Second-Intention Healing in Mohs Micrographic Surgery: A Single-Center Academic Experience.

OBJECTIVE: To describe the trends in second-intention healing (SIH) use at a single Mohs micrographic surgery (MMS) dermatology clinic and assess outcomes and patient satisfaction. METHODS: The authors conducted a single-center, retrospective study of patients who underwent MMS from November 2012 through November 2018. Data obtained for each patient included sex, age, tumor characteristics, number of MMS stages, final defect size, and postoperative complications. Patient satisfaction of SIH was retrospectively assessed by telephone survey. RESULTS: Providers used SIH in 22% of all MMS cases (n = 159/718). It was most commonly used for defects located on the nose, ear, temple, and periocular region. The average defect size and number of MMS stages for tumor clearance were 1.3 cm and 1.5 stages, respectively. Overall, low rates of postoperative complications were observed, and 95% of patients reported optimal or acceptable levels of satisfaction. CONCLUSIONS: This study supports the idea that SIH is a safe, effective alternative for wound management and may have broader practice indications than those traditionally proposed.

Differentiation of Basal Cell Carcinoma and Trichoepithelioma: An Immunohistochemical Study.

ABSTRACT: Basal cell carcinoma (BCC) is the most common malignancy of the skin. It is an epithelial neoplasm with origin in the precursor cells of the interfollicular epidermis. Even though it has low metastatic potential, delay in management may lead to local destruction and morbidity. In contrast, trichoepithelioma (TE) is a benign tumor originating from the outer root sheath of the hair follicle. Similar to BCC, TE tends to affect the head and neck region. Both neoplasms may exhibit clinical and histopathological similarities, making them prone to misdiagnosis. Multiple immunomarkers have been used to distinguish among these entities, but so far, no single agent or combination of agents appear to be neither sensitive nor specific enough to differentiate between them. This study was divided into 2 parts. First, 17 cases of BCC and 14 cases of TE were stained with androgen receptor and bcl-2. Then, 27 cases of borderline/equivocal of BCC and 13 cases of borderline/equivocal TE were stained with the same protocol. Sensitivity and specificity were calculated for each individual immunomarker and for the combination of them. Androgen receptor positivity was 100% specific for BCC and borderline/equivocal BCC, whereas bcl-2 diffuse staining pattern demonstrated a sensitivity of 82.4% for BCC and 88.9% borderline/equivocal BCC. When both immunomarkers were combined, the sensitivity for BCC decreased (70.6%) but the specificity remained high (100%). Similarly, the sensitivity for borderline/equivocal BCC was 55.6%, whereas the specificity was 100%. Although moderately sensitive, combining both immunomarkers showed an excellent specificity to discriminate between BCC and TE.

Defining the Histopathological Term Atypical Intraepidermal Melanocytic Proliferation: A Retrospective Cross-Sectional Study.

BACKGROUND: Atypical intraepidermal melanocytic proliferation (AIMP) is a general term assigned to melanocytic proliferations of uncertain biological potential when a definitive histopathological diagnosis cannot be achieved. There are few data available describing the possibility of malignancy of AIMP, or ways to further define diagnosis. OBJECTIVE: To determine the rate of diagnostic change of AIMP to melanoma or melanoma in situ (MIS) after conventional excision. In addition, to determine the role of immunohistochemistry (IHC) in defining AIMP biopsies. METHODS: Retrospective cross-sectional, single-center review of biopsies with a diagnosis of AIMP with a follow-up conventional excision from 2012-2016 was performed. In a separate analysis, a search was performed for AIMP biopsied lesions in which IHC was subsequently performed. RESULTS: The rate of diagnostic change of AIMP to MIS was 4.8% (8/167) after excision. Punch biopsy was a risk factor for diagnostic change to MIS (odds ratio 12.94, confidence interval 2.56-65.38, P = 0.008). The rate of diagnostic change of AIMP biopsies after examining with IHC was 21.3% (34/160) to MIS and 4.4% (7/160) to melanoma. CONCLUSION: The possibility of malignancy of AIMP lesions must be taken into consideration when counseling patients and when planning treatment options. IHC is a useful tool and should be used in the evaluation of AIMP specimens.

Non-Melanoma Skin Cancer Tumor's Characteristics and Histologic Subtype as a Predictor for Subclinical Spread and Number of Mohs Stages required to Achieve Tumor-Free Margins.

OBJECTIVE: To describe the behavior of non-melanoma skin cancer (NMSC) based on tumor's characteristics. METHODS: A total of 219 of NMSC were analyzed via a retrospective medical chart review. The data obtained from each record included but was not limited to: number of Mohs micrographic surgery (MMS) stages required for tumor clearance, defect size, repair type and size according to the neoplasm's histopathologic subtype. RESULTS: The mean number of stages required to clear morpheaphorm/infiltrative and micronodular basal cell carcinomas (BCCs) (n= 34) was 2.03, while the nodular and superficial BCCs (n= 125) needed a mean of 1.56 stages (p value= .034). Of the tumors located on a high-risk zone, 59.6% required two or more stages to be cleared while 67.7% of the lesions on a non-high risk zone were cleared with one stage (p value = 0.001). Recurrent tumors required a mean 2.22 MMS stages to be cleared, whereas primary tumors required a mean 1.61 stages (p value= .006). CONCLUSION: Subclinical spread was seen in morpheaform/infiltrative and micronodular BCC histologic subtypes, recurrent tumors, and tumors in high-risk locations. These could help predict aggressive tumor behavior and optimize surgical planning.

Pediatric Inpatient and Emergency Dermatology Consultations: A 5-Year Retrospective Analysis.

OBJECTIVE: To characterize and analyze the inpatient and emergency pediatric dermatology consults in our academic hospital center. METHODS: We reviewed 485 consultations that were done by the University of Puerto Rico Department of Dermatology from July 2007 to June 2012. The date, patient age and gender, consulting service, presumptive diagnosis, final diagnosis, and diagnostic procedures performed were documented for each consult. RESULTS: The patients' ages ranged from newborn to 18 years; the 13 to 18 years age group was the most common (29%). Dermatology consults were requested by the general pediatrics ward, primarily (32%), followed by the emergency room (25%). In 236 cases (48.6%), a vague diagnostic impression was provided by the consulting service, whereas in 249 (51.4%) cases, a specific or differential diagnosis was provided. The dermatology service changed the diagnosis in 12% (58/249) of the evaluated cases. The most common misdiagnoses were allergic contact dermatitis, drug eruption, papular urticaria, nutritional deficiency, atopic dermatitis, seborrheic dermatitis, cellulitis, and herpes infection. The most common diagnoses encountered were inflammatory skin conditions, infectious diseases, and drug eruptions. Skin biopsy was the most common procedure performed. In 30% of the cases, more than 1 procedure was performed as part of the evaluation work-up. CONCLUSION: Our study demonstrates the important role of the dermatologist in the diagnosis and management of pediatric patients with dermatological diseases. The information contained within this manuscript should contribute to raising the awareness of pediatricians regarding the most common dermatological diagnoses in this patient population.

Mohs Micrographic Surgery Using MART-1 Immunostain in the Treatment of Invasive Melanoma and Melanoma In Situ.

BACKGROUND: Mohs micrographic surgery (MMS) with melanoma antigen recognized by T-cell (MART-1) immunostaining is an effective treatment of cutaneous melanoma. OBJECTIVE: To determine the efficacy of MMS with MART-1 immunostain in the management of invasive and in situ melanoma. METHODS AND MATERIALS: A retrospective cohort study evaluated 2,114 melanomas in 1,982 patients excised using MMS and MART-1 immunostain. The margins required for excision were calculated based on Breslow thickness, location, and size. Survival and local recurrence rates were calculated and compared with those of historical controls. RESULTS: The mean follow-up period was 3.73 years. Local recurrence was identified in 0.49% (7/1,419) of primary melanomas. Approximately 82% of melanomas were excised with ≤6-mm margins. The surgical margin was significantly related to tumor location and size but not to Breslow thickness. The five-year Kaplan-Meier local recurrence and disease-specific survival rates were 0.59 ± 0.30 and 98.53 ± 0.42, respectively. Mohs micrographic surgery with MART-1 immunostain achieved lower local recurrence rates and equivalent or higher Kaplan-Meier survival rates than conventional wide local excision. CONCLUSION: Mohs micrographic surgery with MART-1 immunostain is an effective treatment of melanoma as evidenced by low local recurrence rates. It offers the advantage of more tissue-conserving margins than those recommended for conventional excision.

Dermatologists in the Emergency Department: A 6-Year Retrospective Analysis.

OBJECTIVE: There are few studies documenting dermatological consultations in the emergency setting. The aim of this study was to evaluate the nature, purpose, and diagnostic accuracy of emergency care physicians in all the dermatology consults evaluated by the Department of Dermatology of the University of Puerto Rico School of Medicine. METHODS: A retrospective analysis of all the consultation reports pertaining to patients evaluated at 4 emergency departments served from July 1, 2007, to June 30, 2013. The data collected from each consultation report consisted of the demographic information of the patient, the name of the consulting hospital, the initial diagnostic impression, the diagnostic impression of a dermatologist, and the procedures, if any, performed by that dermatologist. RESULTS: A total of 429 patients were evaluated (53% men, 47% women) from July 2007 through June 2013. The most common diagnosis was infectious process (37%), followed by eczema (14%) and drug-induced skin reactions (12%). Seventeen percent (17%) of the cases for which consultations were sought were considered true dermatological emergencies. Forty-six percent of cases resulted in no diagnostic impression from the consulting physician. Of the cases that did result in diagnoses, these diagnoses were later changed by a dermatologist in 34% of the cases. CONCLUSION: This study suggests that the role of the dermatologist in the emergency department is very important. In addition, better education in the management of common skin disorders and the identification of true dermatological emergencies should be stressed during medical school and in residency training programs of specialties such as emergency medicine and those that offer primary care.

Clinical and dermoscopic patterns of melanocytic nevi in Hispanic adolescents: a descriptive study.

BACKGROUND: Melanocytic nevi are well-known, important precursors of melanoma among children and adults. The adolescence period is an important period for nevi formation and evolution. This study provides data of a longitudinal study of nevi in a Hispanic adolescent population. MATERIALS AND METHODS: A cross-sectional survey and 1-year prospective follow-up study was performed on Hispanic students from grades 6 and 7 at a school in Caguas, Puerto Rico (n = 90). The survey was completed by the students and one of their parents. The backs of the children were clinically examined for melanocytic nevi using digital photography and dermoscopy. Follow-up was conducted one year later. RESULTS: The study cohort consisted of 53 (59%) boys and 37 (41%) girls, with an average age of 11.9 years (range 11-13 years). At the beginning of the study, 85% (n = 71/90) of the students presented with melanocytic nevi on their backs. After one year, new nevi were identified in 62% (n = 44/71), and there was a mean increase in nevus count of 1.8 (P < 0.001). A trend toward increased nevus count in lighter skin types was observed (P < 0.001). The predominant dermoscopic pattern was reticular (44%). The globular pattern was found most commonly in children with skin-type II (100%), while the reticular pattern was the most common among skin-types III (32%), IV (56%), and V (45%). CONCLUSIONS: This study supports the utility of digital photography and dermoscopy for the evaluation of melanocytic nevi, providing evidence of the interrelationship between nevus count, dermoscopic pattern, and skin phenotype.

Langerhans cell sarcoma: a case report.

Primary cutaneous neoplasms of histiocytes and dendritic cells are rare. Langerhans cells are a subset of antigen-presenting dendritic cells. Neoplasms of Langerhans cells are classified into cytologically benign Langerhans cell histiocytosis and cytologically malignant Langerhans cell sarcoma. Langerhans cell sarcoma is a rare entity characterized by multiorgan involvement and an aggressive clinical course. To date, only 30 cases of Langerhans cell sarcoma, including the present case, have been reported. We report a new case of Langerhans cell sarcoma that presented with multifocal cutaneous involvement. Diagnosis was done based on histopathological, immunohistochemical evaluation, as well as ultrastructural analysis identifying the presence of Birbeck granules. Our case represents a new case of this extremely rare, overtly aggressive neoplasm of Langerhans cells. Within 2 years of diagnosis, the patient developed metastatic disease and consequently died. Early recognition is important because of the tendency of Langerhans cell sarcoma to recur and metastasize. Therefore, ancillary techniques such as immunohistochemical and ultrastructural studies to confirm the diagnosis are very advantageous.