Oncogenic Genodermatoses in Pediatric Skin of Color: A Review.

Cutaneous neoplasms are relatively rare in children. Most commonly, skin cancers arise through environmental factors, particularly ultraviolet radiation; thus, age is the most predictive factor in developing cutaneous carcinomas. However, children born with certain genodermatoses are significantly more likely to develop malignancies and must carefully be monitored and treated. The preponderance of published data is based mainly on signs and symptoms present in White patients. Therefore, we aim to highlight the cutaneous presentations and relative differences of these genodermatoses among skin-of-color (SOC) patients, who are underrepresented in medicine. We conducted a literature review of 504 patients presented in 236 published articles. Manuscripts with accessible case reports for children aged 17 or younger were included. SOC patients often present with fewer classic findings and have a higher incidence of scarring and dyspigmentation. There is also a higher incidence of consanguinity in affected patients. Providers being able to recognize non-classical signs enable proper management and treatment regimens, potentially bringing SOC patient outcomes more in line with White children.

Characterization of Biopsies by Dermatologists and Nonphysician Providers in the Medicare Population: A Rapidly Changing Landscape.

BACKGROUND: Previous studies show that nonphysician providers may require a higher number of biopsies to identify skin malignancies than dermatologists. Therefore, understanding the trends behind the types of providers performing biopsies may help analyze their impact on this vulnerable population. OBJECTIVE: This retrospective study analyzes changes in nationwide, regional, and state-level data on the number and proportion of biopsies performed by dermatologists compared with nonphysician providers. MATERIALS AND METHODS: Biopsy cases were isolated in the Medicare database from 2012 to 2018 using the HCPCS codes 11,100 and 11,101. Cases were limited to biopsies performed by a dermatologist, nurse practitioner (NP), or physician assistant (PA). RESULTS: From 2012 to 2018, national biopsy rates per 100,000 Medicare beneficiaries for dermatologists decreased by 6%, whereas those for NPs and PAs increased by 97% and 82%, respectively. Each state showed variation in both the proportion of biopsies by provider type and the net change in biopsies rates over time. All states saw increases in the number of biopsies per 100,000 Medicare beneficiaries by nonphysician providers. CONCLUSION: As the number of Medicare beneficiaries continues to grow, nonphysician providers are performing an increasing proportion of biopsies, with specific states and regions being affected more than others.

Impact of Preoperative Acetaminophen and Carbohydrate Loading on Pain and Functional Status in Patients Undergoing Mohs Micrographic Surgery for Nonmelanoma Skin Cancers.

BACKGROUND: Preoperative acetaminophen and carbohydrate loading has been shown to improve the functional recovery of surgical patients. OBJECTIVE: To determine the effects of preoperative acetaminophen and carbohydrates on functional outcomes and the use of pain medications after surgery in patients undergoing Mohs Micrographic Surgery (MMS) for nonmelanoma skin cancer (NMSC). MATERIALS AND METHODS: One hundred patients treated with MMS for NMSC at an academic center were randomized into a control group receiving standard preoperative care or an intervention group receiving acetaminophen and carbohydrate drinks immediately before surgery. Patients rated levels of pain, thirst, hunger, anxiety, and fatigue on the day of surgery on a scale of 0 to 100, and reported through a phone interview the use of pain medications within 48 hours of surgery. RESULTS: There was no significant difference between intervention and control groups in maximum pain score on the day of surgery; maximum pain score 48 hours after surgery; use of nonopioid pain medications; and use of opioids. However, the intervention group had lower anxiety levels during and at the end of surgery. CONCLUSION: Patients undergoing MMS for NMSC reported very low levels of pain during and after surgery. Preoperative acetaminophen and carbohydrate loading had no impact on pain levels or the use of pain medications but did reduce levels of anxiety.

A video-based, flipped classroom, simulation curriculum for dermatologic surgery: A prospective, multi-institution study.

BACKGROUND: Medical education is evolving to emphasize trainee engagement. The impact of a flipped classroom curriculum and surgical simulation on dermatology resident education has not been evaluated. OBJECTIVE: To assess the impact of video education and surgical simulation on dermatology resident procedural skills. METHODS: We created a curriculum on foundational surgical skills for 31 first- and second-year dermatology residents at 3 institutions. The flipped classroom approach replaces traditional in-person lectures with at-home viewing of instructional videos. After this self-directed learning, trainees had 3 hands-on sessions using simulated skin models. The Objective Structured Assessment of Technical Skills (OSATS) instrument was used to assess residents performing a simulated elliptical excision with intermediate repair before and after the curriculum. Residents completed precurriculum and postcurriculum surveys evaluating operative confidence and perceived value of the curriculum. RESULTS: Residents' total OSATS score increased from a median of 27 (interquartile range, 22-38.5) before the curriculum to 46 (interquartile range, 39.5-51.5) after the curriculum (P < .001). Self-reported confidence in surgical performance significantly improved, and residents were highly satisfied. LIMITATIONS: Limitations include the small sample size and potential influence from concurrent learning on surgical rotations. CONCLUSIONS: Video education and simulation are effective for improving dermatology residents' procedural skills. We hope to serve as a template for other institutions and nondermatology trainees hoping to improve procedural skills.

Case-Control Study of Tumor Stage-Dependent Outcomes for Cutaneous Squamous Cell Carcinoma in Immunosuppressed and Immunocompetent Patients.

BACKGROUND: Immunosuppressed patients have worse outcomes from cutaneous squamous cell carcinomas (cSCCs), although unclear whether it is due to the development of more high-stage tumors or worse outcomes for a given stage. OBJECTIVE: Analyze the impact of immunosuppression on the development of cSCCs and tumor stage-dependent outcomes. MATERIALS AND METHODS: Single-institution 1:2 case-control study of primary invasive cSCCs from 2005 to 2015 in 106 mixed-cause immunosuppressed patients and 212 control subjects matched to age, gender, and race. RESULTS: Four hundred twelve cSCCs from 106 immunosuppressed patients and 291 tumors from 212 matched immunocompetent patients were included. Both cohorts had similar T-stage distribution, with <5% high-stage tumors, that is, AJCC-7 T2, AJCC-8 T3, and BWH T2b/T3. Immunosuppression significantly increased the likelihood of poor outcomes (POs) (aggregate of local recurrence (LR), nodal and distant metastasis, and squamous cell carcinoma-related deaths) for low-stage tumors, that is, AJCC-7 T1 (odds ratio [OR], 4.29), AJCC-8 T1 (OR, 3.45), AJCC-8 T2 (OR, 3.75), BWH T1 (OR, 3.53), and BWH T2a (OR, 3.41) tumors. There was no significant difference in the treatment: most tumors were treated with Mohs (71% vs 75%) or excision (21% vs 20%) in both cohorts. CONCLUSION: Immunosuppressed patients have an increased risk of POs, specifically LRs, from low-stage cSCCs. Definitive treatment of cSCCs is recommended.

Impact of National Comprehensive Cancer Network Guidelines on Case Selection and Outcomes for Sentinel Lymph Node Biopsy in Thin Melanoma.

BACKGROUND: In 2010, the National Comprehensive Cancer Network (NCCN) recommended sentinel lymph node biopsy (SLNB) for thin melanomas ≤1 mm with mitotic rate (MR) ≥1. In 2016, the criteria were changed to Breslow depth >0.75 mm and MR ≥1. OBJECTIVE: To compare the impact of 2010 and 2016 NCCN guidelines on SLNB case selection and thin melanoma outcomes. MATERIALS AND METHODS: Ten-year retrospective cohort of primary thin melanomas at an academic hospital was retroactively stratified for SLNB eligibility using the 2010 and 2016 NCCN guidelines. Nodal recurrence-free survival (NRFS) and disease-free survival (DFS) were compared. RESULTS: Eight hundred two patients with 859 tumors and median follow-up of 79 months were included. Eleven percent fewer tumors qualified for SLNB under 2016 versus 2010 NCCN guidelines (19% vs 8%, p < .001). The 2016-qualifying cases also had lower 10-year NRFS (70.7% vs 95.2%, p < .001) and DFS (64.7% vs 91.4%, p < .001). Among 2016-qualifying cases, those that received SLNB had improved NRFS (85.6% vs 35.3%, p = .001) and DFS (80.2% vs 30.5%, p < .001) as compared to those that did not receive SLNB. CONCLUSION: The 2016 NCCN guidelines reduced the number of thin melanomas qualifying for SLNB and more accurately selected cases with higher risks of nodal recurrence and death.

Detection of High-Risk Histologic Features and Tumor Upstaging of Nonmelanoma Skin Cancers on Debulk Analysis: A Quantitative Systematic Review.

BACKGROUND: Histologic analysis of tumor debulks from Mohs micrographic surgery (MMS) or wide local excision may lead to the detection of adverse features missed on initial biopsy. OBJECTIVE: Determine the incidence of (1) high-risk features on debulk analysis compared with initial biopsy and (2) upstaging of tumors on debulk analysis according to the American Joint Committee of Cancer-7th Edition (AJCC-7) and the Brigham and Women's Alternative (BWH) staging criteria. MATERIALS AND METHODS: A comprehensive search strategy using PubMed/MEDLINE, Web of Science, and EMBASE was conducted to identify articles published from 1960 to present that detail histology of initial biopsy and debulked tumor. RESULTS: Fourteen studies, encompassing 2,565 cases of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) were included in the data extraction process. BCCs (30.9%) were reclassified from a low-risk histologic subtype to a high-risk subtype on debulk analysis (p < .001). Cases with perineural invasion (89.4%) were detected on debulk analysis. SCC tumors (9.1% and 11.1%) were upstaged according to the AJCC-7 and BWH Alternative criteria, respectively. Ninety percent of high-risk BWH T2b SCCs were inaccurately staged lower on initial biopsy. CONCLUSION: Tumor debulk analysis in MMS may aid in the identification of additional high-risk features, thereby improving staging accuracy, treatment decisions and patient outcomes.

Comparison of the American Joint Committee on Cancer Seventh Edition and Brigham and Women's Hospital Cutaneous Squamous Cell Carcinoma Tumor Staging in Immunosuppressed Patients.

BACKGROUND: The American Joint Committee on Cancer 7th edition (AJCC-7) and Brigham and Women's Hospital (BWH) staging criteria for cutaneous squamous cell carcinoma (cSCC) have not been validated in immunosuppressed patients. OBJECTIVE: To compare the AJCC-7 and BWH staging systems for cSCCs in immunosuppressed patients. MATERIALS AND METHODS: A single-institution retrospective cohort study of cSCCs in immunosuppressed patients. Risks of local recurrence (LR), nodal metastasis (NM), in-transit metastasis, and any poor outcome (PO) were compared among AJCC-7 and BWH tumor T stages. RESULTS: One hundred six patients had 412 primary invasive cSCCs. Eighty-five percent were AJCC-7 T1, and 15% T2. Risks of NM and PO for AJCC-7 T1 versus T2 were 0.9% versus 5% and 12.8% versus 23.3%, respectively, p < .05. Eighty-one percent of tumors were BWH T1, 18% T2a, 1% T2b, and 0.2% T3. Risk of LR for BWH T1 versus T2a was 11.4% versus 20.3%, p < .01. Risk of NM increased from 0.3% for T1 to 4.1%, 25%, and 100% for T2a, T2b, and T3, p < .05. Ninety percent of PO occurred in low-stage BWH T1/T2a. CONCLUSION: Low T-stage cSCCs account for most POs. Brigham and Women's Hospital staging criteria better risk stratifies cSCCs in immunosuppressed patients for risk of NM and LR.

Cutaneous mucinosis in a patient taking ustekinumab for palmoplantar psoriasis.

Discrete papular lichen myxedematosus (DPLM), asubset of localized lichen myxedematosus, is a rarecutaneous mucinosis of unknown etiology. We reporta case of a 57-year-old woman with palmoplantarpsoriasis who developed DPLM 8 weeks after addingustekinumab to a long-term course of methotrexate.The patient had previously failed 2 prior tumor necrosisfactor (TNF) inhibitors, adalimumab and etanercept.This case demonstrates an association between TNFinhibitor and ustekinumab use in a psoriasis patientand localized lichen myxedematosus for the secondtime in the literature. The presented case is of interestbecause of the rare diagnosis of DPLM, especially inassociation with the start of the anti-IL 12/23 agentustekinumab. The appearance of DPLM in this settingsuggests a possible etiology for the disease.

Ablative Fractional Laser-Assisted Topical Fluorouracil for the Treatment of Superficial Basal Cell Carcinoma and Squamous Cell Carcinoma In Situ: A Follow-Up Study.

BACKGROUND: The authors previously reported the safety and short-term efficacy of ablative fractional laser (AFXL)-assisted delivery of topical fluorouracil in the treatment of superficial basal cell carcinoma (sBCC) and squamous cell carcinoma in situ (SCCis). OBJECTIVE: This follow-up study was conducted to assess whether tumor clearance was sustained in this cohort of patients at >9 months post-treatment. METHODS: Thirty primary sBCC or SCCis <2 cm on the trunk or extremities were treated with AFXL and a single application of topical 5-fluorouracil 5% under occlusion for 7 days. Among the 26 patients who achieved tumor clearance at 4 to 8 weeks post-treatment, 20 patients presented for this follow-up study and underwent shave biopsy to confirm histologic clearance. Mean follow-up time was 15 months. RESULTS: Considering those who had persistent tumor at 4 to 8 weeks post-treatment and those who presented for follow-up at >9 months post-treatment, overall treatment success was 79% (95% confidence interval: 67%-96%), with 92% (11/12) for SCCis and 67% (8/12) for sBCC. Neither the tumor location nor size significantly impacted treatment outcome (p = .96 and 0.87, respectively). CONCLUSION: Ablative fractional laser-assisted topical fluorouracil is a reasonable noninvasive treatment option for primary SCCis and sBCC, especially for lesions located in areas where self-application is not possible, or when clinician-administered therapy is preferred.

A quantitative systematic review of the efficacy of imiquimod monotherapy for lentigo maligna and an analysis of factors that affect tumor clearance.

BACKGROUND: The reported efficacy of imiquimod for lentigo maligna varies widely, without consensus on tumor or treatment factors that can impact tumor clearance. OBJECTIVE: We sought to provide a more precise estimate of clearance rates in patients with lentigo maligna who are treated with imiquimod and to analyze factors that can impact tumor clearance. METHODS: We performed a literature search for biopsy-proven lentigo maligna treated with imiquimod monotherapy, linked treatment and outcome data to individual tumors, calculated histologic and clinical clearance rates with 95% confidence intervals (CIs), and analyzed the impact of tumor and treatment factors on tumor clearance using logistic regression. RESULTS: Based on 347 tumors from 45 studies, histologic and clinical clearance rates were 76.2% (95% CI, 71.4-81.0%) and 78.3% (95% CI, 73.6-82.9%), respectively. The incidence of clinical recurrence was 2.3% (95% CI, 0.5-4.2%), with a mean follow-up of 34.2 ± 11.8 months. Treatment with >60 total applications, or with >5 applications per week was associated with a higher likelihood of histologic clearance (odds ratio, 8.4 [95% CI, 2.9-24.1] and odds ratio, 6.0 [95% CI, 2.4-14.7], respectively). LIMITATIONS: Our limitations included the accuracy and scope of published data, variable follow-up times, potential patient selection, and publication bias related to case series/cohort designs of previous studies. CONCLUSION: Imiquimod offers a 76% histologic and 78% clinical clearance rate for lentigo maligna. Both cumulative dose and treatment intensity affect tumor clearance.

Knowledge, understanding, and use of preventive strategies against nonmelanoma skin cancer in healthy and immunosuppressed individuals undergoing Mohs surgery.

BACKGROUND: Despite various national recommendations advising individuals to reduce their exposure to ultraviolet radiation, many people still do not use these skin cancer prevention strategies. OBJECTIVES: To assess patient sources of medical information, knowledge of sun protection strategies, and barriers to implementing these strategies and to compare the overall rate of use of skin cancer prevention strategies of healthy and immunocompromised patients. MATERIALS AND METHODS: Survey-based study conducted on 140 individuals undergoing Mohs surgery. RESULTS: Seventy-three percent of healthy and 74% of immunosuppressed participants identified sunscreen use as a form of protective strategy, whereas 36% and 27%, respectively, used sunscreen daily. Participants cited physicians and the internet as equal sources of medical information. Knowing two or more strategies correlated to a higher self-rating of daily use of any protective strategy. CONCLUSION: General knowledge regarding sun protection strategies is limited, but awareness of multiple strategies correlated with greater sun protective behavior. Despite having a much higher incidence of skin cancers, the immunosuppressed group did not show more awareness of prevention strategies or higher use than healthy participants.