Daniel B. Eisen

Hidradenitis suppurativa: A comprehensive review

Hidradenitis suppurativa, also known as acne inversa, is a chronic, often debilitating disease primarily affecting the axillae, perineum, and inframammary regions. Prevalence rates of up to 4% have been estimated. Our understanding of the disease has changed over time. It is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Clinically, the disease often presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture or coalesce, forming painful, deep dermal abscesses. Eventually, fibrosis and the formation of extensive sinus tracts may result. The location of the lesions may lead to social embarrassment and the failure to seek medical treatment. Therapies in the past have consisted of long-term antibiotics, antiandrogens, and surgery. New treatments like tumor necrosis factor-alfa inhibitors have given clinicians more options against this difficult disease.

Sebaceous lesions and their associated syndromes: Part II

Sebaceous lesions are associated with two syndromes with widespread multisystem disorders and tumors. Linear sebaceous nevus syndrome has been traditionally known as the triad of sebaceous nevus of Jadassohn, seizures, and mental retardation. This syndrome encompasses a much broader spectrum of multisystem disorders, which is explored below. Muir-Torre syndrome is described as the presence of sebaceous tumors or keratoacanthomas with an underlying visceral malignancy. It is caused by mutations in DNA mismatch repair genes. We discuss its relationship with Lynch syndrome and suggest a comprehensive algorithm on how to screen patients with sebaceous neoplasms for Muire-Torre syndrome. We also provide suggested intensive cancer screening guidelines based on recommendations for patients with Lynch syndrome that may also be of value for patients with Muir-Torre syndrome.

Congenital melanocytic nevi: Where are we now?: Part I. Clinical presentation, epidemiology, pathogenesis, histology, malignant transformation, and neurocutaneous melanosis

Congenital melanocytic nevi (CMN) are present at birth or arise during the first few weeks of life. They are quite common, may have a heritable component, and can present with marked differences in size, shape, color, and location. Histologic and dermatoscopic findings may help suggest the diagnosis, but they are not entirely specific. CMN are categorized based on size, and larger lesions can have a significant psychosocial impact and other complications. They are associated with a variety of dermatologic lesions, ranging from benign to malignant. The risk of malignant transformation varies, with larger CMN carrying a significantly higher risk of malignant melanoma (MM), although with an absolute risk that is lower than is commonly believed. They may also be associated with neuromelanosis, which may be of greater concern than cutaneous MM. The information presented herein aims to help dermatologists determine when it is prudent to obtain a biopsy specimen or excise these lesions, to obtain radiographic imaging, and to involve other specialists (eg, psychiatrists and neurologists) in the patients care.

Surgeon's garb and infection control: What's the evidence?

Surgical site infections are an important complication resulting from surgery. Before the 20th century a significant number of surgeries resulted in death from sepsis. One of the rituals resulting from efforts to reduce infection is the donning of surgical garb. A large body of literature has developed on the efficacy of these specialized garments. The available evidence for the efficacy of each individual garb at reducing surgical site infections will be explored. The relevance of this evidence to the outpatient dermatologic surgery setting will also be discussed.

Portable video media for presenting informed consent and wound care instructions for skin biopsies: a randomized controlled trial

Background  In fast‐paced dermatology clinics, the process of obtaining informed consents for biopsies and providing postprocedure instructions may be incomplete and inconsistent.

Congenital melanocytic nevi: Where are we now?: Part II. Treatment options and approach to treatment

Treatment of congenital melanocytic nevi (CMN) is generally undertaken for 2 reasons: (1) to reduce the chances of cutaneous malignant melanoma and (2) for cosmetic reasons. Over the past century, a large number of treatments for CMN have been described in the literature. These include excision, dermabrasion, curettage, chemical peels, radiation therapy, cryotherapy, electrosurgery, and lasers. Only low-level evidence supporting these approaches is available, and large randomized controlled trials have not been published. This article explores therapeutic controversies and makes recommendations based on the best available evidence.

Who do you prefer? A study of public preferences for health care provider type in performing cutaneous surgery and cosmetic procedures in the United States

BACKGROUND The public preference for provider type in performing cutaneous surgery and cosmetic procedures is unknown in the United States. METHODS An internet-based survey was administered to the lay public. Respondents were asked to select the health care provider (dermatologist, plastic surgeon, primary care physician, general surgeon, and nurse practitioner/physicians assistant) they mostly prefer to perform different cutaneous cosmetic and surgical procedures. RESULTS Three hundred fifty-four respondents undertook the survey. Dermatologists were identified as the most preferable health care provider to evaluate and biopsy worrisome lesions on the face (69.8%), perform skin cancer surgery on the back (73.4%), perform skin cancer surgery on the face (62.7%), and perform laser procedures (56.3%) by most of the respondents. For filler injections, the responders similarly identified plastic surgeons and dermatologists (47.3% vs 44.6%, respectively) as the most preferred health care provider. For botulinum toxin injections, there was a slight preference for plastic surgeons followed by dermatologists (50.6% vs 38.4%). Plastic surgeons were the preferred health care provider for procedures such as liposuction (74.4%) and face-lift surgery (96.1%) by most of the respondents. CONCLUSION Dermatologists are recognized as the preferred health care providers over plastic surgeons, primary care physicians, general surgeons, and nurse practitioners/physicians assistants to perform a variety of cutaneous cosmetic and surgical procedures including skin cancer surgery, on the face and body, and laser procedures. The general public expressed similar preferences for dermatologists and plastic surgeons regarding filler injections.

Perceptions of Expertise in Cutaneous Surgery and Cosmetic Procedures: What Primary Care Physicians Think

BACKGROUND Primary care physician (PCP) perceptions regarding expertise in cutaneous surgery and cosmetic procedures are unknown. METHODS An internet‐based survey was administered to physicians in primary care medicine residency programs in the United States. Respondents were asked to select the specialist most qualified to perform different cutaneous cosmetic and surgical procedures. RESULTS Five hundred sixty‐one PCPs undertook the survey. Dermatologists were identified as the most qualified specialist to evaluate and biopsy worrisome lesions on the face (95%), perform skin cancer surgery (56%), inject botulinum toxin (61%), inject fillers (55%), and perform laser procedures (75%). Seventy percent of respondents correctly defined Mohs micrographic surgery (MMS), and 60% of respondents selected a fellowship‐trained dermatologist as the best physician to perform MMS. U.S. medical school graduates were more likely than foreign medical school graduates to select a Mohs fellowship–trained dermatologist as the most qualified physician to perform MMS (adjusted odds ratio (AOR) = 1.52, 95% confidence interval (CI) = 1.05–2.21). PCPs without exposure to dermatology in medical school were about half as likely those with exposure to correctly define MMS (AOR = 0.51, 95% CI = 0.30–0.89). CONCLUSIONS Dermatologists are recognized as the most qualified specialist to perform a variety of cutaneous cosmetic and surgical procedures, including skin cancer surgery, botulinum toxin injections, filler injections, and laser procedures. Mohs fellowship–trained dermatologists were viewed as more qualified to perform MMS than other dermatologists, plastic surgeons, otolaryngologists, or ophthalmologists.

Treatment of Dermatosis Papulosa Nigra in 10 Patients: A Comparison Trial of Electrodesiccation, Pulsed Dye Laser, and Curettage

BACKGROUND Dermatosis papulosa nigra (DPN) is a common variant of seborrheic keratoses in darkly pigmented individuals. Treatment options include cryosurgery, curettage, electrosurgery, and shave removal. OBJECTIVE To compare the efficacy and complications of pulsed dye laser (PDL) therapy for the treatment of DPN with those of curettage and electrodesiccation. METHODS AND MATERIALS Randomized, controlled, single‐center, evaluator‐blinded trial of 10 patients with at least four clinically diagnosed lesions. RESULTS All 10 patients completed the study. Mean lesion clearance was 96% for curettage, 92.5% for electrodesiccation, and 88% for laser. There was no significant difference between the three treatment modalities. All three techniques had an overall cosmetic outcome of good for most patients. Five of the 10 patients preferred electrodesiccation. Patients rated the laser as the most painful treatment method. The most common adverse outcome was hyperpigmentation. There were no significant differences between the treatment groups for any of the measured outcomes. CONCLUSION The efficacy of PDL in the treatment of DPN is not significantly different from the already established treatment modalities of electrodesiccation and curettage. &NA; The authors have indicated no significant interest with commercial supporters.

MICROCYSTIC ADNEXAL CARCINOMA INVOLVING A LARGE PORTION OF THE FACE: WHEN IS SURGERY NOT REASONABLE?

Background We report a case of microcystic adnexal carcinoma (MAC) involving a large portion of the face, one of the largest of any MAC reported thus far in this area, and review the literature regarding the nature of the tumor and available treatments. We also review all of the reported cases of metastases and the possible role of radiation in the etiopathogenesis of this tumor. Objective To review the literature about what is known about therapy for MAC and what options are available to patients who have this disease. Materials and Methods Case report and review of the literature. Results Of the 274 cases of MAC thus far reported, there are 6 cases of metastases, only 1 of which resulted in death. Conclusion Mohs surgery should be the treatment of choice for this tumor; however, when extirpation entails sufficiently large morbidity, given the low rate of metastases and mortality, observation is a reasonable alternative.