Jonathan Olson

Needs Assessment for Mohs Micrographic Surgery

Mohs micrographic surgery (MMS) is a unique technique that can offer the highest cure rates and maximum tissue conservation in the management of specific primary and recurrent skin cancers. However, there are many areas of controversy that surround MMS, including appropriate indications for its use, technical quandaries, and outcomes. Recent efforts in these areas need to be assessed to identify research gaps in MMS to help fuel further work. The usefulness of MMS and its methods for delivery need more stringent, evidence-based, rigorous study.

Foot care education and self management behaviors in diverse veterans with diabetes

The objective of this study was to examine differences in self-reported diabetes foot care education, self management behaviors, and barriers to good foot care among veterans with diabetes by race and ethnicity. Data was collected using the Veterans Health Administration Footcare Survey, a validated tool that assessed demographic, general health, diabetes and foot self-care information, barriers to foot self-care, receipt of professional foot care, and satisfaction with current care. We mailed surveys to a random sample of patients with diabetes from eight VA medical centers. Study participants were 81% White; 13% African American; 4% Asian, and 2% American Indian and Pacific Islanders. The majority of respondents felt that they did not know enough about foot self-care. There were large gaps between self-reported knowledge and actual foot care practices, even among those who reported “knowing enough” on a given topic. There were significant differences in self-reported foot care behaviors and education by race and ethnicity. These findings document the need for culturally-specific self-management education to address unique cultural preferences and barriers to care.

Morgellons Disease and Delusions of Parasitosis

Morgellons disease is a controversial and poorly defined symptom cluster of skin lesions and somatic symptoms, most notably ‘fibers’ in the skin. Because of widespread coverage in the media and on the Internet, there are an increasing number of patients presenting to dermatologists. We present three patients who believed that they had fibers in their skin. We offer a discussion of delusions of parasitosis to demonstrate similarities between these conditions. It has been suggested by a limited number of healthcare providers that an unknown infectious agent underlies this symptom complex yet no available evidence supports this assertion. Laboratory values that would be reflective of an infectious process (e.g. elevated white blood cells, sedimentation rate, C reactive protein) are routinely normal and biopsies often reflect only nonspecific findings such as acute and chronic inflammation with erosion or ulceration.Patients with Morgellons disease generally lack insight into their disease and reject the need for psychiatric help. The goal is to build trust and refrain from minimizing what the patient experiences. Attentive examination of the patient’s skin and fragments they present is necessary to rule out a true underlying pathologic process and to establish a trusting relationship. A supportive, non-confrontational approach is ideal. The patient is best treated by a team of practitioners of several specialties, including dermatologists, psychiatrists, and counselors.

Guideline concordant venous ulcer care predicts healing in a tertiary care Veterans Affairs Medical Center.

This study describes the impact of 80% adherence to guideline concordant care for compression therapy, moist wound‐healing environment, and debridement on venous ulcer outcomes. The retrospective cohort design included patients from a tertiary care Veterans Affairs Medical Center from October 2003 to September 2007. During this 5‐year interval, 155 patients with 400 venous ulcers met study inclusion. A majority of ulcers (n=362) healed, with an average time to healing of 18.1 weeks (range 2–209 weeks, median 10.4 weeks). From the multivariate Poisson regression, the likelihood of ulcer healing increased when compression therapy was provided during at least 80% of visits (relative risk [RR], 1.93; 95% confidence interval [CI], 1.27–2.92) or when a moist wound‐healing environment was provided during at least 80% of visits (RR, 1.63; 95% CI, 1.09–2.42). Debridement alone was not significantly associated with ulcer healing (RR, 1.0; 95% CI, 0.61–1.64). Patients who received all three treatments during at least 80% of their visits were more likely to heal than those who received < 80% treatment (RR, 2.52; 95% CI, 1.53–4.16). Guideline concordant venous ulcer care was significantly associated with venous ulcer healing, when provided at 80% or more of patient visits.

Needs Assessment for Cosmetic Dermatologic Surgery

Cosmetic procedures have been an integral part of dermatologic surgery for over half a century, with a more recent proliferation of devices to improve skin color and texture and modify subcutaneous fat. Overall, cosmetic dermatologic procedures are extremely safe. However, detailed information about safety and effectiveness, and especially comparative effectiveness, is not available for many procedures. There are few randomized control trials of comparative effectiveness of different procedures for similar indications. Key comparative effectiveness studies are briefly reviewed, and areas of substantial deficiency in such research are highlighted.

Needs Assessment for General Dermatologic Surgery

This article reviews current recommendations, strength of evidence, and areas in need of further research in the surgical treatment of melanoma and nonmelanoma skin cancers, as well as other select cutaneous neoplasms. Cryosurgery, electrosurgery, photodynamic therapy, and surgical excision are discussed. Local anesthesia, suturing technique, postsurgical dressings, and optimization of scarring are briefly reviewed. In general, large, high-quality, randomized controlled trials on which to base recommendations are lacking.

Foam Dressing as a Suturing Model

There are a variety of models available for teaching cutaneous suture techniques, from expensive, realistic, full-size models to synthetic tissue pads; animal models such as pig’s feet and skin; and inexpensive models such as plastic, foam, and fabric. Cost can be prohibitive for the higherend models, and pig’s feet and skin are unhygienic and often difficult to work with. We have had little luck with other simpler, lower-cost models such as art foam (ethylene vinyl acetate), which is stiff and a poor proxy for human skin, particularly when trying to teach or practice the all-important technique of wound edge eversion with deep dermal sutures. We have found a simple, widely available, inexpensive model for cutaneous suturing in the form of hydrophilic foam dressing.

Squamous cell carcinoma with perineural and intraneural invasion associated with hyalinized tumor nodules: a diagnostic pitfall and review of the literature.

Cutaneous squamous cell carcinoma with perineural invasion (PNI) is an important inconspicuous finding. We report a case of a common tumor with an uncommon finding. A 57-year-old white man presented with paresthesias and a new lesion at the site of a previously resected squamous cell carcinoma. At the time of case review, present deep in the dermis, were large hyalinized tumor nodules. These nodules could have easily have been dismissed as sclerotic tumor nodules or fibrotic in-transit metastases. With the clinical history in mind, these nodules were further investigated by immunohistochemistry and reviewed in conjunction with the Mohs frozen section slides. These nodules were subsequently diagnosed as significant peri- and intraneural invasion. This extremely unusual presentation of PNI is a potential diagnostic pitfall that is potentially under-recognized by dermatopathologists but crucial for determining patient management.

Teledermatologic views at 16-bit color depth yield accurate diagnoses

The Veterans Affairs (VA) Veterans Integrated Service Network 20 (VISN 20) is a group of healthcare facilities serving 135 counties in the Pacific Northwest and Alaska, an area that encompasses nearly one-quarter of the landmass of the United States.1 Its mission is to provide top-quality care to America’s veterans. Given the physical expanse of the area served, however, geographic constraints can impose challenging difficulties for rural veterans seeking consultations and diagnoses. The VISN 20 teledermatology project2 using remote imaging for diagnostic purposes was implemented in 2009 to help address this issue by providing co-managed dermatology care for these veterans. Multiple studies have compared the diagnostic accuracy of face-to-face imaging with remote imaging—teledermatology— and a majority of these report slightly better accuracy with the former. However, the American Telemedicine Association has determined that 24-bit images3 are suitable for remote diagnoses, and comparisons of face-to-face with remote approaches yielded very similar management concordance and outcomes. Further, patient satisfaction is consistently high with teledermatology.4, 5 Digital-image quality is dependent on multiple factors: the capture device used, image size, compression algorithm (i.e., JPEG, BMP, TIFF, RAW), monitor size and resolution, and color depth. In our study, in which we used similar capture devices, image sizes, and monitors, color depth measured in bits per pixel, or ‘bit,’ was the principal variable. Although in-hospital views on the VA Computerized Patient Record System are shown as 32-bit images, the Internet-based system views on the Citrix Access Gateway, a remote-access device used to produce images from off-site locations, displays 16-bit images. Figure 1. Color banding with 16-bit color occurs in a gradient of a single color.

Modified Locking Horizontal Mattress Suture

The horizontal mattress suture is useful when additional compression for wound edge hemostasis or extra eversion is desired or in wounds with a small amount of tension after deep sutures have been placed, particularly thin and fragile skin. It has been described in multiple iterations: interrupted, fully buried in dermal closure, partially buried, and running. A split-scar study showed a better cosmetic outcome than with simple running sutures, although there are disadvantages; removal can be challenging and painful for the patient, and it is difficult to align the wound edges in a vertical plane precisely, because there is no suture crossing over the wound.