April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Waner & O

Acute exacerbations These are common in patients with active lesions and there is no uniformly accepted treatment. Exacerbations commonly commence after an upper respiratory infection (URI) or trauma to the lesion, but often there is no preceding URI or trauma. Acute swelling and inflammation herald the onset of such an event. Because the signs of an acute exacerbation resemble cellulitis, it is often assumed that this is caused by an acute bacterial infection and for this reason these patients are treated with an array of antibiotics, often to no avail. The exacerbation runs its course and this usually lasts 10 to 12 days. During these events, blood cultures are usually negative and there is often no direct evidence of a bacterial infection. Despite this, antibiotics have formed the mainstay of treatment. Adding corticosteroids to the regimen usually reverses the symptoms and shortens the course of the exacerba- tion. 39 Prednisone 1 to 2 mg/kg of body weight for 5 days and then a taper over a further 5 days is given. Vesicles/lymphorrhea Vesicles of the oral cavity as well as cutaneous lesions should be treated. In the past, ablative modalities such as CO 2 laser ablation and coblation have been used. 20,40,41 Although these modalities have been able to pro- vide relief, recurrence is common. More recently, local injections of bleomycin into the areas of involvement seem to be beneficial. 38 Although there has been no com- parison of the modalities, it seems that bleomycin is at least as effective and possibly more so. A typical treatment consists of an intralesional injection of 1 or 2 mg/mL of bleomycin injected directly into the vesicles or into the mucosa or skin immediately deep to the affected area ( Fig. 9 ). The authors prefer to avoid deep intramuscular injections of the tongue because this is likely to cause marked swelling. After treatment, the area becomes indurated and swollen, and some purpura is common. Some patients experience pain. The mechanism for this is not understood. Pain usually lasts 5 to 6 days and then subsides. The acute changes usually subside in 10 to 14 days and the vesicles usually resolve. Any remaining disease can be treated with a second round of treatment 6 weeks later.

Fig. 9. A patient with extensive microcystic disease of her tongue and vesicles before ( left ) and after ( right ) treatment with bleomycin injections.

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