To the Editor: By 2050, most Americans will have ethnic skin or skin of color (SOC).1 We aimed to assess outcomes in patients with different Fitzpatrick skin types (FSTs) who had surgery to remove their nonmelanoma skin cancers.

BACKGROUND:Few studies show how dermatologic surgeons manage problems with site identification. OBJECTIVE:To estimate frequency and characterize management of skin cancer treated by surgery when the anatomic location of the tumor is in question. METHODS:Nationwide, prospective, multisite cohort study. RESULTS:Among 17,076 cases at 22 centers, 98 (0.60%) were lesions in question for which site identification was initially uncertain, with these more often in patients who were male, older, and biopsied more than 30 days ago. Surgeons employed on average 5.0 (95% CI: 4.61-5.39) additional techniques to confirm the site location, with common approaches including: re-checking available documentation (90 lesions, 92%); performing an expanded physical examination (89 lesions, 91%); and asking the patient to point using a mirror (61 lesions, 62%). In 15%, photographs were requested from the biopsying provider, and also in 15%, frozen section biopsies were obtained. In 10%, the referring physician was contacted. Eventually, surgeons succeeded in definitively identifying 82% (80 of 98) of initially uncertain sites, with the remaining 18% (18 of 98) postponed. Most postponed surgeries were at non-facial sites. LIMITATIONS:Sites were academic centers. CONCLUSIONS:When the anatomic location of the tumor is uncertain, dermatologic surgeons use multiple methods to identify the site, and sometimes cases are postponed.

IMPORTANCE It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. OBJECTIVE To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. EXPOSURES Mohs surgery for nonmelanoma skin cancer. MAIN OUTCOMES AND MEASURES Reason for treatment selection. Results Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Dermatofibrosarcoma protuberans (DFSP) is a low-grade dermal sarcoma that arises from a fibroblast/myofibroblast origin.1 Mohs micrographic surgery (MMS) is the gold standard because of a tendency for local invasion and high rates of recurrence with standard wide excision. We present 2 cases of the rare myxoid variant of DFSP successfully treated with MMS, one of which had the unusual clinical presentation of an atrophic patch.

Work Group: Chair, David J. Kouba, MD, PhD, Matteo C. LoPiccolo, MD, Murad Alam, MD, Jeremy S. Bordeaux, MD, MPH, Bernard Cohen, MD, C. William Hanke, MD, Nathaniel Jellinek, MD, Howard I. Maibach, MD, Jonathan W. Tanner, MD, PhD, Neelam Vashi, MD, Kenneth G. Gross, MD, Trudy Adamson, MSN, RN, DNC, Wendy Smith Begolka, MBS, and Jose V. Moyano, PhD Toledo and Cleveland, Ohio; Detroit and Shelby, Michigan; Chicago and Schaumburg, Illinois; Baltimore, Maryland; Carmel, Indiana; East Greenwich, Rhode Island; San Francisco and San Diego, California; Philadelphia, Pennsylvania; Boston, Massachusetts; and Rochester, Minnesota

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.

Field therapy is a popular and important treatment for actinic keratosis. These agents have unique benefits as well as side effects. Dermatologists and others prescribing topical treatment for actinic keratosis should be aware of several important side effects. One of the most important side effects is the development of impetigo on the treated skin. We present a case of a patient who developed impetigo after applying ingenol mebutate gel for treatment of actinic keratosis. Impetigo is a not uncommon, but important complication of topical therapy for actinic keratosis. Prompt diagnosis and treatment can prevent unnecessary morbidity. Topical pharmacotherapy for treatment of actinic keratosis (AK) is an alternative preferred by some dermatologists over lesion-directed modalities because the former allows for coverage of subclinical AKs (so called “field treatment”). There are several options for dermatologists and patients considering field treatment with a topical agent. Traditionally 5-fluorouracil (5-FU) has been used, but this requires consistent daily to twice daily application for up to four weeks. In comparison, ingenol mebutate (IM) requires only once daily applications for two or three days. Such a schedule allows for enhanced patient adherence. Furthermore, a recent prospective randomized trial confirmed that the local skin reaction (LSR) of patients treated with IM is more short lived compared to those treated with 5-FU (1). Topical pharmacotherapy agents are generally well tolerated. Nearly all patients receiving topical pharmacotherapy for AKs notice erythema and discomfort at the site of treatment. In a multicenter, randomized, doubleblind study, pain and pruritus were found to be the most commonly reported adverse events with IM use (2). A 70-year-old Caucasian male with prior non-melanoma skin cancer history presented with three erythematous macules with adherent scale on the lip and forehead. These were clinically determined to be AKs and were treated with combination cryotherapy and field treatment of the face with IM 0.015% gel for three days. The patient returned four weeks later with bright erythema and honey-colored crust of the upper and lower lip (Figure 1). A bacterial culture was collected and at that time the patient was treated empirically with mupirocin and cephalexin. The bacterial culture subsequently revealed pan-sensitive staphylococcus aureus and the patient rapidly improved. Impetigo during treatment with 5-FU for AK is not uncommon and is presumably a result of a compromised skin barrier. Reasonably, the incidence of impetigo could be expected to be higher in patients receiving 5-FU compared to IM as the LSR is more persistent in the former (1). In a study of 162 patients receiving IM, only one patient developed impetigo (3). Prompt recognition and treatment of this condition is essential to prevent unnecessary morbidity. While IM has a preferable treatment schedule and duration of LSR, it nevertheless can result in the adverse effects like impetigo that are assumed to be more characteristic of 5-FU.

BACKGROUND:Many variations in the surgical treatment of upper eyelid blepharoplasty have been described, including orbicularis oculi muscle stripping. There is no evidence in the literature to support the efficacy of this technique in improving the aesthetic results of the procedure.OBJECTIVES:To conduct a single-blind, randomized, controlled, split-face pilot study to evaluate the effects of orbicularis oculi muscle stripping on upper lid blepharoplasty.METHODS:Ten subjects were randomized to receive upper lid blepharoplasty with orbicularis oculi muscle stripping on one side and skin-only blepharoplasty on the other. Patients and two blinded physicians evaluated the aesthetics of the eyelids at 1-, 3-, and 17-month follow-up visits.RESULTS:Blinded physician evaluation failed to show a difference in the overall cosmetic appearance of the eyelids between the control and treatment sides at any time point. Analysis of the composite of all patient scores showed a trend favoring the control side at 3 months (p = .28) and the treatment side at 17 months (p = .50), but neither difference was significant.CONCLUSION:Based on the data from this pilot study, orbicularis oculi muscle stripping appears to have no affect on the aesthetic outcome of upper lid blepharoplasty.

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.

1Department of Dermatology, Henry Ford Hospital, Detroit, Michigan 2Dermasurgery and Laser Center, Toledo Clinic, Toledo, Ohio Address correspondence and reprint requests to: Christopher T. Burnett, MD, Department of Dermatology, Henry Ford Hospital, 3031 West Grand Blvd., Ste. 800, Detroit, MI 48202, or e-mail: [email protected] The authors have indicated no significant interest with commercial supporters.

Purpose A survey‐based study was conducted to gather expert experience on safety procedures used when performing Mohs micrographic surgery (MMS) on patients with known infectious hepatitis or human immunodeficiency virus (HIV). Methods Six hundred eighty‐four fellowship‐trained Mohs surgeons were surveyed to examine the types of safety protocols used when treating patients with known infectious hepatitis or HIV and the frequency of exposure injuries to laboratory and surgical personnel from these patients. Results One hundred eighty‐eight (27.5%) surveys were collected; 64.7% of respondents reported at least one exposure injury to surgical or laboratory personnel in the past year, and 4.8% reported exposure from a patient with known hepatitis or HIV infection. Risk of reporting at least one injury from a patient with known infection within the past year was significantly less when also reporting disposal of the ink applicator after each use (relative risk [RR] = 0.109) and greater when employing laboratory personnel with no medical education or background (RR = 3.857). No exposures were reported from respondents using blunt skin hooks, safety scalpels, safety syringes, smoke evacuators, a separate ink supply, or 24‐hour formalin fixation. Conclusion Although firm associations cannot be made from this study, the data suggest that certain measures may help to reduce the rate of exposure injuries in MMS.

Mutations in the sonic hedgehog signaling pathway play a key role in the development of basal cell carcinomas. Specifically, mutations in the PTCH1 (also known as PTCH or PTC1) and SMO genes cause tumor formation through constitutive activation of the pathway. Misregulation of the pathway has also been implicated in the nevoid basal cell carcinoma syndrome and other tumors. Understanding the function of the sonic hedgehog pathway has led to novel strategies for treatment. In this review we highlight the role of the pathway in the pathogenesis of basal cell carcinoma and review potential targeted therapies. (J Am Acad Dermatol 2012;66:e167-78.)

1Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, 2Toledo Clinic, Dermasurgery and Laser Center, Toledo, Ohio, Address correspondence and reprint to: Christopher T. Burnett, MD, Department of Dermatology, Henry Ford Hospital, 3031 W. Grand Blvd., Ste. 800, Detroit, MI 48202, or e-mail: [email protected] The authors have indicated no significant interest with commercial supporters.

1Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, 2Dermasurgery and Laser Center, Toledo Clinic, Toledo, Ohio, Address correspondence and reprint requests to: Christopher T. Burnett, MD, Department of Dermatology, Henry Ford Hospital, 3031 West Grand Blvd., Ste. 800, Detroit, MI 48202, or e-mail: [email protected] The authors have indicated no significant interest with commercial supporters.

&NA; Graceway Pharmaceuticals, Bristol, Tennessee, provided the imiquimod cream used in this study.

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Cutaneous lymphadenoma (CL) is a benign neoplasm commonly presenting on the head and neck of young and middle-aged adults. Complete surgical excision of CL is the treatment of choice and appears to be curative. As compared to local excision without margin control, Mohs micrographic surgery (MMS) may allow for more definitive tumor extirpation for large cases of CL and allow for greater tissue preservation at functionally and aesthetically sensitive sites. We present a case of cutaneous lymphadenoma presenting on the right cheek of a middle-aged male who was successfully treated with MMS.