The Detroit Keloid Scale: A Validated Tool for Rating Keloids.

Background: Comparing keloid treatment modalities and assessing response to treatments may be predicted by a better classification system. Objectives: To develop and validate the Detroit Keloid Scale (DKS), a standardized method of keloid assessment. Methods: Forty-seven physicians were polled to develop the DKS. The scale was validated in 52 patients against the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), and Dermatology Life Quality Index (DLQI). Results: The inter-rater reliability was "substantial" for observer DKS and only "moderate" for VSS and observer POSAS (intraclass correlation coefficient were 0.80, 0.60, and 0.47, respectively). Pearson's correlation indicated "moderate" association between observer DKS with observer POSAS (ρ = 0.56, p < 0.001) and "substantial" relationship between observer DKS and VSS (ρ = 0.63, p < 0.001). Pearson's correlation indicated "moderate" association between patient portion of DKS and patient portion of POSAS and patient portion of the DKS and DLQI (0.61 and 0.60, respectively, p < 0.05). DKS total score consistently showed significant "substantial" relationship with POSAS total score (ρ = 0.65, p < 0.001). Conclusions: The DKS offers a validated keloid-specific outcome measure for comparing keloid treatments.

Disease Severity and Quality of Life Outcome Measurements in Patients With Keloids: A Systematic Review.

BACKGROUND: Keloids have been assessed by numerous methods and severity indices resulting in a lack of standardization across published research. OBJECTIVE: This study aims to evaluate published keloid randomized controlled trials (RCTs) and identify the need for a gold standard of assessment. METHODS AND MATERIALS: PubMed, MEDLINE, and Embase were searched for human RCTs on keloid treatment during a 10-year period. Eligible studies were English language RCTs reporting disease severity outcome measures after keloid treatments. RESULTS: A total of 40 disease outcome measures were used in 41 included RCTs. Twenty-four (59%) of the included studies used more than one disease severity scale. The most frequently used outcome measures were the Vancouver Scar Scale (34%) (n = 14), followed by serial photography (24%) (n = 10). These were followed by adverse events and complications (20%) (n = 8), Visual Analogue Scale (12%) (n = 5), keloid dimensions (12%) (n = 5), and Patient and Observer Scar Assessment Scale (10%) (n = 4). Only one study reported quality of life outcomes. CONCLUSION: There is wide variation in keloid outcome measures in the published literature. A standardized method of assessment should be implemented to reduce the disparities between studies and to better be able to compare the numerous treatment modalities.

Intralesional Bleomycin for Warts: Patient Satisfaction and Treatment Outcomes.

BACKGROUND: The treatment of warts is challenging with regards to both tolerability and efficacy. OBJECTIVE: Ascertain the efficacy, tolerability, and patient satisfaction of intralesional bleomycin in the treatment of warts. METHODS: Retrospective chart review followed by telephone interviews with patients from university-based dermatology referral centers. RESULTS: Seventy-four percent (34/46) of patients had complete resolution (CR) of all warts. Of 34 patients who experienced CR, an average of 1.7 treatments were required. Pain experienced during the procedure and recovery, irrespective of outcome, was rated 5.8 out of 10 (range, 1-10; SD, 2.72; SEM, 0.40). Approximately 70% of patients had pain that lasted less than 2 days after treatment. Seventy-eight percent (36/46) of patients in the study were satisfied with treatment and would recommend it to others. CONCLUSION: Patients felt bleomycin to be an effective treatment modality for warts, offering high rates of CR in lesions resistant to more traditional therapies.

National utilization patterns of Mohs micrographic surgery for invasive melanoma and melanoma in situ.

BACKGROUND: Although wide local excision continues to be commonly used for melanoma treatment, Mohs micrographic surgery (MMS) for the treatment of melanomas remains controversial. OBJECTIVE: We sought to determine national utilization patterns for MMS in the treatment of invasive melanoma and melanoma in situ. METHODS: A retrospective analysis of patients receiving surgical excision (MMS or wide local excision) for the treatment of invasive melanoma and melanoma in situ was performed using data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) program. RESULTS: A total of 195,768 melanomas were diagnosed from 2003 through 2009 from the 17 SEER registries. Utilization of MMS for invasive melanoma and melanoma in situ increased by 60% from 2003 to 2008. Of all SEER-captured lesions treated by surgical excision in this time period, 3.5% (6872) were excised by MMS. LIMITATIONS: Patient insurance status, physician reimbursement practices, and health care provider type were not addressed in this article. CONCLUSION: Use of MMS for melanoma appears to be increasing. Future studies should explore whether this is associated with better outcomes.

Utilization of a novel valveless trocar system during robotic-assisted laparoscopic prostatectomy.

PURPOSE: To evaluate the effect of a novel valveless trocar system (VTS) on perioperative outcomes in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). METHODS: A single-institution retrospective review was performed of 792 patients undergoing RALP. Preoperative patient variables, tumor characteristics, and perioperative variables were collected and analyzed. The first 150 patients were excluded from analysis to account for the learning curve of robotic surgery. Univariate and multivariate linear regression models were used to assess factors affecting operative time (ORT). RESULTS: A total of 257 and 385 patients underwent RALP utilizing the VTS and conventional insufflation, respectively. There were no significant differences in American Society of Anesthesiologist score, body mass index (BMI), prostate volume, final Gleason score, estimated blood loss, and complications between the cohorts. The only difference noted was a significantly shorter mean ORT in the VTS cohort (149.5 vs. 170.1 min, p < 0.0001). In light of this finding, further analysis was performed to identify associations with ORT. Multivariable analysis demonstrated that VTS, BMI, final Gleason score, prostate volume, surgeon, and node dissection were significantly associated with ORT. The use of the VTS decreased mean ORT by 23.2 min when controlling for confounding factors (p < 0.001). The performance of a nerve sparing operation was found to decrease ORT by 15.9 min (p < 0.001), though more often performed for lower-risk disease. CONCLUSION: The use of a novel VTS demonstrated decreased ORT in patients undergoing RALP when controlling for confounding factors. Prospective randomized trials are needed to evaluate its ultimate benefit in various surgical cohorts.

Skin cancer screening and primary prevention: facts and controversies.

Skin cancer is both common and responsible for significant morbidity and mortality. Opportunities for both primary and secondary prevention are available to both dermatologists and non-dermatologists. Counseling selected patients about ultraviolet avoidance and proper use of sunscreens is recommended. Due to technical and financial barriers, no study has conclusively confirmed the benefits of skin cancer screening. Both dermatologists and non-dermatologists often do not perform total body skin examinations during clinical encounters, despite high acceptance rates by patients. Many non-dermatologists would benefit from additional education pertaining to the diagnosis of cutaneous malignancy. Teledermatology may have a role in areas with poor access to dermatologists. There are ample opportunities for more to be learned in the future.

Ustekinumab associated with flares of psoriatic arthritis.

IMPORTANCE: Ustekinumab is a human monoclonal antibody that binds to the shared p40 subunit of interleukin (IL) 12 and IL-23. It is approved in the United States for adults (>18 years) with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. In 1 phase 2 trial of ustekinumab for treatment of psoriatic arthritis, joint disease improved. OBSERVATION: We report 4 cases of ustekinumab monotherapy for plaque psoriasis that resulted in disabling flares of known psoriatic arthritis or unmasked previously occult joint disease. In all of our cases, psoriasis improved dramatically with ustekinumab therapy while psoriatic arthritis flared. CONCLUSIONS AND RELEVANCE: Despite early results of a phase 2 ustekinumab trial suggesting efficacy for both plaque psoriasis and psoriatic arthritis, our case series raises concern that ustekinumab may unmask or aggravate joint disease in selected patients. These data underscore the need for further investigation of ustekinumab's effects on psoriatic arthritis.

Linear segmental neurofibromatosis in an L5 distribution.

BACKGROUND AND OBJECTIVE: Neurofibromatosis (NF) is a neurocutaneous disorder with seven subtypes;segmental NF-1 is characterized by neurofibromas and or café-au-lait macules in one or more dermatomes, primarily the thorax and abdomen. We present the rare case of a 36-year-old African-American female with isolated, multiple soft nodules in a linear configuration on the plantar and dorsal surfaces of the left foot. CONCLUSION: This is the first report of isolated segmental NF-1 in a unique linear pattern confined to the L5 dermatome.

High-dose isotretinoin in acne vulgaris: improved treatment outcomes and quality of life.

BACKGROUND: Isotretinoin, for acne treatment, is associated with high rates of permanent remission. However, at recommended doses of 0.5-1.0 mg/kg/day for 5-6 months [average cumulative dose: 120-150 mg/kg], more than 20% of patients experience a relapse within two years that requires further medical management. OBJECTIVE: To examine outcomes of high-dose isotretinoin in a cohort with cystic acne, as well as measuring its impact on quality of life (QOL). METHODS: A single dermatologist, single institution investigation within an academic tertiary care center in Bronx, NY. Eighty patients with nodulocystic acne, maintained on oral isotretinoin at a dose of 1.3 mg/kg/day or greater, were studied from 2006-2009 while additionally participating in a QOL survey. Main outcome measures included documented events, acne clearance, presence of relapse, and quality of life parameters. RESULTS: The mean daily dose of isotretinoin was 1.6 mg/kg/day for an average time course of 178 days [cumulative dose: 290 mg/kg]. No side effects or laboratory abnormalities led to discontinuation of treatment. There were no psychiatric symptoms. One-hundred percent (100%) of patients were disease-free upon completion of treatment. During the three-year study period, 10 patients (12.5%) developed a relapse that required an additional course of isotretinoin. Analysis of QOL domains (self-perception, role-social, symptoms) revealed significant improvement following isotretinoin therapy (p = 0.0124, p = 0.0066, p = 0.0265, respectively). CONCLUSIONS: Isotretinoin prescribed at 1.5 mg/kg/day or greater for 5-6 months [cumulative total dose of 290 mg/kg] is safe and effective compared to current standard dosing practices. We propose the use of high-dose isotretinoin (>1.3 mg/kg/day) as a treatment option in severe nodulocystic acne and encourage larger, prospective, multicenter studies into this therapeutic approach.

Mohs micrographic surgery and surgical excision for nonmelanoma skin cancer treatment in the Medicare population.

OBJECTIVES: To identify Medicare use rates of Mohs micrographic surgery (MMS) and surgical excision for the treatment of nonmelanoma skin cancer (NMSC) and to identify patient, lesion, and geographic characteristics associated with treatment type. DESIGN: A retrospective analysis of Medicare beneficiaries. SETTING: Surveillance, Epidemiology, and End Results database. PATIENTS: Patients undergoing MMS or other surgical intervention for the treatment of NMSC from January 1, 2001, through December 31, 2006. MAIN OUTCOME MEASURES: Surgical treatment, patient, and lesion characteristics. RESULTS: A total of 26,931 operations were performed for the treatment of NMSC from 2001 through 2006, of which 36.4% were MMS. Although the rate of surgical excision slightly increased during this period (1.8 vs 2.1 per 100 Medicare beneficiaries), the rate of MMS doubled (0.75 vs 1.5 per 100 Medicare beneficiaries). In 46.9% of facial lesions, MMS was performed, whereas MMS was used to treat 14.7% of total body lesions. Atlanta, Georgia, had the highest proportion of patients treated with MMS (45.1%); Louisiana had the lowest (11.0%). Age, race, lesion location, and area of country for patient treatment were significantly associated with MMS use (all P < .001). CONCLUSIONS: Surgical treatment of NMSC increased substantially from 2001 through 2006, primarily because of a doubling in the rate of MMS procedures. Significant differences in surgical rates, depending on patient age, race, lesion location, and geographic region, of treatment were found.

Nondermatologists' use of predictive terms for a potentially malignant lesion.

BACKGROUND: Skin cancer is frequently suspected by nondermatologists. Many dermatology practices currently do not triage referrals from nondermatologists. Little is known how nondermatologists describe lesions of concern when making referrals. OBJECTIVE: We sought to assess the descriptive terminology used by nondermatologists when referring patients with potential cutaneous malignancies. METHODS: We completed a retrospective chart review of 400 patients referred by nondermatologists for skin lesions suspicious of malignancy. We collected the reason for the consult, all terminology used to characterize the lesion, and the final diagnosis. RESULTS: Clinicians documented 680 reasons for referring patients with suspicious lesions. General concern (rule out malignancy) without specific descriptors was used in 78 referrals, of which 23% (n = 18) were found to be associated with malignancy. Specific descriptive terminologies used most frequently by nondermatologists to describe suspicious lesions were: hyperpigmented (n = 71), changing size (n = 69), nonhealing (n = 55), irregular border (n = 52), irritated and/or scaly (n = 40), and raised (n = 33). A statistically significant correlation (P < 0.05) was found between skin cancer and the following terms: nonhealing, ulcerated, and rule out basal cell carcinoma. CONCLUSION: The descriptive terminology of potential cutaneous malignancies utilized by nondermatologists may provide important clues to aid dermatologists in triage decisions. Specifically, ulcerated, nonhealing, and rule out basal cell carcinoma may be terms that indicate the patient should be seen by the dermatologist in a timely manner.

Outcomes of referral to dermatology for suspicious lesions: implications for teledermatology.

OBJECTIVES: To determine the proportion of suspicious lesions referred by nondermatologists that are found to be malignant and the number of incidental skin cancers identified at the time of dermatology referral. DESIGN: Retrospective cohort study. SETTING: Veterans Affairs Connecticut Healthcare System. PATIENTS: Four hundred patients referred by nondermatologists for skin lesions suspected of being malignant between January 1, 2006, through December 31, 2009. MAIN OUTCOME MEASURES: Data collected included the type of referring provider, the final diagnosis by the dermatologist, and the number and type of incidental lesions. RESULTS: Only 22.0% of the index lesions (ie, the lesions that prompted the referral) were found to be cancerous. In aggregate, 149 cancerous lesions were noted in 98 patients. However, only 88 (59.1%) were identified in the index lesion; 111 incidental lesions were biopsied by the consulting dermatologist, with 61 (55.0%) additional skin cancers identified. Twelve of the 61 incidental cancers (19.7%) were found in patients whose index lesion was clinically benign and was not biopsied. CONCLUSIONS: Nondermatologists may benefit from focused educational initiatives on skin cancer detection, particularly the significance of the total body skin examination and the expectations for and limitations of teledermatology. A substantial proportion of malignant lesions was incidentally identified by the consulting dermatologist in addition to the primary lesion of concern. The use of teledermatology to assess a specific lesion of concern may be associated with underdiagnosis of clinically significant lesions that are not appreciated by the referring physician. Therefore, teledermatology must not be used as a substitute for a total body skin examination.

A national study of attrition in general surgery training: which residents leave and where do they go?

OBJECTIVE(S): Implementation of the 80-hour mandate was expected to reduce attrition from general surgery (GS) residency. This is the first quantitative report from a national prospective study of resident/program characteristics associated with attrition. METHODS: Analysis included all categorical GS residents entered on American Board of Surgery residency rosters in 2007 to 2008. Cases of attrition were identified by program report, individually confirmed, and linked to demographic data from the National Study of Expectations and Attitudes of Residents in Surgery administered January 2008. RESULTS: All surgical categorical GS residents active on the 2007-2008 resident rosters (N = 6,303) were analyzed for attrition. Complete National Study of Expectations and Attitudes of Residents in Surgery demographic information was available for 3959; the total and survey groups were similar with regard to important characteristics. About 3% of US categorical residents resigned in 2007 to 2008, and 0.4% had contracts terminated. Across all years (including research), there was a 19.5% cumulative risk of resignation. Attrition was highest in PGY-1 (5.9%), PGY-2 (4.3%), and research year(s) (3.9%). Women were no more likely to leave programs than men (2.1% vs. 1.9%). Of several program/resident variables examined, postgraduate year-level was the only independent predictor of attrition in multivariate analysis. Residents who left GS whose plans were known most often pursued nonsurgical residencies (62%), particularly anesthesiology (21%) and radiology (11%). Only 13% left for surgical specialties. CONCLUSIONS: Attrition rates are high despite mandated work hour reductions; 1 in 5 GS categorical residents resigns, and most pursue nonsurgical careers. Demographic factors, aside from postgraduate year do not appear predictive. Residents are at risk for attrition early in training and during research, and this could afford educators a target for intervention.