Periocular and ocular surface nonmelanoma skin cancer.

Periocular and ocular surface nonmelanoma malignancies, including basal cell carcinoma (BCC), squamous cell carcinomas (SCC), and ocular surface squamous neoplasia (OSSN), are rare, but their management requires special considerations. The most common periocular malignancy is BCC, which constitutes 80% to 96% of tumors, followed by SCC, which represents 5% to 10% of tumors. OSSN represents a spectrum of diseases that encompass dysplastic alteration to the squamous epithelium of the eye. OSSN ranges from squamous dysplasia to conjunctival intraepithelial neoplasia/carcinoma in situ to invasive SCC, which is the most common ocular malignancy. These tumors can be staged using the eighth edition of the American Joint Committee on Cancer categorization system. The standard of care for periocular malignancies is Mohs micrographic surgery, while medical management with 5-fluorouracil (5-FU), interferon alfa-2b (INF), and mitomycin C (MMC) or "no touch" surgical excision are options for OSSN. Systemic therapies, including sonic hedgehog inhibitors for BCC and epidermal growth factor inhibitors and immune-checkpoint inhibitors for SCC, can be utilized for advanced disease. Recurrence rates are higher for periorbital and ocular malignancies than their respective cutaneous counterparts. These carcinomas and their respective treatments have unique side effects and considerations in an effort to preserve visual function.

Modified Fitzpatrick Scale-Skin Color and Reactivity.

BACKGROUND: There is growing interest in the development of a skin classification system that captures the world's diverse population. The Fitzpatrick skin classification scale is used both clinically and in research settings to determine an individual's skin color. With the high global burden of skin sensitivity (atopic dermatitis, keloid formation, etc), there is a need for a skin classification system that takes into consideration an individual's reaction to environmental insults and injuries. Our proposal builds on the existing Fitzpatrick skin classification scale by asking two additional questions of patients: do patients have sensitive skin; do patients have a history of hypertrophic scarring or keloids. By separating patients into 2 categories (sensitive vs non-sensitive skin), we create a system that can help dermatologists decide on which treatments to offer patients based on their skin classification. Dermatologists can better predict patient outcomes for dermatologic or cosmetic procedures by knowing how they react to environmental insults/injury. Santiago S, Brown R, Shao K, et al. Modified fitzpatrick scale- skin color and reactivity. J Drugs Dermatol. 2023;22(7):641-646. doi:10.36849/JDD.6859.  .

Racial and Ethnic Healthcare Disparities in Skin Cancer in the United States: A Review of Existing Inequities, Contributing Factors, and Potential Solutions.

Objective: Racial and ethnic health disparities affect the diagnosis and management of melanoma and nonmelanoma skin cancers, leading to deleterious outcomes. Non-Hispanic White patients make up the majority of skin cancers cases, yet racial and ethnic minorities have poorer prognoses and outcomes. The skin cancer literature is fragmented with regards to potential contributors to these healthcare disparities. In this article, we provide a comprehensive review of the skin cancer literature to briefly quantify racial and ethnic inequities, highlight contributing factors, and propose practical changes that can be made. Methods: A PubMed search was completed to identify articles related to racial and ethnic health care disparities in the context of melanoma, basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and dermatofibrosarcoma protuberans. Results: Relative to non-Hispanic White patients, patients of racial and ethnic minorities have differing clinical presentations of skin cancers and genetic risk factors. Insurance, access to specialty care, cultural beliefs, and available educational resources further contribute to racial and ethnic disparities. Limitations: We are limited to the level of detail provided in the existing literature, and at some times are unable to distinguish race of Hispanic populations. We also acknowledge that there are different nationalities grouped under these broad labels as well as multi-racial populations that may not be accounted for. Conclusion: Awareness of and familiarization with innate factors and potentially more modifiable contributors can help inform efforts to close the observed gap in racial and ethnic inequities.

Measuring Stakeholder Assessments of Postsurgical Facial Scars: A Retrospective Cohort Inter-rater Analysis of Patients, Physicians, and Medical Student Observers.

BACKGROUND: The relationship of postoperative facial scar assessments among patients, physicians, and societal onlookers is not clearly defined. OBJECTIVE: To identify differences in perceived scar outcomes by different stakeholders. METHODS AND MATERIALS: Retrospective cohort study at a single Mohs micrographic surgery (MMS) center during which scars were assessed by: patients, physicians, and medical student observers not involved in patients' care using the Patient and Observer Scar Assessment Scale (v.2). Eighty-one patients graded their scars at 2 visits: 1 to 2 weeks post-MMS and 3 months post-MMS. Deidentified patient photographs were taken at each visit and graded by 4 physicians and 12 observers. RESULTS: At week 1, there was a significant difference in overall opinion of scar appearance between patient and physicians (p = .001) and medical student observers and physicians (p < .001). Physicians graded scars more favorably. At 3 months, there remained a difference in scar evaluations between patient and physicians (p = .005), whereas medical student observers rated scars more similarly to physicians (p = .404). CONCLUSION: Postoperative scar perceptions differ among stakeholders. Physicians must be mindful of this disparity when counseling patients in the perioperative setting to align patient expectations with realistic scar outcomes.

Racial and ethnic health disparities in dermatology in the United States. Part 2: Disease-specific epidemiology, characteristics, management, and outcomes.

Racial and ethnic disparities in dermatology negatively affect outcomes such as mortality and quality of life. Dermatologists and dermatologic surgeons should be familiar with disease-specific inequities that may influence their practice. The second article in this 2-part continuing medical education series highlights gaps in frequency, clinical presentation, management, and outcomes by race and ethnicity. We review cutaneous malignancies including basal cell carcinoma, squamous cell carcinoma, melanoma, Merkel cell carcinoma, dermatofibrosarcoma protuberans, and cutaneous T-cell lymphoma, and inflammatory disorders including atopic dermatitis, psoriasis, hidradenitis suppurativa, acne vulgaris, and rosacea.

Racial/ethnic health disparities in dermatology in the United States, part 1: Overview of contributing factors and management strategies.

Racial or ethnic disparities are prevalent in the field of dermatology. Part 1 of this continuing medical education series aims to elucidate contributors to racial and ethnic disparities within dermatology and highlight potential actionable steps to combat these disparities. We review access to care, workforce diversity, cultural competency, implicit bias, dermatologic education material, patient education, and clinical research. Part 2 of the continuing medical education series will address disease-specific inequities that influence the clinical practice of dermatology.

Nutrition and urticaria.

Urticaria is a distressing dermatologic condition for many. Although the wheals of urticaria are characteristically evanescent, lasting less than 24 hours, patients tend to have recurrent episodes. Hives that last less than 6 weeks are considered acute urticaria. Acute urticaria does not routinely require supplementary work-up because the history often identifies a convincing, inciting allergen. Chronic urticaria is defined as episodes that occur for longer than 6 weeks, and there is often not an easily identifiable trigger. For both acute and chronic urticaria, patients frequently report food as a precipitating cause. For acute urticaria, the foods that are associated with true allergies, such as nuts and shellfish, are the most frequent offenders. The relationship between diet and chronic urticaria is not as firmly defined. Many patients unnecessarily restrict their diets, so it becomes the role of dermatologists to help patients identify if there is a reproducible link between their symptoms and their dietary exposures. The literature suggests that diets free from pseudoallergens and histamine-releasing foods may attenuate urticaria. Supplements such as fats, vitamin D, iron, and flavonoids have also been studied and may diminish symptoms.

Nutrition and nonmelanoma skin cancers.

Nonmelanoma skin cancer (NMSC), the most widely diagnosed cancer in the United States, is rising in incidence despite public health and educational campaigns that highlight the importance of sun avoidance. It is,therefore, important to establish other modifiable risk factors that may be contributing to this increase. There is a growing body of evidence in the literature suggesting certain nutrients may have protective or harmful effects on NMSC. We review the current literature on nutrition and its effect on NMSC with a focus on dietary fat, vitamin A, nicotinamide, folate, vitamin C, vitamin D, vitamin E, polyphenols, and selenium.

The effects of alcohol and illicit drug use on the skin.

Early identification of cutaneous manifestations of alcohol and illicit drug use can aid in the diagnosis and management of these uses, as well as their sequelae. In addition, the effects of alcohol and illicit drug use on the skin can result in significant morbidity. Alcohol misuse can present with jaundice, pruritus, pigmentary alterations, urticaria, hair and nail changes, and oral changes. It is also a risk factor for skin cancer and infections. Vascular disturbances associated with alcohol misuse include telangiectasias, palmar erythema, caput medusae, and flushing. Diseases related to alcohol misuse include nutritional deficiencies, porphyria cutanea tarda, psoriasis, seborrheic dermatitis, nummular dermatitis, and rosacea. Other conditions seen in alcohol misuse include Dupuytren contracture, Peyronie disease, and pancreatitis. Dermatologists should also be aware of hepatotoxic medications that are commonly prescribed for skin diseases so as to avoid initiating hepatoxicity in patients who use alcohol. Illicit drug use can manifest with cutaneous fibrosis, scarring, granulomas, ulceration, pruritus, infections, cocaine-levamisole-induced vasculitis, tooth decay, and oral disease. By recognizing the cutaneous stigmata of alcohol and illicit drug use, dermatologists can aid in the identification and treatment of patients suffering from these addictions.

Cannabis and the skin.

The public and health care providers are increasingly curious about the potential medical benefits of Cannabis. In vitro and in vivo studies of Cannabis have suggested it has favorable effects on regulating pain, pruritus, and inflammation, making it a potentially attractive therapeutic agent for many dermatologic conditions. The body of literature reporting on the role of cannabinoids in dermatology is in its infancy but growing. We review the current research, possible cutaneous adverse effects, and future directions for cannabinoids and their use in skin cancer, acne, psoriasis, pruritus, dermatitis, scleroderma, dermatomyositis, cutaneous lupus erythematous, epidermolysis bullosa, pain, and wound healing.

The Natural Evolution of Facial Surgical Scars: A Retrospective Study of Physician-Assessed Scars Using the Patient and Observer Scar Assessment Scale Over Two Time Points.

Background: The natural evolution of facial scars has not been well described. Identifying factors that correlate with optimal scar healing may help patients and physicians during the perioperative period. Methods: A retrospective study of 108 facial skin cancer patient scars was performed. The Patient and Observer Scar Assessment Scale (POSAS) was used to grade scars at two time points (1 week and 3 months postoperatively). Paired two-tailed t-tests identified differences in scar ratings between the time points. Analysis of variance (ANOVA) explored whether POSAS scores differed by anatomic site or reconstruction type. Receiver operating characteristic analysis was performed to identify if 1-week scar appearance correlated with scar appearance at 3 months. Results: Between 1 week and 3 months the total POSAS score improved by 36.3% and overall opinion of the scar improved by 38.6% (p < 0.001). Facial cosmetic units differed in their 1-week and 3-month scores and all anatomic sites demonstrated significant improvement between time points. Differential scoring occurred among reconstruction types. Scar appearance at 1 week was able to predict overall scar appearance at the 3-month visit (area under the curve = 0.7732). Conclusions: Early scar appearance predicts later scar appearance, and scars will improve by nearly 40% 3 months after surgery. These data can be used to assist with perioperative counseling and expectation management.

United States Preventive Services Task Force Overstates Cosmetic Harms of Skin Cancer Screening.

The United States Preventive Services Task Force (USPSTF) 2016 recommendation for skin cancer screening in asymptomatic healthy adults concluded that current evidence is "insufficient to assess the balance and harms of visual skin examination." One contributing factor leading to the insufficient grade was a concern for cosmetic harms resulting from unnecessary biopsies or excisions. This commentary briefly highlights the pertinent studies and currently accepted methods for pigmented lesion biopsy. Reviewing these data will permit clinicians to more thoroughly analyze the USPSTF statement and might assist in routine assessment and management of suspicious pigmented lesions in adult patients.

Lupus-like cutaneous reaction following pembrolizumab: An immune-related adverse event associated with anti-PD-1 therapy.

PD-1 (programmed cell death-1) inhibitors, used to treat metastatic melanoma and other malignancies, are associated with development of immune-related adverse events in the skin. Such reactions include morbilliform eruptions, vitiligo, alopecia areata and bullous pemphigoid. In this report, we describe a patient who developed a lupus-like cutaneous reaction in the setting of pembrolizumab therapy for metastatic melanoma, adding to the spectrum of reactions which may be observed in association with PD-1 inhibitor therapy.