The Role of Toluidine Blue in Mohs Micrographic Surgery: A Systematic Review.

Toluidine blue (TB) is a metachromatic dye used as a stain in frozen sections in Mohs micrographic surgery (MMS). The current literature on the use of TB is sparse and generally qualitative in nature. The aim of this systematic review was to summarize and evaluate the existing literature analyzing TB use in MMS. The PubMed and Cochrane databases were searched for relevant studies published before December 1, 2019. Studies that analyzed the use of TB in frozen sections applicable to MMS were included. A total of 25 articles were reviewed, of which 12 fit the inclusion criteria. Our analysis showed that TB may play an important role in the successful diagnosis and treatment of particular cutaneous tumors.

Accuracy of real-time SNOMED-CT coding by clinicians in an urban tertiary emergency department: A retrospective cohort study.

OBJECTIVE: This study aimed to determine the accuracy of the reported diagnoses and procedures to the National non-Admitted Patient Collection (NNPAC) from Auckland City Hospital Adult Emergency Department, and whether there were disparities between Maori and non-Maori patients. METHODS: We audited 5788 (n = 594 Maori, 5194 non-Maori) visits in February 2021 to determine whether diagnoses and procedures were recorded and whether these were recorded differently for Maori compared to non-Maori. A random sample of case notes, stratified by five common chief presenting complaints (n = 114) were selected to compare clinician recording of diagnoses and procedures in real time, to those derived from the clinical notes by auditors blinded to the actual diagnosis and patient name and ethnicity. The New Zealand Emergency Department SNOMED-CT reference set was used to code diagnoses. RESULTS: Maori were less likely to have a diagnosis recorded when discharged from the ED compared to non-Maori, relative risk 1.48 (1.08, 2.04), p = 0.016 (n = 3045). Failure to record diagnoses was due to flaw in the system for extracting diagnoses from electronic notes, rather than failure to make a diagnosis. There was agreement in 111/114 cases for diagnosis: 53/56, 94.6% (95 %CI 85,99) for Maori, and 58/58, 100% (95 %CI 93,100) for non-Maori; p = 0.115. There was agreement in 60/114 cases for procedures completed: 31/56, 55.4% (95 %CI 42,66) for Maori, and 29/58, 50% (95 %CI 38,62) for non-Maori; p = 0.567. CONCLUSION: Maori were less likely to have a diagnosis recorded at discharge due to systemic bias in how we captured diagnoses electronically. Our system should change to remove this inequity. The diagnoses recorded using SNOMED-CT were mostly an accurate reflection of clinician's notes, while recording of procedures was poor.

Disposition disparities in an urban tertiary emergency department.

OBJECTIVE: To explore disparities between Maori and non-Maori patients with respect to triage acuity and disposition based on presenting complaint. METHODS: This was a retrospective review of 5788 (n = 594 Maori, n = 5194 non-Maori) ED visits in February 2021, extracted from the hospital data warehouse. RESULTS: Maori were triaged similarly to non-Maori but were less likely to be admitted compared to non-Maori: relative risk 0.87 (0.78, 0.97), P = 0.008. CONCLUSION: Maori were less likely to be admitted for similar presenting complaints, despite similar triage acuity. Further research is required to determine the reasons for this apparent inequity.

Management of full-thickness skin grafts.

Full-thickness skin grafts are a commonly used reconstructive method following Mohs micrographic surgery. The literature varies on the most appropriate methods of suturing and securing grafts as well as best practices to dress the graft postoperatively. Our objective was to review various approaches to management of full-thickness skin grafts, including suturing the graft, securing the graft, and topical emollient use on the graft postoperatively. It was found that absorbable sutures, plain gut, provide preferable outcomes with full-thickness skin grafts. The tie-over bolster is the most-used method for securing skin grafts after placement, although several other methods have demonstrated efficacy, including the polyurethane foam, sandwich, and quilting suture methods. While various topical emollients are used in the immediate postoperative period, plain white petrolatum is the least likely to form allergic contact dermatitis.

Is your patient a candidate for Mohs micrographic surgery?

This guide for family physicians describes the advantages of Mohs surgery and which patients make good candidates for the procedure.

Quantity and characteristics of flap or graft repairs for skin cancer on the nose or ears: a comparison between Mohs micrographic surgery and plastic surgery.

One benefit of Mohs micrographic surgery (MMS) is maximal tissue sparing compared to standard excisional surgery techniques. It also has the highest statistical cure rate for appropriately selected nonmelanoma skin cancers (NMSCs) in cosmetically sensitive areas, making it a preferred choice for many self-referred patients or their referring physicians. Patients and nondermatologist physicians may be unaware of how frequently Mohs surgeons perform complex surgical repairs compared to other specialists. Our objective was to compare the quantity and characteristics of flap or graft repairs on the nose or ears following skin cancer extirpation performed by either a fellowship-trained Mohs surgeon or plastic surgeons at 1 academic institution. A retrospective chart review of all skin cancer surgeries was performed to collect data on all flap or graft repairs on the nose or ears at Baylor Scott and White Health (Temple, Texas) from October 1, 2016, to October 1, 2017. We collected secondary data on final defect size prior to the repair, skin tumor type, referring specialty for the procedure, and patient demographics. We found that Mohs surgeons performed a larger number of complex repairs on cosmetically sensitive areas compared to plastic surgeons following skin cancer removal, which may be unrecognized in several specialties that refer patients for management of skin cancers, creating a possible practice gap. More data may aid referring providers in optimally advising and managing patients with cutaneous malignancies.

Mohs Micrographic Surgery for the Management of Cutaneous Malignancies.

Mohs micrographic surgery is a specialized form of skin cancer surgery in which the Mohs surgeon acts as both surgeon and pathologist. The procedure is characterized by its histopathologic margin control and ability to spare tissue, particularly in cosmetically sensitive locations. Mohs surgery is known for both limiting the size of the final defect and its high cure rate. In this review, the authors highlight indications for the procedure, detail the technique itself, discuss cutaneous tumors for which Mohs micrographic surgery is indicated, and present the economic benefit of Mohs surgery.

Cost of diagnosing psoriasis and rosacea for dermatologists versus primary care physicians.

Growing incentives to control health care costs may cause accountable care organizations (ACOs) to reconsider how skin disease is best managed. Limited data have suggested that disease management by a primary care physician (PCP) may be less costly than seeing a specialist, though it is not clear if the same is true for the management of skin disease. This study assessed the cost of seeing a dermatologist versus a PCP for diagnosis of psoriasis and rosacea.

Pharmacoeconomic Considerations in Treating Actinic Keratosis: An Update.

Actinic keratosis is one of the most common dermatological diagnoses worldwide, especially among the elderly, fair-skinned, and immunocompromised, and is associated with a risk of transformation to skin cancer. With actinic keratosis and skin cancer prevalence increasing as the aged population expands in the US, optimizing treatment strategies may produce cost savings for the healthcare system. Since the time of our last review in 2008, investigation of the economic considerations in treating actinic keratosis has advanced. To provide an update of treatment cost effectiveness and to review factors relating to the costs of care, we conducted a systematic review of pharmacoeconomic publications since December 2008. We identified 11 pharmacoeconomic studies, with one cost-of-treatment, five cost-effectiveness, and five cost-utility analyses. Photodynamic therapy (PDT) was well tolerated and produced a favorable cosmetic outcome in most studies. Ingenol mebutate, the newest but most expensive topical field therapy, 5-fluorouracil, and PDT were the most cost-effective treatments in our review. Patient adherence to therapy and the management of adverse effects were significant contributors to treatment costs. In the US, treatment guidelines and formalized cost-effectiveness analyses for actinic keratosis are absent from the recent literature. Future pharmacoeconomic investigation will depend on up-to-date comparative efficacy data, as well as clarification of rates of, and management strategies for, adverse effects, therapeutic non-adherence, and lesion recurrence.

Increasing adherence to topical therapy in psoriasis through use of solution medication.

Patient outcomes and clinical improvement are closely related to topical medication adherence, and is especially important in chronic dermatological diseases such as psoriasis. About one-fifth of patients undergoing topical treatment were dissatisfied with its convenience for various reasons. Providers can help increase adherence through selecting the correct medication vehicle, involving family members or friends in the patient's mediation application, and explaining likely side effects to the patient prior to use of the medication. Increased inherence will lead to better psoriasis disease control.

Most people with psoriasis or rosacea are not being treated: a large population study.

When left untreated, psoriasis and rosacea can have long-term health and psychosocial implications. The purpose of this study was to estimate the percentage of Americans with psoriasis or rosacea who are not being treated. Patient data from a large claims-based database were analyzed to identify the number of patients who are treated for psoriasis or rosacea. The numbers of patients treated were compared to the estimated prevalences of these diseases in the general population, identified from previously published sources. Of the 18,632,362 patients in the database, 140,439 (0.75%) were seen for psoriasis and 165,130 (0.89%) were seen for rosacea. Based on published sources, 3.2% of Americans have psoriasis and about 5.0% have rosacea. We therefore estimated that 77% of people with psoriasis and 82% of people with rosacea are untreated. Greater awareness, resources, and community outreach projects are potential tools that could eliminate this disparity and increase the quality of life for patients with these diseases.

Current status and future prospects for biologic treatments of psoriasis.

INTRODUCTION: Biological agents have transformed psoriasis treatment by selectively targeting immune signaling molecules involved in psoriasis pathogenesis. While biologics offer the most effective treatment of moderate to severe psoriasis, they are not without complications. Some patients treated with biologics have poor clinical responses, form anti-drug antibodies, or develop adverse events. Additionally, there is growing need for head-to-head studies comparing biologic treatment regimens, efficacy, and safety. Areas covered: Here we review the literature surrounding biologics already in clinical use and those undergoing development and clinical trials. We also investigate the development and approval of small molecules inhibitors and biosimilars used to treat psoriasis. Expert commentary: As the psoriasis treatment armamentarium continues to expand, it is important to follow the safety profile of these drugs both in clinical trials and in post-marketing registries to ensure their long-term safety. Physicians must be aware of the limitations of existing safety data of a drug and the potential risk for rare adverse events when selecting appropriate treatments and monitoring patient outcomes.

Current challenges and emerging drug delivery strategies for the treatment of psoriasis.

INTRODUCTION: Psoriasis is a common skin disorder associated with physical, social, psychological and financial burden. Over the past two decades, advances in our understanding of pathogenesis and increased appreciation for the multifaceted burden of psoriasis has led to new treatment development and better patient outcomes. Yet, surveys demonstrate that many psoriasis patients are either undertreated or are dissatisfied with treatment. There are many barriers that need be overcome to optimize patient outcomes and satisfaction. AREAS COVERED: This review covers the current challenges associated with each major psoriasis treatment strategy (topical, phototherapy, oral medications and biologics). It also reviews the challenges associated with the psychosocial aspects of the disease and how they affect treatment outcomes. Patient adherence, inconvenience, high costs, and drug toxicities are all discussed. Then, we review the emerging drug delivery strategies in topical, oral, and biologic therapy. EXPERT OPINION: By outlining current treatment challenges and emerging drug delivery strategies, we hope to highlight the deficits in psoriasis treatment and strategies for how to overcome them. Regardless of disease severity, clinicians should use a patient-centered approach. In all cases, we need to balance patients' psychosocial needs, treatment costs, convenience, and effectiveness with patients' preferences in order to optimize treatment outcomes.

Review of maintenance of response to psoriasis treatments.

BACKGROUND: Biologics are highly effective treatments for moderate-severe psoriasis with a high percentage of patients achieving 75% improvement in Psoriasis Area Severity Index (PASI75) at 12 weeks. However, psoriasis is a chronic disease, and long-term efficacy is critical. OBJECTIVE: Long-term responses of systemic psoriasis treatments and how this effect is reported. METHODS: A PubMed literature was performed to identify studies describing long-term response rates to available systemic psoriasis treatments. Within these studies, we examined how maintenance rates were reported. All studies with long-term efficacy data ranging from 24 to 244 weeks were considered. RESULTS: Thirteen studies met the inclusion criteria. When comparing medications at 1 year, response rates among the initial treatment groups were best with secukinumab (65.2%) and worst with apremilast (18.7%). Among only initial responders at 10-16 weeks who received 1 year of continuous treatment, maintenance was best with adalimumab (95.2%) and worst with apremilast (61%). LIMITATIONS: The different methodologies used to report maintenance of response over time make it difficult to compare response rates across drugs studied in different trials. CONCLUSION: Long-term response rates of systemic treatment of psoriasis are high. Effect may be influenced by many factors and can be analyzed in different ways, making comparisons across different trials difficult.

Review of patient registries in dermatology.

BACKGROUND: Patient registries are datasets containing information on patients with a particular disease or patients who are undergoing a specific treatment. OBJECTIVE: Our objective was to search for and catalog the types of registries being used in dermatology and investigate their characteristics and uses. METHODS: We searched Google, the Registry of Patient Registries, Orphanet, and ClinicalTrials.gov to compile a list of dermatology disease registries. We also conducted a literature review on the uses of dermatology registries using PubMed. RESULTS: We identified 48 dermatology patient registries, with 23 distinct diseases represented. We also identified 11 registries used for postmarketing surveillance of skin disease. LIMITATIONS: Our search was limited to registries in English. CONCLUSIONS: Registries are commonly used for the study of rare dermatologic diseases and for postsurveillance monitoring of systemic therapies in more common dermatologic diseases, such as psoriasis.