Phenol-Croton Oil Chemical Peeling Induces Durable Improvement of Constitutional Periorbital Dark Circles.

BACKGROUND: Constitutional periorbital dark circles (PDC) are common in skin of color and represent a therapeutic challenge. OBJECTIVE: To summarize the experience of the International Peeling Society on the safety and effectiveness of deep chemical peeling in the treatment of constitutional PDC. MATERIALS AND METHODS: Multi-institutional, retrospective case series (1990-2020) of constitutional PDC treated by deep chemical peeling. Descriptive analysis by age, sex, Fitzpatrick phototype, phenol-croton formula, degree and durability of improvement, and complications. RESULTS: Fifty-five phenol-croton oil peels were performed in 52 patients: 3 patients received a second peel for periorbital rhytids 72 to 84 months after the first peel. 92% (48/52) of patients were women; the median age was 46 years (range, 23-68 years). 89% (46/52) of patients were Fitzpatrick III-IV. Most common formula included phenol 60% to 65% and croton oil 0.6% to 0.7%. 89% (49/55) of peels demonstrated >50% clinical improvement. The median duration of improvement was 24 months (range, 1.5-168 months), and 69% (36/52) of patients demonstrated ongoing improvement at the last follow-up. 4% (2/55) of peels exhibited complications of persistent erythema that resolved without scarring. CONCLUSION: Based on its safety and effectiveness, deep chemical peels are a treatment of choice for constitutional PDC.

Neurotropic Cutaneous Malignancies: Case Report on Keratinocyte Derived Malignancies of the Head and Neck With Perineural Invasion.

Background: The recent addition of immunotherapy as a treatment modality to surgery and radiation has vastly improved disease control for patients with keratinocyte-derived carcinomas (KCs) that are incurable with local therapies alone. With the advent of immune checkpoint inhibitors (ICPis) in non-melanoma skin cancers comes diagnostic and therapeutic challenges when considering treatment strategies for patients presenting with clinical perineural invasion (cPNI) of locally advanced KC of the head and neck. Objectives: We report four cases that convey the diagnostic and therapeutic complexity of managing patients with neuropathic symptoms from cutaneous neurotropic carcinomas of the head and neck. We also discuss an updated review regarding immunotherapies and perineural invasion within KC management. Conclusion: Patients presenting with symptoms suspicious for cPNI warrant an expanded diagnostic evaluation to correlate neurological findings with neurotropic spread of disease. While nerve biopsies can be precarious in sensitive areas, a history of skin cancer and clinical presentation suggestive of neurotropism may be enough to pursue timely management in the form of surgery, radiation, and/or systemic therapy given each patient's individual priorities, comorbidities, and prognosis. When adding ICPi as a treatment modality for patients with disease not amenable to local therapies, the potential for immune-related adverse events must be considered. A multi-disciplinary review and approach to the management of patients with KC and cPNI is essential for obtaining optimal patient outcomes.

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement.

IMPORTANCE: There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs). OBJECTIVE: To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs. EVIDENCE REVIEW: Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses. FINDINGS: The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC. CONCLUSIONS AND RELEVANCE: Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Chemical Peels as Field Therapy for Actinic Keratoses: A Systematic Review.

BACKGROUND: Actinic keratoses (AKs) are a common premalignant cutaneous neoplasm and can progress to squamous cell carcinoma. A variety of treatment options are available for field therapy of diffuse AKs. OBJECTIVE: This review systematically analyzes the use of chemical peels for treatment of AKs. MATERIALS AND METHODS: A systematic review of PubMed was performed searching from 1946 to March 2020 to identify the literature on chemical peels for AKs. RESULTS: Of the 151 articles identified, 5 met inclusion criteria for review. Four of the reviewed articles demonstrated the efficacy of chemical peels in reducing AK count and minimal adverse effects. In some studies, chemical peels exhibited potential to prevent additional AK formation and development of keratinocyte carcinomas. CONCLUSION: Chemical peels are an efficacious and affordable treatment option for field treatment of AKs. With improved patient tolerance and adherence, chemical peels are an attractive option for field therapy of AKs for both dermatologists and patients.

Depth Map for Face and Neck Deep Chemical Peel Resurfacing.

BACKGROUND: Chemical peels are applied to the face and neck to improve rhytides and the photoaged appearance of the skin. Peels can be applied to different skin depths depending on the types of chemicals, the volume of solution, and the amount of pressure or friction applied. If a peel is applied too superficially, rhytides will not be removed. If a peel is applied too deeply, scarring or hypopigmentation could occur. OBJECTIVE: To create face and neck depth maps for chemical peeling, which can guide safety when removing rhytides and improving the skin's appearance. MATERIALS AND METHODS: A multicenter retrospective review of records was conducted of patients who underwent phenol-croton oil peeling, from January 1, 2018, to December 31, 2018. Information was collected on facial and neck cosmetic units peeled, peel formula and strength used, outcomes, and complications. RESULTS: A total of 410 patients received deep peels. Two depth maps were created that corresponded to the most common patterns of deep chemical peel applications. CONCLUSION: Different areas of the face and neck are treated with different chemical peel application depths to safely improve rhytides and appearance. Depth maps are created to balance safety and efficacy.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions.

BACKGROUND: In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality. OBJECTIVE: The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures. MATERIALS AND METHODS: An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures. RESULTS: Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements. CONCLUSION: Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.

Advanced chemical peels: Phenol-croton oil peel.

Once considered the standard for deep facial resurfacing, the classical Baker-Gordon phenol-croton oil peel has largely been replaced by formulas with lower concentrations of phenol and croton oil. The improved safety profile of deep peels has ushered in a new era in chemical peeling. Wrinkles can be improved and skin can be tightened with more subtle and natural results. No longer does a deep peel denote "alabaster white" facial depigmentation with complete effacement of wrinkles. Gregory Hetter's research showed that the strength and corresponding depth of penetration of the phenol-croton oil peel can be modified by varying the concentration of croton oil. This second article in this continuing medical education series focuses on the main historical, scientific, and procedural considerations in phenol-croton oil peels.

Basic chemical peeling: Superficial and medium-depth peels.

Chemical peeling, or chemexfoliation, has been used for centuries to improve signs of ultraviolet light-induced sun damage. Over the last 30 years, the science behind chemical peeling has evolved, increasing our understanding of the role of peeling ingredients and treatment indications. The depth of peels is directly related to improved results and to the number of complications that can occur. Key principles for superficial and medium depth peeling are discussed, as well as appropriate indications for these treatments.

Chemical Peels: Indications and Special Considerations for the Male Patient.

BACKGROUND: Chemical peels are a mainstay of aesthetic medicine and an increasingly popular cosmetic procedure performed in men. OBJECTIVE: To review the indications for chemical peels with an emphasis on performing this procedure in male patients. MATERIALS AND METHODS: Review of the English PubMed/MEDLINE literature and specialty texts in cosmetic dermatology, oculoplastic, and facial aesthetic surgery regarding sex-specific use of chemical peels in men. RESULTS: Conditions treated successfully with chemical peels in men include acne vulgaris, acne scarring, rosacea, keratosis pilaris, melasma, actinic keratosis, photodamage, resurfacing of surgical reconstruction scars, and periorbital rejuvenation. Chemical peels are commonly combined with other nonsurgical cosmetic procedures to optimize results. Male patients may require a greater number of treatments or higher concentration of peeling agent due to increased sebaceous quality of skin and hair follicle density. CONCLUSION: Chemical peels are a cost-effective and reliable treatment for a variety of aesthetic and medical skin conditions. Given the increasing demand for noninvasive cosmetic procedures among men, dermatologists should have an understanding of chemical peel applications and techniques to address the concerns of male patients.

Clinical Presentation and Positive Outcome of Two Siblings with Holocarboxylase Synthetase Deficiency Caused by a Homozygous L216R Mutation.

Purpose The L216R mutation, seen in individuals of Polynesian descent, is considered one of the most severe mutations associated with holocarboxylase synthetase (HLCS) deficiency and is regarded as being unresponsive to biotin. This report describes the presentation and outcome in two surviving siblings, homozygous for this highly lethal mutation. Methods and results Both cases had perinatal head imaging findings of brain hemorrhage and subependymal cysts. Both had metabolic decompensation within 24 h after birth consisting of metabolic acidosis, lactic acidosis, and thrombocytopenia. Biochemical profiles were consistent with HLCS deficiency, and genetic analysis confirmed homozygosity for the L216R mutation. After resolution of neonatal metabolic crisis, dosing of biotin was titrated on an outpatient basis to primarily control dermatitis. The eldest is currently on 1.2 g of oral biotin daily, well above any dose previously reported to treat HLCS deficiency. To date, neither patient has required hospital readmission for acute metabolic decompensation. At the age of 7, the eldest child is, to our knowledge, the oldest patient ever described in the literature who is homozygous for the L216R mutation. She has mild intellectual disability. Conclusion This report contrasts previous reports of poor outcomes and neonatal deaths in homozygous L216R patients. We also provide data on the potential upper tolerable limit of biotin. These cases suggest that the outcome of HCLS deficiency due to a homozygous L216R mutation, when diagnosed and treated early with high-level neonatal care and biotin, may not be as severe as previously reported.