Dermatologic Surgery

PHOENIX — Certain minority populations may be at a higher absolute risk of being prescribed opioids after undergoing dermatologic surgery, according to a new study. The study also found that patients who do receive opioids postoperatively are at an increased risk for chronic opioid use and complications.

This report represents the largest analysis to date of opioid prescribing after dermatologic surgery, said lead author Kyle C. Lauck, MD, a dermatology resident at Baylor University Medical Center, Dallas, Texas. “Females, African Americans, and Latino patients may be at a higher risk of opioid prescription after dermatologic surgery. Surgeons should be aware of these populations and the risks they face when determining candidacy for postsurgical opioid analgesia.”

He presented the results at the annual meeting of the American College of Mohs Surgery.

The opioid epidemic is a concern across all areas of medicine, and the majority of opioid prescriptions in dermatology are given following surgery. Dr. Lauck noted that even though guidelines delegate opioids as second line for pain control, the existing data on opioid prescribing in dermatologic surgery is mixed. For example, some reports have shown that up to 58% of patients receive opioids postoperatively. “No consensus exists when we should routinely give opioids to these patients,” he said.

Even though most surgeons prescribe short courses of opioids, even brief regimens are associated with increased risks for overuse and substance abuse. Population-level data are limited concerning opioid prescriptions in dermatologic surgery, and in particular, there is an absence of data on the risk for long-term complications associated with use.

Certain Populations at Risk

To evaluate opioid prescription rates in dermatologic surgery, focusing on disparities between demographic populations, as well as the risk for long-term complications of postoperative opioid prescriptions, Dr. Lauck and colleagues conducted a retrospective study that included 914,721 dermatologic surgery patients, with billing codes for Mohs micrographic surgery. Patient data were obtained from TriNetX, a federated health research network.

The mean age of patients in this cohort was 54 years, and 124,494 (13.6%) were prescribed postsurgical oral opioids. The most common was oxycodone, prescribed to 43% of patients. Dr. Lauck noted that, according to their data, certain groups appeared more likely to receive a prescription for opioids following surgery. These included Black or African American patients (23.75% vs 12.86% for White patients), females (13.73% vs 13.16% for males), and Latino or Hispanic patients (17.02% vs 13.61% non-Latino/Hispanic patients).

Patients with a history of prior oral opioid prescription, prior opioid abuse or dependence, and any type of substance abuse had a significant increase in absolute risk of being prescribed postsurgical opioids (P < .0001). 

The type of surgery also was associated with prescribed postop opioids. For a malignant excision, 18.29% of patients were prescribed postop opioids compared with 14.9% for a benign excision. About a third of patients (34.9%) undergoing a graft repair received opioids.

There was an elevated rate of postop opioid prescribing that was specific to the site of surgery, with the highest rates observed with eyelids, scalp and neck, trunk, and genital sites. The highest overall rates of opioid prescriptions were for patients who underwent excisions in the genital area (54.5%).
 

Long-Term Consequences

The authors also looked at the longer-term consequences of postop opioid use. “Nearly one in three patients who were prescribed opioids needed subsequent prescriptions down the line,” said Dr. Lauck. 

From 3 months to 5 years after surgery, patients who received postsurgical opioids were at significantly higher risk for not only subsequent oral opioid prescription but also opiate abuse, any substance abuse, overdose by opioid narcotics, constipation, and chronic pain. “An opioid prescription may confer further risks of longitudinal complications of chronic opioid use,” he concluded.

Commenting on the study, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery at Icahn School of Medicine at Mount Sinai, New York City, noted an important finding of this study was the long-term sequelae of patients who did receive postop opioids.

“This is striking given that postsurgical opiate prescriptions are for short durations and limited number of pills,” he told this news organization. “This study highlights the potential danger of even short course of opiates and should serve as a reminder to dermatologic surgeons to be judicious about opiate prescribing.”

Dr. Lauck and Dr. Lewin had no disclosures. 
 

A version of this article appeared on Medscape.com.

PHOENIX — Certain minority populations may be at a higher absolute risk of being prescribed opioids after undergoing dermatologic surgery, according to a new study. The study also found that patients who do receive opioids postoperatively are at an increased risk for chronic opioid use and complications.

This report represents the largest analysis to date of opioid prescribing after dermatologic surgery, said lead author Kyle C. Lauck, MD, a dermatology resident at Baylor University Medical Center, Dallas, Texas. “Females, African Americans, and Latino patients may be at a higher risk of opioid prescription after dermatologic surgery. Surgeons should be aware of these populations and the risks they face when determining candidacy for postsurgical opioid analgesia.”

He presented the results at the annual meeting of the American College of Mohs Surgery.

The opioid epidemic is a concern across all areas of medicine, and the majority of opioid prescriptions in dermatology are given following surgery. Dr. Lauck noted that even though guidelines delegate opioids as second line for pain control, the existing data on opioid prescribing in dermatologic surgery is mixed. For example, some reports have shown that up to 58% of patients receive opioids postoperatively. “No consensus exists when we should routinely give opioids to these patients,” he said.

Even though most surgeons prescribe short courses of opioids, even brief regimens are associated with increased risks for overuse and substance abuse. Population-level data are limited concerning opioid prescriptions in dermatologic surgery, and in particular, there is an absence of data on the risk for long-term complications associated with use.

Certain Populations at Risk

To evaluate opioid prescription rates in dermatologic surgery, focusing on disparities between demographic populations, as well as the risk for long-term complications of postoperative opioid prescriptions, Dr. Lauck and colleagues conducted a retrospective study that included 914,721 dermatologic surgery patients, with billing codes for Mohs micrographic surgery. Patient data were obtained from TriNetX, a federated health research network.

The mean age of patients in this cohort was 54 years, and 124,494 (13.6%) were prescribed postsurgical oral opioids. The most common was oxycodone, prescribed to 43% of patients. Dr. Lauck noted that, according to their data, certain groups appeared more likely to receive a prescription for opioids following surgery. These included Black or African American patients (23.75% vs 12.86% for White patients), females (13.73% vs 13.16% for males), and Latino or Hispanic patients (17.02% vs 13.61% non-Latino/Hispanic patients).

Patients with a history of prior oral opioid prescription, prior opioid abuse or dependence, and any type of substance abuse had a significant increase in absolute risk of being prescribed postsurgical opioids (P < .0001). 

The type of surgery also was associated with prescribed postop opioids. For a malignant excision, 18.29% of patients were prescribed postop opioids compared with 14.9% for a benign excision. About a third of patients (34.9%) undergoing a graft repair received opioids.

There was an elevated rate of postop opioid prescribing that was specific to the site of surgery, with the highest rates observed with eyelids, scalp and neck, trunk, and genital sites. The highest overall rates of opioid prescriptions were for patients who underwent excisions in the genital area (54.5%).
 

Long-Term Consequences

The authors also looked at the longer-term consequences of postop opioid use. “Nearly one in three patients who were prescribed opioids needed subsequent prescriptions down the line,” said Dr. Lauck. 

From 3 months to 5 years after surgery, patients who received postsurgical opioids were at significantly higher risk for not only subsequent oral opioid prescription but also opiate abuse, any substance abuse, overdose by opioid narcotics, constipation, and chronic pain. “An opioid prescription may confer further risks of longitudinal complications of chronic opioid use,” he concluded.

Commenting on the study, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery at Icahn School of Medicine at Mount Sinai, New York City, noted an important finding of this study was the long-term sequelae of patients who did receive postop opioids.

“This is striking given that postsurgical opiate prescriptions are for short durations and limited number of pills,” he told this news organization. “This study highlights the potential danger of even short course of opiates and should serve as a reminder to dermatologic surgeons to be judicious about opiate prescribing.”

Dr. Lauck and Dr. Lewin had no disclosures. 
 

A version of this article appeared on Medscape.com.

PHOENIX — Certain minority populations may be at a higher absolute risk of being prescribed opioids after undergoing dermatologic surgery, according to a new study. The study also found that patients who do receive opioids postoperatively are at an increased risk for chronic opioid use and complications.

This report represents the largest analysis to date of opioid prescribing after dermatologic surgery, said lead author Kyle C. Lauck, MD, a dermatology resident at Baylor University Medical Center, Dallas, Texas. “Females, African Americans, and Latino patients may be at a higher risk of opioid prescription after dermatologic surgery. Surgeons should be aware of these populations and the risks they face when determining candidacy for postsurgical opioid analgesia.”

He presented the results at the annual meeting of the American College of Mohs Surgery.

The opioid epidemic is a concern across all areas of medicine, and the majority of opioid prescriptions in dermatology are given following surgery. Dr. Lauck noted that even though guidelines delegate opioids as second line for pain control, the existing data on opioid prescribing in dermatologic surgery is mixed. For example, some reports have shown that up to 58% of patients receive opioids postoperatively. “No consensus exists when we should routinely give opioids to these patients,” he said.

Even though most surgeons prescribe short courses of opioids, even brief regimens are associated with increased risks for overuse and substance abuse. Population-level data are limited concerning opioid prescriptions in dermatologic surgery, and in particular, there is an absence of data on the risk for long-term complications associated with use.

Certain Populations at Risk

To evaluate opioid prescription rates in dermatologic surgery, focusing on disparities between demographic populations, as well as the risk for long-term complications of postoperative opioid prescriptions, Dr. Lauck and colleagues conducted a retrospective study that included 914,721 dermatologic surgery patients, with billing codes for Mohs micrographic surgery. Patient data were obtained from TriNetX, a federated health research network.

The mean age of patients in this cohort was 54 years, and 124,494 (13.6%) were prescribed postsurgical oral opioids. The most common was oxycodone, prescribed to 43% of patients. Dr. Lauck noted that, according to their data, certain groups appeared more likely to receive a prescription for opioids following surgery. These included Black or African American patients (23.75% vs 12.86% for White patients), females (13.73% vs 13.16% for males), and Latino or Hispanic patients (17.02% vs 13.61% non-Latino/Hispanic patients).

Patients with a history of prior oral opioid prescription, prior opioid abuse or dependence, and any type of substance abuse had a significant increase in absolute risk of being prescribed postsurgical opioids (P < .0001). 

The type of surgery also was associated with prescribed postop opioids. For a malignant excision, 18.29% of patients were prescribed postop opioids compared with 14.9% for a benign excision. About a third of patients (34.9%) undergoing a graft repair received opioids.

There was an elevated rate of postop opioid prescribing that was specific to the site of surgery, with the highest rates observed with eyelids, scalp and neck, trunk, and genital sites. The highest overall rates of opioid prescriptions were for patients who underwent excisions in the genital area (54.5%).
 

Long-Term Consequences

The authors also looked at the longer-term consequences of postop opioid use. “Nearly one in three patients who were prescribed opioids needed subsequent prescriptions down the line,” said Dr. Lauck. 

From 3 months to 5 years after surgery, patients who received postsurgical opioids were at significantly higher risk for not only subsequent oral opioid prescription but also opiate abuse, any substance abuse, overdose by opioid narcotics, constipation, and chronic pain. “An opioid prescription may confer further risks of longitudinal complications of chronic opioid use,” he concluded.

Commenting on the study, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery at Icahn School of Medicine at Mount Sinai, New York City, noted an important finding of this study was the long-term sequelae of patients who did receive postop opioids.

“This is striking given that postsurgical opiate prescriptions are for short durations and limited number of pills,” he told this news organization. “This study highlights the potential danger of even short course of opiates and should serve as a reminder to dermatologic surgeons to be judicious about opiate prescribing.”

Dr. Lauck and Dr. Lewin had no disclosures. 
 

A version of this article appeared on Medscape.com.

Local injection of tranexamic acid (TXA) effectively reduced the risk for clinically significant bleeding following Mohs micrographic surgery (MMS), results from a single-center cohort study showed.

“Though Mohs micrographic surgery is associated with low bleeding complication rates, around 1% of patients in the literature report postoperative bleeding,” corresponding author Abigail H. Waldman, MD, director of the Mohs and Dermatologic Surgery Center, at Brigham and Women’s Hospital, Boston, and colleagues wrote in the study, which was published online in the Journal of the American Academy of Dermatology. “Intravenous tranexamic acid has been used across surgical specialties to reduce perioperative blood loss. Prior studies have shown topical TXA, an antifibrinolytic agent, following MMS may be effective in reducing postoperative bleeding complications, but there are no large cohort studies on injectable TXA utilization in all patients undergoing MMS.”

To improve the understanding of this intervention, the researchers examined the impact of off-label, locally injected TXA on postoperative bleeding outcomes following MMS conducted at Brigham and Women’s Hospital. They evaluated two cohorts: 1843 patients who underwent MMS from January 1, 2019, to December 31, 2019 (the pre-TXA cohort), and 2101 patients who underwent MMS from July 1, 2022, to June 30, 2023 (the TXA cohort), and extracted data, including patient and tumor characteristics, MMS procedure details, antithrombotic medication use, systemic conditions that predispose to bleeding, encounters reporting postoperative bleeding, and interventions required for postoperative bleeding, from electronic medical records. Patients reconstructed by a non-MMS surgeon were excluded from the analysis.

Overall, 2509 cases among 1843 patients and 2818 cases among 2101 were included in the pre-TXA and TXA cohorts, respectively. The researchers found that local subcutaneous injection of TXA reduced the risk for postoperative phone calls or visits for bleeding by 25% (RR [risk ratio], 0.75; 0.57-0.99) and risk for bleeding necessitating a medical visit by 51% (RR, 0.49; 0.32-0.77).

The use of preoperative TXA in several subgroups of patients also was also associated with a reduction in visits for bleeding, including those using alcohol (52% reduction; RR, 0.47; 0.26-0.85), cigarettes (57% reduction; RR, 0.43; 0.23-0.82), oral anticoagulants (61% reduction; RR, 0.39; 0.20-0.77), or antiplatelets (60% reduction; RR, 0.40; 0.20-0.79). The use of TXA was also associated with reduced visits for bleeding in tumors of the head and neck (RR, 0.45; 0.26-0.77) and tumors with a preoperative diameter > 2 cm (RR, 0.37; 0.15-0.90).

Impact of Surgical Repair Type

In other findings, the type of surgical repair was a potential confounder, the authors reported. Grafts and flaps were associated with an increased risk for bleeding across both cohorts (RR, 2.36 [1.5-3.6] and 1.7 [1.1-2.6], respectively) and together comprised 15% of all procedures in the pre-TXA cohort compared with 11.1% in TXA cohort. Two patients in the TXA cohort (0.11%) developed deep vein thrombosis (DVT) 10- and 20-days postoperation, a rate that the authors said is comparable to that of the general population. The two patients had risk factors for hypercoagulability, including advanced cancer and recurrent DVT.

“Overall, local injection of TXA was an effective method for reducing the risk of clinically significant bleeding following MMS,” the researchers concluded. “Perioperative TXA may help to limit the risk of bleeding overall, as well as in populations predisposed to bleeding.” Adverse events with TXA use were rare “and delayed beyond the activity of TXA, indicating a low likelihood of being due to TXA,” they wrote.

“Dermatologists performing MMS may consider incorporating local TXA injection into their regular practice,” they noted, adding that “legal counsel on adverse effects in the setting of off-label pharmaceutical usage may be advised.”

In an interview, Patricia M. Richey, MD, director of Mohs surgery at Boston Medical Center, who was asked to comment on the study, said that postoperative bleeding is one of the most commonly encountered Mohs surgery complications. “Because of increased clinic visits and phone calls, it can also often result in decreased patient satisfaction,” she said.

“This study is particularly notable in that we see that local subcutaneous TXA injection decreased visits for bleeding even in those using oral anticoagulants, antiplatelets, alcohol, and cigarettes. Dermatologic surgery has a very low complication rate, even in patients on anticoagulant and antiplatelet medications, but this study shows that TXA is a fantastic option for Mohs surgeons and patients.”

Neither the study authors nor Dr. Richey reported having financial disclosures.

A version of this article first appeared on Medscape.com.

Local injection of tranexamic acid (TXA) effectively reduced the risk for clinically significant bleeding following Mohs micrographic surgery (MMS), results from a single-center cohort study showed.

“Though Mohs micrographic surgery is associated with low bleeding complication rates, around 1% of patients in the literature report postoperative bleeding,” corresponding author Abigail H. Waldman, MD, director of the Mohs and Dermatologic Surgery Center, at Brigham and Women’s Hospital, Boston, and colleagues wrote in the study, which was published online in the Journal of the American Academy of Dermatology. “Intravenous tranexamic acid has been used across surgical specialties to reduce perioperative blood loss. Prior studies have shown topical TXA, an antifibrinolytic agent, following MMS may be effective in reducing postoperative bleeding complications, but there are no large cohort studies on injectable TXA utilization in all patients undergoing MMS.”

To improve the understanding of this intervention, the researchers examined the impact of off-label, locally injected TXA on postoperative bleeding outcomes following MMS conducted at Brigham and Women’s Hospital. They evaluated two cohorts: 1843 patients who underwent MMS from January 1, 2019, to December 31, 2019 (the pre-TXA cohort), and 2101 patients who underwent MMS from July 1, 2022, to June 30, 2023 (the TXA cohort), and extracted data, including patient and tumor characteristics, MMS procedure details, antithrombotic medication use, systemic conditions that predispose to bleeding, encounters reporting postoperative bleeding, and interventions required for postoperative bleeding, from electronic medical records. Patients reconstructed by a non-MMS surgeon were excluded from the analysis.

Overall, 2509 cases among 1843 patients and 2818 cases among 2101 were included in the pre-TXA and TXA cohorts, respectively. The researchers found that local subcutaneous injection of TXA reduced the risk for postoperative phone calls or visits for bleeding by 25% (RR [risk ratio], 0.75; 0.57-0.99) and risk for bleeding necessitating a medical visit by 51% (RR, 0.49; 0.32-0.77).

The use of preoperative TXA in several subgroups of patients also was also associated with a reduction in visits for bleeding, including those using alcohol (52% reduction; RR, 0.47; 0.26-0.85), cigarettes (57% reduction; RR, 0.43; 0.23-0.82), oral anticoagulants (61% reduction; RR, 0.39; 0.20-0.77), or antiplatelets (60% reduction; RR, 0.40; 0.20-0.79). The use of TXA was also associated with reduced visits for bleeding in tumors of the head and neck (RR, 0.45; 0.26-0.77) and tumors with a preoperative diameter > 2 cm (RR, 0.37; 0.15-0.90).

Impact of Surgical Repair Type

In other findings, the type of surgical repair was a potential confounder, the authors reported. Grafts and flaps were associated with an increased risk for bleeding across both cohorts (RR, 2.36 [1.5-3.6] and 1.7 [1.1-2.6], respectively) and together comprised 15% of all procedures in the pre-TXA cohort compared with 11.1% in TXA cohort. Two patients in the TXA cohort (0.11%) developed deep vein thrombosis (DVT) 10- and 20-days postoperation, a rate that the authors said is comparable to that of the general population. The two patients had risk factors for hypercoagulability, including advanced cancer and recurrent DVT.

“Overall, local injection of TXA was an effective method for reducing the risk of clinically significant bleeding following MMS,” the researchers concluded. “Perioperative TXA may help to limit the risk of bleeding overall, as well as in populations predisposed to bleeding.” Adverse events with TXA use were rare “and delayed beyond the activity of TXA, indicating a low likelihood of being due to TXA,” they wrote.

“Dermatologists performing MMS may consider incorporating local TXA injection into their regular practice,” they noted, adding that “legal counsel on adverse effects in the setting of off-label pharmaceutical usage may be advised.”

In an interview, Patricia M. Richey, MD, director of Mohs surgery at Boston Medical Center, who was asked to comment on the study, said that postoperative bleeding is one of the most commonly encountered Mohs surgery complications. “Because of increased clinic visits and phone calls, it can also often result in decreased patient satisfaction,” she said.

“This study is particularly notable in that we see that local subcutaneous TXA injection decreased visits for bleeding even in those using oral anticoagulants, antiplatelets, alcohol, and cigarettes. Dermatologic surgery has a very low complication rate, even in patients on anticoagulant and antiplatelet medications, but this study shows that TXA is a fantastic option for Mohs surgeons and patients.”

Neither the study authors nor Dr. Richey reported having financial disclosures.

A version of this article first appeared on Medscape.com.

Local injection of tranexamic acid (TXA) effectively reduced the risk for clinically significant bleeding following Mohs micrographic surgery (MMS), results from a single-center cohort study showed.

“Though Mohs micrographic surgery is associated with low bleeding complication rates, around 1% of patients in the literature report postoperative bleeding,” corresponding author Abigail H. Waldman, MD, director of the Mohs and Dermatologic Surgery Center, at Brigham and Women’s Hospital, Boston, and colleagues wrote in the study, which was published online in the Journal of the American Academy of Dermatology. “Intravenous tranexamic acid has been used across surgical specialties to reduce perioperative blood loss. Prior studies have shown topical TXA, an antifibrinolytic agent, following MMS may be effective in reducing postoperative bleeding complications, but there are no large cohort studies on injectable TXA utilization in all patients undergoing MMS.”

To improve the understanding of this intervention, the researchers examined the impact of off-label, locally injected TXA on postoperative bleeding outcomes following MMS conducted at Brigham and Women’s Hospital. They evaluated two cohorts: 1843 patients who underwent MMS from January 1, 2019, to December 31, 2019 (the pre-TXA cohort), and 2101 patients who underwent MMS from July 1, 2022, to June 30, 2023 (the TXA cohort), and extracted data, including patient and tumor characteristics, MMS procedure details, antithrombotic medication use, systemic conditions that predispose to bleeding, encounters reporting postoperative bleeding, and interventions required for postoperative bleeding, from electronic medical records. Patients reconstructed by a non-MMS surgeon were excluded from the analysis.

Overall, 2509 cases among 1843 patients and 2818 cases among 2101 were included in the pre-TXA and TXA cohorts, respectively. The researchers found that local subcutaneous injection of TXA reduced the risk for postoperative phone calls or visits for bleeding by 25% (RR [risk ratio], 0.75; 0.57-0.99) and risk for bleeding necessitating a medical visit by 51% (RR, 0.49; 0.32-0.77).

The use of preoperative TXA in several subgroups of patients also was also associated with a reduction in visits for bleeding, including those using alcohol (52% reduction; RR, 0.47; 0.26-0.85), cigarettes (57% reduction; RR, 0.43; 0.23-0.82), oral anticoagulants (61% reduction; RR, 0.39; 0.20-0.77), or antiplatelets (60% reduction; RR, 0.40; 0.20-0.79). The use of TXA was also associated with reduced visits for bleeding in tumors of the head and neck (RR, 0.45; 0.26-0.77) and tumors with a preoperative diameter > 2 cm (RR, 0.37; 0.15-0.90).

Impact of Surgical Repair Type

In other findings, the type of surgical repair was a potential confounder, the authors reported. Grafts and flaps were associated with an increased risk for bleeding across both cohorts (RR, 2.36 [1.5-3.6] and 1.7 [1.1-2.6], respectively) and together comprised 15% of all procedures in the pre-TXA cohort compared with 11.1% in TXA cohort. Two patients in the TXA cohort (0.11%) developed deep vein thrombosis (DVT) 10- and 20-days postoperation, a rate that the authors said is comparable to that of the general population. The two patients had risk factors for hypercoagulability, including advanced cancer and recurrent DVT.

“Overall, local injection of TXA was an effective method for reducing the risk of clinically significant bleeding following MMS,” the researchers concluded. “Perioperative TXA may help to limit the risk of bleeding overall, as well as in populations predisposed to bleeding.” Adverse events with TXA use were rare “and delayed beyond the activity of TXA, indicating a low likelihood of being due to TXA,” they wrote.

“Dermatologists performing MMS may consider incorporating local TXA injection into their regular practice,” they noted, adding that “legal counsel on adverse effects in the setting of off-label pharmaceutical usage may be advised.”

In an interview, Patricia M. Richey, MD, director of Mohs surgery at Boston Medical Center, who was asked to comment on the study, said that postoperative bleeding is one of the most commonly encountered Mohs surgery complications. “Because of increased clinic visits and phone calls, it can also often result in decreased patient satisfaction,” she said.

“This study is particularly notable in that we see that local subcutaneous TXA injection decreased visits for bleeding even in those using oral anticoagulants, antiplatelets, alcohol, and cigarettes. Dermatologic surgery has a very low complication rate, even in patients on anticoagulant and antiplatelet medications, but this study shows that TXA is a fantastic option for Mohs surgeons and patients.”

Neither the study authors nor Dr. Richey reported having financial disclosures.

A version of this article first appeared on Medscape.com.

BALTIMORE — Ice packs or topical anesthesia applied to the face before thermomechanical fractional injury therapy to treat wrinkles around the eyes provided satisfactory comfort to the patient during the procedure without sacrificing posttreatment outcomes, a small study of the recently cleared device found.

The study enrolled 12 patients who were undergoing treatment for periorbital rhytides, or wrinkles, around the eyes. Seven of them received topical anesthetic cream 20 minutes before the procedure, while five were given ice packs to self-apply for 5 minutes beforehand. Patients received four treatment sessions with a month between sessions and were then evaluated up to 3 months after their last session. Study results were presented at the annual conference of the American Society for Laser Medicine and Surgery.

“Based on the approach that we had used, which was to keep the device parameters the same for those who received topical anesthetics and those who received ice, when we looked at the pain levels that the patients had relayed to us when we were doing the procedure, we found that both of them were almost exactly the same in terms of discomfort, a level of 3-4 out of 10, with 10 being the highest discomfort level,” lead investigator Jerome M. Garden, MD, said in an interview after the conference.

“In terms of patient satisfaction using a range of 0-5, again it was fairly equivalent” between the two groups, said Dr. Garden, professor of clinical dermatology and biomedical engineering at Northwestern University, Chicago. “And the overall satisfaction rate was high.”

Dr. Garden

Study Results

The results for the different anesthetic methods were almost identical. Those using ice reported a 0-10 average pain level of 3.95 ± 1.5, while those who received the topical anesthetic reported a pain level of 3.92 ± 1.5. In terms of self-graded improvement at 3-month follow-up, using a scale of 1-4, with 1 representing up to a 25% improvement and 4 a 75%-100% improvement, the patients using ice had a 2.6 ± 0.5 improvement and those using topical cream a 2.8 ± 0.5 improvement, Dr. Garden said during his presentation.

In terms of patient satisfaction, rated on a scale of 1-5, with 5 being very satisfied, the average grade was 3.9 ± 0.9, Dr. Garden added, with 70% rating ≥ 4.

“This is a relatively new device, which uses an approach to help texture changes in wrinkling on the skin in a different fashion than any of the other devices that are currently out there,” Dr. Garden told this news organization after the conference. “I wanted to understand more in depth the different parameters that may impact the outcome” with this device, he added.

The thermomechanical fractional injury device, originally cleared by the US Food and Drug Administration (FDA) in 2021, with a second-generation device cleared in June 2023, deposits heat into the skin, producing controlled thermal injury to promote collagen and elastin production. The device uses only heat, not a laser, which penetrates the skin. A heat sensation on the skin during the procedure can affect patients differently depending on their level of tolerance, Dr. Garden said during his presentation. 

Managing Patient Discomfort

Kachiu C. Lee, MD, MPH, of the Main Line Center for Laser Surgery in Ardmore, Pennsylvania, has used the device in her own practice and found that “it can definitely get a little bit uncomfortable for patients,” she said in an interview after the conference. 

“I would say that as the doctor, my number one priority is to always make sure my patients are comfortable, especially when treating a sensitive area like the eyes,” added Dr. Lee, who was not involved with the study. “I don’t want them to suddenly jump or move from the discomfort when I have a device right next to their eye. I think that the patient comfort is very important to make sure that we’re managing their discomfort so that the procedure is tolerable.”

Dr. Lee

A version of this article appeared on Medscape.com.

BALTIMORE — Ice packs or topical anesthesia applied to the face before thermomechanical fractional injury therapy to treat wrinkles around the eyes provided satisfactory comfort to the patient during the procedure without sacrificing posttreatment outcomes, a small study of the recently cleared device found.

The study enrolled 12 patients who were undergoing treatment for periorbital rhytides, or wrinkles, around the eyes. Seven of them received topical anesthetic cream 20 minutes before the procedure, while five were given ice packs to self-apply for 5 minutes beforehand. Patients received four treatment sessions with a month between sessions and were then evaluated up to 3 months after their last session. Study results were presented at the annual conference of the American Society for Laser Medicine and Surgery.

“Based on the approach that we had used, which was to keep the device parameters the same for those who received topical anesthetics and those who received ice, when we looked at the pain levels that the patients had relayed to us when we were doing the procedure, we found that both of them were almost exactly the same in terms of discomfort, a level of 3-4 out of 10, with 10 being the highest discomfort level,” lead investigator Jerome M. Garden, MD, said in an interview after the conference.

“In terms of patient satisfaction using a range of 0-5, again it was fairly equivalent” between the two groups, said Dr. Garden, professor of clinical dermatology and biomedical engineering at Northwestern University, Chicago. “And the overall satisfaction rate was high.”

Dr. Garden

Study Results

The results for the different anesthetic methods were almost identical. Those using ice reported a 0-10 average pain level of 3.95 ± 1.5, while those who received the topical anesthetic reported a pain level of 3.92 ± 1.5. In terms of self-graded improvement at 3-month follow-up, using a scale of 1-4, with 1 representing up to a 25% improvement and 4 a 75%-100% improvement, the patients using ice had a 2.6 ± 0.5 improvement and those using topical cream a 2.8 ± 0.5 improvement, Dr. Garden said during his presentation.

In terms of patient satisfaction, rated on a scale of 1-5, with 5 being very satisfied, the average grade was 3.9 ± 0.9, Dr. Garden added, with 70% rating ≥ 4.

“This is a relatively new device, which uses an approach to help texture changes in wrinkling on the skin in a different fashion than any of the other devices that are currently out there,” Dr. Garden told this news organization after the conference. “I wanted to understand more in depth the different parameters that may impact the outcome” with this device, he added.

The thermomechanical fractional injury device, originally cleared by the US Food and Drug Administration (FDA) in 2021, with a second-generation device cleared in June 2023, deposits heat into the skin, producing controlled thermal injury to promote collagen and elastin production. The device uses only heat, not a laser, which penetrates the skin. A heat sensation on the skin during the procedure can affect patients differently depending on their level of tolerance, Dr. Garden said during his presentation. 

Managing Patient Discomfort

Kachiu C. Lee, MD, MPH, of the Main Line Center for Laser Surgery in Ardmore, Pennsylvania, has used the device in her own practice and found that “it can definitely get a little bit uncomfortable for patients,” she said in an interview after the conference. 

“I would say that as the doctor, my number one priority is to always make sure my patients are comfortable, especially when treating a sensitive area like the eyes,” added Dr. Lee, who was not involved with the study. “I don’t want them to suddenly jump or move from the discomfort when I have a device right next to their eye. I think that the patient comfort is very important to make sure that we’re managing their discomfort so that the procedure is tolerable.”

Dr. Lee

A version of this article appeared on Medscape.com.

BALTIMORE — Ice packs or topical anesthesia applied to the face before thermomechanical fractional injury therapy to treat wrinkles around the eyes provided satisfactory comfort to the patient during the procedure without sacrificing posttreatment outcomes, a small study of the recently cleared device found.

The study enrolled 12 patients who were undergoing treatment for periorbital rhytides, or wrinkles, around the eyes. Seven of them received topical anesthetic cream 20 minutes before the procedure, while five were given ice packs to self-apply for 5 minutes beforehand. Patients received four treatment sessions with a month between sessions and were then evaluated up to 3 months after their last session. Study results were presented at the annual conference of the American Society for Laser Medicine and Surgery.

“Based on the approach that we had used, which was to keep the device parameters the same for those who received topical anesthetics and those who received ice, when we looked at the pain levels that the patients had relayed to us when we were doing the procedure, we found that both of them were almost exactly the same in terms of discomfort, a level of 3-4 out of 10, with 10 being the highest discomfort level,” lead investigator Jerome M. Garden, MD, said in an interview after the conference.

“In terms of patient satisfaction using a range of 0-5, again it was fairly equivalent” between the two groups, said Dr. Garden, professor of clinical dermatology and biomedical engineering at Northwestern University, Chicago. “And the overall satisfaction rate was high.”

Dr. Garden

Study Results

The results for the different anesthetic methods were almost identical. Those using ice reported a 0-10 average pain level of 3.95 ± 1.5, while those who received the topical anesthetic reported a pain level of 3.92 ± 1.5. In terms of self-graded improvement at 3-month follow-up, using a scale of 1-4, with 1 representing up to a 25% improvement and 4 a 75%-100% improvement, the patients using ice had a 2.6 ± 0.5 improvement and those using topical cream a 2.8 ± 0.5 improvement, Dr. Garden said during his presentation.

In terms of patient satisfaction, rated on a scale of 1-5, with 5 being very satisfied, the average grade was 3.9 ± 0.9, Dr. Garden added, with 70% rating ≥ 4.

“This is a relatively new device, which uses an approach to help texture changes in wrinkling on the skin in a different fashion than any of the other devices that are currently out there,” Dr. Garden told this news organization after the conference. “I wanted to understand more in depth the different parameters that may impact the outcome” with this device, he added.

The thermomechanical fractional injury device, originally cleared by the US Food and Drug Administration (FDA) in 2021, with a second-generation device cleared in June 2023, deposits heat into the skin, producing controlled thermal injury to promote collagen and elastin production. The device uses only heat, not a laser, which penetrates the skin. A heat sensation on the skin during the procedure can affect patients differently depending on their level of tolerance, Dr. Garden said during his presentation. 

Managing Patient Discomfort

Kachiu C. Lee, MD, MPH, of the Main Line Center for Laser Surgery in Ardmore, Pennsylvania, has used the device in her own practice and found that “it can definitely get a little bit uncomfortable for patients,” she said in an interview after the conference. 

“I would say that as the doctor, my number one priority is to always make sure my patients are comfortable, especially when treating a sensitive area like the eyes,” added Dr. Lee, who was not involved with the study. “I don’t want them to suddenly jump or move from the discomfort when I have a device right next to their eye. I think that the patient comfort is very important to make sure that we’re managing their discomfort so that the procedure is tolerable.”

Dr. Lee

A version of this article appeared on Medscape.com.

ORLANDO, FLORIDA — For some people, acne carries a one-two punch. First, they experience acne that is significant enough to decrease their quality of life, followed by scarring that can last a lifetime. For those patients, dermatologists have several options: Subcision to lift the depression of the scar, laser treatment to lower the height of scar tissue, and injections to fill scars.

“In my practice, I find that these [acne scars] are probably the hardest things to treat. But along the way, I created a protocol that I would love to share with you today,” Robyn Siperstein, MD, said at the annual ODAC Dermatology, Aesthetic & Surgical Conference.

Dr. Siperstein starts by identifying the type of acne scar — rolling scars, boxcar scars, or ice pick scars. Rolling scars tend to be shallower with no sharp edges; boxcar scars are deeper, more defined round or oval depressions; and ice pick scars, as the name suggests, look like someone stuck tiny ice picks into the skin, leaving a sunken or pitted appearance.

“It’s really important to categorize so that we know which ones are going to be effectively treated with different modalities and which ones aren’t, so that we can give our patients realistic expectations,” said Dr. Siperstein, a cosmetic dermatologist in private practice in Boca Raton, Florida, and a clinical affiliate associate professor of dermatology at Florida Atlantic University, Boca Raton.

“There’s not going to be one treatment that’s right for everything,” she said. Different approaches may be required even for the same patient because some people present with all three types of acne scars, she added.

Combining Treatments

When it comes to injecting dermal fillers into acne scars to lift the depressed areas, the US Food and Drug Administration approved a filler with polymethyl methacrylate filler and bovine collagen (Bellafill) for this indication (moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over age 21) in 2015. “And off-label, I use hyaluronic acid in my practice,” Dr. Siperstein said. Each filler “probably works a little bit better or differently on different types of scars.”

For rolling scars, she recommends hyaluronic acid (HA) dermal filler for everyone. “Of course, this is my opinion.” She was also a lead investigator in a randomized, placebo-controlled split-face study comparing HA filler with saline for correcting atrophic facial scars in 15 patients. The HA filler emerged superior, although there were some improvements with saline.

In her clinical experience, patients are happy with the results and ask, “Why didn’t the last four doctors do this?”

Boxcar scars are more challenging to fill with HA. In some cases, Dr. Siperstein is able to raise the depressed portion of the scar, but some of the vertical edges remain. In this scenario, she might combine treatments. Laser resurfacing, for example, might help convert boxcar scars into rolling scars, which then can be filled more successfully.

“Ice pick scars are tough,” Dr. Siperstein said. A punch removal technique can work in some cases, or she might try the “cross technique.” This involves placing acetic acid inside the scar using a Q-tip. “You have to be really careful,” she added, “because if you get it around the edges, it’s actually going to make the scar bigger.”
 

Choosing the Right Candidates

Selecting the right candidate for HA treatment of acne scars is essential. Dr. Siperstein shared the example of a lifeguard who had prominent acne scarring down the center of his chest. “He was embarrassed to go to the beach and take off his shirt. He said he felt like he had bullet holes in his chest.”

One month following treatment, “he had a really nice improvement, and now he feels really comfortable,” she said.

Some dermatologists might be reluctant to consider HA fillers for acne scarring because there is a misconception that HA is short-acting, lasting 6 months to 1 year before the effect wears off. That impression can persist from company-sponsored studies that limit follow-up to 6 months or 1 year “to get their drug to market,” she noted.

Also adding to this impression is that HA fillers in wrinkles may not last as long. Dr. Siperstein explained that wrinkles on the face are dynamic and constantly moving. In contrast, acne scars experience less movement, which helps the HA last longer. There is MRI evidence that shows HA fillers last over 2 years in the face, she added.

One tip to predict how well an acne scar might respond to filler injections is to squeeze it and look for the “dimple sign.” If the floor of the scar lifts up when squeezed, “we know that they’ll be a good candidate for hyaluronic acid filler.” Another tip is to inject HA in a retrograde technique high up in the skin. Inject tiny amounts — microdroplets — of the HA filler high on the dermis, she advised.

Deeper injections run the risk of raising the entire scar instead of filling it, she added.

Like many dermatologic procedures, before and after photos are essential to demonstrate improvements, Dr. Siperstein pointed out. Patients are often skeptical. “This happens a lot with acne scar patients. They’ve been to a million places that have promised results, they have not gotten them, and they are frustrated.”

Acne scars can result from picking, inflammation, or treatment. “This is what we see all day in clinic,” Dr. Siperstein said. “Somebody who had to undergo Accutane treatment but unfortunately is left with holes. This is a huge psychological burden on our patients,” she said, describing a younger patient who had scarring, which “led to depression — it was ruining his life.”

“His mom was willing to do whatever it took. And I said, You know what, I think filler will be enough,” Dr. Siperstein said. She counseled them that treatment would not make the scars disappear completely. But patients used to 10% improvements are very happy when their acne scars look 80% or 90% better, she added.

Dr. Siperstein received grant or research support and is a member of the speakers bureau for Allergan and Galderma. She is also a consultant/advisory board member for Allergan.
 

A version of this article appeared on Medscape.com.

ORLANDO, FLORIDA — For some people, acne carries a one-two punch. First, they experience acne that is significant enough to decrease their quality of life, followed by scarring that can last a lifetime. For those patients, dermatologists have several options: Subcision to lift the depression of the scar, laser treatment to lower the height of scar tissue, and injections to fill scars.

“In my practice, I find that these [acne scars] are probably the hardest things to treat. But along the way, I created a protocol that I would love to share with you today,” Robyn Siperstein, MD, said at the annual ODAC Dermatology, Aesthetic & Surgical Conference.

Dr. Siperstein starts by identifying the type of acne scar — rolling scars, boxcar scars, or ice pick scars. Rolling scars tend to be shallower with no sharp edges; boxcar scars are deeper, more defined round or oval depressions; and ice pick scars, as the name suggests, look like someone stuck tiny ice picks into the skin, leaving a sunken or pitted appearance.

“It’s really important to categorize so that we know which ones are going to be effectively treated with different modalities and which ones aren’t, so that we can give our patients realistic expectations,” said Dr. Siperstein, a cosmetic dermatologist in private practice in Boca Raton, Florida, and a clinical affiliate associate professor of dermatology at Florida Atlantic University, Boca Raton.

“There’s not going to be one treatment that’s right for everything,” she said. Different approaches may be required even for the same patient because some people present with all three types of acne scars, she added.

Combining Treatments

When it comes to injecting dermal fillers into acne scars to lift the depressed areas, the US Food and Drug Administration approved a filler with polymethyl methacrylate filler and bovine collagen (Bellafill) for this indication (moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over age 21) in 2015. “And off-label, I use hyaluronic acid in my practice,” Dr. Siperstein said. Each filler “probably works a little bit better or differently on different types of scars.”

For rolling scars, she recommends hyaluronic acid (HA) dermal filler for everyone. “Of course, this is my opinion.” She was also a lead investigator in a randomized, placebo-controlled split-face study comparing HA filler with saline for correcting atrophic facial scars in 15 patients. The HA filler emerged superior, although there were some improvements with saline.

In her clinical experience, patients are happy with the results and ask, “Why didn’t the last four doctors do this?”

Boxcar scars are more challenging to fill with HA. In some cases, Dr. Siperstein is able to raise the depressed portion of the scar, but some of the vertical edges remain. In this scenario, she might combine treatments. Laser resurfacing, for example, might help convert boxcar scars into rolling scars, which then can be filled more successfully.

“Ice pick scars are tough,” Dr. Siperstein said. A punch removal technique can work in some cases, or she might try the “cross technique.” This involves placing acetic acid inside the scar using a Q-tip. “You have to be really careful,” she added, “because if you get it around the edges, it’s actually going to make the scar bigger.”
 

Choosing the Right Candidates

Selecting the right candidate for HA treatment of acne scars is essential. Dr. Siperstein shared the example of a lifeguard who had prominent acne scarring down the center of his chest. “He was embarrassed to go to the beach and take off his shirt. He said he felt like he had bullet holes in his chest.”

One month following treatment, “he had a really nice improvement, and now he feels really comfortable,” she said.

Some dermatologists might be reluctant to consider HA fillers for acne scarring because there is a misconception that HA is short-acting, lasting 6 months to 1 year before the effect wears off. That impression can persist from company-sponsored studies that limit follow-up to 6 months or 1 year “to get their drug to market,” she noted.

Also adding to this impression is that HA fillers in wrinkles may not last as long. Dr. Siperstein explained that wrinkles on the face are dynamic and constantly moving. In contrast, acne scars experience less movement, which helps the HA last longer. There is MRI evidence that shows HA fillers last over 2 years in the face, she added.

One tip to predict how well an acne scar might respond to filler injections is to squeeze it and look for the “dimple sign.” If the floor of the scar lifts up when squeezed, “we know that they’ll be a good candidate for hyaluronic acid filler.” Another tip is to inject HA in a retrograde technique high up in the skin. Inject tiny amounts — microdroplets — of the HA filler high on the dermis, she advised.

Deeper injections run the risk of raising the entire scar instead of filling it, she added.

Like many dermatologic procedures, before and after photos are essential to demonstrate improvements, Dr. Siperstein pointed out. Patients are often skeptical. “This happens a lot with acne scar patients. They’ve been to a million places that have promised results, they have not gotten them, and they are frustrated.”

Acne scars can result from picking, inflammation, or treatment. “This is what we see all day in clinic,” Dr. Siperstein said. “Somebody who had to undergo Accutane treatment but unfortunately is left with holes. This is a huge psychological burden on our patients,” she said, describing a younger patient who had scarring, which “led to depression — it was ruining his life.”

“His mom was willing to do whatever it took. And I said, You know what, I think filler will be enough,” Dr. Siperstein said. She counseled them that treatment would not make the scars disappear completely. But patients used to 10% improvements are very happy when their acne scars look 80% or 90% better, she added.

Dr. Siperstein received grant or research support and is a member of the speakers bureau for Allergan and Galderma. She is also a consultant/advisory board member for Allergan.
 

A version of this article appeared on Medscape.com.

ORLANDO, FLORIDA — For some people, acne carries a one-two punch. First, they experience acne that is significant enough to decrease their quality of life, followed by scarring that can last a lifetime. For those patients, dermatologists have several options: Subcision to lift the depression of the scar, laser treatment to lower the height of scar tissue, and injections to fill scars.

“In my practice, I find that these [acne scars] are probably the hardest things to treat. But along the way, I created a protocol that I would love to share with you today,” Robyn Siperstein, MD, said at the annual ODAC Dermatology, Aesthetic & Surgical Conference.

Dr. Siperstein starts by identifying the type of acne scar — rolling scars, boxcar scars, or ice pick scars. Rolling scars tend to be shallower with no sharp edges; boxcar scars are deeper, more defined round or oval depressions; and ice pick scars, as the name suggests, look like someone stuck tiny ice picks into the skin, leaving a sunken or pitted appearance.

“It’s really important to categorize so that we know which ones are going to be effectively treated with different modalities and which ones aren’t, so that we can give our patients realistic expectations,” said Dr. Siperstein, a cosmetic dermatologist in private practice in Boca Raton, Florida, and a clinical affiliate associate professor of dermatology at Florida Atlantic University, Boca Raton.

“There’s not going to be one treatment that’s right for everything,” she said. Different approaches may be required even for the same patient because some people present with all three types of acne scars, she added.

Combining Treatments

When it comes to injecting dermal fillers into acne scars to lift the depressed areas, the US Food and Drug Administration approved a filler with polymethyl methacrylate filler and bovine collagen (Bellafill) for this indication (moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over age 21) in 2015. “And off-label, I use hyaluronic acid in my practice,” Dr. Siperstein said. Each filler “probably works a little bit better or differently on different types of scars.”

For rolling scars, she recommends hyaluronic acid (HA) dermal filler for everyone. “Of course, this is my opinion.” She was also a lead investigator in a randomized, placebo-controlled split-face study comparing HA filler with saline for correcting atrophic facial scars in 15 patients. The HA filler emerged superior, although there were some improvements with saline.

In her clinical experience, patients are happy with the results and ask, “Why didn’t the last four doctors do this?”

Boxcar scars are more challenging to fill with HA. In some cases, Dr. Siperstein is able to raise the depressed portion of the scar, but some of the vertical edges remain. In this scenario, she might combine treatments. Laser resurfacing, for example, might help convert boxcar scars into rolling scars, which then can be filled more successfully.

“Ice pick scars are tough,” Dr. Siperstein said. A punch removal technique can work in some cases, or she might try the “cross technique.” This involves placing acetic acid inside the scar using a Q-tip. “You have to be really careful,” she added, “because if you get it around the edges, it’s actually going to make the scar bigger.”
 

Choosing the Right Candidates

Selecting the right candidate for HA treatment of acne scars is essential. Dr. Siperstein shared the example of a lifeguard who had prominent acne scarring down the center of his chest. “He was embarrassed to go to the beach and take off his shirt. He said he felt like he had bullet holes in his chest.”

One month following treatment, “he had a really nice improvement, and now he feels really comfortable,” she said.

Some dermatologists might be reluctant to consider HA fillers for acne scarring because there is a misconception that HA is short-acting, lasting 6 months to 1 year before the effect wears off. That impression can persist from company-sponsored studies that limit follow-up to 6 months or 1 year “to get their drug to market,” she noted.

Also adding to this impression is that HA fillers in wrinkles may not last as long. Dr. Siperstein explained that wrinkles on the face are dynamic and constantly moving. In contrast, acne scars experience less movement, which helps the HA last longer. There is MRI evidence that shows HA fillers last over 2 years in the face, she added.

One tip to predict how well an acne scar might respond to filler injections is to squeeze it and look for the “dimple sign.” If the floor of the scar lifts up when squeezed, “we know that they’ll be a good candidate for hyaluronic acid filler.” Another tip is to inject HA in a retrograde technique high up in the skin. Inject tiny amounts — microdroplets — of the HA filler high on the dermis, she advised.

Deeper injections run the risk of raising the entire scar instead of filling it, she added.

Like many dermatologic procedures, before and after photos are essential to demonstrate improvements, Dr. Siperstein pointed out. Patients are often skeptical. “This happens a lot with acne scar patients. They’ve been to a million places that have promised results, they have not gotten them, and they are frustrated.”

Acne scars can result from picking, inflammation, or treatment. “This is what we see all day in clinic,” Dr. Siperstein said. “Somebody who had to undergo Accutane treatment but unfortunately is left with holes. This is a huge psychological burden on our patients,” she said, describing a younger patient who had scarring, which “led to depression — it was ruining his life.”

“His mom was willing to do whatever it took. And I said, You know what, I think filler will be enough,” Dr. Siperstein said. She counseled them that treatment would not make the scars disappear completely. But patients used to 10% improvements are very happy when their acne scars look 80% or 90% better, she added.

Dr. Siperstein received grant or research support and is a member of the speakers bureau for Allergan and Galderma. She is also a consultant/advisory board member for Allergan.
 

A version of this article appeared on Medscape.com.

The use of laser epilation (LE) as a supplement to standard care significantly reduces recurrence of pilonidal disease, compared with standard care alone, according to the results of a randomized trial.

The study, recently published in JAMA Surgery, enrolled 302 patients ages 11-21 with pilonidal disease. Half of the participants were assigned to receive LE (laser hair removal) plus standard treatment (improved hygiene plus mechanical or chemical hair removal), and half were assigned to receive standard care alone.

At 1 year, 10.4% of the patients who had received LE plus standard treatment had experienced a recurrence of pilonidal disease, compared with 33.6% of patients in the standard treatment group (P < .001). Rates were based on the data available on 96 patients in the LE group and 134 patients in the standard care group.

“These results provide further evidence that laser epilation is safe, well-tolerated, and should be available as an initial treatment option or adjunct treatment modality for all eligible patients,” first author Peter C. Minneci, MD, chair of surgery at Nemours Children’s Health, Delaware Valley, Wilmington, Del, said in a press release reporting the results. “There have been few comparative studies that have investigated recurrence rates after LE versus other treatment modalities,” he and his coauthors wrote in the study, noting that the study “was the first, to our knowledge, to compare LE as an adjunct to standard care versus standard care alone and demonstrate a decrease in recurrence rates.”

Pilonidal disease, a common condition, results when cysts form between the buttocks and is most common in adolescents and young adults. It is thought to recur about 33% of the time, with most cases recurring within 1 year of treatment.

In practice, there are large variations in management strategies for pilonidal disease because evidence for an ideal treatment approach is lacking, Dr. Minneci and coauthors wrote. Although lifestyle modifications and nonepilation hair removal strategies have been linked to a reduced need for surgery, compliance with these strategies is low. Additionally, recurrence contributes to “a high degree of psychosocial stress in patients, who often miss school or sports and may avoid social activities,” Dr. Minneci said in the press release. Therefore, some practitioners have begun using LE – which uses selective thermolysis to remove the hair shaft, follicle, and bulb – as an adjunct to standard treatments in the hopes of avoiding surgery. 

A few studies have shown LE is effective in reducing pilonidal disease recurrence, but these studies had small sample sizes, according to the authors.

Study methods

The randomized, nonblinded clinical trial was conducted between 2017 and 2022 at Nationwide Children’s Hospital, Columbus, and enrolled patients aged 11-21 years with a history of pilonidal disease, who did not have active disease.

Those in the control group (151 patients) had an in-person clinic visit where they received education and training about hair removal in the gluteal cleft, and were provided with supplies for hair removal (chemical epilation or shaving) for 6 months (standard of care). Those in the LE group (151 patients) received standard of care therapy, and also received one LE treatment every 4-6 weeks for a total of five treatments. They were encouraged to perform hair removal using chemical or mechanical depilation between visits.

At the 1-year follow-up, data were available in 96 patients in the LE group and 134 patients in the standard care group. At that time, the proportion of those who had a recurrence within 1 year was significantly lower in the LE group than in the standard care group (mean difference, –23.2%; 95% CI, –33.2% to –13.1%; P < .001).

In addition, over the course of a year, those in the LE-treated group had significantly higher Child Attitude Toward Illness scores, indicating that they felt more positively about their illness at 6 months than participants in the standard care group. There were no differences between the groups in terms of patient or caregiver disability days, patient- or caregiver-reported health-related quality of life, health care satisfaction, or perceived stigma. In the LE group, no burns were reported, and no inability to tolerate treatment because of pain.

The study had several limitations, including the potential for participation bias, and because of a loss to follow-up, primary and secondary outcomes were missing data points, which was higher in the LE group. Loss to follow-up in the LE arm increased after 6 months, when laser treatments ended, with many of those patients not completing surveys at 9 and 12 months. The hospital’s pilonidal clinic shut down for 3 months during the COVID-19 pandemic, and when the clinic reopened, 15 patients in the LE arm withdrew from the study.

|In the press release, Dr. Minneci said that confirmation of the effectiveness of LE could help justify insurance coverage for pilonidal disease, noting that LE is usually not covered with insurance, and a course of treatment could cost $800-$1,500.

Dr. Minneci and four of the other six coauthors reported receiving grants from Patient-Centered Outcomes Research Institute during the conduct of the study. One author reported receiving grants from the National Institute on Minority Health and Health Disparities outside the submitted work. The research was funded by a grant from the Patient-Centered Outcomes Research Institute.

The use of laser epilation (LE) as a supplement to standard care significantly reduces recurrence of pilonidal disease, compared with standard care alone, according to the results of a randomized trial.

The study, recently published in JAMA Surgery, enrolled 302 patients ages 11-21 with pilonidal disease. Half of the participants were assigned to receive LE (laser hair removal) plus standard treatment (improved hygiene plus mechanical or chemical hair removal), and half were assigned to receive standard care alone.

At 1 year, 10.4% of the patients who had received LE plus standard treatment had experienced a recurrence of pilonidal disease, compared with 33.6% of patients in the standard treatment group (P < .001). Rates were based on the data available on 96 patients in the LE group and 134 patients in the standard care group.

“These results provide further evidence that laser epilation is safe, well-tolerated, and should be available as an initial treatment option or adjunct treatment modality for all eligible patients,” first author Peter C. Minneci, MD, chair of surgery at Nemours Children’s Health, Delaware Valley, Wilmington, Del, said in a press release reporting the results. “There have been few comparative studies that have investigated recurrence rates after LE versus other treatment modalities,” he and his coauthors wrote in the study, noting that the study “was the first, to our knowledge, to compare LE as an adjunct to standard care versus standard care alone and demonstrate a decrease in recurrence rates.”

Pilonidal disease, a common condition, results when cysts form between the buttocks and is most common in adolescents and young adults. It is thought to recur about 33% of the time, with most cases recurring within 1 year of treatment.

In practice, there are large variations in management strategies for pilonidal disease because evidence for an ideal treatment approach is lacking, Dr. Minneci and coauthors wrote. Although lifestyle modifications and nonepilation hair removal strategies have been linked to a reduced need for surgery, compliance with these strategies is low. Additionally, recurrence contributes to “a high degree of psychosocial stress in patients, who often miss school or sports and may avoid social activities,” Dr. Minneci said in the press release. Therefore, some practitioners have begun using LE – which uses selective thermolysis to remove the hair shaft, follicle, and bulb – as an adjunct to standard treatments in the hopes of avoiding surgery. 

A few studies have shown LE is effective in reducing pilonidal disease recurrence, but these studies had small sample sizes, according to the authors.

Study methods

The randomized, nonblinded clinical trial was conducted between 2017 and 2022 at Nationwide Children’s Hospital, Columbus, and enrolled patients aged 11-21 years with a history of pilonidal disease, who did not have active disease.

Those in the control group (151 patients) had an in-person clinic visit where they received education and training about hair removal in the gluteal cleft, and were provided with supplies for hair removal (chemical epilation or shaving) for 6 months (standard of care). Those in the LE group (151 patients) received standard of care therapy, and also received one LE treatment every 4-6 weeks for a total of five treatments. They were encouraged to perform hair removal using chemical or mechanical depilation between visits.

At the 1-year follow-up, data were available in 96 patients in the LE group and 134 patients in the standard care group. At that time, the proportion of those who had a recurrence within 1 year was significantly lower in the LE group than in the standard care group (mean difference, –23.2%; 95% CI, –33.2% to –13.1%; P < .001).

In addition, over the course of a year, those in the LE-treated group had significantly higher Child Attitude Toward Illness scores, indicating that they felt more positively about their illness at 6 months than participants in the standard care group. There were no differences between the groups in terms of patient or caregiver disability days, patient- or caregiver-reported health-related quality of life, health care satisfaction, or perceived stigma. In the LE group, no burns were reported, and no inability to tolerate treatment because of pain.

The study had several limitations, including the potential for participation bias, and because of a loss to follow-up, primary and secondary outcomes were missing data points, which was higher in the LE group. Loss to follow-up in the LE arm increased after 6 months, when laser treatments ended, with many of those patients not completing surveys at 9 and 12 months. The hospital’s pilonidal clinic shut down for 3 months during the COVID-19 pandemic, and when the clinic reopened, 15 patients in the LE arm withdrew from the study.

|In the press release, Dr. Minneci said that confirmation of the effectiveness of LE could help justify insurance coverage for pilonidal disease, noting that LE is usually not covered with insurance, and a course of treatment could cost $800-$1,500.

Dr. Minneci and four of the other six coauthors reported receiving grants from Patient-Centered Outcomes Research Institute during the conduct of the study. One author reported receiving grants from the National Institute on Minority Health and Health Disparities outside the submitted work. The research was funded by a grant from the Patient-Centered Outcomes Research Institute.

The use of laser epilation (LE) as a supplement to standard care significantly reduces recurrence of pilonidal disease, compared with standard care alone, according to the results of a randomized trial.

The study, recently published in JAMA Surgery, enrolled 302 patients ages 11-21 with pilonidal disease. Half of the participants were assigned to receive LE (laser hair removal) plus standard treatment (improved hygiene plus mechanical or chemical hair removal), and half were assigned to receive standard care alone.

At 1 year, 10.4% of the patients who had received LE plus standard treatment had experienced a recurrence of pilonidal disease, compared with 33.6% of patients in the standard treatment group (P < .001). Rates were based on the data available on 96 patients in the LE group and 134 patients in the standard care group.

“These results provide further evidence that laser epilation is safe, well-tolerated, and should be available as an initial treatment option or adjunct treatment modality for all eligible patients,” first author Peter C. Minneci, MD, chair of surgery at Nemours Children’s Health, Delaware Valley, Wilmington, Del, said in a press release reporting the results. “There have been few comparative studies that have investigated recurrence rates after LE versus other treatment modalities,” he and his coauthors wrote in the study, noting that the study “was the first, to our knowledge, to compare LE as an adjunct to standard care versus standard care alone and demonstrate a decrease in recurrence rates.”

Pilonidal disease, a common condition, results when cysts form between the buttocks and is most common in adolescents and young adults. It is thought to recur about 33% of the time, with most cases recurring within 1 year of treatment.

In practice, there are large variations in management strategies for pilonidal disease because evidence for an ideal treatment approach is lacking, Dr. Minneci and coauthors wrote. Although lifestyle modifications and nonepilation hair removal strategies have been linked to a reduced need for surgery, compliance with these strategies is low. Additionally, recurrence contributes to “a high degree of psychosocial stress in patients, who often miss school or sports and may avoid social activities,” Dr. Minneci said in the press release. Therefore, some practitioners have begun using LE – which uses selective thermolysis to remove the hair shaft, follicle, and bulb – as an adjunct to standard treatments in the hopes of avoiding surgery. 

A few studies have shown LE is effective in reducing pilonidal disease recurrence, but these studies had small sample sizes, according to the authors.

Study methods

The randomized, nonblinded clinical trial was conducted between 2017 and 2022 at Nationwide Children’s Hospital, Columbus, and enrolled patients aged 11-21 years with a history of pilonidal disease, who did not have active disease.

Those in the control group (151 patients) had an in-person clinic visit where they received education and training about hair removal in the gluteal cleft, and were provided with supplies for hair removal (chemical epilation or shaving) for 6 months (standard of care). Those in the LE group (151 patients) received standard of care therapy, and also received one LE treatment every 4-6 weeks for a total of five treatments. They were encouraged to perform hair removal using chemical or mechanical depilation between visits.

At the 1-year follow-up, data were available in 96 patients in the LE group and 134 patients in the standard care group. At that time, the proportion of those who had a recurrence within 1 year was significantly lower in the LE group than in the standard care group (mean difference, –23.2%; 95% CI, –33.2% to –13.1%; P < .001).

In addition, over the course of a year, those in the LE-treated group had significantly higher Child Attitude Toward Illness scores, indicating that they felt more positively about their illness at 6 months than participants in the standard care group. There were no differences between the groups in terms of patient or caregiver disability days, patient- or caregiver-reported health-related quality of life, health care satisfaction, or perceived stigma. In the LE group, no burns were reported, and no inability to tolerate treatment because of pain.

The study had several limitations, including the potential for participation bias, and because of a loss to follow-up, primary and secondary outcomes were missing data points, which was higher in the LE group. Loss to follow-up in the LE arm increased after 6 months, when laser treatments ended, with many of those patients not completing surveys at 9 and 12 months. The hospital’s pilonidal clinic shut down for 3 months during the COVID-19 pandemic, and when the clinic reopened, 15 patients in the LE arm withdrew from the study.

|In the press release, Dr. Minneci said that confirmation of the effectiveness of LE could help justify insurance coverage for pilonidal disease, noting that LE is usually not covered with insurance, and a course of treatment could cost $800-$1,500.

Dr. Minneci and four of the other six coauthors reported receiving grants from Patient-Centered Outcomes Research Institute during the conduct of the study. One author reported receiving grants from the National Institute on Minority Health and Health Disparities outside the submitted work. The research was funded by a grant from the Patient-Centered Outcomes Research Institute.

TOPLINE:

More than half of Mohs surgeons report at least one sharps injury in the past year, mostly self-inflicted, survey finds.

METHODOLOGY:

• Data on the incidence of sharps injuries among dermatologic surgeons is limited.
• In a cross-sectional analysis of anonymous survey responses from members of the American College of , researchers aimed to determine the incidence and types of sharps injuries among Mohs surgeons.
• The researchers used descriptive statistics for continuous and nominal variables (percentage and frequencies) to report survey data and Fisher exact or chi-square analysis of categorical variables to obtain P values.

TAKEAWAY:

• Of the 60 survey respondents, more than half (56.7%) were from single-specialty group practices, 26.6% were from academic practices, and fewer than half (43.3%) had been in practice for 15 or more years.
• In the past year, 56.7% of respondents experienced at least one sharps injury. Of these, 14.7% involved exposure to a blood-borne pathogen, which translated into an annual exposure risk of 7.6% for any given Mohs surgeon.
• The top two types of sharps injuries were self-inflicted suture needlestick (76.5%) and other types of self-inflicted needlestick injuries (26.5%).
• Of respondents who sustained a sharps injury, 44.1% did not report them, while 95% of all survey respondents said they had access to postexposure prophylaxis/protocols at their workplace.
• The researchers determined that the average annual rate of sharps injury was 0.87.

IN PRACTICE:

• “In best practices to prevent sharps injuries, the authors recommend that a standardized sharps handling protocol be developed and disseminated for dermatologic surgeons and their staff,” the researchers wrote.

STUDY DETAILS:

• Faezeh Talebi-Liasi, MD, and Jesse M. Lewin, MD, department of dermatology, Icahn School of Medicine at Mount Sinai, New York, conducted the research. The study was published in Dermatologic Surgery.

LIMITATIONS:

• The study’s cross-sectional observational design and small sample size was skewed toward single-specialty and academic practices.

DISCLOSURES:

• The authors reported having no relevant financial disclosures.

A version of this article appeared on Medscape.com.

TOPLINE:

More than half of Mohs surgeons report at least one sharps injury in the past year, mostly self-inflicted, survey finds.

METHODOLOGY:

• Data on the incidence of sharps injuries among dermatologic surgeons is limited.
• In a cross-sectional analysis of anonymous survey responses from members of the American College of , researchers aimed to determine the incidence and types of sharps injuries among Mohs surgeons.
• The researchers used descriptive statistics for continuous and nominal variables (percentage and frequencies) to report survey data and Fisher exact or chi-square analysis of categorical variables to obtain P values.

TAKEAWAY:

• Of the 60 survey respondents, more than half (56.7%) were from single-specialty group practices, 26.6% were from academic practices, and fewer than half (43.3%) had been in practice for 15 or more years.
• In the past year, 56.7% of respondents experienced at least one sharps injury. Of these, 14.7% involved exposure to a blood-borne pathogen, which translated into an annual exposure risk of 7.6% for any given Mohs surgeon.
• The top two types of sharps injuries were self-inflicted suture needlestick (76.5%) and other types of self-inflicted needlestick injuries (26.5%).
• Of respondents who sustained a sharps injury, 44.1% did not report them, while 95% of all survey respondents said they had access to postexposure prophylaxis/protocols at their workplace.
• The researchers determined that the average annual rate of sharps injury was 0.87.

IN PRACTICE:

• “In best practices to prevent sharps injuries, the authors recommend that a standardized sharps handling protocol be developed and disseminated for dermatologic surgeons and their staff,” the researchers wrote.

STUDY DETAILS:

• Faezeh Talebi-Liasi, MD, and Jesse M. Lewin, MD, department of dermatology, Icahn School of Medicine at Mount Sinai, New York, conducted the research. The study was published in Dermatologic Surgery.

LIMITATIONS:

• The study’s cross-sectional observational design and small sample size was skewed toward single-specialty and academic practices.

DISCLOSURES:

• The authors reported having no relevant financial disclosures.

A version of this article appeared on Medscape.com.

TOPLINE:

More than half of Mohs surgeons report at least one sharps injury in the past year, mostly self-inflicted, survey finds.

METHODOLOGY:

• Data on the incidence of sharps injuries among dermatologic surgeons is limited.
• In a cross-sectional analysis of anonymous survey responses from members of the American College of , researchers aimed to determine the incidence and types of sharps injuries among Mohs surgeons.
• The researchers used descriptive statistics for continuous and nominal variables (percentage and frequencies) to report survey data and Fisher exact or chi-square analysis of categorical variables to obtain P values.

TAKEAWAY:

• Of the 60 survey respondents, more than half (56.7%) were from single-specialty group practices, 26.6% were from academic practices, and fewer than half (43.3%) had been in practice for 15 or more years.
• In the past year, 56.7% of respondents experienced at least one sharps injury. Of these, 14.7% involved exposure to a blood-borne pathogen, which translated into an annual exposure risk of 7.6% for any given Mohs surgeon.
• The top two types of sharps injuries were self-inflicted suture needlestick (76.5%) and other types of self-inflicted needlestick injuries (26.5%).
• Of respondents who sustained a sharps injury, 44.1% did not report them, while 95% of all survey respondents said they had access to postexposure prophylaxis/protocols at their workplace.
• The researchers determined that the average annual rate of sharps injury was 0.87.

IN PRACTICE:

• “In best practices to prevent sharps injuries, the authors recommend that a standardized sharps handling protocol be developed and disseminated for dermatologic surgeons and their staff,” the researchers wrote.

STUDY DETAILS:

• Faezeh Talebi-Liasi, MD, and Jesse M. Lewin, MD, department of dermatology, Icahn School of Medicine at Mount Sinai, New York, conducted the research. The study was published in Dermatologic Surgery.

LIMITATIONS:

• The study’s cross-sectional observational design and small sample size was skewed toward single-specialty and academic practices.

DISCLOSURES:

• The authors reported having no relevant financial disclosures.

A version of this article appeared on Medscape.com.

TOPLINE:

Incipient ulceration in primary cutaneous melanoma may represent a more biologically aggressive disease population than truly nonulcerated tumors.

METHODOLOGY:

• The final cohort included 40 cases of incipient ulceration that were matched 1:2 with 80 nonulcerated controls and 80 ulcerated controls.
• The prognostic significance of incipient ulceration in cutaneous melanoma is unclear.
• Current American Joint Committee on Cancer (AJCC) guidelines classify incipient ulceration as nonulcerated.
• In a retrospective case-control study, researchers drew from the Melanoma Institute Australia database to identify resected primary cutaneous melanomas diagnosed between 2005 and 2015 that had slides available at Royal Prince Alfred Hospital in Sydney and a Breslow thickness greater than 0 mm.
• Clinical outcomes compared between cases and controls were recurrence-free survival (RFS), melanoma-specific survival (MSS), and overall survival (OS).

TAKEAWAY:

• The median Breslow depth was 2.8 mm for incipient cases, compared with 1.0 mm for nonulcerated melanomas and 5.3 mm for ulcerated melanomas, while the median tumor mitotic rate was 5.0 per mm² for incipient cases, compared with 1 per mm² in nonulcerated controls and 9 per mm² in ulcerated controls.
• On univariable analyses, compared with patients with incipiently ulcerated cases, patients with nonulcerated tumors had significantly better OS (hazard ratio [HR], 0.49) and RFS (HR, 0.37), while patients with ulcerated tumors showed worse RFS (HR, 1.67).
• On multivariable analyses, no differences in survival outcomes were observed, perhaps due to the moderate number of incipient ulceration cases included in the study, the authors wrote.

IN PRACTICE:

“Future editions of the AJCC staging system should consider acknowledging this interpretive challenge and provide guidance on how primary melanomas with incipient ulceration should be classified,” the researchers wrote.

SOURCE:

Richard A. Scolyer, MD, a pathologist at Royal Prince Alfred Hospital, Camperdown, Australia, is the senior author on the study, which was published online in JAMA Dermatology.

LIMITATIONS:

Limitations of the study include its retrospective design and the relatively small number of cases that met criteria for inclusion.

DISCLOSURES:

Dr. Scolyer disclosed that he has received grants from the Australian National Health and Medical Research Council and personal fees from MetaOptima, F. Hoffmann-La Roche, Evaxion, Provectus, QBiotics, Novartis, Merck Sharp & Dohme, NeraCare, Amgen, Bristol-Myers Squibb, Myriad Genetics, and GlaxoSmithKline, all outside the submitted work. Four coauthors reported having received financial support outside of the submitted work.

A version of this article appeared on Medscape.com.

TOPLINE:

Incipient ulceration in primary cutaneous melanoma may represent a more biologically aggressive disease population than truly nonulcerated tumors.

METHODOLOGY:

• The final cohort included 40 cases of incipient ulceration that were matched 1:2 with 80 nonulcerated controls and 80 ulcerated controls.
• The prognostic significance of incipient ulceration in cutaneous melanoma is unclear.
• Current American Joint Committee on Cancer (AJCC) guidelines classify incipient ulceration as nonulcerated.
• In a retrospective case-control study, researchers drew from the Melanoma Institute Australia database to identify resected primary cutaneous melanomas diagnosed between 2005 and 2015 that had slides available at Royal Prince Alfred Hospital in Sydney and a Breslow thickness greater than 0 mm.
• Clinical outcomes compared between cases and controls were recurrence-free survival (RFS), melanoma-specific survival (MSS), and overall survival (OS).

TAKEAWAY:

• The median Breslow depth was 2.8 mm for incipient cases, compared with 1.0 mm for nonulcerated melanomas and 5.3 mm for ulcerated melanomas, while the median tumor mitotic rate was 5.0 per mm² for incipient cases, compared with 1 per mm² in nonulcerated controls and 9 per mm² in ulcerated controls.
• On univariable analyses, compared with patients with incipiently ulcerated cases, patients with nonulcerated tumors had significantly better OS (hazard ratio [HR], 0.49) and RFS (HR, 0.37), while patients with ulcerated tumors showed worse RFS (HR, 1.67).
• On multivariable analyses, no differences in survival outcomes were observed, perhaps due to the moderate number of incipient ulceration cases included in the study, the authors wrote.

IN PRACTICE:

“Future editions of the AJCC staging system should consider acknowledging this interpretive challenge and provide guidance on how primary melanomas with incipient ulceration should be classified,” the researchers wrote.

SOURCE:

Richard A. Scolyer, MD, a pathologist at Royal Prince Alfred Hospital, Camperdown, Australia, is the senior author on the study, which was published online in JAMA Dermatology.

LIMITATIONS:

Limitations of the study include its retrospective design and the relatively small number of cases that met criteria for inclusion.

DISCLOSURES:

Dr. Scolyer disclosed that he has received grants from the Australian National Health and Medical Research Council and personal fees from MetaOptima, F. Hoffmann-La Roche, Evaxion, Provectus, QBiotics, Novartis, Merck Sharp & Dohme, NeraCare, Amgen, Bristol-Myers Squibb, Myriad Genetics, and GlaxoSmithKline, all outside the submitted work. Four coauthors reported having received financial support outside of the submitted work.

A version of this article appeared on Medscape.com.

TOPLINE:

Incipient ulceration in primary cutaneous melanoma may represent a more biologically aggressive disease population than truly nonulcerated tumors.

METHODOLOGY:

• The final cohort included 40 cases of incipient ulceration that were matched 1:2 with 80 nonulcerated controls and 80 ulcerated controls.
• The prognostic significance of incipient ulceration in cutaneous melanoma is unclear.
• Current American Joint Committee on Cancer (AJCC) guidelines classify incipient ulceration as nonulcerated.
• In a retrospective case-control study, researchers drew from the Melanoma Institute Australia database to identify resected primary cutaneous melanomas diagnosed between 2005 and 2015 that had slides available at Royal Prince Alfred Hospital in Sydney and a Breslow thickness greater than 0 mm.
• Clinical outcomes compared between cases and controls were recurrence-free survival (RFS), melanoma-specific survival (MSS), and overall survival (OS).

TAKEAWAY:

• The median Breslow depth was 2.8 mm for incipient cases, compared with 1.0 mm for nonulcerated melanomas and 5.3 mm for ulcerated melanomas, while the median tumor mitotic rate was 5.0 per mm² for incipient cases, compared with 1 per mm² in nonulcerated controls and 9 per mm² in ulcerated controls.
• On univariable analyses, compared with patients with incipiently ulcerated cases, patients with nonulcerated tumors had significantly better OS (hazard ratio [HR], 0.49) and RFS (HR, 0.37), while patients with ulcerated tumors showed worse RFS (HR, 1.67).
• On multivariable analyses, no differences in survival outcomes were observed, perhaps due to the moderate number of incipient ulceration cases included in the study, the authors wrote.

IN PRACTICE:

“Future editions of the AJCC staging system should consider acknowledging this interpretive challenge and provide guidance on how primary melanomas with incipient ulceration should be classified,” the researchers wrote.

SOURCE:

Richard A. Scolyer, MD, a pathologist at Royal Prince Alfred Hospital, Camperdown, Australia, is the senior author on the study, which was published online in JAMA Dermatology.

LIMITATIONS:

Limitations of the study include its retrospective design and the relatively small number of cases that met criteria for inclusion.

DISCLOSURES:

Dr. Scolyer disclosed that he has received grants from the Australian National Health and Medical Research Council and personal fees from MetaOptima, F. Hoffmann-La Roche, Evaxion, Provectus, QBiotics, Novartis, Merck Sharp & Dohme, NeraCare, Amgen, Bristol-Myers Squibb, Myriad Genetics, and GlaxoSmithKline, all outside the submitted work. Four coauthors reported having received financial support outside of the submitted work.

A version of this article appeared on Medscape.com.

CARLSBAD, CALIF. – For the estimated 10 million wounds that clinicians treat in the United States each year resulting from surgical procedures, trauma, burns, and other causes, the best outcome is a scar, a fibrotic dermis with a flattened epidermis that contains no sweat glands, no pilosebaceous units, and impaired nerve function.

But what if the outcome was skin regeneration instead of scar formation? At the annual symposium of the California Society of Dermatology & Dermatologic Surgery, Philip O. Scumpia, MD, PhD, described the development of a biomaterial known as microporous annealed particle (MAP) hydrogel, which in preclinical studies has been shown to trigger the immune system leading to improved tissue repair and healthier, stronger skin.

“We’re preprogrammed to undergo scarring,” said Dr. Scumpia, associate professor of dermatology at the University of California, Los Angeles. “Tissue fibrosis is an evolutionary process” where a fibrotic matrix is deposited “as quickly as possible to close the gap caused by an injury,” he noted. “All of the cues in the normal wound healing process result in fibrosis, but we want to move from scarring to tissue regeneration. The goal is to make something that can shift from this evolutionary process, and it’s proven to be inherently difficult.”

Dr. Scumpia

Common approaches to wound treatment include simple and advanced dressings, negative pressure, and hyperbaric oxygen. For wounds that persist beyond 30 days, advanced treatment options include decellularized grafts such as placental membranes, amniotic membranes, and acellular dermal matrices. “There are also cellularized grafts such as dressings that contain neonatal dermal fibroblasts,” which are expensive, said Dr. Scumpia, director of dermatopathology at the West Los Angeles VA Medical Center. “There are also semi-synthetic grafts such as single or double layer dermal replacement templates and synthetic dermal substitutes in the form of sheets or foam. All of these can help with wound coverage and help chronic wounds close on their own.”

Meanwhile, tissue regeneration – or efforts to restore tissue to its original functionality – include growth factors, stem cells, or replacement extracellular matrix (skin substitutes), or a combination. “Bioengineered dressings and bioengineered skin substitutes have shown modest improvement in wound healing but not tissue regeneration,” Dr. Scumpia said. “At best, we can accelerate scar formation and close the wound quicker, but nothing has been shown to regenerate tissue.”

Approaches to skin regeneration

Studies from the embryology literature have helped researchers develop better approaches to skin regeneration. For example, fetal skin heals without scarring when injured. “Hairs form from placodes, then sebaceous glands form, and fibroblasts that are part of the papillary mesenchymal body expressing special factors such as engrailed or CRABP1 drive hair follicle formation,” he said. “Many studies have shown that sonic hedgehog signaling, and Wnt/beta-catenin signaling can play a role in the development of new hair follicles. Also, fibroblasts in the dermis can drive hair follicle formation.”

Researchers are also learning about tissue regeneration from mouse models. For example, African spiny mice have been shown to heal regeneratively. “If you make wounds large enough on lab mice, the center heals regeneratively,” Dr. Scumpia said. “What’s interesting is that these same signals are present in embryonic hair follicle development. Why is this important? Who wants a hairy scar? It’s an organized structure that develops in the wound. That can help us understand what we need to put in so that our body regenerates on its own. In mouse models, the immune system has been shown to play a role in regeneration.”

Expanding on initial work conducted at UCLA, Dr. Scumpia and his colleagues founded San Diego-based Tempo Therapeutics, which is commercializing the MAP hydrogel to mimic the natural porosity and stiffness of skin. They sought to develop a new biomaterial, he said, noting that “the skin is porous on a microscale level, allowing cells to infiltrate different areas.” And the problem with existing biomaterials “is that they don’t incorporate into the skin very well,” he explained. “They’re usually stiff and rubbery and can cause a foreign body reaction, which can result in fibrous encapsulation and inflammation.”

The MAP hydrogel is composed of randomly packed “microsphere building blocks,” including an amino acid that promotes an immune response. When injected into a wound, the hydrogel forms a porous matrix in the tissue. Surface annealing locks in porosity and tissue grows into porous spaces, which avoids scar formation pathways and enables critical organs to regain function.

During in vivo tests, researchers observed decreases in inflammation compared with traditional hydrogels in the first 48 hours. “In mouse models, we found that if you inject in a hydrogel that has no porosity, the body tries to spit it out, and you have an immune reaction,” Dr. Scumpia said. “But when we used the MAP hydrogel, we found that cells can migrate through it, which allows wounds to heal quicker. When we added an antigen in the hydrogel trying to allow the hydrogel to degrade slower, it actually degraded more rapidly, but we found that new hair follicles formed in the center of these wounds, a hallmark of skin regeneration. My lab has been studying why this occurs and trying to use this to our advantage in other models.”

In an unpublished mouse burn wound model study, he and his colleagues excised a wound, but it never healed with regeneration in the center. “We don’t understand why,” he said. But when the researchers used the MAP gel in wounds of hairless mice, they observed the formation of sebaceous glands and hair follicles over the wound beds. “It’s an exciting finding to see hair follicles develop in the center of a wound,” Dr. Scumpia said. He noted that to date, use of the MAP hydrogel has demonstrated tissue regeneration in some of the 27 veterinary cases that have been performed, including for wounds following traumatic injuries or following tumor resections on paws that allowed the pets to avoid amputation.

Clinical trials planned

The first clinical trials of the MAP hydrogel are planned for treating complex diabetic wounds in early 2024 but will likely expand to other difficult-to-treat wounds, including venous stasis ulcers, decubitus ulcers, and use following large surgical resections. Dr. Scumpia and colleagues will also examine the regenerative biomaterial for tissue aesthetics, including dermal and deep tissue filler applications. The next steps in his laboratory, he said, are to combine biomaterials with stem cells, immune factors, or small molecular activators/inhibitors to improve sweat gland, nerve, or hair follicle regeneration.

Dr. Scumpia disclosed that he is a cofounder and shareholder in Tempo Therapeutics. He has also received grant support from the National Institutes of Health, Department of Veteran Affairs, and the LEO Foundation.

CARLSBAD, CALIF. – For the estimated 10 million wounds that clinicians treat in the United States each year resulting from surgical procedures, trauma, burns, and other causes, the best outcome is a scar, a fibrotic dermis with a flattened epidermis that contains no sweat glands, no pilosebaceous units, and impaired nerve function.

But what if the outcome was skin regeneration instead of scar formation? At the annual symposium of the California Society of Dermatology & Dermatologic Surgery, Philip O. Scumpia, MD, PhD, described the development of a biomaterial known as microporous annealed particle (MAP) hydrogel, which in preclinical studies has been shown to trigger the immune system leading to improved tissue repair and healthier, stronger skin.

“We’re preprogrammed to undergo scarring,” said Dr. Scumpia, associate professor of dermatology at the University of California, Los Angeles. “Tissue fibrosis is an evolutionary process” where a fibrotic matrix is deposited “as quickly as possible to close the gap caused by an injury,” he noted. “All of the cues in the normal wound healing process result in fibrosis, but we want to move from scarring to tissue regeneration. The goal is to make something that can shift from this evolutionary process, and it’s proven to be inherently difficult.”

Dr. Scumpia

Common approaches to wound treatment include simple and advanced dressings, negative pressure, and hyperbaric oxygen. For wounds that persist beyond 30 days, advanced treatment options include decellularized grafts such as placental membranes, amniotic membranes, and acellular dermal matrices. “There are also cellularized grafts such as dressings that contain neonatal dermal fibroblasts,” which are expensive, said Dr. Scumpia, director of dermatopathology at the West Los Angeles VA Medical Center. “There are also semi-synthetic grafts such as single or double layer dermal replacement templates and synthetic dermal substitutes in the form of sheets or foam. All of these can help with wound coverage and help chronic wounds close on their own.”

Meanwhile, tissue regeneration – or efforts to restore tissue to its original functionality – include growth factors, stem cells, or replacement extracellular matrix (skin substitutes), or a combination. “Bioengineered dressings and bioengineered skin substitutes have shown modest improvement in wound healing but not tissue regeneration,” Dr. Scumpia said. “At best, we can accelerate scar formation and close the wound quicker, but nothing has been shown to regenerate tissue.”

Approaches to skin regeneration

Studies from the embryology literature have helped researchers develop better approaches to skin regeneration. For example, fetal skin heals without scarring when injured. “Hairs form from placodes, then sebaceous glands form, and fibroblasts that are part of the papillary mesenchymal body expressing special factors such as engrailed or CRABP1 drive hair follicle formation,” he said. “Many studies have shown that sonic hedgehog signaling, and Wnt/beta-catenin signaling can play a role in the development of new hair follicles. Also, fibroblasts in the dermis can drive hair follicle formation.”

Researchers are also learning about tissue regeneration from mouse models. For example, African spiny mice have been shown to heal regeneratively. “If you make wounds large enough on lab mice, the center heals regeneratively,” Dr. Scumpia said. “What’s interesting is that these same signals are present in embryonic hair follicle development. Why is this important? Who wants a hairy scar? It’s an organized structure that develops in the wound. That can help us understand what we need to put in so that our body regenerates on its own. In mouse models, the immune system has been shown to play a role in regeneration.”

Expanding on initial work conducted at UCLA, Dr. Scumpia and his colleagues founded San Diego-based Tempo Therapeutics, which is commercializing the MAP hydrogel to mimic the natural porosity and stiffness of skin. They sought to develop a new biomaterial, he said, noting that “the skin is porous on a microscale level, allowing cells to infiltrate different areas.” And the problem with existing biomaterials “is that they don’t incorporate into the skin very well,” he explained. “They’re usually stiff and rubbery and can cause a foreign body reaction, which can result in fibrous encapsulation and inflammation.”

The MAP hydrogel is composed of randomly packed “microsphere building blocks,” including an amino acid that promotes an immune response. When injected into a wound, the hydrogel forms a porous matrix in the tissue. Surface annealing locks in porosity and tissue grows into porous spaces, which avoids scar formation pathways and enables critical organs to regain function.

During in vivo tests, researchers observed decreases in inflammation compared with traditional hydrogels in the first 48 hours. “In mouse models, we found that if you inject in a hydrogel that has no porosity, the body tries to spit it out, and you have an immune reaction,” Dr. Scumpia said. “But when we used the MAP hydrogel, we found that cells can migrate through it, which allows wounds to heal quicker. When we added an antigen in the hydrogel trying to allow the hydrogel to degrade slower, it actually degraded more rapidly, but we found that new hair follicles formed in the center of these wounds, a hallmark of skin regeneration. My lab has been studying why this occurs and trying to use this to our advantage in other models.”

In an unpublished mouse burn wound model study, he and his colleagues excised a wound, but it never healed with regeneration in the center. “We don’t understand why,” he said. But when the researchers used the MAP gel in wounds of hairless mice, they observed the formation of sebaceous glands and hair follicles over the wound beds. “It’s an exciting finding to see hair follicles develop in the center of a wound,” Dr. Scumpia said. He noted that to date, use of the MAP hydrogel has demonstrated tissue regeneration in some of the 27 veterinary cases that have been performed, including for wounds following traumatic injuries or following tumor resections on paws that allowed the pets to avoid amputation.

Clinical trials planned

The first clinical trials of the MAP hydrogel are planned for treating complex diabetic wounds in early 2024 but will likely expand to other difficult-to-treat wounds, including venous stasis ulcers, decubitus ulcers, and use following large surgical resections. Dr. Scumpia and colleagues will also examine the regenerative biomaterial for tissue aesthetics, including dermal and deep tissue filler applications. The next steps in his laboratory, he said, are to combine biomaterials with stem cells, immune factors, or small molecular activators/inhibitors to improve sweat gland, nerve, or hair follicle regeneration.

Dr. Scumpia disclosed that he is a cofounder and shareholder in Tempo Therapeutics. He has also received grant support from the National Institutes of Health, Department of Veteran Affairs, and the LEO Foundation.

CARLSBAD, CALIF. – For the estimated 10 million wounds that clinicians treat in the United States each year resulting from surgical procedures, trauma, burns, and other causes, the best outcome is a scar, a fibrotic dermis with a flattened epidermis that contains no sweat glands, no pilosebaceous units, and impaired nerve function.

But what if the outcome was skin regeneration instead of scar formation? At the annual symposium of the California Society of Dermatology & Dermatologic Surgery, Philip O. Scumpia, MD, PhD, described the development of a biomaterial known as microporous annealed particle (MAP) hydrogel, which in preclinical studies has been shown to trigger the immune system leading to improved tissue repair and healthier, stronger skin.

“We’re preprogrammed to undergo scarring,” said Dr. Scumpia, associate professor of dermatology at the University of California, Los Angeles. “Tissue fibrosis is an evolutionary process” where a fibrotic matrix is deposited “as quickly as possible to close the gap caused by an injury,” he noted. “All of the cues in the normal wound healing process result in fibrosis, but we want to move from scarring to tissue regeneration. The goal is to make something that can shift from this evolutionary process, and it’s proven to be inherently difficult.”

Dr. Scumpia

Common approaches to wound treatment include simple and advanced dressings, negative pressure, and hyperbaric oxygen. For wounds that persist beyond 30 days, advanced treatment options include decellularized grafts such as placental membranes, amniotic membranes, and acellular dermal matrices. “There are also cellularized grafts such as dressings that contain neonatal dermal fibroblasts,” which are expensive, said Dr. Scumpia, director of dermatopathology at the West Los Angeles VA Medical Center. “There are also semi-synthetic grafts such as single or double layer dermal replacement templates and synthetic dermal substitutes in the form of sheets or foam. All of these can help with wound coverage and help chronic wounds close on their own.”

Meanwhile, tissue regeneration – or efforts to restore tissue to its original functionality – include growth factors, stem cells, or replacement extracellular matrix (skin substitutes), or a combination. “Bioengineered dressings and bioengineered skin substitutes have shown modest improvement in wound healing but not tissue regeneration,” Dr. Scumpia said. “At best, we can accelerate scar formation and close the wound quicker, but nothing has been shown to regenerate tissue.”

Approaches to skin regeneration

Studies from the embryology literature have helped researchers develop better approaches to skin regeneration. For example, fetal skin heals without scarring when injured. “Hairs form from placodes, then sebaceous glands form, and fibroblasts that are part of the papillary mesenchymal body expressing special factors such as engrailed or CRABP1 drive hair follicle formation,” he said. “Many studies have shown that sonic hedgehog signaling, and Wnt/beta-catenin signaling can play a role in the development of new hair follicles. Also, fibroblasts in the dermis can drive hair follicle formation.”

Researchers are also learning about tissue regeneration from mouse models. For example, African spiny mice have been shown to heal regeneratively. “If you make wounds large enough on lab mice, the center heals regeneratively,” Dr. Scumpia said. “What’s interesting is that these same signals are present in embryonic hair follicle development. Why is this important? Who wants a hairy scar? It’s an organized structure that develops in the wound. That can help us understand what we need to put in so that our body regenerates on its own. In mouse models, the immune system has been shown to play a role in regeneration.”

Expanding on initial work conducted at UCLA, Dr. Scumpia and his colleagues founded San Diego-based Tempo Therapeutics, which is commercializing the MAP hydrogel to mimic the natural porosity and stiffness of skin. They sought to develop a new biomaterial, he said, noting that “the skin is porous on a microscale level, allowing cells to infiltrate different areas.” And the problem with existing biomaterials “is that they don’t incorporate into the skin very well,” he explained. “They’re usually stiff and rubbery and can cause a foreign body reaction, which can result in fibrous encapsulation and inflammation.”

The MAP hydrogel is composed of randomly packed “microsphere building blocks,” including an amino acid that promotes an immune response. When injected into a wound, the hydrogel forms a porous matrix in the tissue. Surface annealing locks in porosity and tissue grows into porous spaces, which avoids scar formation pathways and enables critical organs to regain function.

During in vivo tests, researchers observed decreases in inflammation compared with traditional hydrogels in the first 48 hours. “In mouse models, we found that if you inject in a hydrogel that has no porosity, the body tries to spit it out, and you have an immune reaction,” Dr. Scumpia said. “But when we used the MAP hydrogel, we found that cells can migrate through it, which allows wounds to heal quicker. When we added an antigen in the hydrogel trying to allow the hydrogel to degrade slower, it actually degraded more rapidly, but we found that new hair follicles formed in the center of these wounds, a hallmark of skin regeneration. My lab has been studying why this occurs and trying to use this to our advantage in other models.”

In an unpublished mouse burn wound model study, he and his colleagues excised a wound, but it never healed with regeneration in the center. “We don’t understand why,” he said. But when the researchers used the MAP gel in wounds of hairless mice, they observed the formation of sebaceous glands and hair follicles over the wound beds. “It’s an exciting finding to see hair follicles develop in the center of a wound,” Dr. Scumpia said. He noted that to date, use of the MAP hydrogel has demonstrated tissue regeneration in some of the 27 veterinary cases that have been performed, including for wounds following traumatic injuries or following tumor resections on paws that allowed the pets to avoid amputation.

Clinical trials planned

The first clinical trials of the MAP hydrogel are planned for treating complex diabetic wounds in early 2024 but will likely expand to other difficult-to-treat wounds, including venous stasis ulcers, decubitus ulcers, and use following large surgical resections. Dr. Scumpia and colleagues will also examine the regenerative biomaterial for tissue aesthetics, including dermal and deep tissue filler applications. The next steps in his laboratory, he said, are to combine biomaterials with stem cells, immune factors, or small molecular activators/inhibitors to improve sweat gland, nerve, or hair follicle regeneration.

Dr. Scumpia disclosed that he is a cofounder and shareholder in Tempo Therapeutics. He has also received grant support from the National Institutes of Health, Department of Veteran Affairs, and the LEO Foundation.

SAN DIEGO – Injecting a scar with intralesional steroids is a popular way to reduce its size and soften the surrounding tissue, but proper technique matters, according to Victor Ross, MD.

“A lot of lip service is paid to how to inject the steroid,” Dr. Ross, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego, said at the annual Masters of Aesthetics Symposium. “The most important part is the amount and the fastidiousness that you have injecting. You should see the tip of the needle and be very slow. Use a 1 cc syringe.” He used to inject scars with triamcinolone acetate 40 mg/mL, but now he almost always injects 10-20 mg/mL to avoid inducing white streak-like atrophy or hypopigmentation around the treated area.

“When you treat a scar, you treat the features of the scar that make it stand out,” Dr. Ross continued. “If it’s red, you address the hyperemia. If it’s brown, you address the pigment. You want to have a reasonable pathophysiological basis for what you’re doing. Understand how the scar got there and have a reasonable algorithm.” When he counsels patients about clinical outcomes to expect, he emphasizes rehabilitation instead of blemish-free perfection. “It’s not making the scar go away,” he said. “It’s not restoring completely normal skin form and function; it’s a restorative effort to get toward normality. That’s what it’s all about.”

Besides injecting scars with triamcinolone acetate, other scar treatment options include intralesional 5-fluorouracil, oral antihistamines, COX-2 inhibitors, hydrogel sheeting, compression, acoustic wave therapy, photodynamic therapy, radiofrequency, and lasers. “I’m not a big fan of low-level light; it probably does something [to scars], but I’m skeptical,” Dr. Ross said.

In his clinical opinion, most scars respond best to treatments with ablative and nonablative fractional lasers tuned to gentle settings such as an energy level of 20 millijoules at a density of 5%-10%. “Every scar deserves a chance for laser remediation and rehabilitation,” he said. “With radiation scars you want to be particularly gentle. If you have a Mohs scar that has been subsequently treated with radiation, I would lower my settings by half, because I’ve had some scars worsen with settings for red scars after radiation therapy.”

He often uses fractional lasers for stubborn acne scarring. “The hyperemic component you can treat with a vascular laser, then come back [and treat the scarring] with a nonablative fractional laser, or you could use radiofrequency microneedling as well,” Dr. Ross said.

New or innovative scar treatments coming down the pike, he said, include the following: mitomycin C (applied topically, he said that this has worked well for postoperative keloids), tamoxifen, oral methotrexate, imiquimod (which has mixed results to date), platelet-rich plasma, and retinoids.

Dr. Ross disclosed having research and financial ties to numerous pharmaceutical and device companies.

SAN DIEGO – Injecting a scar with intralesional steroids is a popular way to reduce its size and soften the surrounding tissue, but proper technique matters, according to Victor Ross, MD.

“A lot of lip service is paid to how to inject the steroid,” Dr. Ross, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego, said at the annual Masters of Aesthetics Symposium. “The most important part is the amount and the fastidiousness that you have injecting. You should see the tip of the needle and be very slow. Use a 1 cc syringe.” He used to inject scars with triamcinolone acetate 40 mg/mL, but now he almost always injects 10-20 mg/mL to avoid inducing white streak-like atrophy or hypopigmentation around the treated area.

“When you treat a scar, you treat the features of the scar that make it stand out,” Dr. Ross continued. “If it’s red, you address the hyperemia. If it’s brown, you address the pigment. You want to have a reasonable pathophysiological basis for what you’re doing. Understand how the scar got there and have a reasonable algorithm.” When he counsels patients about clinical outcomes to expect, he emphasizes rehabilitation instead of blemish-free perfection. “It’s not making the scar go away,” he said. “It’s not restoring completely normal skin form and function; it’s a restorative effort to get toward normality. That’s what it’s all about.”

Besides injecting scars with triamcinolone acetate, other scar treatment options include intralesional 5-fluorouracil, oral antihistamines, COX-2 inhibitors, hydrogel sheeting, compression, acoustic wave therapy, photodynamic therapy, radiofrequency, and lasers. “I’m not a big fan of low-level light; it probably does something [to scars], but I’m skeptical,” Dr. Ross said.

In his clinical opinion, most scars respond best to treatments with ablative and nonablative fractional lasers tuned to gentle settings such as an energy level of 20 millijoules at a density of 5%-10%. “Every scar deserves a chance for laser remediation and rehabilitation,” he said. “With radiation scars you want to be particularly gentle. If you have a Mohs scar that has been subsequently treated with radiation, I would lower my settings by half, because I’ve had some scars worsen with settings for red scars after radiation therapy.”

He often uses fractional lasers for stubborn acne scarring. “The hyperemic component you can treat with a vascular laser, then come back [and treat the scarring] with a nonablative fractional laser, or you could use radiofrequency microneedling as well,” Dr. Ross said.

New or innovative scar treatments coming down the pike, he said, include the following: mitomycin C (applied topically, he said that this has worked well for postoperative keloids), tamoxifen, oral methotrexate, imiquimod (which has mixed results to date), platelet-rich plasma, and retinoids.

Dr. Ross disclosed having research and financial ties to numerous pharmaceutical and device companies.

SAN DIEGO – Injecting a scar with intralesional steroids is a popular way to reduce its size and soften the surrounding tissue, but proper technique matters, according to Victor Ross, MD.

“A lot of lip service is paid to how to inject the steroid,” Dr. Ross, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego, said at the annual Masters of Aesthetics Symposium. “The most important part is the amount and the fastidiousness that you have injecting. You should see the tip of the needle and be very slow. Use a 1 cc syringe.” He used to inject scars with triamcinolone acetate 40 mg/mL, but now he almost always injects 10-20 mg/mL to avoid inducing white streak-like atrophy or hypopigmentation around the treated area.

“When you treat a scar, you treat the features of the scar that make it stand out,” Dr. Ross continued. “If it’s red, you address the hyperemia. If it’s brown, you address the pigment. You want to have a reasonable pathophysiological basis for what you’re doing. Understand how the scar got there and have a reasonable algorithm.” When he counsels patients about clinical outcomes to expect, he emphasizes rehabilitation instead of blemish-free perfection. “It’s not making the scar go away,” he said. “It’s not restoring completely normal skin form and function; it’s a restorative effort to get toward normality. That’s what it’s all about.”

Besides injecting scars with triamcinolone acetate, other scar treatment options include intralesional 5-fluorouracil, oral antihistamines, COX-2 inhibitors, hydrogel sheeting, compression, acoustic wave therapy, photodynamic therapy, radiofrequency, and lasers. “I’m not a big fan of low-level light; it probably does something [to scars], but I’m skeptical,” Dr. Ross said.

In his clinical opinion, most scars respond best to treatments with ablative and nonablative fractional lasers tuned to gentle settings such as an energy level of 20 millijoules at a density of 5%-10%. “Every scar deserves a chance for laser remediation and rehabilitation,” he said. “With radiation scars you want to be particularly gentle. If you have a Mohs scar that has been subsequently treated with radiation, I would lower my settings by half, because I’ve had some scars worsen with settings for red scars after radiation therapy.”

He often uses fractional lasers for stubborn acne scarring. “The hyperemic component you can treat with a vascular laser, then come back [and treat the scarring] with a nonablative fractional laser, or you could use radiofrequency microneedling as well,” Dr. Ross said.

New or innovative scar treatments coming down the pike, he said, include the following: mitomycin C (applied topically, he said that this has worked well for postoperative keloids), tamoxifen, oral methotrexate, imiquimod (which has mixed results to date), platelet-rich plasma, and retinoids.

Dr. Ross disclosed having research and financial ties to numerous pharmaceutical and device companies.

SAN DIEGO – The need for antibiotic prophylaxis in dermatologic surgery depends on the type of procedure, the patient, what infection you’re trying to keep at bay, and the type of wound, according to Tissa Hata, MD, professor of dermatology at the University of California, San Diego.

Among the many studies in the medical literature that have examined the use of antibiotics to prevent surgical site infections, one study published in 2006 has the largest number of patients to date, Dr. Hata said at a conference on superficial anatomy and cutaneous surgery sponsored by UCSD and Scripps Clinic. In the prospective study of wound infections in patients undergoing dermatologic surgery without prophylactic antibiotics, researchers in Australia prospectively examined 5,091 lesions, mostly nonmelanoma skin cancers, in 2,424 patients over the course of 3 years.

By procedure, the infection rate was highest for skin grafts (8.70%) and wedge excision of the lip or ear (8.57%), followed by skin flap repairs (2.94%), curettage (0.73%), and simple excision and closure (0.54%). By anatomic site, groin excisional surgery had the highest infection rate (10%), followed by surgical procedures below the knee (6.92%), while those performed on the face had a low rate (0.81%). “Based on their analysis, they suggest antibiotic prophylaxis for all procedures below the knee and groin, wedge excisions of the lip and ear, and all skin grafts,” Dr. Hata said.

In 2008, an advisory statement published in the Journal of the American Academy of Dermatology expanded the procedure location and techniques requiring antibiotic prophylaxis to include procedures on the nose and the lower extremity (especially the leg), and for patients with extensive inflammatory disease. According to the statement, in patients without a penicillin allergy, the suggested antibiotic prophylaxis regimen for wedge excision of the lip/ear, flaps on the nose, or all skin grafts include 2 g oral cephalexin or dicloxacillin. In patients with penicillin allergy, the recommended prophylaxis regimen for wedge excision of the lip/ear, flaps on the nose, or all skin grafts include 600 mg oral clindamycin or 500 mg oral azithromycin/clarithromycin.

In the statement, for patients with no penicillin allergy, the suggested prophylaxis regimen for lesions in the groin or on the lower extremities include 2 g oral cephalexin, 1 tablet of oral trimethoprim/sulfamethoxazole (TMP-SMX) DS, or 500 mg of levofloxacin. In patients with penicillin allergy, the recommended prophylaxis regimen for lesions on the groin and lower extremities is 1 tablet of TMP-SMX DS or 500 mg of levofloxacin.

In 2020, a meta-analysis of surgical site infections in patients undergoing Mohs surgery of the ear and nose found that there was no difference in infections in those locations whether patients received oral antibiotic prophylaxis or not. “But the researchers did not specify the type of closure, whether it was a graft or a flap closure,” Dr. Hata commented.

Endocarditis prophylaxis

Dr. Hata also discussed antibiotic recommendations for endocarditis prophylaxis, noting that the mortality rate from endocarditis is as high as 76%, and an estimated 40% of affected patients require heart valve replacement within 5-8 years. “But the good news is that fewer than 10 cases have been possibly linked to dermatologic procedures,” she said.

During outpatient dermatologic surgery, the incidence of bacteremia is in the range of 1.9%-3%, similar to the incidence of 2% that occurs spontaneously in healthy adults, according to Dr. Hata. She said that the following activities or procedures pose a much higher risk of bacteremia: mastication (17%-24%), tooth brushing (24%-40%), tooth extraction (60%-90%), and incision and drainage of an abscess (38%).

American Heart Association guidelines from 2007 recommend antibiotic prophylaxis in only the highest-risk categories of patients. These guidelines were updated in 2017 to include patients with transcatheter prosthetic valves and those with prosthetic material in valve repair. “The primary reason for revision of guidelines is that endocarditis is much more likely to result from frequent exposure to random bacteremia associated with daily activity such as brushing our teeth or having a tooth extracted,” Dr. Hata explained. “Prophylaxis may prevent an exceedingly small number of cases. Authors of the guidelines concluded that the risk of antibiotic-associated adverse event exceeds the benefit of prophylactic therapy, and that maintenance of optimal oral health is more important than prophylactic antibiotics.”

The 2017 AHA guidelines recommend antibiotic prophylaxis in patients with the following cardiac conditions: those with a prosthetic cardiac valve including transcatheter-implanted prostheses and homografts; those with previous endocarditis; those with prosthetic material used for heart valve repair, such as annuloplasty rings, chords or clips; cardiac transplantation recipients who develop cardiac valvulopathy; and those with certain types of congenital heart disease, including unrepaired cyanotic CHD, a completely repaired congenital heart defect with a prosthetic material or device during the first 6 months after the procedure, and repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Procedures that may require prophylaxis for endocarditis include all dental procedures that involve manipulation of the gingival tissue or the periapical region of teeth or perforation of the oral mucosa, and respiratory tract procedures that involve incision or biopsy of the respiratory mucosa such as tonsillectomy or adenoidectomy. Antibiotic prophylaxis is not recommended for procedures involving the gastrointestinal tract or the genitourinary tract unless an active infection is present. As for skin procedures, the guidelines recommend antibiotic prophylaxis for patients in the high-risk category who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue.

In the 2017 AHA guidelines, patients with no penicillin allergy, the suggested antibiotic prophylaxis regimen for endocarditis in non-oral sites includes 2 g oral cephalexin or dicloxacillin, while in patients with penicillin allergy, the suggested prophylaxis for endocarditis in non-oral sites includes 600 mg oral clindamycin or 500 mg oral azithromycin/clarithromycin. In patients without a penicillin allergy, the suggested prophylaxis for endocarditis in oral sites is 2 g oral amoxicillin, while in those with penicillin allergy, the suggested antibiotic prophylaxis for endocarditis in oral sites is 500 mg azithromycin/clarithromycin or doxycycline 100 mg.

“Antibiotic prophylaxis for endocarditis should be given 30-60 minutes prior to surgery, and a follow-up dose of antibiotics is no longer recommended,” Dr. Hata said. “If you forget [to administer the antibiotics] or the patient forgets, antibiotics may be given up to 2 hours after the procedure.”

Dr. Hata reported having no relevant disclosures.

SAN DIEGO – The need for antibiotic prophylaxis in dermatologic surgery depends on the type of procedure, the patient, what infection you’re trying to keep at bay, and the type of wound, according to Tissa Hata, MD, professor of dermatology at the University of California, San Diego.

Among the many studies in the medical literature that have examined the use of antibiotics to prevent surgical site infections, one study published in 2006 has the largest number of patients to date, Dr. Hata said at a conference on superficial anatomy and cutaneous surgery sponsored by UCSD and Scripps Clinic. In the prospective study of wound infections in patients undergoing dermatologic surgery without prophylactic antibiotics, researchers in Australia prospectively examined 5,091 lesions, mostly nonmelanoma skin cancers, in 2,424 patients over the course of 3 years.

By procedure, the infection rate was highest for skin grafts (8.70%) and wedge excision of the lip or ear (8.57%), followed by skin flap repairs (2.94%), curettage (0.73%), and simple excision and closure (0.54%). By anatomic site, groin excisional surgery had the highest infection rate (10%), followed by surgical procedures below the knee (6.92%), while those performed on the face had a low rate (0.81%). “Based on their analysis, they suggest antibiotic prophylaxis for all procedures below the knee and groin, wedge excisions of the lip and ear, and all skin grafts,” Dr. Hata said.

In 2008, an advisory statement published in the Journal of the American Academy of Dermatology expanded the procedure location and techniques requiring antibiotic prophylaxis to include procedures on the nose and the lower extremity (especially the leg), and for patients with extensive inflammatory disease. According to the statement, in patients without a penicillin allergy, the suggested antibiotic prophylaxis regimen for wedge excision of the lip/ear, flaps on the nose, or all skin grafts include 2 g oral cephalexin or dicloxacillin. In patients with penicillin allergy, the recommended prophylaxis regimen for wedge excision of the lip/ear, flaps on the nose, or all skin grafts include 600 mg oral clindamycin or 500 mg oral azithromycin/clarithromycin.

In the statement, for patients with no penicillin allergy, the suggested prophylaxis regimen for lesions in the groin or on the lower extremities include 2 g oral cephalexin, 1 tablet of oral trimethoprim/sulfamethoxazole (TMP-SMX) DS, or 500 mg of levofloxacin. In patients with penicillin allergy, the recommended prophylaxis regimen for lesions on the groin and lower extremities is 1 tablet of TMP-SMX DS or 500 mg of levofloxacin.

In 2020, a meta-analysis of surgical site infections in patients undergoing Mohs surgery of the ear and nose found that there was no difference in infections in those locations whether patients received oral antibiotic prophylaxis or not. “But the researchers did not specify the type of closure, whether it was a graft or a flap closure,” Dr. Hata commented.

Endocarditis prophylaxis

Dr. Hata also discussed antibiotic recommendations for endocarditis prophylaxis, noting that the mortality rate from endocarditis is as high as 76%, and an estimated 40% of affected patients require heart valve replacement within 5-8 years. “But the good news is that fewer than 10 cases have been possibly linked to dermatologic procedures,” she said.

During outpatient dermatologic surgery, the incidence of bacteremia is in the range of 1.9%-3%, similar to the incidence of 2% that occurs spontaneously in healthy adults, according to Dr. Hata. She said that the following activities or procedures pose a much higher risk of bacteremia: mastication (17%-24%), tooth brushing (24%-40%), tooth extraction (60%-90%), and incision and drainage of an abscess (38%).

American Heart Association guidelines from 2007 recommend antibiotic prophylaxis in only the highest-risk categories of patients. These guidelines were updated in 2017 to include patients with transcatheter prosthetic valves and those with prosthetic material in valve repair. “The primary reason for revision of guidelines is that endocarditis is much more likely to result from frequent exposure to random bacteremia associated with daily activity such as brushing our teeth or having a tooth extracted,” Dr. Hata explained. “Prophylaxis may prevent an exceedingly small number of cases. Authors of the guidelines concluded that the risk of antibiotic-associated adverse event exceeds the benefit of prophylactic therapy, and that maintenance of optimal oral health is more important than prophylactic antibiotics.”

The 2017 AHA guidelines recommend antibiotic prophylaxis in patients with the following cardiac conditions: those with a prosthetic cardiac valve including transcatheter-implanted prostheses and homografts; those with previous endocarditis; those with prosthetic material used for heart valve repair, such as annuloplasty rings, chords or clips; cardiac transplantation recipients who develop cardiac valvulopathy; and those with certain types of congenital heart disease, including unrepaired cyanotic CHD, a completely repaired congenital heart defect with a prosthetic material or device during the first 6 months after the procedure, and repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Procedures that may require prophylaxis for endocarditis include all dental procedures that involve manipulation of the gingival tissue or the periapical region of teeth or perforation of the oral mucosa, and respiratory tract procedures that involve incision or biopsy of the respiratory mucosa such as tonsillectomy or adenoidectomy. Antibiotic prophylaxis is not recommended for procedures involving the gastrointestinal tract or the genitourinary tract unless an active infection is present. As for skin procedures, the guidelines recommend antibiotic prophylaxis for patients in the high-risk category who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue.

In the 2017 AHA guidelines, patients with no penicillin allergy, the suggested antibiotic prophylaxis regimen for endocarditis in non-oral sites includes 2 g oral cephalexin or dicloxacillin, while in patients with penicillin allergy, the suggested prophylaxis for endocarditis in non-oral sites includes 600 mg oral clindamycin or 500 mg oral azithromycin/clarithromycin. In patients without a penicillin allergy, the suggested prophylaxis for endocarditis in oral sites is 2 g oral amoxicillin, while in those with penicillin allergy, the suggested antibiotic prophylaxis for endocarditis in oral sites is 500 mg azithromycin/clarithromycin or doxycycline 100 mg.

“Antibiotic prophylaxis for endocarditis should be given 30-60 minutes prior to surgery, and a follow-up dose of antibiotics is no longer recommended,” Dr. Hata said. “If you forget [to administer the antibiotics] or the patient forgets, antibiotics may be given up to 2 hours after the procedure.”

Dr. Hata reported having no relevant disclosures.

SAN DIEGO – The need for antibiotic prophylaxis in dermatologic surgery depends on the type of procedure, the patient, what infection you’re trying to keep at bay, and the type of wound, according to Tissa Hata, MD, professor of dermatology at the University of California, San Diego.

Among the many studies in the medical literature that have examined the use of antibiotics to prevent surgical site infections, one study published in 2006 has the largest number of patients to date, Dr. Hata said at a conference on superficial anatomy and cutaneous surgery sponsored by UCSD and Scripps Clinic. In the prospective study of wound infections in patients undergoing dermatologic surgery without prophylactic antibiotics, researchers in Australia prospectively examined 5,091 lesions, mostly nonmelanoma skin cancers, in 2,424 patients over the course of 3 years.

By procedure, the infection rate was highest for skin grafts (8.70%) and wedge excision of the lip or ear (8.57%), followed by skin flap repairs (2.94%), curettage (0.73%), and simple excision and closure (0.54%). By anatomic site, groin excisional surgery had the highest infection rate (10%), followed by surgical procedures below the knee (6.92%), while those performed on the face had a low rate (0.81%). “Based on their analysis, they suggest antibiotic prophylaxis for all procedures below the knee and groin, wedge excisions of the lip and ear, and all skin grafts,” Dr. Hata said.

In 2008, an advisory statement published in the Journal of the American Academy of Dermatology expanded the procedure location and techniques requiring antibiotic prophylaxis to include procedures on the nose and the lower extremity (especially the leg), and for patients with extensive inflammatory disease. According to the statement, in patients without a penicillin allergy, the suggested antibiotic prophylaxis regimen for wedge excision of the lip/ear, flaps on the nose, or all skin grafts include 2 g oral cephalexin or dicloxacillin. In patients with penicillin allergy, the recommended prophylaxis regimen for wedge excision of the lip/ear, flaps on the nose, or all skin grafts include 600 mg oral clindamycin or 500 mg oral azithromycin/clarithromycin.

In the statement, for patients with no penicillin allergy, the suggested prophylaxis regimen for lesions in the groin or on the lower extremities include 2 g oral cephalexin, 1 tablet of oral trimethoprim/sulfamethoxazole (TMP-SMX) DS, or 500 mg of levofloxacin. In patients with penicillin allergy, the recommended prophylaxis regimen for lesions on the groin and lower extremities is 1 tablet of TMP-SMX DS or 500 mg of levofloxacin.

In 2020, a meta-analysis of surgical site infections in patients undergoing Mohs surgery of the ear and nose found that there was no difference in infections in those locations whether patients received oral antibiotic prophylaxis or not. “But the researchers did not specify the type of closure, whether it was a graft or a flap closure,” Dr. Hata commented.

Endocarditis prophylaxis

Dr. Hata also discussed antibiotic recommendations for endocarditis prophylaxis, noting that the mortality rate from endocarditis is as high as 76%, and an estimated 40% of affected patients require heart valve replacement within 5-8 years. “But the good news is that fewer than 10 cases have been possibly linked to dermatologic procedures,” she said.

During outpatient dermatologic surgery, the incidence of bacteremia is in the range of 1.9%-3%, similar to the incidence of 2% that occurs spontaneously in healthy adults, according to Dr. Hata. She said that the following activities or procedures pose a much higher risk of bacteremia: mastication (17%-24%), tooth brushing (24%-40%), tooth extraction (60%-90%), and incision and drainage of an abscess (38%).

American Heart Association guidelines from 2007 recommend antibiotic prophylaxis in only the highest-risk categories of patients. These guidelines were updated in 2017 to include patients with transcatheter prosthetic valves and those with prosthetic material in valve repair. “The primary reason for revision of guidelines is that endocarditis is much more likely to result from frequent exposure to random bacteremia associated with daily activity such as brushing our teeth or having a tooth extracted,” Dr. Hata explained. “Prophylaxis may prevent an exceedingly small number of cases. Authors of the guidelines concluded that the risk of antibiotic-associated adverse event exceeds the benefit of prophylactic therapy, and that maintenance of optimal oral health is more important than prophylactic antibiotics.”

The 2017 AHA guidelines recommend antibiotic prophylaxis in patients with the following cardiac conditions: those with a prosthetic cardiac valve including transcatheter-implanted prostheses and homografts; those with previous endocarditis; those with prosthetic material used for heart valve repair, such as annuloplasty rings, chords or clips; cardiac transplantation recipients who develop cardiac valvulopathy; and those with certain types of congenital heart disease, including unrepaired cyanotic CHD, a completely repaired congenital heart defect with a prosthetic material or device during the first 6 months after the procedure, and repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Procedures that may require prophylaxis for endocarditis include all dental procedures that involve manipulation of the gingival tissue or the periapical region of teeth or perforation of the oral mucosa, and respiratory tract procedures that involve incision or biopsy of the respiratory mucosa such as tonsillectomy or adenoidectomy. Antibiotic prophylaxis is not recommended for procedures involving the gastrointestinal tract or the genitourinary tract unless an active infection is present. As for skin procedures, the guidelines recommend antibiotic prophylaxis for patients in the high-risk category who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue.

In the 2017 AHA guidelines, patients with no penicillin allergy, the suggested antibiotic prophylaxis regimen for endocarditis in non-oral sites includes 2 g oral cephalexin or dicloxacillin, while in patients with penicillin allergy, the suggested prophylaxis for endocarditis in non-oral sites includes 600 mg oral clindamycin or 500 mg oral azithromycin/clarithromycin. In patients without a penicillin allergy, the suggested prophylaxis for endocarditis in oral sites is 2 g oral amoxicillin, while in those with penicillin allergy, the suggested antibiotic prophylaxis for endocarditis in oral sites is 500 mg azithromycin/clarithromycin or doxycycline 100 mg.

“Antibiotic prophylaxis for endocarditis should be given 30-60 minutes prior to surgery, and a follow-up dose of antibiotics is no longer recommended,” Dr. Hata said. “If you forget [to administer the antibiotics] or the patient forgets, antibiotics may be given up to 2 hours after the procedure.”

Dr. Hata reported having no relevant disclosures.