Electrosurgery in dermatology.

Electrosurgery applies high frequency alternating electrical currents to generate heat, thereby creating tissue damage required for cutting, hemostasis, or destruction. Electrosurgery can be delivered in a variety of different ways and can be tailored to achieve the desired clinical effect. Having a command of the underlying principles of electrosurgery will help dermatologic surgeons use the appropriate form of electrosurgery to safely achieve the desired results. We reviewed basic principles of electrosurgery, described the various techniques and devices, and delineated associated risks of electrosurgery for specific patient populations and providers. All modalities of electrosurgery present a risk of electromagnetic interference, which can negatively affect patients with implanted devices, such as pacemakers, defibrillators, cochlear implants, and deep brain stimulators. In particular, electrosurgery may create a smoke plume containing a number of volatile organic compounds potentially noxious; however, the risk of such exposure remains unknown.

Safe Step Act: does it undermine step therapy?

Drug expenditure in the United States has continued to increase unsustainably; the specialty of dermatology has been particularly affected. Resources are limited - someone has to make decisions about what treatments will be covered and how they will be reimbursed. Step therapy is a cost-control method used by insurers to encourage the use of the most cost-effective treatments before more expensive options are attempted. However, a rigid step therapy policy can be problematic when protocols are out of date, or delay necessary treatment leading to unnecessary suffering, increased morbidity, and overall cost. To address some of these concerns, the proposed Safe Step Act (S. 2546 and H.R. 2279) attempts to create a requirement that insurers provide a transparent, expeditious exceptions process for step therapy protocols. Increased flexibility in this process will allow for the unique circumstances of individual patients and improve access to expensive drugs for special cases. However, this bill may be exploited, further weakening insurers' ability to negotiate on cost. We should be cautious about measures that reduce the effectiveness of this tool, particularly if we, as a society, aim to expand access to basic care to all Americans.

Public Perception of Ethical Issues in Dermatology: Evidenced by New York Times Commenters.

BACKGROUND: A 2017 New York Times (NYT) article questioning the appropriateness of skin cancer treatment modality by dermatology providers stimulated discussion among the public pertaining to ethics in the current state of dermatologic practice. OBJECTIVE: The purpose of this study is to characterize issues raised by the comments on the NYT article, discuss strategies to address these concerns, and encourage reflection on ethics in dermatologic care. MATERIALS AND METHODS: A qualitative analysis was performed on the 309 comments on the NYT article. General themes were identified, resulting in the inclusion of 222 comments. These comments were reviewed and characterized by the type of commenter, his or her stance on health care, and what issues they raised. RESULTS: Providers interested in "profit over patient" was the most common theme, followed by mistrust of APPs, health care system interested in "profit over patient," inadequate supervision by advanced practice providers (APPs), finding the "right" provider, support for coordinated APP and physician care, support for APP credentials, and finally inappropriate elderly care. CONCLUSION: The NYT article raises the concern of identifying quality care and choosing the "right provider"-one who successfully balances the various incentives affecting skin cancer management including appropriate usage of APPs.

Web App- and Text Message-Based Patient Education in Mohs Micrographic Surgery-A Randomized Controlled Trial.

BACKGROUND: Consent and wound care (WC) videos are used for education in Mohs micrographic surgery (MMS). Postoperative text messaging is poorly studied. OBJECTIVE: Develop and evaluate perioperative resources for MMS patients-video modules (DermPatientEd.com) and postoperative text messaging (DermTexts.com). MATERIALS AND METHODS: A study was conducted on 90 MMS patients. Patients were randomized 1:1:1:1 to videos with text messages, videos-only, text messages-only, or control. Primary outcomes included preoperative anxiety and knowledge of MMS and postoperative care. The secondary outcome included helpfulness/preference of interventions. RESULTS: Patients experienced a 19% reduction in anxiety as measured by a visual analog scale after the MMS video (p = .00062). There was no difference in knowledge after the WC video (p = .21498). Patients were more likely to report the WC video "very helpful" when compared with the pamphlet in understanding postoperative WC (p = .0016). Patients in text messaging groups were not more likely to report the service as "very helpful" when compared with the pamphlet (p = .3566), but preferred to receive WC instructions by text message for future visits (p = .0001). CONCLUSION: These resources proved helpful and effective in reducing preoperative anxiety. Patients prefer text message-based WC instructions over pamphlets after experiencing the service, but do not find them more helpful.

Association of pain and itch with depth of invasion and inflammatory cell constitution in skin cancer: results of a large clinicopathologic study.

IMPORTANCE: This study highlights a simple bedside evaluation of itch and pain for suspicious skin lesions. OBJECTIVE: To examine the correlation of pain and itch with histologic features of skin cancers. DESIGN, SETTING, AND PARTICIPANTS: This large, prospective, clinicopathologic study enrolled patients who filled out questionnaires that assessed itch and pain intensity of their skin tumors at the time of excision. Study participants were from the patient population presenting to the Department of Dermatology surgical unit at Wake Forest University Baptist Medical Center from July 1, 2010, through March 31, 2011. Study participants included 268 patients, representing 339 histopathologically confirmed cutaneous neoplasms. The following skin cancer subtypes were represented in this analysis: 166 basal cell carcinomas, 146 squamous cell carcinomas, and 27 melanomas. MAIN OUTCOMES AND MEASURES: Itch and pain associated with skin cancer at the time of excision ranked on an 11-point (score range, 0-10) numerical visual analog scale and histopathologic analysis for each neoplasm (assessment of the amount and type of inflammation, ulceration, perineural invasion, and depth of invasion). RESULTS: The prevalence of itch and pain across all skin cancers was 36.9% and 28.2%, respectively. However, these symptoms were mostly absent in melanomas. Pain intensity was significantly associated with the degree of inflammation (mild or none vs moderate or marked; P < .001), presence of neutrophils in the inflammatory infiltrate (predominantly mononuclear vs mixed or neutrophilic; P = .003), presence of eosinophils (present vs absent; P = .007), ulceration (yes vs no; P = .003), perineural invasion (yes vs no; P < .001), depth of invasion (P = .001), and largest diameter length of skin lesion (P < .003). Itch intensity was significantly associated with the degree of inflammation (mild or none vs moderate or marked; P = .001) and the presence of eosinophils (present vs absent; P = .02). CONCLUSIONS AND RELEVANCE: These findings support the theory that itch emanates from the upper layers of the skin, whereas pain is associated with deeper processes. This study also reports that a simple bedside assessment for the presence and intensity of pain or itch is an easily implementable tool for physicians evaluating suspicious skin lesions.

Electrosurgery: part I. Basics and principles.

The term electrosurgery (also called radiofrequency surgery) refers to the passage of high-frequency alternating electrical current through the tissue in order to achieve a specific surgical effect. Although the mechanism behind electrosurgery is not completely understood, heat production and thermal tissue damage is responsible for at least the majority--if not all--of the tissue effects in electrosurgery. Adjacent to the active electrode, tissue resistance to the passage of current converts electrical energy to heat. The only variable that determines the final tissue effects of a current is the depth and the rate at which heat is produced. Electrocoagulation occurs when tissue is heated below the boiling point and undergoes thermal denaturation. An additional slow increase in temperature leads to vaporization of the water content in the coagulated tissue and tissue drying, a process called desiccation. A sudden increase in tissue temperature above the boiling point causes rapid explosive vaporization of the water content in the tissue adjacent to the electrode, which leads to tissue fragmentation and cutting.

Electrosurgery: part II. Technology, applications, and safety of electrosurgical devices.

Electrosurgical currents can be delivered to tissue in monopolar or bipolar and monoterminal or biterminal modes, with the primary difference between these modes being their safety profiles. A monopolar electrosurgical circuit includes an active electrode and a dispersive (return) electrode, while there are 2 active electrodes in bipolar mode. In monoterminal mode, there is an active electrode, but there is no dispersive electrode connected to the patient's body and instead the earth acts as the return electrode. Biterminal mode uses a dispersive electrode connected to the patient's body, has a higher maximum power, and can be safer than monoterminal mode in certain situations. Electrosurgical units have different technologies for controlling the output power and for providing safety. A thorough understanding of these technologies helps with a better selection of the appropriate surgical generator and modes.

Noncosmetic skin-related procedures performed in the United States: an analysis of national ambulatory medical care survey data from 1995 to 2010.

BACKGROUND: Demand for dermatologic care is increasing alongside a known shortage of physicians in the dermatology workforce. Changes in the volume of dermatologic procedures over time and the physician specialties involved in skin-related procedural care are not well characterized. OBJECTIVE: To determine the frequency of dermatologic procedures performed in the United States between 1995 and 2010 and to analyze the changes in the procedures and physicians performing procedures over time. METHODS: The annual volume of skin-related procedures performed by physician specialties and the rate of procedures performed per physician was determined from data from the National Ambulatory Medical Care Survey (NAMCS) between 1995 to 2004 and 2007 to 2010. RESULTS: Dermatologists and primary care physicians performed most procedures (54.7% and 19.5%, respectively). CONCLUSIONS: Dermatologists perform a larger volume of procedures than in the past, although the proportion of procedures performed by dermatologists is unchanged, and other physician specialties are performing more skin-related procedures to meet increasing demand.

Cosmetic procedures performed in the United States: a 16-year analysis.

BACKGROUND: Cosmetic procedures, particularly those that are minimally invasive, are in demand. The physician specialties performing these procedures are not well-characterized. OBJECTIVE: To examine changes in the frequency of cosmetic dermatologic procedures performed in the United States from 1995 to 2010 and the physician specialties performing them. METHODS: The volume of cosmetic procedures performed by physician specialties and the types of cosmetic procedures performed were determined from data from the National Ambulatory Medical Care Survey (NAMCS) from 1995 to 2010. RESULTS: Cosmetic procedures constituted 8.7% of all skin procedures and have increased since 1995 (p < .001). Botulinum toxin injections were the most frequently performed cosmetic procedure and increased at the greatest rate over time. Plastic surgeons performed the largest proportion of cosmetic procedures (36.1%), followed by dermatologists (33.7%), but other specialties have been performing an increasing proportion of cosmetic procedures. This study was limited to the provision of outpatient procedures, and the nationally representative data of the NAMCS is subject to sample bias. CONCLUSIONS: Plastic surgeons and other physicians performed the majority of outpatient cosmetic procedures. Dermatologists performed one-third of ambulatory cosmetic procedures from 1995 to 2010. This broadening spectrum of physicians and nonphysicians providing cosmetic procedures may have important implications for patient safety.

Nonmelanoma skin cancer treatment training varies across different medical specialists.

BACKGROUND: Physicians from various specialties treat patients with nonmelanoma skin cancer (NMSC). The isolation of specialties from each other may result in different approaches to skin cancer training. PURPOSE: Our purpose was to determine the type and amount of NMSC surgical training that is received during dermatology, general surgery, internal medicine, otolaryngology, and plastic surgery residencies. METHODS: E-mail contact information for residency program directors of all accredited programs in each specialty was compiled through the American Medical Association's online residency database. A total of 920 residency program directors were emailed surveys concerning the training of residents in the treatment of NMSC. RESULTS: Forty-two of 920 surveys were returned. All surveyed specialty groups, except internal medicine, had training in NMSC treatment including simple excision, split thickness skin grafts, and tissue rearrangement. A majority of the dermatology and plastic surgery programs instruct their residents in Mohs micrographic surgery and full thickness skin grafts. Electrodessication and curettage was most often instructed in dermatology, general surgery, and plastic surgery programs. CONCLUSION: Greater consistency in NMSC treatment training may be beneficial. Because different approaches may be best suited to particular clinical situations, NMSC treatment training should include adequate exposure to all NMSC treatment techniques.

Practice trends in the treatment of actinic keratosis in the United States: 0.5% fluorouracil and combination cryotherapy plus fluorouracil are underused despite evidence of benefit.

BACKGROUND: Topical fluorouracil and cryotherapy are among the most commonly used treatments for actinic keratosis. Evidence shows that 0.5% fluorouracil has similar efficacy and is better tolerated than 5% fluorouracil. Evidence also shows that combination therapy with cryosurgery and fluorouracil is beneficial. OBJECTIVE: To examine fluorouracil and cryotherapy use in the treatment of actinic keratosis. METHODS: The National Ambulatory Medical Care Survey database was queried for visits for actinic keratosis. Visits were analyzed for patient demographics, provider specialty, and treatment regimens. Fluorouracil and cryotherapy use was analyzed over time. RESULTS: Cryotherapy was the most commonly used treatment for actinic keratosis. Fluorouracil products were prescribed to 1.1 million patients (6.6%) between 2001 and 2008; of these, dermatologists prescribed 0.5% fluorouracil in 51.8% of cases and 5% fluorouracil in 38.9% of cases. Combination fluorouracil and cryotherapy was used for only 1.1% of actinic keratosis visits between 1993 and 2008 and was never used by nondermatologists. CONCLUSIONS: Despite evidence suggesting comparable efficacy, greater tolerability, and lower cost of 0.5% fluorouracil relative to 5% fluorouracil, 5% fluorouracil is used by dermatologists almost as often as 0.5% fluorouracil. Among nondermatologists, 5% fluorouracil is used exclusively. Combination therapy of fluorouracil and cryotherapy is underused despite evidence of its benefit.

Use of topical antibiotics as prophylaxis in clean dermatologic procedures.

BACKGROUND: Topical antibiotics are not indicated for routine postoperative care in clean dermatologic procedures, but may be widely used. OBJECTIVE: We sought to describe topical antibiotic use in clean dermatologic surgical procedures in the United States. METHODS: The 1993 to 2007 National Ambulatory Medical Care Survey database was queried for visits in which clean dermatologic surgery was performed. We analyzed provider specialty, use of topical antibiotics, and associated diagnoses. Use of topical antibiotic over time was analyzed by linear regression. RESULTS: An estimated 212 million clean dermatologic procedures were performed between 1993 and 2007; topical antibiotics were reported in approximately 10.6 million (5.0%) procedures. Dermatologists were responsible for 63.3% of dermatologic surgery procedures and reported use of topical antibiotic prophylaxis in 8.0 million (6.0%). Dermatologists were more likely to use topical antibiotic prophylaxis than nondermatologists (6.0% vs 3.5%). Use of topical antibiotic prophylaxis decreased over time. LIMITATIONS: Data were limited to outpatient procedures. The assumption was made that when topical antibiotics were documented at procedure visits they were being used as prophylaxis. CONCLUSIONS: Topical antibiotics continue to be used as prophylaxis in clean dermatologic procedures, despite being ineffective for this purpose and posing a risk to patients. Although topical antibiotic use is decreasing, prophylactic use should be eliminated.

Topical antibiotic trends from 1993 to 2007: use of topical antibiotics for non-evidence-based indications.

BACKGROUND: Systemic antibiotic use has become more conservative with the emergence of drug resistance. Topical antibiotics are employed for a variety of indications, although there are only a few evidence-based indications. OBJECTIVE: To examine topical antibiotics use in the outpatient setting. METHODS: Topical antibiotic use was characterized using data from the 1993 to 2007 National Ambulatory Medical Care Survey. Visits were identified at which a topical antibiotic was used and analyzed according to patient demographics, diagnoses, procedures, concomitant medications, and provider specialty. Topical antibiotic use over time was analyzed using linear regression. RESULTS: The most frequent diagnoses associated with topical antibiotic use were benign or malignant neoplasm of skin, impetigo, insect bite, and cellulitis. Data revealed a significant downward trend in topical antibiotics associated with dermatologic surgery (p<.001) and a nonsignificant downward trend in use in conjunction with skin biopsies (p=.09). Topical antibiotic use by dermatologists was noted to be decreasing over time, whereas among non dermatologists, it was noted to be increasing, although neither of these trends was statistically significant. CONCLUSION: Topical antibiotics continue to be used for non-evidence-based indications, despite data that suggest that such use may be detrimental for patients and represents significant costs to the health care system. The authors have indicated no significant interest with commercial supporters.

A Medicare cost comparison of minor cutaneous procedures by surgical setting.

BACKGROUND: Regulations that cause minor cutaneous procedures to be moved from the physician's office to an ambulatory surgery center (ASC) or hospital may have the potential to unnecessarily increase the costs of these procedures from the Medicare perspective. OBJECTIVE: To investigate whether minor cutaneous procedures that could reasonably be performed in the office are being done in more intense settings (ASCs or hospitals), who is performing these procedures in alternative settings, and the cost of higher intensity settings. METHODS: Medicare claims data on a number of minor cutaneous surgery procedures performed by various medical disciplines, the location in which the procedures were performed, and the ratio of minor procedures done in each surgical setting by specialty were obtained using the 1992-2000 Medicare Current Beneficiary Survey (MCBS). We used Medicare reimbursements as a measure of the cost of the procedure. RESULTS: When compared by surgical setting, the mean charges for each minor cutaneous procedure were greatest when the procedure was performed in the hospital setting and least when performed in the office setting. Owing to surgical setting, dermatologists were the most cost-effective specialists for the performance of minor cutaneous procedures. CONCLUSIONS: Regulations that discourage office-based surgery could significantly increase medical care costs.