Patients with skin picking disorders (SPDs) have historically been an under recognized and under treated group. Originally classified an impulse control disorder, skin picking disorder is now considered under the obsessive-compulsive disorder (OCD) and obsessive-compulsive-related disorder (OCRD) spectrum. Workup of SPD concentrates on differentiating this condition from primary skin disorders, systemic conditions associated with pruritus, and psychocutaneous syndromes. It is important to first address any underlying pruritic disorders (if present) that may be a trigger to pick the skin. First-line treatment for SPD is cognitive behavioral therapy. When necessary, pharmacologic therapy can be helpful as well.

anchor stitch at the beginning. 4 Perform an initial anchor stitch and leave a long tail as described above. Complete the rest of the closure as normal and after the final bite is performed, cinch the wound down as taught as possible. Attach a hemostat to the suture where it exits the dermis ( Figure 2) and then perform an instrument tie, tying the free end of the suture to the long tail of the anchor stitch. This modification maximizes the cinching of the purse and allows for the knot to be thrown without tension, allowing for better knot security.Purse-string closures reduce wound size by 50% to 78%, and the buried purse-string suture technique is a good closure option for defects created by dermatological surgery in certain situations. 1 The "purse-string anchor" modification of this technique that the authors have described above allows for better knot security with less slipping during the instrument tie. The purse-string anchor is technically easy and can be combined with the purse-string lockdown to maximally reduce the circumference of a circular defect, providing both security and strength. References 1. Cohen PR, Martinelli PT, Schulze KE. Nelson BR the purse-string revisited: a useful technique for the closure of cutaneous surgical wounds. Int J Dermatol 2007;46:341-7. 2. Weisberg NK, Greenbaum SS. Revisiting the purse-string closure: some new methods and modifications. Dermatol Surg 2003;29:672-6. 3. Harrington AC, Montemarano A, Welch M, et al. Variations of the purse string suture in skin cancer reconstruction.The frequency of opportunistic fungal infections is rising among a growing population of immunosuppressed patients. In this letter, the authors report a case of recurrent cutaneous alternariosis treated with Mohs surgery and the first case in which a graft was used.A man in his sixties with diabetes, status post cardiac transplant on tacrolimus, prednisone, and mycophenolate, presented with a nodule on the finger that enlarged for more than 2 months. The patient did not recall any preceding trauma, although he enjoyed gardening. Figure 1. A knot is tied on the first throw, and a long tail is left when the suture is cut. This knot serves as the anchor as subsequent throws are performed. Figure 2. A variation of the purse-string lockdown using an anchor stitch. The purse is cinched down and a hemostat is placed at the free end where the suture exits the dermis.

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