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.

Health utilities characterize patient health states between 0 (death) and 1 (perfect health). Utilities quantify disease impact on quality of life, allowing comparison of patient preferences for different health states. We assessed utilities associated with nonmelanoma skin cancer (NMSC) for 74 consecutive patients (44 men) with biopsy-proven NMSC. Utilities were obtained by asking individuals about their willingness to trade time in a defined state of health for less time in perfect health. Per the methods of health utility assessment, for each health state, the interviewer read a descriptive paragraph (ie, described a hypothetical health state), and an iterative questionnaire method was used to elicit the subject's utility in months. This allowed collection of utility data from those with and without a given condition.

Acne scarring results from a common inflammatory condition present in many people. These scars can have an impact on quality of life by influencing self-esteem and social acceptance. Current acne scarring treatments, such as chemical peels and laser treatments, often have limited success due to their time-consuming nature and the variability of acne scar types. The subcision technique has shown promise for the treatment of rolling acne scars. There are few studies to date that examine the effects of multiple subcision treatments on rolling acne scars. We evaluated whether the use of multiple subcision treatments improved the appearance of rolling acne scars compared to no treatment. Five patients with rolling acne scars on both sides of their face who met inclusion and exclusion criteria were enrolled in the study. One side of the face was randomized to receive treatment, while the contralateral side of the face received no treatment. Subjects underwent five sequential subcision treatments, spaced 4 weeks apart, with two follow-up visits at weeks 20 and 36 from the 1st treatment. Photographs were taken before and after the initial treatment visit and at each subsequent visit. Acne scar appearance was evaluated by the subject, a blinded live rater, and two double-blinded dermatologist raters. Evaluations of treatment outcomes involved overall acne scar appearance on a 5-point scale, acne scar improvement on a percentage scale, a modified quantitative global scarring grading system, and potential treatment side effects. There was a greater decrease in global scarring scores in the multiple subcision side compared to the control side. There was a greater difference in the average acne scar appearance scores between the Week 36 follow-up visit and baseline for the multiple subcision side compared to that of the control side. 50% of patients reported being more satisfied with the treatment side compared to the control side in regard to overall improvement. The study results suggest that multiple subcision treatments may improve the appearance of rolling acne scars compared to no treatment.

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.

Therapeutic options for acne scars include subcision and suction with microdermabrasion, but these treatment modalities have not been studied in conjunction. To compare effectiveness of subcision alone versus subcision with suction for the treatment of facial acne scars. Randomized, split-faced, evaluator-blinded control trial. Participants underwent one subcision treatment on both sides of the face followed by 10 sessions of suction to one side. Photographs at baseline, 1-month, and 4-months were assessed. Primary outcome measures were the validated Acne Scar Severity Scale (ASSS) (0 = no acne scarring, 4 = severe), Acne Scar Improvement Grading Scale (ASIGS) (-100 to 100%), and modified Quantitative Global Scarring Grades (QGSG) (point-based questionnaire instrument), as well as subject preference. Twenty-eight treatment areas and 154 treatments were analyzed. Dermatologist raters found no differences between subcision alone and subcision-suction at 1-month or 4-months. Mean subject-assessed percent improvement for subcision-suction was higher than that for subcision alone at 1-month (37% versus 24%, p = 0.04) but not at 4-months (p = 0.37). Subjects preferred combination therapy to monotherapy at 1-month (50% vs. 21%) and 4-months (43% vs. 21%). While blinded raters did not detect significant differences, subjects perceived combination treatment as working more quickly than monotherapy, and preferred combination treatment at all time points.Clinical trial registration NCT01696513 on Clinicaltrials.gov.

The LUMIN consortium is hopeful that over the next few years, the LUMIN Registry will garner a significant amount of data entries such that it will facilitate research and answer practical questions that clinicians performing laser procedures may have (e.g. which laser is most effective for a particular condition, the best settings for optimal results, how many treatments are needed, how often treatments should occur, duration of remission after laser treatment, relapse rates after treatment, adverse events and their management).As they better understand these considerations, clinicians will be more adept at counseling and providing care to their patients.Additionally, analysis of registry data may improve therapeutic approaches, thereby enabling better clinical outcomes.

To the Editor: Therapies for actinic keratosis (AK) include photodynamic therapy (PDT), in which blue light activates photosensitizing compounds, like 5-aminolevulinic acid (5-ALA).1 The approved incubation time for 5-ALA before light irradiation is 14-18 hours, with prior studies reporting 0-18 hours.2,3 Nearly 10% of patients cannot complete therapy due to pain.4 This randomized controlled trial compared the effectiveness of BLU-U and Levulan Kerastick (ALA HCL, DUSA Pharmaceuticals) with 1-hour incubation to that without incubation.

Background: Surgical Site Infections are the second most common type of health care-associated infection. Prior to this study, no research of this kind had been done at Ndola Teaching Hospital in Ndola, Zambia, to determine the prevalence of SSI after general surgery. This study therefore aimed at determining the burden and associated risk factors for surgical site infections in General Surgery Department of Ndola Teaching Hospital. Materials and Methods: A hospital-based retrospective descriptive study conducted Ndola Teaching Hospital general surgery dept. Selected and operated patients’ hospital records were reviewed. Pearson Chi-square test and Odds ratio were used to test for each risk factor’s association with SSI followed by their 95% confidence interval. Only p-value less than 0.05 was considered statistically significant. Results: The burden of surgical site infections was 18% [OR=0.394; 95%CI = (0.179-0.867)]. Factors that showed a significant association with the burden were gender [OR=3.394; 95%CI= (1.179-8.867), p=0.014], post-operative duration of hospital stay [OR=20.308; 95%CI= (3.364-27.798), p=0.00], emergency surgeries [OR=3.445; 95%CI = (1.625-7.304), p= 0.001] and intra-operative duration [OR=12.476; 95%CI= (4.104-37.925), p= 0.000]. However, there was no association observed between the qualification of the surgeon and the development of the infection. Conclusion: Surgical site infections were high and associated with the duration of hospital stay, intra-op duration of the procedure, the type of surgery and gender. It remains imperative to find possible interventions to reduce the risk of suffering from surgical site infections among patients who go to theatre.

To the Editor: Mobile applications for detection of suspicious skin lesions have the potential to transform skin cancer prevention.1Sar-Graycar L. Rotemberg V.M. Matsoukas K. Halpern A.C. Marchetti M.A. Hay J.L. Interactive skin self-examination digital platforms for the prevention of skin cancer: a narrative literature review.J Am Acad Dermatol. 2021; 84: 1459-1468https://doi.org/10.1016/j.jaad.2020.07.014Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar,2John A.M. Ragi S.D. Goldberg D.J. Mobile applications in skin cancer detection: a descriptive analysis.Dermatol Surg. 2021; 47: 1285-1286https://doi.org/10.1097/DSS.0000000000003134Crossref PubMed Scopus (1) Google Scholar Sensitivities and specificities of mobile applications †Sensitivity is the ability of a positive test to correctly identify a subject with disease, while specificity is the ability of a negative test to correctly identify a subject without disease.3Ngoo A. Finnane A. McMeniman E. Tan J.M. Janda M. Soyer H.P. Efficacy of smartphone applications in high-risk pigmented lesions.Australas J Dermatol. 2018; 59: e175-e182https://doi.org/10.1111/ajd.12599Crossref PubMed Scopus (33) Google Scholar are generally inferior to those of an in-person dermatologist visit (Supplementary Tables I and II, available via Mendeley at https://doi.org/10.17632/5mgxkdrf2h.1).3Ngoo A. Finnane A. McMeniman E. Tan J.M. Janda M. Soyer H.P. Efficacy of smartphone applications in high-risk pigmented lesions.Australas J Dermatol. 2018; 59: e175-e182https://doi.org/10.1111/ajd.12599Crossref PubMed Scopus (33) Google Scholar This may be the first cross-sectional study to determine minimum levels of sensitivity and specificity that patients and physicians expect from mobile applications for skin cancer screening. Seventy-five physicians (Table I) completed a 2-round modified Delphi process, and 60 patients each underwent a one-on-one interview (Supplementary Table I and Fig 1, available via Mendeley at https://doi.org/10.17632/5mgxkdrf2h.1). Participants were provided the purpose of mobile applications; meaning of "screening test"; US Food and Drug Administration definitions for "sensitivity" and "specificity", and lay definitions; and several clinical vignettes. Patients were given additional education (Supplementary Fig 2, available via Mendeley at https://doi.org/10.17632/5mgxkdrf2h.1). Participants were asked to specify the minimum acceptable sensitivities and specificities for skin cancer screening applications, and how likely they would be to use or recommend an application based on sensitivity.Table IFor each type of skin cancer, differences in minimum acceptable sensitivities and specificities between (a) physicians and patients, and (b) within physician specialtiesAll physicians (n = 75)Patients (n = 60)P-valueSensitivity Melanoma92% [95% CI: 91%-93%]92% [95% CI: 91%-94%].295 Basal Cell Carcinoma88% [95% CI: 87%-90%]92% [95% CI: 90%-93%].002 Squamous Cell Carcinoma89% [95% CI: 88%-91%]92% [95% CI: 90%-93%].010Specificity Melanoma79% [95% CI: 74%-83%]89% [95% CI: 86%-92%]<.001 Basal Cell Carcinoma77% [95% CI: 74%-80%]89% [95% CI: 87%-92%]<.001 Squamous Cell Carcinoma77% [95% CI: 74%-81%]89% [95% CI: 87%-92%]<.001Physicians who did not answer round 2 of the Delphi survey asked to have their responses carried forward. Open table in a new tab Physicians who did not answer round 2 of the Delphi survey asked to have their responses carried forward. Compared to physicians, patients expected higher minimum sensitivities for BCC (92% vs 88%, P = .002) and SCC (92% vs 89%, P = .01), and higher specificities for melanoma (89% vs 79%, P < .001), BCC (89% vs 77%, P < .001), and SCC (89% vs 77%, P < .001). Both patients and physicians expected a minimum sensitivity of 92% for melanoma. Among physicians, PCPs expected lower specificities for melanoma versus dermatologists (69% vs 84%, P = .002) (Table II). There were no differences in sensitivities or specificities by age, sex, race, or ethnicity. If mobile applications were as sensitive as dermatologists, 59% of physicians and 57% of patients would be extremely likely to recommend or use them, compared to only 4% of physicians and 18% of patients if they were 75% as sensitive.Table IIFor each type of skin cancer, differences in minimum acceptable sensitivities and specificities between physician specialtiesPrimary care Providers (n = 15)Oncologists (n = 30)Dermatologists (n = 30)P-valueSensitivity Melanoma93% [95% CI: 91%-95%]91% [95% CI: 89%-93%]92% [95% CI: 90%-94%].381 Basal Cell Carcinoma90% [95% CI: 87%-93%]88% [95% CI: 86%-91%]88% [95% CI: 85%-90%].597 Squamous Cell Carcinoma91% [95% CI: 88%-93%]88% [95% CI: 85%-91%]89% [95% CI: 87%-92%].485Specificity Melanoma69% [95% CI: 56%-82%]77% [95% CI: 70%-85%]84% [95% CI: 80%-89%].022 Basal Cell Carcinoma74% [95% CI: 66%-81%]77% [95% CI: 72%-83%]79% [95% CI: 74%-84%].485 Squamous Cell Carcinoma72% [95% CI: 62%-82%]77% [95% CI: 70%-83%]80% [95% CI: 75%-84%].290 Open table in a new tab Given public service messaging about skin cancer, it is understandable that patients wanted mobile applications that were highly accurate. Notably, since mobile applications for lay use will likely be used to screen low-risk lesions, unlike more equivocal lesions typically evaluated by dermatologists, to provide comparable levels of absolute performance, sensitivities for mobile applications may be expected to be higher than the 90% to 95% range reported for dermatologists.4Seyed Ahadi M. Firooz A. Rahimi H. Jafari M. Tehranchinia Z. Clinical diagnosis has a high negative predictive value in evaluation of malignant skin lesions.Dermatol Res Pract. 2021; 20216618990https://doi.org/10.1155/2021/6618990Crossref PubMed Scopus (1) Google Scholar That PCPs expected significantly lower specificities for melanoma than dermatologists may be explained by the low threshold PCPs have for referring patients to a dermatologist.5Lowell B.A. Froelich C.W. Federman D.G. Kirsner R.S. Dermatology in primary care: prevalence and patient disposition.J Am Acad Dermatol. 2001; 45: 250-255https://doi.org/10.1067/mjd.2001.114598Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar In summary, mobile applications designed to facilitate skin cancer detection do not currently meet physician and patient preferences for minimum thresholds of test specificity and sensitivity. In addition to evidence-based methods of assessing health benefits, patient expectations are an important benchmark for evaluating applications, with skin cancer detection applications ideally judged in the context of both these criteria. Clinical studies may also be undertaken to demonstrate any incremental screening benefit of mobile applications. Since even good mobile applications can merely highlight suspicious lesions, not make diagnoses, it may be appropriate for users with abnormal results to follow up with board-certified dermatologists. None disclosed.

The purpose of this retrospective multicenter cohort study of consecutive cases at 3 academic centers was to determine whether preoperative biopsies of BCC detect all subtypes present. Included were adult patients with biopsy diagnosis of primary BCC and subsequent detection of tumor in Mohs specimens. Two dermatologists recorded subtypes in each biopsy report, and two others, subtypes detected in frozen section glass slides associated with corresponding Mohs excisions. Among 827 biopsies, mixed histology was identified in 57%, but reported in 18%. A median of 1 subtype was observed in biopsies (IQR: 1-1) and 2 in excisions (IQR: 1-2). Ninety-nine percent of cases showed concordance between excision and biopsy, with 31% having identical subtypes. Biopsy and excision histology were equally clinically aggressive in 69%, excision more aggressive in 25%, and biopsy in 6%. Biopsies of BCC can fail to detect all histologic subtypes despite impeccable histologic sectioning and assessment by a dermatopathologist due to the small amount of sampled tissue. Importantly, surgeons performing definitive excisions should realize it is unrealistic to expect all present BCC subtypes to be detected in minute biopsy specimens, and should be prepared to encounter and adequately treat additional aggressive subtypes.

To the Editor: SARS-CoV-2, the pathogen responsible for the COVID-19 pandemic, presents a spectrum of disease severity, ranging from asymptomatic infection to pneumonia and fulminant respiratory failure. Although asymptomatic SARS-CoV-2 infection has been well-documented, data regarding the prevalence of asymptomatic infection in patients scheduled for ambulatory procedures are limited.1-4 However, knowing asymptomatic prevalence rates could be helpful to dermatologic surgeons at increased risk of SARS-CoV-2 transmission given their case mix, which includes a bulk of procedures performed on the head and neck.

Cosmetic dermatology is a key subspecialty of academic dermatology. As such, academic centers are expected to demonstrate excellence in the teaching of cosmetic dermatology skills to trainees, the clinical delivery of cosmetic dermatology services to patients, and the performance of clinical research that advances knowledge and uncovers new therapies in cosmetic dermatology. The Association of Academic Cosmetic Dermatology (AACD), a newly formed medical professional society, includes as its principal aims the support of all of these areas. AACD is comprised of group of board-certified dermatologists who teach cosmetic and laser dermatology at US dermatology residency programs. An expert panel constituted by the AACD recently convened a workshop to review gaps pertaining to academic cosmetic dermatology. This panel considered needs and potential corrective initiatives in three domains: resident education, patient experience, and clinical research. The work of the panel was used to develop a roadmap, which was adopted by consensus, and which will serve to guide the AACD moving forward.

Cosmetic and laser procedures are increasingly popular among patients and are skills in which dermatologists are regarded as well trained. Most dermatology residents intend to incorporate cosmetic procedures into their practice and prefer to learn such procedures during residency through direct patient care. However, there are notable challenges in optimizing how residents are trained in cosmetic and laser dermatology. To address these barriers and elevate the practice of cosmetic dermatology in academic medicine, the Association of Academic Cosmetic Dermatology (AACD) was founded in 2021 as the lead professional society for dermatologists who direct the education of resident trainees in cosmetic and laser dermatology. The AACD, a group of board-certified dermatologists who teach cosmetic and laser dermatology to residents, aims to improve cosmetic dermatology education through collaboration, research, and advocacy.

Background Limited information is available regarding real-world treatment patterns and their effectiveness and safety in patients with locally advanced basal cell carcinoma, including patients not typically represented in clinical trials. The purpose of the current study was to describe how clinicians diagnose and treat locally advanced basal cell carcinoma in the United States. Methods This prospective, multicenter, observational registry study included patients with newly diagnosed, Hedgehog pathway inhibitor–naive locally advanced basal cell carcinoma without basal cell carcinoma nevus syndrome (n = 433) treated at 75 US academic and community practices, including dermatology, Mohs surgery, and medical oncology sites. The main outcomes of this study were treatment patterns and associated effectiveness and safety for patients with locally advanced basal cell carcinoma in real-world settings. Results Determination of locally advanced basal cell carcinoma was mainly based on lesion size (79.6% of patients), histopathology (54.3%), extent of involvement (49.0%), and location (46.2%). Within 90 days of determination of locally advanced disease, 115 patients (26.6%) received vismodegib, 251 (58.0%) received surgery/other (non-vismodegib) treatment, and 67 (15.5%) had not yet received treatment (observation). Vismodegib-treated patients had a higher prevalence of high-risk clinical features predictive for locoregional recurrence than those with non-vismodegib treatment or observation. Clinical response rate was 85.1% with vismodegib and 94.9% with non-vismodegib treatment (primarily surgery). The most common adverse events with vismodegib were ageusia/dysgeusia, muscle spasms, alopecia, and weight loss. Rates of cutaneous squamous cell cancers were comparable between vismodegib and non-vismodegib treatment. Conclusions This prospective observational study offers insight on real-world practice, treatment selection, and outcomes for a nationally representative sample of US patients with locally advanced basal cell carcinoma. For patients with lesions that were not amenable to surgery, vismodegib treatment was associated with effectiveness and safety that was consistent with that observed in clinical trials.

Dermatofibrosarcoma protuberans (DFSP) is a cutaneous sarcoma that has remained a challenge for oncologic and reconstructive surgeons due to a high rate of local recurrence. The objective of this study is to investigate the oncologic and reconstructive benefits of employing a multidisciplinary two-step approach to the treatment of DFSP. A retrospective review was conducted using a prospectively collected database of all patients who underwent resection and reconstruction of large DFSPs by a multidisciplinary team, including a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic and reconstructive surgeon, at one academic institution from 1998–2018. Each patient underwent Mohs micrographic surgery for peripheral margin clearance (Step 1) followed by wide local excision (WLE) of the deep margin by surgical oncology and immediate reconstruction by plastic surgery (Step 2). 57 patients met inclusion criteria. Average defect size after WLE (Step 2): 87.3 cm2 (range 8.5–1073.5 cm2). Mean follow-up time was 37 months (range 0–138 months). There were no cases of recurrence. A two-step multidisciplinary surgical treatment approach for DFSP minimizes risk of recurrence, decreases patient discomfort, and allows immediate reconstruction after deep margin clearance.

BACKGROUND Recent increase in skin biopsies has been attributed to an epidemic of skin cancer. This may be avoidable, with potential savings. OBJECTIVE To determine whether the increase in skin biopsies is attributable to increasing frequency of biopsies associated with histology lacking pathological cutaneous disease. Pathological cutaneous disease was defined as (1) a malignancy, precancerous lesion, or lesion of uncertain behavior; or (2) disease symptomatic or associated with adverse quality of life impact. PATIENTS AND METHODS Retrospective cohort study, 2006 to 2013 of dermatology practice serving Florida and Ohio. Data were a consecutive sample of skin biopsies for diagnosis of dermatologic disease. RESULTS A total of 267,706 biopsies by an average of 52 providers per month from January 06 to December 13 were analyzed. Number of biopsies per visit increased 2% per year (RR: 1.02, CI: 1.00–1.04). Likelihood of biopsy associated with histology indicative of nonpathological cutaneous disease did not increase over time (OR: 0.99, CI: 0.95–1.03, p = .6302). CONCLUSION Rates of biopsies associated with nonpathological cutaneous disease is not increasing. Overall biopsy rates per visit have gradually increased; this seems attributable to greater rates of detection of pathological dermatologic disease.

Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL The authors have indicated no significant interest with commercial supporters.