 152. 2. Doweiko JP, Alter C. Subcutaneous emphysema: report of a case and review of the literature. Dermatology 1992;184:62-4. 3. Willy PJ, McArdle P, Peters WJ. Surgical emphysema and ColletSicard syndrome after cryoblockade of the inferior alveolar nerve. Br J Oral Maxillofac Surg 2003;41:190-2. 4. Dawber RP. Cryosurgery: complications and contraindications. Clin Dermatol 1990;8:108-14. 5. Collins AG. Complication of cryotherapy. Med J Aust 1992; 157:843. 6. Elton RF. Complications of cutaneous cryosurgery. J Am Acad Dermatol 1983;8:513-9. 7. Andrews MD. Cryosurgery for common skin conditions. Am Fam Physician 2004;69:2365-72. 8. Heidenheim M, Jemec GB. Side effects of cryotherapy. J Am Acad Dermatol 1991;24:653. doi:10.1016/j.jaad.2005.09.023
Toxic epidermal necrolysis in a mother and fetus To the Editor: Toxic epidermal necrolysis (TEN) is a rare, life-threatening hypersensitivity reaction to certain medications.1,2 Only 4 cases of TEN in the newborn have been reported in the literature.3-6 We report a case of TEN simultaneously developing in a mother and her fetus.7,8 A 17-year-old, 22-week primigravida female with a history of seizure disorder presented to the emergency department with generalized rash, fever, conjunctivitis, and sore throat or 4 days’ duration. Three weeks before appearance of the rash, her long-standing seizure medication was changed from divalproex, a derivative of valproic acid, to phenytoin. She was not taking any other prescription or over-the-counter medications. Physical examination revealed orolabial and genital erosions as well as irregular, poorly defined purpuric macules on her face, trunk, and extremities, some of which contained flaccid central bullae, and areas of desquamation covering 60% of her body surface area (Fig 1, A). She was given a diagnosis of TEN on the basis of clinical findings. A 3-mm punch biopsy specimen of skin for microscopic evaluation was obtained. Phenytoin was immediately stopped, and divalproex was
Letters S95
VOLUME 55, NUMBER 5
REFERENCES 1. Hofmann B, Stege H, Ruzicka T, Lehmann P. Effect of topical tazarotene in the treatment of congenital ichthyoses. Br J Dermatol 1999;141:642-6. 2. Stege H, Hofmann B, Ruzicka T, Lehmann P. Topical application of tazarotene in the treatment of nonerythrodermic lamellar ichthyosis. Arch Dermatol 1998;134:640. 3. Marulli GC, Campione E, Chimenti MS, Terrinoni A, Melino G, Bianchi L. Type I lamellar ichthyosis improved by tazarotene 0.1% gel. Clin Exp Dermatol 2003;28:391-3. doi:10.1016/j.jaad.2005.09.018
Subcutaneous emphysema resulting from liquid nitrogen spray
Fig 2. Improvement in tazarotene-treated areas on back (A) and right shoulder (B) after 3 months.
acetylenic retinoid with selective binding to RARgamma and RAR-beta receptors, and 90% of retinoid receptors in the skin are of the RAR-gamma subtype. RAR-gamma receptor specificity may be one reason tazarotene can be more effective than systemic retinoids that do not demonstrate receptor specificity. Variability in expression of retinoid receptors and in metabolism of prodrug to the active form may account for individual differences in therapeutic response. Although our patient experienced rapid and significant improvement, larger controlled studies are needed to evaluate the efficacy of topical tazarotene in the treatment of lamellar ichthyosis and other ichthyotic disorders. Roopal V. Kundu, MD,a Amit Garg, MD,b and Sophie M. Worobec, MDc Department of Dermatology, Northwestern University Medical School, Chicago, Illinois,a Division of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts,b Department of Dermatology, University of Illinois College of Medicine, Chicago, Illinoisc Reprint requests: Sophie M. Worobec, MD, Department of Dermatology, University of Illinois College of Medicine, 808 S Wood, 376CME, Chicago, IL 60612 E-mail: [email protected]
To the Editor: The presence of gas within subcutaneous tissue, known as subcutaneous emphysema (SE), can be a worrisome finding. It may indicate the presence of serious infection or may result from antecedent trauma or rupture of a visceral organ. SE has been described in conjunction with a variety of causes, including dental procedures, endotracheal procedures, respiratory and gastrointestinal tract disease, loosely sutured wounds, and even hydrogen peroxide irrigation.1-3 We report a case of SE of the forearm caused by liquid nitrogen spray to a curetted hypertrophic actinic keratosis (HAK). A 79-year-old Caucasian woman presented to our clinic for a routine skin check. Multiple actinic keratoses, including an HAK on the left forearm, were noted. The skin over the dorsum of the hands and forearms was also noted to be significantly atrophic. To achieve maximum therapeutic effect from the liquid nitrogen spray, the HAK was curetted to remove much of the dense hyperkeratosis. On administration of the spray, SE instantly appeared throughout the left forearm, involving an area of approximately 10 cm. Soft tissue swelling was readily visible, and crepitus was palpated diffusely (Fig 1). This effect improved modestly over the next 30 minutes, and the patient was sent home with the reassurance that the air infiltration would continue to dissipate. At the time of follow-up, we learned that the SE had resolved by the following day. As already mentioned, several pathological events can give rise to SE. Perhaps the most serious causes are related to soft tissue infection and respiratory tract disease. Notably, the presence of gas in the subcutaneous tissue does not always indicate a serious underlying disorder, such as in the case of our patient. The association between compressed nitrogen gas causing tissue insufflation has been reported as a complication of cutaneous cryotherapy, but it is rare.1,4-6 Specifically, SE has been described with the use of sprayed liquid nitrogen in the periorbital area in two cases. In one case, the
S96 Letters
J AM ACAD DERMATOL NOVEMBER 2006
Funding sources: None. Conflicts of interest: None identified. Correspondence to: Michael J. Wells, MD, Department of Dermatology, Texas Tech University Health Sciences Center, 3601 Fourth St, Stop 9400, Lubbock, TX 79430 E-mail: [email protected]
Fig 1. Soft-tissue swelling after open-spray cryotherapy preceded by curettage of hypertrophic actinic keratosis on an elderly patient’s atrophic extremity. Crepitus was palpated diffusely.
nozzle aperture was placed in direct contact with an actinic keratosis on fragile elderly skin. The swelling resolved without complication after 12 hours.1,5 The other case involved treatment of an ulcerated basal cell carcinoma. The author makes no reference to the time course to resolution or if other complications were noted.6 The same principle has been described with other types of compressed air injuries. The literature states a benign course is expected, but there is the potential for infection if microbes are carried along with the forced injection of compressed air into the subcutaneous tissue.1 Other complications associated with liquid nitrogen are numerous and have been previously described in detail.1,4,6-8 They may be acute, delayed, protracted, or permanent and include changes such as excessive blistering, bleeding, infection, dyspigmentation, hair loss, altered sensation, nerve damage, atrophy, and scarring. Our case further illustrates a rare and seldom reported complication associated with the use of liquid nitrogen spray. Any type of compressed gas has the potential to insufflate tissue. The risk of this complication is significantly enhanced with cutaneous defects from ulcerations, curettage procedures, and freshly closed wounds. We believe that patients with frail, atrophic skin are at particular risk for this cryotherapy complication. Therefore, in these patients, the use of a cotton-tipped applicator or a cryoprobe may be a better choice. Another option would be to utilize pressure rings or cones when spraying open lesions.6 Overall this complication is benign and self-resolving, but it can be startling to the physician and patient. Thomas J. Lambert, BA, Michael J. Wells, MD, and Keith W. Wisniewski, MD Department of Dermatology, Texas Tech University Health Sciences Center, Lubbock, Texas
REFERENCES 1. Samlaska CP, Maggio KL. Subcutaneous emphysema. Adv Dermatol 1996;11:117-51; discussion 152. 2. Doweiko JP, Alter C. Subcutaneous emphysema: report of a case and review of the literature. Dermatology 1992;184:62-4. 3. Willy PJ, McArdle P, Peters WJ. Surgical emphysema and ColletSicard syndrome after cryoblockade of the inferior alveolar nerve. Br J Oral Maxillofac Surg 2003;41:190-2. 4. Dawber RP. Cryosurgery: complications and contraindications. Clin Dermatol 1990;8:108-14. 5. Collins AG. Complication of cryotherapy. Med J Aust 1992; 157:843. 6. Elton RF. Complications of cutaneous cryosurgery. J Am Acad Dermatol 1983;8:513-9. 7. Andrews MD. Cryosurgery for common skin conditions. Am Fam Physician 2004;69:2365-72. 8. Heidenheim M, Jemec GB. Side effects of cryotherapy. J Am Acad Dermatol 1991;24:653. doi:10.1016/j.jaad.2005.09.023
Toxic epidermal necrolysis in a mother and fetus To the Editor: Toxic epidermal necrolysis (TEN) is a rare, life-threatening hypersensitivity reaction to certain medications.1,2 Only 4 cases of TEN in the newborn have been reported in the literature.3-6 We report a case of TEN simultaneously developing in a mother and her fetus.7,8 A 17-year-old, 22-week primigravida female with a history of seizure disorder presented to the emergency department with generalized rash, fever, conjunctivitis, and sore throat or 4 days’ duration. Three weeks before appearance of the rash, her long-standing seizure medication was changed from divalproex, a derivative of valproic acid, to phenytoin. She was not taking any other prescription or over-the-counter medications. Physical examination revealed orolabial and genital erosions as well as irregular, poorly defined purpuric macules on her face, trunk, and extremities, some of which contained flaccid central bullae, and areas of desquamation covering 60% of her body surface area (Fig 1, A). She was given a diagnosis of TEN on the basis of clinical findings. A 3-mm punch biopsy specimen of skin for microscopic evaluation was obtained. Phenytoin was immediately stopped, and divalproex was