CAPABLE: A Scoring System Utilizing Patient-Reported Measures to Evaluate Patient Experience After Mohs Surgery.

BACKGROUND: Patient experience metrics are gaining prominence in health care. We introduce the CAPABLE survey to assess postoperative experiences of Mohs surgery patients. OBJECTIVE: We sought to determine whether CAPABLE scores aligned with overall patient satisfaction in Mohs surgery. METHODS: This was a cross-sectional, survey-based study of patients presenting for their first postoperative visit after Mohs surgery. The CAPABLE survey included questions on postoperative instructions, activity limitations, pain control, provider accessibility, and bleeding, followed by 2 overall satisfaction questions taken from the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems survey. The pilot study took place at the University of Texas Dell Medical School (DMS), followed by a validation study ( n = 206) at DMS and Oregon Health and Science University (OHSU). We assessed for correlations between CAPABLE scores and overall satisfaction. RESULTS: In the pilot study ( n = 137), overall CAPABLE scores and scores of individual CAPABLE components correlated positively with overall satisfaction.In the multisite validation study ( n = 206) spanning DMS and OHSU, CAPABLE scores correlated positively with overall satisfaction. CONCLUSION: The CAPABLE survey is a concise tool for assessing specific, actionable components of the postoperative patient experience in Mohs surgery, while correlating with overall patient satisfaction.

Safety of Intradermal/Subcutaneous Lidocaine With Epinephrine Use in Dermatologic Surgery.

BACKGROUND: Recently, the safety of lidocaine plus epinephrine use in outpatient surgery has come under scrutiny despite its long history of use in outpatient dermatologic procedures and surgeries. OBJECTIVE: To assess the frequency of crash cart and other emergency interventions during Mohs micrographic surgery when lidocaine plus epinephrine is used as a local anesthetic and evaluate patient comorbidities associated with these events. MATERIALS AND METHODS: A retrospective chart review was conducted in an outpatient Mohs micrographic surgery clinic. RESULTS: One thousand one hundred twenty-seven Mohs cases were reviewed from the period of March 2015 to June 2016 with 864 meeting the inclusion criteria of patient weight, medical history, and amount of lidocaine administered recorded. No adverse events requiring emergency intervention with a crash cart or transfer to the emergency department occurred despite a patient population with advanced age and a wide range of comorbidities. CONCLUSION: No serious adverse events requiring emergency intervention were associated with lidocaine with epinephrine doses administered below the Food and Drug Administration recommended maximum. The authors did not find evidence from this study or after a literature search to support the requirement for a crash cart and other emergency equipment to be present during procedures.

Invasive Melanoma and Melanoma in Situ Treated With Modified Mohs Micrographic Surgery With En Face Permanent Sectioning: A 10-Year Retrospective Review.

BACKGROUND: Successful surgical treatment of cutaneous melanoma is dependent on margin control. OBJECTIVE: To determine efficacy of modified Mohs micrographic surgery (mMMS) with en face permanent margins in management of invasive melanoma (IM) and melanoma in situ (MIS). METHODS: A retrospective cohort study evaluating local recurrence, 5-year recurrence-free survival, and 5-year melanoma-specific survival. Overall, 657 melanomas (128 IM and 529 MIS) from 631 patients were treated using mMMS during a 10-year period. Follow-up information was obtained from medical records and telephone encounters. RESULTS: The median follow-up time was 5.18 years. Most melanomas were located on the head and neck 93.6% (615/657). Margins required for clearance were 0.77 ± 0.44 cm (mean ± SD). Local recurrence was identified in 1.98% (13/657) of melanomas with no local recurrences in IM. Five-year local recurrence-free and melanoma-specific survival rates were estimated to be 96.9% (95% confidence interval [CI]: 94.6%-98.2%) and 99.0% (95% CI: 97.7%-99.6%). There were 5 melanoma-related deaths. CONCLUSION: Modified Mohs micrographic surgery is an effective treatment of melanoma as evidenced by low local recurrence rates and high melanoma-specific survival.

Acral cutaneous metastasis from a primary breast carcinoma following chemotherapy with bevacizumab and paclitaxel.

Acral cutaneous metastasis from internal malignancy is rare, and the pathogenesis is not completely understood. We present the case of a 54-year-old black woman with a history of breast cancer diagnosed 2 years prior who developed multiple cutaneous metastases to acral sites involving the palmar and plantar surfaces of the hands and feet. This case represents an unusual metastatic pattern of breast carcinoma that arose after treatment with bevacizumab, an angiogenesis inhibitor that binds vascular endothelial growth factor A. We propose that bevacizumab-induced vascular changes localized to acral skin may have contributed to the metastatic pattern seen in our patient.

Metastatic vulvovaginal Crohn disease in the setting of well-controlled intestinal disease.

The cutaneous manifestations of Crohn disease (CD) are varied and include pyoderma gangrenosum, erythema nodosum, and metastatic CD (MCD). The latter is defined as the occurrence of granulomatous lesions at a skin site distant from the gastrointestinal tract. Metastatic CD involving the vulva and perineum is rare and thus often is difficult to diagnose. It may precede, coincide with, or develop after the initial diagnosis of intestinal disease. A variety of clinical presentations have been described, including widespread nonspecific pain and swelling, erythematous papules and plaques, and nonhealing ulcers. The diagnosis often is delayed because of a low index of suspicion brought about by the rarity of the disease and its diverse and confusing manifestations. A skin biopsy usually confirms the diagnosis by revealing noncaseating granulomas in the dermis. Multiple oral and parenteral therapies are available, with surgical intervention reserved for resistant cases. We present a case of vulvovaginal MCD in the setting of well-controlled intestinal disease.

Basal cell carcinoma and malignant melanoma cutaneous collision tumor.

Malignant tumors composed of both epithelial and melanocytic populations are exceedingly rare. Because the etiology of these malignant tumors is not yet defined, several authors have argued for the continued cataloging of these lesions. We present a 67-year-old man with a suspicious-appearing lesion on the right forearm; initial biopsy was consistent with a pigmented basal cell carcinoma. On re-excision, a collision of malignant melanoma and basal cell was identified.

Leukocytoclastic vasculitis drug reaction to certolizumab pegol.

Tumor necrosis factor (TNF)-alpha antagonists are a common treatment modality for autoimmune disorders, but their use can be associated with many side effects, including various dermatologic conditions. Certolizumab pegol, a newer TNF antagonist that lacks the Fc portion of the IgG antibody, has recently been approved to treat psoriatic arthritis, rheumatoid arthritis, and Crohn's disease. Though other TNF antagonists have been associated with leukocytoclastic vasculitis, this finding has not yet been reported with certolizumab pegol. We present a case report of leukocytoclastic vasculitis caused by certolizumab pegol.

Epidermolysis Bullosa with Pyloric Atresia and Significant Urologic Involvement.

Epidermolysis bullosa (EB) is a rare inherited disease that causes epidermal fragility, blistering, and erosions. EB results from a variety of mutations in proteins of the skin and mucous membranes of the body. Mutations in plectin a protein involved in hemidesmosome integrity and function, are associated with subtypes of EB, including EB with pyloric atresia and EB with muscular dystrophy. We present two cases of EB with significant urologic involvement resulting from mutations in plectin.

Facial Blanching After Cosmetic Botulinum Toxin Injection: Case Series.

Case 1 A 32-year-old woman was treated for the first time with onabotulinumtoxinA (BoNT), receiving 10 units in her forehead and 20 units in her glabella. She reported no history of skin disease and had a very active lifestyle. She first noticed blanching while doing a group workout and a friend inquired if she had "hives" on her forehead (Figure 1). She continued to note the blanching during workouts 5 months after injection. Each episode lasted 30 minutes to 2 hours. There were no associated symptoms with the blanching other than minor embarrassment. Given her active lifestyle and frequent blanching, she has elected not to receive further injections.

Propranolol for Preoperative Management of a Large Infantile Hemangioma.

Infantile hemangiomas (IHs) are common vascular tumors that typically follow a predictable pattern of rapid proliferation followed by gradual involution. Although most do not require treatment, some large or difficult IHs do, with medical and surgical options available. Prior reports indicate the success of using propranolol, a nonselective ß-blocker, to treat these lesions. This report will demonstrate the use of propranolol preoperatively to manage a large IH followed by surgical excision of the lesion in a collaborative medical and surgical approach.