Using optical coherence tomography to optimize Mohs micrographic surgery.

Mohs micrographic surgery (MMS) is considered the gold standard for treating high-risk cutaneous basal cell carcinoma (BCC), but is expensive, time-consuming, and can be unpredictable as to how many stages will be required or how large the final lesion and corresponding surgical defect will be. This study is meant to investigate whether optical coherence tomography (OCT), a highly researched modality in dermatology, can be used preoperatively to map out the borders of BCC, resulting in fewer stages of MMS or a smaller final defect. In this prospective study, 22 patients with BCC undergoing surgical excision were enrolled at a single institution. All patients had previously received a diagnostic biopsy providing confirmation of BCC and had been referred to our center for excision with MMS. Immediately prior to performing MMS, OCT was used to map the borders of the lesion. MMS then proceeded according to standard protocol. OCT images were compared to histopathology for agreement. Histopathologic analysis of 7 of 22 MMS specimens (32%) revealed a total absence of BCC, indicating resolution of BCC after previous diagnostic biopsy. This outcome was correctly predicted by OCT imaging in 6 of 7 cases (86%). Nine tumors (9/22, 41%) had true BCC and required a single MMS stage, which was successfully predicted by pre-operative OCT analysis in 7 of 9 cases (78%). The final six tumors (27%) had true BCC and required two MMS stages for complete excision; preoperative OCT successfully predicted the need for a second stage in five cases (5/6, 83.3%). Overall, OCT diagnosed BCC with 95.5% accuracy (Cohen's kappa, κ = 0.89 (p-value = < 0.01) in the center of the lesion. Following a diagnostic biopsy, OCT can be used to verify the existence or absence of residual basal cell carcinoma. When residual tumor is present that requires excision with MMS, OCT can be used to predict tumor borders, optimize surgery and minimize the need for additional surgical stages.

Field Cancerization Therapies for the Management of Actinic Keratosis: An Updated Review.

Field cancerization theory highlights that the skin surrounding actinic keratoses (AK) is also at increased risk for possible malignant transformation; thus, field-directed treatments may both reduce the risk of AK recurrence and potentially reduce the risk of development of cutaneous squamous cell carcinoma (cSCC). Photodynamic therapy (PDT) with either aminolevulinic acid (ALA) or methylaminolevulinate (MAL), as well as topical treatments such as 5-fluorouracil (5-FU), diclofenac gel, piroxicam, imiquimod, and ingenol mebutate, have all shown higher efficacy than vehicle treatments. PDT is widely recognized for its high efficacy; however, concerns for associated pain have driven new studies to begin using alternative illumination and pretreatment techniques, including lasers. Among topical treatments, a combination of 5-FU and salicylic acid (5-FU-SA) has shown to be the most effective but also causes the most adverse reactions. Tirbanibulin, a new topical agent approved for use in 2020, boasts a favorable safety profile in comparison with imiquimod, 5-FU, and diclofenac. Meanwhile, ingenol mebutate is no longer recommended for the treatment of AKs due to concerns for increased risk of cSCC development. Moving forward, an increasing number of studies push for standardization of outcome measures to better predict risk of future cSCC and use of more effective measures of cost to better guide patients. Here, we present an updated and comprehensive narrative review both confirming the efficacy of previously mentioned therapies as well as highlighting new approaches to PDT and discussing the use of lasers and novel topical treatments for treatment of AK.

Review of Fractional Nonablative Lasers for the Treatment of Dermatologic Conditions in Darker Skin Phototypes.

BACKGROUND: Fractional nonablative lasers (NAFLs) have demonstrated efficacy and safety for treating dermatologic conditions in patients with darker skin phototypes. Nonablative lasers are preferred in darker skin tones due to lower risk of postinflammatory hyperpigmentation. OBJECTIVE: This review aims to identify the ideal laser options and parameters for treating common dermatologic conditions in patients with skin types IV-VI. MATERIALS AND METHODS: A comprehensive literature search was conducted on PubMed in May 2023. Of 1,065 articles were identified, and 40 articles met the inclusion criteria. The studies were classified based on design, dermatologic condition, and skin phototype of patients, and assigned levels of evidence according to the Modified Criteria of the Oxford Center of Evidence Based Medicine. RESULTS: Strong level 1 evidence supports the treatment of melasma and atrophic scars using NAFL. Moderate level 2 evidence was found for using NAFL in acne vulgaris, striae, and skin rejuvenation; 45% of the studies examined skin types III-IV, 20% III-V, 7.5% II-IV, 5% II-V, 5% IV alone, and 2.5% I-IV. CONCLUSION: Further research is needed to determine the optimal treatment modalities and parameters for skin types V and VI. Appropriate device selection and conservative treatment settings are crucial for optimizing outcomes and minimizing adverse events.

Rapid measurement of epidermal thickness in OCT images of skin.

Epidermal thickness (ET) changes are associated with several skin diseases. To measure ET, segmentation of optical coherence tomography (OCT) images is essential; manual segmentation is very time-consuming and requires training and some understanding of how to interpret OCT images. Fast results are important in order to analyze ET over different regions of skin in rapid succession to complete a clinical examination and enable the physician to discuss results with the patient in real time. The well-known CNN-graph search (CNN-GS) methodology delivers highly accurate results, but at a high computational cost. Our objective was to build a computational core, based on CNN-GS, able to accurately segment OCT skin images in real time. We accomplished this by fine-tuning the hyperparameters, testing a range of speed-up algorithms including pruning and quantization, designing a novel pixel-skipping process, and implementing the final product with efficient use of core and threads on a multicore central processing unit (CPU). We name this product CNN-GS-skin. The method identifies two defined boundaries on OCT skin images in order to measure ET. We applied CNN-GS-skin to OCT skin images, taken from various body sites of 63 healthy individuals. Compared with CNN-GS, our described method reduced computation time by 130 [Formula: see text] with minimal reduction in ET determination accuracy (from 96.38 to 94.67%).

Hidradenitis suppurativa perspectives during the COVID-19 pandemic.

The COVID-19 pandemic created a new set of challenges regarding the care of patients with hidradenitis suppurativa (HS). Access to safe, timely medical care and the use of immunosuppressive therapy were central topics of concern for patients and providers. In addition, the incidence and severity of SARS-CoV-2 infection in patients with HS were critical to examine during the evolving pandemic and to provide recommendations for patients for makinginformed decisions about their disease and its management. Another consideration of the COVID-19 pandemic was the role of the internet to connect individuals with HS with each other and experts in the field. This is a unique contribution that collectively examines the perspectives of HS medical care and support during the COVID-19 pandemic.

Optical coherence tomography confirms non-malignant pigmented lesions in phacomatosis pigmentokeratotica using a support vector machine learning algorithm.

INTRODUCTION: Phacomatosis pigmentokeratotica (PPK), an epidermal nevus syndrome, is characterized by the coexistence of nevus spilus and nevus sebaceus. Within the nevus spilus, an extensive range of atypical nevi of different morphologies may manifest. Pigmented lesions may fulfill the ABCDE criteria for melanoma, which may prompt a physician to perform a full-thickness biopsy. MOTIVATION: Excisions result in pain, mental distress, and physical disfigurement. For patients with a significant number of nevi with morphologic atypia, it may not be physically feasible to biopsy a large number of lesions. Optical coherence tomography (OCT) is a non-invasive imaging modality that may be used to visualize non-melanoma and melanoma skin cancers. MATERIALS AND METHOD: In this study, we used OCT to image pigmented lesions with morphologic atypia in a patient with PPK and assessed their quantitative optical properties compared to OCT cases of melanoma. We implement a support vector machine learning algorithm with Gabor wavelet transformation algorithm during post-image processing to extract optical properties and calculate attenuation coefficients. RESULTS: The algorithm was trained and tested to extract and classify textural data. CONCLUSION: We conclude that implementing this post-imaging machine learning algorithm to OCT images of pigmented lesions in PPK has been able to successfully confirm benign optical properties. Additionally, we identified remarkable differences in attenuation coefficient values and tissue optical characteristics, further defining separating benign features of pigmented lesions in PPK from malignant features.

Noninvasive imaging exploration of phacomatosis pigmentokeratotica using high-frequency ultrasound and optical coherence tomography: Can biopsy of PPK patients be avoided?

BACKGROUND: Phacomatosis pigmentokeratotica (PPK) is a distinct and rare type of epidermal nevus syndrome characterized by coexisting nonepidermolytic organoid sebaceous nevus (SN) with one or more speckled lentiginous nevi (SLN). Atypical nevi including compound Spitz and compound dysplastic may manifest within regions of SLN. Patients with PPK, or similar atypical nevus syndromes, may be subject to a significant lifetime number of biopsies, leading to pain, scarring, anxiety, financial burden, and decreased quality of life. The current literature includes case reports, genetics, and associated extracutaneous symptoms of PPK, but use of noninvasive imaging techniques have not been explored. We aim to investigate the value of high-frequency ultrasound (HFUS) and optical coherence tomography (OCT) in discriminating morphological features of pigmented lesions and nevus sebaceous within one patient with PPK. MATERIALS AND METHODS: Two modalities, (1) HFUS imaging, based on acoustic properties and (2) OCT imaging, based on optical properties, were used to image a patient with PPK. Benign pigmented lesions, which may raise clinical suspicion for significant atypia, and nevus sebaceous, were selected on different areas of the body to be studied. RESULTS: Five pigmented lesions and one area of nevus sebaceous were imaged and analyzed for noninvasive features. Distinct patterns of hypoechoic features were seen on HFUS and OCT. CONCLUSION: HFUS provides a deep view of the tissue, with ability to differentiate gross structures beneath the skin. OCT provides a smaller penetration depth and a higher resolution. We have described noninvasive features of atypical nevi and nevus sebaceous on HFUS and OCT, which indicate benign etiology.

Combination Approaches to Hand Rejuvenation: A Review of the Literature and Discussion.

BACKGROUND: Various noninvasive/minimally invasive modalities for hand rejuvenation exist, and the efficacy and safety of these procedures as both monotherapy and same-day procedures is increasingly being studied. OBJECTIVE: To review data on the efficacy and safety of hand rejuvenation modalities and suggest a practical combination approach for these procedures. METHODS: The PubMed database was queried for peer-reviewed articles regarding hand rejuvenation techniques, including chemical peels, laser and light sources, sclerotherapy, autologous fat transfer, and injectable volumetric fillers. RESULTS: Chemical peels have been studied the least, with most studies evaluating the use of fillers and laser/light-based devices. Most studies reported overall good results with high patient satisfaction. Satisfaction rates were lower in laser/light-based treatments compared with other modalities. Transient erythema, edema, or pain after procedures was common; most studies did not report serious postprocedure complications. Importantly, there was no significant increase in adverse effects after same-day procedures. CONCLUSION: Using same-day procedures allows practitioners to address hand rejuvenation from different aspects, seems to improve outcomes, and reduces time spent in the office for patients. The authors suggest a practical framework for combining cosmetic approaches to achieve the most optimal outcome for hand rejuvenation.

Smoking as a Risk Factor for Forehead Flap Wound Outcomes: An Analysis of 1030 Patients.

Background: The forehead flap is a local transposition flap based on a pedicled vessel commonly used to reconstruct facial defects. Often patients requiring reconstructions are smokers, yet the effects of smoking on forehead flaps are not well defined. Our study is aimed to examine smoking as a preoperative risk factor for complications following forehead flaps. Methods: This retrospective cohort study used data collected from the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2019. Multivariate logistic regression models were fitted to evaluate the association between smoking and development of wound complications. Results: A total of 1030 forehead flaps cases were analyzed and separated into 2 cohorts based on current smoking status: 789 (76.6%) nonsmokers versus 241 (23.4%) smokers. No significant differences in rates of wound complications were found for nonsmokers versus smokers (2.7% vs 4.1%; P = .0807), including when adjusted for comorbidities in a multivariate logistic regression model (adjusted odds ratio, 1.297 [95% confidence interval, 0.55-2.9]; P = .5174). Conclusions: Smoking has been demonstrated to be a risk factor for plastic surgery procedures. However, in our review of 1030 forehead flaps, smokers did not have worse outcomes compared with nonsmokers. Although it is still advised to recommend smoking cessation given multiple health benefits, smoking status should not preclude candidacy for facial reconstruction with a forehead flap based on complication risk.

Pediatric Hospitalizations for Atopic Dermatitis in the United States; Characteristics Associated with the Atopic Triad.

Atopic dermatitis (AD) is one of the most common skin disorders in pediatric patients. Many patients with AD also have asthma and/or allergic rhinitis; when combined, these constitute the atopic triad.1 This study characterized US pediatric patients hospitalized with a primary diagnosis of AD or Eczema (AD-E) and determined characteristics associated with the coexistence of additional diagnoses in the triad. A retrospective analysis was performed, including a multivariate logistic regression model, with data from the 2012 to 2017 National Inpatient Sample. Patients that met the inclusion criteria (N = 901) consisted predominantly of toddlers of male gender and white race. Further, 40% belonged to a household of the lowest quartile annual income and 64% were covered by Medicare/Medicaid. Mean length of stay and total charges were significantly higher for patients with AD-E plus asthma and/or allergic rhinitis when compared to patients with AD-E alone. On multivariate analysis, age and sex were significantly associated with the presence of additional atopic conditions. The mid-childhood group had the highest likelihood compared to infants, and girls had a lower likelihood compared to boys. Understanding characteristics associated with additional atopic conditions in children with AD-E as well as healthcare disparities in this population may yield early intervention, enhanced care, and improved resource allocation.

Applications of bakuchiol in dermatology: Systematic review of the literature.

BACKGROUND: Bakuchiol (BAK), a meroterpene phenol abundant in the plant Psoralea corylifolia, is an emerging cosmeceutical agent with promising anti-aging, anti-inflammatory, and antibacterial properties. The trend for "clean" skincare products and search for anti-aging retinoid alternatives have poised BAK as a "must-have" ingredient in skincare. AIMS: Our aim was to review the data for the applications of BAK in dermatology. METHODS: This is a systematic review of PubMed. RESULTS: Thirty articles matched our search terms ["Bakuchiol" and "Dermatology"] or ["Bakuchiol" and "Skin"] of which one did not meet inclusion criteria, 16 were pre-clinical studies, seven clinical studies, three commentaries, two narrative reviews, and one report on adverse events. BAK has been mostly studied for its effects on photoaging, acne, and post-inflammatory hyperpigmentation (PIH), showing beneficial results comparable to those achieved by topical retinoids. While having no structural resemblance to retinoids, BAK can function as a retinol analog, through retinol-like regulation of gene expression. In in vivo studies, BAK was used alone or in combination with other products resulting in a significant reduction in photodamage, hyperpigmentation, wrinkle scores, and acne severity. Additionally, in vitro studies hinted at its anti-cancer properties by inhibiting epidermal growth factor induced neoplastic cell transformation. Also, demonstrated potential applications in psoriasis by normalizing keratinocyte activity and in pigmentary disorders through inhibition of melanogenesis. There was one adverse event case reported of contact dermatitis in the literature. CONCLUSIONS: Bakuchiol is a retinol alternative with anti-aging, antibacterial, and anti-inflammatory properties. Additional studies are warranted to better understand its applications in dermatology.

Primary Tumor Location Predicts Survival in Melanoma: A Retrospective Cohort Study of 239,257 Melanoma Patients.

The link between primary tumor location and overall survival in melanoma has been studied in the past, but its associated population and prognostic significance is less understood. The purpose of this study was to characterize melanoma demographics and disease-specific survival (DSS) in relation to primary tumor site. Data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program were retrospectively analyzed; from 1973 to 2015, 239,257 patients diagnosed with cutaneous melanoma were included in the study and separated into three cohorts based on primary tumor site. The effect of primary location on melanoma survival was evaluated using Cox proportional hazards models. Tumors were predominantly localized and had a depth of ≤1 mm. Patients diagnosed with tumors originating in the upper and lower extremities had significantly increased DSS probability compared to those of the head and neck. Characteristics, including woman sex, married or widowed status, treated on the Pacific coast, and increasing year of diagnosis, were associated with greater DSS. Conversely, non-white or Hispanic origin, higher age at diagnosis, tumors with increased depth, or nodular or acral melanoma histology were associated with lower DSS. Primary tumor site is a significant predictive factor of DSS in cutaneous melanoma along with additional characteristics supported in our study.

Rescuing medical education in times of COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has caused widespread disruptions in various sectors of medicine, including medical education. Although the necessary focus has been on patient care and public safety and the long-lasting impact of COVID-19 remains to be determined, the impact on medical education warrants further attention and action. While it seems minuscule compared with the toll the global pandemic has caused worldwide, the impact on medical education, including graduate medical education, carries the potential to alter career progression and outcomes. We have assessed the effects of COVID-19 on dermatology clinics, residency education, and medical education, exploring recommendations and actions taken by governing bodies and offering additional suggestions of our own.

Mohs micrographic surgery as treatment option for non-basal cell or squamous cell carcinomas in the United States.

Background: Skin cancer has the highest incidence of all cancers in the United States. Conventional surgical excision (CSE) and Mohs micrographic surgery (MMS) are among the most common surgical treatment options for skin cancer.Objective: The purpose of this study was to examine utilization patterns of MMS compared to CSE in the United States for non-basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) skin cancers.Methods: Data from the NCI SEER program, collected from 1973 to 2015, were retrospectively analyzed. Cases were separated into MMS and CSE. Patient characteristics were analyzed. Multivariate models were fitted to evaluate significant predictors for MMS.Results: Of the total procedures performed during the years 1988-2015, a total of 12,654 MMS cases and 267,291 CSE were considered for analysis. Females, white, and non-Hispanic patients of increasing age were more likely to undergo MMS compared to CSE. Cases diagnosed in the pacific coast, east, and southwest regions were more likely to be treated with MMS compared to those in the northern plains Additionally, in situ cases and of the face had the highest likelihood of being treated with MMS.Conclusions: Studying demographics and tumor characteristics aid in understanding the utilization patterns of MMS.

Mohs Micrographic Surgery for the Treatment of External Ear Melanoma: an Outcome Study.

BACKGROUND: The external ear is composed of thin skin overlying cartilage making melanoma on the external ear difficult to resect while preserving the intricate anatomy. Although surgeons have achieved robust clinical outcomes for nonmelanoma and most recently melanoma skin cancers with Mohs micrographic surgery (MMS), there is still not enough evidence on the MMS application for external ear melanoma treatment. OBJECTIVE: The authors examined survival outcomes in patients treated with MMS, narrow margin excision (NME), and wide margin excision (WME) for melanoma on the external ear. METHODS: Data from the NCI SEER program was retrospectively analyzed. Patients who received surgical treatment on the external ear and had microscopically confirmed diagnosis of cutaneous melanoma were included in the study. The effect of different surgery types: MMS, NME, and WME, on melanoma survival was evaluated. RESULTS: A total of 8,212 melanoma cases of the external ear performed during the years 2000 to 2015 were considered for analysis. There were no significant differences in survival comparing NME and WME with MMS. CONCLUSION: Mohs micrographic surgery is at least equivalent to WME for the treatment of melanoma of the external ear.

Primary Malignant Melanoma of the Brain: A Population-Based Study.

BACKGROUND: Primary melanocytic neoplasms of the central nervous system (CNS) are rare and account for 1% of all melanomas. This study used the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the epidemiology of primary CNS melanoma and further characterize their treatment. METHODS: Data from the National Cancer Institute SEER program, collected from 1973-2015, were retrospectively analyzed. A total of 86 records of malignant melanoma cases with CNS as the primary site were identified, and 54 patients were studied based on the inclusion criteria. Demographic, tumor, and treatment regimen effectiveness were studied. RESULTS: A total of 54 patients were included in this study. Tumors were distributed evenly in size and localized primarily to the cerebral meninges and spinal cord. A total of 13% of patients underwent biopsy, 40.7% gross total resection (GTR), 7.4% subtotal resection (STR), 46.3% radiation therapy (RT), and 27.3% chemotherapy (CT) in a variety of treatment combinations. GTR alone and STR + RT resulted in increased disease-specific survival compared to biopsy alone, but no survival benefit was found with biopsy with RT and/or CT as well as STR alone. CONCLUSIONS: To our knowledge, this is the largest single database study completed for primary malignant melanoma of the CNS. The study identified the need for tumor resection for the proper treatment of these lesions, particularly GTR. GTR could be paired with adjuvant RT or RT + CT providing survival benefit as well. In cases when GTR is unable to be completed, STR + RT provides significant improvement in survival compared to biopsy alone.

Association between C-reactive protein and radiotherapy-related pain in a tri-racial/ethnic population of breast cancer patients: a prospective cohort study.

BACKGROUND: Post-surgery adjuvant radiotherapy (RT) significantly improves clinical outcomes in breast cancer patients; however, some patients develop cancer or treatment-related pain that negatively impacts quality of life. This study examined an inflammatory biomarker, C-reactive protein (CRP), in RT-related pain in breast cancer. METHODS: During 2008 and 2014, breast cancer patients who underwent RT were prospectively evaluated for pre- and post-RT pain. Pre- and post-RT plasma CRP levels were measured using a highly sensitive CRP ELISA kit. Pain score was assessed as the mean of four pain severity items (i.e., pain at its worst, least, average, and now) from the Brief Pain Inventory. Pain scores of 4-10 were classified as clinically relevant pain. Multivariable logistic regression analyses were applied to ascertain the associations between CRP and RT-related pain. RESULTS: In 366 breast cancer patients (235 Hispanic whites, 73 black/African Americans, and 58 non-Hispanic whites), 17% and 30% of patients reported pre- and post-RT pain, while 23% of patients had RT-related pain. Both pre- and post-RT pain scores differed significantly by race/ethnicity. In multivariable logistic regression analysis, RT-related pain was significantly associated with elevated pre-RT CRP (≥ 10 mg/L) alone (odds ratio (OR) = 2.44; 95% confidence interval (CI) = 1.02, 5.85); or combined with obesity (OR = 4.73; 95% CI = 1.41, 15.81) after adjustment for age and race/ethnicity. CONCLUSIONS: This is the first pilot study of CRP in RT-related pain, particularly in obese breast cancer patients. Future larger studies are warranted to validate our findings and help guide RT decision-making processes and targeted interventions.