Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: A registry-based study.

BACKGROUND: Cutaneous reactions after COVID-19 vaccination have been commonly reported; however, histopathologic features and clinical correlations have not been well characterized. METHODS: We evaluated for a history of skin biopsy all reports of reactions associated with COVID-19 vaccination identified in an international registry. When histopathology reports were available, we categorized them by reaction patterns. RESULTS: Of 803 vaccine reactions reported, 58 (7%) cases had biopsy reports available for review. The most common histopathologic reaction pattern was spongiotic dermatitis, which clinically ranged from robust papules with overlying crust, to pityriasis rosea-like eruptions, to pink papules with fine scale. We propose the acronym "V-REPP" (vaccine-related eruption of papules and plaques) for this spectrum. Other clinical patterns included bullous pemphigoid-like (n = 12), dermal hypersensitivity (n = 4), herpes zoster (n = 4), lichen planus-like (n = 4), pernio (n = 3), urticarial (n = 2), neutrophilic dermatosis (n = 2), leukocytoclastic vasculitis (n = 2), morbilliform (n = 2), delayed large local reactions (n = 2), erythromelalgia (n = 1), and other (n = 5). LIMITATIONS: Cases in which histopathology was available represented a minority of registry entries. Analysis of registry data cannot measure incidence. CONCLUSION: Clinical and histopathologic correlation allowed for categorization of cutaneous reactions to the COVID-19 vaccine. We propose defining a subset of vaccine-related eruption of papules and plaques, as well as 12 other patterns, following COVID-19 vaccination.

Safety and Efficacy of Nanosecond Pulsed Electric Field Treatment of Seborrheic Keratoses.

BACKGROUND: Nanosecond pulsed electric field technology (also known as Nano-Pulse Stimulation or NPS) is a nonthermal, drug-free, energy-based technology that has demonstrated effects on cellular structures of the dermis and epidermis in previous clinical studies. OBJECTIVE: To evaluate the safety and efficacy of a single NPS treatment for clearing seborrheic keratoses (SKs). MATERIALS AND METHODS: This study was a prospective, randomized, open-label, multisite, nonsignificant risk trial in which each subject served as their own control. Fifty-eight subjects had 3 of 4 confirmed SK lesions treated, resulting in 174 total treated lesions. Subjects returned for 5 to 6 follow-up evaluations and photographs. RESULTS: At 106 days after NPS treatment, 82% of treated seborrheic keratoses were rated clear or mostly clear by the assessing physician. Seventy-one percent of lesions were rated clear or mostly clear by the 3 independent reviewers based on the 106-day photographs. All treated subjects returned for all study visits, and 78% of the subjects were satisfied or mostly satisfied with the outcome of the treatment. No adverse events were reported. CONCLUSION: The NPS procedure was well tolerated and effective in the removal of SKs.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

A Descriptive Analysis of the American Society for Dermatologic Surgery Presidents.

BACKGROUND: The American Society of Dermatologic Surgery (ASDS) is the major educational organization for dermatologic surgery in the United States. Presidents are elected annually from among their members. OBJECTIVE: The authors investigated the demographics, training, and achievements of the ASDS presidents. MATERIALS AND METHODS: All ASDS presidents (1970-2017) were included. Data were gathered using publicly available information from websites, curriculum vitae, and PubMed. Living presidents were contacted by email (if available) to verify the collected data. RESULTS: Of 46 ASDS presidents, 87% are male, with the first female president elected in 1994. Fifty-nine percent are members of the American College of Mohs Surgery. Seven presidents received dual fellowship training. Four presidents received a second graduate degree. Mean duration from residency to presidency was 22 years, with the mean age being 53 years. PubMed publication average was 34. All presidents have been affiliated with academic institutions, with 26% appointed as department chair and 30% serving as academic dermatologic surgery director. CONCLUSION: The authors report that most of the ASDS presidents have been male with over half receiving Mohs surgery fellowship training. All have had academic affiliations at some point in their careers, with some named department chairs and/or elected as presidents of other national dermatologic societies.

Lasers and Energy-Based Devices in Men.

BACKGROUND: The demand for cosmetic treatments with lasers and energy-based devices has increased among men, but there is a dearth of literature that addresses the approach and treatment of cosmetic male patients. OBJECTIVE: To summarize common cosmetic concerns for which male patients seek cosmetic treatments and to provide sex-specific recommendations for the lasers and energy-based devices that can be used for treatment. MATERIALS AND METHODS: The authors conducted a literature search using the PubMed/MEDLINE and Google Scholar databases using the search terms male, men, gender, and cosmetic dermatology. RESULTS: The authors review sex-specific treatment recommendations regarding the use of lasers and energy-based devices for the conditions for which men most commonly seek cosmetic treatment, which include photo-/actinic damage, acne scarring, rhinophyma, hair removal, axillary hyperhidrosis, and loose neck/submental skin. Cosmetic issues the authors will touch on, but whose approaches or considerations vary less in men compared with women, are hyperpigmentation, vascular lesions, and facial rejuvenation. CONCLUSION: Sex-specific treatment approaches with lasers and energy-based devices should be used to best serve male cosmetic patients.

Understanding Mohs Micrographic Surgery: A Review and Practical Guide for the Nondermatologist.

The incidence and diagnosis of cutaneous malignancies are steadily rising. In addition, with the aging population and increasing use of organ transplant and immunosuppressive medications, subsets of patients are now more susceptible to skin cancer. Mohs micrographic surgery (MMS) has become the standard of care for the treatment of high-risk nonmelanoma skin cancers and is increasingly used to treat melanoma. Mohs micrographic surgery has the highest cure rates, spares the maximal amount of normal tissue, and is cost-effective for the treatment of cutaneous malignancies. As in other medical fields, appropriate use criteria were developed for MMS and have become an evolving guideline for determining which patients and tumors are appropriate for referral to MMS. Patients with cutaneous malignancies often require multidisciplinary care. With the changing landscape of medicine and the rapidly increasing incidence of skin cancer, primary care providers and specialists who do not commonly manage cutaneous malignancies will need to have an understanding of MMS and its role in patient care. This review better familiarizes the medical community with the practice of MMS, its utilization and capabilities, differences from wide excision and vertical section pathology, and cost-effectiveness, and it guides practitioners in the process of appropriately evaluating and determining when patients with skin cancer might be appropriate candidates for MMS.

Unnecessary Cost of Post-Mohs Permanent Pathology.

BACKGROUND: By providing tumor-free margins, Mohs micrographic surgery (MMS) results in high cure rates in the treatment of nonmelanoma skin cancers (NMSCs). However, when closure of the post-MMS defect is coordinated with reconstructive surgery, redundant tissue is sometimes submitted for permanent section evaluation. OBJECTIVE: The purpose of our study was to investigate the frequency and effect of this practice. MATERIALS AND METHODS: Patients (12 years and older) with NMSCs cleared by MMS with coordinated closures from 2014 to 2016 were identified. Cost analysis was performed using the 2016 Current Procedural Terminology codes and averaged nation-wide Medicare reimbursement rates. RESULTS: During the study period, 408 cases were coordinated with reconstructive surgeons post-MMS. Of these, 125 had specimens were submitted for permanent section with none showing residual malignancy. There were no significant differences between the cases sent for permanent section and the remaining coordinated MMS cases, with respect to patient age, to basal cell and squamous cell carcinoma histology, or to defect size (p > .05). The marginal cost of sending specimens for permanent section was $121 per case. CONCLUSION: Sending post-MMS redundant tissue for permanent sections may be of limited utility and should not be performed routinely. Additional work is warranted to determine when this practice should be used in conjunction with MMS.

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

IMPORTANCE: Excisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery. OBJECTIVE: To systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology. EVIDENCE REVIEW: Survey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations. FINDINGS: In total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions. CONCLUSIONS AND RELEVANCE: When definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated.

Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers.

IMPORTANCE: Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES: To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE: Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS: Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE: Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Equal cosmetic outcomes with 5-0 poliglecaprone-25 versus 6-0 polypropylene for superficial closures.

BACKGROUND: Cutaneous sutures should provide an aesthetically pleasing result. After placing subcutaneous sutures, enough absorbable suture often remains for the superficial closure. Mohs surgeons often use a nonabsorbable suture to close the superficial layer to obtain cosmetically elegant results, but using this additional suture is less cost effective than using the remaining absorbable suture. OBJECTIVES: To compare the cosmetic results of simple running sutures using an absorbable suture material (5-0 poliglecaprone-25) with those of a nonabsorbable suture (6-0 polypropylene) in primary closures of suitable facial Mohs defects. MATERIALS AND METHODS: Fifty-two patients with 57 facial Mohs surgery defects appropriate for multilayer primary repair had the defects prospectively randomized into a side-by-side comparison. After closure of the deep layers with 5-0 poliglecaprone-25 sutures, half of the wound was closed with a 5-0 poliglecaprone-25 simple running suture, and the other half of the wound was closed with a 6-0 polypropylene simple running suture. The investigators blindly determined the cosmetically superior side of the closure at 1 week and 4 months after suture removal. RESULTS: Forty-four patients (48 total defects) completed the study. At the 4-month follow-up, 85% (41/48) did not show any difference between poliglecaprone-25 and polypropylene, 4% (2/48) had better outcomes with poliglecaprone-25, and 10% (5/48) had better outcomes with polypropylene. There was no statistically significant cosmetic difference between the two closure types. Wound complications such as infection, hematoma, and dehiscence did not occur in any of the patients. CONCLUSION: In primary closures of facial defects, using 5-0 poliglecaprone-25 or 6-0 polypropylene for the superficial closure did not affect the cosmetic result. Therefore, 5-0 poliglecaprone-25 provides a comparable and cost-effective alternative to nonabsorbable sutures for epidermal approximation in layered closures.

Mohs micrographic surgery for penile cancer: management and long-term followup.

PURPOSE: Mohs micrographic surgery is efficacious for the primary treatment and local recurrence control of nongenital and cutaneous squamous and basal cell cancers. The efficacy of this procedure for squamous cell carcinoma of the penis was reviewed. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients treated with Mohs micrographic surgery for penile cancer at our institution from 1988 to 2006. RESULTS: We identified 33 patients who underwent a total of 41 Mohs procedures. Average +/- SD lesion size was 509 +/- 699 mm(2). An average of 2.6 +/- 1.4 stages were done using Mohs micrographic surgery. Five procedures were terminated with positive margins, including 3 due to urethral involvement and 2 due to defect size. Of the tumors 26 were stage Tis, 4 were T1, 7 were T2 and 4 were T3. A total of 13 defects were reconstructed by primary repair or granulation, 4 were reconstructed by skin grafts and 25 were reconstructed by tissue flaps and urethroplasty. Followup data were available on 25 patients at a mean of 58 +/- 63 months. Eight patients (32%) had recurrence, which was managed by repeat Mohs micrographic surgery in 7 and by penectomy in 1. There were 2 cases of tumor progression, including 1 from T1 to T3 disease (meatal involvement) and 1 from T1 to inguinal lymph node involvement. Two patients died, of whom 1 had no evidence of penile cancer and 1 had metastatic disease. CONCLUSIONS: Mohs micrographic surgery for low stage penile cancer results in a relatively high local recurrence rate. However, with repeat procedures and vigilant followup cancer specific and overall survival rates are excellent and progression rates are low.