Retention of Mohs surgeons in academic dermatology.

BACKGROUND: Retention of academic Mohs surgeons is important for the growth of this specialty and teaching of residents and students. OBJECTIVE: To examine factors that influence retention of Mohs surgeons in academics and to better understand reasons for their departure. MATERIALS AND METHODS: A survey was electronically distributed to academic Mohs surgeons in the American College of Mohs Surgery, asking them to rate the importance of several variables on their decision to remain in academia. Private practice Mohs surgeons who had left academics were also surveyed. RESULTS: Two hundred thirty-six dermatologic surgeons completed the survey. Twenty-nine percent work full time in academics, and approximately 7% work part time. The top reasons for practicing in the academic setting are intellectual stimulation, teaching opportunities, and collaboration with other university physicians and researchers. Seventy-one percent of respondents reported they would stay in academics, 7% indicated they would not, and 22% were unsure. Unfair compensation, inadequate support staff, poor leadership, increased bureaucracy, and decreased autonomy were top reasons that may compel a Mohs surgeon to leave. CONCLUSION: Opportunities for intellectual stimulation, collaboration, and teaching remain the main draw for academic Mohs surgeons. A supportive environment, strong leadership, and establishing fair compensation are imperative in ensuring their stay.

Levamisole toxicity mimicking autoimmune disease.

BACKGROUND: Levamisole is present as a contaminant or additive in most cocaine sold in the United States. Cases of agranulocytosis attributed to levamisole-tainted cocaine have been widely described. A vasculopathic reaction to levamisole has also been reported; however, diagnostic features such as antineutrophil cytoplasmic antibody (ANCA) and additional autoimmune marker positivity are not well recognized. As such, many patients are given a misdiagnosis, prompting aggressive and often unnecessary treatment. OBJECTIVE: We hope to educate practitioners about the clinical and laboratory features of levamisole-induced vasculopathy to ensure accurate diagnosis and management. METHODS: This was a case series. RESULTS: Six patients were admitted with purpuric lesions and vasculitic changes on biopsy specimen; 5 of them were given the diagnosis of and treated for autoimmune conditions before their true diagnosis was revealed. All patients had ANCA positivity, and 4 had additional abnormalities in autoimmune markers. All patients reported recent cocaine abuse, and were ultimately given the diagnosis of levamisole-induced vasculopathy. LIMITATIONS: This observational study is limited by sample size. CONCLUSIONS: Patients presenting with purpuric lesions with ANCA positivity should be assessed for cocaine exposure. It is important to recognize that levamisole may not only induce ANCA positivity but also other autoimmune marker abnormalities. Patients can often be treated with less aggressive therapeutic strategies than what is used for primary ANCA-associated vasculitides.

Superficial basal cell carcinomas of the head and neck.

BACKGROUND: Superficial basal cell carcinomas (BCC) are often considered a non-aggressive form of skin cancer, most often found on the trunk in younger patients. OBJECTIVE: To determine the characteristics of superficial BCC of the head and neck. MATERIALS AND METHODS: A retrospective review of patients undergoing Mohs micrographic surgery (MMS) for the treatment of a purely superficial BCC on the head and neck region was performed. RESULTS: Superficial BCC occurred more commonly in women (66.5%) than men (33.5%), most often on chronically sun-exposed skin such as the central face and nose. Women developed superficial BCC at a younger age than men (58 vs 63 years old, p = 0.02). The clinical sizes of the tumors were significantly smaller than the final Mohs defects for all locations on the head and neck, excluding ears and scalp. Recurrence rates after MMS were 3.6% despite negative histologic margins at the time of surgery. CONCLUSION: Superficial BCC are a unique subtype of BCC that tend to occur in younger patients, particularly women. Mohs surgeons need to be familiar with these tumors on the head and neck given their propensity for skip-lesions, higher recurrence rates, and significantly larger defect sizes than would be expected clinically.