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BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.
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Neoplasias Cutáneas , Cirujanos , Humanos , Neoplasias Cutáneas/cirugía , Cirugía de Mohs , Consenso , BenchmarkingRESUMEN
BACKGROUND: Patient-reported outcome measures (PROMs) are necessary to assess the value of skin cancer treatment and to better compare therapeutic options. OBJECTIVE: To develop and validate the Oxford Skin Cancer Treatment (OxSCanTr) scale, evaluating health-related quality of life and satisfaction after skin cancer treatment. MATERIALS AND METHODS: After qualitative patient interviews, international expert consultation, and item reduction, 2 separate patient samples were used to assess the factor structure of the scale. Exploratory factor analysis with categorical variables and a polychoric correlation matrix followed by promax oblique rotation was performed to establish a factor structure on Group A. Confirmatory factor analysis with a Satorra-Bentler scaled test statistic evaluating the root mean squared error of approximation (RMSEA), standardized root mean squared residual (SRMR), and comparative fit index (CFI) was conducted on Group B. Reliability as internal consistency was assessed using McDonald omega. Convergent and discriminant validity were assessed using the Pearson correlation coefficient. RESULTS: A total of 480 subjects returned completed surveys (completion rate 96%). A 12-item scale was developed encompassing 4 domains: aesthetic satisfaction, treatment choice satisfaction, treatment experience, and future concerns regarding recurrence/spread. Confirmatory factor analysis showed excellent goodness-of-fit characteristics, with RMSEA = 0.048, SRMR = 0.051, and CFI = 0.962 using the 4-factor model. Reliability was very good (McDonald omega 0.81-0.82), as was convergent validity with the FACE-Q skin cancer module appraisal of scars subscale (r = 0.55). Discriminant validity with a single question regarding being conservative was similarly excellent (r = -0.02). CONCLUSION: The OxSCanTr scale is a parsimonious, feasible, and valid PROM for the holistic assessment of the experience of patients who have undergone skin cancer treatment.
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BACKGROUND AND OBJECTIVES: The literature supporting Mohs micrographic surgery and staged excision in treating primary cutaneous melanoma is growing but has not been critically reviewed for bias. METHODS: Articles concerning Mohs micrographic surgery and staged excision for melanoma were assessed using modified "Risk of Bias in Non-randomized Studies of Interventions" (ROBINS-I) criteria, which measures bias in 7 categories. RESULTS: Forty-seven of 48 (97.9%) studies reviewed had serious or critical bias. None were randomized controlled trials. The most frequent cause of critical bias was poorly defined outcomes. The least frequent form of bias observed was change in intervention. LIMITATIONS: The modified ROBINS-I criteria cannot account for all study limitations. Modification of the criteria leads to some degree of subjectivity. CONCLUSION: The current body of literature suffers from limitations due to serious or critical bias in 1 or more ROBINS-I criteria. Local recurrence rate definitions are often poorly defined or not defined at all. Longer follow-up times, clear tumor classifications, and prospective, randomized study designs are necessary to improve the quality of future research.
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Melanoma , Neoplasias Cutáneas , Humanos , Melanoma/cirugía , Melanoma/patología , Neoplasias Cutáneas/cirugía , Neoplasias Cutáneas/patología , Cirugía de Mohs , Estudios Prospectivos , Proyectos de Investigación , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/cirugíaRESUMEN
BACKGROUND: Reconstructing defects requiring replacement of nasal or auricular cartilage after Mohs micrographic surgery can at times be challenging. While autologous cartilage grafting is considered the mainstay for repair, it may be limited by cartilage quality/quantity, donor site availability/morbidity, and surgical complications. Tissue-engineered cartilage has recently shown promise for repairing properly selected facial defects. OBJECTIVE: To (1) provide a comprehensive overview of the literature on the use of tissue-engineered cartilage for nasal alar and auricular defects, and (2) discuss this technology's advantages and future implications for dermatologic surgery. MATERIALS AND METHODS: A literature search was performed using PubMed/MEDLINE and Google Scholar databases. Studies discussing nasal alar or auricular cartilage tissue engineering were included. RESULTS: Twenty-seven studies were included. Using minimal donor tissue, tissue-engineered cartilage can create patient-specific, three-dimensional constructs that are biomechanically and histologically similar to human cartilage. The constructs maintain their shape and structural integrity after implantation into animal and human models. CONCLUSION: Tissue-engineered cartilage may be able to replace native cartilage in reconstructing nasal alar and auricular defects given its ability to overcome several limitations of autologous cartilage grafting. Although further research is necessary, dermatologic surgeons should be aware of this innovative technique and its future implications.
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Nariz , Ingeniería de Tejidos , Animales , Humanos , Ingeniería de Tejidos/métodos , Cartílago Auricular , Cara , Cirugía de MohsRESUMEN
Cutaneous surgery has become critical to comprehensive dermatologic care, and dermatologists must therefore be equipped to manage the risks associated with surgical procedures. Complications may occur at any point along the continuum of care, and therefore assessing, managing, and preventing risk from beginning to end becomes essential. This review focuses on preventing surgical complications pre- and postoperatively as well as during the surgical procedure.
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Procedimientos Quirúrgicos Dermatologicos , Complicaciones Intraoperatorias/prevención & control , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Anestesia/métodos , Anestésicos , Antiinfecciosos Locales/administración & dosificación , Profilaxis Antibiótica/normas , Procedimientos Quirúrgicos Dermatologicos/efectos adversos , Susceptibilidad a Enfermedades , Fibrinolíticos/administración & dosificación , Fibrinolíticos/uso terapéutico , Humanos , Errores Médicos/prevención & control , Selección de Paciente , Premedicación , Gestión de Riesgos , Neoplasias Cutáneas/cirugía , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.
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Procedimientos Quirúrgicos Dermatologicos , Complicaciones Intraoperatorias/prevención & control , Complicaciones Posoperatorias/prevención & control , Analgésicos/uso terapéutico , Profilaxis Antibiótica , Contraindicaciones de los Procedimientos , Procedimientos Quirúrgicos Dermatologicos/efectos adversos , Electrocirugia/efectos adversos , Hematoma/etiología , Hematoma/prevención & control , Hematoma/terapia , Humanos , Complicaciones Intraoperatorias/terapia , Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Seguridad del Paciente , Complicaciones Posoperatorias/terapia , Gestión de Riesgos , Dehiscencia de la Herida Operatoria/prevención & control , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/terapia , Cicatrización de HeridasRESUMEN
BACKGROUND: Metformin has anticarcinogenic properties and is also known to inhibit the sonic hedgehog pathway, but population-based studies analyzing the potential protective effect for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are needed. OBJECTIVES: To delineate the association between metformin use and invasive SCC, SCC in situ (SCCis), and BCC. METHODS: A population-based case-control study design was employed using all 6880 patients diagnosed in Iceland between 2003-2017 with first-time BCC, SCCis, or invasive SCC, and 69,620 population controls. Multivariate odds ratios (ORs) were calculated using conditional logistic regression. RESULTS: Metformin was associated with a lower risk of developing BCC (OR, 0.71; 95% confidence interval [CI], 0.61-0.83), even at low doses. No increased risk of developing SCC was observed. SCCis risk was mildly elevated in the 501-1500 daily dose unit category (OR, 1.40; 95% CI, 1.00-1.96). LIMITATIONS: This study was retrospective in nature with the inability to adjust for ultraviolet exposure, Fitzpatrick skin type, and comorbidities. CONCLUSION: Metformin is associated with decreased risk of BCC development, even at low doses. Metformin might have potential as a chemoprotective agent for patients at high risk of BCC, although this will need confirmation in future studies.
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Carcinoma Basocelular/epidemiología , Metformina/uso terapéutico , Neoplasias Cutáneas/epidemiología , Anciano , Anciano de 80 o más Años , Carcinoma Basocelular/patología , Carcinoma Basocelular/prevención & control , Estudios de Casos y Controles , Femenino , Proteínas Hedgehog/antagonistas & inhibidores , Proteínas Hedgehog/metabolismo , Humanos , Islandia/epidemiología , Masculino , Metformina/farmacología , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Transducción de Señal/efectos de los fármacos , Transducción de Señal/efectos de la radiación , Piel/efectos de los fármacos , Piel/patología , Piel/efectos de la radiación , Neoplasias Cutáneas/etiología , Neoplasias Cutáneas/patología , Neoplasias Cutáneas/prevención & control , Rayos Ultravioleta/efectos adversosRESUMEN
BACKGROUND: Population-based studies analyzing hydrochlorothiazide's (HCTZ's) effect on keratinocyte carcinoma, and particularly invasive squamous cell carcinoma (SCC), are lacking. OBJECTIVES: To characterize the association between HCTZ use and invasive SCC, SCC in situ (SCCis), and basal cell carcinoma (BCC). METHODS: This population-based case-control study included all 6880 patients diagnosed with first-time BCC, SCCis, and invasive SCC between 2003 and 2017 in Iceland and 69,620 population controls. Conditional logistic regression analyses were used to calculate multivariate odds ratios (ORs) for keratinocyte carcinoma associated with HCTZ use. RESULTS: A cumulative HCTZ dose above 37,500 mg was associated with increased risk of invasive SCC (OR, 1.69; 95% confidence interval [CI], 1.04-2.74). Users of HCTZ also had an increased risk of SCCis (OR, 1.24; 95% CI, 1.01-1.52) and BCC (OR, 1.14; 95% CI, 1.02-1.29). LIMITATIONS: Limitations include this study's retrospective nature with the resulting inability to adjust for ultraviolet exposure, Fitzpatrick skin type, and comorbidities. CONCLUSIONS: High cumulative exposure to HCTZ is associated with the development of keratinocyte carcinoma and, most importantly, invasive SCC. Sun protective behaviors alone may not eliminate the carcinogenic potential of HCTZ.
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Antihipertensivos/efectos adversos , Carcinoma Basocelular/epidemiología , Carcinoma de Células Escamosas/epidemiología , Hidroclorotiazida/efectos adversos , Neoplasias Cutáneas/epidemiología , Anciano , Anciano de 80 o más Años , Carcinogénesis/efectos de los fármacos , Carcinoma Basocelular/inducido químicamente , Carcinoma Basocelular/patología , Carcinoma de Células Escamosas/inducido químicamente , Carcinoma de Células Escamosas/patología , Estudios de Casos y Controles , Femenino , Humanos , Hipertensión/tratamiento farmacológico , Islandia/epidemiología , Masculino , Persona de Mediana Edad , Factores de Riesgo , Piel/efectos de los fármacos , Piel/patología , Neoplasias Cutáneas/inducido químicamente , Neoplasias Cutáneas/patología , Factores de TiempoRESUMEN
Nanotechnology is an emerging branch of science that involves the engineering of functional systems on the nanoscale (1-100 nm). Nanotechnology has been used in biomedical and therapeutic agents with the aim of providing novel treatment solutions where small molecule size may be beneficial for modulation of biologic function. Recent investigation in nanomedicine has become increasingly important to cutaneous pathophysiology, such as functional designs directed towards skin cancers and wound healing. This review outlines the application of nanoparticles relevant to dermatologic surgery.
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Procedimientos Quirúrgicos Dermatologicos , Portadores de Fármacos/uso terapéutico , Nanopartículas/uso terapéutico , Quitosano/administración & dosificación , Quitosano/uso terapéutico , Dendrímeros/administración & dosificación , Dendrímeros/uso terapéutico , Evaluación Preclínica de Medicamentos , Fulerenos/administración & dosificación , Fulerenos/uso terapéutico , Humanos , Liposomas/administración & dosificación , Estudios Multicéntricos como Asunto , Óxido Nítrico/administración & dosificación , Óxido Nítrico/uso terapéutico , Fármacos Fotosensibilizantes/administración & dosificación , Fármacos Fotosensibilizantes/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Neoplasias Cutáneas/tratamiento farmacológico , Neoplasias Cutáneas/cirugía , Adhesivos Tisulares/administración & dosificación , Virosomas/administración & dosificación , Cicatrización de Heridas/efectos de los fármacosRESUMEN
BACKGROUND: There is an increasing number of over-the-counter topical products that are said to prevent pathologic scar formation and improve scar cosmesis. However, robust clinical data are lacking to substantiate these claims and to guide selection of topical products. OBJECTIVE: To determine the effectiveness of topical scar management products, including silicone gel, Allium cepa onion extract, vitamin E, trolamine, and microporous tape. METHODS AND MATERIALS: A PubMed search (2005-2019) was performed to identify studies of topical scar management products. Randomized controlled trials (RCTs), quasi-RCTs, meta-analyses, and controlled clinical trials were included for analysis. RESULTS: A total of 34 trials were included in this study. Of the 16 trials investigating silicone gel sheets, numerous high-quality RCTs found that silicone gel sheets and silicone gels significantly improved scar outcomes. Only a limited number of studies supported the effectiveness of onion extract, vitamin E, trolamine, and microporous tape products. CONCLUSION: Silicone gel products are an effective noninvasive treatment to prevent formation of pathologic scars and improve mature scars. Further high-quality studies are needed to elucidate the long-term effectiveness of these therapies.
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Cicatriz/prevención & control , Medicamentos sin Prescripción/administración & dosificación , Geles de Silicona/administración & dosificación , Cicatrización de Heridas/efectos de los fármacos , Administración Tópica , Cicatriz/tratamiento farmacológico , Etanolaminas/administración & dosificación , Humanos , Cebollas/química , Extractos Vegetales/administración & dosificación , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del Tratamiento , Vitamina E/administración & dosificaciónRESUMEN
BACKGROUND: Melanocytic immunostains can assist in margin evaluation of melanoma in situ (MIS) excisions; however, their accuracy and reliability relative to hematoxylin & eosin (H&E) is yet to be determined. OBJECTIVE: The objective of this study was to evaluate the sensitivity, specificity, and concordance of 4 melanocyte-specific immunostains for diagnosing MIS occurring on chronically sun-damaged skin. MATERIALS AND METHODS: Serial permanent sections from representative areas of negative margin and residual tumor were stained using H&E, MITF, MART-1, SOX10, and R21 and examined in a blinded fashion. The study set included 100 digital microscopy images from 10 cases of MIS excisions from the face. Two board-certified dermatopathologists, 4 fellowship-trained Mohs surgeons, 2 Mohs fellows, and 2 dermatology residents independently reviewed the 100 images. RESULTS: The average melanocyte density was 11 versus 28 melanocytes per 0.5 mm for chronically sun-damaged skin versus residual MIS on H&E, respectively. Statistically significantly higher melanocyte densities were observed using MITF, MART-1, and SOX10 on negative margins. The sensitivity and interobserver concordance was highest using MITF and SOX10. The intraobserver agreement on 4 duplicate images was 85%. CONCLUSION: In conclusion, the nuclear immunostains (MITF and SOX10) show the most promise for improving the diagnosis of MIS in chronically sun-damaged skin.
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Anticuerpos Monoclonales/metabolismo , Antígeno MART-1/metabolismo , Melanoma/diagnóstico , Factor de Transcripción Asociado a Microftalmía/metabolismo , Factores de Transcripción SOXE/metabolismo , Neoplasias Cutáneas/diagnóstico , Anticuerpos Monoclonales de Origen Murino , Humanos , Melanocitos , Melanoma/metabolismo , Neoplasia Residual , Variaciones Dependientes del Observador , Sensibilidad y Especificidad , Envejecimiento de la Piel , Neoplasias Cutáneas/metabolismoRESUMEN
The most common cancer in both men and women is basal cell carcinoma (BCC). Although most primary and recurrent BCCs have high cure rates with standard therapies, advanced BCCs present a greater treatment challenge, especially in cosmetically and functionally sensitive areas. In patients unable to undergo surgery or radiation therapy, hedgehog inhibitors can be used neoadjuvantly to reduce tumor size, decreasing the extent and complexity of any subsequent surgery and providing either a cure or palliation. The goal of this review is to summarize the pharmacology, efficacy, and safety of systemic hedgehog inhibitors, as well as their role in daily practice as neoadjuvant therapy. Relevant English-language literature was identified and evaluated based on results from database searches of PubMed. Terms searched included, but were not limited to, "vismodegib," "Erivedge," "sonidegib," "DE225," "BCC," and "neoadjuvant treatment." Additional literature was identified from the reference lists of previously identified articles. The authors' personal experience in treating advanced BCC using hedgehog inhibitors has been incorporated into the recommendations made herein.
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Antineoplásicos/uso terapéutico , Proteínas Hedgehog/antagonistas & inhibidores , Terapia Molecular Dirigida , Neoplasias/tratamiento farmacológico , Neoplasias/metabolismo , Anilidas/farmacología , Anilidas/uso terapéutico , Antineoplásicos/farmacología , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Compuestos de Bifenilo/farmacología , Compuestos de Bifenilo/uso terapéutico , Terapia Combinada , Resistencia a Antineoplásicos , Humanos , Terapia Neoadyuvante , Metástasis de la Neoplasia , Estadificación de Neoplasias , Neoplasias/diagnóstico , Piridinas/farmacología , Piridinas/uso terapéutico , Transducción de Señal/efectos de los fármacos , Nivel de Atención , Resultado del TratamientoAsunto(s)
Conflicto de Intereses , Revisión de la Investigación por Pares/normas , Publicaciones Periódicas como Asunto/normas , Academias e Institutos/ética , Academias e Institutos/normas , Dermatología/ética , Dermatología/normas , Revisión de la Investigación por Pares/ética , Publicaciones Periódicas como Asunto/ética , Estados UnidosAsunto(s)
Carcinoma Basocelular/epidemiología , Carcinoma de Células Escamosas/epidemiología , Neoplasias Cutáneas/epidemiología , Inhibidores del Factor de Necrosis Tumoral/uso terapéutico , Adalimumab/uso terapéutico , Anciano , Anciano de 80 o más Años , Anticuerpos Monoclonales/uso terapéutico , Carcinoma de Células Escamosas/patología , Estudios de Casos y Controles , Etanercept/uso terapéutico , Femenino , Humanos , Islandia/epidemiología , Infliximab/uso terapéutico , Masculino , Persona de Mediana Edad , Sistema de Registros , Factores de Riesgo , Neoplasias Cutáneas/patologíaRESUMEN
BACKGROUND: Targeted anticancer therapies can cause cutaneous adverse events different from classical chemotherapeutic toxicities. OBJECTIVE: To review the literature on dermatologic adverse events (DAEs) of targeted molecular inhibitors for melanoma and nonmelanoma skin cancers with a focus on management options. MATERIALS AND METHODS: A comprehensive literature search related to the side effects and management of these side effects from vemurafenib, dabrafenib, trametinib (BRAF inhibitors), pembrolizumab (antiprogrammed-death-receptor-1 antibody), imatinib (tyrosine kinase inhibitor), ipilimumab (anticytotoxic T-lymphocyte antigen-4 antibody), cetuximab (epidermal growth factor receptor inhibitor), sorafenib (multikinase inhibitor), and vismodegib (smoothened receptor inhibitor). RESULTS: No large controlled studies specifically examining the management of DAEs of targeted molecular inhibitors exist, although there are case report-based recommendations and algorithms developed by expert panels to manage these adverse events. CONCLUSION: Many options for managing the cutaneous side effects of targeted molecular inhibitors are similar to those used in general dermatology practice. When used effectively, drug dosing and patient quality of life may be optimized.
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Antineoplásicos/efectos adversos , Melanoma/tratamiento farmacológico , Terapia Molecular Dirigida/efectos adversos , Enfermedades de la Piel/inducido químicamente , Neoplasias Cutáneas/tratamiento farmacológico , HumanosRESUMEN
BACKGROUND: Targeting specific molecular pathway inhibitors has provided a successful approach to the management of selected patients with advanced non-melanoma skin cancer (NMSC). Clinical trials and case studies have provided a rationale for their use in clinical settings. OBJECTIVE: To review the current approaches to the use of targeted molecular inhibitors for locally advanced and metastatic squamous cell carcinoma, basal cell carcinoma, and dermatofibrosarcoma protuberans. METHODS: Literature review of the current use of molecular inhibitors in the treatment of NMSCs, including case studies, reports, and clinical trials. CONCLUSION: The development of molecular pathway inhibitors for the treatment of advanced and metastatic NMSC has increased survival rates and improved clinical outcomes in selected patients with advanced disease.