Are Episodic and Chronic Migraine One Disease or Two?

Migraine is a debilitating headache disorder that has a significant impact on the world population, in both economic and sociologic capacities. Migraine has two main categories: (1) chronic migraine (CM), defined as the patient having 15 or more headache days per month, with at least five attacks fulfilling measures for EM with aura or EM without aura, and (2) episodic migraine (EM), defined as less than 15 headache days per month. With this definition, CM can only exist in the presence of EM, and it questions whether the two are separate diseases. Migraine has a significant impact on the population, as each year, about 2.5 % of patients with EM develop new-onset CM (Manack et al., Curr Pain Headache Rep 15:70-78, 2011) (Loder et al. Headache 55:214-228, 2015), with certain risk factors being evident only with CM. In addition, there are comorbid diseases that are only associated with CM, suggesting two separate diseases rather than one. Differentiation in response to treatments, both preventive and abortive, demonstrates both a similarity and a difference in EM versus CM. Also, comparing the two processes based upon functional imaging has been a recent development, beginning to show a physiological difference in regional cortical thickness, cortical surface area, and regional volumes in patients with EM and CM. Evidence regarding whether EM and CM demonstrate one disease with a significant level of complication or if two independent processes is inconclusive, and additional research must be performed to further characterize their relationship.

Extragenital lichen sclerosus: a comprehensive review of clinical features and treatment

Lichen sclerosus (LS) is a chronic inflammatory skin disease commonly affecting the anogenital area with less frequent extragenital occurrence. Extragenital LS cutaneous manifestations vary and precipitating factors are not well described. Recent evidence for etiology and clinical associations of extragenital LS provide insight into disease recognition and pathogenesis. Novel diagnostic techniques as well as treatment standardization have the potential to improve management of this rare condition. This review details both past and new insights into the pathogenesis, clinical manifestations, and treatment options of extragenital LS.

The Effect of Bladder Catheterization Technique on Postoperative Urinary Tract Infections After Primary Total Hip Arthroplasty

BACKGROUND

Urinary bladder catheters are potential sources of infection after total hip arthroplasty (THA). Therefore, the goal of this study was to determine if intermittent catheterization provides a decreased risk of postoperative urinary tract infections (UTIs) compared with indwelling catheterization in THA patients.

METHODS

Patients undergoing THA at 15 hospitals within a large health system were prospectively collected between 2017 and 2019 and then stratified based on catheterization technique: no-catheter; indwelling catheter-only; intermittent catheter-only; and both intermittent and indwelling catheter. Patient demographics, medical comorbidities, anesthesia types, and postoperative UTIs were assessed. Independent Student t-tests were used to perform univariate analyses for the catheterization groups. Multiple linear regression models were used to compare the different groups while controlling for confounding variables.

RESULTS

There were a total of 7306 THA patients recorded with 5513 (75%) no-catheter, 1181 (16%) indwelling catheter-only, 285 (3.9%) intermittent catheter-only, and 327 (4.5%) indwelling and intermittent catheterization patients. A total of 580 patients experienced postoperative UTI. Urinary bladder catheterization increased the risk of postoperative UTIs (P < .001) in univariate analyses. Multiple linear regression models showed that indwelling catheter-only (OR: 2.178, P < .001), intermittent catheterization (OR: 1.975, P = .003), and both indwelling and intermittent (OR: 2.372, P = .002) were more likely to experience UTIs compared with no catheters.

CONCLUSION

This study found that patients treated with indwelling catheterization, with or without preceding intermittent catheterization, were significantly more likely to experience UTIs. Therefore, in an effort to decrease the risk of UTIs, THA patients experiencing postoperative urinary retention should be treated with intermittent catheterization.

Outcome Measurement Instruments Used to Evaluate Dermatologic Adverse Events in Cancer Trials: A Systematic Review

Importance

Assessment of type, severity, and impact of dermatologic adverse events (DAEs) necessitates well-developed and validated clinician-reported outcome measures (ClinROMs) and patient-reported outcome measures (PROMs) that evaluate concepts specific to mucocutaneous toxic effects and that allow appropriate interpretation and comparison of DAEs across trials.

Objective

To evaluate heterogeneity and quality of ClinROMs and PROMs used to assess DAEs from systemic cancer therapy.

Evidence Review

Two systematic reviews were conducted by searching PubMed and Embase databases from inception through March 7, 2023, and April 12, 2023. The first search included randomized clinical trials and observational studies reporting systemic cancer treatment-induced DAEs assessed by a ClinROM or PROM. The second included studies evaluating measurement properties of frequently used ClinROM and PROM instruments. The Consensus-Based Standards for the Selection of Health Measurement Instruments risk of bias tool was used to evaluate methodologic quality of validation assessments.

Findings

A total of 395 studies were included. The Common Terminology Criteria for Adverse Events (CTCAE) was utilized in 331 studies meeting inclusion criteria (83.8%). At least 1 skin-related PROM was infrequently utilized in systemic chemotherapy clinical trials (79 studies [20.0%]). Most frequently utilized PROMs were the Dermatology Life Quality Index (DLQI; 34 studies [8.6%]) and Skindex-16 (20 studies [5.1%]). Among studies capturing DAEs, 115 (29.1%) reported a nondescript term (ie, rash) as the only DAE. Eight studies described 44 property assessments of the CTCAE, DLQI, and Skindex. There were no studies evaluating content validity, intrarater reliability, or measurement error for the CTCAE, DLQI, or Skindex. There were no studies evaluating structural validity, internal consistency, and responsiveness of DLQI or Skindex. Interrater reliability and responsiveness were each assessed for 1 DAE-related component of the CTCAE. Construct validity for CTCAE, DLQI, and Skindex was evaluated in 29 (65.9%), 3 (6.8%), and 9 (20.5%) assessments, respectively.

Conclusions and Relevance

In this systematic review, there was a narrow spectrum of ClinROMs and PROMs with limited validity for the measurement of DAEs in the context of systemic chemotherapy interventions in clinical trials. Report of trial DAEs often had low morphologic specificity and meaning. Based on existing gaps in measurement and report of DAEs, a frequent and impactful adverse event to chemotherapy, the framework for evaluating cutaneous toxic effects in oncology trials may need collaborative reevaluation.

Retirement Planning

The retirement process is an individualized endeavor. Both financial and social aspects are important to consider when making plans for retirement. In this article, we discuss details of retirement planning, including the need to save, how much and when to start saving, and types of retirement plans. We also review key considerations for deciding when to retire as well as aspects of retirement outside of financial planning, such as redefining one's purpose and finding meaningful activities to fill the void of work.

Abstract T P209: Post -Thrombolysis Blood Pressure Guideline Violation in “Drip And Ship” Acute Ischemic Stroke Patients is Associated With Higher Mortality

Background: The “drip and ship” protocol is an important treatment for acute ischemic stroke patients who do not have immediate access to comprehensive stroke centers (CSC). Intravenous thrombolysis is initiated at a primary stroke center followed by expeditious transfer to a CSC typically during the tPA infusion. National guidelines recommend attention to blood pressure control (<180/105 mmHg) during and after tPA administration for the first 24 hours. We sought to determine the frequency of BP protocol violations during transfer and the impact on patient outcomes.

Methods: This is a retrospective analysis of 130 consecutive “drip and ship” patients transferred to North Shore University Hospital between July 2012 to June 2014. BP upon arrival to CSC was used to determine adherence to BP guidelines. Poor patient outcome was defined as discharge to hospice or expired, discharge modified Rankin score (mRS) >2, and symptomatic intracerebral hemorrhage (sICH).

Results: A total of 123 patients were confirmed to have an ischemic stroke (7 stroke mimics were excluded). Blood pressure was available for 120 patients. Mean age of the cohort was 62.7 years (range 24 to 100 years). Mean CSC admission NIHSS was 11.0 (range 0 to 28). Mean BP upon CSC arrival was 143.3/77.8 (systolic range 90 to 200 mmHg/diastolic range 44 to 112 mmHg). Mean mRS at discharge was 2.76. Blood pressure parameter violations were documented in 15 (12.5%) patients. Of these, 7 (46.7%) were discharged to hospice or expired, whereas 9/105 (8.6%) without blood pressure parameter violation were discharged to hospice or expired. This difference was statistically significant (p<0.0006, Fisher’s exact test). Symptomatic ICH was observed in 1/15 (6.7%) patients with BP parameter violations and 10/105 (9.5%) patients without BP parameter violations (not significant). Eleven (73.3%) of 15 patients with BP violations had a discharge mRS >2, compared to 54/103 (52.4%) patients without BP parameter violation (not significant).

Conclusions: Post thrombolysis blood pressure guideline violations during drip and ship transfer were significantly associated with in hospital mortality or discharge to hospice, but not with high discharge mRS or symptomatic ICH. Larger studies are needed to confirm these results.

OpenAI's GPT-4 performs to a high degree on board-style dermatology questions

BACKGROUND

Artificial intelligence tools such as OpenAI's GPT-4 have shown promise in medical education, but their potential in dermatology remains unexplored.

OBJECTIVES

To assess GPT-4's performance on dermatology board-style questions and determine its value as a supplementary educational tool for trainees and educators.

METHODS

This cross-sectional study evaluated GPT-4's performance on 250 random dermatology board-style questions sampled from the American Academy of Dermatology's Board Prep Plus resource. Questions were divided into five subspecialties and various difficulty levels. GPT-4 responses were compared to the correct answers and evaluated by two physicians.

RESULTS

GPT-4 achieved an overall accuracy of 75% on the 250 questions, with no significant variation based on subspecialty or question difficulty. The most common errors were factual and misunderstanding inaccuracies. Responses scored high in clarity, accuracy, and relevance but frequently lacked depth and completeness.

CONCLUSION

GPT-4 performed to a high degree and demonstrated promising performance as an educational adjunct in dermatology. Improvements in response depth and completeness are needed before its use as an unsupervised learning tool is established.

The association between obesity and efficacy of psoriasis therapies: An expert consensus panel

BACKGROUND

Psoriasis is a chronic inflammatory skin disease often associated with obesity. Psoriasis therapies may be less effective in patients with obese. The purpose of this expert consensus panel is to evaluate the relationship between obesity and efficacy of psoriasis therapies, thereby optimizing patient care.

METHODS

A comprehensive literature search was completed on July 19, 2024, using the keywords "psoriasis," "obesity," "efficacy," "treatments," and "therapies." A panel of 11 dermatologists with significant expertise in treatment of psoriasis gathered to review the articles and create consensus statements. A modified Delphi process was used to approve each statement and a strength of recommendation was assigned.

RESULTS

The literature search produced 500 articles. A screening of the studies resulted in 22 articles that met criteria. The panel unanimously voted to adopt 10 consensus statements and recommendations, 6 were given a strength of "A," 2 were given a strength of "B," and 2 were given a strength of "C."

CONCLUSION

Psoriasis and obesity have a strong association. Obesity decreases efficacy of biologics and may decrease efficacy and potentiate side effects of conventional therapies. It also impacts drug survival. Weight control is a vital component of caring for patients with psoriasis and the number of therapeutic options available is rising.

The Efficacy and Safety of Bimekizumab for Plaque Psoriasis: An Expert Consensus Panel

INTRODUCTION

Psoriasis is a chronic inflammatory condition affecting the skin, joints, and several other organ systems with significant disease burden. Bimekizumab is the first monoclonal antibody targeting both interleukin (IL)-17A and interleukin-17F and has demonstrated efficacy for treating moderate to severe psoriasis. Limited guidelines exist for incorporating this drug into clinical practice. The purpose of this study was for a panel of experts in psoriasis management to synthesize current literature and provide consensus statements with guidance on use of bimekizumab.

METHODS

A comprehensive literature search of PubMed, Scopus, and Google Scholar was completed for English-language original research articles on the use of bimekizumab for moderate to severe psoriasis and psoriatic arthritis. A panel of nine dermatologists with significant expertise in treatment of psoriasis gathered to review the articles and create consensus statements on this new medication. A modified Delphi process was used to approve each statement and a strength of recommendation was assigned using Strength of Recommendation Taxonomy criteria.

RESULTS

The literature search produced 102 articles that met criteria. A thorough screening of the studies for relevance to the research question resulted in 19 articles. These were distributed to all panelists for review prior to a roundtable discussion. The panel unanimously voted to adopt 14 consensus statements and recommendations, 12 of which were given a strength of "A", one of which was given a strength of "B", and one of which was given a strength of "C".

CONCLUSION

Bimekizumab results in rapid and long-lasting clinical improvement for patients with moderate to severe plaque psoriasis and psoriatic arthritis. It has demonstrated superior efficacy when compared to several other biologics. The safety profile is consistent with other biologics, except for an increased incidence of oropharyngeal candidiasis.

Factors Influencing Patient Selection of Sunscreen

Sunscreen is an essential component of sun protection. The most important characteristics for patient selection of sunscreens have not been evaluated. A cross-sectional survey study was performed at an academic dermatology office. The sunscreen characteristic chosen most frequently was SPF (75.2%). Fewer patients selected broad-spectrum (20.7%) and water-resistance (22.7%). There remains a gap in patient knowledge regarding AAD recommendations for sunscreen characteristics and educational initiatives may be required. J Drugs Dermatol. 2024;23(6):e154-e155.     doi:10.36849/JDD.8324e  .

Safety of Bimekizumab for Plaque Psoriasis: An Expert Consensus Panel

BACKGROUND

Plaque psoriasis is a chronic, relapsing systemic illness that has a significant effect on quality of life. Bimekizumab is the first monoclonal antibody to target both interleukin (IL)-17A and IL-17F, and recently received Food and Drug Administration (FDA) approval for moderate to severe plaque psoriasis. Guidance is necessary regarding the safety of bimekizumab.

METHODS

A comprehensive literature search of PubMed, Scopus, and Google Scholar was completed for English-language original research articles on the safety of bimekizumab for moderate to severe psoriasis. A panel of 9 dermatologists and 1 rheumatologist with significant expertise in the treatment of psoriasis gathered to review the articles and create consensus statements on this new medication. A modified Delphi process was used to approve each statement, and strength of recommendation was assigned using the Strength of Recommendation Taxonomy criteria.

RESULTS

The literature search produced 110 articles that met the criteria. A thorough screening of the studies for relevance to the research question resulted in 15 articles. These were distributed to all panelists for review prior to a roundtable discussion. The panel unanimously voted to adopt 5 consensus statements and recommendations, all of which were given a strength of "A".

CONCLUSION

Bimekizumab has a safety profile consistent with other biologics, except for a higher risk of oral candidiasis. Its hepatic safety profile is comparable with other currently FDA-approved biologics for plaque psoriasis. In addition, the data do not support an association of bimekizumab with suicide, and the incidence of inflammatory bowel disease is not greater than the incidence of other IL-17 blockers. J Drugs Dermatol. 2024;23(8):592-599. doi:10.36849/JDD.8246.

Clinical Utility of a Digital Dermoscopy Image-Based Artificial Intelligence Device in the Diagnosis and Management of Skin Cancer by Dermatologists

BACKGROUND

Patients with skin lesions suspicious for skin cancer or atypical melanocytic nevi of uncertain malignant potential often present to dermatologists, who may have variable dermoscopy triage clinical experience.

OBJECTIVE

To evaluate the clinical utility of a digital dermoscopy image-based artificial intelligence algorithm (DDI-AI device) on the diagnosis and management of skin cancers by dermatologists.

METHODS

Thirty-six United States board-certified dermatologists evaluated 50 clinical images and 50 digital dermoscopy images of the same skin lesions (25 malignant and 25 benign), first without and then with knowledge of the DDI-AI device output. Participants indicated whether they thought the lesion was likely benign (unremarkable) or malignant (suspicious).

RESULTS

The management sensitivity of dermatologists using the DDI-AI device was 91.1%, compared to 84.3% with DDI, and 70.0% with clinical images. The management specificity was 71.0%, compared to 68.4% and 64.9%, respectively. The diagnostic sensitivity of dermatologists using the DDI-AI device was 86.1%, compared to 78.8% with DDI, and 63.4% with clinical images. Diagnostic specificity using the DDI-AI device increased to 80.7%, compared to 75.9% and 73.6%, respectively.

CONCLUSION

The use of the DDI-AI device may quickly, safely, and effectively improve dermoscopy performance, skin cancer diagnosis, and management when used by dermatologists, independent of training and experience.

Managing Advanced Basal Cell Carcinoma: A Guide for the Dermatology Clinician

Objective

Basal cell carcinoma (BCC) is the most common form of skin cancer. Advanced BCCs include locally advanced BCCs (laBCCs), primary or recurrent tumors that are not amenable to surgery or radiation therapy, and metastatic BCCs (mBCCs). The management of advanced BCC has been revolutionized in recent years by the development of hedgehog inhibitors (HHIs) and immunotherapies (ie, PD-1 inhibitors). We aim to review the current literature on therapeutic options and outline treatment strategies to optimize care for patients with advanced BCC.

Methods

A comprehensive literature search was completed using the keywords "advanced basal cell carcinoma," "treatment," "hedgehog inhibitor," "vismodegib," "sonidegib," "PD1-inhibitor," and "cemiplimab." The authors reviewed all studies and included those which addressed the topic of the review.

Results

Surgery or radiotherapy may not be an option for certain high-risk BCCs due to due to invasion into local tissue, location near anatomically sensitive areas, or metastasis. There is increasing evidence for the efficacy of HHIs, including vismodegib and sonidegib, as the first-line treatment for these advanced BCCs. Despite known efficacy, utility of HHIs can be limited by their adverse event profiles. If patients fail HHIs due to inefficacy or adverse effects, there is evidence for use of the PD-1 inhibitor cemiplimab.

Limitations

This is a review article and is limited by the information available in the published literature. In addition, comparison between studies is limited as they utilized varying methodologies.

Conclusion

Treatment of advanced BCCs can be complex and poses challenges for clinicians. HHIs are currently the first-line treatments for laBCC and mBCC, while cemiplimab can be used if patients do not respond to or are unable to tolerate HHIs, or for whom HHIs are not appropriate.

Advances in Technology for Melanoma Diagnosis and Prognosis: An Expert Consensus Panel

BACKGROUND

Cutaneous melanoma (CM) is associated with a higher mortality rate than most other skin cancers. The purpose of this expert consensus panel was to review the published literature on new technological advancements for the diagnosis and prognosis for CM and provide updated guidance on their usage.

METHODS

A comprehensive literature search of PubMed, Scopus, and Google Scholar was completed for English-language original research articles on the topics of non-invasive diagnostic and prognostic testing for CM, including gene expression profiling (GEP) and electrical impedance spectroscopy (EIS). A panel of 10 dermatologists with significant expertise in the treatment of CM gathered to review the articles and create consensus statements. A modified Delphi process was used to approve each statement and a strength of recommendation was assigned using widely recognized Strength of Recommendation Taxonomy criteria.

RESULTS

The literature search produced 200 articles that met the criteria. A screening of the studies resulted in 19 articles. These were distributed to all panelists for review prior to a roundtable discussion. The panel unanimously voted to adopt 7 consensus statements and recommendations, 5 of which were given a strength of "A", 1 of which was given a strength of "B," and 1 of which was given a strength of "C".

CONCLUSION

The 2-GEP test and EIS can aid in the precise diagnosis of clinically indeterminate lesions and the 23-GEP test can be used when histopathology is equivocal. The 31-GEP test can enhance prognostic assessment beyond AJCC8 staging and improve clinical decision-making. J Drugs Dermatol. 2024;23(9):774-781. doi:10.36849/JDD.8365R1.

Efficacy, perception, and utilization of pediatric teledermatology: A systematic review

Background

The use of teledermatology abruptly expanded with the arrival of COVID-19. Here, we review recent studies regarding the efficacy, perception, and utilization of telemedicine in the pediatric population.

Objective

To evaluate the current state of pediatric teledermatology.

Methods

A literature search was performed using the terms "pediatric," "teledermatology," "dermatology," "telemedicine" and "telehealth" in PubMed, Scopus, Embase, and Google Scholar. 44 articles published between 2008 and 2022 were included.

Results

Diagnostic concordance between pediatric teledermatologist and in-person dermatologist ranged from 70.1% to 89%. Conditions treated with pediatric teledermatology were similar to those treated in-person. The rate of in-person follow-up after an initial telemedicine appointment pre and postpandemic was 12% to 51.9% and 13.5% to 28.1%, respectively. Patient satisfaction with teledermatology was between 70% to 98% and provider satisfaction was approximately 95%. The integration of teledermatology can reduce missed appointments and wait times among pediatric patients. However, considerable technological challenges exist, particularly in underserved communities. Globally, teledermatology may expand access to care though limited literature exists regarding its use in pediatric populations.

Conclusion

Telemedicine is effective for the diagnosis and treatment of many dermatological conditions in children, with high patient and provider satisfaction. Implementation of teledermatology can potentially increase access to care both locally and globally, but obstacles to engagement remain.

The Utility of Oral Polypodium Leucotomos Extract for Dermatologic Diseases: A Systematic Review

BACKGROUND

Polypodium leucotomos extract (PLE), a fern plant product with strong anti-inflammatory and immunomodulatory properties, has been employed to reduce photoaging and skin cancer. PLE may also serve as an adjuvant treatment for psoriasis, vitiligo, atopic dermatitis, photodermatoses, and melasma. This systematic review synthesizes the current data on PLE usage to manage dermatological diseases.

METHODS

This systematic review followed the Agency for Healthcare Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative Effectiveness Reviews and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines. PubMed/MEDLINE, Embase, and Cochrane Library were queried using keywords. Articles were screened for inclusion and subsequently grouped by dermatological condition.

RESULTS

Twenty-one of the 152 identified articles met inclusion criteria, including 11 randomized controlled trials and 5 treatment trials. Implicated dermatological conditions were photoaging/skin cancer (9 studies), actinic keratosis (3), photodermatoses (3), melasma (2), vitiligo (3), and atopic dermatitis (1). A thorough article review revealed several potential applications of PLE.

CONCLUSION

PLE exhibits strong therapeutic potential with an encouraging safety profile. It has photoprotective and immunomodulatory properties, underscoring its potential as an adjuvant therapy for multiple dermatological conditions. J Drugs Dermatol. 2025;24(4):346-351. doi:10.36849/JDD.8410R1.

Comparison of Characteristics Influencing Patient Selection of Sunscreen Between Urban and Rural Regions in the United States

Sunscreen greatly reduces the risk of skin cancer and is recommended as a critical component of sun protection. There is limited literature on patient preferences for sunscreen characteristics. A cross-sectional survey was administered to patients in an urban city and rural area in the United States. Sun Protection Factor (SPF) was consistently the most important factor for patients when selecting sunscreen. However, numerous preferences for sunscreen characteristics vary between the 2 regions, including dermatologist recommendation, texture, ingredients, cost, broad-spectrum, and brand. Gaps in patient knowledge of sunscreen recommendations may be present and further educational programs may be necessary. J Drugs Dermatol. 2024;23(8):e171-e172. doi:10.36849/JDD.8449.

Blink of an Eye: Evaluating Dermatologists' Speed Versus Accuracy for Melanoma Diagnosis

BACKGROUND

Detection of melanoma at an early stage is critical to optimize surgical removal outcomes. The time to accurately visually diagnose melanoma has not been studied.

OBJECTIVE

To evaluate dermatologists' speed versus accuracy of melanoma diagnosis.

METHODS

A cross-sectional study with a 20-question quiz was conducted at a national dermatology conference. Questions were asked to identify either melanoma or benign lesion. The first 10 lesions were shown for 4 seconds each, and the next 10 were shown for 0.25 seconds each. Participants included dermatologists and dermatology residents and fellows.

RESULTS

Three hundred fifteen participants completed the quiz. Overall, 79.6% of cases were correctly diagnosed. Melanoma was correctly diagnosed in 78.2% and benign lesions in 81.0% of cases (p < .001). There was a significantly greater diagnostic accuracy found for 0.25 seconds versus 4 seconds (80.6% vs 78.6%, p = .007). Dermatologists practicing for 1 to 10 years had a higher percentage of correct answers and number of correct answers for 0.25 seconds compared with residency/fellowship.

CONCLUSION

Dermatologists have high diagnosis accuracy for melanoma, irrespective of time of lesion observation. Diagnostic accuracy for 0.25 seconds was consistent with findings in the typical clinical setting. Greater length of practice was associated with higher accuracy, but this did not persist after 10 years.

Porcine xenograft and second intention healing on the lower extremities after Mohs surgery: a descriptive case series

There is limited data on benefits of healing after Mohs surgery using porcine xenografts (PXs) compared to second intention (SI). This case series sought to describe healing time, scar size, cosmetic outcome, pain, and infection rates in patients treated with PX or SI for wounds on lower extremities. 14 patients were enrolled. Six patients received treatment with SI, and eight patients received PX. 11 patients (4 SI, 7 PX) completed follow-up visit after 3 months (79% follow-up rate) when primary outcome measure was assessed. 64% of patients took > 3 months to heal. 72% of patients healed within 6 months post-surgery. Scars contracted by > 50% in 7/11 patients completing follow-up. In SI group, 3/5 patients self-reported pain level > 1 out of 10 at 1-week post-surgery compared to 3/8 in the PX group. Two patients in each group developed post-operative wound infection and three patients in PX group experienced other adverse events. These results suggest that healing with PX or SI resulted in small scar size, low post-operative pain level, and low rate of adverse events. Both groups had longer healing times than expected.