Divya Srivastava

Treatment of Surgical Scars with Nonablative Fractional Laser Versus Pulsed Dye Laser: A Randomized Controlled Trial

OBJECTIVE Comparison of the efficacy of nonablative fractional laser (NAFL) and the V‐beam pulsed dye laser (PDL) for improvement of surgical scars. METHODS A randomized blinded split‐scar study. Fifteen scars in 12 patients were treated a minimum of 2 months after Mohs surgery. Patients were treated on half of the scar with a 1,550‐nm NAFL and on the contralateral half with the 595 nm PDL. MAIN OUTCOME MEASURE(S) A nontreating physician investigator evaluated the outcome of the scar in terms of scar dyspigmentation, thickness, texture, and overall cosmetic appearance (5‐point grading scale). RESULTS After a series of four treatments at 2‐week intervals, greater improvements were noted in the portion of surgical scars treated with NAFL (overall mean improvement 75.6%, range 60–100%, vs. PDL, 53.9%, range 20–80%; p<.001). CONCLUSION These data support the use of NAFL as a highly effective treatment modality for surgical scars, with greater improvement in scar appearance than with PDL. It is likely that the greater depth of penetration and focal microthermal zones of injury with NAFL, inducing neocollagenesis and collagenolysis, account for its greater improvement in scar remodeling. These encouraging results lead us to recommend that NAFL be added to the current treatment armamentarium for surgical scars. This project was supported by a grant from the Cosmetic Surgery Foundation.

The molecular genetics underlying basal cell carcinoma pathogenesis and links to targeted therapeutics

Mutations in the sonic hedgehog signaling pathway play a key role in the development of basal cell carcinomas. Specifically, mutations in the PTCH1 (also known as PTCH or PTC1) and SMO genes cause tumor formation through constitutive activation of the pathway. Misregulation of the pathway has also been implicated in the nevoid basal cell carcinoma syndrome and other tumors. Understanding the function of the sonic hedgehog pathway has led to novel strategies for treatment. In this review we highlight the role of the pathway in the pathogenesis of basal cell carcinoma and review potential targeted therapies.

Safety and efficacy of erbium-doped yttrium aluminum garnet fractionated laser for treatment of acne scars in type IV to VI skin.

BACKGROUND Ablative resurfacing lasers are effective for treatment of acne scars, but they have a high risk of complications. Fractional lasers have less severe side effects but more moderate efficacy than ablative devices. Studies were performed in individuals with Fitzpatrick skin type I to VI. OBJECTIVE To determine the efficacy and safety of an erbium 1,550‐nm fractional laser in the treatment of facial acne scars in Fitzpatrick skin types IV to VI. METHODS We conducted a prospective, single‐blind, randomized trial in patients with acne scars (n=15), skin type IV to VI, with a 1,550‐nm erbium fractionated laser. Patients were divided into two groups; one was treated with 10 mJ and the other with 40 mJ. Five monthly laser sessions were performed. A patient questionnaire was distributed. RESULTS There was a significant improvement in the acne scarring and overall appearance (p<.001). No significant difference was found between 10 and 40 mJ. Patients were highly satisfied with their results. Significant postinflammatory hyperpigmentation was seen; pain was significantly higher in darker skin. CONCLUSIONS Fractional photothermolysis is effective for the treatment of acne scars, but practition‐ers should be aware of the higher incidence of pain and postinflammatory hyperpigmentation in individuals with skin types IV to VI. The study was funded by Reliant Technologies, Inc., which participated in the study design. Galderma (Ft. Worth, TX) provided Tri‐luma cream and GlaxoSmithKline (Research Triangle Park, NC) provided valacyclovir (Valtrex).

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

Importance Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population–based incidence in the United States. Objective To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Clinical and Pathologic Factors Predictive of Positive Radiologic Findings in High-Risk Cutaneous Squamous Cell Carcinoma.

BACKGROUND At present, there exists considerable clinical uncertainty regarding the role of radiologic imaging in the staging and management of high-risk cutaneous squamous cell carcinoma (hrSCC). OBJECTIVE The authors sought to investigate the clinical and pathologic features predictive of bony invasion, perineural invasion, or lymphadenopathy in patients that had undergone head and neck imaging for hrSCC. MATERIALS AND METHODS The authors conducted a single-center retrospective chart review of patients (n = 82) that had undergone head and neck imaging for hrSCC. RESULTS Twenty-nine percent (24/82) of patients in the study had positive findings on radiologic imaging. Immunocompromised patients were more likely to have the radiologic finding of lymphadenopathy (p = .04). Tumor size was found to correlate with the radiologic finding of bony invasion (correlation coefficient = 0.40, p = .0002). There was no relationship between either high risk location or high risk histopathology and positive radiologic findings. The low number of patients and its retrospective nature are study limitations. CONCLUSION The clinical features of host immunosuppression and tumor size are predictive of positive imaging findings in hrSCC. The decision to perform radiologic imaging in patients with hrSCC may be influenced by these factors, but continue to be more firmly guided by physical exam and clinical suspicion.

Local Anesthesia: Evidence, Strategies, and Safety

The number of office-based procedures performed utilizing local anesthesia continues to rise, particularly in dermatologic settings. As more emphasis is placed on cost effectiveness in medicine, it is important to understand the role that office-based procedures can play in providing excellent dermatologic care. In addition, it is essential to continually demonstrate that local anesthesia administered in office-based settings is safe and effective in order to maintain a high standard of care within the specialty. Achieving adequate local anesthesia is imperative to ensure patient comfort, reduce anxiety, and promote optimal outcomes. The clinician should have a comprehensive understanding of the pathophysiology, mechanism of action, practical applications and techniques, and potential adverse events of various topical and injectable anesthetics in order to enhance patient satisfaction and safety. Lidocaine, which is the most commonly used local anesthetic, has a rapid onset, moderate duration, and excellent safety profile, making it a staple in office-based procedures.

Patient-Acquired Photographs for the Management of Postoperative Concerns

Author Contributions: Drs Glazer and Rigel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Glazer, Farberg, Rigel. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: All authors. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Glazer, Farberg, Rigel. Administrative, technical, or material support: Glazer, Farberg. Supervision: Rigel.

Self-acquired patient images: the promises and the pitfalls.

Self-acquired patient images, also known as selfies, are increasingly utilized in the practice of dermatology; however, research on their utility is somewhat limited. While the implementation of selfies has yet to be universally accepted, their role in triage appears to be especially useful. The potential for reducing office wait times, expediting referrals, and providing dermatologic services to patients with limited access to care is promising. In addition, as technology advances, the number of smartphone applications related to dermatology that are available to the general public has risen exponentially. With appropriate standardization, regulation, and confidentiality measures, these tools can be feasible adjuncts in clinical practice, dermatologic surgery, and teledermatology. Selfies likely will have a large role in dermatologic practice and delivery in the future.

Mohs Micrographic Surgery: Development, Technique, and Applications in Cutaneous Malignancies

Abstract Mohs micrographic surgery (MMS) is a specialized technique for treating skin malignancies that offers the highest cure rate by allowing histological evaluation of the entire peripheral and deep margins. MMS also maximally preserves as much uninvolved, normal adjacent tissue as possible, allowing for the best cosmetic and functional outcomes. When used for appropriate indications, this technique is also more cost‐effective than other treatment modalities. In this article, the authors will discuss the development of MMS, the steps involved in this procedure, and the indications for this technique. They will also review the use of MMS for basal cell carcinoma, squamous cell carcinoma, melanoma in situ, and some less common skin malignancies.

The multidisciplinary tumor board for the management of cutaneous neoplasms: A national survey of academic medical centers

Which attending physicians are present at[50% MTBs? Dermatologic surgery 36 85.7 General dermatology 30 71.4 Surgical oncology 39 92.9 Medical oncology 39 92.9 Radiation oncology 35 83.3 Pathology 38 90.5 Plastic surgery 11 26.19 Otolaryngology 19 45.2 Diagnostic radiology 14 33.3 Other attendees at[50% MTBs? Community physicians 3 7.1 Residents/fellows 37 88.1 Medical students 18 42.9 Midlevel providers 20 47.6 Ancillary staff (eg, nurse/social worker) 18 42.9