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Background Non-physician practitioners (NPPS), including nurse practitioners (NPs) and physician assistants (PAs) are expanding their scope of practice outside of primary care and performing more procedures in dermatology. Objective To understand the scope and geographic pattern of practice by NPs and PAs in dermatology in the US. Methods Cross-sectional retrospective cohort analysis of dermatology practices in the 2014 Medicare Physician/Supplier Procedure Summary Master File, which reflects Part B carrier and durable medical equipment fee-for-service claims in the US. Results Over 4 million procedures were billed independently by NPs and PAs, which accounts for 11.51% of all. Injection, simple repair, and biopsy were the most commonly billed by non-physician practitioners, but complex procedures were also increasingly billed independently by NPs and PAs. Proportions of their claims are higher in the East Coast, Midwest, and Mountain states. Limitations Data is at the state level, limited to Medicare beneficiaries, and doesn’t include billing incident-to physicians. Conclusions This study demonstrated the increasing scope of practice of NPs and PAs in dermatology, despite limited training and lack of uniform regulations. To ensure quality and safety of care, it is prudent to set benchmarks for proper supervision and utilization of procedures in dermatology.

Background There are no well-defined clinical factors to predict the risk of occult invasion in melanoma of the lentigo maligna type (LM) before complete histopathologic analysis. Objective To evaluate whether clinical size was a predictor of invasion in LM and subclinical extension. Methods Consecutive cases of LM were recorded in a prospectively maintained database from 2006 to 2019. Patient and tumor data were recorded during initial evaluation. The LM clinical area was calculated in square millimeters (length × width). All patients were treated with staged excision. Results We included 600 patients. The mean age was 65.9 years (standard deviation, 12.3; range, 27-95 years); 62.8% (n = 377) were men. The mean LM clinical area was 128.32 mm2 for in situ lesions versus 200.14 mm for invasive lesions (P = .1). Based on quantile regression, the median margin required for complete removal increased with LM clinical area. Limitations The study was performed in a tertiary cancer center with possible referral bias and more complex cases. Conclusions LM can present with variable clinical size, which may correlate with subclinical extension; however, the presence of invasion is not well estimated by LM clinical area.

BACKGROUND Extramammary Paget disease (EMPD) poses treatment challenges. Invasive and noninvasive treatment modalities exist with variable success reported. Reflectance confocal microscopy (RCM) is emerging as an adjuvant diagnostic tool. OBJECTIVE To evaluate the treatment of EMPD patients and the role of RCM. METHODS Prospective study. Demographic and tumor characteristics were recorded. Handheld-RCM was performed and correlated with histology. Treatment, clearance, pathology, and follow-up were all recorded. RESULTS Thirty-six EMPD lesions in 33 patients were included. Mean age was 71.7 years, and 23 were men. Mean number of surgical stages needed to clear margins was 1.9 (SD, 0.9; 1.0-3.0 stages), and mean margin needed to clear was 1.8 cm. Reflectance confocal microscopy correlated well with scouting punch biopsies (kappa, 0.93; p < .001). Disruption of the dermoepidermal junction was associated with invasive EMPD versus in situ (83.3% vs 25.9%) on histology (p = .01). LIMITATIONS Relatively small sample size. CONCLUSION Extramammary Paget disease is challenging, and lesion demarcation is of the utmost importance. Using a staged surgical excision approach, the mean margins needed were 1.8 cm, less than previously reported. Nonsurgical modalities, including radiation therapy, imiquimod, or photodynamic therapy can be considered if surgery is not pursued. Reflectance confocal microscopy is a valuable noninvasive imaging modality for the management of EMPD.

Background Basal cell carcinoma (BCC) treatment modalities can be stratified based on tumor subtype and recurrence risk. The main limitation of non-surgical treatment modalities is the lack of histopathological confirmation. Reflectance confocal microscopy (RCM) is a non-invasive imaging device that provides quasi-histological images. Objective To evaluate the feasibility and efficacy of RCM-guided carbon dioxide (CO2) laser ablation of low-risk BCCs. Methods Prospective study with biopsy-proven low-risk BCCs imaged with RCM. RCM was performed on these sites and ablated; if residual tumor was found, a new series of laser passes were performed. The patients were then followed for recurrence clinically and with RCM. Results Twenty-two tumor sites in nine patients were imaged and treated. Median age was 59±12.9 years (range 30 – 74). Male-to-female ratio was 5:4. Mean tumor size was 7.7 mm (range 5 – 10 mm). Residual tumor was identified in 5/22 cases (22.7%) under RCM on immediate first pass post-ablation sites, prompting additional laser passes. Median follow-up was 28.5 month (22 – 32 months) with no recurrences found. Conclusions Addition of RCM to laser ablation workflow can detect subclinical persistent tumor after initial ablation and may serve as an aid to increase the efficacy of laser ablation.

Background There is little evidence to guide surgical management of biopsies yielding the histologic descriptor atypical intraepidermal melanocytic proliferation (AIMP). Objective Determine frequency of and factors associated with melanoma and melanoma in-situ (MIS) diagnoses after excision of AIMP and evaluate margins used to completely excise AIMP. Methods Retrospective, cross-sectional study of 1127 biopsies reported as AIMP and subsequently excised within one academic institution. Results Melanoma (in situ, stage 1A) was diagnosed after excision in 8.2% (92/1127) of AIMP samples. Characteristics associated with melanoma/MIS diagnosis included age 60-79 years (odds ratio [OR] 8.1, 95% confidence interval [CI] 2.5-26.2), age ≥80 years (OR 7.2, 95% CI 1.7-31.5), head/neck location (OR 4.9, 95% CI 3.1-7.7), clinical lesion partially biopsied (OR 11.0, 95% CI 6.7-18.1), and lesion extending to deep biopsy margin (OR 15.1, 95% CI 1.7-136.0). Average ± standard deviation surgical margin used to excise AIMP lesions was 4.5 ± 1.8 mm. Limitations Single-site, retrospective, observational study; interobserver variability across dermatopathologists. Conclusion Dermatologists and pathologists can endeavor to avoid ambiguous melanocytic designations whenever possible through excisional biopsy technique, interdisciplinary communication, and ancillary studies. In the event of AIMP biopsy, physicians should consider the term a histologic description rather than a diagnosis, and, during surgical planning, use clinicopathologic correlation while bearing in mind factors that might predict true melanoma/MIS.

Background Nonphysicians are expanding practice into specialty medicine. There are limited studies on patient and physician perspectives as well as safety outcomes regarding the nonphysician practice of cosmetic procedures. Objective To identify the patient (consumer) and physician perspective on preferences, adverse events, and outcomes following cosmetic dermatology procedures performed by physicians and nonphysicians. Materials and methods Internet-based surveys were administered to consumers of cosmetic procedures and physician members of the American Society for Dermatologic Surgery. Descriptive statistics and graphical methods were used to assess responses. Comparisons between groups were based on contingency chi-square analyses and Fisher exact tests. Results Two thousand one hundred sixteen commenced the patient survey with 401 having had a cosmetic procedure performed. Fifty adverse events were reported. A higher number of burns and discoloration occurred in the nonphysician-treated group and took place more often in a spa setting. Individuals seeing nonphysicians cited motivating factors such as level of licensure (type) of nonphysician, a referral from a friend, price, and the location of the practitioner. Improper technique by the nonphysician was cited most as a reason for the adverse event. Both groups agree that more regulation should be placed on who can perform cosmetic procedures. Recall bias associated with survey data. Conclusion Patients treated by nonphysicians experienced more burns and discoloration compared with physicians, and they are encountering these nonphysicians outside a traditional medical office, which are important from a patient safety and regulatory standpoint. Motivating factors for patients seeking cosmetic procedures may also factor into the choice of provider. Key points Both patients and physicians think more regulation should be in place on who can perform cosmetic procedures. More adverse events such as burns and discolorations occurred with patients seeing nonphysicians compared with those seeing physicians. In addition, for those seeing nonphysicians, a majority of these encounters took place in spa settings. Patient safety is of utmost concern when it comes to elective cosmetic medical procedures. More adverse events and encounters occurring outside traditional medical settings when nonphysicians performed these procedures call into question the required training and oversight needed for such procedures.

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education article will provide a comprehensive and contemporary review of basal cell carcinoma. The first article in this series describes our current understanding of this disease regarding epidemiology, cost, clinical and histopathologic presentations, carcinogenesis, natural history, and disease associations.

As the most common human cancer worldwide and continuing to increase in incidence, basal cell carcinoma is associated with significant morbidity and cost. Continued advances in research have refined both our insight and approach to this seemingly ubiquitous disease. This 2-part continuing medical education series provides a comprehensive and contemporary review of basal cell carcinoma. The second article in this series will present both the current standard of care and newly developed approaches to diagnosis, treatment, and prevention of this disease.

The long-term survival of patients with cancer has risen dramatically during the last few decades. Despite this remarkable success, the same treatments that have enabled cure or remission often secondarily affect the skin, hair, and nails. Conditions including scarring, striae distensae, persistent alopecia, pigmentary changes, nail alterations, chronic radiation dermatitis, and radiation fibrosis have been associated with anxiety, depression, decreased quality of life, and impaired function. These dermatologic changes are cosmetically disfiguring, may limit activities, and are a visual reminder of past illness. Interventions toward improving these untoward sequelae and restoring the appearance and function of skin and appendages are critical for normalization and may contribute to improved quality of life in cancer survivors. Here, we outline dermatologic sequelae of cancer therapies with a review of medical and procedural treatment strategies to restore dermatologic health in the survivorship population.

Lentigo maligna (LM) is a form of melanoma in situ and represents a diagnostic and therapeutic challenge due to its poorly defined, irregular borders; propensity for subclinical extension; and location on the background of severely sun-damaged skin. Reflectance confocal microscopy (RCM) is a non-invasive optical imaging tool that allows clinicians to detect LM and assess margin status in vivo. RCM is very accurate for diagnosing LM and guiding biopsies, with sensitivities ranging from 93 to 100% and specificities 71–82%. It has also been used pre-operatively to map lesions, intra-operatively for real-time evaluation of surgical margins, and post treatment to monitor for recurrence. The advent of newer technologies, including RCM, has advanced our ability to better diagnose and manage LM. RCM offers clinicians the ability to guide biopsies, accurately detect subclinical disease, and readily map LM margins. Future research is aimed at using RCM to allow clinicians to better spare healthy tissue and to reduce disease recurrence without subjecting patients to the lost time, cost, and potential morbidity associated with multiple surgeries.

Various studies have reported local recurrence (LR) rates after surgical treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM). However, the time to LR of LM/LMM is not currently known, as few studies report time to LR and have long-term follow-up. To define time to LR in LM/LMM after surgical treatment, and to describe features of observed LR. Retrospective single-center study of consecutive patients presenting with locally recurrent LM/LMM. Six hundred forty-nine cases of LM/LMM were reviewed; 29 (21 LM, and 8 LMM) of 41 locally recurrent cases had original histology reports and were included. The mean time to LR was 57.5 months (range 7–194). For cases presenting as primary LM, LR was also in situ in 14/21 (67%) of cases. Seven of 21 LM recurred as LMM. Of the 8 primary LMM, 3/8 (37.5%) presented with subsequent LMM and all were slightly deeper on re-excision. The mean time to LR of LM/LMM is at least 57.5 months, underscoring the importance of long-term follow-up. Seven of 21 LM recurred as invasive disease, but the lack of development of LMM from LM in most recurrent cases confirms LM is slowly progressive.

Introduction Lentigo maligna (LM) is melanoma in situ on sun-damaged skin and presents diagnostic challenges due to overlapping features with benign pigmented lesions. Cosmetic treatments may be inadvertently performed on LM. The aim of this study is to estimate the prevalence of LM with prior cosmetic treatment, and evaluate surgical outcomes. Study Design and Methods Retrospective review of biopsy-proven LM presenting over a 10-year-period (2006–2015). Prior cosmetic treatment and biopsies were recorded. Records were reviewed for demographic data, clinical characteristics, and surgical outcomes. Results 37/503 (7.4%) patients with LM reported prior cosmetic therapy. Most (95%) were on the head and neck; mean size 1.9 cm. Most patients reported cryotherapy (73%), followed by laser (29.7%), topical bleaching agents (18.9%), and electrodessication, and/or curettage (5.3%). Ten patients (27%) received two or more modalities. Eight patients (21.6%) reported prior benign biopsies. Six patients (16%) had invasive disease, two on initial biopsy and 4/34 (11.7%) upstaged upon excision. Average margin for clearance was 9.1 mm. Conclusion Prior cosmetic treatment of LM is not uncommon, and may delay diagnosis and obscure borders, resulting in wider surgical margins. Clinicians should consider a biopsy confirming the benign nature of equivocal lesions prior to cosmetic treatment. Lasers Surg. Med. © 2017 Wiley Periodicals, Inc.

Cutaneous adnexal tumors are rare and can present a diagnostic and therapeutic dilemma. Distinguishing primary cutaneous tumors from metastatic carcinoma to the skin requires thorough diagnostic evaluation, including imaging, endoscopy, and histologic and molecular pathologic analysis. As with many rare cancers, there is no standard of care management.1 Here we present the diagnostic approach for a primary cutaneous adenocarcinoma of the scalp with lymph node metastasis and subsequent multimodal therapy.

Glandular and pseudoglandular tumors of the penile skin are extremely uncommon and can present diagnostic challenges. Primary adenosquamous carcinoma of the penis is an extremely rare tumor, composed of distinct areas of malignant squamous and glandular cells, making it a diagnostically challenging entity. The World Health Organization (WHO) recognizes several subtypes of squamous cell carcinoma (SCC), each with its own distinctive pathologic appearance, clinical associations and prognosis. Among these variants is the exceedingly uncommon adenosquamous carcinoma (ASC), representing 1%-2% of all SCC of the penis. Recent large studies have interrogated the presence of human papillomavirus (HPV) in malignant penile tumors and have shown specific morphologic patterns and clinical presentations to associate with HPV status. However, given the rarity of the adenosquamous variant of SCC, it has largely been excluded from these studies. The glandular components of these lesions can present a confusing appearance, particularly when a large tumor is represented on a small biopsy. Here we describe a difficult histologic presentation of this rare tumor, with the first published characterization of the HPV status of this subtype. This case represents a distinctly unusual case of metastatic HPV-positive primary cutaneous adenosquamous carcinoma of the penis.

Background Reflectance confocal microscopy (RCM) provides real-time noninvasive imaging of cell structure and may be useful in diagnosing lentigo maligna (LM). Few studies have compared performance of RCM with histopathology in diagnosing LM, and specific features influencing RCM interpretation are not well described. Objective We sought to determine concordance rate between RCM and histopathology in the evaluation of suspected LM and to identify factors that may obscure diagnosis. Methods We designed a prospective study involving 17 participants seen for evaluation at a large tertiary referral center. Cases included primary lesions and possible recurrent and/or previously treated lesions. A total of 63 clinically equivocal sites were assessed by RCM and histopathology. Results RCM and histopathology interpretations were concordant in 56 of 63 sites (89%). There were no false-negative and 7 false-positive results using RCM (sensitivity 100%, specificity 71%, positive predictive value 85%, negative predictive value 100%). Features suggestive of LM in the false-positive group included the presence of numerous hyperreflectile large cells at the dermoepidermal junction and follicular localization of these cells. Limitations A larger test set is needed to more reliably distinguish LM from benign lesions using RCM and to improve specificity. Conclusion RCM shows excellent sensitivity for detecting LM although features of benign macules on a background of actinically damaged skin can obscure diagnosis and limit its specificity.

SummaryBackground Laser ablation is an alternative, nonsurgical treatment modality for low-risk basal cell carcinoma (BCC). However, lack of confirmative tumour destruction or residual tumour presence has been a limiting factor to its adoption. Reflectance confocal microscopy (RCM) provides noninvasive, cellular-level resolution imaging of the skin and is capable of identifying tumour. Objectives To evaluate the use of RCM to guide carbon dioxide (CO2) laser ablation of BCC, confirm destruction and correlate findings with histology. Methods RCM was used preablation to evaluate for features of BCC. Ablation was performed with a CO2 laser, and the response rapidly assessed using handheld RCM to evaluate for residual tumour. Confirmative pathology was used to verify confocal imaging. Results Preablation RCM imaging identified tumour with features not identified on normal, surrounding skin. Postablation, RCM documented complete removal of tumour in six cases and residual tumour in two. Histological examination identified the ablated area and confirmed clearance of tumour in the six aforementioned cases and corroborated confocal findings for residual tumour in the other two cases. Conclusions We report successful treatment of superficial and nodular BCC using CO2 laser ablation augmented by RCM imaging for preablation guidance and verification of tumour removal postablation. Akin to complete circumferential and deep margin control techniques, using RCM helps to map peripheral and deep BCC margins to hone in on areas exhibiting persistent tumour after ablation. CO2 laser ablation visually guided by RCM can help circumvent previously cited limiting factors of laser ablation for tumour destruction by providing cellular-level resolution imaging of tumour and margin assessment in between each laser pass and postablation.

Approximately 3.5 million new cases of non-melanoma skin cancers are diagnosed yearly in the United States, of which approximately 80% are basal cell carcinomas (BCCs) [1–2]. Mohs micrographic surgery, which relies on complete histopathological margin assessment, is the most common treatment for high-risk BCCs and provides highest cure rates (five-year, 97–99%) [3–4]. However, for less aggressive and low-risk subtypes of BCCs (i.e. superficial and early nodular), alternative treatment modalities can be less invasive, faster and lower-cost. These include electrodessication and curettage, topical chemotherapy (e.g. Imiquimod), cryotherapy, and coagulative and ablative laser therapies [5–8]. Laser ablation offers highly localized and precisely controlled removal of tissue, and can be particularly effective for minimally invasive treatment of superficial and early nodular BCCs [9–14]. To select the fluence and number of passes (sets of pulses), clinicians usually rely on visual examination and/or the diagnosis of tumor subtype and depth provided by a biopsy and histology [12–14]. However, visual examination may miss subclinical extension of lateral margins, while histology does not often allow for estimation of complete lateral and deep margins across the entire tumor. Furthermore, clinicians heavily rely on the visual appearance of the tissue between passes to estimate whether the tumor has been totally removed. During clinical follow up, monitoring the efficacy of the treatment is also typically based on visual observation. For all these reasons, there is high variability of recurrence rates, ranging from 3.23% to 50% [12–14]. Given the absence of definitive histological confirmation, there is a need for a non-invasive method to guide laser ablation, particularly for accurate determination of lateral and deep tumor margins, selection of laser parameters, and assessment of ablated tissue to confirm clearance of the tumor. Optical imaging is being investigated for its ability to noninvasively guide the detection of lateral and deep margins of tumor, pre-, during and post-ablation [15–17]. By using a contrast agent, high-resolution microscopic-level imaging of cellular and sub-cellular detail can be obtained in post-ablated tissue in vivo. This allows for the presence (or absence) of residual tumor to be detected in post-ablated tissue, providing histopathology-like control directly on the patient. However, this is possible only with a specific set of parameters (number of passes and delivered fluence) that allow for simultaneous removal of BCCs, while controlling of the amount of underlying thermal coagulation, such that cellular structures can be subsequently labeled with a contrast agent and imaged [15–16]. We previously reported the feasibility of reflectance confocal microscopy (RCM) imaging to guide Erbium-doped yttrium aluminum garnet (Er: YAG) laser ablation, in both bench-top studies and on a small number of patients [15–17]. The Er: YAG laser (wavelength 2900nm) allows for vaporization of very thin layers of tissue while producing only a thin underlying zone of thermal coagulation. Two contrast agents, acetic acid and aluminum chloride, were shown to label nuclei and enhance contrast of nuclear morphology [18–21]. From the results, RCM imaging appears to be capable of detecting residual BCCs in post-ablated tissue [16–17]. Our studies have now expanded to include the carbon dioxide (CO2) laser. The CO2 laser (wavelength 10600nm) offers relatively more aggressive vaporization, along with relatively deeper thermal coagulation compared to the Er: YAG laser, affording greater tissue destruction with fewer passes and producing hemostasis in the underlying microvasculature [22–24]. In this paper, we report an ex vivo bench-top study to determine a set of effective ablation parameters (fluence, number of passes) for a CO2 laser. We further report the results of an assessment of the uptake of acetic acid for contrast and our ability to utilize RCM imaging in post-ablated tissue to evaluate for the presence or absence of residual BCC tumors.

The demand for cosmetic medical procedures continues to rise. Dermatologists are increasingly employing non-physicians, and medical spas are hiring individuals without a medical license to meet this demand. This new frontier in medicine has opened the door to a number of legal and regulatory issues regarding scope of practice and appropriate physician supervision of these procedures. Further confounding the matter is state-by-state variation in laws and a lack of federal oversight. We discuss some of the most salient factors clinicians need to be cognizant of in this rapidly evolving field of cosmetic dermatology. Physicians must be aware of the pertinent legal issues they face when using non-physicians in their practice or when acting as the medical director of cosmetic procedures taking place in a non-medical setting. As a medical community, we should be aware of the risks and benefits of non-physicians performing cosmetic procedures on patients.

Background Ambiguous histopathologic diagnoses represent a challenge for clinicians because of a lack of definitive diagnosis and related uncertainty about management. Objective To review the literature on atypical melanocytic proliferations and detail synonymous terms, epidemiology, diagnostic work-up, histopathology, treatment, and prognosis. Methods Databases from PubMed and Web of Science were searched for articles related to atypical melanocytic proliferations. Results Intraepidermal melanocytic proliferations with features worrisome for possible melanoma in situ (MIS) are generally excised as for MIS. Reported rates of upstaging of such cases to invasive melanoma on review of the excision are very low. Because invasion, lymph node spread, and metastasis can occur in atypical melanocytic lesions with a thick intradermal component, these are often treated as for malignant melanoma. Conclusion Because the diagnosis dictates treatment, it is incumbent to establish a diagnosis as definitive as possible, obtaining second or third opinions and using ancillary studies when appropriate. When the diagnosis remains uncertain, it is difficult to provide guidelines for treatment. Clinical care decisions for patients with an uncertain diagnosis are best done on a case-by-case basis weighing probabilities of adverse outcomes against potential benefits and risks from various treatment options.

The diagnosis of melanoma, especially lentigo maligna (LM) occurring on sun-damaged skin, can be quite challenging. Diagnosing and treating melanoma at its earliest stage is key to preventing invasion and spread. While dermoscopy aids in clinical detection, skin biopsy still remains the gold standard for diagnosis. Broad lesions, sampling bias, cosmetically sensitive areas, and trailing edges of melanocytes may all contribute to difficulty in the histopathological diagnosis of LM with traditional biopsy techniques. Non-invasive imaging tools are an exciting prospect to augment the diagnosis of lentigo maligna and provide a real time, in-vivo look at the skin. The current state of non-invasive cutaneous imaging along with the advantages and limitations of such will be discussed herein. With increasing depth of penetration and image resolution we may be approaching a renaissance of cutaneous melanoma imaging.

The computer-assisted diagnosis of melanoma is an exciting area of research where imaging techniques are combined with diagnostic algorithms in an attempt to improve detection and outcomes for patients with skin lesions suspicious for malignancy. Once an image has been acquired, it undergoes a processing pathway which includes preprocessing, enhancement, segmentation, feature extraction, feature selection, change detection, and ultimately classification. Practicality for everyday clinical use remains a vital question. A successful model must obtain results that are on par or outperform experienced dermatologists, keep costs at a minimum, be user-friendly, and be time efficient with high sensitivity and specificity.

Medical imaging has dramatically transformed the practice of medicine, especially the field of dermatology. Imaging is used to facilitate the transfer of information between providers, document cutaneous disease, assess response to therapy, and plays a crucial role in monitoring and diagnosing skin cancer. Advancements in imaging technology and overall improved quality of imaging have augmented the utility of photography. We provide an overview of current imaging technologies used in dermatology with a focus on their role in skin cancer diagnosis. Future technologies include three-dimensional, total-body photography, mobile smartphone applications, and computerassisted diagnostic devices. With these advancements, we are better equipped to capture and monitor skin conditions longitudinally and achieve improved diagnostic accuracy of skin cancer.

Ultraviolet radiation is a major risk factor for the development of skin cancer, the most common form of cancer in the United States.

Lentigo maligna melanoma (LMM) represents a diagnostic and therapeutic challenge because of its heterogeneous nature with poorly defined borders, subclinical extension, and location on sun-damaged skin. Reflectance confocal microscopy (RCM) has advanced the authors’ ability to better diagnose and manage these lesions through noninvasive examination of skin on a cellular level. Herein, the authors report the first case of RCM used intraoperatively, in a multidisciplinary approach involving dermatology and head and neck surgery to manage a challenging LMM. A 77-year-old woman was referred for treatment of an LMM on the left malar cheek approaching the lower eyelid. The lesion had been present for 2 years and previously treated with cryotherapy. On examination, there was an ill-defined 2-cm patch with irregular contour and variegate shades of brown–gray bordering the left lower eyelid (Figure 1). A biopsy revealed spindle cell–type melanoma with a depth of 1.25 mm. Preoperative mapping with RCM identified 2 surrounding areas suspicious for melanoma with epidermal disarray, dendritic hyperreflective melanocytes, and rounded pagetoid cells (Figure 2). Biopsies found invasive melanoma and melanoma in situ. Wide excision in the operating room assisted by RCM with rush pathology and delayed reconstruction was planned. Figure 1 Clinical photograph showing the ill-defined hyperpigmented patch on the left malar cheek approaching the lower eyelid outlined in green. The yellow circles mark areas outside of the clinical lesion where RCM showed suspicious findings, later confirmed ... Figure 2 (A) Reflectance confocal microscopy showing dense areas of hyperreflective, atypical dendritic processes with adnexal tropism. (B) Reflectance confocal microscopy showing pagetoid infiltration within the epidermal layer surrounding the hair follicles. ... Preoperatively, surgical 1 cm margins were defined under Wood lamp. Because of the poorly defined borders, RCM imaging was performed under an institutional review board–approved protocol using a commercially available handheld RCM (VivaScope 3000; Caliber ID, Rochester, NY). The lesion was imaged at the clinical and surgical margins from the stratum corneum down to inside the papillary dermis. Scanning confocal video microscopy was performed to rapidly inspect the border. Reflectance confocal microscopy examination allowed enhanced delineation of the borders and subsequently increased the resection margins. An area around the 9-o’clock margin was suspicious for positivity under RCM because of the presence of sheets of atypical cells and epidermal disarray, but it was not excised for possibility that it was a false positive because it encompassed a separate cosmetic subunit. It was decided to not increase the surgical margin in this area because of the experimental nature of this technology and instead wait for rush permanent hematoxylin and eosin pathology confirmation. Excision of the lesion and margins down to subcutaneous fat was performed. Then, RCM was used to re-evaluate the periphery of the area of resection. The same region of concern, showing dendritic processes and round pagetoid cells around the 9-o’clock position, was highlighted. A video captured intraoperatively was converted into a mosaic by stitching together individual frames to provide a detailed overview of the peripheral margin, highlighting the atypical findings (Figure 3). Figure 3 Representative section from the mosaic created to assess outside of the surgical margin. Area in the blue rectangle represents normal-appearing tissue architecture. The area within the red circle highlights large atypical hyper-reflective cells at the ... Pathology revealed residual invasive and in situ melanoma within the lesion and melanoma in situ extending to the 9-o’clock margin as suspected on confocal microscopy. The patient returned for re-excision along this margin and closure with a cervical facial flap and full-thickness skin graft. No further melanoma was seen on pathology.

Radiation therapy (RT) is a noninvasive treatment for a variety of skin cancers. Although surgery is often preferred for basal cell carcinoma (BCC) and lentigo maligna (LM), these conditions often affect patients that are medically inoperable, who decline surgery, or have lesions in challenging anatomic locations. Although nonsurgical treatments can be employed, close monitoring for disease recurrence and progression is of utmost importance. Typically, this is carried out by clinical examination, without adjunctive imaging. Reflectance confocal microscopy (RCM) is an emerging imaging technology that is proving useful to aid in the assessment of treatment response and disease recurrence (Fig 1). RCM has a high

Importance Extramammary Paget disease (EMPD) is commonly refractory to surgical and nonsurgical therapies. Identifying recurrent or persistent EMPD is challenging because the disease is multifocal, and multiple blind scouting biopsies are usually performed in this setting. Handheld reflectance confocal microscopy (HRCM) has been used to diagnose and map primary EMPD and therefore may be used to identify EMPD recurrences. Objective To evaluate HRCM’s diagnostic accuracy in the setting of recurrent or persistent EMPD as well as its potential diagnostic pitfalls. Design, Setting, and Participants This prospective case series study included patients referred to the Dermatology Service at Memorial Sloan Kettering Cancer Center between January 1, 2014, and December 31, 2016, with biopsy-proven EMPD in whom HRCM was used to monitor treatment response. Five patients were included, and 22 sites clinically concerning for recurrent or persistent disease were evaluated using HRCM and histopathologic examination. In 2 patients, video mosaics were created to evaluate large areas. Main Outcomes and Measures Sensitivity and specificity of HRCM in identifying recurrent or persistent EMPD; causes for false-negative results according to their location, histopathologic findings, and previous treatments. Results Of the 22 clinically suspicious sites evaluated in 5 patients (4 men, 1 woman; median [range] age, 70 [56-77] years), 9 (40.9%) were positive for recurrent disease on HRCM and histopathologically confirmed, and 13 (59.1%) sites were negative on HRCM, but 3 of the 13 were positive for EMPD on histopathological examination. In general, HRCM had a sensitivity of 75% and a specificity of 100% in identifying recurrent or persistent EMPD. False-negative results were found in 2 patients and occurred at the margins of EMPD, close to previous biopsy sites. Creating video mosaics (or video mosaicking) seemed to improve the detection of EMPD. Conclusions and Relevance Handheld reflectance confocal microscopy is a useful auxiliary tool for diagnosing EMPD recurrences and can be used to guide scouting biopsies, thus reducing the number of biopsies needed to render a correct diagnosis.

It is estimated that nearly a quarter of all persons aged 18 to 50 in the United States have a tattoo.1 Demand for tattoo removal has increased, with an estimated 1 in 5 persons considering tattoo removal.1 American Society for Dermatologic Surgery physicians reported about 100,000 laser tattoo removal procedures in 2013, up more than 50% from 2012.2 Motives for removal include aesthetic reasons, poor tattoo result, and professional or social stigma. Laser-assisted tattoo removal remains the gold standard treatment. With increasing demand for tattoo removal, it is important to be cognizant of adverse events that may occur. We report the novel case of a woman who had an allergic cutaneous reaction at a distant, untreated tattoo site, and subsequently had a delayed anaphylactic reaction after laser tattoo removal.