The Two-Stage Folded Paramedian Forehead Flap Without Cartilage Grafts for Full Thickness Distal Nasal Defects: A Review of 35 Patients.

BACKGROUND: Full thickness defects of the ala, soft triangle, and nasal tip involving the nasal lining have traditionally been repaired with the three-stage folded paramedian forehead flap (FPFF), with a cartilage graft for support. For similar defects, the authors utilize the two-stage FPFF without cartilaginous support which provides reproducible functional and aesthetic results.  Objective: To describe the authors’ experience with the two-stage FPFF, including outcomes, complications, and design modifications to enhance functional and aesthetic success.  Methods: An IRB-approved retrospective database review of FPFF was performed at two sites. Using postoperative photographs, outcomes were assessed by blinded non-investigator dermatologist raters using a modified observer scar assessment scale. RESULTS: Thirty-five patients were reconstructed using the two-stage FPFF without cartilage grafts. Subjective assessment of scar vascularity, pigment, relief, and thickness by 3 independent reviewers yielded an overall cosmesis score of 8.4±1.9 (out of 40). CONCLUSION: The two-stage FPFF without cartilage grafts is a reliable, cosmetically elegant repair that can provide optimal functional and aesthetic results for complex unilateral distal nose defects.J Drugs Dermatol. 2024;23(4): doi:10.36849/JDD.7358.

Factors Influencing General Dermatologists When Referring Patients With Head and Neck Melanoma for Mohs Micrographic Surgery: A Nationwide Cross-Sectional Survey.

BACKGROUND: Mohs micrographic surgery (MMS) for cutaneous melanoma has demonstrated higher cure rates, lower local recurrence rates, and improved survival compared with wide local excision (WLE). However, factors affecting referrals by general dermatologists for MMS of head and neck melanoma (HNM) are unknown. OBJECTIVE: To elucidate referral factors and treatment perspectives of general dermatologists regarding MMS for melanoma in situ (MIS)/lentigo maligna (LM) and early-stage melanoma on the head and neck. MATERIALS AND METHODS: A cross-sectional analysis was performed using survey responses of general dermatologists with membership in the American Academy of Dermatology . RESULTS: A total of 231 and 132 of the 402 responding general dermatologists routinely referred melanoma in situ MIS/LM and early invasive melanoma for MMS, respectively. Lack of local access to a Mohs surgeon was the most common deterring reason for MIS/LM referral to MMS, whereas the preference for WLE was the most common deterring reason for early invasive melanoma. CONCLUSION: Lack of local access to a Mohs surgeon treating HNM with MMS is the primary barrier in referrals to Mohs surgeons for MIS and LM. Among general dermatologists, WLE is preferred for early invasive HNM.

Patients are Willing and Successful With Home Suture Removal After Mohs Surgical Procedures.

BACKGROUND: Suture removal after surgery is low risk; however, it is often performed by a medical provider. The current SARS-CoV-2 pandemic has forced providers to assess means of reducing in-person contact. OBJECTIVE: To determine whether patients undergoing Mohs surgery are willing and successful with home suture removal. MATERIALS AND METHODS: A prospective study was performed with patients undergoing Mohs surgery. Before their surgery, patients were assessed for their willingness to remove sutures before and after viewing educational material. Patients who were willing to attempt removal were contacted after expected suture removal date to verify success and assess their experience. RESULTS: One hundred fifty patients were enrolled in the study. 90.1% were willing to attempt home suture removal. Patients were more willing ( p = .003), more confident ( p = .024), and had lower anxiety ( p = .049) with removal after viewing educational resources. Patients with a history of suture removal were more likely to attempt removal after their procedure ( p = .036). Ninety-seven percent of patients who were willing to attempt suture removal were successful. There were no major complications with removal. CONCLUSION: Patients were overwhelmingly successful with suture removal after an educational intervention. Providers should consider providing this option after surgical procedures when clinically appropriate.

The Current State of Mohs Surgery for the Treatment of Melanoma: A Nationwide Cross-Sectional Survey of Mohs Surgeons.

BACKGROUND: The increased use of Mohs micrographic surgery (MMS) to treat melanoma has been accompanied by wide variations in practice patterns and a lack of best practice guidelines. OBJECTIVE: The present study was a nationwide cross-sectional survey of Mohs surgeons to elucidate commonalities and variations in their use of MMS to treat melanoma. MATERIALS AND METHODS: A cross-sectional analysis was performed using survey responses of Mohs surgeons with membership in the American College of Mohs Surgery. RESULTS: A total of 210/513 (40.9%) participants used MMS to treat melanoma of any subtype and 123/210 (58.6%) participants within this group treated invasive T1 melanoma (AJCC Eighth Edition) with MMS. A total of 172/210 (81.9%) participants debulked melanoma in situ (MIS). Average margin size of the first Mohs stage for MIS was 4.96 ± 1.74 mm. A total of 149/210 (71.0%) participants used immunohistochemical stains, with 145/149 (97.3%) using melanoma antigen recognized by T-cells 1 (MART-1) in 96.5% of melanoma cases treated with MMS. CONCLUSION: Over half of surveyed Mohs surgeons treating melanoma with MMS are treating early invasive melanoma with MMS. Most Mohs surgeons treating melanoma with MMS debulk MIS and virtually all use MART-1 when excising invasive melanoma with MMS.

Relative Efficacy of Nonoperative Treatment of Keratoacanthomas.

BACKGROUND: Keratoacanthomas (KAs) are neoplasms of squamous epithelium which exhibit rapid growth and are often difficult to distinguish clinically from squamous cell carcinoma. Excision is the most common treatment, but in refractory cases or for KAs in cosmetically sensitive areas, nonoperative modalities may be better suited. OBJECTIVE: To compare efficacies of topical and intralesional therapies for the treatment of KAs. METHODS: A systematic literature review was performed using Medline, Ovid, and Embase. Studies looking at the efficacy of topical or intralesional treatments for KAs were included. To compare efficacy, 2-tailed t-tests were performed, with P < .05 considered statistically significant. RESULTS: Forty-one studies were identified across 5 modalities. Both topical and intralesional treatments had high KA eradication rates (92%-100%). Intralesional 5-fluorouracil led to faster KA healing times when compared to intralesional methotrexate (3.7 vs 4.6 weeks, P = .017). Similarly, topical 5-fluorouracil led to faster time to heal than topical imiquimod (3.8 vs 7.6 weeks with imiquimod, P < .0001). CONCLUSION: For nonoperative treatment of KAs, strong evidence currently exists for both topical and intralesional therapies. Decisions on which modality to use should be made on a case-by-case basis.

Corrigendum: Successful non-operative treatment of eruptive keratoacanthomas refractory to excision.

The original article was published on March 15, 2020 and corrected on June 15, 2020. The revised version of the article corrects an Author's name. The changes appear in the revised online PDF copy of this article.

Successful non-operative treatment of eruptive keratoacanthomas refractory to excision.

Keratoacanthomas are rapidly growing neoplasms of squamous epithelium. Despite their benign nature, they are often difficult to distinguish from squamous cell carcinoma and require excision. In cases in which excision is not successful or not desired, intralesional treatments may be considered. However, limited research exists on individual therapeutic efficacy. We present a 68-year-old man who developed multiple eruptive keratoacanthomas around the wound edge of a previous keratoacanthoma excision. Considering previous excisional failure, intralesional 5-fluorouracil was used as a treatment modality. Injections every 3-4 weeks over a course of 12 weeks induced clinical keratoacanthoma clearance with excellent cosmetic results. This case showcases that weekly intralesional 5-fluorouracil injections, as was the standard mode of treatment in previous case reports, may not be necessary. This less frequent injection strategy is more convenient for the patient and may lead to fewer treatments and less medication necessary. Although a case-by-case basis is needed for any alternative approach to keratoacanthoma treatment, this report is useful for the practicing clinician in showing that 5-fluorouracil may be efficacious in these difficult-to-treat patients.

The bicycle wheel analogy for linear closures of small suborbital cheek defects.

Primary closure of suborbital skin defects can cause tension along the closure resulting in ectropion. The bicycle wheel analogy is a simple yet effective guide to aid in reducing tension vectors resulting in ectropion.

Patients use more topical medication when the medications come in a larger container.

INTRODUCTION: Research shows that individuals consume more calories when provided with a larger portion size. It is unclear if similar behavior translates to topical medication use. The impact of container size and provider instructions on patient usage of topical medications has yet to be assessed. METHODS: Data was collected from 128 participants in an IRB randomized, controlled trial. To a marked 3cmx8cm rectangle on the forearm, patients applied petroleum jelly from either a large container or a small tube. Pre and post application container weights were measured. RESULTS: Patients applied more topical medication from the large container compared to the small tube. CONCLUSION: Topical medication usage is influenced by the size of the container provided. It is beneficial to consider container size when prescribing topical medications and greater application is desired.

Relative efficacy of systemic treatments for atopic dermatitis.

BACKGROUND: Systemic medications are often required for severe atopic dermatitis (AD) refractory to topical therapies. Biologic medications are a recent advancement in the field and a comparison with standard systemic approaches would be beneficial. OBJECTIVE: To compare efficacies of systemic therapies for the treatment of AD. METHODS: A systematic literature review was performed using Medline, Ovid, and Embase. Randomized controlled trials looking at the efficacy of systemic treatments for AD in adults and children were included. RESULTS: A total of 41 studies met criteria and were included in our final analysis. Consistent improvements in Eczema Area and Severity Index and Scoring Atopic Dermatitis were reported with dupilumab and cyclosporine. Phase 2 clinical trials for lebrikizumab and tralokinumab were effective and would benefit from phase 3 trials. No study reported efficacy of biologic medications in pediatric patients; however, cyclosporine improved clinical severity by the greatest amount in this group. LIMITATIONS: A lack of well controlled comparison studies make direct comparisons between the treatments difficult. CONCLUSION: For treatment of severe AD, the strongest evidence currently exists for dupilumab and cyclosporine at improving clinical disease severity. Further research is required to determine long-term safety and efficacy of biologic medications.

The 5 P's of Pyoderma Gangrenosum

The diagnosis of pyoderma gangrenosum (PG) is often difficult to establish based on a clinical presentation, which can mimic other dermatologic conditions. The formation of a mnemonic that incorporates the most prevalent clinical features of PG could aid in accuracy and speed of diagnosis. The 5 P's of PG: Painful, Progressive, Purple, Pretibial, Pathergy, and systemic associations, incorporate parameters recognizable on the first encounter with a patient with PG without reliance on histopathology and laboratory findings or treatment response. We postulate that this simple mnemonic will have the most utility with non-dermatology clinicians encountering a lesion suspicious for PG. By assisting in differential diagnosis formation, this mnemonic may lead to timelier biopsies and treatment initiation. The limitations of this approach mirror those of other studies and include lower sensitivities in patients with an atypical PG presentation. In conclusion, the 5 P's of PG offer a useful mnemonic for the diagnosis of PG, particularly in the initial clinical diagnosis prior to skin biopsy and treatment. J Drugs Dermatol. 2019;18(12):1282-1283.

Operative Management for Pediatric and Adolescent Scaphoid Nonunions: A Meta-analysis.

INTRODUCTION: Scaphoid fractures in the pediatric population represent ∼3% of all hand and carpal fractures. Cast immobilization has been shown to yield excellent results in the acute phase, however some patients develop nonunions. Currently, there is no consensus regarding the best surgical treatment after development of a pediatric/adolescent scaphoid nonunion. METHODS: A comprehensive literature review was performed utilizing Medline, Ovid, and Embase databases to compare surgical techniques for adolescent scaphoid nonunions on the basis of union rates, functional outcomes, and operative complications. Our initial search returned 2110 publications. Inclusion criteria consisted of a scaphoid fracture with >3 months of no clinical or radiographic improvement after cast immobilization and age less than 18 years. Ultimately, 11 studies met our criteria and were included in the final analysis. RESULTS: A total of 176 surgically treated pediatric/adolescent scaphoid nonunions were identified from the 11 studies, including 157 nonvascularized bone graft procedures and 19 nongrafted rigid fixation procedures. Patients treated with a nongrafted method achieved union with a total random effects model revealing a union rate of 94.6%, whereas the grafted cohort had a union rate of 94.8%. Functional outcomes including range of motion and grip strength were significantly improved in both cohorts. Patients managed operatively with bone graft had 4 complications, in contrast those without bone grafting did not report complications (P=0.9). CONCLUSION: Surgical treatment of pediatric/adolescent scaphoid fracture nonunions produce excellent union rates and functional outcomes after surgical intervention, using both grafted and nongrafted techniques. Future prospective studies are needed to assess if the outcomes of a specific technique are more favorable, as well as to determine if differences exist based on fracture location. LEVEL OF EVIDENCE: Level III. This study is a meta-analysis of studies containing level of evidence of III or greater.

The cotton tipped applicator - a scratch for the itch and more during dermatologic surgery.

An itch during surgery can be distracting. Sterile cotton tipped applicators are inexpensive and multipurpose tools that may be used for a variety of simple surgical tasks such as scratching an itch on the surgeon or patient's face. They may also be used to adjust glasses and turn on surgical lights or the electrocautery machine.