Phillip M. Williford

Destructive procedures are the standard of care for treatment of actinic keratoses

BACKGROUND Actinic keratoses are premalignant lesions resulting from exposure to carcinogens. Recently, some Medicare carriers have limited reimbursement for destruction of actinic keratoses to those lesions unresponsive to topical 5-fluorouracil treatment. OBJECTIVE Our purpose was to determine whether this policy meets the community standard of care for treatment of actinic keratoses. METHODS Data from the 1993 and 1994 National Ambulatory Medical Care Survey were used to determine the frequencies at which different treatments are used for actinic keratoses. These were compared with the frequencies at which procedures and medical therapies are used to treat control conditions (warts, psoriasis, acne, and dermatitis) to determine whether procedures are done because they are available or out of medical necessity. RESULTS Procedures were performed during 78% of visits for actinic keratoses. 5-Fluorouracil was used at 3.6% of visits, and at 39% of these visits a procedure was also performed. There were no observations of use of 5-fluorouracil alone at a first visit for actinic keratosis. Procedures were less likely to be performed at visits for warts, psoriasis, acne, or dermatitis, which indicates that reimbursable procedures are performed not simply because they are available. CONCLUSION Procedures are performed to destroy actinic keratoses out of medical need. Medicare policies mandating initial use of 5-fluorouracil as initial treatment of actinic keratoses do not represent the community standard of care for treatment of these lesions.

Adult pityriasis rubra pilaris: A 10-year case series

BACKGROUND Pityriasis rubra pilaris (PRP) often has a devastating impact on the lives of patients. Descriptions of its histopathologic features are not uniform. Finding a successful therapy can be challenging. OBJECTIVE Our purpose was to examine the histopathologic features and response of patients to our standard therapy of an oral retinoid and concomitant or later addition of low-dose weekly methotrexate. METHODS A retrospective chart review was done on 24 patients with PRP seen from March 1986 to March 1996. Biopsy specimens from 19 patients were reexamined. Telephone follow-up was conducted to determine maintenance of remission. RESULTS All patients had the adult acquired form of PRP. Biopsy specimens from nine patients were characterized by prototypical findings of PRP, while the others included both typical and other features. Twenty-two patients were treated with either isotretinoin, 40 mg twice daily, or etretinate, 25 to 75 mg/day. Six patients with more disabling involvement had low-dose weekly methotrexate ranging from 5 to 30 mg started concurrently. Five patients had weekly methotrexate added at a later time. Seventeen patients showed 25% to 75% response after 16 weeks of therapy. All patients whose skin cleared maintained their remission. CONCLUSION Initial oral retinoid plus concurrent or later low-dose weekly methotrexate resulted in 25% to 75% improvement of PRP in 17 of 24 patients after 16 weeks of therapy. Some of the atypical features seen in biopsy specimens emphasize the importance of clinical and histopathologic correlation in establishing the diagnosis.

Tobacco smoking contributes little to facial wrinkling.

The potential detrimental effects of tobacco smoking have been widely cited. Tobacco smoking has been linked with facial wrinkling, but some previous studies have failed to take into account a number of potential confounders or were unblinded and thus subjective to bias.

Eruptive squamous cell carcinomas, keratoacanthoma type, arising in a multicolor tattoo

Permanent tattoos are formed through the injection of ink solids through the epidermis into the dermis and can cause multiple adverse reactions. We report a 38‐year‐old man who presented to our Dermatologic Surgery Unit with a diagnosis of a superficially invasive squamous cell carcinoma (SCC), keratoacanthoma (KA) type, of the left forearm in a 1‐month‐old tattoo. Since his initial biopsy, he developed four more similar lesions on his left forearm within his tattoo. On physical examination, the patient had a large, multicolor tattoo on his left forearm, a well‐healed surgical biopsy site and four erythematous hyperkeratotic papules within differently pigmented areas of the patient’s tattoo. Histopathological examination showed KA and tattoo pigment. Based on the eruptive nature of these lesions, their clinical presentation and the histopathological changes, we report this as the first case of eruptive KA arising in a multicolor tattoo.

The spectrum of normolipemic plane xanthoma

Normolipemic plane xanthoma (NPX) is a well-characterized clinicopathologic entity distinct from necrobiotic xanthogranuloma (NXG). We present the case of a patient with the classic clinical course of NPX but with many histologic features in common with NXG, namely, multinucleated lipophages, cholesterol clefts, and degeneration of collagen with associated cellular necrosis (necrobiosis). We suggest that NPX and NXG represent part of a spectrum of xanthomatous dermal reactions associated with paraproteinemias and may be more closely related than previously recognized.

Electrosurgery: Part I. Basics and principles

The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage is responsible for at least the majority--if not all--of the tissue effects in electrosurgery. Adjacent to the active electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that determines the final tissue effects of a current is the depth and the rate at which heat is produced. Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation. An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which leads to tissue fragmentation and cutting.

Increasing utilization of dermatologists by managed care: An analysis of the National Ambulatory Medical Care Survey, 1990–1994

Patients with managed care are less likely to see dermatologists for skin problems than are patients with traditional insurance. Through 1992, increase in the demand for treatment of skin problems reduced the effect of managed care on dermatologists. We assessed the continued impact of managed care on visits to dermatologists. Skin disease visits from the National Ambulatory Medical Care Survey were analyzed for the years 1990-1994. We found that demand for treatment of skin problems did not rise between 1992 and 1994, but demand for dermatologists services within the managed care sector more than doubled. In 1994 patients with HMO/prepaid insurance with skin disease were just as likely to see a dermatologist as were patients with commercial insurance. Mean visit duration for skin problems was 19% longer for nondermatologists than for dermatologists (p < 0.001). We conclude that dermatologists are more efficient at treating skin disease than nondermatologists and that utilization of dermatologists within managed care is increasing.

Most topical tretinoin treatment is for acne vulgaris through the age of 44 years: An analysis of the National Ambulatory Medical Care Survey, 1990–1994

BACKGROUND Topical tretinoin is effective treatment for both acne and photoaging. This creates a problem for insurers that cover medication costs, because treatment of acne is often covered but treatment of photoaging is not. The age distributions of patients with acne or photoaging are likely to be very different. Therefore, one approach insurers can use is an age cutoff for covering the cost of topical tretinoin therapy. OBJECTIVE Our purpose was to determine at what age patients are more likely to receive tretinoin for treatment of acne vulgaris versus other conditions to provide a rational basis for insurers to set coverage cutoffs. METHODS National Ambulatory Medical Care Survey data for the years 1990 to 1994 were analyzed to ascertain the age distribution of acne vulgaris office visits and treatment with topical acne agents including tretinoin. These data were compared to office visits and tretinoin treatment of wrinkles, solar elastosis, and other conditions. RESULTS The mean age (+/- standard deviation) of patients seen for acne vulgaris was 24.3 +/-11.5 years old. The age distribution of topical tretinoin treatment paralleled the age distribution of acne. Tretinoin treatment of acne and of nonacne conditions were equal at an age of 44. CONCLUSION The distribution of outpatient visits for acne treatment is skewed toward older patients and persists beyond age 40. A rational age cut-off for coverage of topical tretinoin treatment is 40 years.

Time-efficiency of nondermatologists compared with dermatologists in the care of skin disease

BACKGROUND It has been suggested that using an established primary care doctor potentially could be a more efficient use of physician time than a new visit to a dermatologist for patients seeking care for skin diseases. OBJECTIVE We test the hypothesis that seeing an established primary care doctor for a skin problem is a more efficient use of physician-time resources than a new visit to a dermatologist. METHODS The duration (in minutes) of outpatient visits for dermatologic conditions was obtained from the National Ambulatory Medical Care Survey from 1990 to 1994. To control for the complexity of visits, the analysis was limited to the 62% of these visits in which a single dermatologic condition was the only condition being treated. RESULTS For all outpatient dermatologic visits combined, dermatologist visits for patients 18 years old or younger were 1.5 minutes (12%) shorter than nondermatologist visits, and dermatologist visits for patients older than 18 years were 3.1 minutes (20%) shorter than nondermatologist visits. Compared with nondermatologists, dermatologists have a shorter average visit duration for new, first-time patient encounters and for encounters with established patients. A significant difference in outpatient visit duration does not exist when comparing new, first-time visits for dermatologists to established visits for nondermatologists (P = .3). CONCLUSION A visit to an established primary care provider for treatment of a skin problem is not a more efficient use of physician resources than a new or return visit to a dermatologist.

CD34‐positive eruptive fibromas

The list of entities comprising a proliferation of CD34 (+) spindle cells continues to grow. Described, herein, is a patient who had an indolent eruption of scattered papules composed of CD34 (+) spindle cells, beginning in adolescence.