Establishing Consensus for Mohs Micrographic Surgical Techniques in the Treatment of Melanoma in Situ for Future Clinical Trials: A Modified Delphi Study.

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.

Toxic epidermal necrolysis: five years of treatment experience from a burn unit.

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.

The Tam formula: A pilot study for a new treatment for melasma.

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.

An analysis of pain and analgesia after Mohs micrographic surgery.

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.

Contribution of dermatologic surgery in war.

BACKGROUND: Despite the large contribution by dermatology to military readiness, there have been no published reports regarding dermatologic surgery or skin cancer in the combat environment. OBJECTIVE: To outline the contribution of dermatologic surgery, including skin cancer and benign tumors, to deployed service men and women in Operation Iraqi Freedom. METHODS: A retrospective chart review was performed of all dermatology visits at the 86th Combat Support Hospital, Ibn Sina, Iraq, between January 15, 2008 and July 15, 2008. RESULTS: Two thousand six hundred ninety-six patients were seen in the combat dermatology clinic during the 6-month period reviewed; 8% (205/2,696) of the total visits were for skin cancer, and another 129 patients were treated for actinic keratosis. The specific diagnoses were basal cell carcinoma (n=70), in situ and invasive squamous cell carcinoma (n=68), mycosis fungoides (n=1), bowenoid papulosis (n=1), and in situ and invasive melanoma (n=9). Benign lesions and tumors accounted for 14% (357/2,696) of total patient visits. Three hundred seven surgeries were performed during the 6-month period (178 skin cancers and 129 benign lesions), and 20 patients were referred for Mohs micrographic surgery. The surgical complications included five postoperative wound infections (1 methicillin-resistant Staphylococcus aureus), one wound dehiscence, and seven allergic contact dermatitis. CONCLUSIONS: To the authors' knowledge, this is the first publication regarding skin cancer and dermatologic surgery in the combat setting. This report outlines the important contribution of dermatologic surgery in the combat environment.

Treatment of melasma using fractional photothermolysis: a report of eight cases with long-term follow-up.

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.

Combat dermatology: the prevalence of skin disease in a deployed dermatology clinic in Iraq.

BACKGROUND: Since July 2004, the United States (U.S.) Army has operated a forward-deployed dermatology clinic in Baghdad, Iraq. This paper outlines the prevalence of skin disease among deployed service men and women in Operation Iraqi Freedom. METHODS: A cross-sectional study was performed for all dermatology visits presenting to the Combat Dermatology Clinic, Ibn Sina, Iraq, between January 15, 2008 and July 15, 2008. RESULTS: In the six-month period reviewed, 2,696 total patients were evaluated. The most prevalent diagnoses included eczematous dermatitis [17%, n=462] and benign neoplasms [14%, n=375]. Eight percent (n=205) of the total visits were for skin cancer. This included: basal cell carcinoma, squamous cell carcinoma both in-situ and invasive, mycosis fungoides and melanoma. Actinic keratosis comprised 5% of the total visits (n=129). Bacterial infections comprised 6% (n=158) of the total visits and 31 of these cases were community acquired methicillin resistant Staphylococcus aureus (MRSA). LIMITATIONS: Cross-sectional study with referral bias. CONCLUSION: This is the largest publication of the prevalence of skin disease in an exclusively dermatologic clinic in a combat setting. For the first time the presence of skin cancer is noted in a combat setting. The prevalence of MRSA is noted and was exclusively seen in U.S. soldiers. There was a statistically significant rise in the prevalence of eczematous dermatitides when compared with previous conflicts. Dermatologists can have a significant and strategic impact on deployed military medicine.

The use of the flexible scalpel for minimally invasive and minimally scarring surgery: a case series of four patients with large scalp tumors.

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.

Eosinophilic fasciitis secondary to intravenous iron infusions.

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.

Nephrogenic fibrosing dermopathy.

A 75-year-old woman with end-stage renal disease on hemodialysis presented with a 2-month history of progressive skin thickening of the lower extremities. A punch biopsy specimen showed plump fibroblasts entrapping collagen bundles and positive staining for CD34 and procollagen. These changes were consistent with a diagnosis of nephrogenic fibrosing dermopathy (NFD). Nephrogenic fibrosing dermopathy is a rare, sclerosing disorder in patients with renal failure, which may be mistaken for scleromyxedema. The etiology of NFD is unclear but may be associated with systemic involvement, antecedent surgical procedures, gadolinium, or an underlying hypercoagulable state. The treatment is limited, and only a few reported cases have shown remission after stopping dialysis in transient renal failure.

Allergic contact dermatitis to mafenide acetate: a case series and review of the literature.

Burn patients with extensive involvement of body surface area (BSA >30%) represent a challenge in wound treatment. Multiple topical agents may be used for cleansing, barrier protection, and antimicrobial control leading to complications of contact and/or irritant dermatitis, which may further complicate re-epithelization and eventual wound healing. We present 4 patients who sustained extensive burns during Operation Iraqi Freedom/Operation Enduring Freedom and later developed contact dermatitis to mafenide acetate, a common topical antimicrobial used in burn care treatment, also known as Sulfamylon (alpha-amino-p-toluenesulfonamide monoacetate). All patients who were patch tested to mafenide acetate 7% solution were positive. A rechallenge with mafenide acetate resulted in recrudescence of the eruption in 2 out of the 4 patients. Though cutaneous reactions to mafenide acetate were reported by Yaffe and Dressler in 1969, the most recent case reports are from 1995. This paper presents more recent examples of cutaneous reactions to mafenide acetate, while also reviewing the literature.

Role of skin biopsy to confirm suspected acute graft-vs-host disease: results of decision analysis.

OBJECTIVE: To estimate the value of skin biopsy in the evaluation of suspected acute cutaneous graft-vs-host disease (GVHD) after allogeneic stem cell transplantation. DESIGN: Decision analysis using parameters specified by expert opinion for skin biopsy characteristics, prevalence of acute GVHD, and value of potential outcomes. One-, 2-, and 3-way sensitivity analyses were performed. SETTING: Major stem cell transplantation centers in the United States. PATIENTS: Hypothetical cohort of patients with suspected acute cutaneous GVHD after stem cell transplantation. INTERVENTIONS: The following 3 interventions were compared: treat immediately for GVHD without performing a skin biopsy, perform a skin biopsy and treat immediately but stop treatment if skin biopsy specimen findings are inconsistent with GVHD, and perform a skin biopsy and await results of the skin biopsy specimen before treating. MAIN OUTCOME MEASURES: Number of patients appropriately and inappropriately treated with each intervention, consistency of physician-reported behavior, individualized decision analyses, and preferred intervention based on the aggregate estimates of respondents. RESULTS: The decision to treat immediately for GVHD without performing a skin biopsy yielded the best clinical outcome for the specified clinical setting and under the parameters specified by expert opinion. One-way sensitivity analyses showed that these conclusions are robust if the prevalence of acute cutaneous GVHD in stem cell recipients with rash is greater than 50%, if the sensitivity of skin biopsy specimen is less than 0.8, and the specificity of skin biopsy specimen is less than 0.9. Only 25% of physicians interviewed chose an intervention consistent with their estimates of prevalence, test characteristics, and outcome evaluations, indicating an opportunity to improve management of this important clinical condition. CONCLUSIONS: This decision analysis modeling technique predicts that in patient populations in which the prevalence of GVHD is 30% or greater (typical for allogeneic stem cell transplantation), the best outcomes were obtained with treatment for GVHD and no skin biopsy. In populations with prevalence of GVHD of 30% or less, obtaining a skin biopsy specimen to guide treatment was predicted to provide the best patient outcomes.