Mohs micrographic surgery challenges and new technologies to optimize care of cutaneous malignancies of the ear.

Cutaneous malignancies affecting the ear, exacerbated by extensive ultraviolet (UV) exposure, pose intricate challenges owing to the organ's complex anatomy. This article investigates how the anatomy contributes to late-stage diagnoses and ensuing complexities in surgical interventions. Mohs Micrographic Surgery (MMS), acknowledged as the gold standard for treating most cutaneous malignancies of the ear, ensures superior margin control and cure rates. However, the ear's intricacy necessitates careful consideration of tissue availability and aesthetic outcomes. The manuscript explores new technologies like Reflectance Confocal Microscopy (RCM), Optical Coherence Tomography (OCT), High-Frequency, High-Resolution Ultrasound (HFHRUS), and Raman spectroscopy (RS). These technologies hold the promise of enhancing diagnostic accuracy and providing real-time visualization of excised tissue, thereby improving tumor margin assessments. Dermoscopy continues to be a valuable non-invasive tool for identifying malignant lesions. Staining methods in Mohs surgery are discussed, emphasizing hematoxylin and eosin (H&E) as the gold standard for evaluating tumor margins. Toluidine blue is explored for potential applications in assessing basal cell carcinomas (BCC), and immunohistochemical staining is considered for detecting proteins associated with specific malignancies. As MMS and imaging technologies advance, a thorough evaluation of their practicality, cost-effectiveness, and benefits becomes essential for enhancing surgical outcomes and patient care. The potential synergy of artificial intelligence with these innovations holds promise in revolutionizing tumor detection and improving the efficacy of cutaneous malignancy treatments.

Squamous cell carcinoma of the nail in patients with Fitzpatrick phototypes IV-VI: a systematic review.

Squamous cell carcinoma of the nail unit (nSCC) is a rare malignant tumor of the hand and nail. Although skin cancer rarely affects individuals with phototypes IV-VI, its occurrence in these groups is often associated with greater morbidity and mortality. This study aims to characterize the clinical symptoms, presentations, and treatments of nSCC in patients with darker skin types. A systematic review of PubMed and Embase was performed in May 2023 for all peer-reviewed, English-language nSCC studies involving individuals with Fitzpatrick types IV-VI. Most tumors were located on the fingernails (84%), with the right third finger being the most frequently affected (31%). The nail bed (67%) exhibited a higher prevalence than the lateral/proximal nail folds (33%). The duration of symptoms before diagnosis ranged from 1 month to 7 years. nSCC was most commonly treated with Mohs surgery (38%), followed by amputation (35%). Our study was limited to case reports because of a lack of large nSCC studies that provide information on race or images of each patient. These tumors are generally slow-growing yet often misdiagnosed, leading to delays in presentation and diagnosis. Increased awareness about nSCC in phototype IV-VI individuals will reduce misdiagnoses, unnecessary treatment, and recurrences.

Ultrasound features of high-risk basal cell carcinoma: a systematic review.

Basal Cell Carcinoma (BCC) is the most prevalent skin cancer and continues to witness a surge in incidence rates. The categorization of BCC subtypes into low or high risk, guided by recurrence and invasiveness metrics, underscores the need for precise differentiation. While the punch biopsy remains the gold standard for diagnosis, its invasiveness prompts a need for non-invasive alternatives. Ultrasound (US) has emerged as a noteworthy candidate, gaining momentum in its potential to offer a less intrusive diagnostic approach. We conducted a systematic review regarding features of the high-risk subtypes of BCC on US. A thorough literature search of PubMed Medline, Embase, and CINAHL databases was conducted according to PRISMA guidelines and a total of nine studies meeting our inclusion criteria were included in this review. Evidence is still nascent but US features such as lesional shape, depth, hyperechoic spots, and color doppler may be helpful in differentiating high-risk BCC subtypes. However, further prospective studies with standardized interventions and outcome measures are required.

A systematic review of basal cell carcinoma on the scrotum-reviewing presentation and identifying challenges in management.

Since the scrotum is rarely exposed to sunlight, basal cell carcinoma (BCC) development in this area is an uncommon occurrence. As result, there is a scarcity of research covering this particular presentation, which poses a diagnostic and therapeutic challenge for clinicians. The objective of this systematic review is to provide a thorough overview of scrotal BCC, including a summary of its clinical characteristics, and microscopic subtypes. It also seeks to discuss the many techniques used in the management of this uncommon clinical presentation. Utilizing data from 1957 to October 2023, a systematic review of PubMed and Wiley Online Library was conducted to identify all cases of scrotal BCC with various presentations and managements. A total of 73 patients were included. The median patient age was 65.9 years (range 42 to 87). All studies were either case reports or case series. Our review shows that treatment with Mohs micrographic surgery (MMS), leads to a superior patient outcome based on anecdotal evidence in select cases. To deepen our understanding of Mohs surgery's efficacy in treating scrotal BCC, it is imperative to conduct more robust research in the form of randomized clinical trials.

Examining treatment strategies for xanthelasma palpebrarum: a comprehensive literature review of contemporary modalities.

Xanthelasma palpebrarum (XP) is the predominant form of cutaneous xanthoma, as it accounts for greater than 95% of cases. It is characterized by the presence of foam cell clusters containing a large amount of low-density lipoprotein (LDL), which are located in the connective tissue of skin, tendons, and fascia. XP lesions commonly present as distinctive yellow-orange macules, papules, or nodules, and are primarily on the upper eyelids as well as the inner canthus. Women are affected twice as often as men, with lesions typically emerging between the ages of 35 and 55. The pathophysiology of XP involves abnormal lipid metabolism and is often associated with hyperlipidemic states like Type II and IV hyperlipidemia, hypothyroidism, weight gain, and fatty diet. Despite the availability of various treatment methods, current XP management lacks standardization, particularly due to limited comparative research. To address this gap, we conducted an extensive literature review of 45 studies published between 2012 to 2023, which provides an updated overview of current XP treatment modalities. This comprehensive analysis will inform researchers and clinicians on the evolving landscape of XP management.

Modified Chalazion Clamp: Novel Applications in Dermatologic Surgery.

Biopsies and excisions of mucosal surfaces can be challenging due to poor visualization and bleeding control. Surgeons have utilized chalazion clamps to overcome these challenges. However, its original design incorporates a locking mechanism which restricts its use to more proximal mucosal surfaces, does not allow for flexible exertional pressure control by the operator, and it is only available in one size. We designed a modified chalazion clamp without a locking mechanism and in two different sizes and ring diameters to overcome these challenges. In this report, we demonstrate the enhanced utility and effectiveness of the modified chalazion clamp in dermatological procedures through different cases.

Photodynamic Therapy in Treating a Subset of Basal Cell Carcinoma: Strengths, Shortcomings, Comparisons with Surgical Modalities, and Potential Role as Adjunctive Therapy.

Basal cell carcinoma (BCC) is the most common skin cancer, for which there are multiple treatment options, including the gold standard Mohs micrographic surgery (MMS), surgical excision, electrodesiccation and curettage, radiation therapy, cryosurgery, and photodynamic therapy (PDT). While PDT is currently approved for treating actinic keratosis, it has been used off-label to treat BCC patients who may not tolerate surgery or other treatment modalities. We present a review of the efficacy of these modalities and describe important considerations that affect the usage of PDT and MMS. ALA-PDT and MAL-PDT are both efficacious treatment options for lower-risk BCC that can serve as non-invasive alternatives to surgical excision with favorable cosmetic outcomes in patients unsuitable to undergo surgery. In particular, PDT may be considered an adjuvant for the prevention and treatment of BCC lesions in patients with some genetic syndromes such as Gorlin syndrome, and in combination with surgical excision in lesions presenting in certain locations. Limitations to PDT include lack of margin control to prevent recurrence, pain, and cost of certain photosensitizers. Future studies should investigate the role of PDT as adjunctive therapy, standardization of protocols, and causes and ways to address recurrence following PDT treatment.

Clinical dermatologic applications of ginger: a focused review.

Ginger is a traditional herb with medicinal properties. Although most commonly utilized as a spice, it has been used for various medicinal ailments for thousands of years. Over the past century, the anti-inflammatory, antioxidative, and antimicrobial properties of ginger have been increasingly studied. Ginger has been demonstrated to be beneficial for many conditions including dermatologic, gastrointestinal, neoplastic, and respiratory diseases. Herein, we examine the existing literature regarding the clinical uses of ginger with a focus on its dermatologic applications.

Shedding new light on actinic keratoses and squamous cell carcinoma in situ.

ABSTRACT: Cutaneous squamous cell carcinoma can arise from various premalignant lesions such as actinic keratosis, Bowen disease, and premalignant genital squamous cell lesions. Identification and treatment can prevent malignant transformation and death. This article describes the causes, epidemiology, and characteristics of suspicious premalignant squamous cell lesions so that clinicians can identify these lesions and refer patients for specialist treatment as appropriate.

Evidence-based management of cutaneous scarring in dermatology part 2: atrophic acne scarring.

Atrophic acne scars are the most common type of acne scars and are classified into three main types: icepick, boxcar, and rolling scars. Various procedures and techniques for atrophic acne scarring are discussed in detail, with stronger evidence-based support for lasers (non-fractional, fractional, ablative, and non-ablative), platelet-rich plasma as adjunctive treatment, chemical peels (glycolic acid, trichloroacetic acid, and Jessner's solution), dermal fillers such as hyaluronic acid, and microneedling, and lesser quality evidence for microdermabrasion, subcision, and lipoaspirate grafting. Further research is needed to optimize treatment protocols, assess the efficacy of monotherapies, and establish standardized guidelines for clinicians. This paper will provide a comprehensive review of the evidence-based management of atrophic acne scars, including currently commonly utilized therapies as well as more innovative treatment options.

A review of Merkel cell carcinoma.

ABSTRACT: Merkel cell carcinoma (MCC) is a rare and aggressive type of metastatic, nonmelanoma skin cancer derived from Merkel cells in the epidermis. MCC can be induced by sun exposure or via Merkel cell polyomavirus (MCV) gene expression. MCV is found in most patients with MCC and is associated with a lower recurrence rate of MCC. MCC has a wide range of clinical presentations that make diagnosis challenging. Histologic examination is performed using unique markers to differentiate it from other diagnoses. This article reviews the pathogenesis, clinical presentation, histopathology, differential diagnosis, and treatment of MCC.

Dermatologic conditions and risk factors in people experiencing homelessness (PEH): systematic review.

Limited data is present that characterizes dermatological conditions and their risk factors in people experiencing homelessness (PEH).We conducted a systematic review to investigate the types of dermatological conditions in PEH, their risk factors, and provide solutions when providing dermatological care to this patient population. We searched PubMed, EMBASE and Cochrane for articles written in English from 2012 to 2022. The last search was performed on December 27, 2022. Twelve studies met the inclusion criteria. Fifty-eight percent of the studies took place in the USA (n = 7) and 42% of studies took place in Canada (n = 5). Prevalent dermatological conditions included, skin cancer, cutaneous manifestations of malnutrition, cutaneous diphtheria, Group A Streptococcus infection (iGAS), lice, atopic dermatitis, acne, sexually transmitted infections (STIs), and Staphylococcus aureus infections. Risk factors included substance use disorder, skin trauma, not having access to sunscreen or hats, unstable housing, higher exposure to extreme weather, and higher mobility. Due to studies being conducted in the USA or Canada, results may not be generalizable. This systematic review strongly suggests that many dermatological conditions prevalent in PEH can be contributed to poor skin integrity. Better measures can significantly reduce certain dermatological conditions by improving access to dermatological care.

Systematic review of benefits and practical challenges for application of Mohs surgery for oral tumors.

Mohs micrographic surgery (MMS) may be an effective treatment modality for oral cavity cancers (OCC) due to possibility of more effective visualization of tumor margins and greater preservation of benign tissue. The objective of this study is to review the existing literature on the use of MMS for the treatment of OCC and categorize its uses and limitations. A systematic review was performed in accordance with Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines. PubMed, Scopus, and Google Scholar from inception of databases to January 20, 2023 identified all published studies on the use of MMS for OCC. Nine studies met inclusion criteria. Seventy-seven patients were treated with MMS for OCC, 74 of which (96%) were treated for squamous cell carcinoma (SCC). The tongue was the most common site (n = 57). Six out of seven studies showed no recurrence of disease during the follow-up periods, which ranged from 8 to 42 months, and one study reported significantly lower loco-regional recurrence over a 2-years follow-up period (10.5% vs 25.7%). Mohs technique did not cause a statistically significant increase in operating time. Applicability of MMS is limited by operator comfort with surgical technique and pathological interpretation of specimens in the oral cavity. The main limitation was that various studies did not report specific patient characteristics. In conclusion, MMS may be an effective treatment for OCC, especially for squamous cell carcinomas, and tumors involving the tongue.

Reappraisal and updated review of maggot debridement therapy in chronic lower extremity ulcers.

BACKGROUND: Dating back to the mid-1500s, maggot debridement therapy (MDT) has been a viable treatment modality for chronic wounds. In early 2004, the sterile larvae of Lucilia sericata received FDA approval for medical marketing for neuropathic, venous, and pressure ulcers, traumatic or surgical wounds, and nonhealing wounds that have not responded to standard care. However, it currently remains an under-utilized therapy. The proven efficacy of MDT begs the question if this treatment modality should be considered as a first-line option for all or a subset of chronic lower extremity ulcers. OBJECTIVE: This article aims to address the history, production, and evidence of MDT and discuss future considerations for maggot therapy in the healthcare field. METHODS: A literature search using the PubMed database was conducted using keywords, such as wound debridement, maggot therapy, diabetic ulcers, venous ulcers, among others. RESULTS: MDT reduced short-term morbidity in non-ambulatory patients with neuroischemic diabetic ulcers and comorbidity with peripheral vascular disease. Larval therapy was associated with statistically significant bioburden reductions against both Staphylococcus aureus and Pseudomonas aeruginosa. Faster time to debridement was achieved when chronic venous or mixed venous and arterial ulcers were treated with maggot therapy versus hydrogels. CONCLUSIONS: The literature supports the use of MDT in decreasing the significant costs of treating chronic lower extremity ulcers, with emphasis on those of diabetic origin. Additional studies with global standards for reporting outcomes are necessary to substantiate our results.

Basal cell carcinosarcoma: a systematic review and reappraisal of its challenges and the role of Mohs surgery.

Basal cell carcinosarcoma (BCCS) is a rare malignant biphasic tumor of the skin, composed of epithelial and mesenchymal components, and may be underdiagnosed. We sought to summarize the current understanding of BCCS including its reported history, clinical presentation, diagnosis, and treatment. We also reappraise and present our recommendations of histological interpretation for its diagnosis and treatment. A systematic review of PubMed and EMBASE, from inception of databases to December 1, 2022, identified all reported cases of basal cell carcinosarcoma. A total of 34 reports containing 54 patients with basal cell carcinosarcoma were included. The neoplasm was most commonly associated in areas of sun-exposed skin and primarily affected the elderly. Diagnosis was made on histology specimens using H&E. To address underdiagnosis, additional immunohistochemical markers have been proposed due to unreliable phenotypic appearance in this poorly differentiated neoplasm. Treatment consists of excision of the tumor, typically with Mohs surgery, and is curative in most cases. There are limited treatment options for metastatic disease. There were limitations to this study as various immunohistochemical stains used on suspected BCCS without providing an explanation as to why certain markers were included and others were excluded. Continued efforts in characterizing this complex neoplasm are critical in establishing reliable and accurate diagnostic tests and accompanying treatment options, especially in cases of metastatic disease.

Extracellular vesicles: a comprehensive review of their roles as biomarkers and potential therapeutics in psoriasis and psoriatic arthritis.

Psoriasis is a chronic immune-mediated condition that affects the skin and joints, with current treatments still unable to offer a cure and long-term use of treatments posing health risks. Understanding the pathogenesis of the disease has helped identify new targets that have allowed for the expansion of the therapeutic arsenal. Extracellular vesicles (EVs) have recently emerged as pathophysiological mediators of psoriasis, and there have been increasing reports of EVs as potential biomarkers and therapeutics. Given their innate role as natural vehicles for cell-to-cell communication, EVs have vast potential in their ability to determine disease status based on EV-specific cargo as well as act as therapeutics because of their anti-inflammatory properties and potential for enhancement. In this review we summarize the role of EVs in the pathogenesis of psoriasis and discuss EVs as both diagnostic and therapeutic agents.

Syphilis in Dermatology: Recognition and Management.

The incidence of syphilis has been increasing in the USA since 2000. Notably, the coronavirus disease 2019 pandemic negatively impacted the public health efforts to contain the spread of sexually transmitted diseases including syphilis and congenital syphilis. Clinical manifestations of syphilis are predominantly mucocutaneous lesions, thus dermatologists are primed to recognize the myriad presentations of this disease. Primary syphilis is classically characterized by a painless transient chancre most often located in the genital area. Secondary syphilis typically manifests clinically as systemic symptoms in addition to a mucocutaneous eruption of which a variety of forms exist. Although less common in the era of effective penicillin treatment, late clinical manifestations of syphilis are described as well. In addition to recognition of syphilis on physical examination, several diagnostic tools may be used to confirm infection. Treponema pallidum spirochetes may be detected directly using histopathologic staining, darkfield microscopy, direct fluorescent antibody, and polymerase chain reaction assays. A table detailing the histopathologic features of syphilis is included in this article. Serologic testing, non-treponemal and treponemal tests, is the preferred method for screening and diagnosing syphilis infections. Two serologic testing algorithms exist to aid clinicians in diagnosing positive syphilis infection. Determining the correct stage of syphilis infection combines results of serologic tests, patient history, and physical examination findings. Using the current Centers for Disease Control and Prevention case definitions and treatment guidelines, a management algorithm is proposed here. Penicillin remains the pharmacological treatment of choice although specific clinical situations allow for alternative therapies. Syphilis is a reportable disease in every state and should be reported by stage according to individual state requirements. Screening recommendations are largely based upon risks encountered through sexual exposures. Likewise, sexual partner management includes evaluating and treating persons exposed to someone diagnosed with an infective stage of syphilis. Close clinical follow-up and repeat testing are recommended to ensure appropriate response to treatment. This guide will discuss the current epidemiology of syphilis and focus on practice aspects of diagnosis and management, including public health reporting.

Therapeutic Use of Trace Elements in Dermatology.

Trace elements (microminerals) play a role in many physiological functions, including hormone production and cellular growth. However, their importance in diagnosing and treating dermatologic disease has not been well examined. In this review, we discuss the functions, sources, and recommended requirements of each micromineral. In addition, we analyze the systemic and dermatological manifestations associated with micromineral imbalances. The pathogenesis of genodermatoses, such as Wilson disease, Menkes disease, acrodermatitis enteropathica, and allergic dermatitis, are also discussed. Included are studies examining the potential therapeutic role of zinc, selenium, and copper in inflammatory diseases, skin cancer, and photoaging.

The Importance of Cutaneous Innervation in Wound Healing: From Animal Studies to Clinical Applications.

The skin is a neuroimmunoendocrine organ that regularly undergoes injury and repair. The complex process of wound healing relies heavily on the cutaneous nervous system. Despite the observation that wound healing deficiencies cause significant morbidity and mortality for patients with nervous dysfunction across many disciplinaries, the role of cutaneous innervation in wound repair has not been well elucidated. In a previous article, we learned the basics of cutaneous neuroanatomy and the important neuropeptides involved in the wound healing process. Currently, we aim to synthesize the basics with observations from animal models and human studies for a more comprehensive understanding of nervous system involvement in cutaneous wound healing. We have demonstrated in this review, the importance of the cutaneous nervous system in each phase of wound healing through basic science research, animal experiments, and human studies.