MMS hotspots: a cross-sectional comparison of U.S. counties with and without Mohs micrographic surgery.

Healthcare access greatly impacts skin cancer diagnosis and mortality rates. Recognition of current disparities in Mohs micrographic surgery (MMS) access can assist future policy and clinical decisions to correct them. For the years 2014-2018, the CPT codes for MMS (17,311 and 17,313) were counted on a per county level across the United States per the Medicare Centers for Medicare & Medicaid Services (CMS) Medicare Prescriber Database. Any county with 0 MMS CPT codes recorded were classified as "without MMS cases." MMS "hotspots" were identified as counties that possessed a high average number of MMS cases compared to the national average, while also being surrounded by counties that possessed a low average number of MMS cases compared to the national average. Three thousand eighty-four counties in the United States were analyzed; 785 (25%) counties were designated as "with MMS cases" and 2301 (75%) "without MMS cases." There were no significant differences in age, ethnicity distribution, or cost per enrollee between the two designations. 74% of counties with MMS cases were considered urban, while only 25% of those without cases were urban (p < 0.01). The median household income was markedly higher in counties with MMS cases ($71,428 vs. $58,913, p < 0.01). With respect to education, more individuals in counties with MMS cases possessed their General Education Development (GED) (89% vs. 86%, p < 0.01) or a college degree (30% vs. 19%, p < 0.01). Forty-nine counties were considered MMS "hotspots." The density of MMS procedures varies greatly based on geography, maintaining the urban-rural disparity matched by the distribution of MMS surgeons. Additionally, there remains a wide income and educational gap between counties with and without MMS. Identifying MMS hotspots may facilitate further investigation into potential surgical access disparities.

The Role of Skin Substitutes in Dermatologic Surgery: A Practical Review.

BACKGROUND: The number of skin substitutes (SS) available for wound care management has increased markedly in the last few decades. This presents a challenge as dermatologists attempt to determine the appropriate setting for a skin substitute use. OBJECTIVE: This is a practical review of SS used in dermatologic surgery to assist clinicians in their selection of SS by providing information about the efficacy, risk, availability, shelf-life, and relative cost of the available options. METHODS AND MATERIALS: Relevant data were identified through a search of PubMed, a manual search of relevant company websites, a manual search of the reference sections of relevant papers, and communicating with subject experts. RESULTS: SS can be divided into 7 categories based on composition: amnion, cultured epithelial autograft, acellular allograft, cellular allografts, xenografts, composites, and synthetics. These groups offer unique benefits and disadvantages that are outlined in the manuscript and tables. CONCLUSION: Considerations of the characteristics, settings of use, and efficacies of SS may allow more effective wound care and the potential for faster healing times. Additional studies are needed to evaluate and compare the healing benefits of these substitutes. Trials comparing the efficacy of each of the common SS vs each other and granulation are needed. J Drugs Dermatol. 2023;22(5): doi:10.36849/JDD.7132.

Focused update: Guidelines of care for the management of actinic keratosis.

BACKGROUND: Actinic keratoses (AKs) are rough scaly patches that arise on chronically UV-exposed skin and can progress to keratinocyte carcinoma. OBJECTIVE: In 2021, the American Academy of Dermatology published guidelines to assist in clinical decision-making for the management of AK. The purpose of this focused guideline update is to incorporate recently available evidence on the use of topical tirbanibulin to treat AK. METHODS: A multidisciplinary work group conducted a systematic review to evaluate data on the use of tirbanibulin for AK and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of the evidence and formulating and grading a clinical recommendation. The graded recommendation was voted on to achieve consensus. RESULTS: Two trials were identified, and analysis of the evidence resulted in 1 recommendation. LIMITATIONS: This analysis is based on the best available evidence at the time it was conducted. Long-term efficacy and safety data are not currently available. CONCLUSIONS: A strong recommendation for the use of topical tirbanibulin to join the currently recommended list of topical therapies for AK was made on the basis of the available evidence.

Electrosurgery Use During Post-Mohs Micrographic Surgery Repair and Complication Rates-How Important is a Dry Field?

BACKGROUND: Electrosurgery is used to achieve hemostasis during surgery. There are no studies exploring the effects of the use or avoidance of electrodessication during Mohs micrographic surgery (MMS) repair. Given the growing concerns for tissue aerosolization, occupational smoke exposure, and spread of infectious diseases, it is important to determine the importance of electrical hemostasis. MATERIALS AND METHODS: In this retrospective study, electronic medical records of a single, tertiary, academic dermatology practice were reviewed. All MMS cases that underwent surgical repair from January 1 to December 31, 2019, by 2 dermatologic surgeons (one who used electrodessication during repair and one who did not) were included. Patient demographic data, information regarding the procedures, and complications occurring 90 days after MMS were recorded. RESULTS: One hundred ninety-eight cases of MMS repair used electrodessication, whereas 193 cases did not. There was no significant difference in the demographic makeup, MMS procedure, or 90-day complication rates between the 2 groups. No major adverse events were MMS-related. CONCLUSION: The use or avoidance of electrodessication during MMS repair was not associated with increased 90-day postoperative complications, suggesting that a greater tolerance of moderate oozing at a surgical site during MMS repair is reasonable to minimize electrosurgical tissue damage and occupational smoke exposure.

The Use of Chlorhexidine as a Skin Preparation on the Head and Neck: A Systematic Review of Ocular and Ototoxicity.

BACKGROUND: Chlorhexidine gluconate is one of the most effective surgical preparations, but it has known potential ocular and ototoxicity. OBJECTIVE: To review reported cases of ocular and ototoxicity caused by chlorhexidine and summarize the clinical situations in which chlorhexidine toxicity occurred. METHODS: We performed a systematic review of PubMed and the Web of Science. RESULTS: Fourteen cases reported sensorineural hearing loss from chlorhexidine instilled into the ear. Of the 38 cases of ocular toxicity, 8 cases were caused by direct instillation in the eye and 17 involved periocular surgical preparation. In the remaining cases, the area prepped was less defined. Seven cases involved preparation of the face, 1 for the scalp, 2 cases were drips from distant sites, and 3 cases did not specify the means of exposure. CONCLUSION: The vast majority of toxicity occurred in patients undergoing general anesthesia and was rarely seen in situations where surgery was performed by dermatologists. Ultimately, it should be up to the individual physician to decide whether chlorhexidine is the best choice for a particular outpatient procedure.

The readability of online patient information about laser resurfacing therapy.

Because there are important distinctions between ablative and non-ablative laser resurfacing, accurate and effective patient education is paramount. However, as more patients use the internet as a resource for medical information, little is known about the content and readability of these sources. Thus, we sought to evaluate the readability of major online resources about laser resurfacing while recognizing the recommendations by the American Medical Association and National Institutes of Health. An internet search for the term "Laser Resurfacing" was performed. The first 9 results were identified, patient information from each of these 9 sites were downloaded, and a total of 25 articles were examined. Readability was analyzed using 7 different established tests. Analysis demonstrated an average grade level of at least 9th grade, with all articles exceeding the recommended 6th grade reading level, emphasizing that these resources are too challenging for many patients to read and comprehend. Such materials may hamper appropriate decision-making in patients considering the use of a laser for their dermatologic conditions. The potential detrimental effect on the opinion, participation, and satisfaction of laser resurfacing should spur dermatologists to be more critical of online patient materials and motivated to produce more appropriate resources.

Use of 5-Aminolevulinic Acid and Daylight Photodynamic Therapy for the Treatment of Actinic Keratoses.

BACKGROUND: Photodynamic therapy (PDT) is an effective modality for the treatment of actinic keratoses (AKs). The use of methyl aminolevulinate with daylight PDT (D-PDT) has quickly gained popularity internationally because of its tolerability and high levels of safety and efficacy. However, there is a paucity of studies on the use of D-PDT with 5-aminolevulinic acid (ALA). OBJECTIVE: To study the safety and efficacy of D-PDT in treating AKs on the face and scalp using ALA. MATERIALS AND METHODS: Thirty patients were recruited for this prospective, uncontrolled study. Patients were treated with topical ALA on either the scalp or face, incubated for 30 minutes, and then sat at home in a shady area for 2 hours. Weather conditions, lux measurements, and AK counts at 3 and 6 months were measured. RESULTS: Daylight PDT led to a median of 75% reduction in AK count at 6 months, with no significant adverse effects. Ninety-six percentage of patients were either moderately or very satisfied with the treatment, and the median peak pain score during treatment was 1. There was no correlation between weather or average lux received during treatment and 6-month outcomes. CONCLUSION: Daylight PDT with ALA is a safe and effective treatment modality for AKs on the head.

Pruritus in the older patient: a clinical review.

IMPORTANCE: Pruritus is a common problem among elderly people and, when severe, causes as much discomfort as chronic pain. Little evidence supports pruritus treatment, limiting therapeutic possibilities and resulting in challenging management problems. OBJECTIVES: To present the evidence on the etiology, diagnosis, and treatment of pruritus in the elderly and, using the best available evidence, provide an approach for generalist physicians caring for older patients with pruritus. EVIDENCE REVIEW: PubMed and EMBASE databases were searched (1946-August 2013).The Cochrane Database of Systematic Reviews and the Agency for Healthcare Research and Quality Systematic Review Data Repository were also searched from their inception to August 2013. References from retrieved articles were evaluated. FINDINGS: More than 50% of elderly patients have xerosis (dry skin). Xerosis treatment should be included in the initial therapy for pruritus in all elderly patients. Calcium channel blockers and hydrochlorothiazide are important causes of pruritic skin eruptions in older patients. Neuropathic pruritus is infrequently considered but may cause localized itching (especially in the genital area) and generalized truncal pruritus (especially in patients with diabetes mellitus). Certain skin conditions are more common in elderly patients, including scabies, bullous pemphigoid, transient acantholytic dermatosis, and mycosis fungoides, and should be considered in elderly patients with pruritus. CONCLUSIONS AND RELEVANCE: It is important to evaluate elderly patients for dermatological, systemic, and neurological etiologies of itch. A simple-to-apply diagnostic and therapeutic algorithm can be used. Xerosis, drug reactions, and neuropathy should be considered when evaluating pruritus.

Indoor tanning and non-melanoma skin cancer: systematic review and meta-analysis.

OBJECTIVE: To synthesise the literature on indoor tanning and non-melanoma skin cancer. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed (1966 to present), Embase (1974 to present), and Web of Science (1898 to present). STUDY SELECTION: All articles that reported an original effect statistic for indoor tanning and non-melanoma skin cancer were included. Articles that presented no data, such as review articles and editorials, were excluded, as were articles in languages other than English. DATA EXTRACTION: Two investigators independently extracted data. Random effects meta-analysis was used to summarise the relative risk of ever use versus never use of indoor tanning. Dose-response effects and exposure to indoor tanning during early life were also examined. The population attributable risk fraction for the United States population was calculated. RESULTS: 12 studies with 9328 cases of non-melanoma skin cancer were included. Among people who reported ever using indoor tanning compared with those who never used indoor tanning, the summary relative risk for squamous cell carcinoma was 1.67 (95% confidence interval 1.29 to 2.17) and that for basal cell carcinoma was 1.29 (1.08 to 1.53). No significant heterogeneity existed between studies. The population attributable risk fraction for the United States was estimated to be 8.2% for squamous cell carcinoma and 3.7% for basal cell carcinoma. This corresponds to more than 170 000 cases of non-melanoma skin cancer each year attributable to indoor tanning. On the basis of data from three studies, use of indoor tanning before age 25 was more strongly associated with both squamous cell carcinoma (relative risk 2.02, 0.70 to 5.86) and basal cell carcinoma (1.40, 1.29 to 1.52). CONCLUSIONS: Indoor tanning is associated with a significantly increased risk of both basal and squamous cell skin cancer. The risk is higher with use in early life (<25 years). This modifiable risk factor may account for hundreds of thousands of cases of non-melanoma skin cancer each year in the United States alone and many more worldwide. These findings contribute to the growing body of evidence on the harms of indoor tanning and support public health campaigns and regulation to reduce exposure to this carcinogen.

Ureteral fibroepithelial polyp causing urinary obstruction.

Ureteral polyps are rare causes of ureteropelvic junction (UPJ) obstruction, particularly in children. We report a nine year-old boy with UPJ obstruction initially suggestive of an obstructive urinary stone. CT showed intraureteral calcification at the UPJ and hydronephrosis. A retrograde pyelogram showed narrowing at the UPJ and partial obstruction that was found to be a ureteral polyp. This case illustrates a rare cause of UPJ obstruction that should be considered when the imaging findings and presentation are atypical for more common etiologies of ureteral obstruction.