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Dermatofibrosarcoma protuberans (DFSP) is a cutaneous sarcoma that has remained a challenge for oncologic and reconstructive surgeons due to a high rate of local recurrence. The objective of this study is to investigate the oncologic and reconstructive benefits of employing a multidisciplinary two-step approach to the treatment of DFSP. A retrospective review was conducted using a prospectively collected database of all patients who underwent resection and reconstruction of large DFSPs by a multidisciplinary team, including a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic and reconstructive surgeon, at one academic institution from 1998–2018. Each patient underwent Mohs micrographic surgery for peripheral margin clearance (Step 1) followed by wide local excision (WLE) of the deep margin by surgical oncology and immediate reconstruction by plastic surgery (Step 2). 57 patients met inclusion criteria. Average defect size after WLE (Step 2): 87.3 cm2 (range 8.5–1073.5 cm2). Mean follow-up time was 37 months (range 0–138 months). There were no cases of recurrence. A two-step multidisciplinary surgical treatment approach for DFSP minimizes risk of recurrence, decreases patient discomfort, and allows immediate reconstruction after deep margin clearance.

Recent increase in skin biopsies has been attributed to an epidemic of skin cancer. This may be avoidable, with potential savings.To determine whether the increase in skin biopsies is attributable to increasing frequency of biopsies associated with histology lacking pathological cutaneous disease. Pathological cutaneous disease was defined as (1) a malignancy, precancerous lesion, or lesion of uncertain behavior; or (2) disease symptomatic or associated with adverse quality of life impact.Retrospective cohort study, 2006 to 2013 of dermatology practice serving Florida and Ohio. Data were a consecutive sample of skin biopsies for diagnosis of dermatologic disease.A total of 267,706 biopsies by an average of 52 providers per month from January 06 to December 13 were analyzed. Number of biopsies per visit increased 2% per year (RR: 1.02, CI: 1.00-1.04). Likelihood of biopsy associated with histology indicative of nonpathological cutaneous disease did not increase over time (OR: 0.99, CI: 0.95-1.03, p = .6302).Rates of biopsies associated with nonpathological cutaneous disease is not increasing. Overall biopsy rates per visit have gradually increased; this seems attributable to greater rates of detection of pathological dermatologic disease.

Background Guided imagery and music can reportedly reduce pain and anxiety during surgery, but no comparative study has been performed for cutaneous surgery to our knowledge. Objectives We sought to determine whether short-contact recorded guided imagery or relaxing music could reduce patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures. Methods Subjects were adults undergoing excisional surgery for basal and squamous cell carcinoma. Randomization was to guided imagery (n = 50), relaxing music (n = 54), or control group (n = 51). Primary outcomes were pain and anxiety measured using visual analog scale and 6-item short-form of the State-Trait Anxiety Inventory, respectively. Secondary outcomes were anxiety of surgeons measured by the 6-item short-form of the State-Trait Anxiety Inventory and physical stress of patients conveyed by vital signs, respectively. Results There were no significant differences in subjects' pain, anxiety, blood pressure, and pulse rate across groups. In the recorded guided imagery and the relaxing music group, surgeon anxiety was significantly lower than in the control group. Limitations Patients could not be blinded. Conclusion Short-contact recorded guided imagery and relaxing music appear not to reduce patient pain and anxiety during excisional procedures under local anesthetic. However, surgeon anxiety may be reduced when patients are listening to such recordings.

Mohs micrographic surgery remains the gold standard for the treatment of cutaneous squamous cell carcinomas (SCCs) of the head and neck. However, for recurrent or aggressive SCCs, it can be challenging at times to ensure complete margin control on hematoxylin and eosin (H&E) frozen sections alone. The authors present a case of multiple recurrent SCC that was ultimately found to have occult foci of tumor identifiable only by anticytokeratin immunohistochemistry (IHC). Although a large volume of literature addresses the topic of IHC for melanocytic neoplasms treated by traditional Mohs and “slow Mohs,” there is a relative paucity of commentary on its use in SCCs.1 This unusual case highlights the importance of anticytokeratin IHC for SCCs, especially in tumors that are recurrent or have aggressive or atypical cytomorphology.

Dermatologic surgery, including cancer surgery, cosmetic surgery, and laser and energy device procedures, is a well-established branch of dermatology known for minimally invasive, effective, and safe solutions to patient problems. Over time, clinical research pertaining to dermatologic surgery has improved in terms of methodologic rigor, with dermatologic surgery accounting for a large proportion of the comparative effectiveness studies and randomized controlled trials in dermatology. Further improvements in the quality of studies examining dermatologic surgery therapies will require understanding and overcoming several remaining challenges.

Background Facial erythema is a common symptom that responds to vascular laser treatment, but there are few comparative studies. Objective We sought to compare the effectiveness of microsecond 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with nonpurpuragenic 595-nm pulsed dye laser (PDL) for diffuse facial erythema. Methods This was a split-face, double-blind randomized controlled trial. Bilateral cheeks received 4 treatments each at one month intervals with PDL or Nd:YAG. Spectrophotometer measurements, digital photographs, pain scores, and patient preferences were recorded. Results Sixteen patients enrolled and 2 dropped out. Fourteen patients, all skin types I to III, 57% women, mean age 42 years, completed the study and were analyzed. Spectrophotometer readings changed after both PDL (8.9%) and Nd:YAG (2.5%), but varied by treatment type, with PDL reducing facial redness 6.4% more from baseline than Nd:YAG ( P = .0199; 95% confidence interval −11.6 to −1.2). Pain varied ( P = .0028), with Nd:YAG associated with less pain, at 3.07, than PDL at 3.87. Subjects rated redness as improved by 52% as a result of PDL, and 34% as a result of Nd:YAG ( P = .031; 95% confidence interval −34.6 to −1.94). No serious adverse events were observed. Limitations Lasers settings are not standardized across devices. Conclusion Facial erythema is safely and effectively treated with PDL and Nd:YAG. Nonpupuragenic PDL may be more effective for lighter-skinned patients, but microsecond Nd:YAG may be less painful.

Background Floaters are dislodged pieces of tumor tissue than can obscure Mohs micrographic surgery (MMS) frozen sections and confound their interpretation. Objective To understand the common causes of floaters and identify management strategies. Methods An initial virtual consensus conference of Mohs surgeons based on a 60-item questionnaire. Data were validated in interviews with randomly selected Mohs surgeons. Results Based on retrospective reporting of 230 surgeon-years and 170,404 cases of MMS by 26 surgeons, the mean rate of floaters per tumor treated was 1.8%, and the rate of floaters per tissue block was 0.70%. Not wiping blades between cuts when a stage is separated into subunits can predispose to floaters. There was also strong consensus that basal cell carcinomas, ulcerated tumors, and tissue from the first stage were more likely to yield floaters. There is little consensus on how to manage floaters, with possibilities including taking additional sections, taking an additional stage, or simply noting the floater. Conclusion Floaters are not rare and can complicate MMS margin assessment. There is significant expert consensus regarding the causes of floaters and the tissue features that may predispose to them. Floaters may be prevented by minimizing their likely causes. There is less consensus on what to do with a floater.

BACKGROUND Randomized controlled trials are the gold standard for comparing safety and effectiveness of surgical interventions. Reporting guidelines are available for conveying the results of such trials. OBJECTIVE To assess adherence to standard reporting guidelines among randomized controlled trials in dermatologic surgery. MATERIALS AND METHODS Systematic review. Data source was randomized controlled trials in the journal Dermatologic Surgery, per PubMed search, 1995 to 2014. Studies were appraised for the number of the 37 CONSORT 2010 Checklist criteria reported in each. Analysis included comparison of reporting across 4 consecutive periods. RESULTS Three hundred sixty-three studies were eligible. The mean number of items reported per study increased monotonically from 14.5 in 1995 to 1999 to 16.2 in 2002 to 2004, 17.7 in 2005 to 2009, and 18.0 in 2010 to 2014 (p < .0001). A limitation was that study procedures may have been performed without being reported. CONCLUSION Completeness of reporting in randomized controlled trials in dermatologic surgery has improved significantly during the preceding 2 decades. Some elements are still reported at lower rates.

Background Approximately one in four patients undergoing dermatologic surgery takes an antithrombotic medication. When approaching the management of antithrombotic agents, procedural dermatologists must balance surgical outcomes, bleeding risks, and cardiovascular protection. Continuing antithrombotics during surgery increases the risk hemorrhage, but discontinuation of these agents may increase the risk of thrombotic events. Despite increasing evidence for continuation of antithrombotics during dermatologic surgery, few official guidelines exist, and clinicians have been slow to integrate new evidence into clinical practice. A study in 2007 reported that more than 40% of dermatologic surgeons sometimes discontinue warfarin for surgery. Objective This article reviews antithrombotic agents in the United States and summarize perioperative management recommendations of antithrombotic agents in skin surgery. Materials and Methods A review of the literature was performed focused on antithrombotic medications commercially available in the United States, including the two newest agents, dabigatran and rivaroxaban. Conclusion Although there are concerns regarding bleeding, there are no reports of life-threatening hemorrhage from continued antithrombotic therapy in dermatologic surgery. Furthermore, potentially fatal cardiovascular events after cessation of medically indicated antithrombotic medications are increasingly recognized, leading to the growing acceptance that the risk of stopping most antithrombotics may outweigh the risks of bleeding incurred by continuing antithrombotic therapy.

BACKGROUND A better understanding of the molecular pathways that characterize cell growth, apoptosis, angiogenesis, and invasion has provided novel targets in cancer therapy. Epidermal growth factor receptor (EGFR)-mediated signal transduction has been one of the most studied pathways in carcinogenesis. The phosphorylation of EGFR activates multiple biological processes, including apoptosis, differentiation, cellular proliferation, motility, invasion, adhesion, DNA repair, and survival. EGFR is a transmembrane tyrosine kinase receptor involved in the proliferation and survival of cancer cells. EGFR is the first molecular target against which monoclonal antibodies have been developed for cancer therapy. OBJECTIVE To review the mechanisms underlying the effects of EGFR in nonmelanoma skin cancer (NMSC) and their potential role as targeted therapies in the treatment thereof. CONCLUSIONS EGFR plays an important role in tumorigenesis of NMSC, especially metastatic squamous cell carcinoma, via mechanisms similar to those of other visceral tumors. Pharmacologic inhibitors of EGFR pathway of tumor production may offer an effective therapeutic strategy to block tumor growth. The authors have indicated no significant interest with commercial supporters.

Nonmelanoma skin cancers can be treated by various modalities, including electrodessication and curettage, excisional techniques, and radiation. In selected cases, radiation may be preferable to surgery. When radiation is an option, brachytherapy, a form of radiation therapy that places the radiation source close to the area to be treated, may have advantages relative to conventional external beam radiation in particular patients. After brachytherapy, recurrence rates for nonmelanoma skin cancers are low, especially for small, superficial lesions, with good to excellent functional and cosmetic results. This article reviews the indications, efficacy, and adverse effects of brachytherapy in the treatment of nonmelanoma skin cancers.

OBJECTIVE To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early- to mid-career Mohs surgeons and to assess other factors affecting number of stages. METHODS Statistical analysis of MMS logs of 20 representative early- to mid-career surgeons. RESULTS There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p

Summary Background Dermatological procedures can result in disfiguring bruises that resolve slowly. Objectives To assess the comparative utility of topical formulations in hastening the resolution of skin bruising. Methods Healthy volunteers, age range 21–65 years, were enrolled for this double (patient and rater) blinded randomized controlled trial. For each subject, four standard bruises of 7 mm diameter each were created on the bilateral upper inner arms, 5 cm apart, two per arm, using a 595-nm pulsed-dye laser (Vbeam; Candela Corp., Wayland, MA, U.S.A.). Randomization was used to assign one topical agent (5% vitamin K, 1% vitamin K and 0·3% retinol, 20% arnica, or white petrolatum) to exactly one bruise per subject, which was then treated under occlusion twice a day for 2 weeks. A dermatologist not involved with subject assignment rated bruises [visual analogue scale, 0 (least)–10 (most)] in standardized photographs immediately after bruise creation and at week 2. Results There was significant difference in the change in the rater bruising score associated with the four treatments (anova, P = 0·016). Pairwise comparisons indicated that the mean improvement associated with 20% arnica was greater than with white petrolatum (P = 0·003), and the improvement with arnica was greater than with the mixture of 1% vitamin K and 0·3% retinol (P = 0·01). Improvement with arnica was not greater than with 5% vitamin K cream, however. Conclusions Topical 20% arnica ointment may be able to reduce bruising more effectively than placebo and more effectively than low-concentration vitamin K formulations, such as 1% vitamin K with 0·3% retinol.

BACKGROUND There is a lack of randomized split-face studies investigating treatments for dermatosis papulosa nigra (DPN) in dark skin. OBJECTIVE To compare the efficacy, safety, and tolerability of potassium-titanyl-phosphate (KTP) laser with efficacy, safety, and tolerability of electrodesiccation in the treatment of DPN in subjects with Fitzpatrick skin phototypes IV to VI. METHODS Fourteen subjects with Fitzpatrick skin phototypes IV to VI were randomized to receive two KTP laser treatments 4 weeks apart to half of the face. The contralateral half received two electrodesiccation treatments 4 weeks apart. Response was evaluated by photography reviewed by blinded dermatologists at 4 weeks after the second treatment. A treatment quality questionnaire about side effects and cosmetic outcome was also administered. RESULTS Difference in improvement of DPN between the KTP side and the electrodesiccation side per each rater (p=.99, p=.54) and per raters combined (p=.50) did not reach statistical significance. There was no treatment difference for subjective effectiveness (p=.06) or subjective confidence improvement (p=.99), although there was a significant treatment difference for subjective discomfort (p=.002) in favor of KTP. Both treatments were well tolerated without significant adverse effects. CONCLUSIONS Although treatment of DPN with KTP laser and electrodesiccation are comparable in efficacy, KTP laser is preferable for patient comfort.

During Mohs micrographic surgery of nonmelanoma skin cancer (NMSC), inflammation in histologic frozen sections has been found to occasionally presage the detection of tumors in frozen sections of adjacent excision specimens.To quantify the correlation between the location of inflammation without visible tumor in histologic frozen sections and the location of subsequently detected NMSC.A retrospective cohort study of 3148 cases pertaining to frozen sections associated with the staged excision of NMSC was performed from September 8, 2008, to September 18, 2009, at an urban academic medical center, with the collected data analyzed on May 9, 2013.Consecutive cases of Mohs micrographic surgery performed at an academic medical center.For each wedge-shaped tissue segment corresponding with 1 hour of time on a clock face, the proportion of patients with inflammation at the source location of the segment who subsequently had a tumor at this same location; the proportion of patients who had neither inflammation nor subsequent tumor at the source location of the segment; the probability of subsequent tumor at this location given the prior finding of inflammation at the same location; and the probability that a location was without tumor in the absence of preexisting inflammation at that location.Of the medical records of 3148 cases of NMSC that were reviewed, 60 showed inflammation in histologic frozen sections from an excision specimen that was followed by tumor in the subsequent excision specimen. Of these 60, 39 (65%) were b asal cel carcinoma and 21 (35%) were squamous cell carcinomas; 53 (88%) were Mohs stage 1. In 7 of 12 segments, a significant positive correlation was found between the presence of inflammation and the presence of nearby tumor with correlation coefficients ranging from 0.196 to 0.384 (P .05) . The probability that tumor was absent when inflammation was not seen at a particular location (ie, clock-face segment) in preceding sections from that location was 91%, with segment-specific probability values ranging from 82% to 96%.During Mohs micrographic surgery of NMSC with the examination of frozen sections, histologic inflammation is modestly predictive of adjacent tumor whereas lack of inflammation strongly predicts that no additional tumor will be found.

Background A preponderance of evidence now indicates that storage of reconstituted botulinum toxin solution for longer than the 4 hours recommended by the manufacturer does not result in loss of effectiveness. Objective Then purpose of this study was to assess whether serial re-extraction of reconstituted botulinum toxin solution from vials undergoing prolonged storage is associated with increased risk of microbial contamination. Methods Consecutive 100-U vials of botulinun A exotoxin were reconstituted with 2.5 mL each of normal saline with preservative (benzyl alcohol). Within 1 week after reconstitution, each vial was used to treat 1 to 3 patients, for a total of 60 to 80 U used. Thereafter, each vial was stored in a plastic kidney basin in an unlocked, multiuse medication refrigerator. Two weeks later, a randomly assigned nurse removed the vial from the refrigerator and withdrew and discarded 0.1 mL (5 U) using the same technique used for therapeutic extractions. Iterations of this withdrawal and discarding procedure were continued until a 0.1-mL aliquot could not be withdrawn without prying off the metal cover. Once this threshold was reached, the vial was sent to the microbiology laboratory for sterility testing using a thioglycolate broth. Results In all, 127 vials were handled per protocol. On average (mean), vials underwent 4.5 access procedures, including 1.6 therapeutic extractions for a total of 76 U removed during a period of 7 weeks. Sterility analysis with thioglycolate broth indicated no evidence of contamination. Limitations Preservative-containing saline was used for reconstitution. Conclusion Routine refrigerator storage of medication vials containing reconstituted botulinum toxin does not result in microbial contamination of the contents even after serial re-extraction of solution from these vials, and after handling of such vials by multiple personnel. Storage and subsequent reuse of botulinum toxin appears safe for at least 7 weeks after reconstitution.

Importance Keratosis pilaris (KP) is a common skin disorder of follicular prominence and erythema that typically affects the proximal extremities, can be disfiguring, and is often resistant to treatment. Shorter-wavelength vascular lasers have been used to reduce the associated erythema but not the textural irregularity. Objective To determine whether the longer-wavelength 810-nm diode laser may be effective for treatment of KP, particularly the associated skin roughness/bumpiness and textural irregularity. Design, Setting, and Participants We performed a split-body, rater-blinded, parallel-group, balanced (1:1), placebo-controlled randomized clinical trial at a dermatology outpatient practice of an urban academic medical center from March 1 to October 1, 2011. We included all patients diagnosed as having KP on both arms and Fitzpatrick skin types I through III. Of the 26 patients who underwent screening, 23 met our enrollment criteria. Of these, 18 patients completed the study, 3 were lost to or unavailable for follow-up, and 2 withdrew owing to inflammatory hyperpigmentation after the laser treatment. Interventions Patients were randomized to receive laser treatment on the right or left arm. Each patient received treatment with the 810-nm pulsed diode laser to the arm randomized to be the treatment site. Treatments were repeated twice, for a total of 3 treatment visits spaced 4 to 5 weeks apart. Main Outcomes and Measures The primary outcome measure was the difference in disease severity score, including redness and roughness/bumpiness, with each graded on a scale of 0 (least severe) to 3 (most severe), between the treated and control sites. Two blinded dermatologists rated the sites at 12 weeks after the initial visit. Results At follow-up, the median redness score reported by the 2 blinded raters for the treatment and control sides was 2.0 (interquartile range [IQR], 1-2; P = .11). The median roughness/bumpiness score was 1.0 (IQR, 1-2) for the treatment sides and 2.0 (IQR, 1-2) for the control sides, a difference of 1 ( P = .004). The median overall score combining erythema and roughness/bumpiness was 3.0 (IQR, 2-4) for the treatment sides and 4.0 (IQR, 3-5) for the control sides, a difference of 1 ( P = .005). Conclusions and Relevance Three treatments with the 810-nm diode laser may induce significant improvements in skin texture and roughness/bumpiness in KP patients with Fitzpatrick skin types I through III, but baseline erythema is not improved. Complete treatment of erythema and texture in KP may require diode laser treatment combined with other laser or medical modalities that address redness. Trial Registration clinicaltrials.gov Identifier:NCT01281644

Importance Common noninvasive to minimally invasive cosmetic dermatologic procedures are widely believed to be safe given the low incidence of reported adverse events, but reliable incidence data regarding adverse event rates are unavailable to date. Objective To assess the incidence of adverse events associated with noninvasive to minimally invasive cosmetic dermatologic procedures, including those involving laser and energy devices, as well as injectable neurotoxins and fillers. Design, Setting, and Participants A multicenter prospective cohort study (March 28, 2011, to December 30, 2011) of procedures performed using laser and energy devices, as well as injectable neurotoxins and soft-tissue augmentation materials, among 8 geographically dispersed US private and institutional dermatology outpatient clinical practices focused on cosmetic dermatology, with a total of 23 dermatologists. Participants represented a consecutive sample of 20 399 cosmetic procedures. Data acquisition was for 3 months (13 weeks) per center, with staggered start dates to account for seasonal variation. Exposures Web-based data collection daily at each center to record relevant procedures, by category type and subtype. Adverse events were detected by (1) initial observation by participating physicians or staff; (2) active ascertainment from patients, who were encouraged to self-report after their procedure; and (3) follow-up postprocedural phone calls to patients by staff, if appropriate. When adverse events were not observed by physicians but were suspected, follow-up visits were scheduled within 24 hours to characterize these events. Detailed information regarding each adverse event was entered into an online form. Main Outcomes and Measures The main outcome was the total incidence of procedure-related adverse events (total adverse events divided by total procedures performed), as verified by clinical examination. Results Forty-eight adverse events were reported, for a rate of 0.24% (95% CI, 0.18%-0.31%). Overall, 36 procedures resulted in at least 1 adverse event, for a rate of 0.18% (95% CI, 0.13%-0.25%). No serious adverse events were reported. Adverse events were infrequently associated with known risk factors. Conclusions and Relevance Noninvasive to minimally invasive cosmetic dermatologic procedures, including energy, neurotoxin, and filler procedures, are safe when performed by experienced board-certified dermatologists. Adverse events occur in less than 1% of patients, and most of these are minor and transient.

Background Primary analysis from the pivotal ERIVANCE BCC study resulted in approval of vismodegib, a Hedgehog pathway inhibitor indicated for treatment of adults with metastatic or locally advanced basal cell carcinoma (BCC) that has recurred after surgery or for patients who are not candidates for surgery or radiation. Objective An efficacy and safety analysis was conducted 12 months after primary analysis. Methods This was a multinational, multicenter, nonrandomized, 2-cohort study in patients with measurable and histologically confirmed locally advanced or metastatic BCC taking oral vismodegib (150 mg/d). Primary outcome measure was objective response rate (complete and partial responses) assessed by independent review facility. Results After 12 months of additional follow-up, median duration of exposure to vismodegib was 12.9 months. Objective response rate increased from 30.3% to 33.3% in patients with metastatic disease, and from 42.9% to 47.6% in patients with the locally advanced form. Median duration of response in patients with locally advanced BCC increased from 7.6 to 9.5 months. No new safety signals emerged with extended treatment duration. Limitations Limitations include low prevalence of advanced BCC and challenges of designing a study with heterogenous manifestations. Conclusion The 12-month update of the study confirms the efficacy and safety of vismodegib in management of advanced BCC.

Importance Surgical training in dermatology residencies has increased, and there is growing interest in measuring resident competence more precisely. This study applies the use of the objective structured assessment of technical skills (OSATS) to measure competence in dermatologic surgery. Objective To evaluate the utility of OSATS as a tool for measuring surgery skills during dermatology residency training. Design, Setting, and Participants Multirater, blinded review and ratings of taped video recordings of elliptical excisions performed by senior dermatology residents applying for procedural or Mohs surgery fellowships. Main Outcomes and Measures Ratings on a specific OSATS measure, including global rating scale and task checklist. Results Twelve videos, representing approximately 20% of fellowship applicants during 2009-2010, were rated. Raters agreed on 272 of 288 subscore ratings (94.4%). Mean global ratings were 4 or 5 for all categories, except time and motion, which had a rating of 3. Task checklist ratings had a mean of 14.5 and a mode of 16 (perfect score), with eversion least often performed successfully. No association was found between a resident's scores and the number of surgical rotation months or between scores and the number of Mohs surgeons at the home institution. Conclusions and Relevance Senior dermatology residents preparing for surgery fellowships are highly skilled in performing elliptical excisions and bilayered repairs. The OSATS appears useful and reliable for the evaluation of dermatologic surgery skills.

Background Small-particle calcium hydroxylapatite (Radiesse, Merz, Frankfurt, Germany) is safe and effective for facial wrinkle reduction, and has medium-term persistence for this indication. There is patient demand for similar fillers that may be longer lasting. Objective We sought to assess the safety and persistence of effect in vivo associated with use of large-particle calcium hydroxylapatite (Coaptite, Merz) for facial augmentation and wrinkle reduction. Methods This was a case series of 3 patients injected with large-particle calcium hydroxylapatite. Results Large-particle calcium hydroxylapatite appears to be effective and well tolerated for correction of facial depressions, including upper mid-cheek atrophy, nasolabial creases, and HIV-associated lipoatrophy. Adverse events included erythema and edema, and transient visibility of the injection sites. Treated patients, all of whom had received small-particle calcium hydroxylapatite correction before, noted improved persistence at 6 and 15 months with the large-particle injections as compared with prior small-particle injections. Limitations This is a small case series, and there was no direct control to compare the persistence of small-particle versus large-particle correction. Conclusions For facial wrinkle correction, large-particle calcium hydroxylapatite has a safety profile comparable with that of small-particle calcium hydroxylapatite. The large-particle variant may have longer persistence that may be useful in selected clinical circumstances.

Background There is little information regarding commonalities, differences, and trends in the regulation of minimally invasive cosmetic procedures (MICP) across different state medical boards in the United States. Objective We sought to assess current state medical board regulations regarding MICP, so as to better understand current and emerging trends in rules regarding delegation, and management of patient complaints. Methods We conducted structured interviews with officials at US allopathic medical boards, supplemented with information from board World Wide Web sites. Results A total of 31 (62%) boards participated. Most (20 boards; 63% of total respondents) reported that all MICP can be delegated at the physician's discretion and responsibility to at least one category of nonphysician; 7 states were expecting changes in delegation rules; and 4 states had very specific delegation requirements. Approximately equal numbers of boards required some general supervision of nonphysicians (14, 45%), or required some type of on-site supervision (13, 42%); a small number explicitly permitted off-site supervision (4, 13%). There was variation in the number of physician assistants one physician could supervise. Most boards (15 states) required some type of mandatory reporting, but not necessarily of incidents involving MICP. Very few (4) required reporting of both office- and nonoffice-based MICP incidents. Western states had liberal delegation and supervision requirements; these requirements were more stringent in Southern states. Limitations Not all boards participated in this study. Conclusion There is substantial variation in board regulation of MICP. Many boards are promulgating new rules. Medical boards also have limited ability to regulate nonphysicians.

To assess the comparative efficacy of energy treatments in resolving cherry angiomata.Rater-blinded randomized controlled trial.Outpatient dermatology clinic in an urban referral academic medical center.Fifteen healthy adults aged 21 to 65 years were enrolled. Two eligible individuals who were approached declined to participate, and no one enrolled was withdrawn for adverse effects.For each participant, 3 areas on the torso were demarcated such that each area contained 4 cherry angiomata. Each area was then randomly assigned to receive 1 of the 3 treatments: pulsed-dye laser (PDL) (595 nm), potassium titanyl phosphate (KTP) laser (532 nm), or electrodesiccation. Two treatments spaced 2 weeks apart were delivered to each area.Standardized photographs from before treatment and 3 months after the last treatment were evaluated for color and texture on visual analog scales.Mean change in color was a significant improvement of 7.77 (P.001), but there was no significant difference across treatment arms (P=.19). Mean change in texture was a significant improvement of 6.23 (P.001), and the degree of textural change also differed across treatments (P.001). In pairwise comparisons, cherry angiomata treated with electrodesiccation were significantly less improved than were those receiving KTP laser (P=.003) and those treated with PDL (P=.001). The effects of KTP laser and PDL on texture were not different (P=.50).Cherry angiomata can be effectively treated with electrodesiccation and with laser. Laser, especially PDL, may minimize the likelihood of treatment-associated textural change. Trial Registration clinicaltrials.gov Identifier: NCT00509977.

Squamous cell carcinoma (SCC) has a mortality rate of up to 8% in solid organ transplant recipients (OTRs), and the risk of OTRs developing SCC is up to 250-fold greater than that of the general population.1-3 Despite these risks, patients commonly do not seek health care for skin checks, nor do they routinely perform skin self-examinations (SSEs). Moreover, although patients in 1 study recalled being told to use sunscreen, few were aware that their immunosuppressive medication increased skin cancer risk.4 The present study assesses (1) the optimal time after transplantation to deliver SSE educational intervention; (2) the relationship between lifetime sun exposure and OTRs’ perception of SSE importance; and (3) the impact of SCC discussion with a health care worker on the likelihood of SSE performance.

There are no randomized split-face model studies investigating treatments for postinflammatory hyperpigmentation (PIH) in dark skin.To assess the efficacy, safety, and effect on quality of life of salicylic acid peels for PIH in dark skin.Ten subjects with Fitzpatrick skin phototypes IV to VI were randomized to receive two 20% salicylic acid peels followed by three 30% salicylic acid peels to half of the face. The contralateral half remained untreated. Response was evaluated by photography reviewed by three blinded dermatologists. The Visual Analog Scale, Dermatology Life Quality Index (DLQI), and treatment quality questionnaire were administered.Improvement of PIH on the treatment side according to each rater (p=.81, p=.81, p=.42) and according to the raters combined (p=.11) approached but did not reach statistical significance. Subjects' Visual Analog Scale scores indicated significantly greater improvement of PIH on the treatment side than in the control (p=.004). Quality of life measured according to the DLQI improved after treatment but not statistically significantly so (p=.13). Treatment had no significant adverse effects.Salicylic acid peels are safe in this population. Although patients rated them as clinically effective, blinded raters found a brief series of peels to have less efficacy. Measured quality of life improved nominally.

Background Erythema ab igne is a rare condition with a carcinogenic potential produced by chronic exposure to a heat source. Case description We present the first case of rapid-onset erythema ab igne in the setting of a dental practice. Clinical implication Physicians and dentists should be aware of this disease following short-term local application of heat.

BACKGROUND There are many routes to obtaining training in dermasurgery. OBJECTIVE The objective is to discuss some considerations that may guide selection of dermasurgery training. METHODS Current training options are reviewed. RESULTS Some considerations that may guide selection of type of dermasurgery training include: (1) individual temperament; (2) the subtype of dermasurgery in which training is desired (Mohs, cosmetic surgery, laser); (3) family and geographic factors; (4) preference for private practice versus academic career; and (5) proportion of future practice to be devoted to dermasurgery. CONCLUSIONS There are a growing number of training choices for budding dermasurgeons, with multiple options available for each set of particular circumstances.

Background Injectable calcium hydroxylapatite is a soft-tissue augmentation material that is used off-label for facial augmentation, including repletion of depressed nasolabial folds. Objective We sought to assess the safety of calcium hydroxylapatite injection for correction of nasolabial fold depressions. Specifically, we sought to obtain a quantitative assessment of injection-related adverse events using a reproducible placement technique with long-term follow-up. Methods We conducted an open-label, single-center prospective study using reproducible technique with 1- to 1.5-year follow-up. All patients were treated with infraorbital nerve blocks. Then, parallel linear threading technique using 27-gauge/1.25-in needles was used to place 1 to 2 mL of injectant at the dermal subcutaneous junction into each pair of depressed folds. A triangular array of injectant was deposited under the melonasal junction. At follow-up at 2 to 3 weeks and at 1 to 1.5 years, respectively, patients were asked to report and characterize injection-related redness, swelling, bruising, nodule or granuloma formation, asymmetric correction, textural change, hypersensitivity reactions, degree of correction remaining, and overall satisfaction. In addition, patients who had received other injectable soft-tissue materials were asked to compare these with calcium hydroxylapatite in terms of risk profile and longevity of effect. Results In all, 22 patients were treated and complete follow-up data were obtained from 18. Of the 18 patients, all reported at least mild postinjection redness and swelling, which abated within 1 to 5 days. Bruising was reported by fewer than half, and resolved within 4 to 10 days. Palpable but not visible nodules were reported by 2 of 18 patients; these resolved within 3 months of injection. Asymmetric correction, textural change, granulomas, and hypersensitivity reactions were not reported. In all, 14 of 18 patients reported that cosmetically significant correction lasted longer than 1 year. Two thirds of injected patients who had received other fillers for nasolabial fold correction preferred calcium hydroxylapatite, with the primary reason being increased longevity of effect. Limitations There was a lack of objective outcomes measures. Conclusions When a consistent, defined injection technique is used, injectable calcium hydroxylapatite appears to be a well-tolerated soft-tissue augmentation material for correction of nasolabial fold depressions. A long duration of effect may make this material particularly desirable for some patients.

Importance Neocollagenesis can be achieved using a dermal rolling needle device, thereby reducing the appearance of acne scars. Objective To determine the efficacy of a needling device for treatment of acne scars. Design, Setting, and Participants We performed a single-center, rater-blinded, balanced (1:1), split-face, placebo-controlled, parallel-group randomized clinical trial at an urban academic institution. The study took place from November 30, 2009, through July 27, 2010. Twenty healthy adults (age range, 20-65 years) with acne scars on both sides of the face were enrolled. Fifteen individuals completed the study, and no enrolled participants were withdrawn for adverse effects. Interventions For each participant, one side of the face was randomized for needling. Three needling treatments were performed at 2-week intervals. Main Outcomes and Measures Two blinded dermatologists separately rated participants’ acne scars based on standard digital photographs obtained at baseline and at the 3-month and 6-month follow-up visits on the quantitative global scarring grading system. Results Mean scar scores were significantly lower in the treatment group compared with baseline at 6 months (mean difference, 3.4; 95% CI, 0.2-6.5; P = .03) and nominally but not significantly lower compared with baseline at 3 months (mean difference, 2.4; 95% CI, −0.01 to 4.8; P = .052). In the control group, mean scar scores did not vary significantly from baseline at 3 months (mean difference, 1.0; 95% CI, −1.4 to 3.4; P = .96) and at 6 months (mean difference, 0.4; 95% CI, −2.3 to 3.5; P > .99). The needling procedure was not particularly painful, with a mean pain rating of 1.08 of 10. Participants perceived a 41% mean improvement in overall scar appearance on the treated side. No adverse events were reported. Conclusions and Relevance After 3 needling treatments, there was improvement in the appearance of acne scars over time compared with the control group, with minimal pain reported. Trial Registration clinicaltrials.gov Identifier:NCT00974870

Importance Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. Objectives To quantify adverse events associated with MMS and detect differences relevant to safety. Design, Setting, and Participants Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. Exposure Mohs micrographic surgery. Main Outcomes and Measures Intraoperative and postoperative minor and serious adverse events. Results Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. Conclusions and Relevance Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Keratoacanthomas (KAs) and squamous cell carcinomas (SCCs) are common epidermal neoplasms, particularly in sun-exposed areas of fair-skinned individuals. Although surgical excision is the standard of care, eruptive KAs and SCCs provide a therapeutic challenge. We present an unusual case of a patient who developed eruptive low-grade keratoacanthomatous atypical squamous proliferations (KASPs) in split-thickness skin graft (STSG) donor and recipient sites after SCC excision.