Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

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.

Cutaneous Angiosarcoma Subtypes: A Quantitative Systematic Review of Demographics, Treatments, and Outcomes Within Published Patient-Level Cases.

BACKGROUND: Cutaneous angiosarcoma (cAS) is a highly aggressive malignancy arising from the vascular endothelium. Given its rarity, there is insufficient data detailing patient demographics, management, and survival outcomes. OBJECTIVE: To systematically compile published patient-level cases of cAS and to quantify and analyze data on demographics, management, and outcomes while determining prognostic indicators. MATERIALS AND METHODS: Searches of EBSCOhost, MEDLINE, EMBASE, and the Cochrane Library generated 1,500 cases of cAS with individual level data available. PRISMA guidelines were followed. RESULTS: Cutaneous angiosarcoma presented most often on the scalp of elderly men. Metastasis occurred in 36.3% of cases. Aggregate 5-year survival was 31.6% with the median survival of 25 months. The best 5-year survival was in the radiation-associated subtype (48.8%), whereas the worst was in the Stewart-Treves subtype (21.6%). Using multivariate analysis, gender, age group, disease subtype, treatment modality, and metastasis at presentation had significant effects on survival outcomes ( p < .05). CONCLUSION: The breadth of information obtained enables this study to serve as a resource that clinicians may reference when they encounter cAS.

Refining Field Cancerization: An Institutional Cohort Analysis of Patient Characteristics in a Validation Cohort.

BACKGROUND: Field cancerization is poorly defined in dermatology. The author group previously proposed and applied a classification system in an original cohort to risk-stratify patients with field cancerization. OBJECTIVE: Apply the authors' classification system within a validation cohort. METHODS: Patients with keratinocyte carcinoma history completed a survey regarding demographic information, medical history, and chemoprevention use. Patients were assigned a field cancerization class, and differences between validation and original cohorts were assessed. RESULTS: A total of 363 patients were enrolled (mean age 67.4; 61.7% male). After comparing validation and original cohorts, there were differences in age between class II (p = .02) and class IVb (p = .047), and differences in chemoprevention use in class III (p = .04). Similar to the original cohort, the validation cohort was associated with increases in total number of skin cancers in the last year (p < .001), 5 years (p < .001), lifetime (p < .001), years since first skin cancer (p < .001), and chemoprevention use (p < .001). In the validation cohort, there were increases in age (p = .03) and immunocompromised status (p = .04) with increasing class, which were not observed in the original cohort. CONCLUSION: Differences among field cancerization classes were similar in a validation cohort, further highlighting the importance of class-specific treatment and management.

Melanoma survival by age group: Population-based disparities for adolescent and young adult patients by stage, tumor thickness, and insurance type.

BACKGROUND: Melanoma survival literature predominantly represents patients >65 years of age. Study of younger patients may reveal potential age-group-specific differences in survival outcome. OBJECTIVE: Identify factors associated with differences in melanoma survival in 2 age groups, adolescents and young adults (AYAs; ages 15-39) and older adults (ages 40-64). METHODS: This population-based registry study included all cases (n = 81,597) of cutaneous melanoma diagnosed at ages 15 to 64 from 2004 to 2015 in California. Age-group-specific multivariable Cox hazard regressions were used. RESULTS: In the adjusted, age-group-specific models, AYA patients with stage IV melanoma had worse survival (hazard ratio: 20.39, 95% CI: 13.30-31.20) than was observed among older adults (hazard ratio: 10.79, 95% CI: 9.33-12.48). Thicker tumors and public insurance were also associated with worse survival for AYAs than observed in models for older adults. AYAs experienced better survival when detected at earlier stages. LIMITATIONS: Registry data do not routinely collect behavioral information or family history of melanoma. CONCLUSIONS: Survival was much worse for AYAs with stage IV melanoma than observed among older adults. To improve AYA survival, early melanoma detection is critical. Greater awareness, suspicion, and screening for AYA melanoma may disrupt delays in diagnosis and reduce the excess burden of mortality from stage IV melanoma in young patients.

Refining the Classification of Field Cancerization.

BACKGROUND: Field cancerization is a commonly encountered but poorly defined entity in dermatology. Lack of a consensus definition makes characterizing and studying this condition difficult. OBJECTIVE: Propose a framework for defining and managing field cancerization patients. METHODS: Clinical experience and available data in the literature was used to develop a proposed field cancerization disease classification system and chemoprevention algorithm. RESULTS: The author group developed a field cancerization classification and treatment algorithm that stratifies patients into 5 different classes based on the extent of their field cancerization. They have started to recruit and study the highest risk cohort (Category 4 or 5) and have recruited 57 patients with 5 or more lifetime keratinocyte carcinomas for a prospective study evaluating chemoprevention strategies and disease burden. In these cohorts, the average number of skin cancers was greater than 12; however, less than 39% of these patients had used any chemoprevention in the prior 6 months. CONCLUSION: A meaningful and clinically relevant disease stratification framework with chemoprevention guidance has the potential to highly impact the specialty and patients.

Postoperative Complications After Interpolated Flap Repair for Mohs Defects of the Nose: A Multicenter Prospective Cohort Study.

BACKGROUND: Dermatologists perform most interpolated flaps after skin cancer resection. Prospective, multicenter data on complications after interpolated flap repair in this setting are limited. OBJECTIVE: To determine the rate of physician-reported complications after interpolated flap repair of the nose. METHODS: Multicenter, prospective cohort study of 169 patients undergoing 2-stage interpolated flap repair of post-Mohs nasal defects. Frequency of bleeding, infection, dehiscence, necrosis, hospitalization, and death in the 30 days after flap placement and flap takedown are reported. RESULTS: Patients experienced 23 complications after flap placement (13.61%) and 6 complications after flap takedown (3.55%) that were related to the surgical procedure. The most frequent complication after flap placement was bleeding (9, 5.33%, 95% confidence interval [CI]: 2.83%-9.82%). The most frequent complication after flap takedown was infection (5, 2.96%, 95% CI: 1.27%-6.74%). There was one hospitalization related to an adverse reaction to antibiotics. There were no deaths. CONCLUSION: Most complications after interpolated flap repair for post-Mohs defects of the nose are minor and are associated with flap placement. Interpolated flap repair for post-Mohs defects can be performed safely in the outpatient setting under local anesthesia.

Enhanced metastatic risk assessment in cutaneous squamous cell carcinoma with the 40-gene expression profile test.

Aim: To clinically validate the 40-gene expression profile (40-GEP) test for cutaneous squamous cell carcinoma patients and evaluate coupling the test with individual clinicopathologic risk factor-based assessment methods. Patients & methods: In a 33-site study, primary tumors with known patient outcomes were assessed under clinical testing conditions (n = 420). The 40-GEP results were integrated with clinicopathologic risk factors. Kaplan-Meier and Cox regression analyses were performed for metastasis. Results: The 40-GEP test demonstrated significant prognostic value. Risk classification was improved via integration of 40-GEP results with clinicopathologic risk factor-based assessment, with metastasis rates near the general cutaneous squamous cell carcinoma population for class 1 and ≥50% for class 2B. Conclusion: Combining molecular profiling with clinicopathologic risk factor assessment enhances stratification of cutaneous squamous cell carcinoma patients and may inform decision-making for risk-appropriate management strategies.

Plain language summary Cutaneous squamous cell carcinoma is a common skin cancer, with approximately 2 million cases diagnosed each year in the USA. Because substantial numbers of patients experience metastasis, which can result in death, accurate metastatic risk assessment is important. Clinicians use clinicopathologic factors to determine risk for disease progression. However, traditional methods miss pinpointing many patients who experience metastasis and sometimes categorize patients as at risk who do not develop metastasis, indicating that additional tools are needed. A molecular test, the 40-gene expression profile (40-GEP), was developed to predict metastatic risk based on the biology of the tumor. This study demonstrates that the 40-GEP, either as an independent tool or together with traditional methods, accurately identifies patients' risk of metastasis. Using the 40-GEP could improve patient management to improve patient outcomes.

Patient willingness to receive full-body skin exams based on the sex and/or gender and training level of provider: a survey study.

Full-body skin examinations (FBSEs) involve examination of the patient's skin from head to toe, and may be uncomfortable for some patients. While many patients prefer same-sex providers for pelvic, genital and rectal exams, desire for same-sex providers for FBSEs is not well characterized. This may be further magnified when FBSE is performed by medical trainees. We surveyed 566 subjects using Amazon Mechanical Turk (AMT), an online crowdsourcing platform, to assess the public's willingness to receive FBSEs based on the sex and/or gender and the level of training of the healthcare provider (HCP). The overall willingness by all respondents to undergo FBSE performed by a dermatologist, dermatology resident and medical student was 84.3%, 77.5% and 65.7%, respectively, if the HCP was the same sex/gender, compared with 60.6%, 54.8% and 45.7% if the HCP was a different sex/gender (P < 0.001). In our cohort, unwillingness for FBSEs was greater if the patient was female, if the HCP was a different gender/sex from the patient and if the HCP was a medical student.

Recurrence Status, Perineural Invasion, and Hypothyroidism Are Associated With Lymph Node Metastasis in Cutaneous Squamous Cell Carcinoma: A Case-Control Study.

BACKGROUND: Lymph node metastasis is a critical prognostic indicator for mortality in patients with cutaneous squamous cell carcinoma (SCC). OBJECTIVE: To identify and characterize key risk factors for SCC lymph node metastasis. METHODS: This was a multi-institutional, case-control study of 65 cutaneous SCCs with known lymph node metastasis matched with 195 cutaneous SCCs without lymph node metastasis (3:1 matching). The cases and controls were matched by anatomic location, age, and sex. Odds ratios (ORs) and their 95% confidence intervals (CIs) were generated to determine the association between specific risk factors and lymph node metastasis in a multivariate analysis. RESULTS: Recurrent tumors (p < .001), perineural invasion (p < .001), lymphovascular invasion (p = .002), size of 2 cm or greater (p = .008), and hypothyroidism (p = .03) were significantly more common in the lymph node metastasis cohort. Recurrence (OR 6.3, 95% CI 2.6-15.3), perineural invasion (OR 4.5, 95% CI 1.7-11.8), and hypothyroidism (OR 2.7, 95% CI 1.04-7.0) remained significant on performing a multivariate analysis. CONCLUSION: Lymph node metastasis in SCC is associated with recurrence, perineural invasion, lymphovascular invasion, size of 2 cm or greater, and hypothyroidism. Clinical consideration of these findings within the context of current staging systems may help improve patient outcomes.

Rare Cutaneous Malignancies in Skin of Color.

BACKGROUND: There is a scarcity of information regarding the clinical characteristics of rare cutaneous malignancies in skin of color that has yet to be comprehensively explored. OBJECTIVE: To review and compile the racial differences in epidemiology, clinical presentation, histology, treatments, and outcomes of 3 rare skin cancers: dermatofibrosarcoma protuberans (DFSP), Merkel cell carcinoma (MCC), and sebaceous carcinoma (SC). METHODS: Several searches with keywords denoting specific skin cancer type and race were conducted on PubMed to complete this narrative review. RESULTS: We analyzed 50 sources that were relevant to the initial objective. CONCLUSION: The literature demonstrates that there are nuances in DFSP, MCC, and SC unique to African Americans, Asians/Pacific Islanders, and Hispanics that may differ significantly from Caucasian counterparts. African Americans consistently suffer from the worst clinical outcomes in all 3 rare cutaneous malignancies reviewed. Greater physician awareness and knowledge of the discussed racial differences is the preliminary step to address these disparities.

Effects of Blue Light on the Skin and Its Therapeutic Uses: Photodynamic Therapy and Beyond.

BACKGROUND: Blue light is the most energetic portion of the visible light spectrum. Recent awareness of its ubiquity and potential has led to greater developments in therapeutic uses. OBJECTIVE: Provide up-to-date information on the effects of blue light on the skin, with a focus on the benefits and its place in therapeutic modalities within dermatology. MATERIALS AND METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for articles related to blue light's effect on the skin and therapeutic modalities using blue light. This search resulted in 223 unique results with 60 articles selected for review. RESULTS: Therapeutic modalities using blue light have been proven to be effective as a monotherapy or component of a comprehensive treatment plan for common dermatologic diseases such as actinic keratosis, acne, cutaneous infections, and psoriasis, and early reports support its use in disseminated superficial actinic porokeratosis and actinic cheilitis. CONCLUSION: The benefits and treatment applications of blue light have proven effective in multiple forms and uses. In the correct setting, blue light can be a useful tool to the practicing dermatologist for many common and sometimes refractory skin diseases while remaining low-risk and convenient. Further standardization and monitoring should be pursued to determine the most appropriate use.

Soft Tissue Dermal Filler-Associated Necrosis and Impending Necrosis: A Systematic Review of the Literature.

BACKGROUND: Cosmetic soft tissue fillers are a popular minimally invasive procedure. Necrosis is a rare yet devastating complication of soft tissue fillers. To date, the relationship between soft tissue fillers and necrosis has not been fully described. OBJECTIVE: To systematically compile published cases of soft tissue fillers resulting in necrosis and collect data regarding the injection, treatment, and outcome. METHODS AND MATERIALS: Using PRISMA protocol, a comprehensive search for soft tissue filler necrosis was performed using no time constraints, resulting in 97 articles encompassing 192 cases of soft tissue filler necrosis containing individual-level data. RESULTS: Of the cases analyzed, 66.1% had progressed to necrosis, whereas 33.9% of patients had impending necrosis. Necrosis most commonly resulted from injection of the nasolabial fold (32.4%, n = 88). The filler material most commonly used was hyaluronic acid (71.9%, n = 138). Hyaluronidase was used most frequently as an initial treatment agent (19.1%, n = 88). Forty-three patients (22.4%) with necrosis had a prior minor procedure or surgery. CONCLUSION: This systematic review is an extensive overview of necrosis as a complication of soft tissue fillers. It serves as a reference tool for any clinician who injects soft tissue fillers and any provider who encounters soft tissue filler necrosis.

Over-expression of stromal periostin correlates with poor prognosis of cutaneous squamous cell carcinomas.

Periostin, an extracellular matrix macromolecule implicated in tumorigenesis, serves as a prognostic marker for many cancer types. However, there are no data on periostin expression in cutaneous squamous cell carcinoma (cSCC). This study examined periostin expression in patients with cSCC and explored its clincopathological relationship and prognosis. Using immunohistochemistry and ImageJ analysis, we compared periostin expression in 95 cSCCs across a spectrum of cSCC aggressiveness: cSCC in situ (SCCIS) (n = 25), low-risk cSCC (LR-cSCC) (n = 26), high-risk cSCC (HR-cSCC) (n = 38), and cSCC in recessive dystrophic epidermolysis bullosa patients (RDEB cSCC) (n = 6). Immunohistochemistry demonstrated periostin expression within the intra-tumoral stroma but not within tumor cells. Periostin levels significantly (P < 0.001) increased from SCCIS, LR-cSCC, HR-cSCC to RDEB SCC. The stroma of most of the cSCCs we evaluated contained cancer-associated fibroblasts with a myofibroblastic (α -SMA-positive) phenotype. Co-localization of periostin with α-SMA, evidence of fibroblast periostin expression, and absence of keratinocyte or tumor cell periostin expression suggest that, in cSCC, periostin is a product of the peritumoral microenvironment and not the tumor cells themselves. Our data indicate that fibroblast periostin expression is highly correlated with the aggressiveness of cSCC, and may thereby provide a molecular marker that will be useful for subtyping and diagnosing cSCCs according to their biological nature.

What Is New in Occupational Allergic Contact Dermatitis in the Year of the COVID Pandemic?

PURPOSE OF REVIEW: This article aims to summarize some recent trends in occupational allergic contact dermatitis (ACD), including dermatitis related to pandemic-level personal protective equipment in healthcare workers, hazards patients may experience when working from home, and occupational perspectives on the recent American Contact Dermatitis Society (ACDS) allergens of the year and ACDS Core Allergen Series updates. RECENT FINDINGS: Recent ACDS Allergens of the Year may be particularly relevant to healthcare workers, including isobornyl acrylate, which is present in glucose sensors and propylene glycol present in hand cleansers and disinfectants. Lavender, limonene, and linalool, all of which are new additions to the ACDS Core Allergen Series, have been reported as causes for occupational ACD in massage therapists and aromatherapists. Isothiazolinone allergy continues to rise in both consumer and occupational settings. Finally, the COVID-19 pandemic has resulted in a wave of occupational ACD in healthcare workers to personal protective equipment, and revealed new potential allergens for individuals working from home. Occupational allergic contact dermatitis continues to exert a significant occupational disease burden. Remaining aware of the current trends in allergens may allow for earlier recognition, diagnosis, and treatment, subsequently helping our patients to work in healthier and safer environments.

Validation of a 40-gene expression profile test to predict metastatic risk in localized high-risk cutaneous squamous cell carcinoma.

BACKGROUND: Current staging systems for cutaneous squamous cell carcinoma (cSCC) have limited positive predictive value for identifying patients who will experience metastasis. OBJECTIVE: To develop and validate a gene expression profile (GEP) test for predicting risk for metastasis in localized, high-risk cSCC with the goal of improving risk-directed patient management. METHODS: Archival formalin-fixed paraffin-embedded primary cSCC tissue and clinicopathologic data (n = 586) were collected from 23 independent centers in a prospectively designed study. A GEP signature was developed using a discovery cohort (n = 202) and validated in a separate, nonoverlapping, independent cohort (n = 324). RESULTS: A prognostic 40-GEP test was developed and validated, stratifying patients with high-risk cSCC into classes based on metastasis risk: class 1 (low risk), class 2A (high risk), and class 2B (highest risk). For the validation cohort, 3-year metastasis-free survival rates were 91.4%, 80.6%, and 44.0%, respectively. A positive predictive value of 60% was achieved for the highest-risk group (class 2B), an improvement over staging systems, and negative predictive value, sensitivity, and specificity were comparable to staging systems. LIMITATIONS: Potential understaging of cases could affect metastasis rate accuracy. CONCLUSION: The 40-GEP test is an independent predictor of metastatic risk that can complement current staging systems for patients with high-risk cSCC.

Patient Outcomes and Satisfaction After Mohs Micrographic Surgery in Patients With Nonmelanoma Skin Cancer.

BACKGROUND: Quality in medicine is increasingly being measured through patient-reported outcome measures. Given the rising incidence and costs for nonmelanoma skin cancer (NMSC) treatment, it is imperative to define quality measures specific to dermatologic surgery. OBJECTIVE: This study aims to evaluate patient-reported outcomes and satisfaction with Mohs micrographic surgery (MMS) together with patient and tumor factors to better define their use in developing treatment strategies and quality measures. METHODS AND MATERIALS: A prospective study was conducted among 226 patients undergoing MMS for treatment of NMSC. Patient demographics, quality of life, functional status, satisfaction, and prognostic factors were gathered. Postoperative outcomes were measured at 1 month and included patient-reported problems and provider-reported complications. Relationships between patient factors and outcomes were evaluated through statistical analysis. RESULTS: Average patient satisfaction in the domain of general satisfaction of the Patient Satisfaction Questionnaire-18 was 4.34 of 5. General patient satisfaction did not differ across age, final defect size, sex, or prognostic scores. At 1-month postoperatively, 97 percent of patients expressed willingness to undergo future MMS if indicated. CONCLUSION: Patients are generally satisfied with MMS for treatment of NMSC. Specific patient factors that may affect satisfaction include smoking status and anticoagulation use.

Common Dermatologic Procedures and the Associated Complications Unique to Skin of Color.

BACKGROUND: The skin of color (SOC) population in the United States continues to grow, and these patients are undergoing various cosmetic and surgical procedures at increasing rates. There is a paucity of data on the potential complications associated with surgical and cosmetic procedures in this patient population. OBJECTIVE: We aim to educate dermatologic surgeons and clinicians on surgical and cosmetic procedures in patients of color and increase awareness of the potential complications unique to this patient population. MATERIALS AND METHODS: A thorough PubMed literature search was performed to conduct this review. RESULTS: There are a number of complications in SOC that require special attention, including keloids, postoperative infections, postinflammatory hyperpigmentation, and hypopigmentation. There are also various precautions to consider when performing cosmetic procedures, such as neurotoxin and filler injections, laser therapy, microneedling, and chemical peels. CONCLUSION: Dermatologists should be aware of the potential cosmetic and surgical complications of this growing patient population to provide optimal evidence-based medical care.

Misclassification of Aggressive Basal Cell Carcinoma Subtypes and Implications for Management.

BACKGROUND: Management of basal cell carcinoma (BCC) varies by histopathologic subtype; however, biopsies may inadequately characterize them as nonaggressive, risking potential suboptimal treatment. OBJECTIVE: To characterize the rate of undetected aggressive BCC subtypes by size, location, and histopathology type. MATERIALS AND METHODS: Retrospective cohort study of 928 BCCs treated with Mohs Micrographic Surgery (MMS) at a tertiary academic institution from 2015 to 2017, comparing patient and tumor characteristics and histopathologic subtype on biopsy versus Mohs. RESULTS: Among the 825 BCCs with known subtypes on biopsy, 68% (561/825) were classified as nonaggressive, 28% (159/561) of which were subsequently found to have aggressive subtypes on MMS. Aggressive features were more often underrepresented in biopsy samples taken from Area H compared with Area M/L (odd ratio [OR] 2.65, 95% confidence interval [CI] 1.73-4.08, p < .001) or those with nodular subtypes (OR 2.19, CI 1.08-4.45, p = .03). Of concern, these unsuspected aggressive BCCs required more Mohs stages for clearance (mean 2.37, SD 0.72, p < .001) compared with BCCs that remained nonaggressive on both biopsy and Mohs (mean 1.50, SD 0.75). CONCLUSION: Given the high percentage of BCCs with unsuspected aggressive subtypes, higher clinical suspicion for undiagnosed high-risk BCCs should be given to nodular BCCs and to BCCs on Area H.

The Correlation Between Immunohistochemistry Findings and Metastasis in Squamous Cell Carcinoma: A Review.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) is the second most common type of skin cancer. Only 2% to 5% of SCCs metastasize; however, those do carry a poor prognosis. Immunohistochemistry (IHC) is widely used by pathologists to characterize skin cancers and provide clinically useful information. OBJECTIVE: To evaluate the potential prognostic associations between IHC findings and metastasis in SCC. METHODS: Searches were conducted in MEDLINE via PubMed for articles published between 1999 and 2019. Search criteria included key words "immunohistochemistry" and "cutaneous squamous cell carcinoma." Six hundred and fifty-three articles were returned and screened, which ultimately left 31 for inclusion in our manuscript. RESULTS: Thirty-one articles analyzed in this review included a discussion of the expression of a particular IHC marker and the associated risk of metastasis and/or clinical utility of IHC markers in SCC, especially metastatic SCC. Markers that had several or more studies supporting clinical utility were E-cadherin, podoplanin, CD8+ T cells, PD-L1, epidermal growth factor receptor, and Cyclin D1. CONCLUSION: Immunohistochemistry profiling of SCC may be useful in select cases when providing a prognosis remains challenging and in identification of potential therapeutic targets for high-risk or metastatic tumors.