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Surgical treatment of lupus of the skin
SURGICAL
TREATMENT
OF LUPUS OF THE SKIN*
CASE REPORT
Attending
JACQUES W. MALINIAC, M.D. Plastic and Reconstructive Surgeon, Sydenham NEW
YORK,
A
the surgica1 treatment of lupus is not new, it has not yet met the recognition it deserves, especially among dermatoIogists who are usually the first to see these patients. As far back as 1890, Vatrin (France) treated lupus by excision and skin grafting. NeIaton (France) and Lang (Vienna) also reported favorabIy on surgica1 therapy at the IV International Congress of Dermatology’ in 1900. With the popularization of Finsen therapy, however, conservative treatment gained the nscendency. Cauterization, scarification and radiation therapy have often been successfully used in the treatment of lupus. Many cases, however, derive no benefit from these methods, even when empIoyed with the utmost skiI1. Some do not hea at aI1; others recur after a temporary seeming cure. In this group surgery is the only resort. Surgical method of treatment consists of wide excision of the involved area and a safe margin of healthy tissue. The skin is removed in its entirety, together with a thin layer of subcutaneous fat, as lupus lesions usually tend to spread deep into the derm as lvell as superficially. During surgery, inocuIation of heaIthy skin must be avoided. Indiscreet use of instruments in handling the tissues is sometimes responsible for recurrences. Injection of an anesthetic through the diseased skin may also be an inadvertent agent of tubercuIous inocuIation. Following excision of the Iupus area, the raw surface can be skin grafted at once or left to granulate for a short period of time
to enhance the taking of the graft. I prefer immediate skin grafting foIlowing excision as this simphfies the postoperative care. If part of the skin graft faiIs to take’ or becomes the seat of recurrence, the troublesome area can easiIy be re-grafted later on. DeIay in skin grafting, fohowing excision supof lupus area, has the advantage posedIy of improving the blood supply of the wound and permitting elimination of bacteria which might cause a recurrence. However, since a split (thin) graft is used in this type of repair, delay is unnecessary, because of the ease with which a thin graft can be procured. Following excision of even a small lupus area, it is not usually advisable to try to close the defect by shifting the surrounding skin, because of the possibiIity of recurrence. This method can be used, however, in cases in which temporary skin grafts have been previously apphed and the area has remained free from lesions for a prolonged time. Tubed haps are contraindicated for skin cotTering following lupus excision because of the undue amount of surgery involved in the preparation of these fIaps and the danger of recurrence. The indications for surgery depend upon the size and location of the lesion and the social status of the patient. Small localized areas on any part of the body or face, not involving a cavity or its margin, may be excised for economic reasons, to avoid the protracted treatment usuahy required in conservative procedures. On the other hand, there are certain contraindications which must be strictly respected. Surger!
LTHOUGH
* C&e presentation
kfospitxl
NEW YORK
before the Society of Plastic and Rrconstwctivc ‘23
Surgerv,
IO-V’.
124
American
Journal
of Surgery
MaIiniac-Lupus
is not
indicated in recent cases with rapid extension or in those without definite Iocalization. Neither should it be attempted
FIG. I. Lupus vulgaris of the ear and cheek with malignant degeneration of auricle following proIonged treatment including intensive mdiation therapy.
when the Iupus invoIves margins of cavities, such as the mouth, nostriIs, eyeIids, etc. As a genera1 ruIe, one may say that surgery is indicated in those types of skin Iupus which are fairly we11 localized, without tendency to spread, and which resist a11 conservative therapy. The indications for surgery are strengthened when the lupus Iesions have been exposed to radiation therapy for a proIonged period of time with danger of malignant degeneration. The foIIowing case report iIIustrates the potential danger of protracted treatment of skin Iupus and the beneficia1 resuIts of surgery in such cases: CASE
REPORT
A woman, age forty-two, had been treated continuousIy for an active Iupus vulgaris in a number of dermatoIogica1 clinics for about fifteen years prior to her appearance in the plastic surgery cIinic. The site of the Iesion was the left cheek and auricIe. Treatment had been of various types, incIuding .u-ray therapy. According to her history, lupus on the ear
of the Skin
JANUARY,
I+P
for about thirty-three had been in existence years ancJ on the cheek for twenty ,years. When I lirst saw tile patient in June, 1933, the lupus
FIG. 2. Same patient eight years after amputation of auricle, with wide excision of diseased skin of cheek, foIlowed by free skin grafting. There was no recurrence after surgery.
area extended on the posterior half of the Ieft cheek with active lesions disseminated in an irreguIarIy scarred skin. The left ear had a cauIiff ower appearance and Iobulated, inflamed and ulcerated. In the previous few weeks the ear had become excrutiatingIy painful and the sweIIing had progressed rapidly. No lupus lesions were to be found elsewhere on the body and no other tuberculous process The tuberculous condition was diagnosed. seemed to have been localized on the left cheek and ear for at Ieast two and three decades, respectively, without any tendency to spread. (Figs. I and 2.) PathoIogical examination of a specimen removed from the diseased auricle reveaIed a squamoceI1 epithelioma. (Fig. 4.) The auricIe was amputated with a diathermy knife in JuIy, 1933. There has been no recurrence in that area since. The patient continued to be treated in the dermatoIogica1 clinic for skin Iupus of the cheek until about 1935. In July of that year, the entire Iupus area, as outlined in Figure 3
t-apicll~ spreading lesions \vithout locnliz:~tion and in those in\,ol\.ing of cavities. f
d-
tlclinitc margins
b.
FIG. 3. Diagram outlining free skin graft and its relationship to the lupus areas. a, free skin graft; h, lupus are:l of the skin; c, amputated oricle.
A11 scar tissue above the fascia \~as carefully excked, with proper regard for preservation of the branches of the facial nerve. A thick split graft from the abdomen was sutured into the defect. The usual pressure dressing, with a sea sponge maintained II> rcbtention sutures, was applied. The surgeq M:LSdone in one stage under IocaI anesthesia. (Fig. 2.) The patient has been seen by us periodically in the eight ,vears since the operation and there has hetn no recurrence of Iupus or epithelioma observed in either the graft or the stump of the auricle. The texture and color of the graft have graduaIIy improved I\ ith the passae;e of years. supply.
SUMMARY I.
cases peutic 2.
AND
3. The surgical procedure of choice is \vide excision followed by free skin grafting. 4. A case of’ lupus vulgaris of cheek and ear of over thirty years’ duration is here described. Continuous irritation with physical and chemical agents during prolonged treatment of the lupus had caused rnnlignant degeneration of the ear. There hn\,c been no recurrences of either the lupus or the malignsnc~ since surgery.
CONCLUSIONS
Surgery is the only resort unaffected by conservative measures. Contraindication for surgery
REFERENCE
in
lupus thera-
exists
in
I. 11. L \K\‘(;. Sur
Ies rcsultats dc L’cxtirpation du [upus :LVVCprcscntation dcs rnal:ldes operbs ct gueris. ‘11. Nelaton. Discussion of this paper-l\‘. (Iongrcss International dc Derm;ltologic. et dc Svphilographic. Paris, pp. 16 16;, August. IOC>C~.
TREATMENT
OF LUPUS OF THE SKIN*
CASE REPORT
Attending
JACQUES W. MALINIAC, M.D. Plastic and Reconstructive Surgeon, Sydenham NEW
YORK,
A
the surgica1 treatment of lupus is not new, it has not yet met the recognition it deserves, especially among dermatoIogists who are usually the first to see these patients. As far back as 1890, Vatrin (France) treated lupus by excision and skin grafting. NeIaton (France) and Lang (Vienna) also reported favorabIy on surgica1 therapy at the IV International Congress of Dermatology’ in 1900. With the popularization of Finsen therapy, however, conservative treatment gained the nscendency. Cauterization, scarification and radiation therapy have often been successfully used in the treatment of lupus. Many cases, however, derive no benefit from these methods, even when empIoyed with the utmost skiI1. Some do not hea at aI1; others recur after a temporary seeming cure. In this group surgery is the only resort. Surgical method of treatment consists of wide excision of the involved area and a safe margin of healthy tissue. The skin is removed in its entirety, together with a thin layer of subcutaneous fat, as lupus lesions usually tend to spread deep into the derm as lvell as superficially. During surgery, inocuIation of heaIthy skin must be avoided. Indiscreet use of instruments in handling the tissues is sometimes responsible for recurrences. Injection of an anesthetic through the diseased skin may also be an inadvertent agent of tubercuIous inocuIation. Following excision of the Iupus area, the raw surface can be skin grafted at once or left to granulate for a short period of time
to enhance the taking of the graft. I prefer immediate skin grafting foIlowing excision as this simphfies the postoperative care. If part of the skin graft faiIs to take’ or becomes the seat of recurrence, the troublesome area can easiIy be re-grafted later on. DeIay in skin grafting, fohowing excision supof lupus area, has the advantage posedIy of improving the blood supply of the wound and permitting elimination of bacteria which might cause a recurrence. However, since a split (thin) graft is used in this type of repair, delay is unnecessary, because of the ease with which a thin graft can be procured. Following excision of even a small lupus area, it is not usually advisable to try to close the defect by shifting the surrounding skin, because of the possibiIity of recurrence. This method can be used, however, in cases in which temporary skin grafts have been previously apphed and the area has remained free from lesions for a prolonged time. Tubed haps are contraindicated for skin cotTering following lupus excision because of the undue amount of surgery involved in the preparation of these fIaps and the danger of recurrence. The indications for surgery depend upon the size and location of the lesion and the social status of the patient. Small localized areas on any part of the body or face, not involving a cavity or its margin, may be excised for economic reasons, to avoid the protracted treatment usuahy required in conservative procedures. On the other hand, there are certain contraindications which must be strictly respected. Surger!
LTHOUGH
* C&e presentation
kfospitxl
NEW YORK
before the Society of Plastic and Rrconstwctivc ‘23
Surgerv,
IO-V’.
124
American
Journal
of Surgery
MaIiniac-Lupus
is not
indicated in recent cases with rapid extension or in those without definite Iocalization. Neither should it be attempted
FIG. I. Lupus vulgaris of the ear and cheek with malignant degeneration of auricle following proIonged treatment including intensive mdiation therapy.
when the Iupus invoIves margins of cavities, such as the mouth, nostriIs, eyeIids, etc. As a genera1 ruIe, one may say that surgery is indicated in those types of skin Iupus which are fairly we11 localized, without tendency to spread, and which resist a11 conservative therapy. The indications for surgery are strengthened when the lupus Iesions have been exposed to radiation therapy for a proIonged period of time with danger of malignant degeneration. The foIIowing case report iIIustrates the potential danger of protracted treatment of skin Iupus and the beneficia1 resuIts of surgery in such cases: CASE
REPORT
A woman, age forty-two, had been treated continuousIy for an active Iupus vulgaris in a number of dermatoIogica1 clinics for about fifteen years prior to her appearance in the plastic surgery cIinic. The site of the Iesion was the left cheek and auricIe. Treatment had been of various types, incIuding .u-ray therapy. According to her history, lupus on the ear
of the Skin
JANUARY,
I+P
for about thirty-three had been in existence years ancJ on the cheek for twenty ,years. When I lirst saw tile patient in June, 1933, the lupus
FIG. 2. Same patient eight years after amputation of auricle, with wide excision of diseased skin of cheek, foIlowed by free skin grafting. There was no recurrence after surgery.
area extended on the posterior half of the Ieft cheek with active lesions disseminated in an irreguIarIy scarred skin. The left ear had a cauIiff ower appearance and Iobulated, inflamed and ulcerated. In the previous few weeks the ear had become excrutiatingIy painful and the sweIIing had progressed rapidly. No lupus lesions were to be found elsewhere on the body and no other tuberculous process The tuberculous condition was diagnosed. seemed to have been localized on the left cheek and ear for at Ieast two and three decades, respectively, without any tendency to spread. (Figs. I and 2.) PathoIogical examination of a specimen removed from the diseased auricle reveaIed a squamoceI1 epithelioma. (Fig. 4.) The auricIe was amputated with a diathermy knife in JuIy, 1933. There has been no recurrence in that area since. The patient continued to be treated in the dermatoIogica1 clinic for skin Iupus of the cheek until about 1935. In July of that year, the entire Iupus area, as outlined in Figure 3
t-apicll~ spreading lesions \vithout locnliz:~tion and in those in\,ol\.ing of cavities. f
d-
tlclinitc margins
b.
FIG. 3. Diagram outlining free skin graft and its relationship to the lupus areas. a, free skin graft; h, lupus are:l of the skin; c, amputated oricle.
A11 scar tissue above the fascia \~as carefully excked, with proper regard for preservation of the branches of the facial nerve. A thick split graft from the abdomen was sutured into the defect. The usual pressure dressing, with a sea sponge maintained II> rcbtention sutures, was applied. The surgeq M:LSdone in one stage under IocaI anesthesia. (Fig. 2.) The patient has been seen by us periodically in the eight ,vears since the operation and there has hetn no recurrence of Iupus or epithelioma observed in either the graft or the stump of the auricle. The texture and color of the graft have graduaIIy improved I\ ith the passae;e of years. supply.
SUMMARY I.
cases peutic 2.
AND
3. The surgical procedure of choice is \vide excision followed by free skin grafting. 4. A case of’ lupus vulgaris of cheek and ear of over thirty years’ duration is here described. Continuous irritation with physical and chemical agents during prolonged treatment of the lupus had caused rnnlignant degeneration of the ear. There hn\,c been no recurrences of either the lupus or the malignsnc~ since surgery.
CONCLUSIONS
Surgery is the only resort unaffected by conservative measures. Contraindication for surgery
REFERENCE
in
lupus thera-
exists
in
I. 11. L \K\‘(;. Sur
Ies rcsultats dc L’cxtirpation du [upus :LVVCprcscntation dcs rnal:ldes operbs ct gueris. ‘11. Nelaton. Discussion of this paper-l\‘. (Iongrcss International dc Derm;ltologic. et dc Svphilographic. Paris, pp. 16 16;, August. IOC>C~.