Assessing the outcomes, risks, and costs of local versus general anesthesia: A review with implications for cutaneous surgery.

BACKGROUND: There is a paucity of data providing direct comparison of outcomes, complications, and costs between general and local anesthesia in cutaneous surgery. OBJECTIVE: Analyze the literature from dermatologic and other specialties to compare outcomes, risks, and costs of general and local anesthesia. METHODS: A retrospective analysis of case comparison studies from other specialties comparing outcomes, risks, and/or costs in local versus general anesthesia was performed. A review of the literature from dermatology and other specialties was included. RESULTS: A total of 51 studies were selected; 41 of them directly examined outcomes in procedures performed under local and general anesthesia, and none found a significant difference in outcomes. A total of 41 studies measured adverse effects. Of these, 15 studies (36.6%) report significantly better outcomes between the 2 techniques. Only 2 studies (4.9%) report significantly improved outcomes with use of general anesthesia; 15 of 36 studies (41.7%) report fewer adverse events in local anesthesia. Of the 13 studies that examined costs, all (100%) found significantly decreased costs with use of local anesthesia. LIMITATIONS: These data cannot be seamlessly applied to all cases of cutaneous surgery. CONCLUSION: Local anesthesia techniques provide outcomes equal to or better than general anesthesia and with significantly lower costs.

2015 Arte Poster Competition First Place Winner: Assessing the Correlation Between Patient Anxiety and Satisfaction for Mohs Surgery.

Skin cancer and the surgical treatment thereof have the potential to be sources of great anxiety for patients. Examination of patient satisfaction, anxiety, and contributing factors has the potential to provide information surgeons can use to implement practices that have an impact on patient anxiety and satisfaction regarding dermatologic surgery. This study used a prospective interview to catalog patients' anxiety and experiences before and during the surgical process. Our results indicate that several pre- and perioperative factors have the potential to decrease a patient's overall anxiety. Notably, 33% of surgical patients reported a decrease in anxiety from the time of diagnosis until the day of surgery. Factors that contributed to this included a call discussing the diagnosis and what to expect on the day of surgery as well as reading written material or searching the internet for more information regarding the procedure. Furthermore, a call from the physician compared to a call from a nurse or other team member showed a greater effect on decreasing anxiety. During the surgical procedure, our results highlight several factors that can decrease a patient's anxiety. Most notably, eating, watching TV, bringing a guest, and engaging in small talk with surgeon and staff during the procedure subjectively decreased patients' anxiety. In summary, our results suggest that patients respond to a variety of factors to reduce anxiety and that each patient derives relief from anxiety in different manners. Therefore, offering a spectrum of comforting or distracting activities during the Mohs procedure is ideal and may reduce the need for pharmacologic anxiolytics.

A review of traditional and novel oral anticoagulant and antiplatelet therapy for dermatologists and dermatologic surgeons.

BACKGROUND: Dermatologic surgeons will increasingly encounter patients on novel oral antiplatelet and anticoagulant medications. OBJECTIVES: We conducted a complete overview of the pharmacokinetics, pharmacodynamics, and side effects of traditional and novel oral anticoagulant and antiplatelet therapies along with dietary supplements with anticoagulant or antiplatelet properties. METHODS: A PubMed search was completed for "aspirin," "warfarin," "clopidogrel," "dabigatran," "rivaroxaban," "apixaban," "prasugrel," and "ticagrelor." Review articles and publications emphasizing perioperative management of oral anticoagulant or antiplatelet medications were selected. An additional PubMed search was completed for "hemorrhage," "bleeding," and "thrombosis" in conjunction with "dermatology," "dermatologic surgery," and "cutaneous surgery." RESULTS: Aspirin, clopidogrel, and warfarin have shortfalls in dosing, monitoring, and efficacy. Several trials show superior efficacy with dabigatran, rivaroxaban, and apixaban, with equal or reduced risk of bleeding compared with warfarin. Prasugrel and ticagrelor may be associated with an increased bleeding risk. Many over-the-counter medications also have anticoagulant properties with associated bleeding risks that cannot be overlooked. LIMITATIONS: There are few publications evaluating the novel oral anticoagulants' effects on outpatient surgical procedures. CONCLUSION: Novel anticoagulant and antiplatelet drugs are revolutionizing therapy for cardiovascular diseases. As these medications become more prevalent, dermatologists and dermatologic surgeons must be mindful of the bleeding risk that will apply in our everyday practices.

Management of unusual cutaneous malignancies: atypical fibroxanthoma, malignant fibrous histiocytoma, sebaceous carcinoma, extramammary Paget disease.

Atypical fibroxanthoma, malignant fibrous histiocytoma, sebaceous carcinoma, and extramammary Paget disease are rare cutaneous tumors. Their recognition and diagnosis are critical in decreasing long-term morbidity and mortality. Surgical excision is the treatment of choice for these tumors, and Mohs micrographic surgery has been shown to be as favorable or better than wide local excision in providing long-term clearance rates.

Topical imiquimod or fluorouracil therapy for basal and squamous cell carcinoma: a systematic review.

OBJECTIVES: To conduct a systematic review to determine clearance rates and adverse effects of topical imiquimod or fluorouracil therapy in the treatment of nonmelanoma skin cancers such as basal (BCC) and squamous cell carcinoma (SCC), and to develop recommendations for the use of topical imiquimod or fluorouracil to treat BCC and SCC. DATA SOURCES: MEDLINE, CANCERLIT, and Cochrane databases. STUDY SELECTION: Prospective, retrospective, and case studies in English containing a minimum of 4 subjects and a 6-month follow-up or posttreatment histologic evaluation. DATA EXTRACTION: We calculated the rate of clearance and adverse effects for BCC subtypes and invasive and in situ SCC treated with topical imiquimod or fluorouracil. DATA SYNTHESIS: Clearance rates varied by drug regimen, and most of the studies lacked long-term follow-up. Imiquimod use produced the following clearance rates: 43% to 100% for superficial BCC, 42% to 100% for nodular BCC, 56% to 63% for infiltrative BCC, 73% to 88% for SCC in situ, and 71% for invasive SCC. Fluorouracil use produced the following clearance rates: 90% for superficial BCC and 27% to 85% for SCC in situ. Up to 100% and 97% of patients applying imiquimod and fluorouracil, respectively, experienced at least 1 adverse event. Adverse event intensity ranged from mild to severe; erythema, pruritus, and pain were common. CONCLUSIONS: Evidence supports the use of topical imiquimod as monotherapy for superficial BCC and topical fluorouracil as monotherapy for superficial BCC and SCC in situ. Based on the available evidence, the strength of any recommendations for the use of these 2 agents in the primary treatment of these tumors is weak. We recommend that their use be limited to patients with small tumors in low-risk locations who will not or cannot undergo treatment with better-established therapies for which long-term clearance rates have been determined. Long-term clinical follow-up is essential for patients treated with topical imiquimod or fluorouracil. Limitations of therapy include high rates of adverse effects, lower clearance rates than other treatment modalities, dependence on patient adherence to treatment, and higher costs than other therapies.

Surgical management of congenital dermatofibrosarcoma protuberans.

Congenital dermatofibrosarcoma protuberans (DFSP) is a rare tumor with varying clinical presentations that is commonly misdiagnosed. Treatment of congenital DFSP is complicated by delays in diagnosis and its propensity for subclinical spread. Of 61 reported cases, 11 (18%) were treated with Mohs micrographic surgery (MMS) and 46 (75%) were treated with wide local excision (WLE). One case was treated with imatinib, and the remaining 3 did not differentiate between receiving MMS or WLE. In the cases of congenital DFSP treated with MMS the clearance rate was 100% with an average follow-up of 4.3 years. The clearance rate seen with WLE was 89% with an average follow-up period of 1.9 years. The average margins taken during MMS (1.7 cm) were smaller than those taken with WLE (2.8 cm). Fifty percent of cases with available follow-up undergoing WLE required multiple surgeries. Based on superior cure rates with long-term follow-up, smaller surgical margins, and fewer surgical sessions, MMS should be considered as first-line treatment for congenital DFSP.

Fabric preferences of atopic dermatitis patients.

BACKGROUND: Atopic dermatitis (AD) patients have sensitive skin with impaired barrier function. Lyocell is a cellulosic fiber that offers unique characteristics and may be suitable for use by AD patients. OBJECTIVE: To compare preferences of subjects with atopic dermatitis and normal skin for 100% lyocell clothing and bedding versus 100% cotton fabrics. METHODS: Thirty subjects were enrolled and randomly selected to use cotton or lyocell shirts, pajamas, and bedding for 1 week. Following a 1-week washout period, participants wore the other fabric for 1 week. At the end of each week, participants completed a preference questionnaire, and AD subjects also rated daily itching on a visual analog scale. A random subset of AD and normal participants underwent measurement of transepidermal water loss (TEWL). RESULTS: Overall, there was a significant preference for lyocell (vs cotton) for its softness, temperature control, moisture control, and wrinkle resistance. AD subjects did not have stronger fabric preferences than did normal subjects. Although not significant, lower average itching and decreased TEWL were seen in participants while they wore lyocell. CONCLUSION: Lyocell is superior to cotton in many performance characteristics and equivalent to cotton for itch reduction. Lyocell is currently available as a beneficial fabric to improve patient comfort.