Basal cell carcinomas of the ear are more aggressive than on other head and neck locations.

BACKGROUND: On pathology review, basal cell carcinomas (BCCs) on the ear more commonly present as aggressive subtypes. It is unclear if this histologic observation translates into more clinically aggressive tumors. OBJECTIVE: We sought to determine the clinical aggressiveness of ear BCCs compared with BCCs elsewhere on the head and neck. METHODS: We conducted a retrospective chart review of all BCCs treated at an academic center from 2005 through 2012. Subjects were divided into ear and non-ear groups. Subtypes classified as "aggressive" included morpheaform, infiltrative, micronodular, adenoid, metatypical, and mixed histology. RESULTS: Of the 7732 head and neck BCCs, 758 (9.8%) were on the ear. Ear BCCs presented as larger lesions (1.28 vs 0.98 cm(2)), required more Mohs layers (16.5% vs 10.7%), and produced a larger final defect (4.29 vs 3.49 cm(2)) than non-ear lesions. When comparing only aggressive subtypes, ear BCCs also presented as larger lesions (1.42 vs 1.23 cm(2)), more frequently required 3 or more layers for clearance (22.3% vs 14.2%), and produced a larger final defect (4.92 vs 4.21 cm(2)) than non-ear lesions. LIMITATIONS: Limitations include single-center design and lack of long-term follow-up. CONCLUSION: Ear BCCs appear to exhibit greater subclinical extension compared with non-ear head and neck BCCs. Therefore, the ear should be considered a high-risk location for BCCs.

Panfollicular carcinoma or trichoblastic carcinoma with panfollicular differentiation?

Herein, we report two cases of a follicular neoplasm with panfollicular differentiation showing architectural and cytologic findings suggestive of a malignancy. Immunohistochemical analysis of ß-catenin expression in the neoplasm showed nuclear and cytoplasmic immunoreactivity, with no reactivity in the transitional and shadow cells, consistent with ß-catenin expression of pilomatrical tumors. Staining for BerEp4 was positive at the periphery of both neoplasms, suggesting germinative differentiation of the neoplastic cells, whereas staining for the follicular stem-cell marker PHLDA-1 (TDAG51) showed strong focal expression in the tumor cells of both cases. Given these findings, these neoplasms show features of both panfollicular neoplasms and basal cell carcinoma with panfollicular/matrical differentiation. These are the first cases of this neoplasm reported to date. More reports are needed to assess their malignant potential.

Safety of cosmetic dermatologic procedures during pregnancy.

BACKGROUND: Safety of cosmetic procedures in pregnant women has not been extensively studied. Maternal and fetal health risks are important to consider in any procedure performed. With the increasing popularity of cosmetic procedures, dermatologic surgeons will be faced with scenarios necessitating knowledge regarding the safety of such procedures during pregnancy. Furthermore, dermatologic surgeons may inadvertently perform cosmetic procedures during the first trimester, before the patient is aware of the pregnancy. OBJECTIVE: To investigate the safety of cosmetic procedures during pregnancy and the postpartum period. METHODS AND MATERIALS: A literature search of PubMed and Google Scholar was conducted of all English-language articles published from 1960 through 2012. RESULTS: Definitive recommendations on the safety of procedures such as chemical peels, injectables, fillers, and most laser therapies during pregnancy cannot be made. The safety of onabotulinum toxin usage is well documented in the neurology literature, although isolated events of miscarriage have been reported with high doses of toxin in women with a previous history of miscarriage. Carbon dioxide laser therapy for genital condylomas has considerable evidence supporting its safety during pregnancy. CONCLUSION: There is a lack of controlled trials addressing the safety of cosmetic procedures during pregnancy and postpartum periods. It is advisable to delay elective cosmetic procedures until after the baby is born.

Characteristics of basal cell carcinoma of the lip treated using Mohs micrographic surgery.

BACKGROUND: There is a lack of U.S-based studies on basal cell carcinoma (BCC) of the upper lip treated using Mohs micrographic surgery (MMS). OBJECTIVE: To explore characteristics of BCC of the upper lip treated using MMS. METHODS: We performed a chart review of BCC cases from 2005 to 2011. RESULTS: Two hundred eighty-one cases were identified. There was a slight female predominance (55%). Men had a larger initial (p < .01) and final (p = .03) defect size. Infiltrative tumors had larger initial (p < .01) and final areas (p < .01). Ten percent of tumors were designated recurrent after previous treatment. Recurrent lesions (p < .001) and older age (p = .03) were associated with larger initial size. Complex reconstruction was required: 44% by local flap or graft and 13% by plastic surgery. CONCLUSION: There was a 1.2:1 female to male ratio, in contrast to the previously reported female predominance of 3.5:1. This cohort showed a higher recurrence rate than reported in the literature. Men and elderly patients were also found to have significantly larger initial lesion size. Thirteen percent of patients required repair by plastic surgery, reflecting heightened levels of cosmetic concern. These findings suggest that MMS is important in delineating subclinical tumor spread and providing complex repairs.

Characteristics of squamous cell carcinoma in situ of the ear treated using Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is used to treat squamous cell carcinoma in situ (SCCIS) for tissue conservation. OBJECTIVE: To examine characteristics of patients with SCCIS of the external ear treated using MMS. METHODS: A retrospective review from 2005 to 2011. RESULTS: We identified 173 cases of SCCIS of the ear. The population was 94% male (p < .01), with a mean age of 71. Eight percent (n = 13) of tumors were recurrent after prior treatment. Recurrent tumors occurred exclusively in men and were associated with larger initial size (p = .05), more layers for clearance p = .059), and larger final defect size (p = .01). Tumors with larger initial area were independently associated with older age (p < .01). Complexity of repair was independently associated with more layers (p < .01), larger initial area (p = .01), and larger final area (p = .02). Sex did not affect repair type. CONCLUSION: SCCIS of the ear predominantly affects men in our referral base of 85% to 90% private patients and 10% to 15% veterans. Recurrent tumors were associated with larger initial size and subclinical spread of tumor. Primary tumors on average required 1.6 layers, validating the utility of MMS in this population in delineating the subclinical spread of SCCIS of the ear.

The operative management of melanoma: where does Mohs surgery fit in?

BACKGROUND: Melanoma is a life-threatening malignancy. Surgery is the primary management for melanoma, and management guidelines have evolved gradually over a century from radical surgery with lymph node dissection to conservative margin surgery. There are specific rationales and problems with Mohs micrographic (MMS) surgery for managing melanoma. OBJECTIVE: To review the literature for the surgical management of melanoma and to understand where MMS fits in this spectrum of management options. CONCLUSIONS: MMS should be considered as an option for melanoma surgery, especially when the tumor is found in photodamaged skin. Further randomized prospective clinical trials are needed to select the best therapeutic approach for the treatment of melanoma. Until then, careful margin control is the key for successful tumor removal whether it is standard excision, staged excision, or MMS.

Treatment of squamous cell carcinoma in situ: a review.

BACKGROUND: Squamous cell carcinoma in situ (SCCIS) is thought to be a precursor to squamous cell carcinoma. It should be treated before invasive cancer develops, especially in transplant recipients, who may develop more aggressive skin cancers. Treatment can involve surgical and nonsurgical methods. OBJECTIVE To review the evidence available in the English medical literature for different treatment options of SCCIS on nongenital skin and evaluate the efficacy of each option. METHODS AND MATERIALS: A Pubmed search of articles describing the treatment of SCCIS was conducted. Keywords were "treatment," "Bowen's disease," and "squamous cell carcinoma in situ." Articles describing the use of surgical excision, curettage and electrodesiccation, cryotherapy, 5-fluorouracil, imiquimod, radiation, photodynamic therapy, lasers, and rarer methods were reviewed. RESULTS: No single treatment can be said to be superior for any one situation. Most studies are small, limiting the power of each. Further studies are needed to clarify optimal treatment protocols for nonsurgical methods such as cryotherapy, photodynamic therapy, and topical chemotherapy. CONCLUSION: There are many methods available to treat SCCIS. Physicians should consider each patient's situation while keeping in mind that treatment protocols have not been fully defined for most options. The authors have indicated no significant interest with commercial supporters.

Preoperative methicillin-resistant Staphylococcus aureus screening in Mohs surgery appears to decrease postoperative infections.

BACKGROUND: Colonization with methicillin-resistant Staphylococcus aureus (MRSA) places patients at risk for postoperative MRSA wound infections. OBJECTIVE: To determine the effect of a decontamination and prophylaxis protocol on postoperative MRSA wound infections in patients with nasal MRSA. METHODS & MATERIALS: Wound cultures over a 23-month period were reviewed before and 11 months after implementation of a screening and decontamination protocol. After preoperative MRSA screening with nasal swabs, carriers were instructed to use intranasal mupirocin for 5 to 7 days before surgery and 5 to 7 days of trimethoprim-sulfamethoxazole starting the day before surgery. RESULTS: During the 23 months before prescreening evaluation, we performed 3,633 Mohs surgical cases, and 12 postoperative MRSA wound infections (0.3%) occurred. Subsequently, 963 patients underwent screening for MRSA, and 23 MRSA carriers were identified (2.4%). Of the 22 who underwent the decontamination and treatment protocol, none developed postoperative wound infections. One MRSA carrier did not receive preoperative treatment and subsequently developed a MRSA wound infection. There were no other MRSA infections. CONCLUSION: Preoperative MRSA screening and implementation of a decontamination protocol appears to decrease postoperative MRSA wound infections after Mohs surgery. Although an interesting observation, controlled studies of clinical and cost effectiveness are required before general implementation. The authors have indicated no significant interest with commercial supporters.

Multiple antithrombotic agents increase the risk of postoperative hemorrhage in dermatologic surgery.

BACKGROUND: Studies show that holding single antithrombotic agents perioperatively increases the risk of acute thrombotic events and does not significantly decrease the risk of bleeding complications in dermatological surgery. Recent data suggest that selected patients may benefit from combination therapy in preventing acute thrombotic events. OBJECTIVE: We sought to evaluate postoperative bleeding complications in patients who underwent Mohs micrographic surgery while using multiple agents perioperatively compared with patients using a single agent or none at all. METHODS: We conducted a retrospective chart review of patients treated in one academic Mohs micrographic surgery department during 1 year. RESULTS: Patients taking two or more agents at the time of surgery were more likely to bleed than those taking one agent or none at all (P = .0016, Fisher's exact). LIMITATIONS: Small sample size and retrospective nature were limitations. CONCLUSION: Perioperative use of more than one antithrombotic agent increases postoperative bleeding risk.

A meta-analysis of complications attributed to anticoagulation among patients following cutaneous surgery.

BACKGROUND: The frequency of postoperative bleeding and other complications in anticoagulated patients undergoing cutaneous surgery has not been firmly established and consensus on perioperative continuation of treatment is lacking. OBJECTIVE: The objective was to ascertain the risk of postoperative complications through meta-analysis of data pooled from previously published studies. METHODS: A PubMed search (1966-2005) was performed to identify controlled studies reporting bleeding and other complications among patients undergoing cutaneous surgery who were taking anticoagulant medications. Emphasis was placed on prescription anticoagulant medications (aspirin, NSAIDs, warfarin, clopidogrel) and over-the-counter herbal agents with anticoagulant properties. RESULTS: A total of six studies representing 1,373 patients met criteria for inclusion. Among patients taking aspirin or warfarin, 1.3 and 5.7% experienced a severe postoperative complication, respectively. Patients taking warfarin were nearly seven times as likely to have a moderate-to-severe complication compared to controls (OR, 6.69; 95% CI, 3.03-14.7), a statistically significant difference (p<.001). Patients taking aspirin or NSAIDs were more than twice as likely to have a moderate-to-severe complication compared to controls (OR, 2.0; 95% CI, 0.97-4.13), a strong trend toward statistical significance (p=.06). There were no studies in the literature that examined the effects of combination anticoagulant therapy or the effect of herbal agents on postoperative risk of bleeding. CONCLUSION: The results of this meta-analysis suggest that while low, the risk of bleeding among anticoagulated patients may be higher than baseline. Adequately powered prospective studies are required to more carefully delineate the risk of postoperative bleeding and other complications attributable to anticoagulation therapy. Particular emphasis should be placed on examining the effect of combination anticoagulant therapy as well as herbal agents with anticoagulant properties on risk of bleeding after cutaneous surgery.

Characteristics of Mohs practices in the United States: a recall survey of ACMS surgeons.

OBJECTIVE: The purpose of this study is to better characterize the typical Mohs practice in the United States and to generate data that may be useful in future practice models. METHODS: A survey was mailed in 2004 to all 599 members of the American College of Mohs Surgery with United States addresses listed in the 2003 directory. RESULTS: Most respondents were part of a single speciality group, in a suburban or urban setting, performed between 501-1,000 cases per year, and had been in practice from 0-5 years. The vast majority of Mohs excisions are for basal cell cancers and squamous cell cancers, followed by melanoma. Primary closure is the most common method of repair, followed by the use of flaps. Only 6% of cases were referred to other specialties for closure. Many surgeons augment their practice with non-Mohs cosmetic procedures. CONCLUSION: The characteristics of current Mohs surgery practices in the United States provides useful data for training programs, potential trainees, workforce issues, statistical modeling systems, and Mohs surgeons in the evaluation of their own practices.

Relationship of treatment delay with surgical defect size from keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma of the skin).

Larger keratinocyte carcinoma (KC) lesions are associated with higher morbidity. This study examined the association of potentially modifiable characteristics, including treatment delay, with KC defect size after Mohs micrographic surgery (MMS). A stratified random sample of patients treated for KC with MMS were selected for telephone interview. Two hundred and nineteen interviews were completed (refusal rate 24%). Regression models were used to examine the predictors to defect size and delay. Anatomic site, age, histology, and gender predicted defect size (R(2) = 0.39) and were used as control variables. Self-reported delay between initial physician examination and MMS predicted defect size (p = 0.0004), with greater than 1 y delay being associated with a doubling of defect size (adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.3-3.1). Delays of this duration were associated with initial examination by a primary provider (unadjusted OR 3.9; 95% CI 1.7-8.8), misdiagnosis (unadjusted OR 6.8; 95% CI 2.5-18.7), being treated without biopsy (unadjusted OR 23.3; 95% CI 6.5-83.7), and multiple surgical removals (unadjusted OR 6.2; 95% CI 2.5-15.5). All but provider specialty were independent predictors of delay. Attention to processes of care delivery for KC may have a greater impact on morbidity than efforts are earlier detection by the public.

Meningiomas after medulloblastoma irradiation treatment in a patient with basal cell nevus syndrome.

A 23-year-old woman with basal cell nevus syndrome (BCNS), or Gorlin's syndrome, was given the diagnosis at age 2 years of a medulloblastoma that was resected and treated postoperatively with craniospinal irradiation. Multiple basal cell carcinomas developed at the craniospinal irradiation port site 8 years later. She subsequently developed multiple meningiomas within the area of irradiation at age 20 years. This case reviews early presentation of BCNS, newly described differences between medulloblastomas in patients with BCNS and nonsyndromic medulloblastomas, and global assessment of patients by the treating dermatologist of this patient population. This is the first report in the dermatologic literature, to our knowledge, of radiation-induced meningiomas in a patient with BCNS.

Body dysmorphic disorder: a guide for primary care physicians.

Body dysmorphic disorder (BDD), a preoccupation with an imagined or slight defect in appearance, is a relatively common psychiatric disorder that often presents to nonpsychiatric physicians. Body dysmorphic disorder is associated with marked impairment in functioning, notably poor quality of life, and a high suicide attempt rate. Most patients seek and receive surgery or nonpsychiatric medical or dermatologic treatment, often with a perceived poor outcome despite an objectively acceptable result. In contrast, psychiatric treatment, serotonin-reuptake inhibitors and cognitive-behavioral therapy, often are effective. This clinically focused review describes the clinical features and prevalence of BDD, the disorder's treatment response, how to recognize and diagnose BDD, and practical suggestions for primary care physicians who encounter these often difficult-to-treat patients.

Endocrine mucin-producing sweat gland carcinoma.

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a rare, low-grade, cutaneous neoplasm that may be associated with invasive mucinous carcinoma. Tumors typically present as slow-growing, flesh-colored, nonspecific papules or nodules that favor the eyelids in older individuals. Histologic examination usually reveals basaloid nodules composed of cells with eosinophilic cytoplasm, with focal mucin production and occasional glandular structures. Definitive diagnosis requires immunohistochemical staining. Endocrine mucin-producing sweat gland carcinomas have been noted to stain positively with neuroendocrine markers such as synaptophysin and chromogranins as well as cytokeratin 7, cytokeratin CAM 5.2, epithelial membrane antigen, estrogen receptor, and progesterone receptor. Complete excision with close follow-up is important given EMPSGC's association with invasive mucinous carcinoma. Mohs micrographic surgery is an appropriate choice for treatment. We report 2 cases of EMPSGC presenting on the eyelids in a 72-year-old woman and a 74-year-old man.