Mark Abdelmalek

Geometric Staged Excision for the Treatment of Lentigo Maligna and Lentigo Maligna Melanoma: A Long-term Experience With Literature Review

OBJECTIVE To ascertain and clarify the effectiveness and advantages of the geometric staged excision technique for the removal of lentigo maligna (LM) and lentigo maligna melanoma (LMM). DESIGN This was a retrospective review of a patient database composed of 293 cases of LM and LMM. SETTING The Laser and Dermatologic Surgery Center in St Louis, Missouri, an academic-affiliated, private dermatologic surgery center. PATIENTS All patients with a diagnosis of LM and LMM treated by staged excision from 1999 to 2007. MAIN OUTCOME MEASURES The overall rate of recrudescence, margins required for clearance, stages required for clearance, and lesional characteristics were examined. RESULTS The rate of recrudescence after geometric staged excision was 1.7% (4/239), with a mean of 32.3 months of follow-up. The mean margin to clearance after excision was 6.6 mm for LM and 8.2 mm for LMM. A total of 11.7% of LMM was initially diagnosed as LM on biopsy, with the invasive component discovered during the excision. CONCLUSIONS Geometric staged excision is an optimal method of removal of LM and LMM given its low rate of recrudescence and ability for complete examination of the peripheral and deep margins of the specimens.

Recurrent chondrosarcoma of the right skull base in a patient with Maffucci syndrome.

Maffucci syndrome is a rare, sporadic disease characterized by the development of multiple enchondromas and subcutaneous hemangiomas. Patients with Maffucci syndrome have a 23–37% risk of malignancy, with chondrosarcomas being the most common. Although the development of a chondrosarcoma in a patient with Maffucci syndrome may be expected, intracranial chondrosarcomas are rare. We present a patient with Maffucci syndrome who was diagnosed with an intracranial chondrosarcoma after presenting with hearing loss and vomiting. After three craniotomies and two recurrences of chondrosarcoma of the right skull base, the patient demonstrated a positive outcome to treatment with external radiation therapy.

Equal Cosmetic Outcomes with 5-0 Poliglecaprone-25 Versus 6-0 Polypropylene for Superficial Closures

BACKGROUND Cutaneous sutures should provide an aesthetically pleasing result. After placing subcutaneous sutures, enough absorbable suture often remains for the superficial closure. Mohs surgeons often use a nonabsorbable suture to close the superficial layer to obtain cosmetically elegant results, but using this additional suture is less cost effective than using the remaining absorbable suture. OBJECTIVES To compare the cosmetic results of simple running sutures using an absorbable suture material (5–0 poliglecaprone‐25) with those of a nonabsorbable suture (6–0 polypropylene) in primary closures of suitable facial Mohs defects. MATERIALS AND METHODS Fifty‐two patients with 57 facial Mohs surgery defects appropriate for multilayer primary repair had the defects prospectively randomized into a side‐by‐side comparison. After closure of the deep layers with 5–0 poliglecaprone‐25 sutures, half of the wound was closed with a 5–0 poliglecaprone‐25 simple running suture, and the other half of the wound was closed with a 6–0 polypropylene simple running suture. The investigators blindly determined the cosmetically superior side of the closure at 1 week and 4 months after suture removal. RESULTS Forty‐four patients (48 total defects) completed the study. At the 4‐month follow‐up, 85% (41/48) did not show any difference between poliglecaprone‐25 and polypropylene, 4% (2/48) had better outcomes with poliglecaprone‐25, and 10% (5/48) had better outcomes with polypropylene. There was no statistically significant cosmetic difference between the two closure types. Wound complications such as infection, hematoma, and dehiscence did not occur in any of the patients. CONCLUSION In primary closures of facial defects, using 5–0 poliglecaprone‐25 or 6–0 polypropylene for the superficial closure did not affect the cosmetic result. Therefore, 5–0 poliglecaprone‐25 provides a comparable and cost‐effective alternative to nonabsorbable sutures for epidermal approximation in layered closures. The authors have indicated no significant interest with commercial supporters.

Nonmelanoma Skin Cancer in Nonwhite Organ Transplant Recipients

Importance Organ transplant recipients have a higher incidence of skin cancer. This risk is magnified over time and with continued exposure to immunosuppression. Skin cancer in nonwhite patients is associated with greater morbidity and mortality owing to diagnosis at a more advanced stage, which suggests that nonwhite organ transplant recipients are at even higher risk. Objective To describe demographic and clinical factors and the incidence of skin cancer in nonwhite organ transplant recipients. Design, Setting, and Participants We performed a retrospective medical record review of patients who were organ transplant recipients (154 were white and 259 nonwhite [black, Asian, Hispanic, Pacific Islander]) seen from November 1, 2011, to April 18, 2016 at an academic referral center. Main Outcomes and Measures Variables were analyzed and compared between racial groups, including sex, age, race/ethnicity, Fitzpatrick type, type and location of skin cancer, type of organ transplanted, time to diagnosis of skin cancer after transplantation, and history of condyloma acuminata and/or verruca vulgaris. Results Most of the 413 patients (62.7%) evaluated were nonwhite organ transplant recipients; 264 were men, and 149 were women. Their mean (SD) age was 60.09 (13.59) years. Nineteen skin cancers were identified in 15 patients (5.8%) representing 3 racial/ethnic groups: black (6 patients), Asian (5), and Hispanic (4). All squamous cell carcinomas in blacks were diagnosed in the in situ stage, located on sun-protected sites, and occurred in patients whose lesions tested positive for human papilloma virus (HPV) and/or who endorsed a history of condyloma acuminata or verruca vulgaris. Most skin cancers in Asians were located on sun-exposed areas and occurred in individuals who emigrated from equatorial locations. Conclusions and Relevance Nonwhite organ transplant recipients are at risk for developing skin cancer posttransplantation. Follow-up in a specialized transplant dermatology center and baseline total-body skin examination should be part of posttransplantation care in all organ transplant recipients, including nonwhite patients. A thorough inspection of the groin and genitalia is imperative in black organ transplant recipients. History of HPV infection, particularly in black organ transplant recipients, and sun exposure/emigration history in Asian organ transplant recipients should be documented. Vigilant photoprotection may be of lesser importance in the prevention of skin cancer in black organ transplant recipients. Risk factors for nonwhite organ transplant recipients differ between races/ethnicities and warrant further study in efforts to better counsel and prevent skin cancer in these patients.

Recommendations for Solid Organ Transplantation for Transplant Candidates with a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma: A Consensus Opinion from the International Transplant Skin Cancer Collaborative (ITSCC)

Advancements in solid organ transplantation successfully extend the lives of thousands of patients annually. The tenet of organ stewardship aims to prevent the futile expenditure of scarce donor organs in patient populations with high mortality risk, to the detriment of potential recipients with greater predicted life expectancy. The development of skin cancer posttransplantation portends tremendous morbidity, adversely affecting quality of life for many transplant recipients. This special article, provided by of members of the International Transplant Skin Cancer Collaborative (ITSCC), will provide the transplant professional with a consensus opinion and recommendations as to an appropriate wait period pretransplantation for transplant candidates with a history of either cutaneous squamous cell carcinoma, malignant melanoma, or Merkel cell carcinoma.

Vismodegib for Locally Advanced Basal Cell Carcinoma in a Heart Transplant Patient

IMPORTANCE Immunosuppressed patients with solid organ transplants have an increased risk for nonmelanoma skin cancer. Vismodegib has been reported to be effective for select locally advanced or metastatic basal cell carcinomas. However, there is no data documenting the use and safety of vismodegib in immunosuppressed organ transplant patients. OBSERVATIONS We describe a 78-year-old white man with a history of orthotopic heart transplant, immunosuppressed with low-dose cyclosporine, who presented to a specialty dermatology transplant clinic with multiple, recurrent, locally aggressive facial basal cell carcinomas. Through a multidisciplinary approach, the patient was started on vismodegib therapy. The pharmacokinetics of cyclosporine in the setting of vismodegib administration and weekly monitoring of cyclosporine levels ensured that therapeutic immunosuppression levels were achieved without toxic effects. CONCLUSIONS AND RELEVANCE To our knowledge, this is the first report that details vismodegib use in an immunosuppressed heart transplant patient receiving cyclosporine therapy. With a growing immunosuppressed organ transplant population at high risk for basal cell carcinoma, therapeutic options for locally advanced or metastatic disease are limited. Vismodegib appears to be a safe option for patients receiving cyclosporine therapy with routine monitoring. Future research is needed to evaluate the safety profile of vismodegib with other immunosuppressive agents.

Comparison of Posttransplant Dermatologic Diseases by Race

Importance The risk for skin cancer has been well characterized in white organ transplant recipients (OTRs); however, most patients on the waiting list for organ transplant in the United States are nonwhite. Little is known about cutaneous disease and skin cancer risk in this OTR population. Objective To compare the incidence of cutaneous disease between white and nonwhite OTRs. Design, Setting, and Participants This retrospective review of medical records included 412 OTRs treated from November 1, 2011, through April 22, 2016, at an academic referral center. Prevalence and characteristics of cutaneous disease were compared in 154 white and 258 nonwhite (ie, Asian, Hispanic, and black) OTRs. Clinical factors of cutaneous disease and other common diagnoses assessed in OTRs included demographic characteristics, frequency and type of cancer, anatomical location, time course, sun exposure, risk awareness, and preventive behavior. Main Outcomes and Measures Primary diagnosis of malignant or premalignant, infectious, and inflammatory disease. Results The 412 patients undergoing analysis included 264 men (64.1%) and 148 women (35.9%), with a mean age of 60.1 years (range, 32.1-94.3 years). White OTRs more commonly had malignant disease at their first visit (82 [67.8%]), whereas nonwhite OTRs presented more commonly with infectious (63 [37.5%]) and inflammatory (82 [48.8%]) conditions. Skin cancer was diagnosed in 64 (41.6%) white OTRs and 15 (5.8%) nonwhite OTRs. Most lesions in white (294 of 370 [79.5%]) and Asian (5 of 6 [83.3%]) OTRs occurred in sun-exposed areas. Among black OTRs, 6 of 9 lesions (66.7%) occurred in sun-protected areas, specifically the genitals. Fewer nonwhite than white OTRs reported having regular dermatologic examinations (5 [11.4%] vs 8 [36.4%]) and knowing the signs of skin cancer (11 [25.0%] vs 10 [45.4%]). Conclusions and Relevance Early treatment of nonwhite OTRs should focus on inflammatory and infectious diseases. Sun protection should continue to be emphasized in white, Asian, and Hispanic OTRs. Black OTRs should be counseled to recognize the signs of genital human papillomavirus infection. Optimal posttransplant dermatologic care may be determined based on the race or ethnicity of the patients, but a baseline full-skin assessment should be performed in all patients. All nonwhite OTRs should be counseled more effectively on the signs of skin cancer, with focused discussion points contingent on skin type and race or ethnicity.

Recommendations for Solid Organ Transplantation for Transplant Candidates with a Pretransplant Diagnosis of Cutaneous Squamous Cell Carcinoma, Merkel Cell Carcinoma and Melanoma

Advancements in solid organ transplantation successfully extend the lives of thousands of patients annually. The tenet of organ stewardship aims to prevent the futile expenditure of scarce donor organs in patient populations with high mortality risk, to the detriment of potential recipients with greater predicted life expectancy. The development of skin cancer posttransplantation portends tremendous morbidity, adversely affecting quality of life for many transplant recipients. This special article, provided by of members of the International Transplant Skin Cancer Collaborative (ITSCC), will provide the transplant professional with a consensus opinion and recommendations as to an appropriate wait period pretransplantation for transplant candidates with a history of either cutaneous squamous cell carcinoma, malignant melanoma, or Merkel cell carcinoma.

Use of Latex‐Free Elastic Bandage to Simulate Flap Mechanics

&NA; The authors have indicated no significant interest with commercial supporters.

Two cases of trichodysplasia spinulosa responsive to compounded topical cidofovir 3% cream

Solid organ transplant patients are susceptible to rare and unusual dermatoses as a result of their chronic immunosuppression. Trichodysplasia spinulosa (TS) is one such rare clinical entity observed predominantly in immunosuppressed patients with a history of either solid organ transplantation on immunosuppressive therapy or hematologic malignancies treated with chemotherapy. Herein we present 2 cases of TS that were successfully treated with compounded topical cidofovir.