The Use of a Dehydrated Complete Human Placental Membrane Allograft for Mohs Surgical Defects of the Nose.

BACKGROUND: Repair options for Mohs surgical defects include primary closure, flap or graft, or healing by second intention. These options may not be optimal in all cases. A dehydrated complete human placental membrane (dCHPM) allograft may serve as an alternative repair option. OBJECTIVE: To assess the aesthetic and functional outcomes of an alternative repair technique for Mohs surgical defects of the nose. METHODS: Twenty patients with Mohs surgical defects of the nose repaired with a dCHPM allograft were retrospectively identified. Photographs were used to demonstrate surgical technique and outcomes. Two blinded observers evaluated final outcomes using the Patient and Observer Scar Assessment Scale. RESULTS: Observers rated the scar outcome a combined mean score of 8.4 ± 3.2 (scale 5-50). Patients rated their outcomes a mean of 12.6 ± 7.4 (scale 6-60). The mean "Overall Opinion score" was 2.5 ± 1.8 by patients and 1.9 ± 1.3 by observers (scale 1-10). LIMITATIONS: This was a single institution study with a small sample size. CONCLUSION: Our study demonstrates that dCHPM allografts are a viable alternative repair option for Mohs surgical defects of the nose.

Polidocanol: A Review of Off-Label Dermatologic Uses.

BACKGROUND: Polidocanol is an FDA-approved treatment of incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system, but numerous other off-label dermatological applications have been reported. OBJECTIVE: To describe the various off-label dermatological clinical uses of polidocanol, as well as efficacy and adverse effects. METHODS: The review of studies searchable on PubMed from 2004 to 2021 describing clinical uses of polidocanol to determine efficacy and adverse effects associated with various dermatologic applications. RESULTS: Polidocanol has shown efficacy in the treatment of mucocele of minor salivary gland, hemangioma, upper extremity veins, reticular veins of the chest, facial veins, pyogenic granuloma, lymphangioma circumscriptum, digital mucous cyst, mixed skin ulcers, cutaneous focal mucinosis, seromas, glomuvenous malformations, acne cysts, lymphocele, and dissecting cellulitis. Commonly reported side effects include pain, erythema, swelling, ecchymosis, and ulceration. Most sources were case reports and small prospective studies, as such the strength of data supporting many uses is limited by small sample sizes and lack of controls. CONCLUSION: Although polidocanol is currently only FDA approved for incompetent great saphenous veins, accessory saphenous veins, and visible varicosities of the great saphenous vein system, the use of polidocanol has been selected for a variety of off-label clinical applications.

PD-1 inhibitors for cutaneous squamous cell carcinoma: A meta-analysis.

PD-1 inhibitors are immunotherapeutic agents used in the treatment of advanced cutaneous squamous cell carcinoma (cSCC). This study aimed to determine the pooled objective response and disease control rates of patients with advanced cSCC treated with PD-1 inhibitors. Pubmed, Cochrane Library and EMBASE databases were searched up to 1 January 2021 to include eligible articles. Objective response rate (ORR) and disease control rate (DCR) were pooled and analysed. Subgroup analysis of the odds ratio (OR) for ORR for patients by PD-L1 tumour proportion score (TPS) was performed. Seven articles including a total of 453 patients were identified and included. Pooled estimate of ORR was 44% (95% CI: 39-49%, I2 = 23.7%) and of DCR was 66% (95% CI: 57-74%, I2 = 68.2%). Pooled odds ratio of ORR for patients by PD-L1 TPS was 2.81 (95% CI: 1.22-6.51, I2 = 0.0%). These results were derived from single-arm studies, some of which were retrospective. No head-to-head trials comparing PD-1 inhibitors have been reported. We present aggregate estimates of ORR and DCR for patients with advanced cSCC treated with PD-1 inhibitors, as well as subgroup analysis for ORR for patients by PD-L1 TPS.

A review of emerging and non-US FDA-approved topical agents for the treatment of basal cell carcinoma.

Although surgical therapy continues to be the gold standard for the treatment of basal cell carcinoma given high cure rates and the ability to histologically confirm tumor clearance, there are a number of nonsurgical treatment options that may be considered based on individual tumor characteristics, functional and cosmetic considerations, patient comorbidities and patient preference. Topical 5-fluorouracil 5% cream and imiquimod 5% cream have been US FDA-approved for the treatment of superficial basal cell carcinoma. Additionally, a number of new and emerging topical agents and techniques have been described for the treatment of basal cell carcinoma and will be reviewed herein.

Lay abstract Treatment of basal cell carcinoma is important, as untreated tumors can grow and invade underlying tissue. Surgery has the highest cure rate for basal cell carcinoma. However, there are certain scenarios where surgery may not be appropriate or possible, and there are a number of nonsurgical treatment options. In cases of low-risk basal cell carcinoma where surgery is not appropriate, topical therapy is a potential treatment option. Topical 5-fluorouracil and imiquimod have been relatively well studied. There are a number of other topical agents that have been studied for basal cell carcinoma, with varying amounts of evidence. A number of these agents are still sold online despite having limited evidence of their safety and efficacy. This review will summarize the available literature on the proposed mechanisms of action, safety and efficacy of these topical agents. It is important to note that it is critical for patients to discuss their specific case with their treating healthcare provider to discuss treatment options that are appropriate in their particular situation.

Treatment of advanced cutaneous squamous cell carcinoma: a Mohs surgery and dermatologic oncology perspective.

Locally advanced or metastatic cutaneous squamous cell carcinoma no longer amenable to surgical resection or primary radiation therapy requires an alternative approach to treatment. Until 2018, management consisted of limited systemic chemotherapies, which carried marginal clinical benefit. The introduction of immunotherapy with anti-PD-1 antibodies resulted in alternative treatment options for advanced cutaneous squamous cell carcinoma with substantial antitumor activity, durable response and acceptable safety profile. The field of immunotherapeutics continues to expand with adjuvant, neoadjuvant and intralesional studies currently in progress. Herein, the authors discuss their approach for the treatment of advanced cutaneous squamous cell carcinoma from the perspective of a Mohs surgeon and a dermatologic oncologist.

Linear lichen planus pigmentosus of the face with histological findings of lichen planopilaris - an uncommon variant of lichen planus.

Lichen planus pigmentosus and lichen planopilaris are two clinically and histologically distinct forms of lichen planus. Lichen planus pigmentosus presents with sudden onset hyperpigmented macules and patches, predominantly in darker skin phototypes. On the other hand, lichen planopilaris is a scarring follicular variant of lichen planus that presents with progressive, permanent patches of alopecia. It is not uncommon for different variants of lichen planus to clinically coexist with each other. However, to our knowledge, there has been no previous reporting of linear lichen planus pigmentosus of the face with histological features of lichen planopilaris. We herein present a hybrid case of these two entities.

Review of systemic agents in the treatment of advanced cutaneous squamous cell carcinoma.

Advanced cutaneous squamous cell carcinoma (cSCC) accounts for only 5% of all cases of cSCC but up to 60% of disease related deaths. Historically, this disease has lacked effective treatment options due to a combination of poor response rate, poor response durability and significant treatment-associated morbidity. Autumn of 2018 marked the first time ever that an agent received US FDA approval for advanced cSCC and the future is looking much brighter for this previously neglected patient population. The purpose of this article is to review the various systemic treatment options for advanced cSCC moving from the past to the present, highlighting their relative merits and shortcomings, and to briefly speculate on future developments in the field of advanced cSCC.

Emerging Nonsurgical Therapies for Locally Advanced and Metastatic Nonmelanoma Skin Cancer.

BACKGROUND: Locally advanced and metastatic nonmelanoma skin cancer (NMSC) not amenable to surgical resection requires a different approach to therapy. OBJECTIVE: To review the efficacy and adverse effects of emerging treatment options for locally advanced and metastatic NMSC. MATERIALS AND METHODS: A comprehensive search on PubMed was conducted to identify relevant literature investigating the role of program cell death 1 (PD-1) inhibitor, cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) inhibitor, epidermal growth factor receptor (EGFR) inhibitor, and Hedgehog pathway inhibitors in the treatment of NMSC. RESULTS: PD-1 inhibitor and CTLA-4 inhibitor have shown promising efficacy with tolerable side-effect profiles in the treatment of NMSC, although the number of cases reported is limited. Currently, 3 larger-scale clinical trials are investigating PD-1 inhibitor therapy for NMSC. Similarly, EGFR inhibitor demonstrated marginal success in unresectable cutaneous squamous cell carcinomas. Hedgehog pathway inhibitors were approved by the US FDA for treatment of locally advanced and metastatic basal cell carcinomas and have shown favorable efficacy. Common adverse effects included muscle spasm, alopecia, and dysgeusia. CONCLUSION: Systemic therapies including PD-1 inhibitors and CTLA-4 inhibitors have demonstrated early promising results for difficult-to-treat NMSC. Future studies are necessary to optimize treatment outcome.

Treatment of advanced basal cell carcinoma with sonidegib: perspective from the 30-month update of the BOLT trial.

Sonidegib, a hedgehog pathway inhibitor, was approved by the US FDA for the treatment of locally advanced basal cell carcinoma which cannot be readily treated with surgery or radiotherapy. The pharmacology and pharmacokinetics of sonidegib will be discussed in this review. Additionally, an in-depth analysis of the BOLT trial and data from the 30-month update will be included. This will serve as an update to a previously published article which reported the 12-month update of the BOLT trial.

Mohs Mapping Fidelity: Optimizing Orientation, Accuracy, and Tissue Identification in Mohs Surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is a highly effective process that requires consistent accuracy in resection, mapping, and histologic interpretation. Although the general sequence in MMS is similar, there are numerous variations among Mohs surgeons as to how this process is performed. OBJECTIVE: This article aims to review the process of MMS, with the intent to identify and mitigate the potential errors at each step. Existing variations will be discussed and protocols offered to minimize error and optimize accuracy. METHODS: A Pubmed search was performed for publications on methods of tissue mapping, orienting, and processing in MMS. RESULTS: Our literature review highlights various techniques for tissue orientation, transfer, flattening, inking, mapping, and processing of later stages and multiple specimens. We discuss our system, which reduces error during tissue transfer, tissue identification in vivo and ex vivo, and tissue flattening. Furthermore, we discuss adaptations to increase the accuracy during reexcisions of subsequent Mohs layers. CONCLUSION: Variations in MMS reflects the diverse training and creativity among Mohs surgeons. Unless potential errors are addressed, however, false negatives will occur and undermine the superior cure rate of MMS.

Utility of a High-Resolution Superficial Diagnostic Ultrasound System for Assessing Skin Thickness: A Cross-Sectional Study.

BACKGROUND: Compared with other imaging modalities, ultrasound is relatively deeply penetrating and can be used to evaluate deep dermal and subcutaneous structures. OBJECTIVE: Image skin thickness of the face and neck using high-frequency diagnostic ultrasound devices. MATERIALS AND METHODS: Skin overlying 20 different predesignated face and neck anatomic sites in 32 individuals was imaged using 2 commercially available high-frequency diagnostic ultrasound devices, a dedicated imaging device and a diagnostic device bundled with a therapeutic device. At each site, the subcutaneous and combined epidermal and dermal layer thicknesses were assessed by blinded expert raters. RESULTS: Similar skin thickness measurements were obtained. Notably, subcutaneous fat depth was measured to be 0.2 cm at the forehead; 0.5 cm at the mental eminence; and 0.6 cm at the submental, supraglenoid, and temporal regions. The combined epidermal and dermal thickness was approximately 0.1 cm at the zygomatic process, suborbital area, inferior malar region, gonion, supraglenoid area, and nasolabial-buccal, and nasolabial fold regions. CONCLUSION: This is the first study using high-resolution superficial diagnostic ultrasound to map skin thickness of the face and neck at standard anatomic locations. Ultrasound is an inexpensive, noninvasive, and convenient means to monitor dermatologic conditions and guide their treatment.

Atrophic dermatofibroma in an elderly male - a rarely described variant of a common lesion.

Dermatofibroma frequently presents as a red-brown nodule on the extremities of the middle aged. Atrophic dermatofibroma is a rare variant that has been most commonly described as an atrophic depressed, erythematous lesion in females. The correct diagnosis of atrophic dermatofibroma is often hindered by its infrequent presentation. It has a female preponderance with an occurrence ratio of 10:1. We describe a case of an atrophic dermatofibroma on the back of an elderly man. Skin biopsy demonstrated a spindle cell proliferation in a storiform pattern, loss of elastic fibers, and substantial atrophy of both the underlying dermis and subcutaneous tissue. An aggregation of elastic fibers was found in the periphery of the tumor. These histologic features supported the diagnosis of atrophic dermatofibroma. The dermal and adipocyte atrophy was likely responsible for the retracted appearance of the lesion.

Sodium Tetradecyl Sulfate: A Review of Clinical Uses.

BACKGROUND: Sodium tetradecyl sulfate (STS) is Food and Drug Administration approved for treatment of varicose veins, but numerous other off-label applications have been reported. OBJECTIVE: To describe the clinical uses of STS, as well as efficacy and adverse effects. METHODS: Review of studies searchable on PubMed from 1938 to 2016 describing clinical uses of STS to determine efficacy and adverse effects associated with various applications. RESULTS: Sodium tetradecyl sulfate has shown efficacy in the treatment of varicose veins, telangiectasias, hemangioma, pyogenic granuloma, cherry angioma, Kaposi sarcoma, lymphangioma circumscriptum, digital mucous cyst, ganglion cyst, glomangioma, angiokeratoma of Fordyce, pseudocyst of the auricle, and verruca. Commonly reported side effects include pain, erythema, swelling, hyperpigmentation, telangiectatic matting, and ulceration. Serious side effects such as anaphylaxis, pulmonary embolism, stroke, and myocardial infarction have also been reported. Most sources were case reports and small prospective studies, as such the strength of data supporting many uses is limited by small sample sizes and lack of controls. CONCLUSION: Although not always the most effective method of treatment in off-label usage, use of STS has been frequently selected for a variety of applications for reasons of simplicity, low cost, lack of availability of technologically advanced equipment, and intricacies related to anatomic location.

Lichenoid Dermatitis From Interferon alpha-2a in a Patient With Metastatic Renal Cell Carcinoma and Seronegative HCV.

Cutaneous reactions to interferon, including a lichenoid drug reaction, are most commonly reported in patients undergoing treatment for hepatitis C virus (HCV) infection. There have been case reports of interferon-induced lichen planus in seronegative HCV patients with lymphoproliferative disorders and melanoma. We report the case of a 71-year-old man undergoing treatment with interferon for metastatic renal cell carcinoma (RCC) who developed an eruption 2 months after starting interferon. Clinical and histological findings from biopsies supported a diagnosis of interferon-induced lichen planus. To our knowledge, this is the first known case of a lichenoid drug eruption from interferon in a seronegative HCV patient with metastatic RCC.

J Drugs Dermatol. 2017;16(7):714-716.

Metastatic neuroendocrine carcinoma in the skin.

Cutaneous metastases secondary to neuroendocrinetumors are rare. Herein we report a case of a 75-yearoldwoman who presented with a rare cutaneousmetastatic disease. She was previously diagnosed withmetastatic neuroendocrine carcinoma of unknownprimary, with metastases to liver, lung, and bone.Biopsy of the skin lesion demonstrated archetypicalpathology and positive immunohistochemicalstaining for chromogranin A and synaptophysin. Thepatient started palliative chemo-radiation therapyand passed away soon after.

Multiple eccrine spiradenomas in a zosteriform pattern.

Eccrine spiradenoma (ES) typically presents as a solitary tender lesion. Multiple ES is a rare variant of ES and can present in a segmental, linear, blaschkoid, or zosteriform pattern. The etiology of multiple ES is unknown, but several theories have been suggested including a multipotent stem cell origin. We report the case of a 30-year-old woman with multiple painful ES in a zosteriform pattern on the mid-back and abdomen. Skin biopsy of a representative lesion demonstrated a circumscribed tumor nodule encapsulated by a fibrous capsule with diffuse dense basophilic proliferation located in the dermis. The lesions were then excised on two separate sessions without recurrence.

Sonidegib for the treatment of advanced basal cell carcinoma: a comprehensive review of sonidegib and the BOLT trial with 12-month update.

The Hedgehog inhibitors are promising alternative for patients with advanced basal cell carcinoma that are not amenable to radiotherapy or surgery. Sonidegib, also known as LDE225, is an orally available SMO antagonist that was recently approved by the US FDA for the treatment of patients with locally advanced basal cell carcinoma. This article will provide an overview of the pharmacology and pharmacokinetics of sonidegib and in-depth analysis of the BOLT trial with additional data from the 12-month update. The present challenges associated with Hedgehog inhibitors will also be discussed.