1550-nm Nonablative Fractional Laser Versus 10,600-nm Ablative Fractional Laser in the Treatment of Surgical and Traumatic Scars: A Comparison Study on Efficacy and Treatment Regimen.

BACKGROUND: The appearance and symptoms of scars can cause significant distress to patients. OBJECTIVE: To assess and compare efficacy of the 1,500-nm nonablative fractional laser (NAFL) and 10,600-nm ablative fractional laser (AFL) in reducing symptoms and improving the appearance of traumatic or surgical scars. MATERIALS AND METHODS: Single-center prospective, randomized, blinded, split-scar study was conducted on 100 patients with a scar obtained through trauma or surgery. Three treatments of NAFL or AFL were administered to each half of the scar at 4-week intervals. Scars were self-rated by the patient using the Patient and Observer Scar Assessment Scale and a satisfaction score and objectively evaluated by blinded dermatologists using the Manchester Scar Scale and visual analog scale. RESULTS: Blinded observers found no statistically significant difference in scar appearance. Patient rating showed improvement of scar appearance (p < .0001). Pain was worse after treatment with AFL (p = .0492). Overall, there was no statistically significant evidence of one laser being superior or inferior to the other for patient and blinded observer scores (p = .3173 and p = .2513, respectively). CONCLUSION: Scar treatment with AFL or NAFL is associated with high patient satisfaction. Objective evaluation of scars did not identify improvement in scar appearance.

Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery.

BACKGROUND: Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS). OBJECTIVE: We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS. MATERIALS AND METHODS: A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls. RESULTS: Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure. CONCLUSION: This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Accountable Care Organizations.

An Accountable Care Organization (ACO) is a network of providers that collaborates to manage care and is financially incentivized to realize cost savings while also optimizing standards of care. Since its introduction as part of the 2010 Patient Protection and Affordable Care Act, ACOs have grown to include 16% of Medicare beneficiaries and currently represent Medicare's largest payment initiative. Although ACOs are still in the pilot phase with multiple structural models being assessed, incentives are being introduced to encourage specialist participation, and dermatologists will have the opportunity to influence both the cost savings and quality standard aspects of these organizations. In this article, part of a health care policy series targeted to dermatologists, we review what an ACO is, its relevance to dermatologists, and essential factors to consider when joining and negotiating with an ACO.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology.

With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology.

Acute mucocutaneous methotrexate toxicity associated with interface dermatitis and numerous eosinophils.

Acute mucocutaneous methotrexate toxicity is not classically associated with prominent tissue eosinophilia. We present a case of acute methotrexate toxicity associated with pancytopenia and mucocutaneous erosion with interface dermatitis and numerous eosinophils. A 79-year-old male, with a history of psoriasis vulgaris on methotrexate therapy, presented with blisters of the oral mucosa, groin, sacrum, and extremities after daily consumption of methotrexate. Examination revealed blisters and erosions localized to psoriatic plaques, the perineum, and the oral mucosa. Laboratory evaluation demonstrated pancytopenia, megaloblastic anemia, and elevated liver function tests. A skin biopsy of an eroded plaque revealed psoriasiform epidermal hyperplasia with epidermal erosion, parakeratosis, and loss of the granular cell layer. There was an underlying band-like lymphoid infiltrate with interface dermatitis, dyskeratotic keratinocytes, and numerous eosinophils. Direct immunofluorescence studies were negative for the deposition of immunoreactants. Methotrexate was held, and the patient received leucovorin resulting in improvement of blood counts and cutaneous lesions. The histopathologic changes associated with acute mucocutaneous toxicity have been described as pauci-inflammatory erosions associated with dyskeratotic keratinocytes to interface dermatitis with necrotic keratinocytes and occasionally associated eosinophils. Although these changes are most often superimposed on psoriatic plaques, they have been reported to occur on normal skin. Therefore, the differential diagnosis may include lichen planus, a lichenoid drug eruption, or a fixed drug eruption, and given the presence of mucosal ulceration, incipient pemphigus vulgaris or paraneoplastic pemphigus vulgaris. This case illustrates that acute mucocutaneous methotrexate toxicity may be associated with both interface dermatitis and numerous eosinophils.

Surgical corner. Modified buried suture technique for the scalp.

Large surgical defects on an actinically damaged scalp are notoriously difficult to close primarily. Not only is the skin weak and friable, but the underlying bone often limits the size of "bite" that the surgeon can take with their deep suture. We describe a technique that maximizes the ability to grasp adequate deep tissue with the suture, decreasing the likelihood of tearing through the tissue when the wound edges are brought together.

Hiding in Plain Sight: A Retrospective Review of Unrecognized Tumors During Dermatologic Surgery.

BACKGROUND: Mohs micrographic surgery requires focused attention that may lead to tunnel vision bias, contributing to not recognizing skin cancer at nearby sites. OBJECTIVE: It is to determine if a subsequently diagnosed skin cancer was visible at the time of Mohs surgery. METHODS: A retrospective chart review was performed at a single academic center from 2008 to 2020. Patients who underwent at least two distinct MMS procedures, separated in time to capture subsequent tumors, were included. RESULTS: Four hundred and four individual patients were identified with at least two distinct Mohs procedures, which generated 1,110 Mohs sequences. Fifty-one (4.6%) clinically apparent tumors went unrecognized and 127 (11.4%) tumors were identified and biopsied during the visit. High-risk tumor histology was identified in 10 (20%) unrecognized tumors and 31 (24%) recognized tumors (p-value 0.491). CONCLUSION: Our study suggests that Mohs surgeons may be overlooking adjacent skin cancers when focusing only on the tumor being surgically treated. Tunnel vision bias may account for part of this phenomenon.

Individual drug sampling does not supplant the need for head-to-head trials in dermatology.

A growing body of evidence has highlighted several risks and benefits associated with in-office sampling of prescription medications. While use-testing dermatologic medications from a sample closet may benefit some patients, it seems that the stunning lack of head-to-head trials comparing therapeutic options is a much larger and more important impediment to our determination of when the increased cost of newer agents is justified by superior efficacy, safety, or tolerability. If physicians are to retain the critical autonomy to make independent prescribing decisions in concert with our individual patients, we must take responsibility to call for and generate the comparative data we need to evaluate therapeutic options.

Red man syndrome caused by vancomycin powder.

Red man syndrome (RMS) is a well-known hypersensitivity reaction caused by intravenous administration of vancomycin, with symptoms ranging from flushing, erythematous rash, pruritus, mild to profound hypotension, and even cardiac arrest. RMS has not previously been described from local application of vancomycin powder in a surgical wound, a technique increasingly utilized for infection prophylaxis in many surgical disciplines including neurosurgery. We describe the first reported case of RMS as a result of local intra-wound application of vancomycin powder for infection prophylaxis. A 73-year-old male with a history of Parkinson's disease underwent 2-stage deep brain stimulation implantation surgeries. Vancomycin powder was applied locally in the surgical wounds for infection prophylaxis during both of the surgeries. The patient developed a well-demarcated, geometric erythematous pruritic rash following the second surgery that was clinically diagnosed as RMS and resolved without sequelae.

Intralesional methotrexate treatment for keratoacanthoma tumors: a retrospective study and review of the literature.

BACKGROUND: Intralesional methotrexate (MTX) is an effective treatment for keratoacanthoma (KA). OBJECTIVE: We sought to systematically examine response rates and adverse events in KA treated with intralesional MTX. METHODS: All cases of KA treated with intralesional MTX at our institution from 1991 to 2006 were identified. A MEDLINE and PubMed search of cases of KA treated with intralesional MTX was also performed. RESULTS: In all, 38 cases of KA treated with intralesional MTX were identified: 18 from our institution and 20 from the literature. Intralesional MTX achieved resolution in 92%, requiring an average of 2.1 injections an average of 18 days apart. Adverse events were rare, with two reports of pancytopenia in patients with chronic renal failure. LIMITATIONS: Use of single case reports, small series, and retrospective analysis are limitations. CONCLUSION: Intralesional MTX is a useful nonsurgical therapy for the treatment of KA. Histologic diagnosis before initiation of treatment is preferred. A complete blood cell count at baseline and during treatment should be considered to monitor for potential cytopenia.

Sunscreen use and the risk for melanoma: a quantitative review.

BACKGROUND: Originally developed to protect against sunburn, sunscreen has been assumed to prevent skin cancer. However, conflicting reports include claims that sunscreen increases risk for melanoma. OBJECTIVE: To examine the strength and consistency of associations between melanoma and sunscreen use in the published literature. DATA SOURCES: A comprehensive MEDLINE search of articles published from 1966 to 2003 that reported information on sunscreen use and melanoma in humans. STUDY SELECTION: Analytic studies reporting data on sunscreen use before diagnosis of melanoma. DATA EXTRACTION: Two independent reviewers extracted data. Inconsistencies were rereviewed until agreement was achieved. When necessary, a third party resolved discrepancies. DATA SYNTHESIS: Odds ratios were pooled across studies by using standard meta-analytic techniques. Pooled odds ratios for ever use among 18 heterogeneous studies did not support an association between melanoma and sunscreen use. Variation among odds ratios was explained by studies that did not adjust for confounding effects of sun sensitivity. The lack of a dose-response effect with frequency of use (never, sometimes, or always) or years of use provided further evidence of a null association. CONCLUSIONS: No association was seen between melanoma and sunscreen use. Failure to control for confounding factors may explain previous reports of positive associations linking melanoma to sunscreen use. In addition, it may take decades to detect a protective association between melanoma and use of the newer formulations of sunscreens.

Alpha-1-antitrypsin associated panniculitis: the MS variant.

Over 90 mutant alleles of the alpha-1-antitrypsin (AAT) gene are recognized and classified by mobility on an acid starch gel. The four major categories include: F=fast, M=medium, S=slow, Z=very slow. Among 41 reported cases of AAT panniculitis, most have the ZZ phenotype with AAT levels below normal. We report two cases of AAT panniculitis with MS phenotype and normal AAT levels. In addition, we review the pathophysiology, epidemiology, and extracutaneous manifestations of AAT disease and propose a diagnostic algorithm for ulcerative panniculitis. A 42-year-old man presented with a solitary plaque on the left thigh exacerbated by trauma or excessive activity. The lesion frequently suppurated with a yellowish oily material. Twenty years before, he had fractured his left femur which was repaired with a metal plate. X-rays, histology with special stains for organisms, and cultures were negative. AAT phenotype was MS and AAT value was normal. A 43-year-old woman presented with multiple plaques on the proximal extremities which suppurated with exercise or trauma. AAT phenotype was MS and AAT level was normal. Histologic exam for both patients showed a dense neutrophilic infiltrate with septal and lobular panniculitis and areas of necrobiosis in the lower reticular dermis.