Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. METHODS: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. RESULTS: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood's lamp, dermatoscope, and negative tissue controls was established in Round 2. CONCLUSIONS: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.

Efficacy of an educational intervention with kidney transplant recipients to promote skin self-examination for squamous cell carcinoma detection.

OBJECTIVES: To develop easily disseminated educational materials that enable early detection of skin cancer, and to examine the effectiveness of the materials to promote skin self-examination (SSE) among kidney transplant recipients (KTRs). DESIGN: Randomized controlled trial of an educational intervention in comparison with a group that received only the assessment, education, and treatment as part of usual care with a nephrologist. SETTING: Academic ambulatory nephrology practice. PATIENTS: Seventy-five KTRs returning for routine care to their nephrologists 1 to 1.2 years or 3 to 7 years after transplantation. INTERVENTION: Educational workbook. MAIN OUTCOME MEASURES: Skin self-examination performance and new appointments with a dermatologist if a concerning skin lesion was found. RESULTS: Twenty-two percent of those in the control group checked their skin after the visit compared with 89% of the treatment condition; thus, KTRs receiving the intervention were significantly more likely to have checked their skin (χ(2); P < .001). Among the 8 control KTRs who checked their skin, none found areas of concern. Of the 34 intervention KTRs who checked their skin, 12 participants (35%) found areas of concern. All 12 of these individuals made appointments with a dermatologist for follow-up. CONCLUSIONS: The KTRs were receptive to performing SSE and acted on the recommendation made in the workbook to make an appointment with a dermatologist when a concerning lesion was discovered. Printed educational materials can be initiated in the tertiary care center 1 year after transplantation and used across a continuum of time during which KTRs may be transferred from the tertiary care center to community nephrologists. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01127737.

Two cases of multiple spitz nevi: correlating clinical, histologic, and fluorescence in situ hybridization findings.

BACKGROUND: The occurrence of multiple Spitz nevi is rare, especially the disseminated variant. Multiple Spitz nevi may be confused with, and must be differentiated from, primary spitzoid melanoma and cutaneous melanoma metastases. Over the past decade, fluorescence in situ hybridization (FISH) has emerged as a tool for studying melanocytic neoplasms, helping to differentiate between melanoma and benign melanocytic nevi. We describe 2 cases of patients with multiple Spitz nevi and their FISH results. OBSERVATIONS: One case of disseminated Spitz nevi, in a 17-year-old female, showed balanced tetraploidy using FISH, while the other case, in a 51-year-old female with multiple Spitz nevi, showed normal diploid cells without significant gains or losses in chromosomes 6 or 11. CONCLUSIONS: Patients may present with multiple, even disseminated, Spitz nevi. This phenotype should not be confused with melanoma and/or cutaneous metastasis. The use of FISH studies in context with careful correlation of clinical features and dermoscopic and histologic findings can assist in the diagnostic workup.

Comparison of treatment of cherry angiomata with pulsed-dye laser, potassium titanyl phosphate laser, and electrodesiccation: a randomized controlled trial.

OBJECTIVE: To assess the comparative efficacy of energy treatments in resolving cherry angiomata. DESIGN: Rater-blinded randomized controlled trial. SETTING: Outpatient dermatology clinic in an urban referral academic medical center. PARTICIPANTS: Fifteen healthy adults aged 21 to 65 years were enrolled. Two eligible individuals who were approached declined to participate, and no one enrolled was withdrawn for adverse effects. INTERVENTIONS: For each participant, 3 areas on the torso were demarcated such that each area contained 4 cherry angiomata. Each area was then randomly assigned to receive 1 of the 3 treatments: pulsed-dye laser (PDL) (595 nm), potassium titanyl phosphate (KTP) laser (532 nm), or electrodesiccation. Two treatments spaced 2 weeks apart were delivered to each area. MAIN OUTCOME MEASURES: Standardized photographs from before treatment and 3 months after the last treatment were evaluated for color and texture on visual analog scales. RESULTS: Mean change in color was a significant improvement of 7.77 (P<.001), but there was no significant difference across treatment arms (P=.19). Mean change in texture was a significant improvement of 6.23 (P<.001), and the degree of textural change also differed across treatments (P<.001). In pairwise comparisons, cherry angiomata treated with electrodesiccation were significantly less improved than were those receiving KTP laser (P=.003) and those treated with PDL (P=.001). The effects of KTP laser and PDL on texture were not different (P=.50). CONCLUSIONS: Cherry angiomata can be effectively treated with electrodesiccation and with laser. Laser, especially PDL, may minimize the likelihood of treatment-associated textural change. Trial Registration clinicaltrials.gov Identifier: NCT00509977.

Thoroughness of skin examination by melanoma patients: influence of age, sex and partner.

The aim of this study was to determine the thoroughness of deliberate skin examination by people with a history of melanoma. Patients were randomized into one of two conditions: either to receive the brief educational and skills training intervention alone or as a couple with their spouse or cohabiting partner. Subjects recorded concerning lesions on body maps. At the 4-month visit, a total body skin examination was performed by a dermatologist blinded to the subjects' condition and to their recorded responses. The skin surface was divided according to the region's visibility during skin self-examination and sexual connotations: visible/not sexually sensitive, non-visible/not sexually sensitive and sexually sensitive. The primary point of comparison was missed lesions, defined as the difference between lesions recorded by the subjects and their partners and those recorded by the dermatologist. Among 130 participants, 56 subjects reported partner assistance while performing SSE. Participants missed more lesions in sexually sensitive areas than in the other regions. With the increasing age of the patient, the number of missed lesions in non-visible/not sexually sensitive and sexually sensitive areas decreased. Male patients assisted by female partners missed fewer lesions in all three regions than female patients assisted by male partners. In easily visible areas, male patients missed significantly fewer lesions than female patients (P = 0.01). Older couples performed more thorough partner-assisted skin examinations in non-visible and sexually sensitive areas than younger couples. Male patients who were assisted by female partners performed more thorough partner-assisted skin examinations than female patients assisted by male partners.

Frequency of thromboembolic events associated with thalidomide in the non-cancer setting: a case report and review of the literature.

Thalidomide is increasingly being used due to its effectiveness in the treatment of a variety of dermatologic conditions refractory to other treatments. Although thalidomide's side effects have been well-documented in the literature since its entry in the 1950s, some of the risks associated with its use are still being discovered. Recently, increased incidence of venous thrombosis following thalidomide use has been reported in the treatment of diseases with disease-related thrombotic risks, such as malignancy and lupus with antiphospholipid antibody syndrome, as well as concomitant therapy with chemotherapy and/or systemic corticosteroids. We report a case of deep venous thrombosis (DVT) and pulmonary embolus (PE) following thalidomide use in a patient with leprosy (erythema nodosum leprosum, ENL) who was concurrently treated with prednisone, as well as a review of relevant literature. Our findings substantiate an increase in risk for thrombosis following thalidomide use in the dermatology and non-cancer clinical setting.

Comparison of electrodesiccation and potassium-titanyl-phosphate laser for treatment of dermatosis papulosa nigra.

BACKGROUND: There is a lack of randomized split-face studies investigating treatments for dermatosis papulosa nigra (DPN) in dark skin. OBJECTIVE: To compare the efficacy, safety, and tolerability of potassium-titanyl-phosphate (KTP) laser with efficacy, safety, and tolerability of electrodesiccation in the treatment of DPN in subjects with Fitzpatrick skin phototypes IV to VI. METHODS: Fourteen subjects with Fitzpatrick skin phototypes IV to VI were randomized to receive two KTP laser treatments 4 weeks apart to half of the face. The contralateral half received two electrodesiccation treatments 4 weeks apart. Response was evaluated by photography reviewed by blinded dermatologists at 4 weeks after the second treatment. A treatment quality questionnaire about side effects and cosmetic outcome was also administered. RESULTS: Difference in improvement of DPN between the KTP side and the electrodesiccation side per each rater (p=.99, p=.54) and per raters combined (p=.50) did not reach statistical significance. There was no treatment difference for subjective effectiveness (p=.06) or subjective confidence improvement (p=.99), although there was a significant treatment difference for subjective discomfort (p=.002) in favor of KTP. Both treatments were well tolerated without significant adverse effects. CONCLUSIONS: Although treatment of DPN with KTP laser and electrodesiccation are comparable in efficacy, KTP laser is preferable for patient comfort.

Effectiveness, safety, and effect on quality of life of topical salicylic acid peels for treatment of postinflammatory hyperpigmentation in dark skin.

BACKGROUND: There are no randomized split-face model studies investigating treatments for postinflammatory hyperpigmentation (PIH) in dark skin. OBJECTIVE: To assess the efficacy, safety, and effect on quality of life of salicylic acid peels for PIH in dark skin. METHODS: Ten subjects with Fitzpatrick skin phototypes IV to VI were randomized to receive two 20% salicylic acid peels followed by three 30% salicylic acid peels to half of the face. The contralateral half remained untreated. Response was evaluated by photography reviewed by three blinded dermatologists. The Visual Analog Scale, Dermatology Life Quality Index (DLQI), and treatment quality questionnaire were administered. RESULTS: Improvement of PIH on the treatment side according to each rater (p=.81, p=.81, p=.42) and according to the raters combined (p=.11) approached but did not reach statistical significance. Subjects' Visual Analog Scale scores indicated significantly greater improvement of PIH on the treatment side than in the control (p=.004). Quality of life measured according to the DLQI improved after treatment but not statistically significantly so (p=.13). Treatment had no significant adverse effects. CONCLUSIONS: Salicylic acid peels are safe in this population. Although patients rated them as clinically effective, blinded raters found a brief series of peels to have less efficacy. Measured quality of life improved nominally.

Blackberry-induced hand-foot skin reaction to sunitinib.

Sunitinib is an orally administered small molecule that was approved by the US Food and Drug Administration in January 2006 as monotherapy for the treatment of patients with advanced renal cell carcinoma (RCC) and patients with gastrointestinal stromal tumor after disease progression on or intolerance to imatinib mesylate. Data pooled from multiple sunitinib dose-escalation trials showed that sunitinib is associated with various adverse events, with HFSR occurring in up to 20% of patients. We describe a 48-year-old woman with a history of metastatic colorectal cancer treated with single-agent sunitinib who developed pain and tenderness in areas of friction secondary to Blackberry use, and was diagnosed with trauma-induced hand-foot skin reaction (HFSR) secondary to sunitinib therapy.

Folliculotropic mycosis fungoides: an aggressive variant of cutaneous T-cell lymphoma.

OBJECTIVES: To study the clinical features, therapeutic responses, and outcomes in patients with folliculotropic mycosis fungoides (FMF) and to compare our single-center experience of 43 patients with the findings from the Dutch Cutaneous Lymphoma Group. SETTING: A single-center experience from the Northwestern University Multidisciplinary Cutaneous Lymphoma Group. PATIENTS: Forty-three patients with FMF were included in the study and compared with 43 age- and stage-matched patients with classic epidermotropic mycosis fungoides (MF) with similar follow-up time. RESULTS: Folliculotropic mycosis fungoides showed distinct clinical features, with 37 patients having facial involvement (86%) and only 6 having lesions limited to the torso (14%). The morphologic spectrum of lesions is broad and includes erythematous papules and plaques with follicular prominence with or without alopecia; comedonal, acneiform, and cystic lesions; alopecic patches with or without scarring; and nodular and prurigolike lesions. Sixty-five percent of patients had alopecia, which in 71% of cases involved the face. Severe pruritus was seen in 68% of patients. In general, patients responded poorly to skin-directed therapy and in almost all cases required systemic agents to induce even a partial remission, including patients with early-stage disease. Overall survival was poor. Patients with early-stage disease (< or =IIA) had a 10-year survival of 82%, which took a steep drop off to 41% by 15 years. Patients with late-stage disease (> or =IIB) had an outcome similar to those patients in the control group with conventional epidermotropic MF of a similar stage. CONCLUSIONS: The morphologic spectrum of clinical presentation for FMF is broad and distinct from those in conventional MF. This is at least partially attributed to the ability of FMF to simulate a variety of inflammatory conditions afflicting the follicular unit. The disease course is aggressive, and many patients, including those with early disease, show a poor outcome particularly between 10 and 15 years after the initial onset of disease. Response to skin-directed therapy is poor even in early-stage disease, and our best results were seen with psoralen plus UV-A (PUVA) therapy with oral bexarotene or PUVA with interferon alfa. These findings corroborate those of the Dutch Cutaneous Lymphoma Group and further validate the classification of FMF as a distinct entity.

Impact and management of skin toxicity associated with anti-epidermal growth factor receptor therapy: survey results.

Biologic agents targeting the epidermal growth factor receptor (EGFR) have emerged as a robust treatment option for various solid tumors. Despite lower systemic side effects than conventional chemotherapy, the majority of patients treated with these agents experience cutaneous toxicities, including papulopustular rashes, hair and nail changes, xerosis and pruritus, which have a significant impact on health and quality of life. Currently no consensus or management guidelines exist for these untoward events. Therefore, a retrospective survey was carried out across 110 oncology practioners in the US that were administering EGFR inhibitors. Providers were queried on the impact and management of these untoward events in their practices. Responses suggest that combination therapies (topical and oral) were more effective than either therapy alone, and also lead to a more rapid resolution of the papulopustular rash. Providers also reported that patients frequently complained of physical symptoms associated with the rash (itching and pain), and that they had a positive perception when being treated for their cutaneous side effects. The survey results support that attentive cutaneous care is important in patients treated with EGFR inhibitors, and that proactive/combined interventions may enhance quality of life and optimize consistent drug administration.