How dermatologic surgeons decide to proceed with surgery for nonmelanoma skin cancer when site identification is initially uncertain: A nationwide, multicenter, prospective study.

BACKGROUND: Few studies show how dermatologic surgeons manage problems with site identification. OBJECTIVE: To estimate frequency and characterize management of skin cancer treated by surgery when the anatomic location of the tumor is in question. METHODS: Nationwide, prospective, multisite cohort study. RESULTS: Among 17,076 cases at 22 centers, 98 (0.60%) were lesions in question for which site identification was initially uncertain, with these more often in patients who were male, older, and biopsied more than 30 days ago. Surgeons employed on average 5.0 (95% CI: 4.61-5.39) additional techniques to confirm the site location, with common approaches including: re-checking available documentation (90 lesions, 92%); performing an expanded physical examination (89 lesions, 91%); and asking the patient to point using a mirror (61 lesions, 62%). In 15%, photographs were requested from the biopsying provider, and also in 15%, frozen section biopsies were obtained. In 10%, the referring physician was contacted. Eventually, surgeons succeeded in definitively identifying 82% (80 of 98) of initially uncertain sites, with the remaining 18% (18 of 98) postponed. Most postponed surgeries were at non-facial sites. LIMITATIONS: Sites were academic centers. CONCLUSIONS: When the anatomic location of the tumor is uncertain, dermatologic surgeons use multiple methods to identify the site, and sometimes cases are postponed.

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.

Managing sharps injuries and other occupational exposures to HIV, HBV, and HCV in the dermatology office.

Dermatologists and their staff are at risk for needlestick injuries and exposures to body fluids. Despite the availability of treatment to reduce the risk of blood-borne infection, many exposures go unreported. This paper identifies current recommendations and the specific details for response to occupational exposures to HIV, hepatitis B virus, and hepatitis C virus in the dermatology office. Issues surrounding each virus are discussed individually, and a summary step-by-step algorithm of how to proceed in the event of an occupational exposure is presented. In addition, a focused Practice Improvement Activity that is based on this paper and provides Maintenance of Certification credit has been developed. To view and participate, visit https://secure.dataharborsolutions.com/abdermorg/.

Skin biopsy: Biopsy issues in specific diseases.

Misdiagnosis may result from biopsy site selection, technique, or choice of transport media. Important potential sources of error include false-negative direct immunofluorescence results based on poor site selection, uninformative biopsy specimens based on both site selection and technique, and spurious interpretations of pigmented lesions and nonmelanoma skin cancer based on biopsy technique. Part I of this 2-part continuing medical education article addresses common pitfalls involving site selection and biopsy technique in the diagnosis of bullous diseases, vasculitis, panniculitis, connective tissue diseases, drug eruptions, graft-versus-host disease, staphylococcal scalded skin syndrome, hair disorders, and neoplastic disorders. Understanding these potential pitfalls can result in improved diagnostic yield and patient outcomes.

Skin biopsy: Identifying and overcoming errors in the skin biopsy pathway.

The skin biopsy pathway involves numerous communication requirements, technical events, human handoffs, and cognitive decisions. Every step in the process has an error rate >0. To deliver the highest quality care, dermatologists obtaining skin biopsy specimens should implement systems in their office to minimize errors. This includes the prevention of wrong-site surgery, which in most instances involves accurate communication of the correct biopsy location to the performing surgeon. Part II of this continuing medical education article presents techniques for assessing and planning improvement to the skin biopsy pathway in your office, and provides a simple online quality improvement activity that allows Board-certified dermatologists the opportunity to potentially improve aspects of the skin biopsy process in their own practices, and in the process obtain Maintenance of Certification credit.

Therapeutic options to decrease actinic keratosis and squamous cell carcinoma incidence and progression in solid organ transplant recipients: a practical approach.

BACKGROUND: Solid organ transplant recipients (SOTRs) have a 50 to 250 times greater risk of squamous cell carcinoma (SCC) than the general population and experience higher rates of invasive and metastatic disease. These greater risks are a product of the tumorigenic effects of their immunosuppressive medications. As the number of transplantations and the life expectancy of SOTRs increase, SCCs are becoming a major source of morbidity and mortality. OBJECTIVE: To present a practical approach for busy practicing clinicians to the care of SOTRs who are developing SCCs. Topics include assessment and treatment of new and neglected SOTRs; the dermatologist's role with the transplantation team; and practical considerations in the choice of topical agents, systemic agents, and immunosuppressive therapy manipulation. METHODS AND MATERIALS: An extensive literature search of the understanding of SCC pathophysiology and treatment in SOTRs was conducted. RESULTS: Presented here is a logical, concise guide to the care of SOTRs who are developing actinic keratoses and SCCs. CONCLUSION: Proper assessment of patients, understanding therapeutic alternatives and their application, and early institution of preventative and adjuvant therapies can help to decrease skin cancer-related morbidity and mortality in SOTRs.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Interpreting epithelial cancer biology in the context of stem cells: tumor properties and therapeutic implications.

Over 90% of all human neoplasia is derived from epithelia. Significant progress has been made in the identification of stem cells of many epithelia. In general, epithelial stem cells lack differentiation markers, have superior in vivo and in vitro proliferative potential, form clusters in association with a specialized mesenchymal environment (the 'niche'), are located in well-protected and nourished sites, and are slow-cycling and thus can be experimentally identified as 'label-retaining cells'. Stem cells may divide symmetrically giving rise to two identical stem cell progeny. Any stem cells in the niche, which defines the size of the stem cell pool, may be randomly expelled from the niche due to population pressure (the stochastic model). Alternatively, a stem cell may divide asymmetrically yielding one stem cell and one non-stem cell that is destined to exit from the stem cell niche (asymmetric division model). Stem cells separated from their niche lose their stemness, although such a loss may be reversible, becoming 'transit-amplifying cells' that are rapidly proliferating but have a more limited proliferative potential, and can give rise to terminally differentiated cells. The identification of the stem cell subpopulation in a normal epithelium leads to a better understanding of many previously enigmatic properties of an epithelium including the preferential sites of carcinoma formation, as exemplified by the almost exclusive association of corneal epithelial carcinoma with the limbus, the corneal epithelial stem cell zone. Being long-term residents in an epithelium, stem cells are uniquely susceptible to the accumulation of multiple, oncogenic changes giving rise to tumors. The application of the stem cell concept can explain many important carcinoma features including the clonal origin and heterogeneity of tumors, the occasional formation of tumors from the transit amplifying cells or progenitor cells, the formation of precancerous 'patches' and 'fields', the mesenchymal influence on carcinoma formation and behavior, and the plasticity of tumor cells. While the concept of cancer stem cells is extremely useful and it is generally assumed that such cells are derived from normal stem cells, more work is needed to identify and characterize epithelial cancer stem cells, to address their precise relationship with normal stem cells, to study their markers and their proliferative and differentiation properties and to design new therapies that can overcome their unusual resistance to chemotherapy and other conventional tumor modalities.

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.

Mohs surgery for melanoma in situ.

Mohs micrographic surgery is a valuable option for the treatment of melanoma in situ, especially lesions of the lentigo maligna subtype that are clinically ill defined. Complete peripheral margin assessment of a tumor's borders by means of frozen or permanent sections can help reduce the surgical defect size and maximize cure rate as compared with standard excision with preset 5-mm margins. This article reviews the different variations of Mohs micrographic surgery that are currently used for melanoma in situ.

Treatment options in melanoma in situ: topical and radiation therapy, excision and Mohs surgery.

BACKGROUND: The treatment of melanoma in situ (MIS), particularly the lentigo maligna (LM) subtype, has been a controversial subject in the literature for over a decade. Surgical excision with 5 mm margins is the standard of care in the USA, while several variations of Mohs surgery are frequently used to treat clinically ill-defined lesions. Radiation is much less frequently used. Topical imiquimod has also been more recently proposed, in small case reports in the literature, as a therapy for MIS. However, controversies exist with all approaches. OBJECTIVE: To review the current literature regarding topical imiquimod, radiation therapy, surgical excision, and the various forms of Mohs surgery for MIS, focusing on the LM subtype. METHODS: A literature search was performed in the PubMed database using the following terms: "melanoma in situ,""lentigo maligna,""excisional surgery,""Mohs micrographic surgery,""radiation therapy," and "imiquimod." Articles relevant to the treatment of MIS were reviewed and reported herein. RESULTS: Studies of imiquimod therapy for MIS are hampered by small study numbers and short follow-up periods. The few, better-designed studies reveal relatively low cure rates. In addition, literature review reveals that a significant percentage of cases of MIS that are initially diagnosed as in situ disease by biopsy subsequently prove to have an invasive component upon complete excision. This finding suggests that topical therapy of any kind may be problematic. Studies of radiation therapy for MIS have relatively small numbers of patients and short follow-up. Multiple studies of excisional surgery have shown that 5 mm margins are often insufficient to clear the LM subtype of MIS due to unseen subclinical extension, accounting for this treatment's reported 8-20% recurrence rate. Finally, a number of variants of traditional frozen section Mohs surgery have been utilized to try and achieve complete peripheral margin assessment of clinically ill-defined LM lesions. All studies are retrospective, and most are single-institution and frequently single-operator, limiting the meaningfulness of their results. Nevertheless, they involve moderate numbers of patients, and many have at least a five year follow-up. Collectively, they suggest recurrence rates in the range of 0.5-3.0%. CONCLUSION: Topical imiquimod therapy appears to provide relatively low cure rates for MIS, and because some of these lesions contain an unrecognized invasive component, should be used with extreme caution to treat this disease. Radiation therapy may be a useful second-line therapy if surgery is contraindicated. Excisional surgery is an appropriate therapy for clinically well-defined MIS; however, margins larger than 5 mm may be required when treating larger or indistinct lesions. Finally, for clinically ill-defined LM arising on sun-damaged skin, especially in regions of aesthetic concern, some form of complete peripheral margin assessment - one of the various forms of Mohs surgery - may provide the highest cure rate and create the smallest surgical defect.

Nonmelanoma skin cancer.

This article provides readers with a comprehensive review of the evaluation and management of nonmelanoma skin cancers. Treatment recommendations are heavily based on the most recent guidelines from the National Comprehensive Cancer Network. Merkel cell carcinoma and dermatofibrosarcoma protuberans are also discussed. After reviewing this article, readers should be equipped with a better understanding of these entities and the current recommendations for their management.