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.

Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

Gender Disparities in Reimbursement Among Dermatologists and Dermatologic Surgeons.

BACKGROUND: Previous literature supports a disparity in income between male and female physicians across multiple specialties, even when controlling for variables such as working hours, maternity leave, and productivity. OBJECTIVE: To understand if income disparity exists between male and female general dermatologists (GDs), and in dermatologists who completed a dermatologic surgical fellowship. MATERIALS AND METHODS: The authors surveyed members of the American Academy of Dermatology, including 66 dermatologic surgeons (DSs) (34 male and 32 female DSs) and 252 GDs (119 male and 133 female GDs), on questions related to total annual income, demographics, current employment, and time spent providing patient care. A logarithmic ordinal regression model was used to analyze income and the effect of different variables. RESULTS: Male GDs were 2.46 times more likely than female GDs to be in a higher income category (95% confidence interval [CI]: 1.44-4.23). There was no significant difference between the incomes of male and female DSs (male-to-female odds ratio: 1.46, CI: -0.44 to 1.23). These findings did not change when variables of age, median patient visits, and hours worked were controlled for. CONCLUSION: Income gender inequality exists among GDs. However, this inequality does not seem to extend to DSs.

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.

Gender Disparities in Income Among Board-Certified Dermatologists.

Although there is evidence that gender-based disparities exist in salary, academic rank, and other factors in several areas in medicine, limited data exist on differences between male and female dermatologists. Existing studies have focused on academic dermatologists, not including the vast majority of dermatologists who work in solo and group private practices. A cross-sectional self-reported survey eliciting total annual income and other factors was performed in the fall of 2018 in the United States. A total of 397 board-certified dermatologists (MDs/DOs) participated in this study, including 53.63% female and 46.37% male respondents. A statistically significant difference existed within total annual income between male and female dermatologists (P<.0001). Several factors were identified that demonstrated statistically significant differences between male and female dermatologists, including productivity, practice area of focus, type of fellowship training, and faculty rank. However, despite controlling for these variations, gender remained a statistically significant predictor of income on both univariate and multivariate regression analyses (P=.0002/P<.0001), indicating that a gender-based income disparity exists in the field of dermatology that cannot be explained by other factors.

The Tam formula: A pilot study for a new treatment for melasma.

BACKGROUND: Melasma is a common hyperpigmentation disorder with numerous, but often unsatisfactory treatment options. AIMS: A pilot study to evaluate the efficacy and safety of a novel topical combination of 12% hydroquinone, 6% kojic acid, and 5% vitamin C cream for melasma. PATIENTS AND METHODS: A pilot study of 6 women with melasma was conducted at an academic dermatology department and a private dermatology practice to evaluate the efficacy of a topical combination of 12% hydroquinone, 6% kojic acid, and 5% vitamin C cream, entitled the "Tam Formula." Two blinded evaluators calculated Melasma Area and Severity Index (MASI) Scores before and after treatment to evaluate change from baseline, and statistical analysis was performed. RESULTS: Treatment with this combination topical cream resulted in an average 63.77 ± 22.10 percent reduction in MASI scores. CONCLUSIONS: While there is a need for further investigation, this pilot study indicates the Tam Formula may provide an alternative treatment option for melasma.

Toxic epidermal necrolysis: five years of treatment experience from a burn unit.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a serious drug eruption that results in death in approximately 25% to 50% of patients. There is controversy over whether SCORTEN accurately predicts mortality or if treatment interventions such as intravenous immunoglobulin (IVIg) can alter mortality. OBJECTIVES: We sought to determine whether SCORTEN accurately predicts mortality in this cohort, whether IVIg improved survival, and which drugs and medical comorbidities impacted mortality. METHODS: We summarize our experience prospectively over 5 years and 82 patients. Patients either received supportive care, intravenous immunoglobulin, or cyclosporine as treatment. All patients had a SCORTEN on admission, an offending drug on record, and a list of medical comorbidities. RESULTS: Of the 82 patients, 29% died from TEN. SCORTEN accurately predicted mortality in this cohort with an area under the curve (AUC) of 0.83 in a receiver operator curve (ROC) analysis. A Kaplan-Meier curve did not show improved mortality if patients received IVIg versus supportive care (P = .9). Medications most often responsible for TEN were trimethoprim/sulfamethoxazole, followed by anticonvulsants, nonsteroidal anti-inflammatories, and allopurinol. LIMITATIONS: This prospective cohort study design is not as ideal as patients presenting for a randomized controlled trial. CONCLUSIONS: SCORTEN was an accurate predictor of mortality in this cohort. Age older than 40 years, the presence of metabolic syndrome and/or gout, higher body surface area involvement, higher SCORTEN, and higher number of medical comorbidities statistically significantly increased risk of death. IVIg did not significantly alter mortality. Although the highest number of cases was due to trimethoprim/sulfamethoxazole, the greatest proportion of deaths was due to allopurinol.

Amelanotic melanoma: a detailed morphologic analysis with clinicopathologic correlation of 75 cases.

Amelanotic melanoma can have a varied appearance both clinically and microscopically. Here, we present our experiences with 75 cases of amelanotic melanoma defined clinically as a non-pigmented lesion and histopathologically as a tumor lacking significant melanization. We evaluated microscopic features such as morphology, mitotic count, nuclear atypia and presence of solar elastosis. Our amelanotic melanomas exhibited the following morphology: epitheloid (72%), spindled (18.7%) or desmoplastic (5.3%). In addition, we obtained patient information and clinical presentations on most of the cases (74/75; 98.7%) and follow-up data on 40% (30/75) of the cases. The majority of amelanotic melanomas in men were found on the trunk (13/45; 29%), head and neck (12/45; 26.7%), and lower limb (13/45; 29%) and in women were found on the lower limb (12/30; 40%), upper limb (10/30; 33.3%) and head and neck (6/30; 20%). In addition, we found that an increase in mitotic index correlated with worse survival (p < 0.026), whereas there were no differences in survival for other pathological features, such as nuclear atypia or solar elastosis. Furthermore, in cases with available tissue, all amelanotic melanoma expressed microphthalmia-associated transcription factor and tyrosinase, suggesting that the tumor cells retained melanocytic lineage and an enzyme in melanin formation, respectively. As the occurrence of amelanotic melanoma and the expression melanoma markers were similar to pigmented melanoma, we favor that amelanotic melanoma represents a subtype of melanoma rather than poorly differentiated or de-differentiated melanoma.

The use of the flexible scalpel for minimally invasive and minimally scarring surgery: a case series of four patients with large scalp tumors.

Reconstruction of the scalp after Mohs surgery can pose dilemmas for the dermatologic surgeon, especially for extensive tumors. The authors present a unique technique for removing large in-situ epidermal tumors of the scalp during Mohs surgery in four patients. Although invasive tumor was removed with a standard No. 15 scalpel, the extensive epidermal component of the tumor was removed through the mid-dermis using the flexible scalpel. This technique allowed the superficial defect to heal by second intention. The results showed minimal scarring and hair regrowth in what could have been large defects requiring complex reconstruction.

Treatment of melasma using fractional photothermolysis: a report of eight cases with long-term follow-up.

BACKGROUND: Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities. OBJECTIVES: To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method. MATERIALS AND METHODS: Eight female patients (Fitzpatrick skin type II-IV) with clinically diagnosed melasma on the face were treated using FP (1,550 nm Fraxel SR laser). Two to seven treatments were performed at 3- to 8-week intervals. Treatment levels ranged from 3 to 10, corresponding to 9% to 29% surface area coverage (8-10 passes per treatment). Energies used ranged from 6 to 40 mJ. Physician and patient assessments were recorded at each visit and at a follow-up visit 7 to 36 months (mean 13.5 months) after the last treatment session. RESULTS: At the last treatment, assessments revealed greater than 50% clinical improvement in melasma in five of eight patients. Follow-up assessments by the evaluating physician revealed sustained efficacy in five patients. Recurrence was reported in three patients. No significant adverse effects were noted. CONCLUSIONS: FP is a safe and effective treatment for refractory melasma, with long-term remission.

An analysis of pain and analgesia after Mohs micrographic surgery.

BACKGROUND: Pain characteristics and analgesia in patients undergoing Mohs micrographic surgery have not been systematically studied. It is important to know about pain after Mohs micrographic surgery to better serve patient needs. OBJECTIVE: We sought to measure pain in patients after Mohs micrographic surgery, and to investigate the relationship among postoperative pain, surgical characteristics, patient characteristics, and analgesics used. METHODS: The Wong-Baker 0-to-10 pain scale was prospectively administered postoperatively to all patients presenting for Mohs micrographic surgery in a private practice setting between October 1, 2007, and December 31, 2008. Patients recorded their pain level from the day of surgery through postoperative day 4. The age, sex, location of surgery, number of lesions operated on, postoperative size, type of repair, severity of pain, and oral analgesics consumed and dosages used were recorded. RESULTS: A total of 433 patients were included in the final analysis. The highest pain scores were found on the day of surgery and steadily declined until postoperative day 4 (P < .000). In all, 52% of patients took pain medication on the day of surgery, which declined successively with each postoperative day. The highest mean pain scores were statistically significantly associated with repair type (flaps), age (<66 years), number of lesions, and consumption of narcotics for pain relief. No statistically significant differences existed for sex or postoperative defect size. LIMITATIONS: The instrument used to measure pain relied on patient self-report in a private practice surgery center. Only the validated Wong-Baker pain scale was used to assess pain in this study. CONCLUSION: Approximately half of the patients after Mohs micrographic surgery take medication for pain control. Type of closure, location of surgery, age, and type of pain medication taken were significantly associated with postoperative pain.