Rx -to- OTC switch increased access and lowered cost of topical adapalene.

Topical adapalene gel is an effective and well tolerated acne treatment that transitioned from prescription to over-the-counter (OTC) availability in 2016. Historically, prescription to OTC transitions have lowered costs to patients and payers and increased access to medications. This study used sales and prescriber data to assess access to topical retinoid therapies and their costs in the pre- and post- Rx-to-OTC transition. We demonstrate that the prescription to OTC transition of adapalene gel increased access to this medication, while lowering costs to patients and payers, including Medicare patients. These results provide a necessary call to action for future OTC shifts with other high safety profile, well-tolerated medications in ultimate efforts and hopes of cost savings for patients, insurers, and Medicare within our healthcare industry.

A Cost Comparison Between Mohs Micrographic Surgery and Conventional Excision for the Treatment of Head and Neck Melanomas In Situ and Thin Melanomas.

BACKGROUND: Variation in operative setting and surgical technique exists when treating specialty site melanomas. There are limited data comparing costs among surgical modalities. OBJECTIVE: To evaluate the costs of head and neck melanoma surgery performed with Mohs micrographic surgery or conventional excision in the operating room or office-based settings. METHODS: A retrospective cohort study was performed on patients aged 18 years and older with surgically treated head and neck melanoma in 2 cohorts, an institutional cohort and an insurance claims cohort, for the years 2008-2019. The primary outcome was total cost of care for a surgical encounter, provided in the form of insurance reimbursement data. A generalized linear model was used to adjust for covariates affecting differences between treatment groups. RESULTS: In the institutional and insurance claims cohorts, average adjusted treatment cost was highest in the conventional excision-operating room treatment group, followed by the Mohs surgery and conventional excision-office setting ( p < .001). CONCLUSION: These data demonstrate the important economic role the office-based setting has for head and neck melanoma surgery. This study allows cutaneous oncologic surgeons to better understand the costs of care involved in head and neck melanoma treatment. Cost awareness is important for shared decision-making discussions with patients.

Measuring Stakeholder Assessments of Postsurgical Facial Scars: A Retrospective Cohort Inter-rater Analysis of Patients, Physicians, and Medical Student Observers.

BACKGROUND: The relationship of postoperative facial scar assessments among patients, physicians, and societal onlookers is not clearly defined. OBJECTIVE: To identify differences in perceived scar outcomes by different stakeholders. METHODS AND MATERIALS: Retrospective cohort study at a single Mohs micrographic surgery (MMS) center during which scars were assessed by: patients, physicians, and medical student observers not involved in patients' care using the Patient and Observer Scar Assessment Scale (v.2). Eighty-one patients graded their scars at 2 visits: 1 to 2 weeks post-MMS and 3 months post-MMS. Deidentified patient photographs were taken at each visit and graded by 4 physicians and 12 observers. RESULTS: At week 1, there was a significant difference in overall opinion of scar appearance between patient and physicians (p = .001) and medical student observers and physicians (p < .001). Physicians graded scars more favorably. At 3 months, there remained a difference in scar evaluations between patient and physicians (p = .005), whereas medical student observers rated scars more similarly to physicians (p = .404). CONCLUSION: Postoperative scar perceptions differ among stakeholders. Physicians must be mindful of this disparity when counseling patients in the perioperative setting to align patient expectations with realistic scar outcomes.

Bullous drug eruption after second dose of mRNA-1273 (Moderna) COVID-19 vaccine: Case report.

BACKGROUND: In December 2020, Moderna released the mRNA-1273 vaccine. The most common side effects are headache, muscle pain, redness, swelling, and tenderness at the injection site. In addition, there have been dermatological adverse events, such as hypersensitivity reactions. Although rare, various bullous eruptions have been described following vaccination. Bullous pemphigoid has been reported to occur most often after receipt of influenza and the diphtheria-tetanus-pertussis vaccine. To the best of our knowledge, there have been no reports of bullous drug eruptions resulting from mRNA vaccines. CASE SUMMARY: A 66-years-old obese Guyanese male presented with a bullous rash following receipt of a commercial COVID-19 mRNA vaccine. He received the first dose uneventfully. However, within 24 h of receiving the second dose, he developed fever, myalgias, and malaise accompanied by a painful blistering rash of his torso, arms, and legs. His fever and myalgias improved after 24 h, but his painful rash did not, and five days after the initial symptoms, he presented to the hospital. There were many violaceous, poorly demarcated patches on his trunk, arms, and thighs on examination, many of which had large flaccid bullae within, and a few areas on his buttocks, posterior shoulder, and scrotum were eroded. The exam was also significant for lower extremity muscle tenderness, stiffness with preserved strength. A skin biopsy showed epidermal necrosis and sparse perivascular dermatitis concerning Stevens-Johnson syndrome or erythema multiforme. However, in the absence of mucous membrane involvement or targetoid lesions, the diagnosis of an extensive bullous fixed drug eruption was made. CONCLUSION: This case illustrates that the bullae eruption occurred as a result of receiving the Moderna vaccination.

Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more commonly than basal cell carcinoma and squamous cell carcinoma: A comparison of indications for microscopic margin control prior to reconstruction in 13,664 tumors.

BACKGROUND: On the basis of high-local recurrence risk features and tissue-rearranging reconstruction, consensus guidelines recommend microscopic margin control for keratinocyte carcinomas (KCs) but not for cutaneous melanoma. OBJECTIVE: To compare high-local recurrence risk features and frequency of tissue-rearranging reconstruction for head and neck KC with those for melanoma. METHODS: Retrospective cohort study of KC versus melanoma treated at the Hospital of the University of Pennsylvania with Mohs micrographic surgery. RESULTS: A total of 12,189 KCs (8743 basal cell carcinomas and 3343 squamous cell carcinomas) and 1475 melanomas (1065 melanomas in situ and 410 invasive melanomas) were identified from a prospectively updated Mohs micrographic surgery database. Compared with KCs, melanomas were significantly more likely to have high-local recurrence risk features, including larger preoperative size (2.10 cm vs 1.30 cm [P < .0001]), recurrent status (5.08% vs 3.91% [P = .031]), and subclinical spread (31.73% vs 26.52% [P < .0001]). Tissue-rearranging reconstruction was significantly more common for melanoma than for KCs (44.68% vs 33.02% [P < .0001]; odds ratio, 1.98 [P < .0001]). LIMITATIONS: This was a retrospective study, and it did not compare outcomes with those of other treatment methods, such as slow Mohs or conventional excision. CONCLUSION: Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more frequently than KCs do.

Mycobacterium fortuitum Prosthetic Joint Infection After Total Hip Arthroplasty: A Case Report.

CASE: A 57-year-old man presented with a Mycobacterium fortuitum prosthetic joint infection (PJI) after right total hip arthroplasty refractory to the initial revision surgery and cement spacer placement. The patient was subsequently treated with 2-stage total joint arthroplasty revision surgery using an antibiotic-laden spacer customized to include meropenem and delayed reimplantation to allow for prolonged, systemic antimicrobial treatment with multiple antimicrobials, including levofloxacin and linezolid. CONCLUSIONS: There is little evidence to guide practitioners in the diagnosis and treatment of PJI caused by rare, rapidly growing mycobacteria (RGM) such as M. fortuitum. This case demonstrates a successful strategy for the treatment of RGM PJI.

Comparison of Accuracy of Patient and Physician Scar Length Estimates Before Mohs Micrographic Surgery for Facial Skin Cancers.

Importance: Patients are satisfied when surgical outcomes meet their expectations. Dissatisfaction with surgical scars is one of the most common reasons that patients sue surgeons who perform Mohs micrographic surgery (MMS). Objective: To measure the accuracy of patient and physician estimations of scar length prior to skin cancer removal with MMS. Design, Setting, and Participants: This cross-sectional study was conducted between December 1, 2017, and February 28, 2018, at the MMS clinic of a single tertiary referral center health system. A total of 101 adults presenting for MMS for treatment of facial skin cancers volunteered for this study, and 86 surgeons who performed the MMS procedure participated. Main Outcomes and Measures: Patients and physicians independently drew the anticipated scar length on the patients' skin prior to surgery. Preoperative estimates by patients and surgeons were compared with actual postoperative scar length. Results: Of the 101 patients who participated, 57 patients (56.4%) were men and 57 patients (56.4%) were aged 65 years or older. Eighty-four patients (83.2%) underestimated scar length, whereas 67 of the 86 surgeons (77.9%) correctly estimated the scar length (P < .001). The actual postoperative scar length was 2.2 (interquartile range, 1.5-3.6) times larger than the patients' preoperative estimate but only 1.1 (interquartile range, 1.0-1.2) times larger than the surgeons' preoperative estimate (P < .001). Preoperative consultation with the surgeon, a personal history of MMS, or patient-directed research about MMS were not associated with improvement of patients' estimations of scar length. Conclusions and Relevance: This study's findings suggest that patients with facial skin cancers have unrealistic expectations regarding scars that measure, on average, less than half the length of the actual postoperative scars. Surgeons appear to accurately estimate the length of most surgical scars and have an opportunity to set realistic patient expectations about scar length before surgery.

Variation in Prescribing and Factors Associated With the Use of Prophylactic Antibiotics for Mohs Surgery: A Single-Institution Retrospective Study.

BACKGROUND: Antibiotic use associated with Mohs surgery is increasing. OBJECTIVE: To understand variation in practice patterns and factors associated with antibiotic use. MATERIALS AND METHODS: The authors conducted a retrospective cohort study of antibiotic use among patients treated with Mohs micrographic surgery between July 1, 2013, and June 30, 2017, at an academic medical center. Multivariate logistic regression was used to evaluate for associations between antibiotic prescribing and the surgeon, site, reconstruction, and patient characteristics. RESULTS: The odds of prescribing antibiotics differed significantly between each surgeon evaluated; 3.35-fold variation in postoperative antibiotic use was observed. Increasing number of surgical sites (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.09-1.41), number of Mohs stages required (OR 1.18; 95% CI 1.08-1.28), and defect area (OR 1.31; 95% CI 1.25-1.37), as well as patient female sex (OR 1.14; 95% CI 1.03-1.27), were associated with increased postoperative antibiotic use, whereas age >80 was associated with decreased use (OR 0.75; 95% CI 0.64-0.87) compared with age <60. CONCLUSION: Antibiotics are more commonly prescribed for repairs that are considered higher risk for infection. However, significant variation exists between surgeons, even within a single institution, suggesting a need for prospective trials and consensus guideline development.

Pediatric chondrodermatitis nodularis helicis (CNH) in a child with Beckwith-Wiedemann syndrome (BWS).

Chondrodermatitis nodularis helicis is an idiopathic degenerative process that presents as a painful nodule, papule, or ulcer on the helix or antihelix. It predominantly affects adults and is thought to be associated with trauma to the ear. We describe a case of pediatric chondrodermatitis nodularis helicis occurring in a child with a history of Beckwith-Wiedemann syndrome that was successfully treated with an excisional biopsy and relief from a recurrent source of pressure on the ear.

MART-1-labeled melanocyte density and distribution in actinic keratosis and squamous cell cancer in situ: Pagetoid melanocytes are a potential source of misdiagnosis as melanoma in situ.

BACKGROUND: Actinic keratosis (AK) and squamous cell carcinoma in-situ (SCCIS) within or near melanoma in situ (MIS) can complicate diagnosis due to overlapping clinical and microscopic features. This study aimed to describe basilar melanocyte density and pagetoid spread in AK and SCCIS for improved diagnostic accuracy. METHODS: A total of 22 AK and 22 SCCIS biopsies containing a margin of uninvolved epidermis were immunostained with MART-1 (melanoma antigen recognized by T-cells 1). The basilar melanocyte:keratinocyte ratio and the number and distribution of pagetoid melanocytes were compared in AK, SCCIS, and uninvolved epidermis. An in-vitro human skin model was created to assess the impact of keratinocyte atypia on melanocyte distribution. RESULTS: The median basilar melanocyte:keratinocyte ratio in SCCIS (1:11.49) was lower than in uninvolved epidermis (1:5.59, P = 0.0011), and the ratio in AK (1:6.94) was similar to uninvolved epidermis (P = 0.987). Pagetoid melanocytes were absent in perilesional skin but common in AK (21/22, P < 0.0001) and SCCIS (22/22, P < 0.0001). Pagetoid melanocytes at or above the mid-spinous layer were more common in SCCIS (21/22) vs AK (7/22, P < 0.0001). Pagetoid melanocytes were present in the in-vitro skin model made with neoplastic but not normal keratinocytes. CONCLUSIONS: Pagetoid melanocytes in AK and SCCIS should be interpreted with caution to avoid overdiagnosis of MIS.