The 2023 Annual Report of DataDerm™: The Database of The American Academy of Dermatology (AAD).

The American Academy of Dermatology (AAD) launched DataDerm™ in 2016 as the clinical data registry platform of AAD. DataDerm has evolved to be the largest database in the world containing information about dermatology patients, capturing information about their course of disease, associated therapeutic interventions, and health outcomes. As of December 31, 2022, DataDerm contained data from 14.2 million unique patients and 53.5 million unique patient visits, with 415 practices representing 1,663 clinicians actively participating in DataDerm in 2022. This article is the fourth in a series of Annual Reports about the status of DataDerm. This year's 2023 annual report presents the progress DataDerm has made in conjunction with OM1, the data analytics partner of DataDerm, with a special highlight on the longitudinal care of common dermatologic conditions in the registry and a detailed focus on skin cancer. Furthermore, we review the current status of DataDerm as a robust representation of real world specialty data, reflecting the day-to-day dermatologic care of patients over time.

Hiding in Plain Sight: A Retrospective Review of Unrecognized Tumors During Dermatologic Surgery.

BACKGROUND: Mohs micrographic surgery requires focused attention that may lead to tunnel vision bias, contributing to not recognizing skin cancer at nearby sites. OBJECTIVE: It is to determine if a subsequently diagnosed skin cancer was visible at the time of Mohs surgery. METHODS: A retrospective chart review was performed at a single academic center from 2008 to 2020. Patients who underwent at least two distinct MMS procedures, separated in time to capture subsequent tumors, were included. RESULTS: Four hundred and four individual patients were identified with at least two distinct Mohs procedures, which generated 1,110 Mohs sequences. Fifty-one (4.6%) clinically apparent tumors went unrecognized and 127 (11.4%) tumors were identified and biopsied during the visit. High-risk tumor histology was identified in 10 (20%) unrecognized tumors and 31 (24%) recognized tumors (p-value 0.491). CONCLUSION: Our study suggests that Mohs surgeons may be overlooking adjacent skin cancers when focusing only on the tumor being surgically treated. Tunnel vision bias may account for part of this phenomenon.

1550-nm Nonablative Fractional Laser Versus 10,600-nm Ablative Fractional Laser in the Treatment of Surgical and Traumatic Scars: A Comparison Study on Efficacy and Treatment Regimen.

BACKGROUND: The appearance and symptoms of scars can cause significant distress to patients. OBJECTIVE: To assess and compare efficacy of the 1,500-nm nonablative fractional laser (NAFL) and 10,600-nm ablative fractional laser (AFL) in reducing symptoms and improving the appearance of traumatic or surgical scars. MATERIALS AND METHODS: Single-center prospective, randomized, blinded, split-scar study was conducted on 100 patients with a scar obtained through trauma or surgery. Three treatments of NAFL or AFL were administered to each half of the scar at 4-week intervals. Scars were self-rated by the patient using the Patient and Observer Scar Assessment Scale and a satisfaction score and objectively evaluated by blinded dermatologists using the Manchester Scar Scale and visual analog scale. RESULTS: Blinded observers found no statistically significant difference in scar appearance. Patient rating showed improvement of scar appearance (p < .0001). Pain was worse after treatment with AFL (p = .0492). Overall, there was no statistically significant evidence of one laser being superior or inferior to the other for patient and blinded observer scores (p = .3173 and p = .2513, respectively). CONCLUSION: Scar treatment with AFL or NAFL is associated with high patient satisfaction. Objective evaluation of scars did not identify improvement in scar appearance.

Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery.

BACKGROUND: Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS). OBJECTIVE: We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS. MATERIALS AND METHODS: A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls. RESULTS: Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure. CONCLUSION: This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.

Red man syndrome caused by vancomycin powder.

Red man syndrome (RMS) is a well-known hypersensitivity reaction caused by intravenous administration of vancomycin, with symptoms ranging from flushing, erythematous rash, pruritus, mild to profound hypotension, and even cardiac arrest. RMS has not previously been described from local application of vancomycin powder in a surgical wound, a technique increasingly utilized for infection prophylaxis in many surgical disciplines including neurosurgery. We describe the first reported case of RMS as a result of local intra-wound application of vancomycin powder for infection prophylaxis. A 73-year-old male with a history of Parkinson's disease underwent 2-stage deep brain stimulation implantation surgeries. Vancomycin powder was applied locally in the surgical wounds for infection prophylaxis during both of the surgeries. The patient developed a well-demarcated, geometric erythematous pruritic rash following the second surgery that was clinically diagnosed as RMS and resolved without sequelae.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and Alternative Payment Models in dermatology.

With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Accountable Care Organizations.

An Accountable Care Organization (ACO) is a network of providers that collaborates to manage care and is financially incentivized to realize cost savings while also optimizing standards of care. Since its introduction as part of the 2010 Patient Protection and Affordable Care Act, ACOs have grown to include 16% of Medicare beneficiaries and currently represent Medicare's largest payment initiative. Although ACOs are still in the pilot phase with multiple structural models being assessed, incentives are being introduced to encourage specialist participation, and dermatologists will have the opportunity to influence both the cost savings and quality standard aspects of these organizations. In this article, part of a health care policy series targeted to dermatologists, we review what an ACO is, its relevance to dermatologists, and essential factors to consider when joining and negotiating with an ACO.

Surgical corner. Modified buried suture technique for the scalp.

Large surgical defects on an actinically damaged scalp are notoriously difficult to close primarily. Not only is the skin weak and friable, but the underlying bone often limits the size of "bite" that the surgeon can take with their deep suture. We describe a technique that maximizes the ability to grasp adequate deep tissue with the suture, decreasing the likelihood of tearing through the tissue when the wound edges are brought together.

Acute mucocutaneous methotrexate toxicity associated with interface dermatitis and numerous eosinophils.

Acute mucocutaneous methotrexate toxicity is not classically associated with prominent tissue eosinophilia. We present a case of acute methotrexate toxicity associated with pancytopenia and mucocutaneous erosion with interface dermatitis and numerous eosinophils. A 79-year-old male, with a history of psoriasis vulgaris on methotrexate therapy, presented with blisters of the oral mucosa, groin, sacrum, and extremities after daily consumption of methotrexate. Examination revealed blisters and erosions localized to psoriatic plaques, the perineum, and the oral mucosa. Laboratory evaluation demonstrated pancytopenia, megaloblastic anemia, and elevated liver function tests. A skin biopsy of an eroded plaque revealed psoriasiform epidermal hyperplasia with epidermal erosion, parakeratosis, and loss of the granular cell layer. There was an underlying band-like lymphoid infiltrate with interface dermatitis, dyskeratotic keratinocytes, and numerous eosinophils. Direct immunofluorescence studies were negative for the deposition of immunoreactants. Methotrexate was held, and the patient received leucovorin resulting in improvement of blood counts and cutaneous lesions. The histopathologic changes associated with acute mucocutaneous toxicity have been described as pauci-inflammatory erosions associated with dyskeratotic keratinocytes to interface dermatitis with necrotic keratinocytes and occasionally associated eosinophils. Although these changes are most often superimposed on psoriatic plaques, they have been reported to occur on normal skin. Therefore, the differential diagnosis may include lichen planus, a lichenoid drug eruption, or a fixed drug eruption, and given the presence of mucosal ulceration, incipient pemphigus vulgaris or paraneoplastic pemphigus vulgaris. This case illustrates that acute mucocutaneous methotrexate toxicity may be associated with both interface dermatitis and numerous eosinophils.