The Two-Stage Folded Paramedian Forehead Flap Without Cartilage Grafts for Full Thickness Distal Nasal Defects: A Review of 35 Patients.

BACKGROUND: Full thickness defects of the ala, soft triangle, and nasal tip involving the nasal lining have traditionally been repaired with the three-stage folded paramedian forehead flap (FPFF), with a cartilage graft for support. For similar defects, the authors utilize the two-stage FPFF without cartilaginous support which provides reproducible functional and aesthetic results.  Objective: To describe the authors’ experience with the two-stage FPFF, including outcomes, complications, and design modifications to enhance functional and aesthetic success.  Methods: An IRB-approved retrospective database review of FPFF was performed at two sites. Using postoperative photographs, outcomes were assessed by blinded non-investigator dermatologist raters using a modified observer scar assessment scale. RESULTS: Thirty-five patients were reconstructed using the two-stage FPFF without cartilage grafts. Subjective assessment of scar vascularity, pigment, relief, and thickness by 3 independent reviewers yielded an overall cosmesis score of 8.4±1.9 (out of 40). CONCLUSION: The two-stage FPFF without cartilage grafts is a reliable, cosmetically elegant repair that can provide optimal functional and aesthetic results for complex unilateral distal nose defects.J Drugs Dermatol. 2024;23(4): doi:10.36849/JDD.7358.

Factors Influencing General Dermatologists When Referring Patients With Head and Neck Melanoma for Mohs Micrographic Surgery: A Nationwide Cross-Sectional Survey.

BACKGROUND: Mohs micrographic surgery (MMS) for cutaneous melanoma has demonstrated higher cure rates, lower local recurrence rates, and improved survival compared with wide local excision (WLE). However, factors affecting referrals by general dermatologists for MMS of head and neck melanoma (HNM) are unknown. OBJECTIVE: To elucidate referral factors and treatment perspectives of general dermatologists regarding MMS for melanoma in situ (MIS)/lentigo maligna (LM) and early-stage melanoma on the head and neck. MATERIALS AND METHODS: A cross-sectional analysis was performed using survey responses of general dermatologists with membership in the American Academy of Dermatology . RESULTS: A total of 231 and 132 of the 402 responding general dermatologists routinely referred melanoma in situ MIS/LM and early invasive melanoma for MMS, respectively. Lack of local access to a Mohs surgeon was the most common deterring reason for MIS/LM referral to MMS, whereas the preference for WLE was the most common deterring reason for early invasive melanoma. CONCLUSION: Lack of local access to a Mohs surgeon treating HNM with MMS is the primary barrier in referrals to Mohs surgeons for MIS and LM. Among general dermatologists, WLE is preferred for early invasive HNM.

Patients are Willing and Successful With Home Suture Removal After Mohs Surgical Procedures.

BACKGROUND: Suture removal after surgery is low risk; however, it is often performed by a medical provider. The current SARS-CoV-2 pandemic has forced providers to assess means of reducing in-person contact. OBJECTIVE: To determine whether patients undergoing Mohs surgery are willing and successful with home suture removal. MATERIALS AND METHODS: A prospective study was performed with patients undergoing Mohs surgery. Before their surgery, patients were assessed for their willingness to remove sutures before and after viewing educational material. Patients who were willing to attempt removal were contacted after expected suture removal date to verify success and assess their experience. RESULTS: One hundred fifty patients were enrolled in the study. 90.1% were willing to attempt home suture removal. Patients were more willing ( p = .003), more confident ( p = .024), and had lower anxiety ( p = .049) with removal after viewing educational resources. Patients with a history of suture removal were more likely to attempt removal after their procedure ( p = .036). Ninety-seven percent of patients who were willing to attempt suture removal were successful. There were no major complications with removal. CONCLUSION: Patients were overwhelmingly successful with suture removal after an educational intervention. Providers should consider providing this option after surgical procedures when clinically appropriate.

Impact of the COVID Pandemic on Mohs Micrographic Surgery: A Nationwide Survey.

BACKGROUND: At the onset of the COVID-19 pandemic, many Mohs micrographic surgeries (MMS) were delayed over concerns for propagating further infectious spread and scarcity of medical resources. OBJECTIVE: To assess the impact of the pandemic on MMS and the treatment of skin cancer Methods and Materials: An electronic survey was sent to fellowship trained Mohs surgeons to assess patient outcomes, practice viability, and physician sentiment related to performing MMS during the COVID-19 pandemic. RESULTS: Of the 303 respondents, 82% reported declines in case volume for at least 3 months, and average case difficulty increased for 69% of surgeons following these delays. Instances of local tumor spread following delays were seen by 69% of respondents, and 20% noted cases of regional or systemic metastasis. Only 8 cases of staff testing positive (and 7 cases of patients) were reported, and 97% of respondents felt comfortable performing MMS during the pandemic. Private practice surgeons more often viewed practice restriction recommendations negatively initially (42% vs 26% in academics, P=0.03) and in hindsight (63% vs 36% in academics, P<0.001). CONCLUSIONS: Mohs surgeon’s ability to minimize spread of COVID-19 during routine patient care, alongside potential risks of delaying treatment of skin cancers, should be considered in future recommendations for patient care. J Drugs Dermatol. 2022;21(5):545-547. doi:10.36849/JDD.6189.

Most Patient-Oriented Video Resources Do Not Comprehensively Explain Mohs Micrographic Surgery.

Mohs micrographic surgery (MMS) is increasingly utilized for treatment of skin cancer, however the technique used is markedly different than other surgical modalities.1,2 Explaining MMS to patients is difficult, and anxiety following a skin cancer diagnosis likely leads many to seek out additional resources to supplement their understanding.3,4.

Patients Frequently Overestimate Their Comprehension of Common Mohs Micrographic Surgery Terms: A Cross-Sectional Survey.

BACKGROUND: Patients who understand their diagnosis and treatment are more likely to be satisfied with their care and more compliant with treatment. Dermatologic surgery is a specialized field with associated jargon that many patients may not understand. OBJECTIVE: The aim of the study was to assess patient understanding of dermatology medical terminology. METHODS: This was a single-blinded study conducted with patients 18 years and older from an academic dermatology clinic surveying patients on 12 terms that are frequently used in dermatologic surgery. Participants rated their level of confidence in their understanding of each term using a 5-point Likert scale, followed by explaining the definition of the term. 3 blinded physicians graded each participant’s definition using a 5-point scale of accuracy of understanding, designed to mimic the Likert scale. RESULTS: A total of 200 respondents completed the survey (96% response rate). The average term perceived understanding was 3.90 ±0.66, the average term accuracy was 3.26±0.93. Patients overestimated their understanding 44% of the time, and underestimated their knowledge 17% of the time. The terms with the lowest respondent confidence were the terms secondary intention, Mohs, and flaps. The terms with the lowest respondent accuracy was secondary intention, defect, and Mohs surgery. CONCLUSION: There is a gap in knowledge in commonly used dermatologic surgery terms among patients. Certain demographics appear to be more at risk for not understanding medical jargon or overestimating their understanding of terms. Obtaining these patient demographics may help to identify patients needing additional education regarding dermatologic surgery. J Drugs Dermatol. 2021;20(11):1252-1254. doi:10.36849/JDD.6174.

Transformation of Chlorofluorocarbons Investigated via Stable Carbon Compound-Specific Isotope Analysis.

Compound-specific isotope analysis (CSIA) is a valuable tool in contaminant remediation studies. Chlorofluorocarbons (CFCs) are ozone-depleting substances previously thought to be persistent in groundwater under most geochemical conditions but more recently have been found to (bio)transform in some laboratory experiments. To date, limited applications of CSIA to CFCs have been undertaken. Here, biotransformation-associated carbon isotope enrichment factors, εC,bulk for CFC-113 (εC,bulk = -8.5 ± 0.4‰) and CFC-11 (εC,bulk = -14.5 ± 1.9‰), were determined. δ13C signatures of pure-phase CFCs and hydrochlorofluorocarbons were measured to establish source signatures. These findings were applied to investigate potential in situ CFC transformation in groundwater at a field site, where carbon isotope fractionation of CFC-11 suggests naturally occurring biotransformation by indigenous microorganisms. The maximum extent of CFC-11 transformation is estimated to be up to 86% by an approximate calculation using the Rayleigh concept. CFC-113 δ13C values in contrast were not resolvably different from pure-phase sources measured to date, demonstrating that CSIA can aid in identifying which compounds may, or may not, be undergoing reactive processes at field sites. Science and public attention remains focused on CFCs, as unexplained source inputs to the atmosphere have been recently reported, and the potential for CFC biotransformation in surface and groundwaters remains unclear. This study proposes δ13C CSIA as a novel application to study the fate of CFCs in groundwater.

The Current State of Mohs Surgery for the Treatment of Melanoma: A Nationwide Cross-Sectional Survey of Mohs Surgeons.

BACKGROUND: The increased use of Mohs micrographic surgery (MMS) to treat melanoma has been accompanied by wide variations in practice patterns and a lack of best practice guidelines. OBJECTIVE: The present study was a nationwide cross-sectional survey of Mohs surgeons to elucidate commonalities and variations in their use of MMS to treat melanoma. MATERIALS AND METHODS: A cross-sectional analysis was performed using survey responses of Mohs surgeons with membership in the American College of Mohs Surgery. RESULTS: A total of 210/513 (40.9%) participants used MMS to treat melanoma of any subtype and 123/210 (58.6%) participants within this group treated invasive T1 melanoma (AJCC Eighth Edition) with MMS. A total of 172/210 (81.9%) participants debulked melanoma in situ (MIS). Average margin size of the first Mohs stage for MIS was 4.96 ± 1.74 mm. A total of 149/210 (71.0%) participants used immunohistochemical stains, with 145/149 (97.3%) using melanoma antigen recognized by T-cells 1 (MART-1) in 96.5% of melanoma cases treated with MMS. CONCLUSION: Over half of surveyed Mohs surgeons treating melanoma with MMS are treating early invasive melanoma with MMS. Most Mohs surgeons treating melanoma with MMS debulk MIS and virtually all use MART-1 when excising invasive melanoma with MMS.

Relative Efficacy of Nonoperative Treatment of Keratoacanthomas.

BACKGROUND: Keratoacanthomas (KAs) are neoplasms of squamous epithelium which exhibit rapid growth and are often difficult to distinguish clinically from squamous cell carcinoma. Excision is the most common treatment, but in refractory cases or for KAs in cosmetically sensitive areas, nonoperative modalities may be better suited. OBJECTIVE: To compare efficacies of topical and intralesional therapies for the treatment of KAs. METHODS: A systematic literature review was performed using Medline, Ovid, and Embase. Studies looking at the efficacy of topical or intralesional treatments for KAs were included. To compare efficacy, 2-tailed t-tests were performed, with P < .05 considered statistically significant. RESULTS: Forty-one studies were identified across 5 modalities. Both topical and intralesional treatments had high KA eradication rates (92%-100%). Intralesional 5-fluorouracil led to faster KA healing times when compared to intralesional methotrexate (3.7 vs 4.6 weeks, P = .017). Similarly, topical 5-fluorouracil led to faster time to heal than topical imiquimod (3.8 vs 7.6 weeks with imiquimod, P < .0001). CONCLUSION: For nonoperative treatment of KAs, strong evidence currently exists for both topical and intralesional therapies. Decisions on which modality to use should be made on a case-by-case basis.

Corrigendum: Successful non-operative treatment of eruptive keratoacanthomas refractory to excision.

The original article was published on March 15, 2020 and corrected on June 15, 2020. The revised version of the article corrects an Author's name. The changes appear in the revised online PDF copy of this article.

Successful non-operative treatment of eruptive keratoacanthomas refractory to excision.

Keratoacanthomas are rapidly growing neoplasms of squamous epithelium. Despite their benign nature, they are often difficult to distinguish from squamous cell carcinoma and require excision. In cases in which excision is not successful or not desired, intralesional treatments may be considered. However, limited research exists on individual therapeutic efficacy. We present a 68-year-old man who developed multiple eruptive keratoacanthomas around the wound edge of a previous keratoacanthoma excision. Considering previous excisional failure, intralesional 5-fluorouracil was used as a treatment modality. Injections every 3-4 weeks over a course of 12 weeks induced clinical keratoacanthoma clearance with excellent cosmetic results. This case showcases that weekly intralesional 5-fluorouracil injections, as was the standard mode of treatment in previous case reports, may not be necessary. This less frequent injection strategy is more convenient for the patient and may lead to fewer treatments and less medication necessary. Although a case-by-case basis is needed for any alternative approach to keratoacanthoma treatment, this report is useful for the practicing clinician in showing that 5-fluorouracil may be efficacious in these difficult-to-treat patients.

The bicycle wheel analogy for linear closures of small suborbital cheek defects.

Primary closure of suborbital skin defects can cause tension along the closure resulting in ectropion. The bicycle wheel analogy is a simple yet effective guide to aid in reducing tension vectors resulting in ectropion.

Patients use more topical medication when the medications come in a larger container.

INTRODUCTION: Research shows that individuals consume more calories when provided with a larger portion size. It is unclear if similar behavior translates to topical medication use. The impact of container size and provider instructions on patient usage of topical medications has yet to be assessed. METHODS: Data was collected from 128 participants in an IRB randomized, controlled trial. To a marked 3cmx8cm rectangle on the forearm, patients applied petroleum jelly from either a large container or a small tube. Pre and post application container weights were measured. RESULTS: Patients applied more topical medication from the large container compared to the small tube. CONCLUSION: Topical medication usage is influenced by the size of the container provided. It is beneficial to consider container size when prescribing topical medications and greater application is desired.

Proteogenomics Reveals Novel Reductive Dehalogenases and Methyltransferases Expressed during Anaerobic Dichloromethane Metabolism.

Dichloromethane (DCM) is susceptible to microbial degradation under anoxic conditions and is metabolized via the Wood-Ljungdahl pathway; however, mechanistic understanding of carbon-chlorine bond cleavage is lacking. The microbial consortium RM contains the DCM degrader "Candidatus Dichloromethanomonas elyunquensis" strain RM, which strictly requires DCM as a growth substrate. Proteomic workflows applied to DCM-grown consortium RM biomass revealed a total of 1,705 nonredundant proteins, 521 of which could be assigned to strain RM. In the presence of DCM, strain RM expressed a complete set of Wood-Ljungdahl pathway enzymes, as well as proteins implicated in chemotaxis, motility, sporulation, and vitamin/cofactor synthesis. Four corrinoid-dependent methyltransferases were among the most abundant proteins. Notably, two of three putative reductive dehalogenases (RDases) encoded within strain RM's genome were also detected in high abundance. Expressed RDase 1 and RDase 2 shared 30% amino acid identity, and RDase 1 was most similar to an RDase of Dehalococcoides mccartyi strain WBC-2 (AOV99960, 52% amino acid identity), while RDase 2 was most similar to an RDase of Dehalobacter sp. strain UNSWDHB (EQB22800, 72% amino acid identity). Although the involvement of RDases in anaerobic DCM metabolism has yet to be experimentally verified, the proteome characterization results implicated the possible participation of one or more reductive dechlorination steps and methyl group transfer reactions, leading to a revised proposal for an anaerobic DCM degradation pathway.IMPORTANCE Naturally produced and anthropogenically released DCM can reside in anoxic environments, yet little is known about the diversity of organisms, enzymes, and mechanisms involved in carbon-chlorine bond cleavage in the absence of oxygen. A proteogenomic approach identified two RDases and four corrinoid-dependent methyltransferases expressed by the DCM degrader "Candidatus Dichloromethanomonas elyunquensis" strain RM, suggesting that reductive dechlorination and methyl group transfer play roles in anaerobic DCM degradation. These findings suggest that the characterized DCM-degrading bacterium Dehalobacterium formicoaceticum and "Candidatus Dichloromethanomonas elyunquensis" strain RM utilize distinct strategies for carbon-chlorine bond cleavage, indicating that multiple pathways evolved for anaerobic DCM metabolism. The specific proteins (e.g., RDases and methyltransferases) identified in strain RM may have value as biomarkers for monitoring anaerobic DCM degradation in natural and contaminated environments.

Biotic and Abiotic Dehalogenation of 1,1,2-Trichloro-1,2,2-trifluoroethane (CFC-113): Implications for Bacterial Detoxification of Chlorinated Ethenes.

Chlorofluorocarbons including 1,1,2-trichloro-1,2,2-trifluoroethane (CFC-113) often occur in groundwater plumes comingled with chlorinated solvents such as trichloroethene (TCE). We show that CFC-113 inhibits reductive dechlorination by Dehalococcoides mccartyi (Dhc) in a concentration-dependent manner, causing cis-1,2-dichloroethene (cis-DCE) stalls. Following a 17-day exposure of Dhc-containing consortium SDC-9 to 76 µM CFC-113, cis-DCE dechlorination activity did not recover after CFC-113 removal. River sediment microcosms demonstrated that CFC-113 was subject to microbial degradation under anoxic conditions, and chlorotrifluoroethene (CTFE) was observed as a transformation product. No degradation of CFC-113 was observed in killed controls and in incubations with reactive minerals including mackinawite, green rust, magnetite, and manganese dioxide. In vitro experiments with reduced corrinoid (i.e., vitamin B12) mediated reductive dechlorination of CFC-113 to CTFE and trifluoroethene (TFE) followed by reductive defluorination of TFE to cis-1,2-difluoroethene (cis-DFE) as an end product. This biomimetic degradation of CFC-113 to cis-DFE was also demonstrated in vivo using the corrinoid-producing homoacetogen Sporomusa ovata, suggesting the cometabolic microbial reductive dechlorination and reductive defluorination of CFC-113 to cis-DFE is feasible under anoxic in situ conditions. The CFC-113 degradation intermediates CTFE, TFE, and cis-DFE did not inhibit TCE dechlorination by Dhc, indicating that the initial reductive transformation step can overcome cis-DCE stalls.

Relative efficacy of systemic treatments for atopic dermatitis.

BACKGROUND: Systemic medications are often required for severe atopic dermatitis (AD) refractory to topical therapies. Biologic medications are a recent advancement in the field and a comparison with standard systemic approaches would be beneficial. OBJECTIVE: To compare efficacies of systemic therapies for the treatment of AD. METHODS: A systematic literature review was performed using Medline, Ovid, and Embase. Randomized controlled trials looking at the efficacy of systemic treatments for AD in adults and children were included. RESULTS: A total of 41 studies met criteria and were included in our final analysis. Consistent improvements in Eczema Area and Severity Index and Scoring Atopic Dermatitis were reported with dupilumab and cyclosporine. Phase 2 clinical trials for lebrikizumab and tralokinumab were effective and would benefit from phase 3 trials. No study reported efficacy of biologic medications in pediatric patients; however, cyclosporine improved clinical severity by the greatest amount in this group. LIMITATIONS: A lack of well controlled comparison studies make direct comparisons between the treatments difficult. CONCLUSION: For treatment of severe AD, the strongest evidence currently exists for dupilumab and cyclosporine at improving clinical disease severity. Further research is required to determine long-term safety and efficacy of biologic medications.

The 5 P's of Pyoderma Gangrenosum

The diagnosis of pyoderma gangrenosum (PG) is often difficult to establish based on a clinical presentation, which can mimic other dermatologic conditions. The formation of a mnemonic that incorporates the most prevalent clinical features of PG could aid in accuracy and speed of diagnosis. The 5 P's of PG: Painful, Progressive, Purple, Pretibial, Pathergy, and systemic associations, incorporate parameters recognizable on the first encounter with a patient with PG without reliance on histopathology and laboratory findings or treatment response. We postulate that this simple mnemonic will have the most utility with non-dermatology clinicians encountering a lesion suspicious for PG. By assisting in differential diagnosis formation, this mnemonic may lead to timelier biopsies and treatment initiation. The limitations of this approach mirror those of other studies and include lower sensitivities in patients with an atypical PG presentation. In conclusion, the 5 P's of PG offer a useful mnemonic for the diagnosis of PG, particularly in the initial clinical diagnosis prior to skin biopsy and treatment. J Drugs Dermatol. 2019;18(12):1282-1283.

Operative Management for Pediatric and Adolescent Scaphoid Nonunions: A Meta-analysis.

INTRODUCTION: Scaphoid fractures in the pediatric population represent ∼3% of all hand and carpal fractures. Cast immobilization has been shown to yield excellent results in the acute phase, however some patients develop nonunions. Currently, there is no consensus regarding the best surgical treatment after development of a pediatric/adolescent scaphoid nonunion. METHODS: A comprehensive literature review was performed utilizing Medline, Ovid, and Embase databases to compare surgical techniques for adolescent scaphoid nonunions on the basis of union rates, functional outcomes, and operative complications. Our initial search returned 2110 publications. Inclusion criteria consisted of a scaphoid fracture with >3 months of no clinical or radiographic improvement after cast immobilization and age less than 18 years. Ultimately, 11 studies met our criteria and were included in the final analysis. RESULTS: A total of 176 surgically treated pediatric/adolescent scaphoid nonunions were identified from the 11 studies, including 157 nonvascularized bone graft procedures and 19 nongrafted rigid fixation procedures. Patients treated with a nongrafted method achieved union with a total random effects model revealing a union rate of 94.6%, whereas the grafted cohort had a union rate of 94.8%. Functional outcomes including range of motion and grip strength were significantly improved in both cohorts. Patients managed operatively with bone graft had 4 complications, in contrast those without bone grafting did not report complications (P=0.9). CONCLUSION: Surgical treatment of pediatric/adolescent scaphoid fracture nonunions produce excellent union rates and functional outcomes after surgical intervention, using both grafted and nongrafted techniques. Future prospective studies are needed to assess if the outcomes of a specific technique are more favorable, as well as to determine if differences exist based on fracture location. LEVEL OF EVIDENCE: Level III. This study is a meta-analysis of studies containing level of evidence of III or greater.

The cotton tipped applicator - a scratch for the itch and more during dermatologic surgery.

An itch during surgery can be distracting. Sterile cotton tipped applicators are inexpensive and multipurpose tools that may be used for a variety of simple surgical tasks such as scratching an itch on the surgeon or patient's face. They may also be used to adjust glasses and turn on surgical lights or the electrocautery machine.

Dual Carbon-Chlorine Isotope Analysis Indicates Distinct Anaerobic Dichloromethane Degradation Pathways in Two Members of Peptococcaceae.

Dichloromethane (DCM) is a probable human carcinogen and frequent groundwater contaminant and contributes to stratospheric ozone layer depletion. DCM is degraded by aerobes harboring glutathione-dependent DCM dehalogenases; however, DCM contamination occurs in oxygen-deprived environments, and much less is known about anaerobic DCM metabolism. Some members of the Peptococcaceae family convert DCM to environmentally benign products including acetate, formate, hydrogen (H2), and inorganic chloride under strictly anoxic conditions. The current study applied stable carbon and chlorine isotope fractionation measurements to the axenic culture Dehalobacterium formicoaceticum and to the consortium RM comprising DCM degrader Candidatus Dichloromethanomonas elyunquensis. Degradation-associated carbon and chlorine isotope enrichment factors (εC and εCl) of -42.4 ± 0.7‰ and -5.3 ± 0.1‰, respectively, were measured in D. formicoaceticum cultures. A similar εCl of -5.2 ± 0.1‰, but a substantially lower εC of -18.3 ± 0.2‰, were determined for Ca. Dichloromethanomonas elyunquensis. The εC and εCl values resulted in distinctly different dual element C-Cl isotope correlations (ΛC/Cl = Δδ13C/Δδ37Cl) of 7.89 ± 0.12 and 3.40 ± 0.03 for D. formicoaceticum and Ca. Dichloromethanomonas elyunquensis, respectively. The distinct ΛC/Cl values obtained for the two cultures imply mechanistically distinct C-Cl bond cleavage reactions, suggesting that members of Peptococcaceae employ different pathways to metabolize DCM. These findings emphasize the utility of dual carbon-chlorine isotope analysis to pinpoint DCM degradation mechanisms and to provide an additional line of evidence that detoxification is occurring at DCM-contaminated sites.