Search

Background: Few studies show how dermatologic surgeons manage problems with site identification., Objective: To estimate frequency and characterize management of skin cancer treated by surgery when the anatomic location of the tumor is in question., Methods: Nationwide, prospective, multisite cohort study., Results: Among 17,076 cases at 22 centers, 98 (0.60%) were lesions in question for which site identification was initially uncertain, with these more often in patients who were male, older, and biopsied more than 30 days ago. Surgeons employed on average 5.0 (95% CI: 4.61-5.39) additional techniques to confirm the site location, with common approaches including: re-checking available documentation (90 lesions, 92%); performing an expanded physical examination (89 lesions, 91%); and asking the patient to point using a mirror (61 lesions, 62%). In 15%, photographs were requested from the biopsying provider, and also in 15%, frozen section biopsies were obtained. In 10%, the referring physician was contacted. Eventually, surgeons succeeded in definitively identifying 82% (80 of 98) of initially uncertain sites, with the remaining 18% (18 of 98) postponed. Most postponed surgeries were at non-facial sites., Limitations: Sites were academic centers., Conclusions: When the anatomic location of the tumor is uncertain, dermatologic surgeons use multiple methods to identify the site, and sometimes cases are postponed., Competing Interests: Conflicts of interest Dr Bolotin reported serving as principal investigator on a clinical trial sponsored by Replimune outside the submitted work. Dr Cohen reported serving as a clinical investigator, consultant, or speaker or trainer for Accure, Allergan, Almirall/Athenex, Avuta, Biofrontera Bioscience, Biopelle, Brickell Biotech, Croma, Elta, Endo Pharmaceuticals, Ferndale, Galderma, InMode, IntraDerm, Lutronic, Merz, Novan, PCA, Pulse Biosciences, Raziel, Recros Medica, Revance, Revision, Sciton, and Sente outside the submitted work. Dr Council reported receiving personal fees from Sanofi-Genzyme Regeneron, AbbVie, and Castle Biosciences outside the submitted work. Dr Schmults reported serving as the National Comprehensive Cancer Network nonmelanoma panel chair, on the American Society for Dermatologic Surgery board of directors, and as International Society for Dermatologic and Esthetic Surgery secretary. Dr Xu serves as the National Comprehensive Cancer Network nonmelanoma panel member. Drs Ahmed, Campbell, Ibrahim, Kang, Aylward, Bari, Cherpelis, Condon, Farhang, Firoz, Garrett, Geronemus, Golda, Humphreys, Hurst, Jiang, Karia, Asadi, Kouba, MacFarlane, Maher, Miller, Moioli, Morrow, Neckman, Pearson, Peterson, Poblete-Lopez, Prather, Ranario, Rubin, Swanson, Urban, Xu, Pearlman, Yoo, Harikumar, Schaeffer, Iyengar, Poon, Cahn and Alam and authors Shi, Koza, Ma, Haq, Nadir, Yi, Dave, Hisham, Lin, Dirr, Bhatti, Helming, Jacobson, and Weil have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier Inc.)

Competing Interests: Conflicts of interest Dr Bolotin reported serving as principal investigator on a clinical trial sponsored by Replimune outside the submitted work. Dr Cohen reported serving as a clinical investigator, consultant, or speaker or trainer for Accure, Allergan, Almirall/Athenex, Avuta, Biofrontera Bioscience, Biopelle, Brickell Biotech, Croma, Elta, Endo Pharmaceuticals, Ferndale, Galderma, InMode, IntraDerm, Lutronic, Merz, Novan, PCA, Pulse Biosciences, Raziel, Recros Medica, Revance, Revision, Sciton, and Sente outside the submitted work. Dr Council reported receiving personal fees from Sanofi Genzyme Regeneron, AbbVie, and Castle Biosciences outside the submitted work. Dr Riley has served as an advisory board member for Novartis Pharmaceuticals. The other authors have no conflicts of interest to declare.

Competing Interests: Conflicts of interest None disclosed.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs., Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals., Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019., Exposures: Mohs surgery for nonmelanoma skin cancer., Main Outcomes and Measures: Reason for treatment selection., Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%])., Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Background: Limited information is available regarding real-world treatment patterns and their effectiveness and safety in patients with locally advanced basal cell carcinoma, including patients not typically represented in clinical trials. The purpose of the current study was to describe how clinicians diagnose and treat locally advanced basal cell carcinoma in the United States., Methods: This prospective, multicenter, observational registry study included patients with newly diagnosed, Hedgehog pathway inhibitor-naive locally advanced basal cell carcinoma without basal cell carcinoma nevus syndrome (n = 433) treated at 75 US academic and community practices, including dermatology, Mohs surgery, and medical oncology sites. The main outcomes of this study were treatment patterns and associated effectiveness and safety for patients with locally advanced basal cell carcinoma in real-world settings., Results: Determination of locally advanced basal cell carcinoma was mainly based on lesion size (79.6% of patients), histopathology (54.3%), extent of involvement (49.0%), and location (46.2%). Within 90 days of determination of locally advanced disease, 115 patients (26.6%) received vismodegib, 251 (58.0%) received surgery/other (non-vismodegib) treatment, and 67 (15.5%) had not yet received treatment (observation). Vismodegib-treated patients had a higher prevalence of high-risk clinical features predictive for locoregional recurrence than those with non-vismodegib treatment or observation. Clinical response rate was 85.1% with vismodegib and 94.9% with non-vismodegib treatment (primarily surgery). The most common adverse events with vismodegib were ageusia/dysgeusia, muscle spasms, alopecia, and weight loss. Rates of cutaneous squamous cell cancers were comparable between vismodegib and non-vismodegib treatment., Conclusions: This prospective observational study offers insight on real-world practice, treatment selection, and outcomes for a nationally representative sample of US patients with locally advanced basal cell carcinoma. For patients with lesions that were not amenable to surgery, vismodegib treatment was associated with effectiveness and safety that was consistent with that observed in clinical trials., Competing Interests: A. Sekulic has no conflict of interest to declare. S. Yoo has no conflict of interest to declare. R. Kudchadkar has served on advisory boards and received honoraria from Bristol Myers Squibb and has received grants/research funding from Merck. J. Guillen has no conflict of interest to declare. G. Rogers has no conflict of interest to declare. A.L.S. Chang has served as a clinical investigator for research studies funded by Roche/Genentech, Merck, Novartis, and Regeneron. S. Guenthner has served on advisory boards and received grants/research funding and honoraria from Genentech, Pfizer, AbbVie, Amgen, LEO Pharma, Lilly, Dermira, Sun Pharma, UCB, Vanda, and Janssen. B. Raskin has no conflict of interest to declare. K. Dawson, Y. Mun, L. Chu, and E. McKenna are employees of Genentech and hold stock/stock options in Roche/Genentech. M. Lacouture has received royalties from Legacy Healthcare Services, Apricity Health, Azitra, Deciphera, Galderma, Johnson & Johnson, NCODA, Novocure, Kyowa Kirin, Loxo, Merck Sharp & Dohme, Janssen, Menlo Therapeutics, Novartis, QED Therapeutics, F. Hoffmann-La Roche, Amgen, AstraZeneca, Genentech, Seagen, Lutris, Paxman Collers, OnQuality Pharmaceuticals, and Takeda Millennium and has received research funding from Veloce, US Biotest, Lutris, Paxman, and Novocure.

Because many patients with unresectable basal cell carcinoma (BCC) are aged ≥65 years, this study explores the efficacy and safety of vismodegib in these patients with locally advanced (la) or metastatic (m) basal cell carcinoma (BCC) in the ERIVANCE BCC trial and the expanded access study (EAS).We compared patients aged ≥65 years to patients aged <65 years taking vismodegib 150 mg/day, using descriptive statistics for response and safety. Patients aged ≥65 years (laBCC/mBCC) were enrolled in ERIVANCE BCC (33/14) and EAS (27/26). Investigator-assessed best overall response rate in patients ≥65 and <65 years was 46.7%/35.7% and 72.7%/52.6% (laBCC/mBCC), respectively, in ERIVANCE BCC and 45.8%/33.3% and 46.9%/28.6%, respectively, in EAS. These differences were not clinically meaningful. Safety was similar in both groups, although those aged ≥65 years had a higher percentage of grade 3-5 adverse events than those aged <65 years. Vismodegib demonstrated similar clinical activity and adverse events regardless of age.

Background: Aberrant activation of the Hedgehog (Hh) pathway is a key driver in the pathogenesis of basal cell carcinomas (BCCs), including patients with BCC nevus syndrome (BCCNS). It is unclear whether BCCs arising in patients with BCCNS respond differently to vismodegib than in patients without BCCNS. We examined the best overall response rate (BORR) and adverse events (AEs) of vismodegib in patients with advanced BCC (aBCC) with and without BCCNS., Methods: Patients were treated with vismodegib 150 mg/day in the ERIVANCE BCC trial (ClinicalTrials.gov number, NCT00833417) and the expanded access study (EAS; ClinicalTrials.gov number, NCT01160250). BCCNS diagnosis was based on medical history at the time of enrollment. Metastatic BCC response was evaluated using Response Evaluation Criteria In Solid Tumors, version 1.0 (RECIST v1.0) in both studies. Locally advanced BCC was evaluated by a novel composite end point in ERIVANCE BCC and by RECIST v1.0 in the EAS. Response assessments were performed every 8 weeks in ERIVANCE BCC and every 8-16 weeks in the EAS. Safety assessments (National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0) were performed monthly in both trials. Because of described differences in response assessment/schedule, patients with BCCNS were not pooled across trials. Analytic cohorts for BCCNS and sporadic aBCC were created within each trial for comparison using descriptive statistical methods., Results: Forty-one patients with BCCNS were included in the study: 22 from ERIVANCE BCC and 19 from the EAS. Investigator-assessed BORR in BCCNS groups ranged from 31 to 81 % in patients with locally advanced BCC (n = 33) and was 50 % in patients with metastatic BCC (n = 6). These results were comparable with the non-BCCNS groups. Incidence and severity of AEs were also comparable between the BCCNS and non-BCCNS groups. Amenorrhea was observed in both patient cohorts and was reversible in two patients who discontinued treatment., Conclusion: Vismodegib demonstrated comparable efficacy and safety against aBCC in patients with and without BCCNS.

Background: Guided imagery and music can reportedly reduce pain and anxiety during surgery, but no comparative study has been performed for cutaneous surgery to our knowledge., Objectives: We sought to determine whether short-contact recorded guided imagery or relaxing music could reduce patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures., Methods: Subjects were adults undergoing excisional surgery for basal and squamous cell carcinoma. Randomization was to guided imagery (n = 50), relaxing music (n = 54), or control group (n = 51). Primary outcomes were pain and anxiety measured using visual analog scale and 6-item short-form of the State-Trait Anxiety Inventory, respectively. Secondary outcomes were anxiety of surgeons measured by the 6-item short-form of the State-Trait Anxiety Inventory and physical stress of patients conveyed by vital signs, respectively., Results: There were no significant differences in subjects' pain, anxiety, blood pressure, and pulse rate across groups. In the recorded guided imagery and the relaxing music group, surgeon anxiety was significantly lower than in the control group., Limitations: Patients could not be blinded., Conclusion: Short-contact recorded guided imagery and relaxing music appear not to reduce patient pain and anxiety during excisional procedures under local anesthetic. However, surgeon anxiety may be reduced when patients are listening to such recordings., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Primary analysis from the pivotal ERIVANCE BCC study resulted in approval of vismodegib, a Hedgehog pathway inhibitor indicated for treatment of adults with metastatic or locally advanced basal cell carcinoma (BCC) that has recurred after surgery or for patients who are not candidates for surgery or radiation., Objective: An efficacy and safety analysis was conducted 12 months after primary analysis., Methods: This was a multinational, multicenter, nonrandomized, 2-cohort study in patients with measurable and histologically confirmed locally advanced or metastatic BCC taking oral vismodegib (150 mg/d). Primary outcome measure was objective response rate (complete and partial responses) assessed by independent review facility., Results: After 12 months of additional follow-up, median duration of exposure to vismodegib was 12.9 months. Objective response rate increased from 30.3% to 33.3% in patients with metastatic disease, and from 42.9% to 47.6% in patients with the locally advanced form. Median duration of response in patients with locally advanced BCC increased from 7.6 to 9.5 months. No new safety signals emerged with extended treatment duration., Limitations: Limitations include low prevalence of advanced BCC and challenges of designing a study with heterogenous manifestations., Conclusion: The 12-month update of the study confirms the efficacy and safety of vismodegib in management of advanced BCC., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Importance: Keratosis pilaris (KP) is a common skin disorder of follicular prominence and erythema that typically affects the proximal extremities, can be disfiguring, and is often resistant to treatment. Shorter-wavelength vascular lasers have been used to reduce the associated erythema but not the textural irregularity., Objective: To determine whether the longer-wavelength 810-nm diode laser may be effective for treatment of KP, particularly the associated skin roughness/bumpiness and textural irregularity., Design, Setting, and Participants: We performed a split-body, rater-blinded, parallel-group, balanced (1:1), placebo-controlled randomized clinical trial at a dermatology outpatient practice of an urban academic medical center from March 1 to October 1, 2011. We included all patients diagnosed as having KP on both arms and Fitzpatrick skin types I through III. Of the 26 patients who underwent screening, 23 met our enrollment criteria. Of these, 18 patients completed the study, 3 were lost to or unavailable for follow-up, and 2 withdrew owing to inflammatory hyperpigmentation after the laser treatment., Interventions: Patients were randomized to receive laser treatment on the right or left arm. Each patient received treatment with the 810-nm pulsed diode laser to the arm randomized to be the treatment site. Treatments were repeated twice, for a total of 3 treatment visits spaced 4 to 5 weeks apart., Main Outcomes and Measures: The primary outcome measure was the difference in disease severity score, including redness and roughness/bumpiness, with each graded on a scale of 0 (least severe) to 3 (most severe), between the treated and control sites. Two blinded dermatologists rated the sites at 12 weeks after the initial visit., Results: At follow-up, the median redness score reported by the 2 blinded raters for the treatment and control sides was 2.0 (interquartile range [IQR], 1-2; P = .11). The median roughness/bumpiness score was 1.0 (IQR, 1-2) for the treatment sides and 2.0 (IQR, 1-2) for the control sides, a difference of 1 (P = .004). The median overall score combining erythema and roughness/bumpiness was 3.0 (IQR, 2-4) for the treatment sides and 4.0 (IQR, 3-5) for the control sides, a difference of 1 (P = .005)., Conclusions and Relevance: Three treatments with the 810-nm diode laser may induce significant improvements in skin texture and roughness/bumpiness in KP patients with Fitzpatrick skin types I through III, but baseline erythema is not improved. Complete treatment of erythema and texture in KP may require diode laser treatment combined with other laser or medical modalities that address redness., Trial Registration: clinicaltrials.gov Identifier: NCT01281644.

Importance: Neocollagenesis can be achieved using a dermal rolling needle device, thereby reducing the appearance of acne scars., Objective: To determine the efficacy of a needling device for treatment of acne scars., Design, Setting, and Participants: We performed a single-center, rater-blinded, balanced (1:1), split-face, placebo-controlled, parallel-group randomized clinical trial at an urban academic institution. The study took place from November 30, 2009, through July 27, 2010. Twenty healthy adults (age range, 20-65 years) with acne scars on both sides of the face were enrolled. Fifteen individuals completed the study, and no enrolled participants were withdrawn for adverse effects., Interventions: For each participant, one side of the face was randomized for needling. Three needling treatments were performed at 2-week intervals., Main Outcomes and Measures: Two blinded dermatologists separately rated participants' acne scars based on standard digital photographs obtained at baseline and at the 3-month and 6-month follow-up visits on the quantitative global scarring grading system., Results: Mean scar scores were significantly lower in the treatment group compared with baseline at 6 months (mean difference, 3.4; 95% CI, 0.2-6.5; P = .03) and nominally but not significantly lower compared with baseline at 3 months (mean difference, 2.4; 95% CI, -0.01 to 4.8; P = .052). In the control group, mean scar scores did not vary significantly from baseline at 3 months (mean difference, 1.0; 95% CI, -1.4 to 3.4; P = .96) and at 6 months (mean difference, 0.4; 95% CI, -2.3 to 3.5; P > .99). The needling procedure was not particularly painful, with a mean pain rating of 1.08 of 10. Participants perceived a 41% mean improvement in overall scar appearance on the treated side. No adverse events were reported., Conclusions and Relevance: After 3 needling treatments, there was improvement in the appearance of acne scars over time compared with the control group, with minimal pain reported., Trial Registration: clinicaltrials.gov Identifier: NCT00974870.

Importance: Surgical training in dermatology residencies has increased, and there is growing interest in measuring resident competence more precisely. This study applies the use of the objective structured assessment of technical skills (OSATS) to measure competence in dermatologic surgery., Objective: To evaluate the utility of OSATS as a tool for measuring surgery skills during dermatology residency training., Design, Setting, and Participants: Multirater, blinded review and ratings of taped video recordings of elliptical excisions performed by senior dermatology residents applying for procedural or Mohs surgery fellowships., Main Outcomes and Measures: Ratings on a specific OSATS measure, including global rating scale and task checklist., Results: Twelve videos, representing approximately 20% of fellowship applicants during 2009-2010, were rated. Raters agreed on 272 of 288 subscore ratings (94.4%). Mean global ratings were 4 or 5 for all categories, except time and motion, which had a rating of 3. Task checklist ratings had a mean of 14.5 and a mode of 16 (perfect score), with eversion least often performed successfully. No association was found between a resident's scores and the number of surgical rotation months or between scores and the number of Mohs surgeons at the home institution., Conclusions and Relevance: Senior dermatology residents preparing for surgery fellowships are highly skilled in performing elliptical excisions and bilayered repairs. The OSATS appears useful and reliable for the evaluation of dermatologic surgery skills.

Importance: Excisional skin cancer surgery is a common procedure, with no formal consensus for mitigating the risk of wrong-site cutaneous surgery., Objective: To systematically consider the usefulness and feasibility of proposed methods for correct biopsy site identification in dermatology., Evidence Review: Survey study with a formal consensus process. Item development was via a literature review and expert interviews, followed by 2 stages of a Delphi process to develop consensus recommendations., Findings: In total, 2323 articles were reviewed in the literature search, with data extraction from 14. Twenty-five experts underwent 30-minute structured interviews, which were transcribed and coded. The resulting survey was composed of 42 proposed interventions by multiple stakeholders (biopsying physicians, operating physicians, nurses, ancillary staff, patients, caregivers, and family members) at 3 time points (day of biopsy, delay and consultation period, and day of definitive surgery). Two rounds of a Delphi process with 59 experts (25 academic and 34 private practice) scored the survey. Strong consensus was obtained on 14 behaviors, and moderate consensus was obtained on 21 other behaviors. In addition, a 2-state simultaneous algorithm was developed to model surgeon behavior on the day of definitive surgery based on surgeon and patient perceptions., Conclusions and Relevance: When definitive surgery is performed after the initial biopsy and by a different surgeon, procedures can be implemented at several time points to increase the likelihood of correct site identification. The specific circumstances of a case suggest which methods may be most appropriate and feasible, and some may be implemented. The risk of wrong-site cutaneous surgery can be reduced but not eliminated.

Importance: Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events., Objectives: To quantify adverse events associated with MMS and detect differences relevant to safety., Design, Setting, and Participants: Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times., Exposure: Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events., Results: Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events., Conclusions and Relevance: Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Background: Facial erythema is a common symptom that responds to vascular laser treatment, but there are few comparative studies., Objective: We sought to compare the effectiveness of microsecond 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with nonpurpuragenic 595-nm pulsed dye laser (PDL) for diffuse facial erythema., Methods: This was a split-face, double-blind randomized controlled trial. Bilateral cheeks received 4 treatments each at one month intervals with PDL or Nd:YAG. Spectrophotometer measurements, digital photographs, pain scores, and patient preferences were recorded., Results: Sixteen patients enrolled and 2 dropped out. Fourteen patients, all skin types I to III, 57% women, mean age 42 years, completed the study and were analyzed. Spectrophotometer readings changed after both PDL (8.9%) and Nd:YAG (2.5%), but varied by treatment type, with PDL reducing facial redness 6.4% more from baseline than Nd:YAG (P = .0199; 95% confidence interval -11.6 to -1.2). Pain varied (P = .0028), with Nd:YAG associated with less pain, at 3.07, than PDL at 3.87. Subjects rated redness as improved by 52% as a result of PDL, and 34% as a result of Nd:YAG (P = .031; 95% confidence interval -34.6 to -1.94). No serious adverse events were observed., Limitations: Lasers settings are not standardized across devices., Conclusion: Facial erythema is safely and effectively treated with PDL and Nd:YAG. Nonpupuragenic PDL may be more effective for lighter-skinned patients, but microsecond Nd:YAG may be less painful., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: There are few data to indicate whether the type of final wound defect is associated with the type of post-Mohs repair., Objective: To determine the methods of reconstruction that Mohs surgeons typically select and, secondarily, to assess the association between the method and the number of stages, tumor type, anatomic location, and patient and surgeon characteristics., Methods: Statistical analysis of procedure logs of 20 representative young to mid-career Mohs surgeons., Results: The number of stages associated with various repairs were different (analysis of variance, p < .001.). Linear repairs, associated with the fewest stages (1.5), were used most commonly (43-55% of defects). Primary repairs were used for 20.2% to 35.3% of defects of the nose, eyelids, ears, and lips. Local flaps were performed typically after two stages of Mohs surgery (range 1.98-2.06). Referral for repair and skin grafts were associated with cases with more stages (2.16 and 2.17 stages, respectively). Experienced surgeons were nominally more likely perform flaps than grafts. Regression analyses did not indicate any association between patient sex and closure type (p = .99) or practice location and closure type (p = .99)., Conclusions: Most post-Mohs closures are linear repairs, with more bilayered linear repairs more likely at certain anatomic sites and after a larger number of stages., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Approximately one in four patients undergoing dermatologic surgery takes an antithrombotic medication. When approaching the management of antithrombotic agents, procedural dermatologists must balance surgical outcomes, bleeding risks, and cardiovascular protection. Continuing antithrombotics during surgery increases the risk hemorrhage, but discontinuation of these agents may increase the risk of thrombotic events. Despite increasing evidence for continuation of antithrombotics during dermatologic surgery, few official guidelines exist, and clinicians have been slow to integrate new evidence into clinical practice. A study in 2007 reported that more than 40% of dermatologic surgeons sometimes discontinue warfarin for surgery., Objective: This article reviews antithrombotic agents in the United States and summarize perioperative management recommendations of antithrombotic agents in skin surgery., Materials and Methods: A review of the literature was performed focused on antithrombotic medications commercially available in the United States, including the two newest agents, dabigatran and rivaroxaban., Conclusion: Although there are concerns regarding bleeding, there are no reports of life-threatening hemorrhage from continued antithrombotic therapy in dermatologic surgery. Furthermore, potentially fatal cardiovascular events after cessation of medically indicated antithrombotic medications are increasingly recognized, leading to the growing acceptance that the risk of stopping most antithrombotics may outweigh the risks of bleeding incurred by continuing antithrombotic therapy., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Alterations in hedgehog signaling are implicated in the pathogenesis of basal-cell carcinoma. Although most basal-cell carcinomas are treated surgically, no effective therapy exists for locally advanced or metastatic basal-cell carcinoma. A phase 1 study of vismodegib (GDC-0449), a first-in-class, small-molecule inhibitor of the hedgehog pathway, showed a 58% response rate among patients with advanced basal-cell carcinoma., Methods: In this multicenter, international, two-cohort, nonrandomized study, we enrolled patients with metastatic basal-cell carcinoma and those with locally advanced basal-cell carcinoma who had inoperable disease or for whom surgery was inappropriate (because of multiple recurrences and a low likelihood of surgical cure, or substantial anticipated disfigurement). All patients received 150 mg of oral vismodegib daily. The primary end point was the independently assessed objective response rate; the primary hypotheses were that the response rate would be greater than 20% for patients with locally advanced basal-cell carcinoma and greater than 10% for those with metastatic basal-cell carcinoma., Results: In 33 patients with metastatic basal-cell carcinoma, the independently assessed response rate was 30% (95% confidence interval [CI], 16 to 48; P=0.001). In 63 patients with locally advanced basal-cell carcinoma, the independently assessed response rate was 43% (95% CI, 31 to 56; P<0.001), with complete responses in 13 patients (21%). The median duration of response was 7.6 months in both cohorts. Adverse events occurring in more than 30% of patients were muscle spasms, alopecia, dysgeusia (taste disturbance), weight loss, and fatigue. Serious adverse events were reported in 25% of patients; seven deaths due to adverse events were noted., Conclusions: Vismodegib is associated with tumor responses in patients with locally advanced or metastatic basal-cell carcinoma. (Funded by Genentech; Erivance BCC ClinicalTrials.gov number, NCT00833417.).

Background: There is little information regarding commonalities, differences, and trends in the regulation of minimally invasive cosmetic procedures (MICP) across different state medical boards in the United States., Objective: We sought to assess current state medical board regulations regarding MICP, so as to better understand current and emerging trends in rules regarding delegation, and management of patient complaints., Methods: We conducted structured interviews with officials at US allopathic medical boards, supplemented with information from board World Wide Web sites., Results: A total of 31 (62%) boards participated. Most (20 boards; 63% of total respondents) reported that all MICP can be delegated at the physician's discretion and responsibility to at least one category of nonphysician; 7 states were expecting changes in delegation rules; and 4 states had very specific delegation requirements. Approximately equal numbers of boards required some general supervision of nonphysicians (14, 45%), or required some type of on-site supervision (13, 42%); a small number explicitly permitted off-site supervision (4, 13%). There was variation in the number of physician assistants one physician could supervise. Most boards (15 states) required some type of mandatory reporting, but not necessarily of incidents involving MICP. Very few (4) required reporting of both office- and nonoffice-based MICP incidents. Western states had liberal delegation and supervision requirements; these requirements were more stringent in Southern states., Limitations: Not all boards participated in this study., Conclusion: There is substantial variation in board regulation of MICP. Many boards are promulgating new rules. Medical boards also have limited ability to regulate nonphysicians., (Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: A better understanding of the molecular pathways that characterize cell growth, apoptosis, angiogenesis, and invasion has provided novel targets in cancer therapy. Epidermal growth factor receptor (EGFR)-mediated signal transduction has been one of the most studied pathways in carcinogenesis. The phosphorylation of EGFR activates multiple biological processes, including apoptosis, differentiation, cellular proliferation, motility, invasion, adhesion, DNA repair, and survival. EGFR is a transmembrane tyrosine kinase receptor involved in the proliferation and survival of cancer cells. EGFR is the first molecular target against which monoclonal antibodies have been developed for cancer therapy., Objective: To review the mechanisms underlying the effects of EGFR in nonmelanoma skin cancer (NMSC) and their potential role as targeted therapies in the treatment thereof., Conclusions: EGFR plays an important role in tumorigenesis of NMSC, especially metastatic squamous cell carcinoma, via mechanisms similar to those of other visceral tumors. Pharmacologic inhibitors of EGFR pathway of tumor production may offer an effective therapeutic strategy to block tumor growth., (© 2011 by the American Society for Dermatologic Surgery, Inc.)

Nonmelanoma skin cancers can be treated by various modalities, including electrodessication and curettage, excisional techniques, and radiation. In selected cases, radiation may be preferable to surgery. When radiation is an option, brachytherapy, a form of radiation therapy that places the radiation source close to the area to be treated, may have advantages relative to conventional external beam radiation in particular patients. After brachytherapy, recurrence rates for nonmelanoma skin cancers are low, especially for small, superficial lesions, with good to excellent functional and cosmetic results. This article reviews the indications, efficacy, and adverse effects of brachytherapy in the treatment of nonmelanoma skin cancers., (Copyright © 2010 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: Small-particle calcium hydroxylapatite (Radiesse, Merz, Frankfurt, Germany) is safe and effective for facial wrinkle reduction, and has medium-term persistence for this indication. There is patient demand for similar fillers that may be longer lasting., Objective: We sought to assess the safety and persistence of effect in vivo associated with use of large-particle calcium hydroxylapatite (Coaptite, Merz) for facial augmentation and wrinkle reduction., Methods: This was a case series of 3 patients injected with large-particle calcium hydroxylapatite., Results: Large-particle calcium hydroxylapatite appears to be effective and well tolerated for correction of facial depressions, including upper mid-cheek atrophy, nasolabial creases, and HIV-associated lipoatrophy. Adverse events included erythema and edema, and transient visibility of the injection sites. Treated patients, all of whom had received small-particle calcium hydroxylapatite correction before, noted improved persistence at 6 and 15 months with the large-particle injections as compared with prior small-particle injections., Limitations: This is a small case series, and there was no direct control to compare the persistence of small-particle versus large-particle correction., Conclusions: For facial wrinkle correction, large-particle calcium hydroxylapatite has a safety profile comparable with that of small-particle calcium hydroxylapatite. The large-particle variant may have longer persistence that may be useful in selected clinical circumstances., (Copyright © 2010 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)