Lymphovascular Invasion in Cutaneous Squamous Cell Carcinoma

BACKGROUND

Although there is a large body of literature regarding risk stratification and outcomes for perineural invasion (PNI) in cutaneous squamous cell carcinoma (cSCC), there is a relative paucity of studies exploring the role of lymphovascular invasion (LVI) in cSCC and a lack of clear evidence-based guidelines for how to manage patients with these tumors.

OBJECTIVE

This article is intended to review the available literature regarding LVI in cSCC and formulate evidence-based recommendations for clinical management.

METHODS AND MATERIALS

A literature review was conducted using PubMed to find relevant articles relating to outcomes and management of primary cSCC with LVI.

RESULTS

The available literature suggests that LVI is a major risk factor for poor outcomes and increased morbidity and mortality in cSCC.

CONCLUSION

Lymphovascular invasion is a very high-risk feature that should place these tumors in the highest-risk category, and management of these tumors should be similar to that of squamous cell carcinoma with PNI.

Nationwide Case-Control Analysis of Merkel Cell Carcinoma and Associated Skin Cancer Comorbidities: An Examination of the All of Us Database

Introduction Merkel cell carcinoma is an aggressive neuroendocrine tumor that is related to immunosuppression and the Merkel cell polyomavirus. It is more common on the head and neck and has been associated with other skin malignancies such as basal cell carcinoma, squamous cell carcinoma, and melanoma. However, there has never been a nationwide investigation that quantifies Merkel cell carcinoma's connection with these subgroups. Methods Utilizing the National Institutes of Health's All of Us open-access database, a retrospective study was conducted by filtering for Merkel cell carcinoma through the International Classification of Diseases, 9th and 10th Clinical Modification codes 209.* and C4A.*, respectively. This led to the inclusion of 41 patients in the study, with each instance compared to four control patients without merkel cell carcinoma, matched by age, race, and gender. The data's demographics and skin cancer co-morbidities were collected and evaluated with odds ratios and 95% confidence intervals using Wald's method. Results In patients with merkel cell carcinoma, a statistically significant gradient of increasing risk for developing basal cell carcinoma (Odds Ratio, 11.63; 95% Confidence Interval, 4.30-31.45; P < 0.0001), squamous cell carcinoma (Odds Ratio, 15.09; 95% Confidence Interval, 3.87-58.84; P = 0.0001), and melanoma (Odds Ratio, 27.94; 95% Confidence Interval, 3.26-239.48; P = 0.0024) was observed. The race/ethnicity demographics showed that 85.4% of the patients were white, and they were at the highest risk of developing merkel cell carcinoma. However, the study has limitations, such as the inability to identify the stage of merkel cell carcinoma among patients and the lack of consideration for other confounding variables. Conclusion The study examines the link between merkel cell carcinoma and other skin malignancies, underscoring the need for more national research to better understand the underlying causes that contribute to this link. The findings also indicate the possibility of sample bias in the All of Us database, emphasizing the need to assess the patient population's representativeness in such investigations.

An Algorithm for Managing Spitting Sutures

Spitting sutures are a common complication of dermatologic surgery following closure of a cutaneous defect using buried sutures. This development can be distressing and uncomfortable for patients and may lead to further complications, such as surgical-site infection and abscess. Presented here is a straightforward and reliable algorithm to guide management of spitting sutures and their complications.

Upper Lip Anatomy, Mechanics of Local Flaps, and Considerations for Reconstruction

Reconstruction of defects involving the upper lip can be challenging. The purpose of this review was to analyze the anatomy and function of the upper lip and provide an approach for reconstruction of upper lip defects. The primary role of the upper lip is coverage of dentition and animation, whereas the lower lip is critical for oral competence, speech, and eating. The orbicularis oris (OO) and several other muscles contribute to upper lip function. There are various insertion points for animation muscles, including the upper lip dermis, OO, and modiolus. Special attention should be paid to the philtrum, Cupid's bow, and vermilion border during reconstruction. Advantages and disadvantages of the Abbe, Estlander, and Karapandzic flaps are presented. Knowledge of mechanics, indications, and properties of local flaps while considering unique characteristics of upper lip anatomy and function are crucial for optimal aesthetic and functional outcomes.

Managing pain associated with dermatologic procedures

Dermatologists are faced with an aging population, accompanied by an increase in the incidence of skin cancer, especially nonmelanoma skin cancer. With this increase in cutaneous malignancy comes an increase in the number of dermatologic procedures being performed. A common concern of dermatologists and dermatology patients is the attenuation and management of pain associated with dermatologic procedures. Fortunately, there are several techniques that may be used in the preoperative, intraoperative, and postoperative periods to manage patient anxiety, minimize injection pain, and safely and effectively treat postoperative pain.

Psychodermatology fellowship: is it time?

The fields of dermatology and psychiatry have overlap in the patient populations and diseases they treat. However, there are not currently fellowship opportunities for dermatologists or psychiatrists specifically interested in gaining expertise in psychodermatology. We discuss the logistics of a one-year psychodermatology fellowship, open to residents after completing either dermatology or psychiatry residencies, and the potential benefits that it could bring to both dermatology and psychiatry training programs across the county.

Clinical Pearl: advantages of the scalp as a split-thickness skin graft donor site

Common challenges associated with split-thickness skin graft (STSG) donor site wounds include slow healing times and poor scar cosmesis. The technique described here improves these shortcomings by utilizing a Weck knife with adjustable thickness controls to harvest STSGs from the scalp.

Medical school ranking and dermatology match results: an analysis of the 2018 match data

Dermatology is a specialty with fewer residency positions each year than total applicants, leading to increased competition in the match. Applicants tend to have substantial research experience and high national board scores. This study sought to explore whether there is a difference in the percentage of graduates matching into dermatology residencies based on the rank of the medical school. Publicly available match lists from highly ranked medical schools were compared to match lists from other allopathic schools to determine the proportion of graduates matching into dermatology. The data was analyzed using a chi square test and a significant difference was found between the percentage of students matching into dermatology from top schools (5.19%) compared to control schools (1.92%), (P<0.0001).

Dermatologic features in good film characters who turn evil: the transformation

Dermatologic depictions in film are often used to symbolize evil. To ascertain whether certain dermatologic characteristics are more representative of evil in movies, skin findings in film characters before and after evil transformation were compared using the Good Movie Characters Turned Bad poll courtesy of The Internet Movie Database (IMDb). The poll ranked the 35 most remarkable moral transformations in cinema. Data was analyzed from 27 characters who met study criteria and there was a statistically significant, greater number of dermatologic features seen in characters after an evil transformation. Periorbital hyperpigmentation, infraorbital edema, alopecia, pallor, and nonspecific hyperpigmented skin abnormalities (telangiectasias, ecchymosis) were dermatologic traits that were found at a statistically significantly higher frequency post-evil transformation. This work suggests an effort should be made to educate audiences and film makers that skin conditions in reality are not a marker of evil intent.

Deepithelialized flaps and grafts: applications in dermatologic surgery

Deepithelialized flaps and grafts have been widely used by reconstructive surgeons in a diverse array of surgical specialties and have more recently made an appearance in dermatologic surgery. These techniques may be advantageous in their enabling of contour preservation of deep defects, reconstructions in areas of high mechanical tension, single-stage repairs, auricle reconstruction requiring tissue transfer, and reconstruction requiring free margins in areas with a paucity of local soft tissue. This article provides a review of the literature on deepithelialized flaps and grafts. We also highlight the use of these techniques in the field of dermatology and encourage appropriate application of deepithelialized flaps and grafts in dermatologic surgery.

Progressive Tightening of Pulley Sutures for Primary Repair of Large Scalp Wounds

Supplemental Digital Content is available in the text.

Scalp defects greater than 2 cm in diameter are not usually amenable to primary closure and require local tissue rearrangement, grafting, tissue expansion, or prolonged second intention healing. Scalp flap reconstruction is a significant undertaking that requires elevation of a total flap surface area that is 3–6 times the size of the defect, often involves profuse bleeding, and can be challenging to perform without conscious sedation or general anesthesia. Anticoagulated and medically complex patients pose additional challenges and limit options for treatment. The pulley suture uses the mechanical advantage of the pulley to distribute tension across a wound and is useful in areas of high tension such as scalp wounds. For scalp wounds greater than 2 cm, pulley sutures are placed along the length of the wound. An assistant exerts equal tension on the pulley sutures, and the surgeon sequentially ties the sutures. The sutures are tightened and retied weekly until complete scalp closure is achieved. The pulley sutures can be used for rapid primary closure of scalp wounds up to 2.5–3.0 cm in diameter under local anesthesia. For scalp wounds larger than 3 cm, we have also found that pulley sutures can be progressively tightened yielding additional tissue expansion every week. Scalp wounds greater than 3.0 cm can be easily closed via primary repair and weekly tightening of pulley sutures without the need for flap reconstruction, traditional tissue expander placement, or second intention healing.

A Systematic Review of Lower Lip Anatomy, Mechanics of Local Flaps, and Special Considerations for Lower Lip Reconstruction

Reconstruction of defects of the lower lip can be very challenging. The aim of this review is to analyze the unique characteristics of lower lip anatomy and provide a systematic approach for lower lip reconstruction. A review of current literature was performed using the PubMed database. Articles analyzing the anatomic and histologic characteristics of the lower lip, mechanics of local faps, and different lower lip reconistruction techniques were included. Articles focused on lower lip reconstruction with free faps were excluded. The orbicularis oris has been described as the main supportive mechanism, however, a number of other structures have been shown to provide mechanical support to the lower lip, including septations of connective tissue extending from the epithelium to the orbicularis oris, a fbroelastic meshwork located in the mentolabial sulcus, and subdermal muscular fibers with dermal terminations in the area of the modiolus. Depending on the location, size, and depth of the wound, a number of reconstruction options are available. Preservation of the competency of orbicularis oris, relation-ship of the modiolus with associated muscles, and sensation, are critical components of functional reconstruction. Primary closure and local faps are assessed for these 3 components and analysis is provided. In conclusion, knowledge of the static and dynamic structural support of the lower lip, as well as the characteristics of different reconstructive options, is imperative for optimal functional and aesthetic outcomes.

Delayed Diagnosis of Basal Cell Carcinoma of the Upper Lip: The Possible Role of Incidental Multinucleated Foreign Body Giant Cells

Herpes simplex and basal cell carcinoma (BCC) can have similar clinical presentations due to overlapping lesional morphology. We describe the unusual case of a BCC masquerading as herpes labialis due to a possible false-positive Tzanck smear. The confounding diagnosis led to a failed trial of valacyclovir and subsequent loss of the patient for 1 year before the lesion was biopsied and diagnosed as a BCC. This case report highlights the importance of careful inspection of herpetic lesions and that further investigation should be pursued if the etiology is uncertain or if the treatment is not yielding the expected results.

Dermatologic Features of Classic Movie Villains: The Face of Evil

Importance

Dichotomous dermatologic depictions of heroes and villains in movies have been used since the silent film age.

Objective

To evaluate the hero-villain skin dichotomy in film by (1) identifying dermatologic findings of the all-time top 10 American film villains, (2) comparing these dermatologic findings to the all-time top 10 American film heroes quantitatively and qualitatively, and (3) analyzing dermatologic portrayals of film villains in depth.

Design, Setting, and Participants

In this cross-sectional study, dermatologic findings for film heroes and villains in mainstream media were identified and compared quantitatively using a χ2 test with α < .05, as well as qualitatively. The all-time top 10 American film villains and heroes were obtained from the American Film Institute 100 Greatest Heroes and Villains List.

Main Outcomes and Measures

Primary outcomes include identification and frequencies of dermatologic findings of the top 10 film villains and of the top 10 film heroes.

Results

Six (60%) of the all-time top 10 American film villains have dermatologic findings, including cosmetically significant alopecia (30%), periorbital hyperpigmentation (30%), deep rhytides on the face (20%), multiple facial scars (20%), verruca vulgaris on the face (20%), and rhinophyma (10%). The top 10 villains have a higher incidence of significant dermatologic findings than the top 10 heroes (60% vs 0%; P = .03).

Conclusions and Relevance

Dermatologic findings of the all-time top 10 American villains are used in film to highlight the dichotomy of good and evil, which may foster a tendency toward prejudice in our society directed at those with skin disease.

Mohs Surgical Reconstruction Educational Activity: a resident education tool

BACKGROUND

Surgical reconstructive planning following Mohs surgery can be a difficult subject for dermatology residents to master. Prior research demonstrates that active learning is preferred and more effective compared to passive learning models and that dermatology residents desire greater complexity and volume in surgical training. We present a novel, active, problem-based learning tool for the education of Mohs reconstruction with the goal of improving residents' ability to plan surgical reconstructions.

MATERIALS AND METHODS

The Mohs Surgical Reconstruction Educational Activity is an active, problem-based learning activity in which residents designed repairs for planned Mohs defects prior to surgery on an iPad application or on a printed photograph. The attending Mohs surgeon reviewed the reconstructive designs, provided feedback, guided discussion, and facilitated insight into additional issues requiring further review. Residents performed or observed the Mohs and reconstructive surgical procedures for respective repairs. Surveys were administered to participants before and after participating in the Mohs Surgical Reconstruction Educational Activity to assess the educational value of the activity. Survey responses were recorded on a 5-point Likert scale.

RESULTS

Mean participant-reported confidence in flap and graft knowledge, flap and graft planning, and flap and graft performance increased 1.50-2.50 Likert scale points upon completion of the Mohs surgery rotation by residents participating in the educational activity. The observed trend was larger in the dermatology resident subset, with increases of 2.00-3.50 Likert scale points reported for these questions. Mean participant-reported likelihoods of performing flaps and grafts in the future increased 0.25-0.50 Likert scale points among all residents participating in the educational activity and 0.50-1.00 Likert scale points in the dermatology resident subset. All residents participating in the educational activity somewhat or completely agreed with the statement, "I am faster at planning reconstructions after my Mohs rotation." In addition, 88% of participants "somewhat or completely agreed" that the exercise was a good educational experience.

CONCLUSION

The Mohs Surgical Reconstruction Educational Activity is a valuable novel tool for learning reconstructive planning that is easy to incorporate into existing dermatology residency curricula, inexpensive, and utilizes active learning.

Utility of a dermatology interest group blog: the impact of medical student interest groups and Web 2.0 tools as educational resources

The open access University of Texas Dermatology Interest Group blog was established in 2004 for the purposes of increasing communication and collaboration between medical students and dermatology faculty, residents, and alumni, as well as to promote educational opportunities and the missions for which the interest group was created. This blog is unique because of its longevity and continuous postings directed toward the educational and professional needs of medical students and residents. A blog user survey was performed to assess viewers' thoughts, purpose of viewing, demographic profile, subscriber status, usage of the blog and other Web 2.0 tools (forums, Facebook, blogs, Twitter, podcasts), and perceived usefulness. Sixty-one anonymous online surveys were completed during a 1-month period. Statistical analyses of the responses demonstrated that the utilization of web-based tools and the blog were valuable resources for students, especially for blog subscribers, those more involved in an interest group, and those reading the blog for a longer period of time. The usefulness and impact of this method of communication and dissemination of information in medical education may encourage other student groups, faculty advisors, and educators to implement similar educational tools at their institutions.

Incorporating resident research into the dermatology residency program

Programmatic changes for the dermatology residency program at The University of Texas Medical Branch were first introduced in 2005, with the faculty goal incorporating formal dermatology research projects into the 3-year postgraduate training period. This curriculum initially developed as a recommendation for voluntary scholarly project activity by residents, but it evolved into a program requirement for all residents in 2009. Departmental support for this activity includes assignment of a faculty mentor with similar interest about the research topic, financial support from the department for needed supplies, materials, and statistical consultation with the Office of Biostatistics for study design and data analysis, a 2-week elective that provides protected time from clinical activities for the purpose of preparing research for publication and submission to a peer-reviewed medical journal, and a departmental award in recognition for the best resident scholarly project each year. Since the inception of this program, five classes have graduated a total of 16 residents. Ten residents submitted their research studies for peer review and published their scholarly projects in seven dermatology journals through the current academic year. These articles included three prospective investigations, three surveys, one article related to dermatology education, one retrospective chart review, one case series, and one article about dermatopathology. An additional article from a 2012 graduate about dermatology education has also been submitted to a journal. This new program for residents was adapted from our historically successful Dermatology Honors Research Program for medical students at The University of Texas Medical Branch. Our experience with this academic initiative to promote dermatology research by residents is outlined. It is recommended that additional residency programs should consider adopting similar research programs to enrich resident education.

Porcine xenograft biosynthetic wound dressings for the management of postoperative Mohs wounds

Cadaveric allografts and a large variety of other biologic dressings have been reported as being useful for the postoperative management of Mohs micrographic surgery (MMS) wounds. Although the use of porcine xenografts for the immediate postoperative management of these wounds is known, their use has not been detailed in the dermatology literature. A case series of 15 consecutive Mohs micrographic surgery patients (mean age = 74.9 years, range = 49 to 89 years) with wounds initially managed with porcine xenografts is described. Porcine xenografts were useful in a variety of clinical settings following MMS. These included: (1) wound management when tumor margins were indeterminate pending additional dermatopathology studies and (2) wound management when there are issues such as through and through nasal defects involving the mucosa, large wound depth, exposed cartilage and or bone, or patient medical comorbidities that delay or prevent plans for immediate wound reconstruction. Future controlled studies of biologic dressings are needed to determine which options are best for micrographic surgery wounds. Comparisons should also include the traditional option of second intention healing without biologic dressings.

The dermatology acting internship

Acting internships are an important component of modern day medical school curriculum. Several specialties outside of internal medicine now offer acting internship experiences to fourth year medical students. We have found that a dermatology acting internship is a valuable experience for fourth year medical students who are interested in pursuing a residency in dermatology. Our experience with the dermatology acting internship over the 2010-2011 academic year is described.

Television depictions about dermatology and skin diseases in Seinfeld

The iconic television situation comedy Seinfeld frequently referenced dermatologists and topics involving the integument, using satire for comedic effect. However, selecting satire to portray an already misunderstood and unknown subject matter may perpetuate incorrect public beliefs and stereotypes about those with skin diseases and diminish cultural sensitivity towards people who have dermatologic conditions and their caregivers.

The "away" dermatology elective for visiting medical students: Educational opportunities and barriers

Dermatology electives allow medical students an opportunity to explore the field of dermatology. In order to gain greater exposure to the specialty of dermatology, some medical students have an interest in taking "away" dermatology electives at other U.S. medical schools. A telephone survey was conducted to better understand the opportunities and barriers that exist for visiting medical students to take an elective in dermatology. Areas of focus in the survey included dermatology elective offerings, institutional policies toward visiting students, academic requirements for visiting students, timing of electives, financial costs of electives incurred by the student and institutional and regional preferences of the host medical school. Survey results indicated considerable opportunities for medical students to explore the field of dermatology among U.S. medical schools, but variance among schools regarding the number and types of dermatology electives offered. Medical schools with dermatology residencies were statistically more likely to offer dermatology electives to visiting medical students than those that did not (p<0.0001). Students from schools that do not provide more advanced electives may find it difficult to explore the field beyond a general dermatology elective because of the limited availability of subspecialty elective rotations for visiting students. Other barriers for "away" electives include academic requirements, priority in course registration for a school's own students, differing rotation schedules, and additional financial costs.

Sunburn risk factors for beachgoing children

Sunburn prevention in children and the early establishment of sun protective behavior is predicted to result in a decreased future incidence of skin cancer. A survey of beachgoing families was conducted to evaluate the parental/guardian role in the use of sun protection for their minor children. Ethnicity and Fitzpatrick Skin Type of children and their parents were the best predictors for sunburn. White, non-Hispanic children were 7.8 times more likely to have a history of sunburn than children whose parents identified them as Hispanic when controlled for the same Fitzpatrick Skin Types.

Marginal excision of squamous cell carcinomas of the hand

Squamous cell carcinoma is the most common malignant tumor of the hand. Most hand surgery texts recommend wide excision with 1- to 2-cm margins. During a 10-year period, 32 patients with 35 lesions were treated with marginal surgical excision for squamous cell carcinoma of the hand. Greater potential morbidity and functional loss associated with wide excision was avoided in these patients. No recurrences were found at a mean follow-up of 31 months. One case of possible metastasis was identified. Three (8%) tumors required further treatment due to positive surgical margins. Marginal excision of squamous cell carcinoma of the hand is associated with a low rate of recurrence and metastasis. In addition, the potential for improved cosmesis and diminished morbidity when compared to older more radical surgical methods supports marginal excision for squamous cell carcinoma of the hand as a viable treatment technique.

Topical Imiquimod as an Adjuvant to Laser Removal of Mature Tattoos in an Animal Model

BACKGROUND

Lasers are a commonly employed method of tattoo removal; however, numerous treatments are often needed and laser treatment may fail to eliminate the tattoo completely. It has been shown in animal studies that topical application of imiquimod cream, alone, fades tattoos. It is suspected that the combination of both imiquimod and laser treatment will result in enhanced tattoo pigment clearance.

OBJECTIVE

The objective was to evaluate the efficacy of topical imiquimod cream as an adjuvant to laser removal of mature tattoos.

METHODS

Fourteen albino guinea pigs were tattooed with black ink, then randomly assigned into two groups: one underwent sequential laser treatments with a Q-switched alexandrite laser in conjunction with triweekly applications of 5% imiquimod cream, while the other group underwent laser therapy alone. Subjects were evaluated with clinical photographs and skin biopsies after six laser treatment sessions.

RESULTS

The combination laser and imiquimod treated group was clinically and histologically rated as having less pigment than the tattoos that were treated with laser alone (p=.012 and p=.047, respectively). Adjuvant imiquimod treatment had greater inflammation (p=.002) and fibrosis (p=.002) on posttreatment skin biopsies.

CONCLUSION

Imiquimod appears to be a useful adjuvant to experimental laser tattoo removal in guinea pigs.