Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus.

BACKGROUND: Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence. OBJECTIVE: To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction. METHODS: This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval. RESULTS: Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid. CONCLUSION: Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

A review of non-pharmacologic approaches to enhance the patient experience in dermatologic surgery.

Efforts to increase patient comfort by minimizing pain and anxiety have been shown to improve clinical outcomes, reduce pain thresholds, decrease analgesic requirements and complication risk, strengthen the physician-patient relationship, and increase overall patient satisfaction. Patients also have a strong preference for patient-centered communication and educational discussion with physicians. In recent years, the increasing emphasis on patient experience scores as a metric for quality care has had significant implications for physician practice and has reinforced attempts to provide more patient-centered care. Though different pharmacologic agents and techniques have been extensively reviewed in the dermatologic literature, there have been few studies of non-pharmacologic strategies for improving patient-centered care. This evidence-based review describes alternative techniques that have been suggested for use in dermatologic surgery. Mechanoanesthesia, cold therapy, verbal and audiovisual distraction, music, optimal needle insertion methods, hypnosis and guided-imagery, perioperative communication, and educational strategies have been reported to improve the patient experience in dermatologic surgery. These interventions are often cost-effective and easy to implement, avoid medication side effects, and serve as adjunct approaches to enhance patient comfort. This review examines the corresponding evidence for these nonpharmacologic strategies to provide a clinical resource for the dermatologic surgeon seeking to optimize the patient experience.

Performance of a computer-aided digital dermoscopic image analyzer for melanoma detection in 1,076 pigmented skin lesion biopsies.

BACKGROUND: Digital dermoscopic image analysis of pigmented skin lesions (PSLs) has become increasingly popular, despite its unclear clinical utility. Unbiased, high-powered studies investigating the efficacy of commercially available systems are limited. OBJECTIVE: To investigate the diagnostic performance of the FotoFinder Mole-Analyzer in assessing PSLs for cutaneous melanoma. METHODS: In this 15-year retrospective study, the histopathologies of 1076 biopsied PSLs among a total of 2500 imaged PSLs were collected. The biopsied PSLs were categorized as benign or malignant (cutaneous melanoma) based on histopathology. Analyzer scores (0-1.00) for these PSLs were obtained and grouped according to histopathology. RESULTS: At an optimized cutoff score of 0.50, a sensitivity of 56% and a specificity of 74% were achieved. The area under the receiver operating characteristics curve was 0.698, indicating poor accuracy as a diagnostic tool. LIMITATIONS: This study had a retrospective design and involved only a single institution. CONCLUSION: Our study reveals a low sensitivity of the scoring function of this digital dermoscopic image analyzer for detecting cutaneous melanomas. Physicians must apply keen clinical judgment when using such devices in the screening of suspicious PSLs.

Intralesional and Laser-Assisted 5-Fluorouracil in Dermatologic Disease: A Systematic Review.

INTRODUCTION: 5-fluorouracil has proven to be an effective therapy in the treatment of a variety of dermatologic conditions. Approved by the United States Food and Drug Administration for the topical treatment of actinic keratoses and superficial basal cell carcinoma, 5-fluorouracil has also demonstrated efficacy in the treatment of a variety of other dermatologic diseases. While best known for its use as a topical medication, 5-fluorouracil can also be delivered intralesionally for the treatment of dermatologic disease. Recently, laser-assisted modalities for increased delivery of 5-fluorouracil have also been described METHODS: A search of the MEDLINE standard computer database, MEDLINE advanced database, and EMBASE database was conducted. RESULTS: 38 articles met criteria for inclusion in this review. These articles represented 14 randomized controlled trials and 24 case series. Each article was reviewed and summarized. The main limitation of this review is the limited number of large randomized controlled trials, as well as the non-uniformity in treatment regimens between studies. DISCUSSION: Intralesional and laser-assisted 5-fluorouracil are used in a variety of dermatologic disease processes with a wide range of efficacy and levels of evidence. Based on extent and level of evidence, our disease-specific systematic review found that the evidence is strongest for intralesional 5-FU use in the treatment of keloids, hypertrophic scars, and keratoacanthomas. This review serves as a comprehensive summary of intralesional and laser-assisted 5-fluorouracil use in dermatology.

J Drugs Dermatol. 2018;17(3):274-280.

Tie-Over Bolster Dressings vs Basting Sutures for the Closure of Full-Thickness Skin Grafts: A Review of the Literature.

BACKGROUND: Full-thickness skin grafting is a well-established technique in the reconstruction of various tissue defects and wounds. However, lack of uniformity in the procedure of closing and securing the grafts has led to a wide range of different techniques. OBJECTIVE: This article reviews the use of tie-over bolster dressings compared to basting sutures for the fixation and postsurgical immobilization of full-thickness skin grafts (FTSGs), discusses details of each method, and proposes a practice guideline for the closure of FTSGs. METHODS: A traditional review of the literature was performed through a search of PubMed using the following keywords: full-thickness skin graft, FTSG, closure, suture, tie-over bolster, quilting, and bolster. RESULTS: The current literature regarding tie-over bolster dressings does not demonstrate improved outcomes compared to quilting sutures. The 2 techniques appear equivalent in terms of utility and outcome, both possessing distinct advantages and disadvantages. CONCLUSION: Despite minimal head-to-head studies between tie-over bolsters and quilting, the best evidence from the literature appears to show comparable results regarding graft take, cosmetic outcomes, and postoperative complications. Ultimately, the choice of using a tie-over bolster technique or quilting sutures relies on surgeon preference and anatomic location.

Identifying and Managing Local Anesthetic Allergy in Dermatologic Surgery.

BACKGROUND: Local anesthetic (LA) allergy is a concern for dermatologic surgeons given the large number of procedures performed yearly with LAs. Many patients also have anxiety about past or potential anesthesia allergy. OBJECTIVE: This article will review the symptoms of IgE-mediated allergic reactions, the prevalence of IgE-mediated LA allergy, discuss common mimics of LA, and propose a practical approach for diagnostic and therapeutic options for LA allergy for the dermatologic surgeon in practice. MATERIALS AND METHODS: A literature search of Pubmed using keywords "lidocaine," "local anesthetic," "hypersensitivity," and "allergy" was performed. RESULTS: Amide anesthetics result in the most reports of true local anesthetic immediate hypersensitivity. CONCLUSION: True IgE-mediated anaphylaxis to local anesthesia is very rare. Dermatologic surgeons should be aware of the symptoms of anesthetic allergy and its mimickers, as well as how to manage allergic reactions in their clinical practice.

Challenges, Considerations, and Strategies in Hand Rejuvenation.

Hand rejuvenation is an increasingly requested procedure in dermatology. Dorsal hand augmentation with soft tissue filler is one aspect of hand rejuvenation. Calcium hydroxyapatite is FDA approved for this purpose, while at the present time other filler products are utilized but are considered off-label for dorsal hand augmentation. This article reviews the relevant anatomy, the general and filler-specific techniques commonly employed, and potential complications that may arise.

J Drugs Dermatol. 2016;15(7):809-815.

Undermining and Hemostasis.

BACKGROUND: Undermining and hemostasis are basic surgical techniques that can have a significant impact on surgical outcomes. OBJECTIVE: To review the mechanisms and techniques of undermining and hemostasis, with an emphasis on the advantages and limitations of each modality. MATERIALS AND METHODS: The PubMed database was searched for articles with the keywords "undermining," "hemostasis," and "electrosurgery." RESULTS: Whether performing blunt, sharp, or electrosurgical techniques, undermining at the appropriate depth and width is necessary for tissue movement during closures. Both excessive and inadequate undermining can compromise surgical healing. Surgical hemostasis techniques include pressure, suture ligation, topical hemostatic agents, and electrosurgery. Dermatologic surgeons should select the appropriate amount and type of hemostasis for each procedure. Particular care should be taken in performing electrosurgery, given the potential for complications. CONCLUSION: Understanding and optimizing hemostasis and undermining will allow dermatologic surgeons to execute complex closures with minimal complications.

Promoter of lncRNA MORT is aberrantly methylated in colorectal cancer.

Aberrant DNA methylation plays essential roles in the colorectal cancer (CRC) carcinogenesis and has been demonstrated as a promising marker for cancer early detection. In this project, methylation status of the MORT promoter was studied in CRC and their marginal tissues using qMSP assay. Furthermore, we investigated the molecular function of MORT in CRC progression using computational analysis. The results showed a high methylation level of MORT promoter in CRC tissues. By in silico analysis, we found that MORT downregulation could promote the proliferation of CRC cells via sponging of has-miR-574-5p and has-miR-31-5p, and alteration of their targets expression pattern such as MYOCD and FOXP2. In conclusion, based on our results, promoter hypermethylation of MORT might be considered as a potential biomarker for CRC detection.

Pilar Cyst of the Dorsal Hand: A Rare Presentation of a Common Cyst.

Pilar cysts are common benign cysts of follicular origin that typically arise in areas of skin containing dense hair follicles such as the scalp. Here we describe a unique case of a young woman who was found to have a pilar cyst on the dorsum of her hand, a rather atypical location given the relative lack of pilosebaceous units. This case illustrates the variability in pilar cyst presentation and the importance of considering a pilar cyst in the differential diagnosis of a patient presenting with a tumor of the dorsal hand.

A case of cutaneous leishmaniasis found in Indiana.

Cutaneous leishmaniasis was diagnosed in an Indiana resident, an 80-year-old man who had visited Afghanistan 7 months earlier. Although cultures were negative, skin biopsy demonstrated round to oval bodies that stained strongly positive with Giemsa staining. His ulcerated plaques cleared readily with oral ketoconazole.