Antibiotic Practices in Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery is a safe procedure with low rates of infection. OBJECTIVE: To establish current antibiotic prescribing practices amongst Mohs surgeons. METHODS AND MATERIALS: 16-question survey sent to American College of Mohs Surgery members. RESULTS: 305 respondents with collectively 7,634+ years of experience. The majority performed outpatient surgery (95.0%) and avoided oral or topical antibiotics for routine cases (67.7% and 62.8%, respectively). Prophylactic antibiotics were routinely prescribed for artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), extensive inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%). A minority consistently swabbed the nares to check for staphylococcus aureus carriage (26.7%) and decolonized carriers prior to surgery (28.0%). CONCLUSION: Disparity exists in antibiotic prescribing practices amongst Mohs surgeons. There may be under-prescription of antibiotics for high risk factors like nasal flaps, wedge excisions, skin grafts, anogenital/lower extremity site, and extensive inflammatory disease. Conversely, there may be over-prescription for prosthetic joints or cardiac valves. Increased guideline awareness may reduce post-operative infections and costs/side effects from antibiotic over-prescription. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4695.

Methacrylate Polymer Powder Dressing for a Nasal Surgical Defect

The fusion of technology and medicine has led to the advent of advanced wound healing techniques that may be adapted to the management of surgical defects. Shortened duration of healing and ease-of-use are two potential benefits under investigation. Here we describe a 65-year-old male with a nasal alar wound that was allowed to heal with secondary intention, assisted by a novel methacrylate polymer powder dressing. J Drugs Dermatol. 2019;18(12):1274-1275.

Presurgical Curettage Improves Accuracy for Nonmelanoma Skin Cancer Excision.

BACKGROUND: Presurgical curettage before nonmelanoma skin cancer surgery may help delineate tumor subclinical extensions. OBJECTIVE: To determine histologically whether presurgical curettage appropriately or inappropriately changes excision specimen size. MATERIALS AND METHODS: One hundred fifty consecutive nonmelanoma skin cancers treated with Mohs micrographic surgery. The clinical margin (CM) was marked. Presurgical curettage was then performed and the resultant presurgical curettage margin (PCM) marked. Frozen section analysis of the CM and PCM revealed whether the curettage-induced margin change was appropriate or unnecessary. RESULTS: Presurgical curettage appropriately increased the surgical margin in 9.3% of cases, reducing the number of Mohs stages from 2 to 1. It appropriately decreased the surgical margin in 17.3% thereby conserving normal skin. In 19.4% of cases the curettage increased the margin in situations where the CM had underestimated the size of the tumor; however, in these cases, the curettage did not increase the margin sufficiently to clear the tumor. In 44.0% of cases the PCM did not change the size of the stage I specimen compared to the CM and confirmed the CM. In 10.0% of cases, preoperative curettage reduced margin accuracy by removing healthy tissue (8.0%) or underestimating tumor (2.0%). These errors were associated with eyelid location, severe background photodamage, and morpheiform/infiltrating/sclerosing basal cell carcinomas. CONCLUSION: Presurgical curettage can improve tumor excision accuracy and efficiency. Careful tumor selection is important to optimize curette utility.

Patients with drug-eluting stents and management of their anticoagulant therapy in cutaneous surgery.

Whether a patient has a drug-eluting stent (DES) implanted may not seem to be an immediate concern for a dermatologist. However, the clinician needs to consider a patient's risk of bleeding if a patient is to undergo a cutaneous surgical procedure. Patients with skin cancer are generally older with a higher risk of comorbidities such as cardiovascular disease with history of cardiac stent implantation. After DES placement, patients are typically on long-term dual antiplatelet therapy, which increases the risk of bleeding. However, stopping antiplatelet therapy prematurely can lead to serious thrombotic complications. Thus, when performing a dermatologic procedure in a patient with a DES, the physician must weigh the risks of bleeding complications with continuing antiplatelet therapy against the risk of thrombotic complications associated with stopping antiplatelet therapy. The aim of this review is to identify the issues for the dermatologist and the dermatologic surgeon surrounding the perioperative treatment of patients with a DES and to discuss the treatment of patients with an implanted DES.

Catastrophic cutaneous carcinomatosis in the non-organ transplant patient.

BACKGROUND: The increased frequency of nonmelanoma skin cancers (NMSCs) in organ transplant recipients has been termed "catastrophic cutaneous carcinomatosis" (CCC). We have treated a cohort of immunocompetent patients with an increased number of NMSCs that meets the definition of CCC whom we have termed "catastrophic cutaneous carcinomatosis-immunocompetent" (CCC-IC). OBJECTIVE: We sought to further understand the epidemiologic characteristics of this subset of immunocompetent patients with a high burden of NMSCs. METHODS: Our pathology database was searched over a 4-year experience of a Mohs surgeon to identify patients with greater than 10 basal cell carcinomas (BCCs) and/or squamous cell carcinomas (SCCs) in a 12-month period who had no underlying systemic cause of immunosuppression or genetic predisposition to form NMSCs. Information regarding the 13 patients who met inclusion criteria was collected by questionnaire and analyzed. RESULTS: There was no statistically significant difference in the constitutional variables of this patient population. Patients with CCC-IC had a SCC:BCC ratio of 2.5:1, similar to what is seen in organ transplant recipients where the SCC:BCC ratio is 2:1 with SCC predominance. There was a statistically significant increase in the number of SCCs in patients with CCC-IC (8.77/patient) as compared with control patients (2.27/patient). Most strikingly, a 13.8-fold higher incidence of malignant melanoma in the CCC-IC group was found as compared with the general population. LIMITATIONS: Limitations to this study include a small sample size and recall bias. CONCLUSION: Our data suggest that patients with CCC-IC have skin cancer profiles of SCC and BCC similar to organ transplant recipients and have a markedly higher incidence of malignant melanoma than the general population. These patients require strict monitoring and combination therapeutic approaches toward management of cutaneous carcinomas.

Analyzing Controversies in Management and Surveillance of Early-Stage Melanoma.

The incidence of cutaneous melanoma continues to rise dramatically worldwide, presenting a significant burden to the healthcare system. Despite this, there is still controversy in the guidelines regarding follow-up surveillance for patients with thin melanoma. Since there are no randomized clinical trials to support evidence-based guidelines for follow-up surveillance, dermatologic and oncologic organizations have developed their own recommendations based on expert opinion. However, these recommendations differ widely and are often vague, resulting in considerable variability in the management of early-stage melanoma among clinicians. The benefits of frequent follow-up visits are early detection of recurrent lesions, lower cost of early-stage melanoma compared to that of late-stage melanoma, decreased need for sentinel lymph node biopsy and adjuvant therapies, and the opportunity to educate patients on self-examination and sun protection. However, the high cost of screening and potential increased rates of biopsy, as well as over-imaging and overtreating, pose serious concerns about this approach. While more rigorous research is needed to resolve this controversy, currently clinicians should follow a relatively universal recommendation to tailor the follow-up regimen based on the patient's relative risk of recurrence and comfort.

Soft tissue tumors of the hand. 2. Malignant.

Soft tissue tumors of the hand arise from skin, subcutaneous tissue, tendons, nerve, and blood vessels. Many of these lesions occur on other parts of the body; however, the hand remains a unique site because these tumors have symptoms, appearances, treatments, and prognoses that may be quite different than when on other parts of the body. Their characteristics and the severity of symptoms vary markedly depending on the exact location, size, and type of tumor-and many of these tumors can have multiple forms of presentation. Two articles are intended to provide an overview of benign (previous article) and malignant tumors (this article) of the hand. The rarer and more deleterious tumors are discussed in detail while the common tumors and epidermal lesions with which practitioners are familiar are briefly overviewed. At the completion of these review articles, participants should be able to identify and diagnose various benign and malignant hand tumors as well as understand the accepted current treatment of these growths.

Melanoma of the scalp: an underdiagnosed malignancy?

We report a case of scalp melanoma that was found incidentally after the patient complained of pruritic lesions on his scalp. The melanoma was 13 mm in diameter and had a Breslow thickness of 0.25 mm. The incidence of melanoma has been on the rise, with a high incidence occurring in men on the head, neck, and trunk. This case stresses the need to thoroughly examine the entire scalp when performing total body screening examinations for skin cancer.

Soft tissue tumors of the hand. 1. Benign.

Soft tissue tumors of the hand arise from skin, subcutaneous tissue, tendons, nerve, and blood vessels. Many of these lesions occur on other parts of the body; however, the hand remains a unique site because these tumors have symptoms, appearances, treatments, and prognoses that may be quite different than when on other parts of the body. Their characteristics and the severity of symptoms vary markedly depending on the exact location, size, and type of tumor-and many of these tumors can have multiple forms of presentation. Two articles are intended to provide an overview of benign (this article) and malignant tumors (subsequent issue) of the hand. The rarer and more deleterious tumors are discussed in detail while the common tumors and epidermal lesions with which practitioners are familiar are briefly overviewed. At the completion of these review articles, participants should be able to identify and diagnose various benign and malignant hand tumors as well as understand the accepted current treatment of these growths.

Laser surgery: an approach to the pediatric patient.

UNLABELLED: Revolutionary advances in laser research and technology have led to expanded dermatologic laser applications. With the wide range of lasers now available, a large spectrum of skin conditions in the pediatric population can be successfully treated or, in some cases, completely eradicated. Laser treatment of the pediatric population poses a unique challenge for the clinician on a variety of levels. Physically, the composition of many vascular and pigmented lesions changes as children age making them more resistant to laser therapy. Thus, in many cases, treating lesions at an early age has resulted in clearing in fewer sessions and with decreased complications. Mechanically, lasers and laser settings used for the treatment of adult lesions may have to be adjusted for the smaller vessels and the unpredictable nature of scarring with children's skin. For vascular lesions, the pulsed dye laser is considered the laser of choice for its efficacy and low-risk profile, whereas the Q-switched, pigment-specific lasers are ideal for most childhood pigmented lesions, allowing for single pigment cell destruction. Other conditions such as acne and acne scars, psoriasis, keloids, warts and hypertrichosis that traditionally have been treated with a variety of modalities are now being managed safely with laser surgery. Other issues specific to the pediatric population include the determination of suitable anesthesia, the provision of size-appropriate safety equipment, and the assessment and management of patient and parent anxiety. The use of lasers specifically designed for structural differences in pediatric lesions and the recognition of emotional issues surrounding a young patient during laser surgery are critical components of successful treatment. LEARNING OBJECTIVE: At the conclusion of this learning activity, participants should be familiar with the mechanism of laser technology, current trends in the use of lasers for skin lesions in the pediatric population, and the issues specific to treating a patient with laser surgery.