Medical Oversight and Scope of Practice of Medical Spas (Med-Spas).

BACKGROUND: The regulation of medical spas (med-spas) in the United States varies considerably from state to state with important ramifications for patient safety. OBJECTIVE: To describe the current state of med-spas in the United States and degree of medical oversight in these facilities. MATERIALS AND METHODS: Descriptive study based on web search and standardized phone interviews of med-spas in the most heavily populated cities in each state of the United States. Information obtained included the following: whether medical directors were listed; if so, whether they were advertised as being on site; medical directors' training and board certification; and services offered. RESULTS: Of 247 medical spas reviewed, 72% advertised a medical director on their website, and 6.5% claimed that the director was on site. Of listed medical directors, 41% were trained in dermatology and/or plastic surgery. In phone interviews, 79% of med-spas endorsed the medical director to be board certified, and 52% stated that the medical director was on site less than 50% of the time. CONCLUSION: There is significant variation in medical directorship and oversight among medical spas in the United States. Appropriate regulation of medical directors' training and the degree of oversight provided are warranted to optimize patient safety.

Cutaneous T-cell lymphoma (CTCL): Current practices in blood assessment and the utility of T-cell receptor (TCR)-Vß chain restriction.

BACKGROUND: Accurate quantification of malignant cells in the peripheral blood of patients with cutaneous T-cell lymphoma is important for early detection, prognosis, and monitoring disease burden. OBJECTIVE: We sought to determine the spectrum of current clinical practices; critically evaluate elements of current International Society for Cutaneous Lymphomas (ISCL) B1 and B2 staging criteria; and assess the potential role of T-cell receptor-Vß analysis by flow cytometry. METHODS: We assessed current clinical practices by survey, and performed a retrospective analysis of 161 patients evaluated at Yale (2011-2014) to compare the sensitivity, specificity, positive predictive value, and negative predictive value of parameters for ISCL B2 staging. RESULTS: There was heterogeneity in clinical practices among institutions. ISCL B1 criteria did not capture 5 Yale cohort cases with immunophenotypic abnormalities that later progressed. T-cell receptor-Vß testing was more specific than polymerase chain reaction and aided diagnosis in detecting clonality, but was of limited benefit in quantification of tumor burden. LIMITATIONS: Because of limited follow-up involving a single center, further investigation will be necessary to conclude whether our proposed diagnostic algorithm is of general clinical benefit. CONCLUSION: We propose further study of modified B1 criteria: CD4/CD8 ratio 5 or greater, %CD4(+) CD26(-) 20% or greater, or %CD4(+) CD7(-) 20% or greater, with evidence of clonality. T-cell receptor-Vß testing should be considered in future diagnostic and staging algorithms.

Langerhans Cells Facilitate UVB-Induced Epidermal Carcinogenesis.

UVB light is considered the major environmental inducer of human keratinocyte (KC) DNA mutations, including within the tumor-suppressor gene p53, and chronic exposure is associated with cutaneous squamous cell carcinoma formation. Langerhans cells (LCs) comprise a dendritic network within the suprabasilar epidermis, yet the role of LCs in UVB-induced carcinogenesis is largely unknown. Herein we show that LC-intact epidermis develops UVB-induced tumors more readily than LC-deficient epidermis. Although levels of epidermal cyclopyrimidine dimers following acute UVB exposure are equivalent in the presence or absence of LCs, chronic UVB-induced p53 mutant clonal islands expand more readily in association with LCs, which remain largely intact and are preferentially found in proximity to the expanding mutant KC populations. The observed LC facilitation of mutant p53 clonal expansion is completely αß and γδ T-cell independent and is associated with increased intraepidermal expression of IL-22 and the presence of group 3 innate lymphoid cells. These data demonstrate that LCs have a key role in UVB-induced cutaneous carcinogenesis and suggest that LCs locally stimulate KC proliferation and innate immune cells that provoke tumor outgrowth.