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Although current guidelines recommend a 5 mm surgical margin for the excision of melanoma in situ (MIS), increasing evidence has shown this may be suboptimal to achieve tumor clearance. To evaluate margins required for optimal cure rates with excision of MIS on the head and neck and investigate tumor and/or patient factors in those requiring >5 mm margins to achieve tumor clearance. A retrospective chart review was performed on 846 (807 primary and 39 recurrent) MIS cases on the head and neck treated in the authors' dermatologic surgery department over a 126-month (10.5 year) period. Sixty-two percent were cleared with 5 mm margins. A total of 15 mm margins were required to achieve a 97% clearance rate. Difference in clearance rate between margin thresholds was significant (P <.001). Tumor location on the cheek and larger preoperative size correlated with requiring >5 mm margins to achieve tumor clearance (P =.006 and P =.001, respectively). This is a single-center retrospective study which relies on accurate documentation of clinical data. This study demonstrates that MIS on the head and neck often requires margins >5 mm margins to achieve tumor clearance. When Mohs micrographic surgery is not possible, excision margins of ≥10 mm are likely necessary for head and neck tumors. [ABSTRACT FROM AUTHOR]

Proliferating pilar tumors (PPTs) are rare cutaneous neoplasms arising from hair follicles that have both malignant and metastatic potential. To present a systematic review of the epidemiology, clinical characteristics, and treatment and outcome data on PPTs. Using the OVID platform, MEDLINE and Embase were searched from inception until May 26, 2022. All studies that provided original data on PPTs in English were included. References of these studies were also cross-checked to identify any additional relevant articles. Oxford's Levels of Evidence-Based Medicine was used for quality assessment. A total of 114 articles, providing data on 361 cases of PPTs, were included in our synthesis. Every study included was either a case series or case report. The mean age at diagnosis was 61.7. Most patients in the synthesis were female (71%), and the majority of cases occurred on the scalp (73.1%). The presence or absence of cytological atypia was only reported in one-third of the cases; 36.8% of cases were classified as malignant and 7.5% metastasized. Although no lesions treated with Mohs micrographic surgery required adjuvant radiation and only one reported recurrence occurred after Mohs surgery, there is insufficient data to make conclusions on a superior treatment modality. All studies in this review were either case reports or case series. Our study supports the notion that PPTs occur most commonly on the scalp of elderly female patients. Moreover, our findings confirm that PPT is capable of demonstrating aggressive biology and metastasis. Given the lack of uniformity in histologic description, pathologists should be encouraged to comment on the presence and degree of cytological atypia when reporting cases of rare neoplasms such as the PPT. Greater consensus on diagnosis and classification as well as more robust data is needed regarding optimal management. [ABSTRACT FROM AUTHOR]

Background: There is limited literature on the long-term outcomes and prognostic factors of high-risk cutaneous squamous cell carcinomas (hrSCC) treated with Mohs micrographic surgery (MMS).Objective: To determine the rates of local recurrence, metastatic disease, and disease-specific death in hrSCCs treated with MMS and patient or tumor factors associated with poor outcomes.Methods: Single-institution, retrospective cohort analysis of hrSCC treated with MMS alone and MMS with adjuvant therapy.Results: A total of 882 cases of hrSCC treated with MMS were identified, of which 842 were treated with MMS alone, with a median follow-up time of 2.4 years. The rate of local recurrence was 2.5%, of metastatic disease was 1.9%, and of disease-specific death was 0.57%. Perineural invasion, poor differentiation, and immunosuppression were significantly associated with poor outcomes. In propensity score-matched case patients treated with adjuvant therapy and control patients treated with Mohs alone, there was no significant difference in progression-free survival, but matching was imperfect.Limitations: Single-institution, retrospective review.Conclusions: MMS remains an effective treatment for hrSCC. Current SCC staging systems may be limited by inconsistent inclusion of poor differentiation. Immunosuppression, especially transplant, should be considered a high-risk clinical feature. Further study is needed on the effect of adjuvant treatment. [ABSTRACT FROM AUTHOR]

Cutaneous surgery has become critical to comprehensive dermatologic care, and dermatologists must therefore be equipped to manage the risks associated with surgical procedures. Complications may occur at any point along the continuum of care, and therefore assessing, managing, and preventing risk from beginning to end becomes essential. This review focuses on preventing surgical complications pre- and postoperatively as well as during the surgical procedure. [ABSTRACT FROM AUTHOR]

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety. [ABSTRACT FROM AUTHOR]

Background: Many studies have identified cardiovascular risk factors in patients with psoriasis. Some psoriasis therapies may increase cardiovascular disease (CVD) and others may decrease CVD. Objective: We reviewed the literature to define the impact of common psoriasis therapies on cardiovascular measures and outcomes. Results: Phototherapy has no major cardiovascular impact and may reduce levels of proinflammatory cytokines. Acitretin increases serum lipids and triglycerides, but has not been shown to increase cardiovascular risk. Cyclosporine A increases blood pressure, serum triglycerides, and total cholesterol. Methotrexate is associated with a decreased risk of CVD morbidity and mortality. Among the biologics, data for tumor necrosis factor inhibitors suggest an overall reduction in cardiovascular events. Most data on short-term ustekinumab use suggest no effect on major adverse cardiovascular events, however some authorities remain concerned. Nevertheless, ustekinumab use over a 4-year period shows a decrease in major adverse cardiovascular events when compared both with the general US population and with psoriatics in Great Britain. Limitations: Most studies lack the power and randomization of large clinical trials and long-term follow-up periods. In addition, the increased risk of CVD associated with psoriasis itself is a confounding factor. Conclusion: Some therapies for moderate to severe psoriasis, including methotrexate and tumor necrosis factor inhibitors, may reduce cardiovascular events in psoriatic patients. Ustekinumab appears to be neutral but there may be a long-term benefit. Appropriate patient counseling and selection and clinical follow-up are necessary to maximize safety with these agents. Further long-term study is necessary to quantify the benefits and risks associated with biologic therapies. [Copyright &y& Elsevier]

Port-wine stains (PWS) and morphea are distinct conditions that are easily recognized and diagnosed in pediatric patients. Rarely, early localized morphea may mimic an acquired PWS. We present 4 such cases, in two of which the initial clinical impression of acquired PWS was thought to be confirmed by histopathology. A diagnosis of morphea was made approximately 6 months to 3 years after the onset of the acquired PWS. Clinicians should be aware that an apparent acquired PWS may be an early manifestation of localized morphea and continue to monitor these lesions. [ABSTRACT FROM AUTHOR]

Background: It is projected that by the year 2050, close to 50% of the US population will comprise people with skin of color. Objective: We sought to assess whether future dermatologists will be prepared to treat patients with skin of color. Methods: An e-mail with a link to a brief 9-question survey was sent to 109 program directors and chief residents. Results: A total of 41 (37.6%) program directors and 63 (50.0%) chief residents completed the online survey. In all, 14.3% (P < .001) of chief residents and 14.6% (P < .001) of program directors recognized an expert at their institutions who conducted a skin of color clinic. In all, 25.4% (P < .001) of chief residents and 19.5% (P < .001) of program directors reported having lectures on skin of color from an acknowledged expert. In all, 30.2% (P < .001) of chief residents and 12.2% (P < .001) of program directors reported a specific rotation in which residents gained specific experience in treating patients with skin of color. In all, 52.4% (P = .70) of chief residents and 65.9% (P < .02) of program directors reported to have either lectures or didactic sessions focusing on diseases in skin of color incorporated into their curriculums. In all, 84.1% (P < .001) of chief residents and 90.2% (P < .001) of program directors reported having training programs in which residents gained experience treating patients with central centrifugal cicatricial alopecia. In all, 100% (P < .001) of both chief residents and program directors reported having training programs in which residents gained experience treating patients with keloids and melasma. Limitations: The limitations of this study included recall bias, an incomplete response rate, unsure respondents, and questions that may not have applied to certain programs. Conclusion: The results indicate a need for increased exposure, educational sessions, and overall training in diseases pertaining to skin of color in US dermatology residencies. [Copyright &y& Elsevier]