Epidemiology, clinical characteristics, treatment, and outcomes of proliferating pilar tumors: A systematic review.

BACKGROUND: Proliferating pilar tumors (PPTs) are rare cutaneous neoplasms arising from hair follicles that have both malignant and metastatic potential. OBJECTIVE: To present a systematic review of the epidemiology, clinical characteristics, and treatment and outcome data on PPTs. METHODS: Using the OVID platform, MEDLINE and Embase were searched from inception until May 26, 2022. All studies that provided original data on PPTs in English were included. References of these studies were also cross-checked to identify any additional relevant articles. Oxford's Levels of Evidence-Based Medicine was used for quality assessment. RESULTS: A total of 114 articles, providing data on 361 cases of PPTs, were included in our synthesis. Every study included was either a case series or case report. The mean age at diagnosis was 61.7. Most patients in the synthesis were female (71%), and the majority of cases occurred on the scalp (73.1%). The presence or absence of cytological atypia was only reported in one-third of the cases; 36.8% of cases were classified as malignant and 7.5% metastasized. Although no lesions treated with Mohs micrographic surgery required adjuvant radiation and only one reported recurrence occurred after Mohs surgery, there is insufficient data to make conclusions on a superior treatment modality. LIMITATIONS: All studies in this review were either case reports or case series. CONCLUSIONS AND RELEVANCE: Our study supports the notion that PPTs occur most commonly on the scalp of elderly female patients. Moreover, our findings confirm that PPT is capable of demonstrating aggressive biology and metastasis. Given the lack of uniformity in histologic description, pathologists should be encouraged to comment on the presence and degree of cytological atypia when reporting cases of rare neoplasms such as the PPT. Greater consensus on diagnosis and classification as well as more robust data is needed regarding optimal management.

Excision margins for melanoma in situ on the head and neck-A single-center 10-year retrospective review of treatment with Mohs micrographic surgery.

BACKGROUND: Although current guidelines recommend a 5 mm surgical margin for the excision of melanoma in situ (MIS), increasing evidence has shown this may be suboptimal to achieve tumor clearance. OBJECTIVE: To evaluate margins required for optimal cure rates with excision of MIS on the head and neck and investigate tumor and/or patient factors in those requiring >5 mm margins to achieve tumor clearance. METHODS: A retrospective chart review was performed on 846 (807 primary and 39 recurrent) MIS cases on the head and neck treated in the authors' dermatologic surgery department over a 126-month (10.5 year) period. RESULTS: Sixty-two percent were cleared with 5 mm margins. A total of 15 mm margins were required to achieve a 97% clearance rate. Difference in clearance rate between margin thresholds was significant (P < .001). Tumor location on the cheek and larger preoperative size correlated with requiring >5 mm margins to achieve tumor clearance (P = .006 and P = .001, respectively). LIMITATIONS: This is a single-center retrospective study which relies on accurate documentation of clinical data. CONCLUSION: This study demonstrates that MIS on the head and neck often requires margins >5 mm margins to achieve tumor clearance. When Mohs micrographic surgery is not possible, excision margins of ≥10 mm are likely necessary for head and neck tumors.

Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

A Systematic Review of the Epidemiology, Clinical Characteristics, Treatment, and Outcomes for Desmoplastic Trichoepithelioma: Underscoring Mohs Micrographic Surgery in Management.

BACKGROUND: Desmoplastic trichoepithelioma (DTE) is an uncommon benign adnexal tumor that histologically may mimic malignant tumors including basal cell carcinoma and microcystic adnexal carcinoma. OBJECTIVE: To present a systematic review of the epidemiology, clinical characteristics, treatment, and outcome data on DTEs, with emphasis on comparing Mohs micrographic surgery (MMS) with other treatments. METHODS: Using the OVID platform, MEDLINE and Embase were searched from inception for studies providing original data on DTEs. RESULTS: A total of 338 cases of DTE from 61 articles were included. No recurrence/persistence (0%) was reported following MMS ( n = 24, mean follow-up of 41.9 months), 13.1% with standard excision ( n = 38, mean follow-up 16.9 months), and 2.1% for electrosurgery/cautery ( n = 49, follow-up 3-72 months). 100% recurrence/persistence for imiquimod ( n = 2) and liquid nitrogen ( n = 4) were identified. In patients who underwent biopsy only, there was a 12.5% recurrence/persistence ( n = 32, mean follow-up 16.5 months). Overall, duration of follow-up varied from 2 months to 6 years for the various management strategies. CONCLUSION: Data are limited regarding DTE outcomes. In this review, surgical modalities, specifically MMS, had the lowest rates of recurrence/persistence compared with other options. Given that most lesions are found on cosmetically sensitive locations, MMS seems to be the optimal management strategy for actively managing DTEs.

Nasal Lining Repair: A Comprehensive Literature Review.

BACKGROUND: Currently, there are limited reviews in the dermatology literature on how to approach reconstruction of nasal lining in full-thickness nasal defects resulting from Mohs micrographic surgery. Given variable training and experience, dermatologic surgeons may seek additional references to help reconstruct certain advanced defects. We sought to synthesize literature from dermatologic surgery, plastic surgery, and otolaryngology to review repair options and considerations for repair of nasal lining defects. OBJECTIVE: To present a comprehensive literature review of repair options for nasal lining reconstruction and discuss advantages, disadvantages, specific anatomic considerations, and techniques to execute such options. MATERIALS AND METHODS: Articles from several different reconstructive specialties including dermatologic/Mohs surgery, otolaryngology, and plastic and reconstructive surgery were reviewed. Instructive images were compiled to illustrate several techniques, with additional medical illustration recreations included to help showcase important reconstructive approaches. RESULTS: A comprehensive descriptive review of nasal lining repair options for the reconstructive surgeon. CONCLUSION: Advanced tumors can result in full-thickness nasal defects, and this review describes various reconstructive options for reconstruction based on the extent of the defect.

Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review.

BACKGROUND: Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations. OBJECTIVE: To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis. MATERIALS AND METHODS: A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors. RESULTS: The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures. CONCLUSION: These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations.

Evaluating Public Perceptions of Cosmetic Procedures in the Medical Spa and Physician's Office Settings: A Large-scale Survey.

BACKGROUND: Medical spa and cosmetic procedure markets have grown substantially in recent years. The lack of consistent medical oversight at medical spas raises safety concerns. OBJECTIVE: To understand how the public views medical spas compared with physician's offices as places to receive cosmetic procedures with a focus on safety. METHODS: 1,108 people were surveyed on an internet platform about their perceptions of the safety of receiving cosmetic procedures at medical spas and physician's offices. Respondents were grouped by their past experiences. Chi-squared and analysis of variance models were used to determine statistically significant differences between groups at the 0.05 level. RESULTS: Respondents who had only received cosmetic procedures at physician's offices or had never received a cosmetic procedure cared more about being treated by a physician ( p < .001) and rated safety as more important ( p = .03). Total complication rates were numerically higher at medical spas compared with physician's offices ( p = .41). Minimally invasive skin tightening (0.77 vs 0.0, p < .001) and nonsurgical fat reduction (0.80 vs 0.36, p = .04) had higher complication rates at medical spas. CONCLUSION: There were concerns among the public about the safety of cosmetic procedures at medical spas, and some procedures demonstrated higher complication rates in this setting.

Outcomes of Squamous Cell Carcinoma of the Lip Treated With Mohs Micrographic Surgery: A Retrospective Cohort Study.

BACKGROUND: Cutaneous squamous cell carcinomas (cSCCs) of the lip have been reported to be at higher risk for poorer post-treatment outcomes. OBJECTIVE: To examine outcomes of patients with SCC of the lip treated with Mohs micrographic surgery (MMS) and identify factors for recurrence. MATERIALS AND METHODS: This retrospective review of a single tertiary referral center's Mohs case logs from 2010 to 2019 identified cases of lip SCC. Clinicopathologic characteristics and outcomes (local recurrence [LR], metastasis, and disease-specific death) were reviewed. RESULTS: One hundred ninety cases of SCC of the lip were identified and demonstrated that MMS offered a disease-free survival of 96.8% over an average follow-up period of 42 months. Younger age (61 vs 74 years p = .006), increased MMS stages ( p = .009), and higher American Joint Committee on Cancer and Brigham and Women's Hospital T stages were risk factors for LR. Immunosuppression, large tumor size, mucosal lip involvement, aggressive histology, and perineural invasion were not associated with LR. CONCLUSION: The results of this study show that SCC of the lip behaved similarly to cSCC outside the lip area, and that both primary and recurrent lesions can be treated effectively with MMS.

Inferiorly Based Rotation Flaps for Infraorbital Cheek Defects.

BACKGROUND: The infraorbital cheek is a common location for cutaneous malignancy and thus surgical defects. Reconstruction in this region must maintain nearby free margins to ensure optimal cosmetic and functional outcomes. Large defects may require a flap using lateral or inferior tissue reservoirs. OBJECTIVE: To examine outcomes of inferiorly based rotation flaps in the repair of infraorbital cheek defects and highlight pearls for optimal long-term results. METHODS: Chart review of patients with a defect of the infraorbital cheek repaired with an inferiorly based rotation flap between February 2010 and December 2018 at a single academic institution. The Visual Analog Scale (VAS) was used for scar assessment. RESULTS: Sixty-five patients underwent extirpation of a cutaneous malignancy resulting in defects ranging from 1.0 × 1.0 to 4.5 × 5.5 cm (mean area = 4.8 cm2). Most of the patients did not experience complications. Ectropion occurred in 7 patients. The mean VAS score was 11.6. CONCLUSION: An inferiorly based rotation flap yields acceptable outcomes for infraorbital cheek defects and can be considered for defects as large as 5.5 cm. Using pearls for surgical execution presented in this article may allow reconstructive surgeons to include this flap in their repertoire.

Oncologic outcomes in primary squamous cell carcinoma of the auricle: a retrospective cohort analysis.

PURPOSE: The prognostic significance of auricular location in cutaneous squamous cell carcinoma (cSCC) is controversial. We aimed to characterize risk factors for, and evaluate the cumulative incidence of, locoregional recurrence in a cohort of patients with primary auricular cSCC. METHODS: The study design was a single-institution retrospective cohort review from 1/2007 to 12/2016. RESULTS: Among 851 potentially eligible individuals, 178 patients with primary auricular cSCC met strict criteria for inclusion. Median follow-up was 32 months, 93% were AJCC 8th edition (AJCC8) stage I and 6% were AJCC8 stage II. Most underwent Mohs micrographic surgery (MMS; 97%) and the remainder underwent wide local excision ± parotidectomy ± neck dissection ± adjuvant therapy (3%). Recurrences occurred in seven patients (4%): six were local and one was regional. The 3-year cumulative incidence of local and regional recurrence for AJCC8 stage I-II tumors were 1% (95% CI 0-5%) and 0%, respectively. Among ten patients upstaged to pT3 disease who underwent MMS alone, none recurred locoregionally. Compared to their respective counterparts, advanced stage, PNI, and LVI associated with a significantly increased risk of locoregional recurrence. CONCLUSIONS: Our findings suggest that auricular location may not be a significant risk factor for cSCC staging systems. In the absence of other risk factors, unimodal therapy appears adequate for patients with primary, stage I-II auricular cSCC. The prognostic significance of pT3 auricular cSCC stage due to depth of invasion alone should be evaluated further.

High-Risk Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Clinical Review.

BACKGROUND: Given the rapidly evolving nature of the field, the current state of "high-risk" head and neck cutaneous squamous cell carcinoma (HNcSCC) is poorly characterized. METHODS: Narrative review of the epidemiology, diagnosis, workup, risk stratification, staging and treatment of high-risk HNcSCC. RESULTS: Clinical and pathologic risk factors for adverse HNcSCC outcomes are nuanced (e.g., immunosuppression and perineural invasion). Frequent changes in adverse prognosticators have outpaced population-based registries and the variables they track, restricting our understanding of the epidemiology of HNcSCC and inhibiting control of the disease. Current heterogeneous staging and risk stratification systems are largely derived from institutional data, compromising their external validity. In the absence of staging system consensus, tumor designations such as "high risk" and "advanced" are variably used and insufficiently precise to guide management. Evidence guiding treatment of high-risk HNcSCC with curative intent is also suboptimal. For patients with incurable disease, an array of trials are evaluating the impact of immunotherapy, targeted biologic therapy, and other novel agents. CONCLUSION: Population-based registries that broadly track updated, nuanced, adverse clinicopathologic risk factors, and outcomes are needed to guide development of improved staging systems. Design and development of randomized controlled trials (RCTs) in advanced-stage HNcSCC populations are needed to evaluate (1) observation, sentinel lymph node biopsy, or elective neck dissection for management of the cN0 neck, (2) indications for surgery plus adjuvant radiation versus adjuvant chemoradiation, and (3) the role of immunotherapy in treatment with curative intent. Considering these knowledge gaps, the authors explore a potential high-risk HNcSCC treatment framework.

Factors predicting outcomes of patients with high-risk squamous cell carcinoma treated with Mohs micrographic surgery.

BACKGROUND: There is limited literature on the long-term outcomes and prognostic factors of high-risk cutaneous squamous cell carcinomas (hrSCC) treated with Mohs micrographic surgery (MMS). OBJECTIVE: To determine the rates of local recurrence, metastatic disease, and disease-specific death in hrSCCs treated with MMS and patient or tumor factors associated with poor outcomes. METHODS: Single-institution, retrospective cohort analysis of hrSCC treated with MMS alone and MMS with adjuvant therapy. RESULTS: A total of 882 cases of hrSCC treated with MMS were identified, of which 842 were treated with MMS alone, with a median follow-up time of 2.4 years. The rate of local recurrence was 2.5%, of metastatic disease was 1.9%, and of disease-specific death was 0.57%. Perineural invasion, poor differentiation, and immunosuppression were significantly associated with poor outcomes. In propensity score-matched case patients treated with adjuvant therapy and control patients treated with Mohs alone, there was no significant difference in progression-free survival, but matching was imperfect. LIMITATIONS: Single-institution, retrospective review. CONCLUSIONS: MMS remains an effective treatment for hrSCC. Current SCC staging systems may be limited by inconsistent inclusion of poor differentiation. Immunosuppression, especially transplant, should be considered a high-risk clinical feature. Further study is needed on the effect of adjuvant treatment.

Preventing complications in dermatologic surgery: Presurgical concerns.

Cutaneous surgery has become critical to comprehensive dermatologic care, and dermatologists must therefore be equipped to manage the risks associated with surgical procedures. Complications may occur at any point along the continuum of care, and therefore assessing, managing, and preventing risk from beginning to end becomes essential. This review focuses on preventing surgical complications pre- and postoperatively as well as during the surgical procedure.

Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns.

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

Janus Kinase Inhibitors and Non-Melanoma Skin Cancer.

OPINION STATEMENT: JAK (janus kinase) inhibitors are becoming increasingly prescribed for various conditions from dermatologic diseases to graft versus host disease in bone marrow transplant recipients. This class of drugs has been found to be truly life-changing for many, though they are not without potential adverse effects. While JAK inhibitors have not been shown to significantly increase the risk of non-melanoma skin cancer (NMSC) in large scale clinical trials, NMSC is one of the most concerning possible adverse events, and there have been several reported cases of aggressive squamous cell carcinomas, especially in our already immunosuppressed patient populations. In these patients, it is incredibly important that patients are on the lowest possible dosage of the JAK inhibitor. In addition, these patients must be routinely screened by a dermatologist with a comprehensive skin exam to ensure early detection if skin cancer was to develop. For those patients diagnosed with skin cancer, early intervention is key to optimize outcomes, and at times, multi-disciplinary care coordination is needed. In the future, large-scale studies with longer follow-up of patients would help determine whether JAK inhibitors significantly increase the risk of NMSC.

Nail Unit Melanoma In Situ Treated With Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is under used in the treatment of nail unit melanoma in situ (MIS), with limited studies in the literature. OBJECTIVE: Report clinical outcomes for nail unit MIS using MMS with melanoma antigen recognized by T cells-1 (MART-1) immunostaining. METHODS: A retrospective observational study at a single academic institution of patients with a diagnosis of nail unit MIS treated with MMS with MART-1 immunostaining from January 1, 2006, to December 30, 2016. The primary outcome measure was the recurrence rate after MMS. RESULTS: Fourteen patients were identified. With an average follow-up of 6.0 years (71.6 months; range = 5-139 months), 1 patient developed recurrence 6.6 years after undergoing initial MMS, requiring amputation with no further treatment or recurrence thereafter. CONCLUSION: Mohs micrographic surgery for nail unit MIS offers a high cure rate similar to other surgical modalities and can reduce the need for digital amputation. The evolution of the Mohs technique over time, namely, using MART-1 immunostaining, has led to improvement in treatment outcomes. Performing complete nail unit excision with nail plate remaining intact attached to the nail bed may also contribute to improved outcomes. Further refinement in technique and more data are necessary to continue to advance this treatment.

Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment.

BACKGROUND: Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. OBJECTIVE: To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. MATERIALS AND METHODS: Multi-center, prospective discrete choice experiment (DCE). RESULTS: Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. CONCLUSION: Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.

Opioid Prescribing Recommendations After Mohs Micrographic Surgery and Reconstruction: A Delphi Consensus.

BACKGROUND: Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence. OBJECTIVE: To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction. METHODS: This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval. RESULTS: Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid. CONCLUSION: Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.

Systematic Review of Technical Variations for Mohs Micrographic Surgery for Melanoma.

BACKGROUND: Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies. OBJECTIVE: To define variations in published techniques for MMS for melanoma. METHODS AND MATERIALS: A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS. RESULTS: Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma. CONCLUSION: Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.

Pink nodule of the chin: an unusual presentation of metastatic carcinoma.

Renal cell carcinoma (RCC) is the most lethal urological tumor, often because it is widely metastasized at the time of diagnosis. There are reports of cutaneous metastases, most commonly to the head and neck, presenting late after RCC is diagnosed. This case presentation explores a 45-year old female patient with a growing skin lesion on her chin, previously treated as an epidermoid cyst before presenting to dermatology clinic. We present a case of cutaneous metastatic clear cell renal cell carcinoma presenting 7 years after initial diagnosis.