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Competing Interests: Conflicts of interest None disclosed.

Importance: There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs)., Objective: To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs., Evidence Review: Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses., Findings: The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC., Conclusions and Relevance: Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer., (© 2019 Steunstichting ESOT.)

Importance: Despite receiving dermatologic care, many patients with or without a history of skin cancer either do not use sun protection or fail to use it in an effective manner., Objective: To examine the association of a brief dermatologist-delivered intervention vs usual care with patient satisfaction and sun protection behavior., Design, Setting, and Participants: A longitudinal controlled cohort study among adults receiving dermatology care was conducted from April 25 to November 6, 2017, at 2 dermatologic clinic sites within a Northeastern health care system to compare outcomes associated with the intervention with that of usual care on 1- and 3-month patient outcomes. The sample consisted primarily of non-Hispanic white patients aged 21 to 65 years. Participants were assigned to the intervention group (n = 77) or the control group (n = 82) based on the site location of their dermatologists., Interventions: The intervention (<3 minutes) was delivered by dermatologists during a skin examination or the suturing phase of skin cancer surgery. The intervention consisted of 6 components targeting sun risk and protective behaviors., Main Outcomes and Measures: First, patient's satisfaction with the dermatologist's communication was assessed. Second, the association of the intervention with changing sun protection behavior of the patient was examined., Results: Patients in the intervention group (46 women and 31 men; mean [SD] age, 52.4 [9.6] years) rated dermatologist-patient communication more positive compared with patients in the control group (59 women and 23 men; mean [SD] age, 51.4 [11.3 years]). Eighteen percent (14 of 77) of patients in the intervention group reported 1 or more sunburns 1 month after the intervention compared with 35% (29 of 82) of patients in the control group (P = .01). No differences in report of sunburns were seen at the 3-month follow-up. Patients in the intervention group reported increased use of sunscreen across 3 months (face: intervention, increased 12% and controls, decreased 4%; P = .001; body: intervention, increased 12% and controls, decreased 1%; P = .02; reapplication: intervention, increased 15% and controls, remained stable; P = .002)., Conclusions and Relevance: The intervention was delivered by dermatologists after minimal standardized training and resulted in a higher level of satisfaction with dermatologist-patient communication and improved sun protection behavior among patients across several months.

Background: When addressing skin malignancies of the periorbita, it is important to limit the excision of healthy tissue and preserve normal anatomic features while minimizing complications., Objective: The aim of this study was to identify perioperative risk factors associated with postoperative complications in a single-surgeon cohort., Methods: This was a retrospective review of consecutive patients who underwent periorbital Mohs reconstruction by a single surgeon at a teaching institution from 2008 to 2012. Demographics, patient and tumor characteristics, reconstructive technique, and postoperative complications were reviewed. Multivariate logistic regression was performed to identify perioperative risk factors associated with postoperative complications., Results: A total of 135 patients met the inclusion criteria. Local tissue rearrangement was performed for 74% of reconstructions, followed by full-thickness skin graft (FTSG) (20%) and cheek rotational flap (6%). Complications occurred in 23% of reconstructions, and 19% of complications required secondary surgery. Two variables were significantly associated with primary complications (p < .05): FTSG (p = .0017) and lid graft donor site (p = .0006). Reconstruction of a multisubunit defect trended toward a significant association with complications (p = .1005)., Conclusion: Our results indicate that FTSG and lid graft, in particular, result in a higher overall rate of complications when controlling for defect size.

Background: Areas of dense inflammation are commonly removed during Mohs micrographic surgery for basal cell carcinoma because of the concern that they may mask areas of tumor., Objective: Our purpose was to determine whether inflammation masks tumor during Mohs surgery for primary basal cell carcinoma., Methods: Twenty-five consecutive cases of primary basal cell carcinoma with areas of dense inflammation encountered during Mohs surgery were sectioned and stained with hematoxylin and eosin and Ber-EP4., Results: In no cases did the dense inflammation mask residual tumor., Conclusion: Dense inflammation does not mask primary basal cell carcinoma during Mohs surgery and should be carefully evaluated before additional surgery is performed.

The nose occupies an important feature of a person's central face. The size, shape, and proportions of the various characteristics of the face provide a visual basis suggesting the character of the person. Scars, asymmetries, and any abnormalities of the central face are easily recognizable and noted by even a casual observer. Over the centuries, therefore, much attention has been paid to reconstruction of facial and nasal abnormalities of both acquired and congenital etiologies. The purpose of this article is to address the reconstruction of smaller defects of the nose, encompassing surface areas of 1.5 to 2 centimeters.

Trichogenic tumors are neoplasms of the hair germ cell that usually exhibit benign behavior. We describe a case of a large invasive trichoblastoma requiring Mohs micrographic surgery for its removal. Immunohistochemical studies performed demonstrate overlapping features of this trichogenic tumor with basal cell carcinoma.

Background: Skin cancer is the most common malignancy occurring after kidney transplantation., Objective: Our purpose was to identify the skin problems of kidney transplant recipients, the extent of their awareness of skin cancer, and interest in skin cancer screenings., Methods: One hundred twenty-two patients were administered an oral questionnaire during regular follow-up at a renal transplant clinic., Results: The average time from transplantation was 3.1 years. Thirty-nine percent of patients reported skin problems, including warts, fungal infection, and skin cancer. Forty-one percent of patients were unable to recall specific skin cancer education, and 52% expressed an interest in skin cancer screening. Twenty-seven percent of patients had seen a dermatologist since their transplant, but only 14% were followed up regularly by a dermatologist., Conclusion: We believe the need for continuing skin cancer education and early detection and treatment of skin lesions establishes an important role for the dermatologist on the transplant recipient's health care team.

During the normal development of skin, pluripotential cells give rise to keratinocytes, sebaceous glands, hair follicles, apocrine glands, and eccrine glands. In epidermal nevi, these components emerge in an abnormal mixture within a circumscribed site. Many authors have categorized epidermal nevi based on their predominant component; however, there is often notable overlap that occurs within a single area or within contiguous areas. We report a verrucous epidermal nevus contiguous to a nevus sebaceus of Jadassohn. The categories of epidermal nevi are somewhat artificial. Our case supports the view that epidermal nevi have a spectrum of manifestations, including verrucous epidermal nevi and nevus sebaceus of Jadassohn.

Background: Squamous cell carcinoma (SCC) may present with a history of rapid growth. Although multiple subtypes have been described regarding histologic characteristics and etiology, the subset of rapidly growing squamous cell carcinomas (RGSCC) has not been described., Objective: To evaluate and describe the clinical and histologic characteristics of squamous cell carcinomas that grow rapidly., Methods: Recorded clinical data and biopsies of 26 lesions with a history of rapid growth and histologically diagnosed as SCC were reviewed., Results: Rapidly growing SCC occurred most commonly on the head and neck, followed by hands and extremities, and had an average duration of 7 weeks before diagnosis. The average size of the lesions was 1.29 cm and nearly 20% occurred in immunosuppressed patients., Conclusions: Some SCCs may grow rapidly. The reason for the rapid growth is not clear and several hypotheses are discussed including immunosuppression and viral etiology. These lesions should be treated aggressively as their behaviour and prognosis are not yet well described.

Background: The simultaneous occurrence of Sweet's syndrome (SS) and erythema nodosum (EN) in 1 patient is rare. Our review of the literature revealed only 11 biopsy-proved cases in which the 2 reactive dermatoses occurred together. None were associated with an underlying malignant neoplasm., Observations: We report a biopsy-proved case of SS and EN occurring simultaneously in a patient with an underlying malignant neoplasm (specifically, acute myelogenous leukemia). We also report another biopsy-proved case of SS and EN occurring simultaneously in a patient with underlying Crohn's disease., Conclusions: The simultaneous occurrence of SS and EN in 1 patient is rarely reported. Both disorders are reactive dermatoses that share many overlapping features. Although individually distinctive, SS and EN are also part of a growing continuum of reactive dermatoses. Our expanded understanding of the similarities and simultaneous manifestation of SS and EN may help us in the future to identify a common underlying mechanism of pathogenesis.

Background: Dermatoscopy (DS) has been used primarily to evaluate pigmented skin lesions. Little information is available on DS findings of basal cell carcinoma (BCC). Dermatoscopy is a noninvasive technique that allows visualization of cutaneous features from the skin surface to the papillary dermis. Basal cell carcinoma, the most common cutaneous malignancy, is traditionally diagnosed clinically and confirmed with biopsy., Objective: To determine the dermatoscopic features of nonpigmented basal cell carcinomas., Methods: The dermatoscopic findings of 27 lesions that clinically were suspicious for BCC were analyzed., Results: Of these 27 clinically suspect lesions, the biopsies revealed BCC in 20 specimens and squamous cell carcinoma (SCC) in two specimens. Twenty of these 22 specimens had dermatoscopic findings of BCC: diffusely distributed, branching blood vessels, asymmetric, and narrow blood vessels distributed deeper in the dermis, or a milky-red corona with superficial wide blood vessels. One nodular BCC in our study showed no distinct findings., Conclusions: Many BCCs have characteristic DS findings; however, dermatoscopic examination of some tumours will not demonstrate any known characteristic findings. As such, the DS criteria we propose for BCC are best utilized as an adjunctive study of clinical impressions. Biopsy remains the definitive diagnostic tool.

Background: There have been nearly 70 different histologic subtypes of basal cell carcinoma (BCC) described. Some of the subtypes have been shown to have clinical relevance. The degree to which one type may merge to another, within the same tumor mass, has been poorly studied., Objective: To determine if BCCs maintain biopsy histology throughout the entire architecture of the tumor., Method: Tumors were evaluated with a prospective histologic analysis of all primary BCCs using the Mohs "removal in layers" technique. All BCCs that required more than a single Mohs stage to clear were included in analysis., Results: One hundred forty-nine tumors were examined. Fourteen of these were of mixed histologic subtype on biopsy and were not included in the analysis. Six biopsy specimens were inadequate to make a subtype diagnosis and were excluded from calculation. Of the remaining 129 tumors 59% maintained their biopsy diagnosis at first Mohs stage, and 49% at the second Mohs stage. Infiltrative tumors were the most likely to maintain their histologic subtype classification. Of the tumors that showed nodular BCC on biopsy, 13% were infiltrative or micronodular at first Mohs stage., Conclusion: While many BCCs demonstrate a single histological subtype, roughly 40% change in their microscopic appearance at the subclinical extension. This finding has the potential to alter therapy.

Cutaneous metastatic disease may be evident in a variety of forms and locations. Anatomically, it may on occasion be confined as localized limb metastases. We report on two patients with localized limb metastases, one from melanoma and the other from Merkel cell carcinoma. Patients with localized limb metastasis have a poor prognosis; however, treatment options not available for generalized cutaneous metastatic disease, such as amputation or isolated limb perfusion with chemotherapeutic agents, can be at times be beneficially employed.

Background: Many patients who undergo cutaneous surgery take medications that can affect bleeding. The role of these medications in postoperative bleeding complications is unclear. Dermatologists have no clear guidelines regarding the need to discontinue these medications preoperatively., Objective: We designed a prospective study to evaluate the incidence of postoperative bleeding complications in patients taking aspirin, warfarin, or nonsteroidal antiinflammatory agents., Methods: Data were collected from patients undergoing Mohs surgery regarding preoperative medication history, operative bleeding, and postoperative bleeding. Frequency of postoperative bleeding complications was then evaluated., Results: There was no statistically significant difference in postoperative bleeding complications between patients on aspirin, warfarin, or nonsteroidal antiinflammatory agents, when compared with controls., Conclusion: It may not be necessary to discontinue aspirin, warfarin, or nonsteroidal antiinflammatory agents in patients undergoing many common dermatologic surgical procedures, such as Mohs surgery.

Microcystic adnexal carcinoma is an aggressive, locally destructive cutaneous neoplasm with a high rate of recurrence. This tumor is often misdiagnosed clinically and histologically. It usually occurs in middle-aged to older adults. We describe a 44-year-old man with a large microcystic adnexal carcinoma that was present for more than 20 years. The tumor invaded the perichondrium, muscle, nerve, and blood vessel adventitia. A review of the literature suggests that these tumors are often histologically misdiagnosed because the biopsy specimens may be too small to reveal all the characteristic histologic features. The clinical presence of marked induration, a smooth surface, and, possibly, sensory changes should alert the clinician to the possibility of this neoplasm. The initial biopsy specimen must be large enough to demonstrate the identifying histologic features. Mohs surgery is currently the treatment of choice for microcystic adnexal carcinoma, as it often spreads far beyond clinically evident tumor.