John Strasswimmer

Adverse Events Associated With Mohs Micrographic Surgery Multicenter Prospective Cohort Study of 20 821 Cases at 23 Centers

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.

Multicenter prospective cohort study of the incidence of adverse events associated with cosmetic dermatologic procedures: Lasers, energy devices, and injectable neurotoxins and fillers

IMPORTANCE Common noninvasive to minimally invasive cosmetic dermatologic procedures are widely believed to be safe given the low incidence of reported adverse events, but reliable incidence data regarding adverse event rates are unavailable to date. OBJECTIVE To assess the incidence of adverse events associated with noninvasive to minimally invasive cosmetic dermatologic procedures, including those involving laser and energy devices, as well as injectable neurotoxins and fillers. DESIGN, SETTING, AND PARTICIPANTS A multicenter prospective cohort study (March 28, 2011, to December 30, 2011) of procedures performed using laser and energy devices, as well as injectable neurotoxins and soft-tissue augmentation materials, among 8 geographically dispersed US private and institutional dermatology outpatient clinical practices focused on cosmetic dermatology, with a total of 23 dermatologists. Participants represented a consecutive sample of 20 399 cosmetic procedures. Data acquisition was for 3 months (13 weeks) per center, with staggered start dates to account for seasonal variation. EXPOSURES Web-based data collection daily at each center to record relevant procedures, by category type and subtype. Adverse events were detected by (1) initial observation by participating physicians or staff; (2) active ascertainment from patients, who were encouraged to self-report after their procedure; and (3) follow-up postprocedural phone calls to patients by staff, if appropriate. When adverse events were not observed by physicians but were suspected, follow-up visits were scheduled within 24 hours to characterize these events. Detailed information regarding each adverse event was entered into an online form. MAIN OUTCOMES AND MEASURES The main outcome was the total incidence of procedure-related adverse events (total adverse events divided by total procedures performed), as verified by clinical examination. RESULTS Forty-eight adverse events were reported, for a rate of 0.24% (95% CI, 0.18%-0.31%). Overall, 36 procedures resulted in at least 1 adverse event, for a rate of 0.18% (95% CI, 0.13%-0.25%). No serious adverse events were reported. Adverse events were infrequently associated with known risk factors. CONCLUSIONS AND RELEVANCE Noninvasive to minimally invasive cosmetic dermatologic procedures, including energy, neurotoxin, and filler procedures, are safe when performed by experienced board-certified dermatologists. Adverse events occur in less than 1% of patients, and most of these are minor and transient.

Raman spectroscopy differentiates squamous cell carcinoma (SCC) from normal skin following treatment with a high‐powered CO2 laser

The number of cases of non‐melanoma skin cancer (NMSC), which include squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), continues to rise as the aging population grows. Mohs micrographic surgery has become the treatment of choice in many cases but is not always necessary or feasible. Ablation with a high‐powered CO2 laser offers the advantage of highly precise, hemostatic tissue removal. However, confirmation of complete cancer removal following ablation is difficult. In this study we tested for the first time the feasibility of using Raman spectroscopy as an in situ diagnostic method to differentiate NMSC from normal tissue following partial ablation with a high‐powered CO2 laser.

Posaconazole Substitution for Voriconazole-Associated Phototoxic Effects.

Posaconazole Substitution for VoriconazoleAssociated Phototoxic Effects Voriconazole is used for long-term prophylaxis or treatment of fungal infections. Voriconazole-induced phototoxic effects and photocarcinogenesis is an independent risk factor for squamous cell carcinoma (SCC) development in organ transplant recipients.1 An alternative for patients at risk for cutaneous cancer has not been well studied. We describe a patient with voriconazole-induced photocarcinogenesis whose symptoms and tumor count improved after substitution with posaconazole.

Four-year experience with vismodegib hedgehog inhibitor therapy

REFERENCES 1. Xia Y, Cho S, Greenway H, Zelac D, Kelley B. Infection rates of wound repairs during Mohs micrographic surgery using sterile versus nonsterile gloves: a prospective randomized pilot study. Dermatol Surg. 2011;37:651-656. 2. Martin JE, Speyer LA, Schmults CD. Heightened infectioncontrol practices are associated with significantly lower infection rates in office-based Mohs surgery. Dermatol Surg. 2010;36:1529-1536. 3. Rhinehart BM, Murphy ME, Farley MF, Albertini JG. Sterile versus nonsterile gloves during Mohs micrographic surgery: infection rate is not affected. Dermatol Surg. 2006;32:170-176. 4. Rogues AM, Lasheras A, Amici JM, et al. Infection control practices and infectious complications in dermatological surgery. J Hosp Infect. 2007;65:258-263. 5. Hughes K, Cornwall J, Theis J, Brooks H. Bacterial contamination of unused, disposable non-sterile gloves on a hospital orthopaedic ward. Austr Med J. 2013;6:331-338.

Barbed Absorbable Suture Closure for Large Mohs Surgery Defect

Section Editor: Edward W. Cowen, MD, MHSc; Assistant Section Editors: Murad Alam, MD; Ruth Ann Vleugels, MD Article InformationCorresponding Author: John Strasswimmer, MD, PhD, Advanced Mohs Surgery, 2605 W Atlantic Ave, Ste D-204, Delray Beach, FL 33480 (DelrayMohs@mac.com). Accepted for Publication: March 9, 2013. Author Contributions:Study concept and design: Strasswimmer. Acquisition of data: All authors. Analysis and interpretation of data: All authors. Drafting of the manuscript: Strasswimmer. Critical revision of the manuscript for important intellectual content: All authors. Administrative, technical, and material support: All authors. Study supervision: Strasswimmer. Conflict of Interest Disclosures: Dr Strasswimmer serves on the speakers bureau of Angiotech Inc and is a paid speaker for Genentech Inc, DUSA Inc, and Elekta Radiation Therapy Inc.

Umbilical endometriosis mistaken for a keloid in a premenopausal woman of Caribbean descent.

CASE DESCRIPTION A32-year-oldpremenopausalwomanwithnoprior pregnancies presented to the Dermatology Mission Clinic (www.DermatologyMissions.org) with a mass in her umbilicus. This international volunteer program was established in St George’s, Grenada, as a collaboration with the Ministry of Health to improve dermatologic care for underserved populations. The lesion was present for approximately 18 months, with associated symptoms of pruritus and irritation at the lesion; she noted that the symptoms were worse after menstruation. However, she denied dysmenorrhea, dyspareunia, or dyschezia. The remainder of her medical history was unremarkable, and she took no prescription medications. The patient was single, denied any history of infertility, and had no history of abdominal or pelvic surgery or trauma. She was previously referred to a general surgeon, who had diagnosed keloids approximately 1 year before her presentation to our dermatology clinic. She was prescribed betamethasone 0.05% cream, with no improvement. She subsequently underwent 3 intralesional injections of triamcinolone over the next 2 months, also with no clinical effect. Routine gynecologic evaluation approximately 1 year before presentation found incidental uterine leiomyoma, and she received depot medroxyprogesterone acetate. During this time, the lesion did not change in appearance but were no longer painful. On physical examination, a single hyperpigmented nodule with papillary projections, 1 cm in diameter, was located in the umbilicus, with a slight

JAAD Grand Rounds quiz: Multiple papules on the nose

Instructions: In answering each question, refer to the specific directions provided. Because it is often necessary to provide information occurring later in a series that give away answers to earlier questions, please answer the questions in each series in sequence.

Dermatologic Surgery Needs in Low-Income, Uninsured, and Minority Communities.

Uninsured, immigrant, and minority populations are underrepresented in dermatologic services including skin cancer. The index patient in our series is illustrative: in 2010, aHaitianman presentedwith a fungating tumor on his foot, which we diagnosed as melanoma before his death. His case prompted the initiation of a program at a large nonprofit clinic to advance dermatology services,with an emphasis on surgical care, to local underserved communities. This permitted us to successfully treat underserved patients, as illustrated by more than two-year survival of a second patient who presented with a fungating acral melanoma (Figure 1).