Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

Recurrent Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Induced by Levamisole-Adulterated Cocaine.

ABSTRACT: Levamisole, an anthelmintic and immunomodulatory drug, was withdrawn from the US market in 1999 due to adverse effects, including agranulocytosis and vasculitis. In recent years, levamisole has been used as a common cocaine adulterant, and its use has led to an autoimmune syndrome characterized by an antineutrophil cytoplasmic antibody-associated vasculitis presenting with necrotic retiform purpura on the face and extremities. We present a case of recurrent levamisole-induced vasculitis initially misdiagnosed as systemic lupus erythematosus to highlight this easily misdiagnosed entity and to demonstrate re-exposure leading to recurrent vasculitis with more extensive clinical manifestations.

Neuromuscular ultrasound for taxane peripheral neuropathy in breast cancer.

BACKGROUND: Our study aim was to evaluate neuromuscular ultrasound (NMUS) for the assessment of taxane chemotherapy-induced peripheral neuropathy (CIPN), the dose-limiting toxicity of this agent. METHODS: This cross-sectional study of breast cancer patients with taxane CIPN measured nerve cross-sectional area (CSA) by NMUS and compared with healthy historical controls. Correlations were determined between CSA and symptom scale, nerve conduction studies, and intraepidermal nerve fiber density (IENFD). RESULTS: A total of 20 participants reported moderate CIPN symptoms at a median of 3.8 months following the last taxane dose. Sural nerve CSA was 1.2 mm2 smaller than healthy controls (P ≤ .01). Older age and time since taxane were associated with smaller sural nerve CSA. For each 1 mm2 decrease in sural nerve CSA, distal IENFD decreased by 2.1 nerve/mm (R2 0.30; P = .04). CONCLUSIONS: These data support a sensory predominant taxane neuropathy or neuronopathy and warrant future research on longitudinal NMUS assessment of CIPN.

Melanocytic Nevi of Special Sites.

Melanocytic nevi located on specific regions of the body can demonstrate unusual histopathological features such as asymmetry, irregular nesting patterns, pagetoid spread, cytologic atypia, and rarely, mitotic activity. However, despite these features that may raise concern for malignant melanoma, these lesions follow a benign clinical course and do not require intervention. Also known as nevi of special sites or nevi with site-related atypia, these melanocytic nevi were initially described on acral sites and genitalia. Now, additional anatomical sites with known site-related atypia include the ear, conjunctivae, scalp, breast, flexural skin, legs, and back and shoulder. This continuing medical education article presents a review of the histopathological characteristics of special site nevi based on anatomic location. It is imperative for dermatologists, pathologists, and dermatopathologists to distinguish benign melanocytic nevi with site-related atypia from malignant melanoma to avoid unnecessary surgical intervention or treatment.

To test or not to test? An updated evidence-based assessment of the value of screening and monitoring tests when using systemic biologic agents to treat psoriasis and psoriatic arthritis.

BACKGROUND: Safety profiles of systemic biologic agents for the treatment of psoriasis and psoriatic arthritis (PsA) encompass a wide spectrum of adverse events. To date, no uniform evidence-based guidelines exist regarding screening and monitoring patients who are undergoing biologic therapy. OBJECTIVE: We sought to identify studies evaluating screening and monitoring tests in the treatment of psoriasis and PsA with systemic biologic agents, and to propose evidence-based practical guidelines. METHODS: The MEDLINE database was searched to identify data on risks associated with adalimumab, etanercept, infliximab, and ustekinumab. Articles were reviewed and graded according to methods developed by the US Preventative Services Task Force. RESULTS: Evidence was strongest (grade B) for tuberculosis screening. Interferon-gamma release assay was preferable to tuberculin skin testing. Among known hepatitis B virus carriers, the evidence grade was C for monitoring liver function tests and viral load. LIMITATIONS: This study was limited by the lack of high-quality controlled trials evaluating screening and monitoring tests in patients treated with biologic agents. CONCLUSIONS: Baseline tuberculosis testing remains the only screening test with strong evidence to support its practice. Other screening and monitoring tests commonly performed in patients who are taking biologic agents are supported only in certain clinical settings or lack evidence to support or recommend against their practice.

Mycosis fungoides: an updated review of clinicopathologic variants.

Mycosis fungoides (MF) is the most common primary cutaneous T-cell lymphoma. Although it was first described in 1833, our understanding of this disease has continued to evolve. From a diagnostic perspective, the diagnosis of MF can be challenging particularly in the early stages of the disease, because of overlap between the histological features of early MF lesions and many other inflammatory dermatoses. Furthermore, there has been an emergence of numerous clinicopathologic and immunohistochemical variants of MF reported in the literature. Although the prognostic significance of some of the rare variants is still not fully understood, certain variants, such as folliculotropic and bullous MF, have demonstrated less indolent clinical courses compared with classic MF and necessitate aggressive therapeutic measures. Thus, it is important for dermatologists and dermatopathologists to be knowledgeable of the widely varied clinical, histological, and immunohistochemical presentations of MF to arrive at a prompt and accurate diagnosis and initiate appropriate treatment.

Most common dermatologic conditions encountered by dermatologists and nondermatologists.

The dermatologic conditions that are most commonly encountered by nondermatologists are not well characterized, which can hamper efforts to train them in skin disease management. The purpose of this study was to identify the 20 most common dermatologic conditions encountered by nondermatologic specialties (ie, emergency medicine, family practice, general surgery, internal medicine, otolaryngology, pediatrics). Data from the National Ambulatory Medical Care Survey from 2001 to 2010 were analyzed to evaluate the dermatologic diagnoses made by each specialty during this time period. The most common skin conditions reported by dermatologists were compared to those reported by nondermatologists. Nondermatologists evaluated 52.9% of cutaneous diseases that presented in the outpatient setting. Among each nondermatologic specialty included in the study, only 6 to 10 of the top 20 conditions overlapped with the top 20 conditions reported by dermatologists. This study is a retrospective review of a large database and only included skin conditions that were diagnosed in an outpatient setting. The skin conditions that most frequently presented to nondermatologists differed considerably from those most commonly seen by dermatologists. Because dermatologists often are responsible for training nondermatologists in the diagnosis and management of skin disease, curriculum content should reflect these differences to enhance the efficacy of such training opportunities.

Cosmetic procedures performed in the United States: a 16-year analysis.

BACKGROUND: Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well-characterized. OBJECTIVE: To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them. METHODS: The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010. RESULTS: Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p < .001). Botulinum toxin injections were the most frequently performed cosmetic procedure and increased at the greatest rate over time. Plastic surgeons performed the largest proportion of cosmetic procedures (36.1%), followed by dermatologists (33.7%), but other specialties have been performing an increasing proportion of cosmetic procedures. This study was limited to the provision of outpatient procedures, and the nationally representative data of the NAMCS is subject to sample bias. CONCLUSIONS: Plastic surgeons and other physicians performed the majority of outpatient cosmetic procedures. Dermatologists performed one-third of ambulatory cosmetic procedures from 1995 to 2010. This broadening spectrum of physicians and nonphysicians providing cosmetic procedures may have important implications for patient safety.

Noncosmetic skin-related procedures performed in the United States: an analysis of national ambulatory medical care survey data from 1995 to 2010.

BACKGROUND: Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin-related procedural care are not well characterized. OBJECTIVE: To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time. METHODS: The annual volume of skin-related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010. RESULTS: Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively). CONCLUSIONS: Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin-related procedures to meet increasing demand.

An adverse effect of an injectable cosmetic procedure: a case of mistaken identities.

Minimally invasive cosmetic procedures are being performed at increasing rates. This is likely due to the combination of a growing aging population, an increased accessibility through non-physician providers, and a common association of "minimally invasive" with the concept of fewer side effects. Despite their overall successes, there are adverse effects associated with these procedures, which are most often related to injection location, amount, and technique. This case describes a patient who sought botulinum toxin injections to smooth the appearance of periorbital lines who presented 12 months later with chronic multiple palpable nodules in the injection sites. Histopathological evaluation demonstrated a foreign body reaction resembling the reaction against semi-permanent or permanent fillers such as poly-L-lactic acid or polymethylmethacralate. Knowledge of the biochemical properties and life cycles of dermal fillers guided the decision to surgically excise the nodules, with cosmetically satisfactory results.

Patterns of vitamin D analog use for the treatment of psoriasis.

BACKGROUND: Psoriasis is a chronic disease that significantly impacts patients' quality of life. It most commonly manifests as localized disease, for which there are various treatment options. OBJECTIVE: To determine the prescription patterns of topical corticosteroids and vitamin D analogs for the treatment of psoriasis in the United States and how their use has changed over time. METHODS: Data from the National Ambulatory Medical Care Survey (NAMCS) from 1994 to 2010 were queried for visits linked with a psoriasis diagnosis. Prescriptions for topical corticosteroids and vitamin D analogs were described. Vitamin D analogs usage was compared across physician specialties. For each sampled visit reported in the NAMCS, visits meeting our inclusion criteria that also mentioned the following medications were identified: topical calcipotriene, topical calcipotriene/betamethasone or any topical corticosteroid indicated for the treatment of psoriasis. RESULTS: There were an estimated 2.05 million psoriasis visits per year over the 1994-2010 interval. Dermatologists were responsible for 67% of these encounters followed by family practice (14%) and internal medicine (11%). Dermatologists prescribed a vitamin D product at 15% of psoriasis visits, followed by family physicians at 12%, and internists at 5%. Dermatologists prescribed calcipotriene, calcipotriene/betamethasone, and topical corticosteroids in 15%, 4% and 59% of psoriasis visits, respectively. Over time, there was no significant change in the use of topical steroids or vitamin D products by physicians.This study is limited by the inability to determine the severity of psoriasis from the data collected, and the lack of data on the length of treatment with different medications. CONCLUSIONS: Despite their demonstrated efficacy and safer side effect profile, vitamin D analogs are used less often than topical corticosteroids for the treatment of psoriasis. These findings suggest that vitamin D products may not be utilized to their fullest potential as effective topical therapy or adjuncts to therapy for localized plaque psoriasis.

Deployed Airbag Causes Bullous Reaction Following a Motor Vehicle Accident.

Airbags can be lifesaving during a motor vehicle accident (MVA), but airbag deployment has been the cause of dermatologic injuries including irritant dermatitis, as well as thermal, friction, and chemical burns. A highly corrosive alkaline aerosol composed of sodium hydroxide, sodium bicarbonate, and metallic oxides is released during airbag deployment. We present the case of a 35-year-old man who developed a bullous reaction to released by-products from airbag deployment during an MVA.

Rare but Foreseeable: Rapidly Expanding Retropharyngeal Hematoma After Fall from Height.

CASE PRESENTATION: An elderly man presented to the emergency department after a fall from a 15-foot height. Initial examination revealed signs of head and neck trauma without airway compromise. Computed tomography imaging identified cervical fractures at the first and second level with a retropharyngeal hematoma. In discussion with the trauma service, the patient was admitted to the hospital for airway monitoring. After 10 hours he clinically deteriorated, resulting in acute respiratory failure, and ultimately required intubation. The patient was intubated with a hyperangulated video laryngoscopy, and a surgical set-up was also prepared. The intubation was uncomplicated and resulted in clinical improvement. The patient was extubated after three days without difficulty and was ultimately discharged following an uncomplicated hospital course. DISCUSSION: Retropharyngeal hematoma is a rare but significant clinical condition. Rapid decline and airway compromise have been described. Patients often require intubation and mechanical ventilation to avoid airway obstruction and respiratory failure. Coagulopathies should be reversed, if present. Prompt recognition and treatment of this condition is crucial to successful management.

Malignant Sweat Gland Tumors.

Malignant sweat gland neoplasms are a confusing area within dermatopathology, with many entities reported under several designations in the literature. This review describes the key clinical and histopathologic features of select malignant adnexal neoplasms, including porocarcinoma, papillary carcinoma, adenoid cystic carcinoma, cribriform carcinoma, apocrine hidradenocarcinoma, malignant mixed tumor of the skin, syringoid carcinoma, cylindrocarcinoma, spiradenocarcinoma, mucinous carcinoma, polymorphous sweat gland carcinoma, microcystic adnexal carcinoma, secretory carcinoma of the skin, and primary cutaneous signet ring cell carcinoma. For entities with overlapping features, differential diagnoses are discussed.