Narrow excision margins are appropriate for Merkel cell carcinoma when combined with adjuvant radiation: Analysis of 188 cases of localized disease and proposed management algorithm.

BACKGROUND: Merkel cell carcinoma (MCC) management typically includes surgery with or without adjuvant radiation therapy (aRT). Major challenges include determining surgical margin size and whether aRT is indicated. OBJECTIVE: To assess the association of aRT, surgical margin size, and MCC local recurrence. METHODS: Analysis of 188 MCC cases presenting without clinical nodal involvement. RESULTS: aRT-treated patients tended to have higher-risk tumors (larger diameter, positive microscopic margins, immunosuppression) yet had fewer local recurrences (LRs) than patients treated with surgery only (1% vs 15%; P = .001). For patients who underwent surgery alone, 7 of 35 (20%) treated with narrow margins (defined as ≤1.0 cm) developed LR, whereas 0 of 13 patients treated with surgical margins greater than 1.0 cm developed LR (P = .049). For aRT-treated patients, local control was excellent regardless of surgical margin size; only 1% experienced recurrence in each group (1 of 70 with narrow margins ≤1 cm and 1 of 70 with margins >1 cm; P = .56). LIMITATIONS: This was a retrospective study. CONCLUSIONS: Among patients treated with aRT, local control was superb even if significant risk factors were present and margins were narrow. We propose an algorithm for managing primary MCC that integrates risk factors and optimizes local control while minimizing morbidity.

Summary and evidence grading of over-the-counter scar treatments.

BACKGROUND: Many products claiming to improve scar appearance are readily available on the Internet. Data behind these claims are often difficult to find or summarize. Patients often ask their surgeon for advice for scarring postdermatologic surgery. OBJECTIVE: We aim to review the evidence behind several advertised products and techniques that claim to improve postsurgical scarring. METHODS: A PubMed search was performed using products and methods claiming to improve scar appearance along with the terms "scar" and "scarring". RESULTS: Published literature on scar massage, taping of scars, silicone gel and sheeting, onion-based extract products, and vitamin E was reviewed. Silicone gel/sheeting as well as taping have the most evidence to help improve scarring, but even then the evidence is conflicting and weak. CONCLUSION: Online advertising may tempt patients to buy and trial products to help minimize scarring, although the evidence for the effectiveness of these products is absent to minimal. Dermatologists must be aware of these products to maintain effective patient counseling.

Review of Common Alternative Herbal "Remedies" for Skin Cancer.

BACKGROUND: Alternative herbal remedies for skin cancer are commonly found on the Internet. Many websites contain inaccurate or false information regarding side effects and efficacy. OBJECTIVE: To review the evidence behind several commonly advertised herbal remedies that claim to cure skin cancer: black salve, eggplant, frankincense, cannabis, black raspberry, milk thistle, St. John's wort, and turmeric. METHODS: A PubMed search was performed using the common and scientific names of frequently advertised herbal remedies along with the terms "nonmelanoma skin cancer," or "basal cell carcinoma" or "squamous cell carcinoma," or "melanoma." RESULTS: Some preclinical studies have shown positive evidence that these substances can induce apoptosis in skin cancer, but clinical studies proving efficacy are either insufficient, nonexistent, or show negative evidence. Botanicals that were excluded are those that do not have published studies of their efficacy as skin cancer treatments. CONCLUSION: Online advertising may tempt patients to use botanical agents while citing efficacy found in preclinical studies. However, many agents lack strong clinical evidence of efficacy. Dermatologists must be aware of common herbal alternatives for skin cancer treatment to maintain effective patient communication and education.

Fire Safety in Mohs Micrographic Surgery.

BACKGROUND: Surgical fire is a rare event, but one with potentially devastating patient outcomes. OBJECTIVE: This study was conducted to investigate the incidence, risk factors, and outcome of surgical fires experienced by members of the American College of Mohs Surgeons (ACMS). METHODS: An internet survey was developed and sent to ACMS members. Data collected included total years of experience, total number of cases, typical management of supplemental oxygen, and surgical fires experienced. RESULTS: Eighty participants contributed data on 886,200 cases of MMS. Nine surgeons (11%) reported at least 1 surgical fire, yielding an estimated incidence of 1 fire per 88,620 cases (0.001%). The most common site of involvement was the scalp (67%). Common ignition sources included monopolar electrosurgical devices (78%) and battery-powered thermal cautery (22%). Fuel sources included towels or drapes, gauze, isopropyl alcohol, aluminum chloride, hairspray, and diethyl ether. Supplemental oxygen was not involved in any of the cases. Five patients suffered singed hair while 4 patients did not suffer any injuries. None suffered any permanent functional or aesthetic deformities. CONCLUSION: The overall risk of surgical fire in MMS is minimal. However, safety measures and greater awareness of fire risks are necessary to prevent patient harm.

Eye Protection: Survey of Dermatologists and Office Staff.

BACKGROUND: Splash injuries to mucosal membranes during procedures have been well documented in dermatology and carry a potential risk of blood-borne virus transmission. The risk to the ocular mucosa can be minimized with proper eye protection. OBJECTIVE: To examine the prevalence of wearing eye protection during dermatologic procedures by physicians, trainees, and office staff in dermatology. METHODS: A Cross-sectional observational study of US dermatologists, residents, nurses, and medical assistants was performed regarding eye protection during dermatologic procedures. RESULTS: The rates of wearing eye protection in every dermatologic procedure are as follows: dermatologists 42.3%, residents/fellows 39.6%, and nurses/medical assistants 25%. Ninety-eight percent of respondents thought blood-borne illnesses could be transmitted by splash injury. The rates of having splash injury during your career are as follows: dermatologists 73.1%, residents/fellows 16.7%, and nurses/medical assistants 50%. The rates of having a splash injury within the last year are as follows: dermatologists 11.5%, residents/fellows 8.3%, and nurses/medical assistants 35.7%. CONCLUSION: The use of eye protection is an important component of the personal protective equipment to help prevent transmission of blood-borne illnesses. Dermatologists and staff should strive to increase awareness and the use of face masks with eye shields or face mask with separate eye protection in every dermatologic procedure.

Patients' Experiences With Extramammary Paget Disease: An Online Pilot Study Querying a Patient Support Group.

OBJECTIVE: To illustrate the heterogeneous care delivered to patients with extramammary Paget disease (EMPD), a rare and lethal malignancy with poorly described treatment methodologies, by characterizing the clinical and pathologic characteristics of an international patient support group. MATERIALS AND METHODS: Institutional review board approval was obtained to develop and distribute a nonvalidated survey to patients from an international, online EMPD support group. The survey was developed to capture patient clinical and pathologic details and was distributed between January 2017 and February 2017. RESULTS: Forty-two patients completed the survey. At a mean age of 64 years, patients most commonly developed rash, pruritus, or erythema in the genital and perianal regions. Patients presented to their primary care physician, gynecologist, or dermatologist and were initially treated with topical agents for benign diagnoses. After failing conservative treatments, patients underwent biopsy by a dermatologist or gynecologist and were diagnosed with EMPD on average 21 months after the onset of symptoms. Wide local and Mohs excisions were the most frequently administered treatments with positive margins reported in 43% of patients. Fewer patients underwent noninvasive treatment with imiquimod cream and radiation. In total, 29% of patients developed regional recurrence and distant disease. There was wide variation regarding medical specialties involved, diagnostic evaluation, treatment, and clinical follow-up. CONCLUSION: This study provides a novel view of the varied clinical and pathologic details from patients treated across varying institutions and medical specialties. This study will hopefully educate providers of the overall disease process of EMPD and encourage the development of standardized treatment recommendations.

Dermatologic Surgical Instruments: A History and Review.

BACKGROUND: Dermatologic surgery requires precision and accuracy given the delicate nature of procedures performed. The use of the most appropriate instrument for each action helps optimize both functionality and cosmetic outcome. OBJECTIVE: To review the history of surgical instruments used in dermatology, with a focus on mechanism and evolution to the instruments that are used in current practice. MATERIALS AND METHODS: A comprehensive literature search was conducted via textbook and journal research for historic references while review of current references was conducted online using multiple search engines and PubMed. RESULTS: There are a number of articles that review instruments in dermatology, but this article adds a unique perspective in classifying their evolution, while also presenting them as levers that serve to increase human dexterity during the course of surgery. CONCLUSION: Surgical instruments allow fine manipulation of tissue, which in turn produces optimal outcomes. Surgical tools have been around since the dawn of man, and their evolution parallels the extent to which human civilization has specialized over time. This article describes the evolution of instruments from the general surgical armamentaria to the specialized tools that are used today.