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3. Sakata S, Howard A, Tosti A, Sinclair R. Follow up of 12 patients with trachyonychia. Australas J Dermatol 2006;47:166–8. 4. Madke B, Gadkari R, Nayak C. Median canaliform dystrophy of Heller. Indian Dermatol Online J 2012;3:224–5. 5. Serour F. Recurrent ingrown big toenails are efficiently treated by CO2 laser. Dermatol Surg 2002;28:509–12.

Nicole F. Vélez, MD Dermatology Professionals, Inc. East Greenwich Rhode Island

Nathaniel J. Jellinek, MD Dermatology Professionals, Inc. East Greenwich Rhode Island Department of Dermatology Warren Alpert Medical School at Brown University Providence, Rhode Island Division of Dermatology University of Massachusetts Medical School Worcester, Massachusetts

Open Access Sclerotherapy: An Alternative Technique to Treat Complex Venous Malformations Vascular malformations in the hand and forearm are uncommon. Interventions include conservative management with compressive garments or antithrombotic drugs, sclerotherapy, embolization, or excision. We present a case of a 4-year-old girl with a venous malformation (VM) in the flexor compartment of her left forearm extending into the hand causing symptoms consistent with carpal tunnel syndrome, including swelling, pain, and altered sensation. Ultrasoundguided percutaneous sclerotherapy was only partially successful because of the limited access to deeper components of the lesion and greater caution exercised to avoid the risk of median nerve injury. Open access sclerotherapy was successfully performed by the careful titration of sclerosant under direct visualization at the time of surgical decompression of the forearm, hand, and carpal tunnel. This approach provides an alternative treatment for complicated vascular malformations that are inaccessible, multiloculated, or in proximity to vital neurovascular structures.

Venogram of the left upper limb demonstrated multiple tortuous low-flow filling vessels consistent with a VM. Magnetic resonance imaging confirmed a large lobulated lesion, along the flexor tendons extending into the palmar aspect of the hand, surrounding and compressing the median nerve (Figure 2). The patient had 6 multiple previous attempts at percutaneous sclerotherapy at approximately 6-week intervals with 3% sodium tetradecyl sulfate (STS) Tessari foam (1 unit liquid, 4 units room air) in the angiography suite, 2 of which resulted in postprocedural worsening of symptoms. The procedure involved direct percutaneous puncture of the palmar varicosity and volar forearm malformation under ultrasound and fluoroscopic guidance while under general anesthesia. Follow-up venography and ultrasound imaging at the end of the treatment period showed partial sclerosis of the target lesion. Failure to

Case Report A 4-year-old girl was diagnosed with a large VM on the flexor aspect of her left forearm extending through the carpel tunnel into the palmar aspect of the hand. It was present since the age of 2 years and was associated with swelling, pain, and altered sensation (Figure 1). She had no other concurrent medical problems other than mild asthma. Childhood development was otherwise normal.

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Figure 1. Venous malformation in the left forearm extending into the hand causing carpal tunnel syndrome.

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Figure 3. Visualization of venous malformation intraoperatively seen as a multilobulated lesion with deep submuscular components in proximity to the median nerve.

was suboptimal because of limited visualization and a conservative approach aiming to prevent postoperative exacerbation of carpal tunnel syndrome and resultant median nerve injury. As the compressive symptoms persisted, our patient was subsequently admitted for surgical decompression and open access sclerotherapy. Surgical decompression of the forearm, hand, and carpal tunnel was performed. This involved general anesthesia, tourniquet control, and Bruner incision of the left forearm with dissection to release the forearm fascia extending to the palm. Bruner incision is an oblique zigzag-like incision on the volar surface on the digits and/or palm. We used this incision to minimize the risk of flexion contracture from scarring. After dissection, the VM was visualized as a multilobulated lesion with deep submuscular components. At the time of surgery, sclerotherapy with 3% STS foam was performed with injection of the sclerosant into the lesion under direct visualization (Figure 3).

Figure 2. Magnetic resonance imaging confirming large lobulated lesion compressing the median nerve.

achieve more complete sclerosis was thought to be due to limited access to the deeper infiltrative components of the lesion. Treatment of the deeper aspects

The procedure was uneventful, and the patient remained pain-free for a period of several months. At 12 months follow-up, a progress ultrasound demonstrated a small residual patent component although the symptoms remained well controlled. The patient is managed conservatively with regular clinical and ultrasound follow-ups.

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Discussion Venous malformation consist of dysplastic vessels that can infiltrate any organ or tissue, particularly the muscle. They occur in the extremities but are less common in the hand and forearm. Percutaneous injection of sclerosing agents is the mainstay of treatment.1 Here, we present a patient with a complex VM treated by open access sclerotherapy. Sclerotherapy is considered to have better efficacy, lower complication rates, and a lower recurrence rate than surgery.2 This is particularly the case for surgically inaccessible lesions. In most cases, surgical excision alone is suboptimal because of unwanted functional and aesthetic sequelae and high recurrence rate. Furthermore, surgical excision is difficult to undertake when lesions occupy multiple anatomic spaces, or encase critical structures or have ill-defined margins. A combined approach of surgical excision with intraoperative sclerotherapy or preoperative embolotherapy is considered the most effective means to control infiltrating extratruncular VM.1 Here, we report the treatment of a complex VM of the forearm and hand with open access sclerotherapy. In this patient, routine image-guided percutaneous sclerotherapy was restricted by the location of the VM alongside the flexor tendons and median nerve extending deep into the carpal tunnel. This access was markedly improved by dividing the transverse carpal ligament at the time of open carpal tunnel release, allowing direct visualization of the malformation, thereby facilitating sclerotherapy. Direct access also allows accurate titration of the volume of sclerosant injected as the lesion is observed to fill with sclerosant foam, and hence the use of excessive volumes can be avoided. Open access sclerotherapy is preferable to simple excision and ligation as the sclerosant foam can be guided to enter surgically inaccessible and infiltrative segments of target lesions. Several sclerosants are commonly used in the treatment of VM including STS, polidocanol (POL), and ethanol.3 Both STS and POL are classified as detergent sclerosants, whereas ethanol is a chemical irritant. The choice of the sclerosant, its format, and

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concentration depend on the size and location of the target lesion. In this case, we selected STS over the other available agents. We avoided ethanol because of its toxicity, potential for postoperative swelling resulting in compartment syndrome and the risk of median nerve injury.1 Sodium tetradecyl sulfate was preferred to POL because it is approximately 3 times more potent demonstrating significantly more lytic activity at equivalent concentrations.4 This is due to differences in the charge and molecular size of the detergent molecule. Detergents with a neutral large head group and longer hydrocarbon chains (such as POL) have milder properties. By contrast, detergents with a charged, small head group and short hydrocarbon chain (such as STS) have harsher properties and more frequently denature proteins or disrupt membrane protein complexes.5 We followed our patient for 12 months. The follow-up ultrasound demonstrated small patent segments within the largely sclerosed lesion. Recurrence and persistence are hallmarks of all congenital vascular malformations,1 and this procedure was not considered to be curative. Annual assessments will monitor the progress of the lesion long-term. In summary, we adopted a multidisciplinary approach in the management of a complex VM with full integration of embolization techniques with open surgical treatment. This approach provides an alternative treatment strategy in the management of infiltrative multiloculated lesions.

References 1. Lee BB, Bergan J, Gloviczki P, Laredo J, et al. Diagnosis and treatment of venous malformations: consensus document of the international union of phlebology. Int Angiol 2009;28:434–51. 2. Burrows PE, Mason KP. Percutaneous treatment of low flow vascular malformations. J Vasc Interv Radiol 2004;15:431–45. 3. Uehara S, Osuga K, Yoneda A, Oue T, et al. Intralesional sclerotherapy for subcutaneous venous malformations in children. Pediatr Surg Int 2009;25:709–71. 4. Parsi K, Exner T, Connor DE, Herbert A, et al. The lytic effects of detergent sclerosants on erythrocytes, platelets, endothelial cells and microparticles are attenuated by albumin and other plasma components in vitro. Eur J Vasc Endovasc Surg 2008;36:216–23. 5. Prive GG. Detergents for the stabilization and crystallization of membrane proteins. Methods 2007;41:388–97.

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Burcu Kim, MBBS Naveen Somia, MBBS, PhD, FRACS Department of Plastic and Reconstructive Surgery, Prince of Wales Hospital Burcu Kim, MBBS Naveen Somia, MBBS, PhD, FRACS John Pereira, MBBS, BSc(Med), FRANZCR Kurosh Parsi, MBBS, MSc(Med), PhD, FACP, FACD Faculty of Medicine The University of New South Wales Sydney, Australia

John Pereira, MBBS, BSc(Med), FRANZCR Kurosh Parsi, MBBS, MSc(Med), PhD, FACP, FACD Department of Medical Imaging Prince of Wales and Sydney Children’s Hospital Sydney, Australia Kurosh Parsi, MBBS, MSc(Med), PhD, FACP, FACD Department of Dermatology St Vincent’s Hospital Sydney Australia

Long-term Efficacy and Quality of Life Assessment for Treatment of Axillary Hyperhidrosis With a Microwave Device In a prior report,1 we provided 1-year efficacy and safety data for subjects with axillary hyperhidrosis treated with a microwave technology. This letter provides 2-year follow-up data for a majority of those patients and a further exploration of the potential for quality of life improvement.

The results for baseline and each follow-up time point are shown in Table 1. The primary overall efficacy measure was the percentage of subjects who reduced their HDSS scores from 3 or 4 at baseline down to scores of 1 or 2 at the follow-up surveys. This remained greater than 90% and stable.

The original study enrolled 31 adult subjects with primary axillary hyperhidrosis in a single-group unblinded study at 2 centers. All subjects had Hyperhidrosis Disease Severity Scale (HDSS) ratings of 3 or 4 and a gravimetric sweat assessment of at least 50 mg per 5 minutes in each axilla. Baseline Dermatology Life Quality Index (DLQI) scores ranged from 1 to 28, with a mean of 11.8. The subjects were treated with a microwave-based device (miraDry System; Miramar Labs, Sunnyvale, CA). Nineteen of the original study group signed consent for a follow-on Web-based survey for a second year of follow-up that included the HDSS and DLQI questionnaires, and questions on odor reduction. At 1 year after treatment, all side effects (except underarm hair loss) had resolved in all patients who were active in the study. No patients noted any new side effects during the second year.

For the DLQI score, the average score across all patients at baseline was compared with the average score at the indicated follow-up time point, as well as the percentage of patients with at least a 5-point drop in DLQI. In addition, an analysis of the response to individual DLQI questions (percentage of subjects who responded that their activity was “very much” or “a lot” affected by their hyperhidrosis) identified those areas of daily activity that were most impacted by excessive sweat before the treatment: effect on clothing choices (84%), embarrassed or self-conscious (71%), prevented from work or studying (52%), and affected social or leisure activities (45%). After treatment, the percentages were between 0% and 11% and stable, as shown in Table 1. An analysis for odor reduction was conducted by calculating the percentage of subjects who stated that

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Open access sclerotherapy: an alternative technique to treat complex venous malformations.

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