Kavita Mariwalla

Mohs micrographic surgery histopathology concordance

BACKGROUND The low recurrence rate and tissue-sparing benefit associated with Mohs micrographic surgery (MMS) requires accurate interpretation of frozen sections by the MMS surgeon. OBJECTIVE We sought to assess concordance between dermatopathologists and MMS surgeons when reporting cutaneous malignancy in the MMS setting. METHODS This study is a retrospective analysis of 1156 slides submitted during 10 years as part of a pre-existing randomized, blinded, quality assurance protocol. Slides were read by one of 5 dermatopathologists and represent cases from 3 MMS surgeons and 5 MMS fellows. Agreement or disagreement was recorded. RESULTS Of the 1156 slides, 32 slides (2.8%) were disparate. Aside from differences regarding intraepidermal neoplasia, the concordance rate was 99.7%. LIMITATIONS This study represents data collected at a single institution in the United States alone. CONCLUSION There was statistically significant concordance between MMS surgeons and dermatopathologists in frozen section interpretation in the MMS setting. Discordance was primarily related to the interpretation of in situ malignancy.

Prophylactic and empiric use of antibiotics in dermatologic surgery: a review of the literature and practical considerations.

BACKGROUND Although the risk of postoperative infection and bacteremia from dermatologic procedures remains low, many dermatologic surgeons continue to prescribe antibiotics, pre‐ and postoperatively. This practice can lead to unwanted morbidity and mortality and significantly increases associated healthcare costs and, even more ominously, increases bacterial resistance in the community. OBJECTIVE To provide a comprehensive overview of antibiotic usage in dermatologic surgery and use evidence‐based medicine to provide recommendations for antibiotic usage tailored to microbial pathogens. MATERIALS AND METHODS A literature review was conducted to provide the most current overview of the guidelines for antibiotic use against surgical site infections, infective endocarditis, and hematogenous joint infection. In addition, recommendations for antibiotic use with implantable materials, such as fillers, and for special populations, such as organ transplant recipients, are provided. RESULTS AND CONCLUSION We focused on the most common bacterial pathogens related to surgical sites and effective antibiotics for each. In doing so, we seek to limit the unwarranted use of antibiotics in dermatologic surgery.

Mohs Surgeons' Use of Topical Emollients in Postoperative Wound Care

Background Although there is no universally accepted topical emollient recommended for wound care, there has been a trend toward minimizing exposure to common culprits of allergic contact dermatitis. Objective To assess the current practices of postoperative emollient use of dermatologic surgeons. Methods and Materials An anonymous 10‐question survey on postoperative emollient use for clean surgical wounds was e‐mailed to 857 members of the American College of Mohs Surgery. Results Two hundred ninety‐four members (34.3%) responded. After routine closure, the most commonly used topical emollient placed immediately postoperatively was petroleum jelly (53.1%), followed by Aquaphor (Beiersdorf Inc., Wilton, CT) (19.4%) and bacitracin (8.2%) (p < .001). Respondents recommended that patients use the following topical emollients at home to keep the wound moist: petroleum jelly (69.4%), Aquaphor (38.4%), bacitracin (10.0%), mupirocin (9.2%), polymyxin (8.8%), neomycin (2.0%), and gentamicin (1.0%) (p < .001). The three most common topical emollients that were requested not to be used were neomycin (92.8%), polymyxin (44.3%), and bacitracin (44.3%) (p < .001). Conclusion Although emollients with low risk for contact allergy such as petroleum jelly are used more frequently, topical antimicrobials with known sensitizing potential are being applied and recommended for clean surgical wounds. A change in practice is needed to avoid these allergens.

Use of 2-octyl cyanoacrylate to obviate daily wound care after Mohs surgery.

In summary, the authors propose that Mohs surgery is an effective and tissue-sparing approach for MPTTs.Wide local excision with 1-cmmargins may also be considered, but Mohs provides superior margin evaluation that is extremely important in tumors with infiltrative borders such as MPTT. All cases of MPTT should at minimum be evaluated with local imaging to assess the extent of local involvement and investigate for regional metastases. Computed tomography with contrast of the head and neck seems to be appropriate for scalp tumors. Any suspicion for metastases should prompt systemic work-up including a positron emission tomography scan. Radiation therapy and/or chemotherapy may be considered in some cases. Patients should be followed closely with frequent examinations to evaluate for the possibility of recurrence or metastases. References

Expanding the histologic findings in smallpox-related post-vaccinial non-viral folliculitis.

Post‐vaccinial non‐viral folliculitis has been recognized in the past decade as a new adverse cutaneous reaction to smallpox vaccination. Contrary to more serious smallpox vaccine reactions, post‐vaccinial non‐viral folliculitis has a benign course and resolves spontaneously within approximately 7 days. We describe additional histopathologic findings associated with post‐vaccinial non‐viral folliculitis, which has only been described once previously. New findings include the presence of a neutrophilic or lymphohistiocytic infiltrate that is concentrated around the hair follicles. We compare our findings to the follicular nature of varicella and herpes zoster infections, generating the hypothesis of deposition of vaccinia protein within folliculosebaceous units as a potential pathophysiologic mechanism behind post‐vaccinial non‐viral folliculitis.

Commentary on Facial treatment preferences in aesthetically aware women

As experts in facial aesthetics, we each have a tailored way of performing the cosmetic consultation. Our aesthetic consultations emphasize listening to our patients, and start by “handing the mirror to the patient,” and asking questions to better understand patient aesthetic desires and wishes, rather than leading the discussion during such encounters. Indeed, it is often surprising what an individual patient is looking for. However, for the first time, the study published by Narurkar and colleagues gives an unbiased insight into what female patients are most interested in correcting, which will no doubt inform the patient discussions. What makes this survey-based study important is that it asks patients, outside the doctor’s office environment, what they would “fix,” keeping in mind that the women surveyed are treatment naive but not treatment unaware.

Expanding the histological findings in postvaccinial non-viral folliculitis

Post‐vaccinial non‐viral folliculitis has been recognized in the past decade as a new adverse cutaneous reaction to smallpox vaccination. Contrary to more serious smallpox vaccine reactions, post‐vaccinial non‐viral folliculitis has a benign course and resolves spontaneously within approximately 7 days. We describe additional histopathologic findings associated with post‐vaccinial non‐viral folliculitis, which has only been described once previously. New findings include the presence of a neutrophilic or lymphohistiocytic infiltrate that is concentrated around the hair follicles. We compare our findings to the follicular nature of varicella and herpes zoster infections, generating the hypothesis of deposition of vaccinia protein within folliculosebaceous units as a potential pathophysiologic mechanism behind post‐vaccinial non‐viral folliculitis.

Expanding the histologic findings in smallpox-related post-vaccinial non-viral folliculitis: Post-vaccinial non-viral folliculitis

Post‐vaccinial non‐viral folliculitis has been recognized in the past decade as a new adverse cutaneous reaction to smallpox vaccination. Contrary to more serious smallpox vaccine reactions, post‐vaccinial non‐viral folliculitis has a benign course and resolves spontaneously within approximately 7 days. We describe additional histopathologic findings associated with post‐vaccinial non‐viral folliculitis, which has only been described once previously. New findings include the presence of a neutrophilic or lymphohistiocytic infiltrate that is concentrated around the hair follicles. We compare our findings to the follicular nature of varicella and herpes zoster infections, generating the hypothesis of deposition of vaccinia protein within folliculosebaceous units as a potential pathophysiologic mechanism behind post‐vaccinial non‐viral folliculitis.