5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study.

BACKGROUND: Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE: To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS: The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS: A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION: The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.

Timeline: The Evolution of Fellowship Training in Micrographic Surgery and Dermatologic Oncology.

The Accreditation Council for Graduate Medical Education (ACGME) granted accreditation to the first 5 Procedural Dermatology Fellowship Training Programs in 2004. The name of the training program was changed from Procedural Dermatology to Micrographic Surgery and Dermatologic Oncology by the ACGME/Residency Review Committee for Dermatology in 2014. The American Board of Dermatology/American Board of Medical Specialties conducted the first certification examination in Micrographic Dermatology Surgery in October 2021. This article chronicles the history and development of the subspecialty. J Drugs Dermatol. 2022;21(8):861-863.: doi:10.36849/JDD.6933.

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.

Incidence of Epinephrine Reactions With Local Anesthesia in Mohs Micrographic Surgery.

BACKGROUND: The incidence of reactions to epinephrine-containing local anesthetics in Mohs micrographic surgery (MMS) has not been established. OBJECTIVE: To estimate the incidence of epinephrine-induced reactions from local anesthetics in patients who undergo MMS for the removal of cutaneous malignancies. METHODS: From 2016 to 2018, 200 MMS patients were recruited from the authors' surgical center. Assessments were obtained throughout the entirety of the Mohs cases during a single visit. RESULTS: This study estimated the incidence of epinephrine reactions in patients who undergo MMS to be 2.0% (95% confidence interval: 0.1%-3.9%). No relationship between epinephrine dose and incidence of adverse effects was found. Patient age was a significant risk factor for the development of an epinephrine reaction. CONCLUSION: Systemic reactions to epinephrine from local anesthetics are an infrequent adverse event in MMS cases. The data suggest that the absolute dose of local anesthetic with epinephrine does not correlate with the risk of developing an epinephrine reaction. Older age seems to have a protective effect.

Expert Opinion Regarding Appropriately Timing Dermatological Surgeries in Patients With Recent Myocardial Infarctions.

BACKGROUND: There is limited data on the risk of perioperative myocardial infarctions (MIs) in patients with a recent MI who undergo dermatologic surgeries. OBJECTIVE: Present the recommendations of dermatologic surgeons and cardiologists to determine the safety of dermatologic surgeries after a recent MI. METHODS: An electronic survey was distributed to Mohs surgeons and cardiologists to infer the risk of major adverse cardiac events (MACE) inherent to dermatologic surgery and determine timing of dermatologic surgery in patients with a recent MI. RESULTS: One hundred twenty Mohs surgeons and 30 cardiologists were surveyed. Ninety-seven percent of cardiologists and 87% of Mohs surgeons deemed cutaneous excisions and Mohs micrographic surgery as low-risk procedures with less than one-percent chance of MACE. Seventy-seven percent of cardiologists and 46% of Mohs surgeons stated dermatologic surgery should either not be delayed or be delayed up to 1 month after an MI. Responses between cardiologists and Mohs surgeons did not significantly differ. CONCLUSION: A preponderance of surveyed experts believe that most dermatologic surgeries may be safely performed in patients with a history of an MI within 1 month. The decision to implement urgent dermatologic surgery in patients with a recent MI should account for all clinically significant factors.

Nodal staging of high-risk cutaneous squamous cell carcinoma.

BACKGROUND: While progress has been made in defining the clinical and histopathologic features of high-risk cutaneous squamous cell carcinoma (HRcSCC), optimal staging guidelines remain elusive. OBJECTIVE: We seek to guide clinical practice regarding nodal staging options for patients with HRcSCC via review of evolving definitions of HRcSCC, nodal staging options, and how nodal staging may impact treatment and affect outcomes. METHODS: This was a retrospective review of the published peer-reviewed literature regarding risk stratification, nodal staging, and treatment and outcomes for patients with HRcSCC via PubMed. RESULTS: For patients without clinical lymphadenopathy, based on literature from head and neck SCC, preoperative nodal staging with ultrasonography may be more useful than computed tomography or magnetic resonance imaging. Early nodal disease is usually curable, and therefore obtaining a sentinel lymph node biopsy specimen may be considered in those with negative imaging while we await studies of nodal staging outcomes. LIMITATIONS: More data are needed to validate the relationships between primary tumor stage and sentinel lymph node biopsy status and to determine if early detection of nodal disease impacts survival for patients with HRcSCC. CONCLUSION: It is reasonable to consider nodal staging for patients with HRcSCC (Brigham and Women's Hospital stage T2b and T3) in the absence of clinically palpable lymphadenopathy via radiographic imaging and, if negative, sentinel lymph node biopsy.

Pulsed dye laser repurposed: Treatment of refractory molluscum contagiosum in renal transplant patient.

We present a case of a 15-year-old girl with an allogenic renal transplant secondary to chronic glomerulonephritis of unknown etiology who presented with treatment refractory molluscum contagiosum of the lower extremities and perineum. Treatment of mollusca with pulsed dye laser resulted in a clinically significant and sustained response. To our knowledge, this is the first report of a successful treatment of molluscum contagiosum with pulsed dye laser in the setting of a renal transplant.

Hooked on Hooks? A Study in the Utilization of Skin Hooks.

BACKGROUND: The skin hook is a valuable instrument used in the practice of dermatologic surgery. However, because of numerous factors, the degree of its use varies extensively. OBJECTIVE: The purpose of this study was to examine practice trends among dermatologic surgeons regarding the use of skin hooks, as well as analyze factors influencing their use. METHODS: A survey comprising 14 questions was distributed to members of the American College of Mohs Surgery and the American Society for Dermatologic Surgery. Results were recorded, and statistical analysis was conducted using the 2-sample z-test to compare 2 population proportions. RESULTS: Five hundred seventy-one responses were received, with comments. 85.1% of respondents reported using skin hooks. Their use was further characterized as minimal (20.7%), moderate (29.0%), and extensive (35.4%). The utilization of skin hooks was additionally categorized based on age, gender, fellowship training, number of years in practice, practice setting, and history of experience/observance of a sharps exposure. Only the presence or absence of fellowship training demonstrated a statistically significant difference in the use of skin hooks. CONCLUSION: Skin hooks are highly used tools among dermatologic surgeons. Their use requires appropriate training and experience, and care must be taken to minimize risk of exposure.

LN2, CD10, and Ezrin Do Not Distinguish Between Atypical Fibroxanthoma and Undifferentiated Pleomorphic Sarcoma or Predict Clinical Outcome.

BACKGROUND: Atypical fibroxanthoma (AFX) is a rare cutaneous spindled cell neoplasm. For both diagnostic and therapeutic purposes, it is important to distinguish AFX from other poorly differentiated tumors, including undifferentiated pleomorphic sarcoma (UPS). OBJECTIVE: The authors aimed to identify the clinical, histologic, and immunohistochemical expression of LN2, ezrin, and CD10 in AFX and UPS tumors. METHODS AND MATERIALS: The authors retrospectively examined the charts of patients with AFX and UPS treated with Mohs micrographic surgery (MMS) at 2 academic institutions. Patient demographics, tumor characteristics, and clinical course data were collected. Immunohistochemical stains were performed on primary and recurrent AFX and UPS tumors with monoclonal antibodies against the B-cell marker LN2 (CD74), CD10, and ezrin. RESULTS: In the series of 169 patients with AFX included in this study, local recurrence was rare at 3%. In contrast, the seven patients with UPS had an aggressive clinical course with 1 local recurrence and 2 distant metastases. Immunohistochemistry staining for ezrin, LN2, and CD10 were similar in AFX and UPS tumors. CONCLUSION: AFX can be treated with MMS with rare instances of recurrence. Undifferentiated pleomorphic sarcoma has a more aggressive clinical course with increased risk for recurrence and metastasis. Staining with ezrin, LN2, and CD10 did not differentiate AFX or UPS tumors.

Importance of vertical pathology of debulking specimens during Mohs micrographic surgery for lentigo maligna and melanoma in situ.

BACKGROUND: Recent Recovery Audit Contractor audits have targeted Mohs micrographic surgery (MMS) if permanent-section pathology codes have been used on the same day. In lentigo maligna (LM) or melanoma in situ (MIS) cases, this is done to further evaluate the tumor for staging. OBJECTIVE: To determine the percentage of LM, MIS, and thin invasive melanomas upstaged when a central debulking specimen from MMS is sent for permanent vertical sections. METHODS: A single-center retrospective study examining LM, MIS, and thin melanomas treated with MMS between January 1, 2004, and September 30, 2011, at Vanderbilt University was performed. The elements needed for staging, sex, age, tumor location, size, and previous skin cancer history were obtained. RESULTS: Fourteen of 173 cases (8.1%; 95% confidence interval = 4.9-13.1%) were identified in which the tumor was upstaged; 13 of the cases initially diagnosed as LM or MIS were invasive (average Breslow depth 0.69 mm). One melanoma at 0.6 mm depth on initial biopsy increased to 1.2 mm after the debulking specimen from Mohs surgery was examined histologically. Debulking in four cases revealed a depth of 1 mm or greater. No differences existed in characteristics between upstaged and nonupstaged cases. CONCLUSION: When performing MMS for LM or MIS, it is appropriate and necessary to send the central debulking specimen for permanent histology for accurate tumor staging.

Gene expression profiling for cardiac rejection surveillance is not predictive of post-transplantation skin cancer.

BACKGROUND: The risk of skin cancer in solid organ transplant recipients (SOTR) is 50 to 100 times as great as in those without a transplant. Multiple factors, including immunosuppression, influence the development of post-transplantation skin cancer. Individuals with cardiac transplant are serially screened for organ rejection and immunosuppressive regimen effectiveness. Gene expression profiling of peripheral blood mononuclear cells has been established as a noninvasive test for monitoring cardiac rejection. OBJECTIVE: We examined individuals with cardiac transplant monitored using peripheral gene expression profiling to determine whether the profile of peripheral blood mononuclear cell activity could correlate with the development of post-transplantation skin cancer. METHODS AND MATERIALS: Sixty-one patient records were examined for initial endomyocardial biopsy results, gene expression profiling data, immunosuppressive regimens, and post-transplantation skin cancer. RESULTS: There was no relationship between acute rejection and the development of skin cancer. No relationship between peripheral gene expression profiling and the development of post-transplantation skin cancer was observed. The most common skin cancer in the population was squamous cell carcinoma. SOTR suppressed with azathioprine had a significantly higher incidence of squamous cell carcinoma. CONCLUSION: Although gene expression tests have advanced transplant surveillance, they were not associated with post-transplantation skin cancer.

Mohs micrographic surgery for cutaneous lymphadenoma.

Cutaneous lymphadenoma clinically present as pink papules or plaques resembling a basal cell carcinoma on the head and neck of young adults. Surgical excision is the treatment for these benign tumors. Cutaneous lymphadenoma may occur in an anatomically sensitive area, where margin control and conservative excision are indicated. Although not previously described in the literature, Mohs micrographic surgery (MMS) is a treatment option for cutaneous lymphadenoma. We present a series of three individuals with cutaneous lymphadenoma treated with MMS.

Clinical spectrum of atypical fibroxanthoma and undifferentiated pleomorphic sarcoma in solid organ transplant recipients: a collective experience.

BACKGROUND: Atypical fibroxanthoma (AFX) and undifferentiated pleomorphic sarcoma (UPS) are uncommon, spindle cell cutaneous malignancies. Solid organ transplant recipients (SOTRs) are immunosuppressed and therefore have a higher incidence of cutaneous malignancies. OBJECTIVE: We describe the clinical spectrum of AFX and a more-aggressive, deeper variant, UPS, in SOTRs. MATERIALS AND METHODS: A retrospective chart review of AFX and UPS in SOTRs was implemented. Cases from Vanderbilt University, Emory University, Mayo Clinic-Jacksonville, and University of Rochester were included. A literature search included previously published cases. RESULTS: The average age of SOTRs at time of tumor presentation was younger than typically seen in immunocompetent patients for AFX. Rates of local recurrences and metastases were higher in the SOTRs than is noted in the immunocompetent literature. Rates of recurrence were higher in those treated with excision than in those treated with Mohs micrographic surgery (MMS). CONCLUSION: AFX and UPS may have a greater risk for recurrence, metastases, and mortality in SOTRs, in whom early treatment with MMS may demonstrate certain advantages in terms of minimizing risk of recurrence and metastasis. UPS and recurrent tumors should be staged appropriately and may respond to adjuvant radiation therapy and reduction of immunosuppression. Immunohistochemical evaluation is recommended to exclude other spindle cell tumors.

Assessing individual patients' knowledge of benign versus malignant skin lesions in the dermatology clinic population.

Skin cancer education targeted to patients' needs is a goal of practicing dermatologists. Data regarding dermatology patients' baseline knowledge regarding skin cancer could aid clinicians in tailoring education efforts. Objective: To help quantify existing patients' existing visual recognition of skin cancer and common benign lesions, with the goal of helping to provide more targeted and meaningful education to patients. Methods: Two hundred forty-four adult patients from the dermatology clinics at University of Oklahoma and Loyola University Chicago were surveyed using digital images and questions regarding personal and family history of skin cancer, sun protection practices and sun protection knowledge. Results: Of the 244 subjects, 43% percent had a positive personal history of skin cancer, 40% had a positive family history. Scores differed minimally by personal history of skin cancer (p = .37) but differed more markedly by family history of skin cancer (p = .02). Limitations: Lack of generalizability to the general public, age range of subjects. Conclusions: There are knowledge gaps within the dermatology patient population regarding common benign and malignant skin lesions.

Basaloid squamous cell carcinoma of the skin.

BACKGROUND: Basaloid squamous cell carcinoma (BSCC), an aggressive tumor of the aerodigestive tract, was described over 20 years ago, and its defining histologic parameters remain largely unchanged. While rare reports have noted cutaneous metastatic deposition, primary tumors have not been previously described. OBJECTIVE: Although most cutaneous malignancies with basaloid features comprise variants of basal cell carcinomas, a subset exhibit histologic attributes suggestive of more aggressive tumors. We evaluated 3 such tumors submitted to our dermatopathology service over a 6-month period. METHODS: Immunohistochemical stains useful in differentiating the lineage of cutaneous malignancies with basaloid-appearing tumor cells were employed. Human papillomavirus (HPV) detection and typing were performed by using polymerase chain reaction and sequencing. RESULTS: The tumor cells expressed high molecular weight cytokeratin (34ßE12) and cytokeratin 5/6 but not Ber-EP4 or bcl-2. This pattern of immunohistochemical staining and the histologic attributes of the neoplasms are inconsistent with those expected in better defined cutaneous basaloid malignancies but are characteristic of BSCC. Two of the tumors arose in the inguinal crease of middle-aged men, and two patients were known to be immunosuppressed. HPV genotype 33 was detected in the tumor tissue from both inguinal lesions. LIMITATIONS: The number of cases available for evaluation is small and any prognostic implications therefore tenuous. CONCLUSIONS: The differential diagnosis of cutaneous malignancies exhibiting basaloid cells should include BSCC, a tumor with an unusual pattern of immunohistochemical staining and a potentially poor prognosis.

Guarding against nonmelanoma skin cancer in solid organ transplant recipients.

Periodic skin examination and ongoing counseling are central in your posttransplantation care of these patients at high risk of skin malignancy.

Communication Strategies in Mohs Micrographic Surgery: A Survey of Methods, Time Savings, and Perceived Patient Satisfaction.

Mohs micrographic surgery (MMS) entails multiple time-consuming surgical and histological examinations for each patient. Efficient communication is key in improving clinic flow, and we surveyed members of the American College of Mohs Surgery to evaluate the efficacy of different techniques utilized by Mohs surgeons across the nation.

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement.

IMPORTANCE: There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs). OBJECTIVE: To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs. EVIDENCE REVIEW: Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses. FINDINGS: The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC. CONCLUSIONS AND RELEVANCE: Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Skin Cancer and Immunosuppression.

Immunosuppressed patients are at significantly increased risk of developing cutaneous malignancies. These malignancies are often more aggressive compared with the general population and require multidisciplinary care. This article highlights the incidence and risk factors of cutaneous malignancies in this cohort. The treatment and prevention strategies are discussed. There continues to be a need for evidence-driven guidelines regarding the management of skin cancers in these patients.

Evaluation of a Peer-to-Peer Data Transparency Intervention for Mohs Micrographic Surgery Overuse.

IMPORTANCE: Mohs micrographic surgery (MMS) is a skin cancer treatment that uses staged excisions based on margin status. Wide surgeon-level variation exists in the mean number of staged resections used to treat a tumor, resulting in a cost disparity and question of appropriateness. OBJECTIVE: To evaluate the effectiveness of a behavioral intervention aimed at reducing extreme overuse in MMS, as defined by the specialty society, by confidentially sharing stages-per-case performance data with individual surgeons benchmarked to their peers nationally. DESIGN, SETTING, AND PARTICIPANTS: This nonrandomized controlled intervention study included 2329 US surgeons who performed MMS procedures from January 1, 2016, to March 31, 2018. Physicians were identified using a 100% capture of Medicare Part B claims. The intervention group included physicians affiliated with the American College of Mohs Surgery, and the control group included physicians not affiliated with the American College of Mohs Surgery. INTERVENTIONS: Individualized performance reports were delivered to all outlier surgeons, defined by the specialty society as those with mean stages per case 2 SDs above the mean, and inlier surgeons in the intervention group. MAIN OUTCOMES AND MEASURES: The primary outcome was surgeon-level change in mean stages per case between the prenotification (January 2016 to January 2017) and postnotification (March 2017 to March 2018) periods. A multivariable linear regression model was used to evaluate the association of notification with this surgeon-level outcome. The surgeon-level metric of mean stages per case was not risk adjusted. The mean Medicare cost savings associated with changes in practice patterns were calculated. RESULTS: Of the 2329 included surgeons, 1643 (70.5%) were male and 2120 (91.0%) practiced in metropolitan areas. In the intervention group (n = 1045), 53 surgeons (5.1%) were outliers; in the control group (n = 1284), 87 surgeons (6.8%) were outliers. Among the outliers in the intervention group, 44 (83%) demonstrated a reduction in mean stages per case compared with 60 outliers in the control group (69%; difference, 14%; 95% CI of difference, -1 to 27; P = .07). There was a mean stages-per-case reduction of 12.6% among outliers in the intervention group compared with 9.0% among outliers in the control group, and outliers in the intervention group had an adjusted postintervention differential decrease of 0.14 stages per case (95% CI, -0.19 to -0.09; P = .002). The total administrative cost of the intervention program was $150 000, and the estimated reduction in Medicare spending was $11.1 million. CONCLUSIONS AND RELEVANCE: Sharing personalized practice pattern data with physicians benchmarked to their peers can reduce overuse of MMS among outlier physicians.