Atypical fibroxanthoma (AFX), pleomorphic dermal sarcoma (PDS), and undifferentiated sarcoma, pleomorphic subtype (US) are rare malignant neoplasms of mesenchymal origin with many shared clinicopathologic features. AFX are usually superficial at time of diagnosis with low risk for recurrence or metastasis following surgical extirpation. In contrast, PDS and US display greater adverse histopathological features and subcutaneous invasion which portend higher risk for local recurrence, metastasis, and death. AFX and PDS form a biological spectrum defined by shared ultraviolet (UV)-signature mutations and arise on sun-exposed skin. Malignant fibrous histiocytoma (MFH), later termed undifferentiated pleomorphic sarcoma (UPS), has been repeatedly reclassified since the 1960s, leading to ambiguity in the literature. Although histopathology may overlap with AFX and PDS, US (former MFH/UPS) lacks UV-associated mutations, shows a complex karyotype, occurs on sun-protected areas, and is a diagnosis of exclusion once lineage-defined sarcomas are ruled out by ancillary studies. Due to the rarity of these tumors, definitive diagnostic, management, and surveillance guidelines have not been established. Multidisciplinary teams are recommended in more advanced cases. For unresectable, recurrent, or metastatic disease, adjunctive therapies including radiation, chemotherapeutics, and immunotherapies have been utilized with varying efficacy.

BACKGROUND:Circulating tumor DNA (ctDNA) measures cancer-specific genetic material migrated from a tumor to a patient's bloodstream. Limited research exists aggregating data on ctDNA as a measure of recurrence, treatment success, and survival in patients with melanoma. OBJECTIVE:The authors aim to evaluate evidence for ctDNA as a measurement of recurrence and survival, and how those results differ by tumor grade and measurement time point in cutaneous melanoma treated with dermatologic surgery. METHODS:An OVID Medline search and manual filtering resulted in six studies meeting the inclusion criteria: evaluating survival and/or disease recurrence by ctDNA measurement in patients with cutaneous melanoma who had undergone dermatologic surgery. RESULTS:Sequencing methods varied: some studies analyzed known gene mutations and others developed individual tumor assays. Individual assays provide more information but are less practical to perform. Significant relationships between postoperative ctDNA level and disease recurrence and survival were found in multiple studies. The most represented stages of melanoma included were II and III. All studies measured postoperative ctDNA, but at unique time points. CONCLUSION:ctDNA measurement may be a useful tool in measuring treatment efficacy and disease recurrence in patients with cutaneous melanoma treated with dermatologic surgery.

BACKGROUND Oral clindamycin is associated with colonization by Clostridioides difficile ( C. difficile ). No data have been reported on the incidence of C. difficile infection in patients receiving intraincisional clindamycin. OBJECTIVE The goal of this study was to evaluate the incidence of C. difficile infection in dermatologic surgery patients treated with intraincisional clindamycin, compared with patients who did not receive intraincisional clindamycin and with historical rates reported for oral clindamycin. MATERIALS AND METHODS Dermatologic surgery patients were grouped by whether they received intralesional clindamycin. Patients' records were searched for “ C. difficile ” or analogous terms. The groups were compared with one another and historical rates reported for oral clindamycin. RESULTS There was no significant difference in the rate of C. difficile infections between the intralesional clindamycin ( N = 9) and no intralesional clindamycin ( N = 6) cohorts (χ 2 [1, N = 15] = 0.31, p = .57) or any of their stratified groups. There was a significant difference in infection rate between the group receiving neither intralesional nor oral clindamycin ( N = 3) and historical rate reported for oral clindamycin ( N = 92) (χ 2 [1, N = 95] = 5.81, p = .01). There was also a significant difference in the infection rate between the group receiving intralesional clindamycin without oral antibiotics ( N = 4) and the historical rate reported for oral clindamycin (χ 2 [1, N = 96] = 3.71, p = .05). CONCLUSION There was no difference in the rate of C. difficile infection between the cohort receiving intralesional clindamycin and those not. However, patients who received no form of antibiotics or intralesional clindamycin without oral antibiotics had significantly lower infection rates than the historical rates reported for oral clindamycin.

Importance:Currently, there are no standardized outcome domains or measures in clinical trials for facial aging. Heterogeneity in outcome domains and measurement instruments across clinical trials creates difficulty in directly comparing interventions, determining superior therapies, and developing high-quality meta-analyses. Objective:To develop a core outcome set (COS) of essential domains to be reported in clinical trials evaluating the efficacy of interventions for facial aging. Evidence Review:PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, and CINAHL were searched from September 2005 to September 2015. An updated search of the same databases was performed from September 2015 to February 2026. Studies were included if (1) they were randomized clinical trial or controlled clinical trial in design, (2) they assessed the efficacy or safety of an intervention for facial aging, (3) they were published in English, and (4) they involved human participants. Complementary sources, including patient interviews, were used to capture further relevant outcomes. Two rounds of Delphi surveys, followed by consensus meetings, were used to identify outcome domains considered most important by both patient and physician stakeholders. Findings:The final COS consists of 6 outcome domains: (1) overall convenience of treatment; (2) time to return to normal work and social activity; (3) overall assessment of focused area of treatment (at the point in time when treatment is expected to provide peak benefit); (4) duration of treatment effect; (5) severity of persistent local or systemic adverse events, including pigmentary change, skin texture change, delayed healing, scarring, and serious adverse events; and (6) patient satisfaction with treatment. Conclusions and Relevance:The 6 outcome domains identified through a Delphi consensus are recommended for reporting in future facial aging trials to ensure that outcomes that matter most to patients and clinicians are measured and that results are comparable across interventions.

BACKGROUND:Hypertension (HTN) is common in patients presenting for dermatologic surgery and may be a modifiable risk factor for procedural complications, yet standardized dermatology-specific guidelines on blood pressure (BP) management are limited. OBJECTIVE:To synthesize evidence on the impact of HTN on cutaneous surgery and clarify dermatologists' role in BP assessment and management and propose practical clinical guidelines. MATERIALS AND METHODS:The authors conducted a literature search, identified studies relevant to HTN management in dermatologic surgery, comparable office-based surgical specialties, and recent American Heart Association perioperative guidelines. RESULTS:Although HTN may increase perioperative complications, rigid BP cutoffs are not supported by current evidence. Rather, a risk-based framework is supported: surgery may proceed with caution until BP exceeds 200/110 mm Hg without symptoms of acute hypertensive end organ damage. For BP above this threshold, clinicians should attempt to lower BP through rest, anxiolytics, or other calming measures. If BP remains uncontrolled, surgery should be deferred and patients referred for primary care provider management. Dermatologists should measure BP at the initial consultation visit, continue home antihypertensives, maintain adequate analgesia, and use 5-mg diazepam as needed for perioperative anxiety. CONCLUSION:A risk-stratified approach to HTN, combined with adjunct BP management strategies, supports safe and timely dermatologic surgery.

This literature review has addressed key areas in the management of AKs, focusing on therapeutic clinical trials, pathophysiological research, and the effectiveness of program implementation. The progress in PDT protocols, novel topical agents, and the application of advanced diagnostic tools and AI to enhance treatment precision has been outlined. Studies on the pathophysiology of AK have offered insights into its molecular basis, aiming to direct future therapeutic strategies. Additionally, investigations into program implementation have sought to improve diagnostic accuracy, treatment adherence, and patient-centric care.

BACKGROUND:Cellular dermatofibromas (CDFs) are uncommon benign fibrous histiocytomas with histologic patterns resembling malignancies. Despite their benign nature, CDFs can recur and metastasize. Physicians are uncertain about the management of CDF, given its resemblance to dermatofibrosarcoma protuberans. OBJECTIVE:This review aims to review CDF's clinical and histologic features, differentiate it from similar presenting malignancies, and discuss treatments and outcomes for better clinical management. MATERIALS AND METHODS:In April 2024, a PubMed and Google Scholar search was completed using "cellular dermatofibroma" through the University of California Davis Medical School's library databases. The search included meta-analyses, randomized controlled trials, observational studies, reviews, and case studies published within the past 70 years. References from retrieved articles were utilized as additional resources. RESULTS:Clinical signs of CDF include firm, skin-colored to hyperpigmented lesions usually larger than 2 cm, typically on extremities. Currently, there are no definitive indicators for CDF recurrence or metastasis. Diagnosis requires microscopic and histopathologic examination, with surgical excision as the preferred treatment. Recurrence is not uncommon, while metastasis is rare. CONCLUSION:CDFs often develop in young/middle-aged adults with a tendency to recur and in rare cases can metastasize. Future studies could explore lesion characteristics that are associated with potential for recurrence and metastasis.

BACKGROUND:Despite the growth in patient-centered care, multicenter prospective studies investigating satisfaction after skin cancer surgery are limited. OBJECTIVE:To assess trends in esthetic satisfaction, symptoms, and quality of life over 1 year in facial skin cancer patients. METHODS:Patients with facial skin cancer who underwent surgery were enrolled at 4 hospitals across the United States. A total of 990 patients were included. The FACE-Q Skin Cancer questionnaire was administered before surgery, at 2-week, 6-month, and 1-year intervals postsurgery. RESULTS:Patients reported increased satisfaction with FACE-Q scales over 1 year. Significant factors influencing outcomes included sex, age, history of facial skin cancer, cosmetic surgery, defect size, and cancer location. Males reported higher satisfaction with appearance (P = .003) and scar (P < .001), and reduced psychosocial distress (P < .001). Larger defects were associated with greater psychosocial distress (P = .037) and lower scar appraisal (P = .008). Patients with nose skin cancer reported lower satisfaction with appearance and scars (P = .026, P < .001), higher psychosocial distress (P = .004), and increased cancer worry (P = .045). Patients with cancer near the eyes reported increased cancer worry (P = .004). Reconstruction types did not influence satisfaction. CONCLUSIONS:Clinical and patient characteristics significantly influence patient-reported outcomes, highlighting the need for personalized treatment approaches to optimize outcomes in dermatologic surgery.

BACKGROUND:Both running horizontal mattress (HM) and running subcuticular (SQ) suturing techniques have been suggested to be superior to other running cuticular suturing techniques. These 2 techniques have not been directly compared. OBJECTIVE:To compare cosmetic outcomes between a running HM and a running SQ technique in a split scar model following linear closure of trunk and extremity defects. METHODS:Fifty patients were enrolled in a randomized, evaluator-blinded, split-scar study. One side of the surgical wound was randomized to receive one intervention (HM vs SQ) with the other side receiving the alternate intervention. The primary outcome was the Patient and Observer Scar Assessment Scale (POSAS) score at a minimum of 3 months postoperatively. RESULTS:Observer POSAS sum of components was 19.49 and 17.76 for HM and SQ, respectively (P = .14). The mean score for patient overall opinion was 4.71 for HM and 3.50 for the SQ technique (P = .02). Overall opinion scores of evaluators were 3.87 and 3.29 for HM and SQ, respectively (P = .03). LIMITATIONS:Single-center study of a relatively homogenous population. CONCLUSION:Although there was no significant difference in the sum of POSAS components between HM and SQ (P = .14), both patients and evaluators had a superior overall opinion of the SQ-treated side (patient P = .02, evaluator P = .03).

Amin, Mina MD; Kneiber, Diana MD; Cassarino, David MD, PhD; Eisen, Daniel B. MD Author Information

OBJECTIVE:The FACE-Q Skin Cancer Module is a Patient-Reported Outcome Measure (PROM) utilized to assess outcomes following facial skin cancer resection. However, the lack of Minimal Important Difference (MID) estimates hinders the interpretability of the PROM scores. This study established MID estimates for the four outcome scales from the FACE-Q Skin Cancer Module using distribution-based methods. METHODS:A prospective cohort study at four hospitals in the United States, enrolled participants who underwent Mohs Micrographic Surgery (MMS) for facial skin cancer between April 2020 and April 2022. Participants completed the Satisfaction with Facial Appearance, Appearance-related Psychosocial Distress, Cancer Worry, and Appraisal of Scars scales at four time points: pre-operatively, 2-week, 6-month, and 1-year post-surgery. RESULTS:A total of 990 patients participated in the study, with completion rates of 98.4% for the pre-operative assessment, 70.8% at 2 weeks, 59.3% at 6 months, and 60.4% at 1 year. MID estimates, calculated using 0.2 standard deviation and 0.2 standardized response mean, were determined for the four scales. The mean MID estimates, based on a Rasch transformed score ranging from 0 to 100, were 5 for the Appraisal of Scars scale and 4 for the remaining three scales. CONCLUSION:This multicenter study provides valuable MID estimates for the FACE-Q Skin Cancer Module, specifically for the MMS patient population, enabling clinicians and researchers to better interpret scores, determine appropriate sample sizes, and apply the findings in clinical care.

Background: Mohs micrographic surgery (MMS) is a promising treatment modality for melanoma in situ (MIS). However, variations in surgical technique limit the generalizability of existing data and may impede future study of MMS in clinical trials. Methods: A modified Delphi method was selected to establish consensus on optimal MMS techniques for treating MIS in future clinical trials. The Delphi method was selected due to the limited current data, the wide range of techniques used in the field, and the intention to establish a standardized technique for future clinical trials. A literature review and interviews with experienced MMS surgeons were performed to identify dimensions of the MMS technique for MIS that (1) likely impacted costs or outcomes of the procedure, and (2) showed significant variability between surgeons. A total of 8 dimensions of technical variation were selected. The Delphi process consisted of 2 rounds of voting and commentary, during which 44 expert Mohs surgeons across the United States rated their agreement with specific recommendations using a Likert scale. Results: Five of eight recommendations achieved consensus in Round 1. All 3 of the remaining recommendations achieved consensus in Round 2. Techniques achieving consensus in Round 1 included the use of a starting peripheral margin of ≤5 mm, application of immunohistochemistry, frozen tissue processing, and resecting to the depth of subcutaneous fat. Consensus on the use of Wood’s lamp, dermatoscope, and negative tissue controls was established in Round 2. Conclusions: This study generated 8 consensus recommendations intended to offer guidance for Mohs surgeons treating MIS. The adoption of these recommendations will promote standardization to facilitate comparisons of aggregate data in multicenter clinical trials.