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Little is known about the possible association between nonmelanoma skin cancer (NMSC) and allograft survival and overall patient survival.To determine the association between posttransplant NMSC and early to mid-term allograft survival and overall patient survival after kidney, liver, or heart transplantation.We retrospectively reviewed patients identified from the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. The study included adult recipients of kidney (n=46,216), liver (n=8,049), and heart (n=8,519) transplants from 1996 to 2001.Multivariate analysis showed that kidney recipients with NMSC had a significantly lower risk of allograft loss (relative risk (RR)=0.55, p.001) and death (RR=0.55; p.001) within 5 years of transplantation than recipients without NMSC. Significantly lower risk of death was also observed for liver recipients (RR=0.28, p.001) and heart recipients (RR=0.25; p.001) with NMSC.Longer early to mid-term allograft and overall survival was seen in patients with NMSC, but long-term survival rates must be examined to determine whether mortality rates increase later for patients with NMSC, as noted in previous studies.

BACKGROUND An association exists between chronic lymphocytic leukemia and malignant melanoma. OBJECTIVES To study the clinical behavior of malignant melanoma in patients with chronic lymphocytic leukemia. METHODS A retrospective chart review was conducted of patients with chronic lymphocytic leukemia and malignant melanoma. RESULTS Sixty-nine patients had malignant melanoma and chronic lymphocytic leukemia. The recurrence-free and metastasis-free survival rates at 2, 5, and 10 years were 93.4% and 89.1%, 83.8% and 93.4%, and 87.4% and 82.1%, respectively. No significant difference was observed in age- and sex-adjusted mortality rates between patients with chronic lymphocytic leukemia diagnosed before malignant melanoma and those with chronic lymphocytic leukemia diagnosed after malignant melanoma. LIMITATIONS Retrospective study and small patient population. CONCLUSION Patients with malignant melanoma and chronic lymphocytic leukemia were not shown to have worse survival rates than those with stage IA, IB, and IIA disease. Further research and prospective study are needed.

BACKGROUND A large proportion of facial skin cancers occur on the nose, and defects after Mohs surgery in this location often present a reconstructive challenge. For intermediate-sized defects, the choice of reconstruction is usually between skin flap and full-thickness skin graft. Ongoing debate exists, and limited data are available to determine which of these methods is more satisfactory. OBJECTIVE To evaluate and compare the clinical appearance of wound healing after surgical repair with a skin graft versus a skin flap for Mohs defects on the nose. METHOD In this study, 43 flaps and 24 grafts were evaluated using a modified Hollander Wound Evaluation Scale and a visual analogue scale. RESULTS The mean visual analogue scale score was significantly better for flap repairs than for graft repairs. In addition, 100% of flaps had an acceptable overall cosmetic appearance on the basis of the Hollander Wound Evaluation Scale, compared with only 75% of skin grafts. CONCLUSIONS For defects on the nose where flap and graft repair may both be technically possible, a flap may be more likely to result in superior cosmetic outcome.

Background There is concern that the immunologic tumor malignant melanoma (MM) may have worse outcomes in immunosuppressed hosts than in the general population. Objective We sought to describe outcomes of MM in immunosuppressed solid organ transplant recipients and compare them with the general population. Methods We conducted a retrospective review of medical charts and pathology slides of cases of MM and solid organ transplantation between 1978 and 2007, with comparison of outcomes. Results In all, 48 MMs were identified in 43 transplant recipients. No patient with MM before transplant receipt had melanoma recurrence, subsequent metastasis, or death caused by melanoma. Of patients with MM diagnosed after transplantation, metastases developed in 3 patients, and two patients died of melanoma. Limitations Retrospective review and low number of cases are limitations. Conclusions Outcomes of MM in immunosuppressed transplant recipients appeared similar to those in prognostically matched nonimmunosuppressed hosts. The small number of cases limited statistical comparisons.

BACKGROUNDSirolimus, a TOR (target of rapamycin)-binding immunosuppressant, has been associated with wound healing complications; however, its effects have not been documented in dermatologic surgery.OBJECTIVEThe objective was to determine the effect of sirolimus on wound healing in dermatologic sur

Sunscreen use is a widely accepted method of primary prevention against skin cancer, sunburn, and photoaging. However, many people do not routinely apply sunscreen because they find application objectionable.To determine which types of sunscreen subjects are willing to use on more than one occasion.A split-face, randomized, blinded trial of commercially available sunscreens was performed among 139 community members in Rochester, Minnesota.Subjects were significantly more likely to indicate that they would use alcohol-based spray sunscreen again than two of the seven sunscreens assessed (P.05). This sunscreen was endorsed as being less greasy, less likely to leave a film, and less likely to leave them feeling hot and sweaty than at least two of the other sunscreens.Only a representative selection of commonly available sunscreens was tested.An alcohol-based spray formulation of sunscreen was rated more favorable. Recommendations to use alcohol-based spray sunscreens may increase patient compliance.

BACKGROUND Electrosurgery used during dermatologic surgical procedures can cause malfunction of pacemakers and implantable cardiac defibrillators (ICDs), producing problems with rhythm detection, proper function, or alteration of the device. Well-documented safety data on electrosurgery in patients with cardiac devices are limited. At Mayo Clinic in Rochester, Minnesota, the Pacemaker Clinic manages all patients with pacemakers and ICDs undergoing dermatologic surgery. The preoperative and postoperative evaluations provide a unique opportunity to evaluate the safety of dermatologic surgery with electrosurgery in such patients. OBJECTIVES The objective was to review the evaluation and management, by an experienced cardiology team, of patients with cardiac devices undergoing dermatologic surgery and to characterize perioperative complications. METHODS A retrospective chart review of all patients identified with pacemakers or ICDs undergoing Mohs micrographic or dermatologic excisional surgery with electrosurgery at Mayo Clinic 2001 through 2004 were identified. Data were abstracted to identify any possible complications. RESULTS The 173 patients with pacemakers and 13 with ICDs undergoing dermatologic surgery had no documented complications from electrosurgery. CONCLUSION The lack of complications associated with pacemakers and ICDs with electrosurgery is reassuring. The authors support published recommendations about techniques and precautions to optimize safety during electrosurgery in patients with cardiac devices. The care of patients with ICDs in particular requires special consideration.

Background. Solid-organ transplant recipients constitute a complex patient population that experiences numerous and aggressive skin cancers. Proactive, comprehensive, ongoing, and effective dermatologic care of these patients is a necessity. Objective. The objective of this study was to emphasize the need for organized dermatologic care for transplant recipients and to collect and present various proactive paradigms established in and designed for different practice settings to manage organ transplant recipients at high risk for skin cancer. Methods. Information about practice setting, patient demographics, and the care model used was obtained through questionnaires sent to a selection of 12 physicians known to care for transplant recipients in various practice settings. Results. All 12 physicians completed the questionnaire. The organized dermatologic care of transplant recipients occurs in three basic clinic settings: multidisciplinary transplant clinics, designated dermatology transplant subspecialty clinics, and integration of transplant recipient care within existing dermatology clinics. Conclusions. Various practice settings offer both advantages and disadvantages in providing preventive and therapeutic care of organ transplant recipients at risk for skin cancer. Regardless of the clinic design used, an organized and firmly established clinic model to allow proactive and ongoing care for these patients is important for education, prevention, and early intervention.

Background. Cutaneous leiomyomas are benign tumors that can be exquisitely painful. Symptomatic lesions often necessitate treatment, but many options are inadequate or create substantial morbidity. Without a definitive therapy of first choice, the search continues for alternative methods to alleviate discomfort in affected patients. Objective. To describe the use of CO2 laser ablation for the symptomatic treatment of a 73-year-old woman with multiple cutaneous leiomyomas in whom pharmacologic therapy was contraindicated and surgical excision was impractical. Methods. CO2 laser ablation of six symptomatic cutaneous leiomyomas was performed under local anesthesia. After initial success, all remaining symptomatic lesions were treated. Results. There was complete pain relief in the originally treated lesions 9 months postoperatively, and in all remaining treated lesions 3 months postoperatively. Conclusion. CO2 laser ablation may be an effective alternative treatment for symptomatic cutaneous leiomyomas.

Reported here is a 15-year-old with lesions demonstrating histologic features of targetoid hemosiderotic hemangioma (THH) developing after trauma to inflammatory lesions. These lesions pose as simulators of THH. Targetoid hemosiderotic hemangioma is a benign vascular lesion first described by Santa Cruz and Aaronburg. It classically presents as a single, small, red/brown, targetoid lesion on the trunk or extremities of a young or middle-aged individual. Histologically, it is characterized by ectatic vascular lumina in the papillary dermis lined by a single layer of endothelial cells with an epithelioid or "hobnail" appearance. In the deeper dermis, vascular spaces become slit-like and angulated, appearing to dissect through collagen bundles. A commonly proposed etiology of THH is trauma to a preexisting hemangioma. This case is remarkable for its unusual clinical presentation, histologic simulation of THH, and for its support for the theory that trauma can induce the histologic changes seen in THH.

A paucity of data exists concerning the utilization of in-patient dermatologic consultations. Previous studies on this subject have indicated a knowledge deficit of primary care providers with regard to common dermatoses, prompting a need for more effective teaching mechanisms in this area.To identify dermatologic conditions in the in-patient setting that are frequently misdiagnosed by non-dermatologists in order to improve future patient care and cost reduction through physician education.Retrospective chart review of 271 consecutive dermatologic consultations from primary ward teams between January 20, 1998, and May 19, 1999.Non-dermatology in-patient services at a Midwestern state-supported university hospital system in the U.S.Patients hospitalized on non-dermatology wards with skin problems prompting a formal dermatologic consultation.None.Prevalence of dermatologic conditions that are most frequently misdiagnosed on non-dermatology in-patient services.Seventy-six percent of the dermatologic consults were requested by Internal Medicine, Surgery, and Psychiatry departments. Common skin conditions accounted for a large majority of dermatologic consultations including: dermatitis (21.0%) and drug eruption (10.0%). The primary ward team submitted a correct dermatologic diagnosis in only 23.9 percent of cases. Dermatology consultation resulted in a change in or addition to treatment in 77 percent of patients.Our results suggest that common skin conditions account for a large majority of dermatologic consultations in a University hospital setting. Modern hospital ward teams continue to struggle with accurately recognizing and appropriately managing common skin problems resulting in inappropriate treatment, wasted resources, and prolonged hospitalization. Increasing medical student and house staff knowledge and experience in the diagnosis and management of common skin disorders could help address this problem.

Context A paucity of data exists concerning the utilization of in-patient dermatologic consultations. Previous studies on this subject have indicated a knowledge deficit of primary care providers with regard to common dermatoses, prompting a need for more effective teaching mechanisms in this area. Objective To identify dermatologic conditions in the in-patient setting that are frequently misdiagnosed by non-dermatologists in order to improve future patient care and cost reduction through physician education. Design Retrospective chart review of 271 consecutive dermatologic consultations from primary ward teams between January 20, 1998, and May 19, 1999. Setting Non-dermatology in-patient services at a Midwestern state-supported university hospital system in the U.S. Patients Patients hospitalized on non-dermatology wards with skin problems prompting a formal dermatologic consultation. Interventions None. Main outcome measure Prevalence of dermatologic conditions that are most frequently misdiagnosed on non-dermatology in-patient services. Results Seventy-six percent of the dermatologic consults were requested by Internal Medicine, Surgery, and Psychiatry departments. Common skin conditions accounted for a large majority of dermatologic consultations including: dermatitis (21.0%) and drug eruption (10.0%). The primary ward team submitted a correct dermatologic diagnosis in only 23.9 percent of cases. Dermatology consultation resulted in a change in or addition to treatment in 77 percent of patients. Conclusions Our results suggest that common skin conditions account for a large majority of dermatologic consultations in a University hospital setting. Modern hospital ward teams continue to struggle with accurately recognizing and appropriately managing common skin problems resulting in inappropriate treatment, wasted resources, and prolonged hospitalization. Increasing medical student and house staff knowledge and experience in the diagnosis and management of common skin disorders could help address this problem.

Sirolimus, a TOR (target of rapamycin)-binding immunosuppressant, has been associated with wound healing complications; however, its effects have not been documented in dermatologic surgery.The objective was to determine the effect of sirolimus on wound healing in dermatologic surgery.Databases at Mayo Clinic were queried for organ transplant recipients undergoing dermatologic surgery. Medical records were reviewed retrospectively, and telephone interviews were conducted. Patients receiving sirolimus were compared with patients not receiving sirolimus.Postoperative infections occurred in 19.2% of the sirolimus group (n=26) and 5.4% of the controls (n=37; p=.11; odds ratio [OR], 4.2; 95% confidence interval [CI], 0.7-23.4). The incidence of wound dehiscence was greater in the sirolimus group (7.7% vs. 0%; p=.17; OR, 7.7; 95% CI, 0.4-166.3).No significantly increased risk of wound complications was found in organ transplant recipients receiving sirolimus while undergoing dermatologic surgery. However, this study was retrospective and had a small sample size. A larger study is necessary for corroboration.

Objective To determine whether an intensive educational program focused on the risk of skin cancer in organ transplant recipients, a population at high risk for development of skin cancer because of immunosuppression, produced measurable improvement in patient knowledge and sun-protective behavior. Design Patients were randomly assigned to receive standard episode-of-care–based education or intensive repetitive written education about skin cancer after organ transplantation. Preintervention knowledge was assessed and documented through a self-administered educational assessment tool. Retention of knowledge and the effect on sun-protective behavior were assessed with a follow-up questionnaire at 3 and 10 months. Setting Transplant center of an academic medical center. Patients Two hundred two patients presenting for transplant dermatologic consultation. Intervention Randomized intensive, repetitive written educational reinforcement. Main Outcome Measures Retention of knowledge and the effect on sun-protective behavior were assessed with a follow-up questionnaire at 3 and 10 months. Results Both intervention groups had similarly high baseline and 3- and 10-month scores on the knowledge portion of the surveys, and they had similar scores on the behavioral assessment portion of the surveys at baseline. Subjects receiving intensive education scored significantly better on the behavioral assessment at 3 and 10 months, although an improvement in knowledge was not documented. Conclusions This cohort of transplant recipients was well educated about skin cancer prevention before educational intervention and retained this knowledge. Patients who received the intensive educational intervention were significantly more compliant with recommendations for sun-protective behavior than those who received standard education, although differences in knowledge were not apparent. Lack of time and hassle were the most commonly cited barriers to behavioral compliance with sun protection.

Objective To determine if healing of punch biopsy wounds by second intention is equivalent to healing with primary closure. Design Prospective, randomized, method comparison equivalence study. Setting Tertiary academic medical center. Participants Study volunteers were recruited from the general population and enrolled between January 7, 2002, and August 20, 2002. Patients with immunodeficiency, peripheral vascular disease, or history of keloid formation and those receiving anticoagulation therapy or systemic corticosteroids were excluded. Intervention Study volunteers had two 4-mm or two 8-mm punch biopsies performed on the upper outer arms, midlateral aspect of the thighs, or upper back. One biopsy site was closed with interrupted 4-0 nylon suture, and the contralateral biopsy site was allowed to heal by second intention. Main Outcome Measures At 9 months, scar appearance was evaluated blindly and independently by 3 physicians using a visual analog scale (0 indicating poor and 100 indicating best). Results Seventy-seven of 82 enrolled volunteers completed the study. Mean (SD) visual analog scale score was 57.1 (19.5) for biopsy sites allowed to heal by second intention and 58.9 (19.7) for biopsy sites that healed with primary closure. The median surface area of the biopsy scars at 9 months was 32 mm 2 for second intention and 33 mm 2 for primary closure. For the 8-mm biopsies, the volunteers preferred the appearance of the sites that healed with primary closure; however, for the 4-mm biopsies, volunteers had no significant preference for either biopsy method. Costs were lower for second intention, and complications were equivalent. Conclusions Punch biopsy sites allowed to heal by second intention appear at least as good as biopsy sites closed primarily with suture. Although volunteers preferred suturing at larger biopsy sites, elimination of suturing of punch biopsy wounds would result in personnel efficiency and economic savings for both patients and medical institutions.

Background Solid organ transplant recipients are at increased risk for posttransplant neoplasms. Objective Our purpose was to determine whether various diseases causing end-organ failure are associated with different degrees of risk of skin cancer development after transplantation. Methods The Organ Procurement and Transplantation Network/United Network for Organ Sharing Transplant Tumor Registry was searched for the incidence of skin cancer among kidney, liver, and heart transplant recipients in the United States between 1996 and 2001. Multivariate analysis was used to determine the association between disease diagnosis and posttransplant skin cancer. Results Transplant recipients with specific pretransplant diseases, such as polycystic kidney disease and cholestatic liver disease, were at increased risk for skin cancer. Patients with diabetes mellitus had a lower incidence of skin cancer after kidney transplantation. Limitations The study had only a brief follow-up period, indirect assessment of photodamage, and possible underreporting. Conclusion Transplant recipients with a history of certain diseases warrant intensive skin cancer surveillance and strict sun-protective practices.

Lentigo maligna melanoma is a melanoma in situ on sun-damaged skin. It is a variably brown-pigmented flat patch on the head or neck of elderly patients. Its growth is generally slow, but it can become an invasive form of melanoma. Multiple reported treatment options are reviewed. Wide-margin Mohs micrographic surgery with peripheral permanent pathologic confirmation of a clear margin is recommended as treatment of choice.

Background. In-transit metastases from cutaneous squamous cell carcinoma (SCC) may occur in organ transplant recipients and may indicate aggressive disease and poor prognosis. Objective. The objective of this study was to describe in-transit metastases from cutaneous SCC and to identify factors associated with this phenomenon in a series of 21 patients. We also attempted to evaluate outcome with respect to status as an organ transplant recipient or nonorgan transplant recipient. Methods. A multicenter case series of patients was reviewed; factors included clinical presentation, management, and outcome. Results. Twenty-one patients, 15 organ transplant recipients, and 6 nontransplant recipients with in-transit metastases were reviewed. In-transit metastases presented most commonly as discrete, dermal papules distinct from but in the vicinity of the primary tumor site. Histologic differentiation was variable. At a mean follow up of 24 months, 33% the transplant patients had no evidence of disease compared with 80% of nontransplant patients. Thirty-three percent were dead from disease and 33% were alive with nodal or distant metastases. In contrast, 80% of nonimmunosuppressed patients had no evidence of disease and none had died at mean follow-up of 24 months. Conclusion. In-transit metastasis from cutaneous SCC is a unique presentation of metastatic SCC, more commonly described in organ transplant recipients, and is associated with poor prognosis in that group. This description represents the largest experience with in-transit metastases from cutaneous SCC in the literature.

Objective To determine malignant melanoma cause-specific and overall survival among patients with melanoma diagnosed after organ transplantation compared with a national sample with malignant melanoma. Design Retrospective review. Setting Mayo Clinic sites. Patients Immunosuppressed organ transplant recipients with malignant melanoma identified from surgical and medical databases at Mayo Clinic (1978-2007), the Organ Procurement and Transplantation Network/United Network for Organ Sharing database (1999-2006), and the Israel Penn International Transplant Tumor Registry (1967-2007). Main Outcome Measures Prognostic analyses by Breslow thickness and Clark level of overall and melanoma cause-specific survival. Expected survival rates were estimated by applying the age-, sex-, and calendar year –specific survival rates of patients with malignant melanoma cases reported in the Surveillance, Epidemiology, and End Results Program to the study cohort. Results Malignant melanoma was diagnosed in 638 patients (724 cases) after transplantation. Breslow thickness was available for 123 patients; Clark level, for 175. Three-year overall survival rates for patients stratified by Breslow thickness ( ≤ 0.75, 0.76-1.50, 1.51-3.00, and >3.00 mm) were 88.2%, 80.8%, 51.2%, and 55.3%, respectively, and 3-year cause-specific survival rates (95% confidence intervals) were 97.8% (93.7%-100%), 89.4% (76.5%-100%), 73.2% (53.2%-100%), and 73.9% (56.4%-96.6%), respectively. Three-year cause-specific survival rates (95% confidence intervals) for patients stratified by Clark level (I-IV) were 100%, 97.4% (92.4%-100%), 82.8% (65.3%-100%), and 65.8% (51.8%-83.7%), respectively. For patients with Breslow thickness of 1.51 to 3.00 mm and Clark level III or IV, the cause-specific survival rate in the study sample was significantly different from the expected estimates for patients with the same Breslow thickness or Clark level. Conclusions Compared with the expected survival rates derived from malignant melanoma cases reported in the Surveillance, Epidemiology, and End Results Program, immunosuppressed organ transplant recipients with thicker melanomas (ie, with a Clark level of III or IV or a Breslow thickness of 1.51 to 3.00 mm) had a significantly poorer malignant melanoma cause-specific survival rate. The overall survival rate was worse among patients with a prior history of transplantation, regardless of Breslow thickness or Clark level.

ContextThe incidence of nonmelanoma skin cancer is increasing rapidly among elderly persons, but little is known about its incidence in the population younger than 40 years.ObjectivesTo estimate the sex- and age-specific incidences of basal cell carcinoma and squamous cell carcinoma in persons younger than 40 years in Olmsted County, Minnesota, and to evaluate change in incidence over time; to describe the clinical presentation, rate of recurrence and metastasis, and histologic characteristics of these tumors in this population-based sample.DesignPopulation-based retrospective incidence case review.SettingResidents of Olmsted County, Minnesota, a population with comprehensive medical records captured through the Rochester Epidemiology Project.ParticipantsPatients younger than 40 years with basal cell carcinoma or squamous cell carcinoma diagnosed between 1976 and 2003.Main Outcome MeasuresIncident basal cell carcinomas and squamous cell carcinomas and change in incidence of these tumors over time.ResultsDuring the study period, 451 incident basal cell carcinomas were diagnosed in 417 patients and 70 incident squamous cell carcinomas were diagnosed in 68 patients. Of these tumors, 328 were histologically confirmed basal cell carcinomas and 51 were histologically confirmed squamous cell carcinomas. Overall, the age-adjusted incidence of basal cell carcinoma per 100 000 persons was 25.9 (95% confidence interval [CI], 22.6-29.2) for women and 20.9 (95% CI, 17.8-23.9) for men. The incidence of basal cell carcinoma increased significantly during the study period among women (P