ABSTRACT
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.
Subject(s)
Carcinoma, Basal Cell , Carcinoma, Squamous Cell , Skin Neoplasms , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Carcinoma, Basal Cell/surgery , Carcinoma, Basal Cell/pathology , Carcinoma, Squamous Cell/surgery , Carcinoma, Squamous Cell/pathology , Mohs Surgery , Prospective Studies , Skin Neoplasms/surgery , Skin Neoplasms/pathology , Skin Pigmentation , Treatment OutcomeABSTRACT
BACKGROUND: Previous literature supports a disparity in income between male and female physicians across multiple specialties, even when controlling for variables such as working hours, maternity leave, and productivity. OBJECTIVE: To understand if income disparity exists between male and female general dermatologists (GDs), and in dermatologists who completed a dermatologic surgical fellowship. MATERIALS AND METHODS: The authors surveyed members of the American Academy of Dermatology, including 66 dermatologic surgeons (DSs) (34 male and 32 female DSs) and 252 GDs (119 male and 133 female GDs), on questions related to total annual income, demographics, current employment, and time spent providing patient care. A logarithmic ordinal regression model was used to analyze income and the effect of different variables. RESULTS: Male GDs were 2.46 times more likely than female GDs to be in a higher income category (95% confidence interval [CI]: 1.44-4.23). There was no significant difference between the incomes of male and female DSs (male-to-female odds ratio: 1.46, CI: -0.44 to 1.23). These findings did not change when variables of age, median patient visits, and hours worked were controlled for. CONCLUSION: Income gender inequality exists among GDs. However, this inequality does not seem to extend to DSs.
Subject(s)
Physicians, Women , Surgeons , Pregnancy , United States , Female , Male , Humans , Dermatologists , Income , EmploymentABSTRACT
Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.
Subject(s)
Carcinoma, Basal Cell , Skin Neoplasms , Aged , Carcinoma, Basal Cell/pathology , Carcinoma, Basal Cell/surgery , Female , Humans , Male , Mohs Surgery , Private Practice , Prospective Studies , Skin/pathology , Skin Neoplasms/pathology , Skin Neoplasms/surgerySubject(s)
Carcinoma, Basal Cell/diagnosis , Hydroxyurea/adverse effects , Neoplasm Recurrence, Local/diagnosis , Optical Imaging , Skin Neoplasms/diagnosis , Carcinoma, Basal Cell/chemically induced , Carcinoma, Basal Cell/surgery , Female , Head and Neck Neoplasms , Humans , Middle Aged , Neoplasm, Residual/surgery , Scalp , Skin/diagnostic imaging , Skin Neoplasms/chemically induced , Skin Neoplasms/surgery , Thrombocythemia, Essential/drug therapyABSTRACT
Although there is evidence that gender-based disparities exist in salary, academic rank, and other factors in several areas in medicine, limited data exist on differences between male and female dermatologists. Existing studies have focused on academic dermatologists, not including the vast majority of dermatologists who work in solo and group private practices. A cross-sectional self-reported survey eliciting total annual income and other factors was performed in the fall of 2018 in the United States. A total of 397 board-certified dermatologists (MDs/DOs) participated in this study, including 53.63% female and 46.37% male respondents. A statistically significant difference existed within total annual income between male and female dermatologists (P<.0001). Several factors were identified that demonstrated statistically significant differences between male and female dermatologists, including productivity, practice area of focus, type of fellowship training, and faculty rank. However, despite controlling for these variations, gender remained a statistically significant predictor of income on both univariate and multivariate regression analyses (P=.0002/P<.0001), indicating that a gender-based income disparity exists in the field of dermatology that cannot be explained by other factors.
Subject(s)
Dermatologists , Dermatology , Cross-Sectional Studies , Efficiency , Female , Humans , Male , Salaries and Fringe Benefits , United StatesSubject(s)
Extremities , Torso , Dermatologic Surgical Procedures , Humans , Surgical Wound Infection , Suture Techniques , SuturesABSTRACT
BACKGROUND: Melasma is a common hyperpigmentation disorder with numerous, but often unsatisfactory treatment options. AIMS: A pilot study to evaluate the efficacy and safety of a novel topical combination of 12% hydroquinone, 6% kojic acid, and 5% vitamin C cream for melasma. PATIENTS AND METHODS: A pilot study of 6 women with melasma was conducted at an academic dermatology department and a private dermatology practice to evaluate the efficacy of a topical combination of 12% hydroquinone, 6% kojic acid, and 5% vitamin C cream, entitled the "Tam Formula." Two blinded evaluators calculated Melasma Area and Severity Index (MASI) Scores before and after treatment to evaluate change from baseline, and statistical analysis was performed. RESULTS: Treatment with this combination topical cream resulted in an average 63.77 ± 22.10 percent reduction in MASI scores. CONCLUSIONS: While there is a need for further investigation, this pilot study indicates the Tam Formula may provide an alternative treatment option for melasma.
Subject(s)
Melanosis , Ascorbic Acid/therapeutic use , Female , Humans , Hydroquinones/therapeutic use , Melanosis/drug therapy , Pilot Projects , Skin Cream , Treatment OutcomeSubject(s)
Melanoma , Skin Neoplasms , Humans , Melanoma/surgery , Mohs Surgery , Postoperative Period , Skin Neoplasms/surgerySubject(s)
Neoplasm Recurrence, Local/pathology , Nevus, Pigmented/surgery , Skin Neoplasms/surgery , Adult , Female , Humans , Leg , Skin TransplantationSubject(s)
Carcinoma, Squamous Cell/drug therapy , Cetuximab/adverse effects , Dermatitis/etiology , Heart Transplantation , Skin Neoplasms/drug therapy , Skin/pathology , Voriconazole/pharmacology , Antineoplastic Agents, Immunological/administration & dosage , Antineoplastic Agents, Immunological/adverse effects , Biopsy , Carcinoma, Squamous Cell/diagnosis , Cetuximab/administration & dosage , Cytochrome P-450 CYP3A Inhibitors/pharmacology , Dermatitis/diagnosis , Humans , Male , Middle Aged , Neoplasm Staging , Skin/drug effects , Skin Neoplasms/diagnosisABSTRACT
BACKGROUND: Toxic epidermal necrolysis (TEN) is a serious drug eruption that results in death in approximately 25% to 50% of patients. There is controversy over whether SCORTEN accurately predicts mortality or if treatment interventions such as intravenous immunoglobulin (IVIg) can alter mortality. OBJECTIVES: We sought to determine whether SCORTEN accurately predicts mortality in this cohort, whether IVIg improved survival, and which drugs and medical comorbidities impacted mortality. METHODS: We summarize our experience prospectively over 5 years and 82 patients. Patients either received supportive care, intravenous immunoglobulin, or cyclosporine as treatment. All patients had a SCORTEN on admission, an offending drug on record, and a list of medical comorbidities. RESULTS: Of the 82 patients, 29% died from TEN. SCORTEN accurately predicted mortality in this cohort with an area under the curve (AUC) of 0.83 in a receiver operator curve (ROC) analysis. A Kaplan-Meier curve did not show improved mortality if patients received IVIg versus supportive care (P = .9). Medications most often responsible for TEN were trimethoprim/sulfamethoxazole, followed by anticonvulsants, nonsteroidal anti-inflammatories, and allopurinol. LIMITATIONS: This prospective cohort study design is not as ideal as patients presenting for a randomized controlled trial. CONCLUSIONS: SCORTEN was an accurate predictor of mortality in this cohort. Age older than 40 years, the presence of metabolic syndrome and/or gout, higher body surface area involvement, higher SCORTEN, and higher number of medical comorbidities statistically significantly increased risk of death. IVIg did not significantly alter mortality. Although the highest number of cases was due to trimethoprim/sulfamethoxazole, the greatest proportion of deaths was due to allopurinol.
Subject(s)
Burn Units/statistics & numerical data , Burns/mortality , Immunoglobulins, Intravenous/administration & dosage , Stevens-Johnson Syndrome/drug therapy , Stevens-Johnson Syndrome/mortality , Adult , Aged , Allopurinol/adverse effects , Anti-Inflammatory Agents, Non-Steroidal/adverse effects , Anticonvulsants/adverse effects , Antimetabolites/adverse effects , Area Under Curve , Comorbidity , Drug Combinations , Female , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Predictive Value of Tests , Prospective Studies , ROC Curve , Stevens-Johnson Syndrome/immunology , Sulfadoxine/adverse effects , Trimethoprim/adverse effects , Young AdultABSTRACT
Amelanotic melanoma can have a varied appearance both clinically and microscopically. Here, we present our experiences with 75 cases of amelanotic melanoma defined clinically as a non-pigmented lesion and histopathologically as a tumor lacking significant melanization. We evaluated microscopic features such as morphology, mitotic count, nuclear atypia and presence of solar elastosis. Our amelanotic melanomas exhibited the following morphology: epitheloid (72%), spindled (18.7%) or desmoplastic (5.3%). In addition, we obtained patient information and clinical presentations on most of the cases (74/75; 98.7%) and follow-up data on 40% (30/75) of the cases. The majority of amelanotic melanomas in men were found on the trunk (13/45; 29%), head and neck (12/45; 26.7%), and lower limb (13/45; 29%) and in women were found on the lower limb (12/30; 40%), upper limb (10/30; 33.3%) and head and neck (6/30; 20%). In addition, we found that an increase in mitotic index correlated with worse survival (p < 0.026), whereas there were no differences in survival for other pathological features, such as nuclear atypia or solar elastosis. Furthermore, in cases with available tissue, all amelanotic melanoma expressed microphthalmia-associated transcription factor and tyrosinase, suggesting that the tumor cells retained melanocytic lineage and an enzyme in melanin formation, respectively. As the occurrence of amelanotic melanoma and the expression melanoma markers were similar to pigmented melanoma, we favor that amelanotic melanoma represents a subtype of melanoma rather than poorly differentiated or de-differentiated melanoma.
Subject(s)
Biomarkers, Tumor/biosynthesis , Gene Expression Regulation, Neoplastic , Head and Neck Neoplasms , Melanoma, Amelanotic , Skin Neoplasms , Adult , Aged , Aged, 80 and over , Cell Nucleus/metabolism , Cell Nucleus/pathology , Disease-Free Survival , Female , Follow-Up Studies , Head and Neck Neoplasms/metabolism , Head and Neck Neoplasms/mortality , Head and Neck Neoplasms/pathology , Humans , Male , Melanins/metabolism , Melanoma, Amelanotic/metabolism , Melanoma, Amelanotic/mortality , Melanoma, Amelanotic/pathology , Middle Aged , Mitosis , Retrospective Studies , Sex Factors , Skin Neoplasms/metabolism , Skin Neoplasms/mortality , Skin Neoplasms/pathology , Survival RateABSTRACT
Reconstruction of the scalp after Mohs surgery can pose dilemmas for the dermatologic surgeon, especially for extensive tumors. The authors present a unique technique for removing large in-situ epidermal tumors of the scalp during Mohs surgery in four patients. Although invasive tumor was removed with a standard No. 15 scalpel, the extensive epidermal component of the tumor was removed through the mid-dermis using the flexible scalpel. This technique allowed the superficial defect to heal by second intention. The results showed minimal scarring and hair regrowth in what could have been large defects requiring complex reconstruction.
Subject(s)
Cicatrix/surgery , Head and Neck Neoplasms/surgery , Minimally Invasive Surgical Procedures/instrumentation , Mohs Surgery/instrumentation , Scalp , Skin Neoplasms/surgery , Surgical Instruments , Aged , Female , Humans , Male , Middle AgedABSTRACT
BACKGROUND: Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities. OBJECTIVES: To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method. MATERIALS AND METHODS: Eight female patients (Fitzpatrick skin type II-IV) with clinically diagnosed melasma on the face were treated using FP (1,550 nm Fraxel SR laser). Two to seven treatments were performed at 3- to 8-week intervals. Treatment levels ranged from 3 to 10, corresponding to 9% to 29% surface area coverage (8-10 passes per treatment). Energies used ranged from 6 to 40 mJ. Physician and patient assessments were recorded at each visit and at a follow-up visit 7 to 36 months (mean 13.5 months) after the last treatment session. RESULTS: At the last treatment, assessments revealed greater than 50% clinical improvement in melasma in five of eight patients. Follow-up assessments by the evaluating physician revealed sustained efficacy in five patients. Recurrence was reported in three patients. No significant adverse effects were noted. CONCLUSIONS: FP is a safe and effective treatment for refractory melasma, with long-term remission.
Subject(s)
Laser Therapy , Melanosis/surgery , Adult , Face , Follow-Up Studies , Humans , Melanosis/physiopathology , Middle Aged , Treatment OutcomeABSTRACT
BACKGROUND: Pain characteristics and analgesia in patients undergoing Mohs micrographic surgery have not been systematically studied. It is important to know about pain after Mohs micrographic surgery to better serve patient needs. OBJECTIVE: We sought to measure pain in patients after Mohs micrographic surgery, and to investigate the relationship among postoperative pain, surgical characteristics, patient characteristics, and analgesics used. METHODS: The Wong-Baker 0-to-10 pain scale was prospectively administered postoperatively to all patients presenting for Mohs micrographic surgery in a private practice setting between October 1, 2007, and December 31, 2008. Patients recorded their pain level from the day of surgery through postoperative day 4. The age, sex, location of surgery, number of lesions operated on, postoperative size, type of repair, severity of pain, and oral analgesics consumed and dosages used were recorded. RESULTS: A total of 433 patients were included in the final analysis. The highest pain scores were found on the day of surgery and steadily declined until postoperative day 4 (P < .000). In all, 52% of patients took pain medication on the day of surgery, which declined successively with each postoperative day. The highest mean pain scores were statistically significantly associated with repair type (flaps), age (<66 years), number of lesions, and consumption of narcotics for pain relief. No statistically significant differences existed for sex or postoperative defect size. LIMITATIONS: The instrument used to measure pain relied on patient self-report in a private practice surgery center. Only the validated Wong-Baker pain scale was used to assess pain in this study. CONCLUSION: Approximately half of the patients after Mohs micrographic surgery take medication for pain control. Type of closure, location of surgery, age, and type of pain medication taken were significantly associated with postoperative pain.
Subject(s)
Analgesics/therapeutic use , Mohs Surgery , Pain, Postoperative/physiopathology , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Mohs Surgery/adverse effects , Pain, Postoperative/drug therapy , Skin Transplantation , Surveys and QuestionnairesABSTRACT
A 43-year-old African-American female with anemia secondary to uterine leiomyomas and menorrhagia presented with induration and stiffness of the right arm and hand four weeks after receiving intravenous iron infusions at multiple infusion sites along the right proximal forearm. Multiple intravenous sites between her right antecubital fossa and wrist had to be used because developing pain necessitated the site changes. The iron infusions were performed because the patient had refused blood transfusions and her symptoms failed to resolve on oral iron supplementation. The skin induration persisted and progressed for several months at which time a skin biopsy was performed. The skin histology was consistent with eosinophilic fasciitis and her complete blood count was notable for a peripheral eosinophilia. Because of the location of the fibrosis and the time proximity in relation to her infusions, a relationship between the iron infusions and eosinophilic fasciitis was made. Cutaneous fibrosis has been linked to immunologic dysfunction, autoantibody production, tissue hypoxia, and vascular damage, which may have been contributing factors in this patient. Eosinophilic fasciitis has been linked to certain drugs and chemicals, notably L-tryptophan ingestion and the statin family of drugs.