Omer Ibrahim

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.

The comparative effectiveness of suction-curettage and onabotulinumtoxin-A injections for the treatment of primary focal axillary hyperhidrosis: a randomized control trial.

BACKGROUND Botulinum toxin injections and suction-curettage have been separately shown to be effective in treating axillary hyperhidrosis but have not been compared in the same patients. OBJECTIVE We sought to compare effectiveness of suction-curettage versus neurotoxin for the treatment of axillary hyperhidrosis. METHODS Each of 20 patients was randomized to receive toxin injections to one axilla and suction-curettage to the contralateral axilla. The primary outcome measure was reduction of sweat rate measured by gravimetry, and the secondary measure was quality of life as measured by a patient-directed questionnaire. RESULTS At 3 months posttreatment, toxin injections decreased baseline resting sweat production by 72.1% versus 60.4% (P = .29) for suction-curettage, and baseline exercise-induced sweat production by 73.8% versus 58.8% (P = .10). When patients were stratified into the categories of light and heavy sweaters, there was a difference among heavy sweaters, with exercise-induced sweat production lower by 10.48 mg/min or 34.3% (P = .0025) at toxin-treated sites. Compared with suction-curettage, toxin also resulted in greater improvements in quality of life by 0.80 points (P = .0002) and 0.90 points (P = .0017) at 3 and 6 months posttreatment, respectively, as measured by the patient questionnaire. LIMITATIONS The follow-up period was limited to 6 months. CONCLUSIONS By objective measures 3 months after treatment, neurotoxin injections are nominally more effective than suction-curettage in all cases, and markedly more effective in heavy sweaters. Patients have a very significant preference for neurotoxin injections at 3 months, and this is maintained at 6 months.

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.

Treatment of Alopecia Areata With Tofacitinib

This medical record review describes the characteristics and outcomes of patients with alopecia areata before and after treatment with tofacitinib.

Prevalence of atopic comorbidities in eosinophilic esophagitis: A case-control study of 449 patients

Table I. Demographics and prevalence of atopy in patients with eosinophilic esophagitis Prevalence of atopic comorbidities in eosinophilic esophagitis: A case-control study of 449 patients Gender Female 136 (30.3%) Male 313 (69.7%) Age at EoE onset Mean (SD) 30.52 (17.54) Race White 394 (87.8%) Black 26 (5.8%) Asian/Pacific Islander 6 (1.3%) Multiracial 2 (0.5%) Unknown/not reported 21 (4.7%) Atopic disease At least 1 atopic disease 348 (77.5%) Allergic rhinitis 278 (61.9%) Asthma 175 (39.0%) Atopic dermatitis 207 (46.1%) [1 Atopic disease 215 (47.9%) Family history of atopy 194 (43.2%) To the Editor: Eosinophilic esophagitis (EoE) is a chronic, immune-mediated esophageal disease characterized by symptoms of esophageal dysfunction in combination with evidence of eosinophilpredominant esophageal inflammation. EoE has been closely linked with a personal and family history of atopic disorders, including asthma, eczema, rhinitis, and food allergies. However, the prevalence of atopic disease in patients with EoE varies widely between studies, as estimates have mostly been based on small cohorts. Two large database searches estimated prevalence based on diagnostic codes rather than systematic chart review of clinical and pathologic features of individual patients. The goal of this institutional review boarde approved study was to provide an estimate of prevalence of these atopic diseases in a large singlecenter EoEpopulation.We identified449patientswho presented with clinical and pathological features of EoE and received an esophageal biopsy between January 1, 2005, and June 30, 2015, at the Cleveland Clinic; we examined their electronic medical records for diagnoses or medical history of asthma, atopic dermatitis, and allergic rhinitis. Demographic information, esophageal disease characteristics, family history of atopy, peripheral eosinophil counts, and serum IgE levels were also extracted from medical records. Categorical factors were evaluated using Pearson 2 tests. Normally distributed continuous measures were compared using 2-sample t tests. Other variables were compared using Wilcoxon rank sum tests. Variables with missing responses were excluded from the analysis. Of the 449 patients with EoE, 348 (77.5%) had at least 1 atopic disease, 215 (47.9%) had more than 1 atopic disease, and 97 (21.6%) had all 3 atopic diatheses (Table I). Patients with atopic diseases tended to be younger, more likely to have a family history of atopy, and have significantly higher peripheral eosinophils and serum IgE levels (Table II). The prevalence of asthma, allergic rhinitis, and atopic dermatitis in the United States is estimated to be 22.3%, 19.1%, and 8.3%, respectively. In contrast, the estimated prevalence of asthma, allergic rhinitis, and atopic dermatitis in our EoE

Low-Dose Naltrexone Treatment of Familial Benign Pemphigus (Hailey-Hailey Disease)

Importance Familial benign pemphigus, or Hailey-Hailey disease (HHD), is a rare and debilitating genetic dermatosis characterized by chronic, recurrent vesicles, erosions, and maceration in flexural areas. Despite the reported therapeutic modalities, such as topical and systemic corticosteroids, systemic immunomodulators, topical and systemic retinoids, and laser, HHD can still be markedly difficult to control. Objective To assess low-dose naltrexone hydrochloride in the treatment of recalcitrant HHD. Design, Setting, and Participants In this case series, 3 patients with biopsy-proven recalcitrant HHD were evaluated in the outpatient dermatology clinic at the Cleveland Clinic. Each patient was treated with low-dose naltrexone hydrochloride at a dosage of 1.5 to 3.0 mg per day. No laboratory monitoring was necessary. Clinical response (healing of erosions, improvement in erythema, and alleviation of pain), adverse effects, and subjective quality of life were monitored throughout the treatment. The study dates were January 2016 to January 2017. Main Outcomes and Measures Objective clinical response as assessed by the treating dermatologist, subjective quality of life as reported by the patient, and recorded adverse effects were monitored throughout the treatment at intervals of 2 to 3 months. Results The 3 patients included a woman in her 40s and 2 men in their 60s. Each patient exhibited at least an 80% improvement in extent of disease, with one patient demonstrating 90% clearance. All 3 patients had substantial improvement in quality of life, with one patient reporting improvement in his depression. No adverse effects were recorded. Conclusions and Relevance Low-dose naltrexone may represent a low-cost and low-risk alternative or adjunct in the treatment of HHD.

Advances in diagnosis and treatment of nonmelanoma skin cancer.

AbstractThe incidence of nonmelanoma skin cancer (NMSC) is rising. Research in the field of these tumors is aimed toward developing earlier and less invasive diagnostic methods and more effective, more accessible therapeutic options. Although there is much advancement in the diagnosis and treatment of NMSC, there are few literatures cataloging these developments. The aim of this review was to present the sensitivity and specificity of new imaging modalities, the dosing regimen and clearance rates of topical treatments, newer systemic treatment modalities, and discuss developments in the use of radiation as a mode of therapy. Recent developments in the diagnosis of NMSC include imaging modalities such as reflectance confocal microscopy, elastic scattering spectroscopy, and spectrophotometric intracutaneous analysis. Recent advances in the treatment of these tumors include systemic therapies such as epidermal growth factor receptor inhibitors, and topical immunomodulating drugs such as imiquimod. The progress in the diagnosis and treatment of these tumors is a gradual but fruitful growth. Scientists and clinicians alike must continue their exploration and study to address these tumors and, hopefully in the future, prevent their occurrence.

When erythema ab igne warrants an evaluation for internal malignancy

2012; 2012: 952753. 4 Humbert P, Pelletier F, Dreno B, et al. Gluten intolerance and skin diseases. Eur J Dermatol 2006; 16: 4–11. 5 Francesco Stefanini G, Resta F, Marsigli L, et al. Prurigo nodularis (Hydes prurigo) disclosing celiac disease. Hepatogastroenterology 1999; 46: 2281–2284. 6 Bonciolini V, Bonciani D, Verdelli A, et al. Newly described clinical and immunopathological feature of dermatitis herpetiformis. Clin Dev Immunol 2012; 2012: 967974. 7 Cannistraci C, Lesnoni La Parola ICardinali G, et al. Co-localization of IgA and TG3 on healthy skin of coeliac patients. J Eur Acad Dermatol Venereol 2007; 21: 509–514.

Pain in naïve and non-naïve subjects undergoing nonablative skin tightening dermatologic procedures: a nested randomized control trial.

BACKGROUND Pain is expected during noninvasive skin tightening and can be anxiety provoking, especially for those who have not had prior treatments. OBJECTIVE To compare pain reported by patients naïve to nonablative skin tightening energy devices with those who were not naive. METHODS AND MATERIALS The non‐naïve group at least three nonablative laser procedures or one nonablative skin tightening procedure, and the naïve group no previous treatments. Four sites at each of two anatomic locations (periorbital and midface or cheek) were treated in each subject with needle prick, pulsed dye laser, radiofrequency, and ultrasound with the order of the interventions randomized. All interventions except ultrasound were also applied to three abdominal sites. The difference in mean pain scores between naïve and nonnaïve subjects were averaged over the anatomic sites. RESULTS Ten naïve and 10 non‐naïve subjects completed study procedures. Mean pain scores ranged from 1.3 to 4.9. The mean for all naïve conditions was 2.3 ± 1.0, vs 2.2 ± 1.4 for non‐naïve conditions. There was no overall difference according to group, device, or anatomic area. CONCLUSIONS There was no significant difference in pain between naïve and non‐naïve subjects undergoing cutaneous energy treatments. Individual devices may elicit more pain at specific anatomic locations.

Floaters in Mohs micrographic surgery.

Background Floaters are dislodged pieces of tumor tissue than can obscure Mohs micrographic surgery (MMS) frozen sections and confound their interpretation. Objective To understand the common causes of floaters and identify management strategies. Methods An initial virtual consensus conference of Mohs surgeons based on a 60‐item questionnaire. Data were validated in interviews with randomly selected Mohs surgeons. Results Based on retrospective reporting of 230 surgeon‐years and 170,404 cases of MMS by 26 surgeons, the mean rate of floaters per tumor treated was 1.8%, and the rate of floaters per tissue block was 0.70%. Not wiping blades between cuts when a stage is separated into subunits can predispose to floaters. There was also strong consensus that basal cell carcinomas, ulcerated tumors, and tissue from the first stage were more likely to yield floaters. There is little consensus on how to manage floaters, with possibilities including taking additional sections, taking an additional stage, or simply noting the floater. Conclusion Floaters are not rare and can complicate MMS margin assessment. There is significant expert consensus regarding the causes of floaters and the tissue features that may predispose to them. Floaters may be prevented by minimizing their likely causes. There is less consensus on what to do with a floater.