Postinflammatory Hyperpigmentation Following Mohs Micrographic Surgery: An Observational Study.

IMPORTANCE: Functional and cosmetic outcomes following Mohs micrographic surgery (MMS) are poorly studied in individuals with skin of color (SOC). Postinflammatory hyperpigmentation (PIH) may be long-lasting and highly distressing. SOC individuals are particularly susceptible to PIH following procedures.  Objective: To characterize factors that contribute to the development of PIH following MMS in SOC. DESIGN: This retrospective study included 72 SOC individuals with 83 cases of keratinocyte carcinoma treated with MMS between August 2020 and August 2021 at a single medical center in the Bronx, New York. RESULTS: Postinflammatory hyperpigmentation following Mohs micrographic surgery was more common in Fitzpatrick skin types (FST) IV to V (48.0%) compared to FST I to III (18.2%; P=0.006). Grafts and granulation resulted in higher rates of PIH compared to linear repairs and flaps (87.5% vs 30.7%; P=0.003). Cases with postoperative complications resulted in higher rates of PIH compared to cases without (81.8% vs 29.2%; P=0.001). In a subset analysis of linear repairs, polyglactin 910 as a subcutaneous suture produced a higher rate of PIH compared to poliglecaprone 25 (46.2% vs 7.1%; P=0.015).  Conclusions and Relevance: Individuals with SOC (FST IV to V) are more likely to develop PIH following MMS. Grafts and granulation lead to PIH more often than linear repairs and flaps. Postoperative complications significantly increase the risk of PIH. Surgeons should consider these risk factors during surgical planning in an effort to mitigate PIH in SOC individuals. Studies with larger sample sizes are indicated.  J Drugs Dermatol. 2024;23(5):316-321. doi:10.36849/JDD.8146.

Navigating Barriers to Patient Access and Reimbursement in Mohs Micrographic Surgery.

BACKGROUND: Insurance companies have implemented new policies including excessive prior authorization (PA) requirements, high-deductible plans, and complicated billing structures in an effort to curb rising health care costs. Studies investigating the real-time impact on providers and patients are emerging, but few within the field of dermatology have been published. OBJECTIVE: To assess the impact of cost-cutting policies on patients and physicians. METHODS: A survey was electronically distributed to members of the American College of Mohs Surgery (ACMS). RESULTS: The majority of respondents (78.2%) practiced in a private setting, with no other demographic differences. The majority of respondents (70%) dedicated 1 to 2 employees to obtaining PAs. Fifty percent reported an average time of 30 minutes spent per PA. Fifty-six percent of respondents obtained PA from private insurance before Mohs surgery, whereas only 24.5% obtained PA from Medicare. Forty-nine percent of practitioners provided patients with a financial disclosure prior to Mohs surgery. Moreover, many practitioners reported screening patients for high-deductible policies and request an advanced deposit against the deductible. Sixty percent reported difficulty obtaining payment for service in the absence of an advanced deposit. CONCLUSION: The burden of restrictive health care policies will have long-term consequences for the patient-provider interaction and patient outcomes.

Procedural management of rhinophyma: A comprehensive review.

BACKGROUND: Rhinophyma is a cosmetically deforming disease characterized by nodular overgrowth of the lower 2/3 of the nose and is considered the end stage of acne rosacea. AIMS: Review the spectrum of procedural techniques for treatment of rhinophyma with a focus on the advantages and disadvantages of each modality. METHODS: A comprehensive literature search was conducted using the search terms "rhinophyma," "treatment," and "surgery" in PubMed. Case reports, case series, and small retrospective trials using procedural techniques for management of rhinophyma were included for review. Animal studies, non-English articles, and reports of medical treatment of rhinophyma were excluded. RESULTS: There are currently no prospective, randomized controlled studies evaluating procedural management of rhinophyma. The most commonly employed treatments include scalpel excision, resection with heated knives, dermabrasion, electrosurgery and lasers, specifically carbon dioxide (CO2 ) and erbium:yttrium-aluminum-garnet (Er:YAG). The main complication associated with complete excision of rhinophymatous tissue is excessive scarring. To correct for this adverse effect, partial or tangential excision with preservation of underlying adnexal structures is now the accepted technique, irrespective of the chosen modality. CONCLUSION: There is no accepted gold standard for management of rhinophyma, and each modality succeeds in maintaining hemostasis, reducing scarring and achieving satisfactory cosmesis to different degrees. There is a conflicting data on the theoretical risk of recurrence with partial excision due to incomplete removal of tissue. Further studies evaluating this risk and alternate methods of prevention are required.

Non-ablative lasers.

Non-ablative laser devices exert their effects by inducing dermal collagen remodeling while sparing the epidermis. The remodeling process is achieved by producing thermal energy in a controlled and precise fashion, which recruits fibroblasts and stimulates collagen production. Although these devices do not produce the same degree of improvement as traditional CO(2) or er:YAG resurfacing techniques, they are an excellent alternative for people seeking gradual aesthetic improvement with minimal downtime. They are also extremely well suited to patients with darker skin types. In this chapter, we review the various non-ablative devices currently available on the market, with an emphasis on safety profiles and efficacy.

High-fluence and high-density treatment of perioral rhytides using a new, fractionated 2,790-nm ablative erbium-doped Yttrium Scandium Gallium Garnet Laser.

BACKGROUND: In this study, we evaluated the safety and efficacy of a novel 2,790-nm erbium-doped yttrium scandium gallium garnet (Er:YSGG) laser system for the treatment of facial photodamage and perioral wrinkles using a single-treatment, high-fluence, high-density protocol. METHODS: Eleven female participants with Fitzpatrick skin types II to III and facial wrinkles underwent a single full-face fractional ablative treatment with a 2,790-nm Er:YSGG laser. Follow-up visits were completed at 1, 2, and 6 weeks 3 and 6 months. Quartile improvement scale (0-4) and Fitzpatrick wrinkle scores (1-9) were used for the assessments. RESULTS: Based on blinded photographic assessments, the mean difference in Fitzpatrick wrinkle scores for full face wrinkles was 1.5 ± 1.2 (a reduction from 6.6 to 5.1; paired t-test, p = .003). There was also a statistically significant mean reduction of 1.7 ± 1.3 in perioral wrinkle scores (from 6.7 to 5.0; p = .002). No serious adverse events were reported. CONCLUSION: A novel, fractionated, ablative 2,790-nm Er:YSGG laser can safely and effectively treat photodamage and perioral wrinkles in a single treatment using a high-fluence, high-density protocol. Cutera provided the equipment used in this study and funding to Dr. Goldberg.

A split-face comparison of two ablative fractional carbon dioxide lasers for the treatment of photodamaged facial skin.

OBJECTIVE: To compare the safety and efficacy of two fractional carbon dioxide (CO(2)) laser devices for the treatment of photodamaged facial skin. METHODS: Eight healthy subjects underwent full-face resurfacing for photodamaged skin with two fractionated CO(2) laser devices using manufacturer-recommended settings for facial rejuvenation. For each subject, one device with a rolling handpiece was used on one side and a second device with a stamping handpiece was used on the other. Patients were evaluated 3 months postoperatively and photographed. A blinded physician investigator assessed the photographs and rated each side for improvement in four categories (wrinkles, pigmentation, skin laxity, and overall appearance). Patient ratings for overall improvement for each side were also recorded. RESULTS: All patients had improved on the basis of photographic and clinical assessments at 3 months. No significant differences in patient ratings of overall improvement and physician-measured parameters of clinical improvement were found, although intraoperative times and pain ratings were greater with the laser with the stamping handpiece. No complications were experienced with either device. CONCLUSIONS: Both fractionated CO(2) resurfacing devices used in the study were safe and effective for the treatment of photodamaged facial skin, but the modality using a stamping handpiece was associated with longer operative times and greater intraoperative pain. The authors have indicated no significant interest with commercial supporters.

Intense pulsed light: what works, what's new, what's next.

Intense pulsed light technology has revolutionized the noninvasive treatment of a whole variety of cutaneous cosmetic problems. Today's machines are safer, more diverse, less painful, and readily available. Intense pulsed lights can be used to treat vascular and pigmented lesions and are used for facial rejuvenation and the removal of unwanted hair. Newer, less powerful home-device intense pulsed light sources will not replace those used in a physician's office but will augment the use of today's more powerful medical office systems.

Quality of life and treatment satisfaction among patients with psoriasis and psoriatic arthritis and patients with psoriasis only : results of the 2005 Spring US National Psoriasis Foundation Survey.

INTRODUCTION: Five to forty percent of patients with cutaneous psoriasis develop an inflammatory, oligoarticular spondyloarthropathy known as psoriatic arthritis. OBJECTIVE: To compare health-related quality of life (QOL) between cutaneous psoriatic patients with and without psoriatic arthritis. METHOD: Secondary cross-sectional analysis of data obtained from the 2005 Spring US National Psoriasis Foundation Quality of Life Telephone/Internet Survey. 426 patients with psoriasis and/or psoriatic arthritis were included in the 2005 survey. Among these respondents, the self-reported disease histories of 140 patients with cutaneous psoriasis and psoriatic arthritis were compared with those of 278 patients with cutaneous psoriasis only. Both groups were compared with respect to demographics, skin disease severity, treatment history and satisfaction, and QOL using previously validated assessment scales. RESULTS: Compared with those with skin psoriasis only, respondents with cutaneous psoriasis and psoriatic arthritis were slightly older, more likely to be female and members of the National Psoriasis Foundation, and more likely to report a younger age of disease onset. They were also more likely to be unemployed, to report their job was affected by their condition, and to report a higher mean estimate of lost annual wages. On both univariate and multivariate analysis, however, no significant differences between groups were detected in skin disease severity, overall QOL, and satisfaction with current treatment options. At the same time, individuals with skin psoriasis and psoriatic arthritis were more likely to be taking systemic agents. They also reported higher mean scores for pain, while those with cutaneous psoriasis reported higher mean scores for self-consciousness only. CONCLUSION: In contrast to previous reports that did not control for skin disease severity, this study demonstrates that patients with cutaneous psoriasis and psoriatic arthritis do not report significantly worse health-related QOL compared with patients with cutaneous psoriasis only. Nor do they report significantly greater dissatisfaction with current treatment options. These findings may reflect the intrinsic inadequacy of the QOL instruments used in this study for capturing the additional burden of joint disease. Alternatively, these findings may reflect the existence of a threshold of joint disease in patients with skin psoriasis and psoriatic arthritis below which joint symptoms are perceived as negligible relative to cutaneous disease.