Clinical Versus Histologic Margins for Cutaneous Squamous Cell Carcinoma: Comparing Outcomes for High-Risk Tumors Treated With Mohs Micrographic Surgery.

BACKGROUND: High-risk cutaneous squamous cell carcinoma (cSCC) is associated with poor clinical outcomes. Traditionally, preoperative clinical tumor size ≥2 cm, based on Brigham and Women's Hospital (BWH) staging criteria, is high risk. OBJECTIVE: To compare outcomes of cSCC treated with Mohs micrographic surgery (MMS) with a preoperative size ≥2 cm (clinically ≥2 cm) versus cSCC with preoperative size <2 cm and postoperative defect size ≥2 cm (histologically ≥2 cm). METHODS: Prospective data were collected from January 1, 2014, to December 31, 2020, on MMS cases for cSCC with a preoperative and/or postoperative size ≥2 cm. Clinical outcomes were followed until March 15, 2023. Data were analyzed using multivariate regression. RESULTS: Three hundred thirty cases of MMS for cSCC were included. Cutaneous squamous cell carcinoma clinically ≥2 cm occurred more frequently in elderly patients; cSCC histologically ≥2 cm were more commonly located in the H region, required wider surgical margins, and more MMS stages to achieve clearance. There were no significant differences in rates of recurrence and metastasis between the groups. CONCLUSION: These data suggest that postoperative (histologic) MMS defect size may allow for better risk stratification of high-risk cSCC and improved staging of cSCC.

Permanent section margin concordance after Mohs micrographic surgery with immunohistochemistry for invasive melanoma and melanoma in situ: A retrospective dual-center analysis.

BACKGROUND: Mohs micrographic surgery (MMS) for melanoma practices vary among dermatologic surgeons. The implementation of immunohistochemical staining in MMS for melanoma mitigates challenges associated with slide interpretation; however, the reliability of melanoma antigen recognized by T cells 1 (MART-1), the preferred immunostain for melanoma, has yet to be compared with permanent section pathology. OBJECTIVE: To assess concordance rates of MART-1 frozen sections and permanent section pathologic interpretation of melanoma treated with MMS. METHODS: A dual-center retrospective analysis was conducted to collect concordance and demographic data. Chi-square tests were performed for group comparisons of categorical variables. RESULTS: Of the 379 permanent sections sent, 367 were concordant with frozen section pathology for an overall concordance rate of 96.8%. Cases were stratified into indeterminately concordant and indisputably concordant. Twenty-two (6%) of cases were indeterminately concordant, whereas 345 (94.0%) of cases were indisputably concordant. LIMITATIONS: The concordance rate is derived from a comparison of adjacent tissue margins, an inevitable consequence of utilizing 2 techniques. CONCLUSION: To the author's knowledge, this study represents the largest investigation examining concordance rates of MART-1 frozen sections in Mohs for melanoma. High concordance disputes the ongoing need for additional permanent margins when using MART-1 in routine cases.

Review of radiofrequency microneedling: history, devices and uses.

Radiofrequency microneedling (RFM) has recently become a popular choice for the treatment of various dermatologic conditions and rejuvenation. Many studies have sought to evaluate the efficacy of RFM. However, its role in the management of these conditions remains unclear. A comprehensive literature search including randomized controlled trials, cohort studies, and case series evaluating the efficacy of RFM in various skin conditions was performed. In this review, we discuss the history and mechanism of RFM, describe various device features, and discuss the use of RFM in various skin conditions and rejuvenation.

Antibiotic Use and Surgical Site Infections in Immunocompromised Patients After Mohs Micrographic Surgery: A Single-Center Retrospective Study.

BACKGROUND: As Mohs micrographic surgery becomes more widely used in immunosuppressed patients, it is important to understand the risks in this unique population. OBJECTIVE: To determine whether immunosuppressed patients are at an increased risk for surgical site infection and evaluate the utility of postoperative antibiotics for the prevention of surgical site infection. MATERIALS AND METHODS: A single-center retrospective review of patients who underwent Mohs micrographic surgery between October 9, 2014, and August 20, 2021, was performed. RESULTS: Five thousand eight hundred eighty-six independent cases were identified. Factors associated with an increased incidence of antibiotic use included preoperative lesion size >40 mm (86.7%, n = 13; p < .01) and high-risk lesion location (46.4%, n = 1,268; p < .01). Patients were not more likely to be prescribed antibiotics if immunosuppressed (37.0%, n = 269 vs 34.2%, n = 1765; p = .14), and immunosuppression was not independently associated with antibiotic use on multivariate analysis (odds ratio 1.2, 95% confidence interval 1.0-1.5). Infection rates were similar between immunocompromised patients and immunocompetent patients (2.1%, n = 15 vs 1.6%, n = 80, respectively; p = .30). In immunosuppressed patients, antibiotic use did not decrease the likelihood of infection (3.0%, n = 8 vs 1.5%, n = 7; p = .19). CONCLUSION: There was no association between immunosuppression and surgical infection rate. Furthermore, postoperative antibiotics should not be indicated in these patients unless other high-risk criteria exist.

Complications associated with infraorbital filler injection.

Soft tissue augmentation with injectable fillers is increasingly being performed, and providers must be prepared to understand and treat complications. Periorbital skin presents unique challenges due to its thin nature, easily evident pigmentary and textural irregularities, and anatomical considerations including vasculature and subcutaneous layers. The most common complications of infraorbital filler include ecchymosis, malar edema, blue-gray hue, and contour irregularities. Uncommon complications include infection and biofilm formation, skin necrosis, and blindness. This purpose of this review is to highlight the infraorbital anatomy, complications of filler injection in this region, and techniques to avoid these complications.

Specific complications associated with non-surgical rhinoplasty.

Non-surgical rhinoplasty is becoming an increasingly common procedure to alter the appearance and cosmesis of the nose. Although rare, complications with this procedure do exist, some of which can be devastating. Major complications include infection, vascular compromise, skin necrosis, and blindness. Here we discuss the nasal anatomy, complications associated with non-surgical rhinoplasty, and techniques to prevent these complications.

Patterns of antimicrobial resistance in intensive care unit patients: a study in Vietnam.

BACKGROUND: Antimicrobial resistance has emerged as a major concern in developing countries. The present study sought to define the pattern of antimicrobial resistance in ICU patients with ventilator-associated pneumonia. METHODS: Between November 2014 and September 2015, we enrolled 220 patients (average age ~ 71 yr) who were admitted to ICU in a major tertiary hospital in Ho Chi Minh City, Vietnam. Data concerning demographic characteristics and clinical history were collected from each patient. The Bauer-Kirby disk diffusion method was used to detect the antimicrobial susceptibility. RESULTS: Antimicrobial resistance was commonly found in ceftriaxone (88%), ceftazidime (80%), ciprofloxacin (77%), cefepime (75%), levofloxacin (72%). Overall, the rate of antimicrobial resistance to any drug was 93% (n = 153/164), with the majority (87%) being resistant to at least 2 drugs. The three commonly isolated microorganisms were Acinetobacter (n = 75), Klebsiella (n = 39), and Pseudomonas aeruginosa (n = 29). Acinetobacter baumannii were virtually resistant to ceftazidime, ceftriaxone, piperacilin, imipenem, meropenem, ertapenem, ciprofloxacin and levofloxacin. High rates (>70%) of ceftriaxone and ceftazidime-resistant Klebsiella were also observed. CONCLUSION: These data indicated that critically ill patients on ventilator in Vietnam were at disturbingly high risk of antimicrobial resistance. The data also imply that these Acinetobacter, Klebsiella, and Pseudomonas aeruginosa and multidrug resistance pose serious therapeutic problems in ICU patients. A concerted and systematic effort is required to rapidly identify high risk patients and to reduce the burden of antimicrobial resistance in developing countries.

The Worsening Profile of Alcoholic Hepatitis in the United States.

BACKGROUND: Alcoholic hepatitis (AH) is a major cause of liver-related hospitalization. The profile, treatment patterns, and outcomes of subjects admitted for AH in routine clinical practice are unknown. Also, it is not known whether these are changing over time. This study is thus aimed to identify temporal trends in hospitalization rates, clinical characteristics, treatment patterns, and outcomes of subjects admitted for AH in a routine clinical setting. METHODS: A retrospective analysis of adults admitted for AH from 2000 to 2011 was performed using an anonymized EMR database of patient-level data from 169 U.S. medical centers. RESULTS: (i) EPIDEMIOLOGY: The proportion of baby boomers admitted for AH increased from 2000 to 2011 (26 to 31%, p < 0.0001). (ii) CLINICAL: The median Model for End-Stage Liver Disease (MELD) score increased over time from 12 to 14 (p = 0.0014) driven mainly by increased international normalized ratio (1.2 to 1.4, p < 0.0001). The median Charlson Comorbidity Index increased from 0 to 1 (p < 0.0001) with increased diabetes, chronic obstructive pulmonary disease, and heart disease. (iii) COMPLICATIONS: The following increased from 2001 to 2011: Gastrointestinal bleed-7 to 10% (p = 0.03); hepatic encephalopathy-7 to 13% (p < 0.0001); hepatorenal syndrome-1.8 to 2.8% (p = 0.0003); sepsis-0 to 6% (p < 0.0001); and pancreatitis-11 to 16% (p = 0.0061). (iv) Treatment patterns and mortality: Eight to 9% of subjects received steroids while pentoxifylline use increased to 2.2%. In those with MELD ≥ 22, mortality remained between 19 and 20% and only steroids modestly improved survival in this subset. CONCLUSIONS: Severe AH continues to have a high mortality. The severity and comorbidities and complications associated with AH have worsened. Drug therapy remains suboptimal.

The "Heart Sign": An Early Indicator of Dose-Dependent Doxycycline-Induced Phototoxicity.

Oral doxycycline is an antibiotic commonly used for the treatment of inflammatory acne in adolescents. Dose-dependent phototoxicity, unrelated to dose duration, is a well-known complication of its use. We present three adolescents who developed bilateral phototoxic rashes on the dorsal thenar spaces of their hands while taking doxycycline for their acne. Identification of the "heart sign" rash as a specific doxycycline-related phototoxic reaction should alert clinicians to the need for prompt intervention, including sun protection counseling and a possible change in antibiotics, in the uniquely vulnerable adolescent population. Early recognition may allow patients to avoid future, more widespread phototoxic drug reactions.

Palisaded Neutrophilic Granulomatous Dermatitis in a Child with Juvenile Idiopathic Arthritis on Etanercept.

Palisaded neutrophilic granulomatous dermatitis (PNGD) is a rare neutrophilic dermatosis that may be associated with significant morbidity because of associated pruritus and pain. It is typically seen in adults with collagen vascular diseases, but may be associated with medications as well. PNGD is rarely reported in children. We describe a girl with polyarticular juvenile idiopathic arthritis who developed PNGD after administration of etanercept and demonstrated rapid and significant improvement upon treatment with topical triamcinolone 0.1% ointment.

"EB, or Not EB?" Neonatal Desquamative Impetigo in a Degloving Pattern.

We present the case of a 7-day-old boy with significant, rapidly spreading blistering and desquamation in a "degloving" pattern on the hands that mimicked epidermolysis bullosa but was ultimately diagnosed as bullous impetigo caused by a clinically aggressive strain of Staphylococcus aureus. Bullous impetigo is a desquamating condition caused by local release of S. aureus exfoliative toxin A and is more commonly seen in children. This case highlights the fragility of newborn skin and reviews the major diagnoses that should be considered in an infant with significant blistering.

Ablative fractional laser resurfacing with topical paromomycin as adjunctive treatment for a recalcitrant cutaneous leishmaniasis wound.

BACKGROUND AND OBJECTIVE: Leishmaniasis is a vector borne disease that can cause disease manifestations that range from localized skin ulceration to lethal visceral disease. With increased global travel, cutaneous leishmaniasis (CL) is becoming more common in developed nations. However, current treatment options are limited. STUDY DESIGN: We report a 16-year-old female who presented with several non-tender, non-healing CL wounds on her bilateral upper and lower extremities. Ablative fractional laser resurfacing (AFR) was used in conjunction with topical paromomycin via laser-assisted delivery to treat the largest non-healing CL wound on the patient's distal lower extremity. RESULTS: Upon follow-up after two treatments with AFR, the patient's wound healed completely without evidence of infection and with minimal scarring. CONCLUSION: AFR with laser-assisted delivery of topical paromomycin represents a novel treatment option for resistant, non-healing CL wounds. The technique may prove additionally useful for concurrent mitigation of scarring related to CL.

A review of scar assessment scales.

At our current level of understanding, scars are an unavoidable result of disruption of the integument following trauma and other sources of injury in the postnatal period. Millions of people worldwide suffer from diminished quality of life due to varying degrees of disfigurement, functional impairment, and psychosocial comorbidity. Scars also represent a significant financial burden to the healthcare system at large. Substantial momentum currently exists in scar research associated with innovative techniques and devices devoted to treating scars. In order to properly ascertain and compare responses to various therapies, accurate and reproducible qualitative and quantitative assessments are vital. At least 10 different scar assessment scales and tools have been created to date in an attempt to quantify scar severity. However, a "gold standard" scar scale still does not yet exist. A major limitation of most scar scales is their focus on a relatively narrow group of individual subjective and objective features, while failing to address the overall cosmetic, functional, and psychological sequelae. Herein, we provide a brief review of current scar assessment scales, discuss some of the major advantages and limitations of each, and introduce several characteristics that might be addressed in a new "gold standard" scar scale. The assessment and treatment of scars, particularly large traumatic scars, is frequently a multidisciplinary effort. The creation of an "ideal" scar scale will undoubtedly require input from therapists, surgeons, dermatologists, and other professionals alike.

Scalp necrosis overlying a ventriculoperitoneal shunt: a case report and literature review.

BACKGROUND: The use of ventriculoperitoneal (VP) shunts has become ubiquitous in neurosurgery for the treatment of hydrocephalus. VP shunts work by creating a conduit for cerebrospinal fluid (CSF) to flow from the cerebral ventricles to the peritoneum and thus relieving pressure. Although typically safe, VP shunt complications are extremely common, occurring in up to 29% of adult cases and approximately half of pediatric cases. These complications may require patients to undergo several revisions throughout their lifetime Purpose: We describe a man who developed scalp necrosis overlying his VP shunt. We also summarize the potential complications of VP shunts. We discuss the presentation and pathogenesis of scalp necrosis in these patients. MATERIALS AND METHODS: A PubMed search of the following terms was performed and relevant citations were assessed: ventriculoperitoneal shunt, VP shunt, shunt complications, scalp necrosis, skin necrosis, ventriculoperitoneal shunt induced scalp necrosis, ventriculoperitoneal shunt induced skin necrosis. RESULTS: A 73-year-old man developed VP shunt-induced scalp necrosis leading to loss of skin overlying the shunt valve. The patient was emergently referred to neurosurgery and admitted for revision of the shunt due to the significant risk for infection. The VP shunt was replaced with an external drain and a skin flap was used to repair the defect. CONCLUSION: VP shunts are devices that are frequently used for reducing intracranial pressure associated with hydrocephalus. The insertion of the shunt beneath the scalp sets the stage for potential pressure-induced scalp necrosis. The early recognition and diagnosis of VP shunt-induced scalp necrosis is essential to prevent infections and future complications.

Convergence of anatomy, technology, and therapeutics: a review of laser-assisted drug delivers.

This is a very exciting time in cutaneous laser surgery with an ever-expanding therapeutic armamentarium and an increased sophistication of available technology. These recent trends have allowed for both a rapid development of interest and exploration of laser-assisted drug delivery and its potential applications. We review the current literature on anatomy, technology, and therapeutics as it relates to laser-assisted drug delivery. The focus of our review is on two areas of interest that have received much attention to date - photodynamic therapy in the treatment of actinic keratoses and nonmelanoma skin cancers as well as the treatment of scarring. We will also discuss potential complications of existing modalities used independently and in laser-assisted drug delivery and conclude with future indications for this burgeoning therapeutic methodology.

Curcumin: a novel treatment for skin-related disorders.

Curcumin, or diferuloylmethane, is a crystalline compound which gives the East Asian spice turmeric its bright yellow color. The medicinal properties of this spice have been referenced in numerous countries and cultures throughout the world. Today, there is growing scientific evidence suggesting curcumin's utility in the treatment of chronic pain, inflammatory dermatoses, acceleration of wound closure, skin infections, as well as cosmetic ailments such as dyspigmentation. In addition, curcumin may have a protective role against various pollutants and cytotoxic agents, indicating that it may be beneficial in a mitigational or prophylaxis role. Although turmeric has been used for thousands of years in alternative medicine, curcumin has yet to emerge as a component of our mainstream dermatologic therapeutic armamentarium. Interestingly, curcumin provides an ideal alternative to current therapies because of its relative safety profile even at high doses. Although the advantageous properties of curcumin in medicine are well established, its therapeutic potential thus far has been limited because of its poor oral bioavailablity. Topical administration of curcumin can directly deliver it to the affected tissue making it useful in treating skin-related disorders. However, limitations still exist such as the cosmetically unpleasing bright yellow-orange color, its poor solubility, and its poor stability at a high pH. Here the current literature detailing the potential and current use of curcumin in dermatology is reviewed.

Pathophysiology guided treatment of nonalcoholic steatohepatitis.

Nonalcoholic fatty liver disease is a spectrum that ranges from benign steatosis to steatohepatitis. It has become the most common cause of chronic liver disease, and yet there continues to be a lack of effective therapeutic options. This article reviews current concepts underlying the pathophysiological basis of nonalcoholic steatohepatitis from development of insulin resistance to the establishment of fibrosis. Then using a physiology-based approach, specific targeted therapeutics are reviewed along with their drawbacks. The evidence behind current therapies is based predominantly on small trials and, thus, no recommendations can be made until larger randomized trials are conducted.