Diagnosis and management of longitudinal erythronychia: A clinical review by an expert panel.

Longitudinal erythronychia (LE) is defined as a longitudinal red band of the nail(s) and is classified as localized (involvement of 1 nail) or polydactylous (involvement of more than 1 nail). The differential diagnosis is distinct for these classifications. The etiologies of localized longitudinal erythronychia are most frequently benign subungual neoplasms and less often malignancies. Polydactylous longitudinal erythronychia is typically secondary to regional or systemic diseases, including lichen planus and Darier disease. LE is a common but underrecognized clinical finding. Increased dermatologist awareness of the clinical characteristics and differential diagnosis for LE is necessary given the possibility for malignancy and associated systemic disease. In this clinical review, the clinical features, differential diagnosis, evaluation, and management of LE are described.

Review and Therapeutic Approach to Malalignment of the Great Toenails: A Common Condition That Is Uncommonly Diagnosed.

BACKGROUND: Malalignment of the great toenails is a common nail disorder that is uncommonly recognized in general practice. OBJECTIVE: Review available literature on lateral malalignment of the great toenails to increase awareness of this underdiagnosed condition and provide management recommendations. METHODS: A PubMed search was conducted using the terms "congenital malalignment toenail" and "malalignment great toenail". All articles were reviewed, and all relevant articles were included in this analysis. RESULTS: Thirty-four distinct articles encompassing 117 patients with similar clinical findings: lateral deviation of the great toenails with yellow brown dyschromia, thickening, and scalloping. LIMITATIONS: Description of malalignment and terminology can vary, which may have led to exclusion of some relevant articles. CONCLUSION: Lateral malalignment is a common nail condition that is underappreciated and often misdiagnosed in general dermatologic and medical practice. This review aims to increase awareness to facilitate better care of these patients.

Expert Consensus on Nail Procedures and Selection of CPT Codes.

BACKGROUND: Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE: To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS: A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS: Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS: Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION: Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Management of primary skin cancer during a pandemic: Multidisciplinary recommendations.

During the coronavirus disease 2019 (COVID-19) pandemic, providers and patients must engage in shared decision making regarding the pros and cons of early versus delayed interventions for localized skin cancer. Patients at highest risk of COVID-19 complications are older; are immunosuppressed; and have diabetes, cancer, or cardiopulmonary disease, with multiple comorbidities associated with worse outcomes. Physicians must weigh the patient's risk of COVID-19 complications in the event of exposure against the risk of worse oncologic outcomes from delaying cancer therapy. Herein, the authors have summarized current data regarding the risk of COVID-19 complications and mortality based on age and comorbidities and have reviewed the literature assessing how treatment delays affect oncologic outcomes. They also have provided multidisciplinary recommendations regarding the timing of local therapy for early-stage skin cancers during this pandemic with input from experts at 11 different institutions. For patients with Merkel cell carcinoma, the authors recommend prioritizing treatment, but a short delay can be considered for patients with favorable T1 disease who are at higher risk of COVID-19 complications. For patients with melanoma, the authors recommend delaying the treatment of patients with T0 to T1 disease for 3 months if there is no macroscopic residual disease at the time of biopsy. Treatment of tumors ≥T2 can be delayed for 3 months if the biopsy margins are negative. For patients with cutaneous squamous cell carcinoma, those with Brigham and Women's Hospital T1 to T2a disease can have their treatment delayed for 2 to 3 months unless there is rapid growth, symptomatic lesions, or the patient is immunocompromised. The treatment of tumors ≥T2b should be prioritized, but a 1-month to 2-month delay is unlikely to worsen disease-specific mortality. For patients with squamous cell carcinoma in situ and basal cell carcinoma, treatment can be deferred for 3 months unless the individual is highly symptomatic.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

Rhombic Flap: A Useful Flap for Small-to-Medium Defects of the Medial Canthus.

BACKGROUND: Medial canthal defects are frequently encountered yet present specific challenges for the reconstructive surgeon. Surgical repair in this area may inadvertently lead to canthal webbing, ectropion, and/or epiphora. The rhombic flap is a versatile workhorse in the reconstructive armamentarium for canthal defects. OBJECTIVE: To describe the use of the inferiorly based rhombic flap for reconstructing defects on the medial canthus. METHODS: A retrospective analysis of the Mohs micrographic surgery cases was performed. All cases in which an inferiorly based rhombic flap was used for canthal reconstruction between 2012 and 2017 were identified. Defect size, location, and any postoperative complications were noted. Surgical scars were scored using the Vancouver Scar Scale. RESULTS: There were 34 cases (17 men and 17 women). Age ranged from 38 to 86 (mean 69). Defect size varied from 0.6 to 2.1 cm in diameter. Postoperative complications were uncommon and minor. CONCLUSION: The rhombic flap is a versatile and useful option for reconstructing surgical defects of the medial canthus.

Use of Extranasal Bilobed Transposition Flaps in Cutaneous Reconstructive Surgery at 2 Institutions.

BACKGROUND: Bilobed transposition flaps are versatile random pattern flaps used in nasal and extranasal reconstruction as they preserve free margins, access distal tissue reservoirs, and reliably repair dynamic defects. OBJECTIVE: We highlight the utility of extranasal bilobed flaps to encourage surgeons to consider these flaps for Mohs micrographic surgery defects. METHODS: A two-institution retrospective chart review of patients reconstructed using an extranasal bilobed flap after Mohs micrographic surgery was performed. A validated scar scale was applied to postoperative photographs. Statistical analyses of the patient and surgery characteristics including patient co-morbidities, anatomic distribution, flap dimensions, and postprocedural events, including revisions, were conducted. RESULTS: Forty-eight patients were identified. Site-specific flap dimensions were obtained with the cheek/lower eyelid requiring greater tissue mobilization with a higher final to primary defect ratio when compared with other sites. Postoperative events (complications, erythema, flap fullness, dehiscence, infection, etc.) were minimal. No major complications were noted. Nine cases of flap fullness or swelling were identified. Neither flap fullness nor dehiscence compromised flap integrity or cosmetic outcome. Independent flap cosmetic outcome review was good using a validated photographic scar scale. CONCLUSION: Bilobed transposition flaps are versatile repairs for extranasal reconstruction with a favorable safety and outcome profile.

Longitudinal Erythronychia: Retrospective Single-Center Study Evaluating Differential Diagnosis and the Likelihood of Malignancy.

BACKGROUND: Longitudinal erythronychia (LE) is an underappreciated and understudied clinical diagnosis. The rates of malignancy and prevalence within the differential diagnosis are not well-established. OBJECTIVE: To examine the prevalence of biopsy-proven diagnoses in patients presenting with LE. METHODS: Retrospective single-center study of 65 consecutive patients undergoing biopsy of LE. RESULTS: Malignancy was identified in only 3 of 65 cases (in situ carcinoma in 2 and melanoma in 1). Onychopapilloma was the most common diagnosis in cases of localized LE. Lichen planus was the most common diagnosis in cases of polydactylous (generalized) LE. CONCLUSION: Longitudinal erythronychia is not a rare clinical finding. The differential diagnosis includes neoplasms, inflammatory conditions, infectious conditions, and scar. Clinicopathologic correlation is required to make the diagnosis in many cases. Malignancy is uncommon, but not rare, with squamous cell carcinoma in situ representing the most common malignancy.

A Retrospective Study of Nail Squamous Cell Carcinoma at 2 Institutions.

BACKGROUND: Squamous cell carcinoma (SCC) of the nail is infrequently reported in the medical literature and its causes are poorly understood. Studies have shown strong associations with immunosuppression, tobacco use, toxin/radiation exposure, and trauma. Common treatments include Mohs surgery and digital amputation. OBJECTIVE: Review a series of nail SCCs treated at 2 institutions. Outcomes evaluated included rates of recurrence and disease progression/metastasis after treatment. MATERIALS AND METHODS: A retrospective review of patients treated between 2005 and 2008. Medical record review and phone call follow-up using a standardized questionnaire were used. RESULTS: Forty-two tumors were identified in 34 patients. Twenty-seven patients were male (79% CI, 62%-91%) and most tumors were located on the fingernails (39/42; 91% CI, 81%-99%). Twenty-four of 39 tumors (62% CI, 45%-77%) were on the nondominant hand. The middle third finger was the most frequent digit affected (16/42). Common symptoms reported were nail dystrophy (31/42; 74% CI, 58%-86%), followed by onycholysis (22/42; 52% CI, 36%-68%). Most tumors (35/42; 83% CI, 69%-93%) were treated with Mohs surgery. CONCLUSION: Nail SCC is found nearly exclusively in adults and predominantly in men. There are multiple effective treatment possibilities including Mohs surgery, distal digital amputation, and early evidence suggesting radiotherapy.