Evaluating Symptomatic and Psychosocial Well-being After Keloid Treatment With SCAR-Q.

BACKGROUND: Many patients with keloids experience symptoms, such as pain and pruritus, and may present with significant psychosocial burdens. However, no single therapeutic regimen has been firmly established for treatment of keloids. OBJECTIVES: The aim of this study was to assess patients' perspectives on their keloids after treatment by comparing preoperative and postoperative surveys. METHODS: All patients seen at the keloid clinic, both preoperatively and postoperatively, were contacted by telephone call. Information about demographics, keloid characteristics, and levels of pain and pruritus were recorded. Participants also completed all 3 parts (appearance, symptoms, and psychosocial impact) of the SCAR-Q, a validated patient-reported outcome measure questionnaire. Statistical analysis was performed with SPSS version 23 (IBM Corp., Armonk, NY). RESULTS: Of the 60 patients who participated in the study, 35 preoperative and 34 postoperative surveys were completed. Patients experienced significant reductions in mean [standard deviation] pain levels (from 5.6 [4.0] to 0.1 [0.4], P < 0.001) and pruritus (from 6.5 [3.0] to 0.8 [1.5], P < 0.001) postintervention. Significant improvements in all 3 parts of the SCAR-Q were noted. Appearance improved from 26.5 [22.3] to 73.4 [23.0] (P < 0.001); symptoms from 44.0 [15.7] to 81.4 [16.7] (P < 0.001); and psychosocial impact from 27.7 [30.7] to 82.6 [26.3] (P < 0.001). CONCLUSIONS: Patients with keloids experience significant improvement in their symptomatic and psychosocial burden after treatment. Although management modalities are not well established, it is essential that plastic surgeons do not overlook the therapeutic benefits for their patients' well-being.

Protocol for development of a core outcome set for clinical trials in melasma.

INTRODUCTION: Melasma is a pigmentation disorder of the skin. Characterised by brown to gray-brown patches on the face and neck, the condition predominantly affects women and has been associated with pregnancy, hormonal variation and sun exposure. Melasma can be disfiguring and anxiety-provoking, and quality of life is often adversely impacted. Management includes sun protection, laser and energy device therapy, topical and oral skin-bleaching agents and chemical peels. While clinical trials of melasma exist, there is a lack of consistency in reported outcomes, which has been a barrier to the aggregation of data in systematic reviews and meta-analyses. This protocol describes a planned process for development of a minimum set of outcomes (ie, 'core outcome set') that should be measured in all clinical trials of melasma. METHODS AND ANALYSIS: An exhaustive list of potential outcomes will be extracted from four sources: (1) systematic literature review of outcomes in clinical trials; (2) semistructured patient interviews; (3) brochures, pamphlets, clinical trial registries, and other published and unpublished sources and documentation; and (4) interviews with non-patient, non-physician stakeholders, including federal regulators, industry scientists and non-physician providers. An international two-round Delphi process will then be performed to identify the outcomes deemed most important to patients and physicians. Subsequently, a consensus meeting will be convened to review and process the results, and to vote on a final set of core outcomes. ETHICS AND DISSEMINATION: Ethics approval was provided by the Northwestern University Institutional Review Board (protocol ID: STU00201637). This study is registered with both the Core Outcome Measures in Effectiveness Trials and Cochrane Skin-Core Outcome Set Initiative initiatives, and this protocol is in accordance with the guidelines for protocol development of both groups. All findings from the study described in this protocol will be disseminated to all stakeholders involved in the development process and will be submitted for publication in peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42020214189.

Universal Protocol in Mohs Micrographic Surgery: Incorporating a "Time Out" Procedure in Histopathologic Interpretation

In 1999, the Institute of Medicine's (IOM) first report, "To Err Is Human", brought forth the issue of medical error in patient care.1 In this publication, the IOM recognized that mistakes or failures to prevent mistakes were mostly caused by flawed systems, processes, and conditions. It outlined a four-tiered approach to improve safety including: 1) development of leadership, research, tools, and protocols to enhance the knowledge base on safety, 2) a nationwide public mandatory reporting system and encouraging voluntary participation to identify and learn from errors, 3) oversight organizations, professional groups, health care purchasers to raise performance standards and expectations, and 4) implementation of safety systems in the healthcare organization to ensure delivery of safe practice. This was the first roadmap towards a safer health system.

Histopathology of Basal Cell Carcinoma After Treatment With Vismogedib

Background: Vismodegib used in the treatment of metastatic basal cell carcinoma (BCC) or locally advanced, recurrent BCC not amenable to surgery or radiation leads to various clinical changes. Objective: Aim was to elucidate the histopathology that corresponds to tumor involution observed with vismodegib therapy. Methods: Retrospective case series of patients treated with vismodegib between May 2012 and April 2017 with intra- or post-treatment biopsy. Results: 42 biopsy specimens and 4 Mohs frozen sections were analyzed. Necrosis, fibrosis, and increased plasma cells were common features. Limitations: Single center study. Conclusion: The histologic findings of BCCs treated with vismodegib correlate with clinical response. J Drugs Dermatol. 2019;18(2):136-138.

Measuring the Depth of Perineural Invasion in Cutaneous Squamous Cell Carcinoma: Implications on Biopsy Technique.

BACKGROUND: Perineural invasion (PNI) is a high-risk feature of cutaneous squamous cell carcinoma (CSCC). Depths at which PNI occurs are unknown. OBJECTIVE: To determine the most superficial depth at which PNI occurs in CSCC and stratify by tumor clinical diameter and body location. METHODS AND MATERIALS: Single-institution retrospective review of CSCC specimens reporting PNI on pathology reports between January 2004 and August 2014. Depth was defined as distance from top of granular layer to middle of nerve invaded by CSCC or distance from erosion to middle of nerve affected by CSCC. RESULTS: Of 66 specimens identified with PNI, 45 specimens were included. Mean histopathologic depth to PNI was 2.7 mm (SD = 1.8 mm, median depth = 2.2 mm, range 0.5-12 mm). Perineural invasion depth varied by anatomic location, with the head associated with most superficial average PNI depth (2.2 mm) and trunk with greatest average PNI depth (4.3 mm). Perineural invasion depth correlated with clinical tumor diameter. The largest percentage of specimens with PNI were of clinical diameter of at least 2 cm (20/45 = 44%). CONCLUSION: Clinicians encountering lesions suspicious for CSCC have the greatest chance of detecting PNI using biopsy techniques that reach at least 3 to 4 mm deep.

Vismodegib and the Hedgehog Pathway Inhibitors: A Historical Perspective to Current Clinical Application.

Vismodegib (Erivedge, Genentech-Roche) is the first in class of Hedgehog pathway inhibitors approved for treatment of metastatic basal cell carcinoma (BCC), or locally advanced BCC that has recurred after surgery or is not amenable to surgery or radiation. Its path to discovery has been unique and traces its origin to corn lilies, sheep, Drosophila flies, and the Hedgehog signaling pathway. J Drugs Dermatol. 2018;17(5):506-508.

Liposuction of the Neck: Low Incidence of Nerve Injury and Other Complications in 987 Patients.

The neck is one of the most common areas treated by liposuction. Neck liposuction decreases fat volume, causes skin contraction, and restores a more youthful appearance. We present a large case series (n=987) performed by three dermatologic surgeons. Five patients developed temporary post-operative marginal mandibular dysfunction, one patient had submandibular gland ptosis and one patient had arterial bleeding. Seroma, skin necrosis, scarring, and hyperpigmentation did not occur following neck liposuction. Neck liposuction performed with tumescent local anesthesia is a safe procedure associated with a low incidence of nerve injury and other complications.

J Drugs Dermatol. 2018;17(1):30-34.

Use of immediate dermal fat graft for scalp contour defect following resection of arteriovenous malformation.

Arterial venous malformations (AVMs) are rare conditions that are difficult to manage. Therapeutic options include selective embolization with or without surgical excision. Recurrence, however, is high despite correction of the primary abnormality. Cosmetic concern is among the indications for treatment, particularly if the AVM occurs on the face or scalp. Historically, AVM excision and the residual defect correction have been performed separately. We present the first case reported of a successful embolization and interval excision with immediate reconstruction using a dermal fat graft, as a novel approach to correct soft tissue defect following the resection of an AVM. A 35-year-old man presented with a 20-year history of a nonpulsating mass posterior to the hairline in the right frontoparietal region, measuring 4.0 cm on its longest axis. Embolization of the AVM was achieved by injecting N-butyl cyanoacrylic acid and ethiodol. One month after embolization, surgical excision of the mass was performed. The resulting disfiguring contour defect was immediately corrected using a dermal fat graft harvested from the groin. At 4 months' follow-up, the graft was viable with no evidence of resorption or epidermal cyst formation. In addition, there was no recurrence of the AVM and no complications at the donor site. This case demonstrates the utility of a dermal fat grafts in correcting the impending defect in 1 stage avoiding a second-stage procedure and significant period of cosmetic disfigurement. This method should be considered as a treatment option for patients requiring moderately sized AVM excisions in cosmetically sensitive areas.

Presentation of reticulate acropigmentation of kitamura and dowling-degos disease overlap.

The authors report a case of overlapping reticulate acropigmentation of Kitamura and Dowling-Degos disease seen in a 57-year-old woman. This is a unique presentation of two rare entities that some believe to be the same disease with variable phenotypic expression. This is an interesting case of reticulated pigmentation that unfortunately has limited treatment options.

Wound Healing Society (WHS) venous ulcer treatment guidelines: what's new in five years?

Since the establishment of the guidelines for the treatment of venous ulcers by the Wound Healing Society in 2006, there has been an abundance of new literature, both in accord and discord with the guidelines. The goal of this update is to highlight new findings since the publication of these guidelines to assist practitioner and patient in appropriate health care decisions, as well as to drive future research endeavors.

Atypical ulcers: wound biopsy results from a university wound pathology service .

Chronic wounds are an increasing health burden across the continuum of care and encountered by a wide variety of healthcare providers and physicians of all specialties. The majority of chronic wounds are caused by vascular insufficiency, neuropathy, or prolonged pressure. Wounds caused by other underlying health conditions or external factors such as radiation or spider bites are usually referred to as atypical. Although a wound biopsy generally is recommended in the case of refractory, nonhealing ulcers or when wounds present with atypical signs and symptoms, little is known about the distribution of atypical ulcers. A retrospective, descriptive study was conducted to describe the proportion and differential diagnosis of atypical ulcer biopsies received during a 2-year period by the wound pathology division in the division of Dermatopathology at the University of Miami Department of Dermatology and Cutaneous Surgery. Of the 350 wound biopsies received for diagnostic purposes, 104 (29.7%) were due to atypical causes. The majority of specimens were neoplasms (n = 24). Pyoderma gangrenosum was the most common atypical diagnosis encountered (n = 14). Vasculitis, predominantly leukocytoclastic vasculitis, and external causes were diagnosed in 16 and 15 biopsies, respectively. This study represents the first published case series of atypical ulcer biopsy results from a wound pathology division. Although the prevalence results cannot be generalized and are likely lower in the general population of patients with nonhealing wounds, the results confirm the usefulness of obtaining wound biopsies to provide a definitive diagnosis and to guide care.

Use of dermal fat graft for augmentation of the labia majora.

Dermal fat grafts have been utilized in plastic surgery for both reconstructive and aesthetic purposes of the face, breast, and body. There are multiple reports in the literature on the male phallus augmentation with the use of dermal fat grafts. Few reports describe female genitalia aesthetic surgery, in particular rejuvenation of the labia majora. In this report we describe an indication and use of autologous dermal fat graft for labia majora augmentation in a patient with loss of tone and volume in the labia majora. We found that this procedure is an option for labia majora augmentation and provides a stable result in volume-restoration.

Penile reconstruction.

A variety of surgical options exists for penile reconstruction. The key to success of therapy is holistic management of the patient, with attention to the psychological aspects of treatment. In this article, we review reconstructive modalities for various types of penile defects inclusive of partial and total defects as well as the buried penis, and also describe recent basic science advances, which may promise new options for penile reconstruction.