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Merkel cell carcinoma (MCC) is an aggressive neoplasm with high rates of recurrences. Current guidelines recommend wide local excision (WLE) with 1 to 2 cm margins. However, Mohs micrographic surgery (MMS) offers a potential advantage over WLE because of its ability of sparing healthy tissue and assessing 100% of margins.To systematically evaluate the surgical modalities for the treatment of MCC.Eligible articles were identified using MEDLINE, Scopus, EMBASE, and Cochrane Library. All available studies investigating surgical treatment of MCC with WLE or MMS were considered.Forty studies met the inclusion criteria. Thirty-one studies described patients treated with WLE, 3 with MMS, and 6 with either WLE or MMS. Subgroup analysis of Stage I MCC showed recurrence rates similar in both surgical modalities with local recurrence rate of 6.8% for WLE versus 8.5% for MMS (p = .64) and a regional recurrence rate of 15.2% for WLE versus 15.3% for MMS (p = .99).Overall WLE cases were at a higher stage at presentation. Subgroup analysis showed that MMS is not inferior to WLE excision for the treatment of Stage I MCC and is a reasonable option for anatomic locations where tissue sparing is important.

Background Reconstructing defects on the nose can be challenging. The bilobed transposition flap and the nasalis-based V to Y (NBVY) flaps can be excellent repair options, each with their own advantages and disadvantages. Objective To compare bilobed and NBVY flap scar appearances, postoperative complications, scar revision rates, flap sizes, and relative costs. Materials and methods We reviewed 95 cases of Mohs surgery defects on the nose repaired with either a bilobed or a NBVY flap from 2010 to 2018 at our institution. Eleven reviewers judged postoperative scar images using a modified visual analog scale. Results There were no significant differences in reviewer-rated scar appearances, complication rates, or revision rates between bilobed and NBVY flaps. The NBVY flaps were 50% smaller than bilobed flaps, with significantly lower CPT billing codes. The NBVY flaps yielded better scar appearance scores compared with bilobed flaps on highly sebaceous noses. Conclusion The NBVY and bilobed flaps demonstrated similar scar appearance outcomes, but the NBVY flap has several advantages. Compared with the bilobed flap, the NBVY flap is smaller, less expensive, and may yield better cosmetic outcomes in patients with highly sebaceous noses.

Cutaneous angiosarcomas may express programmed death ligand-1 (PD-L1) and PD-L1 expression, and the presence of tumor-infiltrating lymphocytes (TILs) correlates with outcome. These observations provide a basis for PD-1/PD-L1 inhibitor therapy. Lymphocyte activation gene 3 (LAG-3) is an inhibitory receptor that interacts with the PD-L1 axis and is considered to be a marker of immune exhaustion. The presence of LAG-3-positive lymphocytes in cutaneous angiosarcoma has not been established. We reviewed 10 cases of treatment naive angiosarcoma of skin and superficial soft tissue and assessed for PD-L1 (ZR3) expression, presence of TILs, and expression of CD8, PD1, and LAG-3 by tumor-associated inflammatory cells by immunohistochemistry. All 10 angiosarcomas were positive for PD-L1: 7 with high expression and 3 with low expression. TILs were present in all tumors: brisk in 7 and nonbrisk in 3. CD8 lymphocytes were present in all tumors with a range of 212-1274 cells per square millimeter (mean 557 CD8 cells/mm2). LAG-3-positive lymphocytes were present in 9 of 10 angiosarcomas with a range of 0-728 cells/mm2 (mean 146 LAG-3 cells cells/mm2). The ratio of LAG-3 lymphocytes to CD8 lymphocytes was 0%-59% (mean 27%). The PD1 cell counts were intermediate between CD8 and LAG3 counts. Cutaneous angiosarcomas frequently express PD-L1, have prominent numbers of CD8 positive, and have smaller numbers of LAG-3-positive and PD-1-positive TILs. Our findings provide further evidence of PD-L1 expression in cutaneous angiosarcoma and the promise for immune checkpoint inhibitor therapy.

Background Reconstruction of large nasal surgical defects often warrant the use of mucosal flaps to repair the inner lining. This often presents a challenge for surgical reconstruction. Objective To describe a unique reconstructive option for the repair of large surgical wounds that necessitate mucosal nasal lining. Materials and methods This study is a retrospective review of 10 patients who underwent surgical reconstruction of large nasal and/or heminasal surgical defects following Mohs micrographic surgery. A nasolabial turnover interpolation flap was used to repair missing nasal mucosal lining, coupled with a cutaneous flap which typically involved a paramedian forehead flap. The duration of follow-up was 8 months. An aesthetic and functional surgical outcomes measure was used to assess the final repair. Results Favorable aesthetic outcomes were obtained in all patients and without need of revision surgery by the use of a nasolabial turnover interpolation flap. Conclusion The nasolabial turnover interpolation flap offers a reliable and effective method of repair for large transmural nasal surgical wounds. We typically paired this nasal lining flap with a paramedian forehead flap with reliable and aesthetic outcomes. This technique is straightforward, reproducible, and with both good aesthetic and functional outcomes.

There is a lack of data characterizing tumors located within male facial hair subunits and determining if terminal hair growth obscures tumor detection, thus leading to a delay in diagnosis. Our objective was to evaluate the difference in cutaneous tumor size in men who had facial hair compared to men without facial hair. This retrospective chart review analyzed Mohs micrographic surgery cases of tumors located within facial hair subunits from January 2015 to December 2018 at The University of North Carolina at Chapel Hill. Patients and dermatologists should maintain a high index of suspicion for any concerning lesion contained within skin underlying facial hair to ensure prompt diagnosis and treatment of cutaneous tumors.

EMPD is an intraepidermal adenocarcinoma most often limited to the epidermis, with typical cases affecting genital skin in women and men. In patients with invasive disease, prognosis is based on the degree of invasion, with tumors less than 1 mm deep having very low mortality. Careful evaluation for an underlying malignancy should be carried out to exclude life-threatening disease, but the association of many coexistent malignancies is controversial. Reported underlying adnexal adenocarcinoma may, at least in some patients, represent invasive spread of primary epidermal disease. Mohs surgery has proven effective in the treatment of EMPD, and the implementation of CK7 immunostaining shows promise in further reducing the recurrence rate. Alternative treatments, including topical treatment with imiquimod and 5-fluorouracil as well as photodynamic therapy, may be effective in select cases of EMPD.

Background Mohs micrographic surgery (MMS) has been used effectively to treat invasive melanoma. Objective To further study the safety and efficacy of MMS in the treatment of invasive melanoma. Methods and materials A retrospective cohort study evaluated 123 melanomas excised using MMS with MART-1 immunostain. Local recurrence, metastasis, overall survival, and disease-free survival rates were calculated. These were compared with historical controls. Results Among included patients, 78 were men (63%) and 45 were women (37%), with a mean age of 66.48 years. Mean follow-up time was 1,273 days (3.49 years). Local recurrence was identified in 2/123 (1.63%; 95% confidence interval, 0.20%-5.75%) lesions. Local recurrence was identified in 1/70 (1.43%; 95% confidence interval, 0.04%-7.70%) of head and neck cases. Tumor location was head and neck in 70 lesions (56.9%). Overall survival was 95.12% and disease-specific survival was 100%. Conclusion Mohs micrographic surgery is an effective treatment method for invasive melanoma, as evidenced by low recurrence rates and high rates of disease-free survival.

Background Complications associated with Mohs surgery have been evaluated by single-surgeon studies. While these studies provide evidence for the safety of the procedure, prospective, multicenter studies afford a higher level of clinical evidence and establish further the safety profile of Mohs surgery in the ambulatory setting. Objective This study was designed to prospectively evaluate major and minor complications as well as postoperative pain associated with Mohs surgery. Methods A multicenter prospective cohort study was conducted evaluating the rate of major and minor complications as well as postoperative pain associated with the treatment of skin cancer using Mohs surgery in 1550 patients with 1792 tumors. Follow-up was obtained in 1709 of the 1792 tumors treated (95.3%). Results No major complications occurred during Mohs surgery or reconstruction. A total of 44 (2.6%) minor primary postoperative complications occurred during the study. On a scale from 0 to 10, the average peak postoperative pain level was 1.99. Limitations Limitations of the study include the variability of practice patterns across practice sites as well as the 4.7% of patients lost to follow-up. Conclusion Mohs surgery is performed with a high degree of safety and is well tolerated by patients.

Eosinophilic fasciitis is an uncommon entity characterized by peripheral eosinophilia and fasciitis. To our knowledge, approximately 30 pediatric patients have been reported. We describe a 12-year-old girl with eosinophilic fasciitis. The patient received interdisciplinary treatment including methotrexate, systemic steroids, and physical therapy with progressive improvement. Her presentation provides more evidence of a potential phenotype of this disease specific to childhood eosinophilic fasciitis.

Several important cutaneous neoplasms present with basaloid cells in the dermis. Desmoplastic trichoepithelioma (DTE), infiltrative/morpheaform basal cell carcinoma (BCC), and microcystic adnexal carcinoma (MAC) are tumors in this category that may be difficult to differentiate, especially when evaluating thin biopsy specimens. An accurate diagnosis has important clinical implications. While DTE is a benign neoplasm with indolent behavior, infiltrative/morpheaform BCC and MAC can be highly aggressive, leading to substantial local destruction and potential metastasis. We present a patient with an unusual tumor demonstrating basaloid cells in the dermis and discuss the diagnostic approach for these lesions, emphasizing the potential role of cytokeratin 20 (CK20) in determining the need for Mohs micrographic surgery.

Isotretinoin is the most effective treatment for severe nodulocystic acne. More than 12 million patients have been treated with this life-changing medicine since its approval by the Food and Drug Administration (FDA) in 1982. The use of isotretinoin for acne remains controversial due to the significant potential for teratogenicity and increasing concerns about its association with depression and suicide. Because isotretinoin is prescribed almost exclusively for adolescents and young adults, pediatricians are likely to encounter patients undergoing treatment. This article discusses the indications for isotretinoin, its teratogenicity, its regulation by the FDA, and its side-effect profile, including possible association with depression and suicide. ABOUT THE AUTHORSBradley Merritt, MD, is with the Department of Dermatology, University of North Carolina, Chapel Hill. Craig N. Burkhart, MD, is Assistant Professor, and Director of Medical Student Education, Department of Dermatology, UNC Chapel Hill. Dean S. Morrell, MD, is Associate Professor, and Residency Training Program Director, Department of Dermatology, UNC Chapel Hill. Address correspondence to: Bradley Merritt, MD, University of North Carolina, Chapel Hill, Department of Dermatology, 3100 Thurston-Bowles Bldg, CB #7287, Chapel Hill, NC 27599; fax: 919-966-3898; e-mail: BMerritt@unch.unc.edu. Dr. Merritt; Dr. Burkhart; and Dr. Morrell have disclosed no relevant financial relationships. doi: 10.3928/00904481-20090512-01