Removal of Incidental Skin Cancer During Mohs Micrographic Surgery Indicated for a Different Primary Tumor

BACKGROUND

Mohs surgery is a tissue-sparing, microscopically controlled procedure used to treat biopsy-proven skin cancers. Because Mohs surgery allows for examination of the complete margin of each tissue layer removed, separate cancers can be treated concomitantly when identified. As early detection of skin cancer is beneficial for reducing morbidity, incidental tumors discovered during Mohs surgery are of significant interest.

OBJECTIVE

Our objective was to determine the prevalence and characteristics of incidental skin cancers found during Mohs surgery.

METHODS

A retrospective chart review of cases seen at University of California, San Diego, from 2014 to 2021 was performed.

RESULTS

Of 13,464 Mohs surgery cases, 4.53% ( n = 610) had incidental skin cancers found during removal of the initially identified tumor. Of the 610 cases, 88.4% ( n = 539) had basal cell carcinoma as the primary tumor and either squamous cell carcinoma (SCC) or SCC in situ as the incidental tumor. About 7.87% ( n = 48) had SCC as the primary tumor and basal cell carcinoma as the incidental tumor. All tumors were removed with clear margins and without significant complications.

CONCLUSION

Diagnosis of incidental tumors during Mohs surgery enables early detection of skin cancer and circumvents the need for additional surgery, likely resulting in decreased morbidity and improved cost-effectiveness.

Novel Application of the 730 and 785 nm Picosecond Titanium Sapphire Lasers for the Treatment of Nevus of Ota

BACKGROUND AND OBJECTIVES

Nevus of Ota is a benign dermal melanocytosis that may pose significant psychosocial distress to patients. Q-switched nanosecond lasers have traditionally been considered the first-line treatment but pain, bleeding, and postinflammatory pigmentary alteration are common adverse effects. Picosecond devices have been increasingly used to treat nevus of Ota with promising results. We present two cases demonstrating novel applications of the 730 and 785 nm picosecond titanium sapphire lasers for the treatment of nevus of Ota in two patients with types III and IV skin.

STUDY DESIGN/MATERIALS AND METHODS

A 730 and 785 nm picosecond titanium sapphire laser with pulse durations of 250 and 300 picoseconds, respectively, were used to treat two cases of nevus of Ota. Four to seven treatment sessions were conducted at monthly intervals, and follow-up evaluation was performed 1-3 months following the final treatment session.

RESULTS

Both cases demonstrated greater than 75% clearance following treatment. There were no adverse events or pigmentary alteration noted as a result of picosecond titanium sapphire laser treatment.

CONCLUSIONS

The 730 and 785 nm picosecond titanium sapphire lasers are safe and effective for the treatment of nevus of Ota. Lasers Surg. Med. 00:00-00, 2021. © 2021 Wiley Periodicals LLC.

Current Practices in Pediatric Dermatology Laser Therapy: An International Survey

BACKGROUND AND OBJECTIVES

To date, there are no well-established guidelines regarding laser therapy for the treatment of cutaneous lesions in pediatric patients. We aim to ascertain the types of lasers commonly used, types of lesions treated, and factors that affect the selection of specific laser modalities in pediatric patients.

STUDY DESIGN/MATERIALS AND METHODS

An anonymous online survey was distributed to healthcare providers who treat children with lasers through listservs of four major national and international dermatology and laser organizations.

RESULTS

Outpatient office-based procedure rooms are the most common clinical setting for laser procedures (74.4%), and pulsed dye laser is the most commonly used laser (95.4%). Conditions routinely treated with lasers included port wine stains (95.4%), infantile hemangiomas (81.5%), other vascular lesions (81.5%), scars (77.7%), and hair (60.8%). 84.4% of respondents expressed concern about general anesthesia in patients <2 years old. Nevi of Ota is treated with laser more frequently (52.3%) than other pigmented lesions.

LIMITATIONS

Limited generalizability of case examples to general conditions.

CONCLUSIONS

Vascular lesions are the most common lesions treated with lasers in pediatric dermatology patients, and most providers are using these devices in the outpatient setting. Many providers are concerned about the effects of repeated general anesthesia in infants, and there appears to be a trend toward providing laser therapy in the outpatient setting without general anesthesia. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Allergenic potential, marketing claims, and pricing of facial moisturizers

Ingredients found in facial moisturizers can impact a myriad of skin conditions, including sensitive skin syndrome and contact dermatitis. There is a paucity of evidence on the allergenic potential and marketing claims of facial moisturizers, posing challenges to clinician recommendation and consumer selection. In this study, we systematically evaluate the 100 top-selling sun protective facial moisturizers that claim to be natural, fragrance free, expert-approved, age preventing, beneficial for sensitive skin, and sun protective. Allergenic potential of these moisturizers is evaluated based on ingredients used and prices and consumer ratings are compared. Accordingly, 75 of 100 marketed at least one additional benefit. "Anti-aging" products had the highest average price ($14.99/oz) and "expert-approved" had the lowest ($5.91/oz). Consumer rating was highest for facial moisturizers that were "fragrance-free" (4.35/5.00) whereas products that were "natural" received the lowest ratings (3.49/5.00). The most prevalent allergens found in these moisturizers were ethylenediamine tetraacetic acid (EDTA), phenoxyethanol, and cetyl alcohol. "Expert-approved" products had the fewest average allergens in their ingredient lists (P=0.033), whereas products advertising "SPF" had significantly more (P&lt;0.001). Marketing claims play a role in product sales and ratings. When recommending products, physicians should balance allergenic risk with affordability and consumer preferences.

Therapeutic Potential of Lebrikizumab in the Treatment of Atopic Dermatitis

Background

Atopic dermatitis (AD) is a chronic, relapsing skin condition with a wide disease spectrum. Moderate-to-severe cases often need systemic treatment. Conventional immunosuppressants have extensive side effect profiles and require close monitoring. In recent decades, there has been increasing interest in developing targeted systemic immunomodulators for AD, as they have been shown to have efficacy for AD as well as favorable safety profiles. Herein, we review the recent data on lebrikizumab, an interleukin (IL)-13 inhibitor, and its potential role in the treatment of AD.

Objective

Review the mechanism of action, and available data on the efficacy and safety of lebrikizumab for the treatment of AD.

Methods

PubMed, Google Scholar, and clinicaltrials.gov searches were performed with the following terms: “atopic dermatitis,” “dermatitis,” “eczema,” “lebrikizumab,” “IL-4,” and “IL-13.”

Results

Two Phase II randomized controlled clinical trials have been conducted to evaluate the use of lebrikizumab in a total of 289 patients with moderate-severe AD and inadequate response to topical corticosteroids. Patients treated with lebrikizumab experienced significantly more improvement in their AD compared to placebo, as measured by Eczema Area and Severity Index (EASI)-50 and EASI-75 scores, pruritus scores, and reduction in body surface area (BSA). Its clinical efficacy appears to be dose-dependent, and it has a favorable side effect profile and is generally well tolerated.

Conclusion

Lebrikizumab appears to be a promising emerging targeted biologic for the treatment of moderate-to-severe AD. Further Phase III studies investigating optimal dosing regimens and safety profile are needed.

Undergarment and Fabric Selection in the Management of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory condition manifesting as recurrent and exquisitely painful nodules in intertriginous regions. The role of mechanical stress in HS pathogenesis is gaining attention, as factors including intertriginous distribution of lesions, obesity, sweating, and suboptimal clothing contribute to increased friction and exacerbation of disease. Undergarment and clothing selection are often-overlooked components of HS management and should be addressed with patients as practical lifestyle changes that can decrease the frequency of disease flares and reduce symptoms of pain and irritation at involved sites. Selection of breathable and absorbent fabrics can also aid in reducing microbial colonization, sweat retention, and odor. This discussion is based on expert recommendations and aims to provide practitioners with the rationale for appropriate undergarment and clothing selection for HS patients. We propose practical principles for choosing undergarment design and fabrics for breathability, absorbency, and skin pressure reduction.

An unusual presentation of seborrheic keratoses in a man with hereditary hemochromatosis

Hereditary hemochromatosis is an autosomal recessive disorder that disturbs iron metabolism and results in iron deposition throughout the body. Iron accumulation in various organs may cause a wide range of systemic symptoms and cutaneous manifestations of the disease are particularly striking. Classically, hereditary hemochromatosis has been termed "bronze diabetes." Although diffuse hyperpigmentation is a well-described feature of this disease, other cutaneous symptoms may also occur, and a variety of anomalies may be observed. We present a case of long-standing hereditary hemochromatosis associated with hypopigmented plaques, which were found to be seborrheic keratoses on histologic examination. The cutaneous findings in hereditary hemochromatosis are summarized and an unusual case of seborrheic keratosis manifesting as hypopigmented plaques in a man with hereditary hemochromatosis is described. PubMed was used to search the following terms: hemochromatosis, hereditary, hyperpigmentation, hypopigmentation, keratosis, melanin, seborrheic, siderosis. Despite the generalized hyperpigmentation that is usually observed in hereditary hemochromatosis, seborrheic keratosis may present rarely as hypopigmented lesions in individuals affected by this disease. Therefore, seborrheic keratoses should be considered in the differential diagnosis in hemochromatosis patients who present with uncharacteristic pigmentation.

Pityriasis rosea in pregnancy: report of a spousal occurrence and craniosynostosis in the healthy newborn

BACKGROUND

Pityriasis rosea is a papulosquamous disease. It may occur during pregnancy; in this setting, it has occasionally been associated with adverse outcomes.

PURPOSE

A woman who developed pityriasis rosea at the beginning of her eighth week of gestation is described. The outcomes in newborns delivered by pregnant women who developed pityriasis rosea during gestation are summarized.

METHOD

A 28-year-old woman developed pityriasis rosea during her eighth week of pregnancy. Her husband had pityriasis rosea two months earlier. PubMed was searched for the following terms: conjugal, craniosynostosis, newborn, pityriasis, pregnancy, rosea, sagittal, spouse. The papers were reviewed and the references cited were evaluated.

RESULTS

Our patient delivered a healthy male infant after 41 weeks of gestation. He had normal weight, height, and Apgar scores. Isolated sagittal craniosynostosis was diagnosed and was successfully treated at nine weeks after birth without complications.

CONCLUSION

Several retrospective studies have investigated the possibility of adverse outcomes in infants born to women who developed pityriasis rosea during pregnancy, such as stillbirth, low gestational weight, hypotonia, and premature delivery. However, there are also reports of healthy newborns in women who have had pityriasis rosea during gestation. Our patient carried the fetus one week post-term and delivered a healthy boy via C-section; isolated sagittal craniosynostosis was later diagnosed and successfully repaired. The occurrence of craniosynostosis in a woman who developed pityriasis rosea during her first trimester of pregnancy may be two coincidental events.

Infliximab-Associated Psoriasiform Dermatitis: Case Report and Review of a Seemingly Paradoxical Inflammatory Response

Background: Tumor necrosis factor-α (TNF-α) inhibitors, such as infliximab, adalimumab, and certolizumab pegol are effective agents in the treatment of inflammatory bowel disease. Some individuals undergoing anti-TNF-α therapy for Crohn’s disease or ulcerative colitis develop psoriasiform lesions. This is a paradoxical finding, as classical psoriasis is known to respond to these agents.

Purpose: The clinical features of anti-TNF-α-induced psoriatic dermatitis are described.

Method: A 60-year-old man with Crohn’s disease treated with infliximab, who developed anti-TNF-α-induced psoriasiform dermatitis, is described.

Results: The man developed erythematous skin lesions in the bilateral axillae two years after beginning infliximab treatment for Crohn’s disease. Biopsy revealed psoriasiform dermatitis, consistent with a diagnosis of anti-TNF-α-induced psoriasiform dermatitis. He was treated with clobetasol 0.05% ointment twice daily for two weeks and had significant improvement. Subsequently, he used the corticosteroid ointment two days per week and calcipotriene 0.005% ointment twice daily for five days per week to achieve and maintain clear skin.

Conclusions: Anti-TNF-α-induced psoriasiform dermatitis is an infrequent complication of infliximab therapy. However, the condition may require discontinuation of the anti-TNF-α agent. Anti-TNF-α-induced psoriasiform dermatitis should be considered in the differential diagnosis when evaluating a new erythematous skin condition in an individual with a history of inflammatory bowel disease who is being treated with a TNF-α inhibitor.

Red Dot Basal Cell Carcinoma: An Unusual Variant of a Common Malignancy

BACKGROUND

Red dot basal cell carcinoma is a distinct but rare subtype of basal cell carcinoma (BCC). It presents as a red macule or papule; therefore, in most cases, it may easily be mistaken for a benign vascular lesion, such as a telangiectasia or angioma.<BR />

PURPOSE

A red dot BCC in an older woman is described. Clinical and histological differences between red dot BCCs and telangiectasias are described.<BR />

METHOD

A 72-year-old woman initially presented with a painless red macule on her nose. Biopsy of the lesion established the diagnosis of a red dot BCC. Pubmed was searched for the following terms: angioma, basal cell carcinoma, dermoscope, diascopy, red dot, non-melanoma skin cancer, telangiectasia, and vascular. The papers were reviewed for cases of red dot basal cell carcinoma. Clinical and histological characteristics of red dot basal cell carcinoma and telangiectasias were compared.<BR />

CONCLUSION

Red dot BCC is an extremely rare variant of BCC that may be confused with benign vascular lesions. Although BCCs rarely metastasize and are associated with low mortality, they have the potential to become locally invasive and destructive if left untreated. Thus, a high index of suspicion for red dot BCC is necessary.<BR /><BR /> <em>J Drugs Dermatol</em>. 2016;15(5):645-647.

Darwin's Tubercle: Review of a Unique Congenital Anomaly

BACKGROUND

"Darwin's tubercle" is a term used to describe an atavistic swelling of the posterior helix that is present in some individuals. Little is known about its prevalence, characteristics, and function. With growing interest in the individuality of external ear patterns and its possible applications to personal identification, more knowledge about this tubercle is warranted.

PURPOSE

We review the history, clinical presentation, and modern-day influences of Darwin's tubercle.

METHOD

A comprehensive review of the literature was performed. Pubmed was searched with the key words: auricle, congenital, Darwin, ear, evolution, helix, pinna, tubercle, Woolnerian.

RESULT

Darwin's tubercle has been documented to be present in about 10.5% of the Spanish adult population, 40% of Indian adults, and 58% of Swedish school children. It has a variety of clinical presentations, which may be classified by its degree of protuberance. The influence of genetics on the expression of Darwin's tubercle is unclear, and there are conflicting observations about its correlations with age and gender. Although usually present bilaterally in individuals who do possess this trait, a portion of this population does display asymmetric expression.

CONCLUSION

Darwin's tubercle is a benign and unique helical feature. It contributes to the individuality of human ears and may have applications toward personal identification in the future.