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Importance: Functional and cosmetic outcomes following Mohs micrographic surgery (MMS) are poorly studied in individuals with skin of color (SOC). Postinflammatory hyperpigmentation (PIH) may be long-lasting and highly distressing. SOC individuals are particularly susceptible to PIH following procedures.  Objective: To characterize factors that contribute to the development of PIH following MMS in SOC., Design: This retrospective study included 72 SOC individuals with 83 cases of keratinocyte carcinoma treated with MMS between August 2020 and August 2021 at a single medical center in the Bronx, New York., Results: Postinflammatory hyperpigmentation following Mohs micrographic surgery was more common in Fitzpatrick skin types (FST) IV to V (48.0%) compared to FST I to III (18.2%; P=0.006). Grafts and granulation resulted in higher rates of PIH compared to linear repairs and flaps (87.5% vs 30.7%; P=0.003). Cases with postoperative complications resulted in higher rates of PIH compared to cases without (81.8% vs 29.2%; P=0.001). In a subset analysis of linear repairs, polyglactin 910 as a subcutaneous suture produced a higher rate of PIH compared to poliglecaprone 25 (46.2% vs 7.1%; P=0.015).  Conclusions and Relevance: Individuals with SOC (FST IV to V) are more likely to develop PIH following MMS. Grafts and granulation lead to PIH more often than linear repairs and flaps. Postoperative complications significantly increase the risk of PIH. Surgeons should consider these risk factors during surgical planning in an effort to mitigate PIH in SOC individuals. Studies with larger sample sizes are indicated.  J Drugs Dermatol. 2024;23(5):316-321. doi:10.36849/JDD.8146.

Competing Interests: Conflicts of interest None disclosed.

Competing Interests: None declared.

Background: Insurance companies have implemented new policies including excessive prior authorization (PA) requirements, high-deductible plans, and complicated billing structures in an effort to curb rising health care costs. Studies investigating the real-time impact on providers and patients are emerging, but few within the field of dermatology have been published., Objective: To assess the impact of cost-cutting policies on patients and physicians., Methods: A survey was electronically distributed to members of the American College of Mohs Surgery (ACMS)., Results: The majority of respondents (78.2%) practiced in a private setting, with no other demographic differences. The majority of respondents (70%) dedicated 1 to 2 employees to obtaining PAs. Fifty percent reported an average time of 30 minutes spent per PA. Fifty-six percent of respondents obtained PA from private insurance before Mohs surgery, whereas only 24.5% obtained PA from Medicare. Forty-nine percent of practitioners provided patients with a financial disclosure prior to Mohs surgery. Moreover, many practitioners reported screening patients for high-deductible policies and request an advanced deposit against the deductible. Sixty percent reported difficulty obtaining payment for service in the absence of an advanced deposit., Conclusion: The burden of restrictive health care policies will have long-term consequences for the patient-provider interaction and patient outcomes.

Background: Rhinophyma is a cosmetically deforming disease characterized by nodular overgrowth of the lower 2/3 of the nose and is considered the end stage of acne rosacea., Aims: Review the spectrum of procedural techniques for treatment of rhinophyma with a focus on the advantages and disadvantages of each modality., Methods: A comprehensive literature search was conducted using the search terms "rhinophyma," "treatment," and "surgery" in PubMed. Case reports, case series, and small retrospective trials using procedural techniques for management of rhinophyma were included for review. Animal studies, non-English articles, and reports of medical treatment of rhinophyma were excluded., Results: There are currently no prospective, randomized controlled studies evaluating procedural management of rhinophyma. The most commonly employed treatments include scalpel excision, resection with heated knives, dermabrasion, electrosurgery and lasers, specifically carbon dioxide (CO 2 ) and erbium:yttrium-aluminum-garnet (Er:YAG). The main complication associated with complete excision of rhinophymatous tissue is excessive scarring. To correct for this adverse effect, partial or tangential excision with preservation of underlying adnexal structures is now the accepted technique, irrespective of the chosen modality., Conclusion: There is no accepted gold standard for management of rhinophyma, and each modality succeeds in maintaining hemostasis, reducing scarring and achieving satisfactory cosmesis to different degrees. There is a conflicting data on the theoretical risk of recurrence with partial excision due to incomplete removal of tissue. Further studies evaluating this risk and alternate methods of prevention are required., (© 2018 Wiley Periodicals, Inc.)

A recent national survey suggests that up to one-third of facial reconstructive and plastic surgeons do not adhere to the classical principle of subunit reconstruction. While single-stage flaps and grafts may be easier and less time consuming, they can also lead to a poor cosmetic outcome. Here, the authors describe how the authors repaired a complex post-Mohs surgery facial defect involving multiple cosmetic subunits and how adherence to the subunit principle was essential to obtaining the most optimal functional and esthetic outcome.

Background: In this study, we evaluated the safety and efficacy of a novel 2,790-nm erbium-doped yttrium scandium gallium garnet (Er:YSGG) laser system for the treatment of facial photodamage and perioral wrinkles using a single-treatment, high-fluence, high-density protocol., Methods: Eleven female participants with Fitzpatrick skin types II to III and facial wrinkles underwent a single full-face fractional ablative treatment with a 2,790-nm Er:YSGG laser. Follow-up visits were completed at 1, 2, and 6 weeks 3 and 6 months. Quartile improvement scale (0-4) and Fitzpatrick wrinkle scores (1-9) were used for the assessments., Results: Based on blinded photographic assessments, the mean difference in Fitzpatrick wrinkle scores for full face wrinkles was 1.5 ± 1.2 (a reduction from 6.6 to 5.1; paired t-test, p = .003). There was also a statistically significant mean reduction of 1.7 ± 1.3 in perioral wrinkle scores (from 6.7 to 5.0; p = .002). No serious adverse events were reported., Conclusion: A novel, fractionated, ablative 2,790-nm Er:YSGG laser can safely and effectively treat photodamage and perioral wrinkles in a single treatment using a high-fluence, high-density protocol. Cutera provided the equipment used in this study and funding to Dr. Goldberg., (© 2011 by the American Society for Dermatologic Surgery, Inc.)

Objective: To compare the safety and efficacy of two fractional carbon dioxide (CO(2)) laser devices for the treatment of photodamaged facial skin., Methods: Eight healthy subjects underwent full-face resurfacing for photodamaged skin with two fractionated CO(2) laser devices using manufacturer-recommended settings for facial rejuvenation. For each subject, one device with a rolling handpiece was used on one side and a second device with a stamping handpiece was used on the other. Patients were evaluated 3 months postoperatively and photographed. A blinded physician investigator assessed the photographs and rated each side for improvement in four categories (wrinkles, pigmentation, skin laxity, and overall appearance). Patient ratings for overall improvement for each side were also recorded., Results: All patients had improved on the basis of photographic and clinical assessments at 3 months. No significant differences in patient ratings of overall improvement and physician-measured parameters of clinical improvement were found, although intraoperative times and pain ratings were greater with the laser with the stamping handpiece. No complications were experienced with either device., Conclusions: Both fractionated CO(2) resurfacing devices used in the study were safe and effective for the treatment of photodamaged facial skin, but the modality using a stamping handpiece was associated with longer operative times and greater intraoperative pain. The authors have indicated no significant interest with commercial supporters., (© 2011 by the American Society for Dermatologic Surgery, Inc.)

Non-ablative laser devices exert their effects by inducing dermal collagen remodeling while sparing the epidermis. The remodeling process is achieved by producing thermal energy in a controlled and precise fashion, which recruits fibroblasts and stimulates collagen production. Although these devices do not produce the same degree of improvement as traditional CO(2) or er:YAG resurfacing techniques, they are an excellent alternative for people seeking gradual aesthetic improvement with minimal downtime. They are also extremely well suited to patients with darker skin types. In this chapter, we review the various non-ablative devices currently available on the market, with an emphasis on safety profiles and efficacy., (Copyright © 2011 S. Karger AG, Basel.)

Intense pulsed light technology has revolutionized the noninvasive treatment of a whole variety of cutaneous cosmetic problems. Today's machines are safer, more diverse, less painful, and readily available. Intense pulsed lights can be used to treat vascular and pigmented lesions and are used for facial rejuvenation and the removal of unwanted hair. Newer, less powerful home-device intense pulsed light sources will not replace those used in a physician's office but will augment the use of today's more powerful medical office systems., (Thieme Medical Publishers.)

Background/objective: Various techniques for blepharoplasty have been described, including those performed with the assistance of the short pulse carbon dioxide laser and those performed with the assistance of the Colorado microdissection needle attached to an electrocautery unit. Although the superiority of the carbon dioxide laser to cold steel has been demonstrated for the performance of eyelid blepharoplasty, no studies have ever compared the carbon dioxide laser to the Colorado needle., Study Design/materials and Methods: This is a paired comparison study in which 12 healthy patients underwent bilateral blepharoplasty of their upper and/or lower eyelids by a single surgeon. For each patient, a short pulse carbon dioxide laser was used on one side, and a Colorado needle attached to an electrocautery unit was used on the other. Intraoperative times were recorded. At five post-operative visits patients were evaluated for post-operative healing parameters including edema, erythema, scar width, and bruising. Finally, excised tissue was assessed histologically for thermal damage., Results: Comparing both techniques, no difference in patient or physician-measured parameters of healing were noted up to 1 month post-operatively. However, Colorado needle assisted blepharoplasty resulted in slightly shorter intraoperative times. It also resulted in less thermal damage on a histologic level, although these differences were not clinically significant., Conclusions: For the performance of blepharoplasty, the Colorado needle tip with electrocautery offers benefits equivalent to those of the short pulsed CO2 laser but has the advantage of shorter intraoperative times and lower cost.

Introduction: Five to forty percent of patients with cutaneous psoriasis develop an inflammatory, oligoarticular spondyloarthropathy known as psoriatic arthritis., Objective: To compare health-related quality of life (QOL) between cutaneous psoriatic patients with and without psoriatic arthritis., Method: Secondary cross-sectional analysis of data obtained from the 2005 Spring US National Psoriasis Foundation Quality of Life Telephone/Internet Survey. 426 patients with psoriasis and/or psoriatic arthritis were included in the 2005 survey. Among these respondents, the self-reported disease histories of 140 patients with cutaneous psoriasis and psoriatic arthritis were compared with those of 278 patients with cutaneous psoriasis only. Both groups were compared with respect to demographics, skin disease severity, treatment history and satisfaction, and QOL using previously validated assessment scales., Results: Compared with those with skin psoriasis only, respondents with cutaneous psoriasis and psoriatic arthritis were slightly older, more likely to be female and members of the National Psoriasis Foundation, and more likely to report a younger age of disease onset. They were also more likely to be unemployed, to report their job was affected by their condition, and to report a higher mean estimate of lost annual wages. On both univariate and multivariate analysis, however, no significant differences between groups were detected in skin disease severity, overall QOL, and satisfaction with current treatment options. At the same time, individuals with skin psoriasis and psoriatic arthritis were more likely to be taking systemic agents. They also reported higher mean scores for pain, while those with cutaneous psoriasis reported higher mean scores for self-consciousness only., Conclusion: In contrast to previous reports that did not control for skin disease severity, this study demonstrates that patients with cutaneous psoriasis and psoriatic arthritis do not report significantly worse health-related QOL compared with patients with cutaneous psoriasis only. Nor do they report significantly greater dissatisfaction with current treatment options. These findings may reflect the intrinsic inadequacy of the QOL instruments used in this study for capturing the additional burden of joint disease. Alternatively, these findings may reflect the existence of a threshold of joint disease in patients with skin psoriasis and psoriatic arthritis below which joint symptoms are perceived as negligible relative to cutaneous disease.

The presence and severity of skin and joint symptoms in patients with psoriasis and psoriatic arthritis frequently do not correspond, a discrepancy that has raised the question of whether they represent two related but different disease processes. The fact that some agents seem to work preferentially in one state over the other reinforces this idea. However, there are also several agents with combined efficacy against cutaneous and articular inflammation that appear to support the existence of a common aetiology. Here we review the clinical, epidemiological and genetic evidence for and against a common pathogenesis for the two diseases. We then discuss the cellular and molecular targets of their selected therapies and how they potentially implicate effector pathways as a common immunopathogenic mechanism. Finally, we examine a recently proposed model of psoriasis pathogenesis involving type 1 interferon-producing plasmacytoid dendritic cells and how it may provide further clues to the aetiological links between psoriasis and psoriatic arthritis.

An injury to a finger or toe can result in a collection of blood under the nail plate that if unrelieved can cause extreme discomfort due to pressure. In this case, a 47-year-old man developed a subungual hematoma of the right thumb due to a crush injury. Controlled nail trephination was performed using a uniquely designed drill that penetrated the nail plate without breaching the nail bed. The subungual hematoma was successfully drained, and there was a substantial relief in pain over the subsequent 8 hours. This technique appears to be a quick and convenient method of evacuating subungual hematomas with minimal discomfort and minimal risk.

Dendritic cells are attractive candidates for vaccine-based immunotherapy because of their potential to function as natural adjuvants for poorly immunogenic proteins derived from tumors or microbes. In this study, we evaluated the feasibility and consequences of introducing foreign genetic material by retroviral vectors into dendritic cell progenitors. Proliferating human bone marrow and cord blood CD34+ cells were infected by retroviral vectors encoding the murine CD2 surface antigen. Mean transduction efficiency in dendritic cells was 11.5% from bone marrow and 21.2% from cord blood progenitors. Transduced or untransduced dendritic cell progeny expressed comparable levels of HLA-DR, CD83, CD1a, CD80, CD86, S100, and p55 antigens. Granulocytes, macrophages, and dendritic cells were equally represented among the transduced and mock-transduced cells, thus showing no apparent alteration in the differentiation of transduced CD34+ precursors. The T-cell stimulatory capacity of retrovirally modified and purified mCD2-positive allogeneic or nominal antigen-pulsed autologous dendritic cells was comparable with that of untransduced dendritic cells. Human CD34+ dendritic cell progenitors can therefore be efficiently transduced using retroviral vectors and can differentiate into potent immunostimulatory dendritic cells without compromising their T-cell stimulatory capacity or the expression of critical costimulatory molecules and phenotypic markers. These results support ongoing efforts to develop genetically modified dendritic cells for immunotherapy.

Human dendritic cells can be generated from bone marrow CD34+ progenitors in the presence of GM-CSF and TNF alpha. The addition of a factor like c-kit-ligand optimizes the expansion of dendritic cells, as well as the other myeloid progeny grown under the same conditions, and facilitates their identification and characterization. In contrast to cord blood, where dendritic cells account for the majority of the class II MHC positive myeloid progeny, bone marrow CD34(+)-derived dendritic cells are less frequent than macrophages. When mature macrophages are depleted from days 5-6 cultures, terminally differentiated CD14+ HLA-DR dendritic cells as well as non-monocyte/macrophage CD14+ HLA-DR+ cells can be distinguished. The latter are post-CFU, bipotential, intermediate precursors that can terminally differentiate into either dendritic cells or macrophages depending on subsequent cytokine exposure. Human CD34+ progenitors isolated from bone marrow, as well as cord and peripheral blood, include CFU-DC that give rise to pure dendritic cell colonies in the combined presence of GM-CSF and TNF alpha. The different sources of CD34+ progenitors are not equivalent, however, with respect to frequency of CFU-DC growth. Cord blood is relatively enriched for dendritic cell progenitors. The developmental relationship of CFU-DC and CFU-GM, to the early developing dendritic cells and the bipotential intermediates observed in suspension culture, is not yet established.