Dermatologic Surgery

WAIKOLOA, HAWAII – Every dermatologic surgeon ought to have at hand a wide array of techniques for improving surgical scars, according to American Academy of Dermatology President-elect George J. Hruza, MD – and he’s got a raft of them.

Bruce Jancin/MDedge News

“There are going to be situations where your scars aren’t going to be as wonderful as you’d like, or even if they’re pretty good, you might improve them further if you do some modifications,” he observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He became convinced of the importance of having a large toolbox for scar improvement in part as a result of an Australian prospective study of 576 patients surveyed 6-9 months following skin cancer surgery. Far and away the most important factor influencing patients’ overall perception of their experience wasn’t the cost, pain, quality of nursing care, complications, wait time prior to surgery, or gratitude that they’d successfully had a cancer removed. It was their perception of the scar (J Am Acad Dermatol. 2007 Sep;57[3]:445-53).

To be effective, interventions for scar improvement need to be timed in sync with the three phases of cellular activity involved in wound healing. For example, neurotoxin injections are effective during the first few days of the initial acute inflammation period, when cellular migration is active. Silicone and taping are of value when employed long term, starting at about 1 month and continuing for 3-6 months, throughout the neovascularization/granulation phase, then the time of fibroblast proliferation and matrix formation that follows, and even beyond. Pulsed dye and fractionated ablative lasers are best utilized to reshape matrix formation, starting at about 2 weeks. Intervention using dermabrasion or fillers has to wait for the scar to be a bit more mature, at about 2 months; utilized earlier these can cause dehiscence, explained Dr. Hruza of St. Louis University.

He shared what he called his “scar improvement hierarchy,” the sequence of interventions he turns to from the most to least often. But he began with prevention, noting that more than 2 decades ago, he and his coinvestigators demonstrated that running horizontal mattress sutures for primary closures of facial wounds provide better cosmetic results, with a final scar that’s smoother and flatter than the more commonly used simple running sutures (Dermatol Surg. 2005 Oct;31[10]:1313-6).
 

Scar improvement sequence

Massage. “I recommend this to almost every patient. I have them start at about 6 weeks and do it for several months. It’s really more like kneading dough, not rubbing. You want the skin pressing on the bone underneath,” according to Dr. Hruza. Various investigators have suggested that scar massage works by increasing hydration and capillary proliferation, while promoting desensitization, but the evidence is really anecdotal.

“I think it’s mainly tincture of time. Scars get better on their own,” he observed. Regardless, massage allows patients the satisfaction of actively participating in their own recovery.

Intralesional triamcinolone. Dr. Hruza calls this “our big friend.”

“I find that 90% of the time when you look at a thickened scar and you think, ‘Oh gee, I’m going to have to do some scar revision, the intralesional triamcinolone takes care of the problem,” he said. He usually injects the site at about 6 weeks post surgery using 10 mg/mL. If the response is inadequate he reinjects about a month later using 20 mg/mL. He generally avoids going to 40 mg/mL for facial scars. The goal is to make therapeutic use of the steroid’s major side effect – atrophy – to shrink the thickened scar. But because this can be a tricky business, of late he has turned increasingly to intralesional triamcinolone and 5-fluorouracil (5-FU).

Intralesional triamcinolone plus 5-FU. This combination causes less atrophy, hypopigmentation, and telangiectasias than full-on triamcinolone. He injects 0.9 mL of 5-FU at 50 mg/mL and 0.1 mL of triamcinolone at 40 mg/mL into and under the scar. The 5-FU inhibits fibroblast proliferation. It is rated pregnancy category D, so he avoids using it in women of childbearing age.

Spot dermabrasion. “To me, this is the go-to. After my intralesional steroids, if the scar hasn’t fully smoothed out, then I go to dermabrasion or the spot CO₂ laser,” Dr. Hruza said.

“Dermabrasion is an old technology, but it’s actually still very useful,” he continued. “Do it at 6-10 weeks; that’s the sweet spot. Do it sooner and you can get into problems with dehiscence. And if you do it later than 10 weeks the improvement is much less because everything is stabilized and the collagen is set.” He uses a diamond fraise to abrade and sculpt, rather than sandpaper, which doesn’t allow him to go sufficiently deep once bleeding starts and the sandpaper gets wet.

Spot conventional CO₂ or Er:YAG laser resurfacing. “I really find in my hands these ablative techniques are much more effective than using a fractionated laser, which only gives you a little bit of improvement,” he said.

Pulsed dye laser. Very effective for red, thickened scars. Dr. Hruza does two to four treatments at 4-week intervals. At wavelengths of 585-595 nm, a pulse of 0.5-1.5 millisecs, and 4-5 Joules/cm², there is only minimal purpura.

The pulsed dye laser can also be employed preventively starting at the time of suture removal and then again at 4-6 weeks in order to reduce hypertrophy. “It’s something to consider in areas like the chest, upper back, and shoulders, where you’re trying to prevent problems. The only danger is occasionally patients have dehiscence,” according to the dermatologic surgeon.

Fractionated nonablative laser. Four or five treatments are typically required in order to achieve significant resurfacing.

Micropore tape. Dr. Hruza finds this works just as well as topical silicone gel sheets, rolls, and gels, all of which are quite expensive. A roll of micropore tape costs only a few dollars and will last a patient for a couple months. Patients are taught to apply the tape at the time of suture removal in a line parallel to the suture line, replacing the tape when it begins to peel off. As with the vastly more expensive silicone products, the tape needs to be left on 12-24 hours per day for 3-6 months in order to achieve a flat white scar. The benefit is thought to come from relief of mechanical stress coupled with occlusion.

Botulinum toxin A and other neurotoxins. Inject into muscle near the wound edges right after closing the wound, using 1-3 units at 1- to 3-cm intervals in order to prevent scar formation, Dr. Hruza advised. If the wound is on one side of the face, the other side needs to receive injections as well in order to spare the patient from several months of cosmetically undesirable asymmetry. However, Dr. Hruza rarely utilizes neurotoxin injections. “It’s a cost issue. I’m in the Midwest, where a lot of insurers are unwilling to pay for it,” he explained.

Flap defatting. Here the surgeon opens the flap and keeps digging with scalpel and scissors until the scar is slightly depressed, since there is likely to be some recurrence. Then it’s time to resuture the flap.

Technical scar revision procedures. The simplest of these is Z-plasty, which entails making two skin incisions to create a Z-shaped incision, then flipping the two sides to reorient the scar. The Z-plasty has two major uses: correction of a retracted lip or medial canthus webbing. “If you get either of these, Z-plasty is the way to go,” Dr. Hruza said.

Fillers for atrophic scars. “To me, this is the last thing to go to. The reason is that, if a patient has skin cancer surgery, they don’t expect to pay extra to improve that scar. And I can do dermabrasion with no incremental product cost to the practice,” he commented. The technique entails making a subcision to create a pocket for the filler. The products marketed as Restylane Silk, Belotero, and Radiesse all yield good results, he said.

Dr. Hruza reported having no financial conflicts of interest regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]
 

WAIKOLOA, HAWAII – Every dermatologic surgeon ought to have at hand a wide array of techniques for improving surgical scars, according to American Academy of Dermatology President-elect George J. Hruza, MD – and he’s got a raft of them.

Bruce Jancin/MDedge News

“There are going to be situations where your scars aren’t going to be as wonderful as you’d like, or even if they’re pretty good, you might improve them further if you do some modifications,” he observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He became convinced of the importance of having a large toolbox for scar improvement in part as a result of an Australian prospective study of 576 patients surveyed 6-9 months following skin cancer surgery. Far and away the most important factor influencing patients’ overall perception of their experience wasn’t the cost, pain, quality of nursing care, complications, wait time prior to surgery, or gratitude that they’d successfully had a cancer removed. It was their perception of the scar (J Am Acad Dermatol. 2007 Sep;57[3]:445-53).

To be effective, interventions for scar improvement need to be timed in sync with the three phases of cellular activity involved in wound healing. For example, neurotoxin injections are effective during the first few days of the initial acute inflammation period, when cellular migration is active. Silicone and taping are of value when employed long term, starting at about 1 month and continuing for 3-6 months, throughout the neovascularization/granulation phase, then the time of fibroblast proliferation and matrix formation that follows, and even beyond. Pulsed dye and fractionated ablative lasers are best utilized to reshape matrix formation, starting at about 2 weeks. Intervention using dermabrasion or fillers has to wait for the scar to be a bit more mature, at about 2 months; utilized earlier these can cause dehiscence, explained Dr. Hruza of St. Louis University.

He shared what he called his “scar improvement hierarchy,” the sequence of interventions he turns to from the most to least often. But he began with prevention, noting that more than 2 decades ago, he and his coinvestigators demonstrated that running horizontal mattress sutures for primary closures of facial wounds provide better cosmetic results, with a final scar that’s smoother and flatter than the more commonly used simple running sutures (Dermatol Surg. 2005 Oct;31[10]:1313-6).
 

Scar improvement sequence

Massage. “I recommend this to almost every patient. I have them start at about 6 weeks and do it for several months. It’s really more like kneading dough, not rubbing. You want the skin pressing on the bone underneath,” according to Dr. Hruza. Various investigators have suggested that scar massage works by increasing hydration and capillary proliferation, while promoting desensitization, but the evidence is really anecdotal.

“I think it’s mainly tincture of time. Scars get better on their own,” he observed. Regardless, massage allows patients the satisfaction of actively participating in their own recovery.

Intralesional triamcinolone. Dr. Hruza calls this “our big friend.”

“I find that 90% of the time when you look at a thickened scar and you think, ‘Oh gee, I’m going to have to do some scar revision, the intralesional triamcinolone takes care of the problem,” he said. He usually injects the site at about 6 weeks post surgery using 10 mg/mL. If the response is inadequate he reinjects about a month later using 20 mg/mL. He generally avoids going to 40 mg/mL for facial scars. The goal is to make therapeutic use of the steroid’s major side effect – atrophy – to shrink the thickened scar. But because this can be a tricky business, of late he has turned increasingly to intralesional triamcinolone and 5-fluorouracil (5-FU).

Intralesional triamcinolone plus 5-FU. This combination causes less atrophy, hypopigmentation, and telangiectasias than full-on triamcinolone. He injects 0.9 mL of 5-FU at 50 mg/mL and 0.1 mL of triamcinolone at 40 mg/mL into and under the scar. The 5-FU inhibits fibroblast proliferation. It is rated pregnancy category D, so he avoids using it in women of childbearing age.

Spot dermabrasion. “To me, this is the go-to. After my intralesional steroids, if the scar hasn’t fully smoothed out, then I go to dermabrasion or the spot CO₂ laser,” Dr. Hruza said.

“Dermabrasion is an old technology, but it’s actually still very useful,” he continued. “Do it at 6-10 weeks; that’s the sweet spot. Do it sooner and you can get into problems with dehiscence. And if you do it later than 10 weeks the improvement is much less because everything is stabilized and the collagen is set.” He uses a diamond fraise to abrade and sculpt, rather than sandpaper, which doesn’t allow him to go sufficiently deep once bleeding starts and the sandpaper gets wet.

Spot conventional CO₂ or Er:YAG laser resurfacing. “I really find in my hands these ablative techniques are much more effective than using a fractionated laser, which only gives you a little bit of improvement,” he said.

Pulsed dye laser. Very effective for red, thickened scars. Dr. Hruza does two to four treatments at 4-week intervals. At wavelengths of 585-595 nm, a pulse of 0.5-1.5 millisecs, and 4-5 Joules/cm², there is only minimal purpura.

The pulsed dye laser can also be employed preventively starting at the time of suture removal and then again at 4-6 weeks in order to reduce hypertrophy. “It’s something to consider in areas like the chest, upper back, and shoulders, where you’re trying to prevent problems. The only danger is occasionally patients have dehiscence,” according to the dermatologic surgeon.

Fractionated nonablative laser. Four or five treatments are typically required in order to achieve significant resurfacing.

Micropore tape. Dr. Hruza finds this works just as well as topical silicone gel sheets, rolls, and gels, all of which are quite expensive. A roll of micropore tape costs only a few dollars and will last a patient for a couple months. Patients are taught to apply the tape at the time of suture removal in a line parallel to the suture line, replacing the tape when it begins to peel off. As with the vastly more expensive silicone products, the tape needs to be left on 12-24 hours per day for 3-6 months in order to achieve a flat white scar. The benefit is thought to come from relief of mechanical stress coupled with occlusion.

Botulinum toxin A and other neurotoxins. Inject into muscle near the wound edges right after closing the wound, using 1-3 units at 1- to 3-cm intervals in order to prevent scar formation, Dr. Hruza advised. If the wound is on one side of the face, the other side needs to receive injections as well in order to spare the patient from several months of cosmetically undesirable asymmetry. However, Dr. Hruza rarely utilizes neurotoxin injections. “It’s a cost issue. I’m in the Midwest, where a lot of insurers are unwilling to pay for it,” he explained.

Flap defatting. Here the surgeon opens the flap and keeps digging with scalpel and scissors until the scar is slightly depressed, since there is likely to be some recurrence. Then it’s time to resuture the flap.

Technical scar revision procedures. The simplest of these is Z-plasty, which entails making two skin incisions to create a Z-shaped incision, then flipping the two sides to reorient the scar. The Z-plasty has two major uses: correction of a retracted lip or medial canthus webbing. “If you get either of these, Z-plasty is the way to go,” Dr. Hruza said.

Fillers for atrophic scars. “To me, this is the last thing to go to. The reason is that, if a patient has skin cancer surgery, they don’t expect to pay extra to improve that scar. And I can do dermabrasion with no incremental product cost to the practice,” he commented. The technique entails making a subcision to create a pocket for the filler. The products marketed as Restylane Silk, Belotero, and Radiesse all yield good results, he said.

Dr. Hruza reported having no financial conflicts of interest regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]
 

WAIKOLOA, HAWAII – Every dermatologic surgeon ought to have at hand a wide array of techniques for improving surgical scars, according to American Academy of Dermatology President-elect George J. Hruza, MD – and he’s got a raft of them.

Bruce Jancin/MDedge News

“There are going to be situations where your scars aren’t going to be as wonderful as you’d like, or even if they’re pretty good, you might improve them further if you do some modifications,” he observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He became convinced of the importance of having a large toolbox for scar improvement in part as a result of an Australian prospective study of 576 patients surveyed 6-9 months following skin cancer surgery. Far and away the most important factor influencing patients’ overall perception of their experience wasn’t the cost, pain, quality of nursing care, complications, wait time prior to surgery, or gratitude that they’d successfully had a cancer removed. It was their perception of the scar (J Am Acad Dermatol. 2007 Sep;57[3]:445-53).

To be effective, interventions for scar improvement need to be timed in sync with the three phases of cellular activity involved in wound healing. For example, neurotoxin injections are effective during the first few days of the initial acute inflammation period, when cellular migration is active. Silicone and taping are of value when employed long term, starting at about 1 month and continuing for 3-6 months, throughout the neovascularization/granulation phase, then the time of fibroblast proliferation and matrix formation that follows, and even beyond. Pulsed dye and fractionated ablative lasers are best utilized to reshape matrix formation, starting at about 2 weeks. Intervention using dermabrasion or fillers has to wait for the scar to be a bit more mature, at about 2 months; utilized earlier these can cause dehiscence, explained Dr. Hruza of St. Louis University.

He shared what he called his “scar improvement hierarchy,” the sequence of interventions he turns to from the most to least often. But he began with prevention, noting that more than 2 decades ago, he and his coinvestigators demonstrated that running horizontal mattress sutures for primary closures of facial wounds provide better cosmetic results, with a final scar that’s smoother and flatter than the more commonly used simple running sutures (Dermatol Surg. 2005 Oct;31[10]:1313-6).
 

Scar improvement sequence

Massage. “I recommend this to almost every patient. I have them start at about 6 weeks and do it for several months. It’s really more like kneading dough, not rubbing. You want the skin pressing on the bone underneath,” according to Dr. Hruza. Various investigators have suggested that scar massage works by increasing hydration and capillary proliferation, while promoting desensitization, but the evidence is really anecdotal.

“I think it’s mainly tincture of time. Scars get better on their own,” he observed. Regardless, massage allows patients the satisfaction of actively participating in their own recovery.

Intralesional triamcinolone. Dr. Hruza calls this “our big friend.”

“I find that 90% of the time when you look at a thickened scar and you think, ‘Oh gee, I’m going to have to do some scar revision, the intralesional triamcinolone takes care of the problem,” he said. He usually injects the site at about 6 weeks post surgery using 10 mg/mL. If the response is inadequate he reinjects about a month later using 20 mg/mL. He generally avoids going to 40 mg/mL for facial scars. The goal is to make therapeutic use of the steroid’s major side effect – atrophy – to shrink the thickened scar. But because this can be a tricky business, of late he has turned increasingly to intralesional triamcinolone and 5-fluorouracil (5-FU).

Intralesional triamcinolone plus 5-FU. This combination causes less atrophy, hypopigmentation, and telangiectasias than full-on triamcinolone. He injects 0.9 mL of 5-FU at 50 mg/mL and 0.1 mL of triamcinolone at 40 mg/mL into and under the scar. The 5-FU inhibits fibroblast proliferation. It is rated pregnancy category D, so he avoids using it in women of childbearing age.

Spot dermabrasion. “To me, this is the go-to. After my intralesional steroids, if the scar hasn’t fully smoothed out, then I go to dermabrasion or the spot CO₂ laser,” Dr. Hruza said.

“Dermabrasion is an old technology, but it’s actually still very useful,” he continued. “Do it at 6-10 weeks; that’s the sweet spot. Do it sooner and you can get into problems with dehiscence. And if you do it later than 10 weeks the improvement is much less because everything is stabilized and the collagen is set.” He uses a diamond fraise to abrade and sculpt, rather than sandpaper, which doesn’t allow him to go sufficiently deep once bleeding starts and the sandpaper gets wet.

Spot conventional CO₂ or Er:YAG laser resurfacing. “I really find in my hands these ablative techniques are much more effective than using a fractionated laser, which only gives you a little bit of improvement,” he said.

Pulsed dye laser. Very effective for red, thickened scars. Dr. Hruza does two to four treatments at 4-week intervals. At wavelengths of 585-595 nm, a pulse of 0.5-1.5 millisecs, and 4-5 Joules/cm², there is only minimal purpura.

The pulsed dye laser can also be employed preventively starting at the time of suture removal and then again at 4-6 weeks in order to reduce hypertrophy. “It’s something to consider in areas like the chest, upper back, and shoulders, where you’re trying to prevent problems. The only danger is occasionally patients have dehiscence,” according to the dermatologic surgeon.

Fractionated nonablative laser. Four or five treatments are typically required in order to achieve significant resurfacing.

Micropore tape. Dr. Hruza finds this works just as well as topical silicone gel sheets, rolls, and gels, all of which are quite expensive. A roll of micropore tape costs only a few dollars and will last a patient for a couple months. Patients are taught to apply the tape at the time of suture removal in a line parallel to the suture line, replacing the tape when it begins to peel off. As with the vastly more expensive silicone products, the tape needs to be left on 12-24 hours per day for 3-6 months in order to achieve a flat white scar. The benefit is thought to come from relief of mechanical stress coupled with occlusion.

Botulinum toxin A and other neurotoxins. Inject into muscle near the wound edges right after closing the wound, using 1-3 units at 1- to 3-cm intervals in order to prevent scar formation, Dr. Hruza advised. If the wound is on one side of the face, the other side needs to receive injections as well in order to spare the patient from several months of cosmetically undesirable asymmetry. However, Dr. Hruza rarely utilizes neurotoxin injections. “It’s a cost issue. I’m in the Midwest, where a lot of insurers are unwilling to pay for it,” he explained.

Flap defatting. Here the surgeon opens the flap and keeps digging with scalpel and scissors until the scar is slightly depressed, since there is likely to be some recurrence. Then it’s time to resuture the flap.

Technical scar revision procedures. The simplest of these is Z-plasty, which entails making two skin incisions to create a Z-shaped incision, then flipping the two sides to reorient the scar. The Z-plasty has two major uses: correction of a retracted lip or medial canthus webbing. “If you get either of these, Z-plasty is the way to go,” Dr. Hruza said.

Fillers for atrophic scars. “To me, this is the last thing to go to. The reason is that, if a patient has skin cancer surgery, they don’t expect to pay extra to improve that scar. And I can do dermabrasion with no incremental product cost to the practice,” he commented. The technique entails making a subcision to create a pocket for the filler. The products marketed as Restylane Silk, Belotero, and Radiesse all yield good results, he said.

Dr. Hruza reported having no financial conflicts of interest regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]
 

WASHINGTON – The 31-gene expression profile test has met the highest level of evidence under the Strength of Recommendation Taxonomy (SORT) method as a prognostic marker for accurately predicting recurrence-free survival and distant metastasis-free survival and melanoma-specific survival, according to results presented by Bradley N. Greenhaw, MD, at a late-breaking research session at the annual meeting of the American Academy of Dermatology.

Dr. Greenhaw, a dermatologist affiliated with the North Mississippi Medical Center-Tupelo, and his colleagues pooled together 1,268 patients from the following studies that analyzed results from melanoma patients who had their disease classified with the 31-gene expression profile (31-GEP) test.

• A single-center study, conducted by Dr. Greenhaw and his associates (Greenhaw BN et al. Dermatol Surg. 2018 Dec. doi: 10.1097/DSS.0000000000001588.
• A multicenter prospective study (J Hematol Oncol. 2017 Aug. doi: 10.1186/s13045-017-0520-1.
• A retrospective archival study (J Am Acad Dermatol. 2019 Jan. doi: 10.1016/j.jaad.2018.07.028.

The 31-GEP test stratifies an individual’s likelihood of developing metastasis within 5 years as low and high risk. In the three studies, the test was used to identify tumors with low-risk (class 1A, class 1B), higher-risk (class 2A), and highest-risk (class 2B) melanoma based on tumor gene expression. In these individual studies, class 2B melanoma independently predicted recurrence-free survival (RFS), distant metastasis–free, and melanoma-specific survival.

Dr. Greenhaw and colleagues performed a meta-analysis of 1,268 patients with stage I through stage III melanoma from those three studies, using fixed and random effects weighting to account for study differences and heterogeneity, respectively. For class 2B tumors, they found a 2.96 increased risk for recurrent metastases and a 2.88 increased risk for distant metastases. The researchers also found no heterogeneity across the studies.

Melanoma-specific survival was not included in the meta-analysis because one paper did not contain any mortality events in class 1A melanoma patients.

“The meta-analysis demonstrated that the GEP test was able to accurately identify those melanoma patients who were at higher risk of metastasis, and we saw a consistent effect across multiple studies,” Dr. Greenhaw said.

Since publication of the 2019 JAAD paper, there were an additional 211 patients who met inclusion criteria and were included in an additional meta-analysis to determine whether inclusion of these patients affected the results. Dr. Greenhaw and colleagues found a 91.4% recurrence-free survival rate and a 94.1% distant metastasis–free survival rate for class 1A melanomas, compared with 45.7% and 55.5% , respectively, for class 2B tumors.

“You can see a big divergence,” Dr. Greenhaw said at the meeting. “Just by using this one test, it’s able to separate out melanomas that otherwise may be grouped in together under current AJCC [American Joint Committee on Cancer] staging,” he added. “The class 2B designation really did confirm a higher risk for recurrence in distant metastasis.”

The researchers used the SORT method to rate the quality of the data across all three studies. Level 1 evidence under the SORT method represents a systematic review or meta-analysis of good-quality studies and/or a prospective study with good follow-up, while an A-level recommendation represents good, quality evidence. Based on the meta-analysis results, the 31-GEP test meets level 1A evidence under the SORT method, Dr. Greenhaw said.

As a prognostic tool, 31-GEP has the potential to change how dermatologists manage their patients with regard to follow-up and adjuvant therapy. “It is being used not just as this novel test that gives us more information, it’s being used clinically,” said Dr. Greenhaw, who noted he regularly uses the 31-GEP test in his practice.

This is the first time that a meta-analysis has been performed for this test, he noted.

Dr. Greenhaw reports a pending relationship with Castle Biosciences.

SOURCE: Greenhaw BN et al. AAD 19. Session F055, Abstract 11370.

WASHINGTON – The 31-gene expression profile test has met the highest level of evidence under the Strength of Recommendation Taxonomy (SORT) method as a prognostic marker for accurately predicting recurrence-free survival and distant metastasis-free survival and melanoma-specific survival, according to results presented by Bradley N. Greenhaw, MD, at a late-breaking research session at the annual meeting of the American Academy of Dermatology.

Dr. Greenhaw, a dermatologist affiliated with the North Mississippi Medical Center-Tupelo, and his colleagues pooled together 1,268 patients from the following studies that analyzed results from melanoma patients who had their disease classified with the 31-gene expression profile (31-GEP) test.

• A single-center study, conducted by Dr. Greenhaw and his associates (Greenhaw BN et al. Dermatol Surg. 2018 Dec. doi: 10.1097/DSS.0000000000001588.
• A multicenter prospective study (J Hematol Oncol. 2017 Aug. doi: 10.1186/s13045-017-0520-1.
• A retrospective archival study (J Am Acad Dermatol. 2019 Jan. doi: 10.1016/j.jaad.2018.07.028.

The 31-GEP test stratifies an individual’s likelihood of developing metastasis within 5 years as low and high risk. In the three studies, the test was used to identify tumors with low-risk (class 1A, class 1B), higher-risk (class 2A), and highest-risk (class 2B) melanoma based on tumor gene expression. In these individual studies, class 2B melanoma independently predicted recurrence-free survival (RFS), distant metastasis–free, and melanoma-specific survival.

Dr. Greenhaw and colleagues performed a meta-analysis of 1,268 patients with stage I through stage III melanoma from those three studies, using fixed and random effects weighting to account for study differences and heterogeneity, respectively. For class 2B tumors, they found a 2.96 increased risk for recurrent metastases and a 2.88 increased risk for distant metastases. The researchers also found no heterogeneity across the studies.

Melanoma-specific survival was not included in the meta-analysis because one paper did not contain any mortality events in class 1A melanoma patients.

“The meta-analysis demonstrated that the GEP test was able to accurately identify those melanoma patients who were at higher risk of metastasis, and we saw a consistent effect across multiple studies,” Dr. Greenhaw said.

Since publication of the 2019 JAAD paper, there were an additional 211 patients who met inclusion criteria and were included in an additional meta-analysis to determine whether inclusion of these patients affected the results. Dr. Greenhaw and colleagues found a 91.4% recurrence-free survival rate and a 94.1% distant metastasis–free survival rate for class 1A melanomas, compared with 45.7% and 55.5% , respectively, for class 2B tumors.

“You can see a big divergence,” Dr. Greenhaw said at the meeting. “Just by using this one test, it’s able to separate out melanomas that otherwise may be grouped in together under current AJCC [American Joint Committee on Cancer] staging,” he added. “The class 2B designation really did confirm a higher risk for recurrence in distant metastasis.”

The researchers used the SORT method to rate the quality of the data across all three studies. Level 1 evidence under the SORT method represents a systematic review or meta-analysis of good-quality studies and/or a prospective study with good follow-up, while an A-level recommendation represents good, quality evidence. Based on the meta-analysis results, the 31-GEP test meets level 1A evidence under the SORT method, Dr. Greenhaw said.

As a prognostic tool, 31-GEP has the potential to change how dermatologists manage their patients with regard to follow-up and adjuvant therapy. “It is being used not just as this novel test that gives us more information, it’s being used clinically,” said Dr. Greenhaw, who noted he regularly uses the 31-GEP test in his practice.

This is the first time that a meta-analysis has been performed for this test, he noted.

Dr. Greenhaw reports a pending relationship with Castle Biosciences.

SOURCE: Greenhaw BN et al. AAD 19. Session F055, Abstract 11370.

WASHINGTON – The 31-gene expression profile test has met the highest level of evidence under the Strength of Recommendation Taxonomy (SORT) method as a prognostic marker for accurately predicting recurrence-free survival and distant metastasis-free survival and melanoma-specific survival, according to results presented by Bradley N. Greenhaw, MD, at a late-breaking research session at the annual meeting of the American Academy of Dermatology.

Dr. Greenhaw, a dermatologist affiliated with the North Mississippi Medical Center-Tupelo, and his colleagues pooled together 1,268 patients from the following studies that analyzed results from melanoma patients who had their disease classified with the 31-gene expression profile (31-GEP) test.

• A single-center study, conducted by Dr. Greenhaw and his associates (Greenhaw BN et al. Dermatol Surg. 2018 Dec. doi: 10.1097/DSS.0000000000001588.
• A multicenter prospective study (J Hematol Oncol. 2017 Aug. doi: 10.1186/s13045-017-0520-1.
• A retrospective archival study (J Am Acad Dermatol. 2019 Jan. doi: 10.1016/j.jaad.2018.07.028.

The 31-GEP test stratifies an individual’s likelihood of developing metastasis within 5 years as low and high risk. In the three studies, the test was used to identify tumors with low-risk (class 1A, class 1B), higher-risk (class 2A), and highest-risk (class 2B) melanoma based on tumor gene expression. In these individual studies, class 2B melanoma independently predicted recurrence-free survival (RFS), distant metastasis–free, and melanoma-specific survival.

Dr. Greenhaw and colleagues performed a meta-analysis of 1,268 patients with stage I through stage III melanoma from those three studies, using fixed and random effects weighting to account for study differences and heterogeneity, respectively. For class 2B tumors, they found a 2.96 increased risk for recurrent metastases and a 2.88 increased risk for distant metastases. The researchers also found no heterogeneity across the studies.

Melanoma-specific survival was not included in the meta-analysis because one paper did not contain any mortality events in class 1A melanoma patients.

“The meta-analysis demonstrated that the GEP test was able to accurately identify those melanoma patients who were at higher risk of metastasis, and we saw a consistent effect across multiple studies,” Dr. Greenhaw said.

Since publication of the 2019 JAAD paper, there were an additional 211 patients who met inclusion criteria and were included in an additional meta-analysis to determine whether inclusion of these patients affected the results. Dr. Greenhaw and colleagues found a 91.4% recurrence-free survival rate and a 94.1% distant metastasis–free survival rate for class 1A melanomas, compared with 45.7% and 55.5% , respectively, for class 2B tumors.

“You can see a big divergence,” Dr. Greenhaw said at the meeting. “Just by using this one test, it’s able to separate out melanomas that otherwise may be grouped in together under current AJCC [American Joint Committee on Cancer] staging,” he added. “The class 2B designation really did confirm a higher risk for recurrence in distant metastasis.”

The researchers used the SORT method to rate the quality of the data across all three studies. Level 1 evidence under the SORT method represents a systematic review or meta-analysis of good-quality studies and/or a prospective study with good follow-up, while an A-level recommendation represents good, quality evidence. Based on the meta-analysis results, the 31-GEP test meets level 1A evidence under the SORT method, Dr. Greenhaw said.

As a prognostic tool, 31-GEP has the potential to change how dermatologists manage their patients with regard to follow-up and adjuvant therapy. “It is being used not just as this novel test that gives us more information, it’s being used clinically,” said Dr. Greenhaw, who noted he regularly uses the 31-GEP test in his practice.

This is the first time that a meta-analysis has been performed for this test, he noted.

Dr. Greenhaw reports a pending relationship with Castle Biosciences.

SOURCE: Greenhaw BN et al. AAD 19. Session F055, Abstract 11370.

WAIKOLOA, HAWAII – “Nothing can ruin your day more than a lot of bleeding,” said Mohs surgeon Daniel Siegel, MD, clinical professor of dermatology at the State University of New York Downstate Medical Center, New York.

Vidyard Video

“Part of planning for surgery is to prevent that sort of problem,” and fortunately, when sutures and pressure don’t do the trick for excess bleeding, there are several hemostatic products that can be used, and some are very inexpensive. There’s even a “fancy form of potato starch” that can be left in the wound and sewn over, he said in an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation.

During the interview, Dr. Siegel described several options and how to use them. They are good products to have on hand in the clinic, just in case, he said.

SDEF/Global Academy for Medical Education and this news organization and are owned by the same parent company.
 

[email protected]

WAIKOLOA, HAWAII – “Nothing can ruin your day more than a lot of bleeding,” said Mohs surgeon Daniel Siegel, MD, clinical professor of dermatology at the State University of New York Downstate Medical Center, New York.

Vidyard Video

“Part of planning for surgery is to prevent that sort of problem,” and fortunately, when sutures and pressure don’t do the trick for excess bleeding, there are several hemostatic products that can be used, and some are very inexpensive. There’s even a “fancy form of potato starch” that can be left in the wound and sewn over, he said in an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation.

During the interview, Dr. Siegel described several options and how to use them. They are good products to have on hand in the clinic, just in case, he said.

SDEF/Global Academy for Medical Education and this news organization and are owned by the same parent company.
 

[email protected]

WAIKOLOA, HAWAII – “Nothing can ruin your day more than a lot of bleeding,” said Mohs surgeon Daniel Siegel, MD, clinical professor of dermatology at the State University of New York Downstate Medical Center, New York.

Vidyard Video

“Part of planning for surgery is to prevent that sort of problem,” and fortunately, when sutures and pressure don’t do the trick for excess bleeding, there are several hemostatic products that can be used, and some are very inexpensive. There’s even a “fancy form of potato starch” that can be left in the wound and sewn over, he said in an interview at the Hawaii Dermatology Seminar, provided by Global Academy for Medical Education/Skin Disease Education Foundation.

During the interview, Dr. Siegel described several options and how to use them. They are good products to have on hand in the clinic, just in case, he said.

SDEF/Global Academy for Medical Education and this news organization and are owned by the same parent company.
 

[email protected]

ORLANDO – When caring for individuals with sun-damaged skin, dermatologists need comfort with the full spectrum of photo-related skin disease. From assessment and treatment of actinic keratoses (AKs) and field cancerization, to long-term follow-up of cutaneous squamous cell carcinomas (SCCs), appropriate treatment and staging can improve patient quality of life and reduce health care costs, Vishal Patel, MD, said at the Orlando Dermatology Aesthetic and Clinical Conference.

Kari Oakes/MDedge News

“Actinic keratosis/squamous cell carcinoma in situ is not a disease; it’s a symptom of cutaneous carcinogenesis or field cancerization,” said Dr. Patel, director of cutaneous oncology at George Washington University Cancer Center, Washington. On the other hand, he added, “field disease can be a marker for invasive squamous cell carcinoma risk, and it requires field treatment.” Treatment that reduces field disease is primary prevention because it decreases the formation of invasive SCC, he noted.

“But this level of disease – AKs and SCC in situ – doesn’t kill people,” he emphasized. “I want to leave you with an ability to stage this disease,” said Dr. Patel, noting that SCC mortality may eventually surpass melanoma mortality as deaths from the latter decline and numbers of older Americans with high ultraviolet light exposure and other risk factors climb.

While the majority of AKs regress within 5 years, he looks at the total burden of AKs as a marker for field cancerization “because having less than five in situ or actinic lesions puts you at less than a 1% risk of squamous cell carcinoma formation. Having more than 20 increases that risk 20-fold to 20%,” he said. “That’s the way we need to start thinking about this: Is this a disease – or a symptom?”

Rather than thinking of each AK or SCC in situ as a separate disease event, “the disease we need to be focusing on and treating is field cancerization,” he continued. Within this context, “we should not be thinking that … we need to be aggressive in our management,” which is what results in high costs.

“The reality is that this is a big quality of life issue for our patients. So what do we do?” Field treatment is appropriate for field disease, he said. Dr. Patel said that at GW only field treatment is used; destructive treatment for AKs and SCC in situ is not used. In the absence of patient and lesion characteristics that elevate risk,“surgery is really not the standard of care for in situ lesions for us,” he commented.

“We start by discerning the field disease from the invasive disease” with an initial round of field treatment and, if needed, adjunctive oral chemoprophylaxis. “We lather, rinse, and repeat” the field therapy, continuously if needed, Dr. Patel said.

“We like to do that because we can then identify those specific lesions we want to go after. No cryosurgery, no destructive therapy, because we run the risk of burying those tumors under the scar. They may recur and make it more difficult to accurately stage them in the future,” he noted.

“I like to be more sophisticated in thinking about our approach to the outcomes of these individual lesions,” he said. When it comes to excising lesions that have been biopsied and show invasive SCC, “disc excision may be a more cost-effective way to treat many low-risk SCCs,” he noted. In any case, “removal with clear surgical margins is key.”

Primary tumors with such low-risk attributes as diameter under a centimeter and thickness under 2 mm; well-defined borders; location on the trunk, neck, or extremities; well-differentiated histology; and lack of perineural invasion can all be considered for a disc technique, especially if the patient is immunocompetent without background chronic inflammation or a history of prior radiation therapy.

Staging SCCs, said Dr. Patel, is where things really get tricky. Older staging systems for SCC “led us to overtreat nonaggressive disease and undertreat aggressive disease. I think we have the responsibility to lead the charge to having a more sophisticated approach.” For example, patients whose tumors were staged T2 in the American Joint Commission on Cancer (AJCC) 7 classification system were most likely to have poor outcomes – in part because so few tumors were staged higher – which meant AJCC 7 didn’t provide adequate differentiation for useful risk prognostication.

A group of researchers at the Brigham and Women’s Hospital (BWH), Boston, “came up with a better system to better differentiate those T2 tumors into a high-risk and a low-risk subtype,” according to Dr. Patel.

With use of validated risk factors, the investigators applied a long list of risk factors to 2,000 tumors to see which risk factors, taken individually, were really contributing to poor outcomes. Eventually, four risk factors that made the most difference were identified: size greater than 2 cm, poor tumor differentiation, perineural invasion greater than 0.1 mm in diameter, and tumor invasion beyond subcutaneous fat. “I really want to highlight the size portion of those risk factors,” said Dr. Patel. “Something I’d like you to do in your clinical practice is to measure and document the size of the lesion. … That really, clearly helps” with risk prognostication.

These four factors were then used to break out a T2a stage for tumors with one risk factor and a T2b stage for tumors with two or three risk factors. Tumors with no risk factors are stage T1, and those with all four risk factors are stage T3. In situ SCC is T0.

Applying this new staging system to a 2,000-patient cohort with SCC yielded clear separation in outcomes including recurrence, nodal metastasis, disease-specific death, and overall survival between patients with the T2a and T2b tumors (P less than .001 for all; J Clin Oncol. 2014 Feb 1;32[4]:327-34).

While AJCC 8 is “significantly better” than AJCC 7 in its incorporation of meaningful risk factors into the SCC staging system, “it still underperforms in comparison” with the BWH staging system using the 2000 patient cohort, he said. Recent work has shown the BWH classification system to have superior specificity and positive predictive value in detecting nodal metastasis and disease-specific death in higher-grade tumors. But both BWH and AJCC 8 need further refinement.

“So what are the staging pearls to take home?” Dr. Patel asked. “First, utilize a staging system.” “Staging of SCC utilizing should be done routinely. Most data seems to suggest that the BWH system appears to outperform AJCC 8, and it is what we currently use routinely at GW,” he said.

Patients who are T1 by BWH criteria, with no risk factors, are at low or even no risk, he noted. He pointed out that of the nearly 1,400 patients who met T1 criteria, there were just eight local recurrences, one nodal metastasis, and no distant metastases or deaths. Knowing this should guide physicians on a treatment path that will reduce costs and provide patients with peace of mind, he said.

In the BWH schema, T2a patients fared almost as well, with a 2% risk of nodal metastasis and an overall 1% risk of disease-specific death. “T2a disease is low risk, in my mind. Most of these patients will go on to do well,” he said.

By contrast, “there may be a number of tumors that you are missing” that are candidates for close follow-up if the BWH criteria are not being used, said Dr. Patel. These are the T2b tumors. “For those patients, we want to aggressively follow them and think about a more aggressive management plan.”

The bottom line is that BWH T2b and T3 tumors are both high risk, and management needs to acknowledge this, he said. The current protocol in our cutaneous oncology program includes using routine radiologic nodal staging in patients with BWH stage 2b and above SCCs and considering sentinel lymph node biopsy for certain individuals.

For patients with BWH T2b and T3 tumors, dermatologists should give consideration to tertiary care or cancer center referrals so they have access to the full spectrum of diagnostic and therapeutic modalities and the opportunity to participate in clinical trials, Dr. Patel said.

Dr. Patel reported that he is a speaker for Regeneron/Sanofi and a cofounder of the Skin Cancer Outcomes (SCOUT) consortium.

This article was updated 2/9/2019

[email protected]

ORLANDO – When caring for individuals with sun-damaged skin, dermatologists need comfort with the full spectrum of photo-related skin disease. From assessment and treatment of actinic keratoses (AKs) and field cancerization, to long-term follow-up of cutaneous squamous cell carcinomas (SCCs), appropriate treatment and staging can improve patient quality of life and reduce health care costs, Vishal Patel, MD, said at the Orlando Dermatology Aesthetic and Clinical Conference.

Kari Oakes/MDedge News

“Actinic keratosis/squamous cell carcinoma in situ is not a disease; it’s a symptom of cutaneous carcinogenesis or field cancerization,” said Dr. Patel, director of cutaneous oncology at George Washington University Cancer Center, Washington. On the other hand, he added, “field disease can be a marker for invasive squamous cell carcinoma risk, and it requires field treatment.” Treatment that reduces field disease is primary prevention because it decreases the formation of invasive SCC, he noted.

“But this level of disease – AKs and SCC in situ – doesn’t kill people,” he emphasized. “I want to leave you with an ability to stage this disease,” said Dr. Patel, noting that SCC mortality may eventually surpass melanoma mortality as deaths from the latter decline and numbers of older Americans with high ultraviolet light exposure and other risk factors climb.

While the majority of AKs regress within 5 years, he looks at the total burden of AKs as a marker for field cancerization “because having less than five in situ or actinic lesions puts you at less than a 1% risk of squamous cell carcinoma formation. Having more than 20 increases that risk 20-fold to 20%,” he said. “That’s the way we need to start thinking about this: Is this a disease – or a symptom?”

Rather than thinking of each AK or SCC in situ as a separate disease event, “the disease we need to be focusing on and treating is field cancerization,” he continued. Within this context, “we should not be thinking that … we need to be aggressive in our management,” which is what results in high costs.

“The reality is that this is a big quality of life issue for our patients. So what do we do?” Field treatment is appropriate for field disease, he said. Dr. Patel said that at GW only field treatment is used; destructive treatment for AKs and SCC in situ is not used. In the absence of patient and lesion characteristics that elevate risk,“surgery is really not the standard of care for in situ lesions for us,” he commented.

“We start by discerning the field disease from the invasive disease” with an initial round of field treatment and, if needed, adjunctive oral chemoprophylaxis. “We lather, rinse, and repeat” the field therapy, continuously if needed, Dr. Patel said.

“We like to do that because we can then identify those specific lesions we want to go after. No cryosurgery, no destructive therapy, because we run the risk of burying those tumors under the scar. They may recur and make it more difficult to accurately stage them in the future,” he noted.

“I like to be more sophisticated in thinking about our approach to the outcomes of these individual lesions,” he said. When it comes to excising lesions that have been biopsied and show invasive SCC, “disc excision may be a more cost-effective way to treat many low-risk SCCs,” he noted. In any case, “removal with clear surgical margins is key.”

Primary tumors with such low-risk attributes as diameter under a centimeter and thickness under 2 mm; well-defined borders; location on the trunk, neck, or extremities; well-differentiated histology; and lack of perineural invasion can all be considered for a disc technique, especially if the patient is immunocompetent without background chronic inflammation or a history of prior radiation therapy.

Staging SCCs, said Dr. Patel, is where things really get tricky. Older staging systems for SCC “led us to overtreat nonaggressive disease and undertreat aggressive disease. I think we have the responsibility to lead the charge to having a more sophisticated approach.” For example, patients whose tumors were staged T2 in the American Joint Commission on Cancer (AJCC) 7 classification system were most likely to have poor outcomes – in part because so few tumors were staged higher – which meant AJCC 7 didn’t provide adequate differentiation for useful risk prognostication.

A group of researchers at the Brigham and Women’s Hospital (BWH), Boston, “came up with a better system to better differentiate those T2 tumors into a high-risk and a low-risk subtype,” according to Dr. Patel.

With use of validated risk factors, the investigators applied a long list of risk factors to 2,000 tumors to see which risk factors, taken individually, were really contributing to poor outcomes. Eventually, four risk factors that made the most difference were identified: size greater than 2 cm, poor tumor differentiation, perineural invasion greater than 0.1 mm in diameter, and tumor invasion beyond subcutaneous fat. “I really want to highlight the size portion of those risk factors,” said Dr. Patel. “Something I’d like you to do in your clinical practice is to measure and document the size of the lesion. … That really, clearly helps” with risk prognostication.

These four factors were then used to break out a T2a stage for tumors with one risk factor and a T2b stage for tumors with two or three risk factors. Tumors with no risk factors are stage T1, and those with all four risk factors are stage T3. In situ SCC is T0.

Applying this new staging system to a 2,000-patient cohort with SCC yielded clear separation in outcomes including recurrence, nodal metastasis, disease-specific death, and overall survival between patients with the T2a and T2b tumors (P less than .001 for all; J Clin Oncol. 2014 Feb 1;32[4]:327-34).

While AJCC 8 is “significantly better” than AJCC 7 in its incorporation of meaningful risk factors into the SCC staging system, “it still underperforms in comparison” with the BWH staging system using the 2000 patient cohort, he said. Recent work has shown the BWH classification system to have superior specificity and positive predictive value in detecting nodal metastasis and disease-specific death in higher-grade tumors. But both BWH and AJCC 8 need further refinement.

“So what are the staging pearls to take home?” Dr. Patel asked. “First, utilize a staging system.” “Staging of SCC utilizing should be done routinely. Most data seems to suggest that the BWH system appears to outperform AJCC 8, and it is what we currently use routinely at GW,” he said.

Patients who are T1 by BWH criteria, with no risk factors, are at low or even no risk, he noted. He pointed out that of the nearly 1,400 patients who met T1 criteria, there were just eight local recurrences, one nodal metastasis, and no distant metastases or deaths. Knowing this should guide physicians on a treatment path that will reduce costs and provide patients with peace of mind, he said.

In the BWH schema, T2a patients fared almost as well, with a 2% risk of nodal metastasis and an overall 1% risk of disease-specific death. “T2a disease is low risk, in my mind. Most of these patients will go on to do well,” he said.

By contrast, “there may be a number of tumors that you are missing” that are candidates for close follow-up if the BWH criteria are not being used, said Dr. Patel. These are the T2b tumors. “For those patients, we want to aggressively follow them and think about a more aggressive management plan.”

The bottom line is that BWH T2b and T3 tumors are both high risk, and management needs to acknowledge this, he said. The current protocol in our cutaneous oncology program includes using routine radiologic nodal staging in patients with BWH stage 2b and above SCCs and considering sentinel lymph node biopsy for certain individuals.

For patients with BWH T2b and T3 tumors, dermatologists should give consideration to tertiary care or cancer center referrals so they have access to the full spectrum of diagnostic and therapeutic modalities and the opportunity to participate in clinical trials, Dr. Patel said.

Dr. Patel reported that he is a speaker for Regeneron/Sanofi and a cofounder of the Skin Cancer Outcomes (SCOUT) consortium.

This article was updated 2/9/2019

[email protected]

ORLANDO – When caring for individuals with sun-damaged skin, dermatologists need comfort with the full spectrum of photo-related skin disease. From assessment and treatment of actinic keratoses (AKs) and field cancerization, to long-term follow-up of cutaneous squamous cell carcinomas (SCCs), appropriate treatment and staging can improve patient quality of life and reduce health care costs, Vishal Patel, MD, said at the Orlando Dermatology Aesthetic and Clinical Conference.

Kari Oakes/MDedge News

“Actinic keratosis/squamous cell carcinoma in situ is not a disease; it’s a symptom of cutaneous carcinogenesis or field cancerization,” said Dr. Patel, director of cutaneous oncology at George Washington University Cancer Center, Washington. On the other hand, he added, “field disease can be a marker for invasive squamous cell carcinoma risk, and it requires field treatment.” Treatment that reduces field disease is primary prevention because it decreases the formation of invasive SCC, he noted.

“But this level of disease – AKs and SCC in situ – doesn’t kill people,” he emphasized. “I want to leave you with an ability to stage this disease,” said Dr. Patel, noting that SCC mortality may eventually surpass melanoma mortality as deaths from the latter decline and numbers of older Americans with high ultraviolet light exposure and other risk factors climb.

While the majority of AKs regress within 5 years, he looks at the total burden of AKs as a marker for field cancerization “because having less than five in situ or actinic lesions puts you at less than a 1% risk of squamous cell carcinoma formation. Having more than 20 increases that risk 20-fold to 20%,” he said. “That’s the way we need to start thinking about this: Is this a disease – or a symptom?”

Rather than thinking of each AK or SCC in situ as a separate disease event, “the disease we need to be focusing on and treating is field cancerization,” he continued. Within this context, “we should not be thinking that … we need to be aggressive in our management,” which is what results in high costs.

“The reality is that this is a big quality of life issue for our patients. So what do we do?” Field treatment is appropriate for field disease, he said. Dr. Patel said that at GW only field treatment is used; destructive treatment for AKs and SCC in situ is not used. In the absence of patient and lesion characteristics that elevate risk,“surgery is really not the standard of care for in situ lesions for us,” he commented.

“We start by discerning the field disease from the invasive disease” with an initial round of field treatment and, if needed, adjunctive oral chemoprophylaxis. “We lather, rinse, and repeat” the field therapy, continuously if needed, Dr. Patel said.

“We like to do that because we can then identify those specific lesions we want to go after. No cryosurgery, no destructive therapy, because we run the risk of burying those tumors under the scar. They may recur and make it more difficult to accurately stage them in the future,” he noted.

“I like to be more sophisticated in thinking about our approach to the outcomes of these individual lesions,” he said. When it comes to excising lesions that have been biopsied and show invasive SCC, “disc excision may be a more cost-effective way to treat many low-risk SCCs,” he noted. In any case, “removal with clear surgical margins is key.”

Primary tumors with such low-risk attributes as diameter under a centimeter and thickness under 2 mm; well-defined borders; location on the trunk, neck, or extremities; well-differentiated histology; and lack of perineural invasion can all be considered for a disc technique, especially if the patient is immunocompetent without background chronic inflammation or a history of prior radiation therapy.

Staging SCCs, said Dr. Patel, is where things really get tricky. Older staging systems for SCC “led us to overtreat nonaggressive disease and undertreat aggressive disease. I think we have the responsibility to lead the charge to having a more sophisticated approach.” For example, patients whose tumors were staged T2 in the American Joint Commission on Cancer (AJCC) 7 classification system were most likely to have poor outcomes – in part because so few tumors were staged higher – which meant AJCC 7 didn’t provide adequate differentiation for useful risk prognostication.

A group of researchers at the Brigham and Women’s Hospital (BWH), Boston, “came up with a better system to better differentiate those T2 tumors into a high-risk and a low-risk subtype,” according to Dr. Patel.

With use of validated risk factors, the investigators applied a long list of risk factors to 2,000 tumors to see which risk factors, taken individually, were really contributing to poor outcomes. Eventually, four risk factors that made the most difference were identified: size greater than 2 cm, poor tumor differentiation, perineural invasion greater than 0.1 mm in diameter, and tumor invasion beyond subcutaneous fat. “I really want to highlight the size portion of those risk factors,” said Dr. Patel. “Something I’d like you to do in your clinical practice is to measure and document the size of the lesion. … That really, clearly helps” with risk prognostication.

These four factors were then used to break out a T2a stage for tumors with one risk factor and a T2b stage for tumors with two or three risk factors. Tumors with no risk factors are stage T1, and those with all four risk factors are stage T3. In situ SCC is T0.

Applying this new staging system to a 2,000-patient cohort with SCC yielded clear separation in outcomes including recurrence, nodal metastasis, disease-specific death, and overall survival between patients with the T2a and T2b tumors (P less than .001 for all; J Clin Oncol. 2014 Feb 1;32[4]:327-34).

While AJCC 8 is “significantly better” than AJCC 7 in its incorporation of meaningful risk factors into the SCC staging system, “it still underperforms in comparison” with the BWH staging system using the 2000 patient cohort, he said. Recent work has shown the BWH classification system to have superior specificity and positive predictive value in detecting nodal metastasis and disease-specific death in higher-grade tumors. But both BWH and AJCC 8 need further refinement.

“So what are the staging pearls to take home?” Dr. Patel asked. “First, utilize a staging system.” “Staging of SCC utilizing should be done routinely. Most data seems to suggest that the BWH system appears to outperform AJCC 8, and it is what we currently use routinely at GW,” he said.

Patients who are T1 by BWH criteria, with no risk factors, are at low or even no risk, he noted. He pointed out that of the nearly 1,400 patients who met T1 criteria, there were just eight local recurrences, one nodal metastasis, and no distant metastases or deaths. Knowing this should guide physicians on a treatment path that will reduce costs and provide patients with peace of mind, he said.

In the BWH schema, T2a patients fared almost as well, with a 2% risk of nodal metastasis and an overall 1% risk of disease-specific death. “T2a disease is low risk, in my mind. Most of these patients will go on to do well,” he said.

By contrast, “there may be a number of tumors that you are missing” that are candidates for close follow-up if the BWH criteria are not being used, said Dr. Patel. These are the T2b tumors. “For those patients, we want to aggressively follow them and think about a more aggressive management plan.”

The bottom line is that BWH T2b and T3 tumors are both high risk, and management needs to acknowledge this, he said. The current protocol in our cutaneous oncology program includes using routine radiologic nodal staging in patients with BWH stage 2b and above SCCs and considering sentinel lymph node biopsy for certain individuals.

For patients with BWH T2b and T3 tumors, dermatologists should give consideration to tertiary care or cancer center referrals so they have access to the full spectrum of diagnostic and therapeutic modalities and the opportunity to participate in clinical trials, Dr. Patel said.

Dr. Patel reported that he is a speaker for Regeneron/Sanofi and a cofounder of the Skin Cancer Outcomes (SCOUT) consortium.

This article was updated 2/9/2019

[email protected]

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

Dermatologists are prescribing fewer antibiotics for acne and rosacea, but prescribing after dermatologic surgery has increased in the past decade.

In a study published online Jan. 16 in JAMA Dermatology, researchers report the results of a cross-sectional analysis of antibiotic prescribing by 11,986 dermatologists between 2008 and 2016, using commercial claims data.

The analysis showed that, over this period of time, the overall rate of antibiotic prescribing by dermatologists decreased by 36.6%, from 3.36 courses per 100 dermatologist visits to 2.13 courses. In particular, antibiotic prescribing for acne decreased by 28.1%, from 11.76 courses per 100 visits to 8.45 courses, and for rosacea it decreased by 18.1%, from 10.89 courses per 100 visits to 8.92 courses.

John S. Barbieri, MD, of the department of dermatology, University of Pennsylvania, and his coauthors described the overall decline in antibiotic prescribing as “encouraging,” considering that in 2013 dermatologists were identified as the “most frequent prescribers of oral antibiotics per clinician.” The decline resulted in an estimated 480,000 fewer antibiotic courses a year, they noted.

“Much of the decrease in extended courses of antibiotic therapy is associated with visits for acne and rosacea,” they wrote. “Although recent guidelines suggest limiting the duration of therapy in this patient population, course duration has remained stable over time, suggesting that this decrease may be due to fewer patients being treated with antibiotics rather than patients being treated for a shorter duration.”

However, the rate of oral antibiotic prescriptions associated with surgical visits increased by 69.6%, from 3.92 courses per 100 visits to 6.65. This increase was concerning, given the risk of surgical-site infections was low, the authors pointed out. “In addition, a 2008 advisory statement on antibiotic prophylaxis recommends single-dose perioperative antibiotics for patients at increased risk of surgical-site infection,” they added.

The study also noted a 35.3% increase in antibiotic prescribing for cysts and a 3.2% increase for hidradenitis suppurativa.

Over the entire study period, nearly 1 million courses of oral antibiotics were prescribed. Doxycycline hyclate accounted for around one quarter of prescriptions, as did minocycline, while 19.9% of prescriptions were for cephalexin.

“Given the low rate of infectious complications, even for Mohs surgery, and the lack of evidence to support the use of prolonged rather than single-dose perioperative regimens, the postoperative courses of antibiotics identified in this study may increase risks to patients without substantial benefits,” they added.

The study was partly supported by the National Institute of Arthritis and Musculoskeletal Skin Diseases. No conflicts of interest were declared.

SOURCE: Barbieri J et al. JAMA Dermatology. 2019 Jan 16. doi: 10.1001/jamadermatol.2018.4944.

BOSTON – Fat grafting has taken off in recent years, especially for breast reconstruction, but it’s become clear that it also has a role in scar treatment, according to Benjamin Levi, MD, director of the burn/wound and regenerative medicine laboratory at the University of Michigan, Ann Arbor.

Some corners of the Internet tout it as “some sort of magic stem cell surgery,” Dr. Levi said, but in reality, for scar surgeons, it’s just another useful tool in the armamentarium, one that excels at filling skin depressions due to underlying tissue loss, whether from burns, trauma, or surgery. Unlike hyaluronic acid and other options, fat grafts last; about half of injected adipocytes remain indefinitely. Fat grafting might also help soften scars, he said.

To get the most out of the procedure, of course, it has to be done correctly, so Dr. Levi took a few minutes at the annual clinical congress of the American College of Surgeons to share his tips on harvesting and spinning down fat grafts, injecting adipocytes, and other matters. Although the concepts of fat grafting are straightforward, the techniques are a bit tricky. Dr. Levi hoped his treatment pearls would help other physicians, especially those considering adding fat grafting to their practice.
 

[email protected]

BOSTON – Fat grafting has taken off in recent years, especially for breast reconstruction, but it’s become clear that it also has a role in scar treatment, according to Benjamin Levi, MD, director of the burn/wound and regenerative medicine laboratory at the University of Michigan, Ann Arbor.

Some corners of the Internet tout it as “some sort of magic stem cell surgery,” Dr. Levi said, but in reality, for scar surgeons, it’s just another useful tool in the armamentarium, one that excels at filling skin depressions due to underlying tissue loss, whether from burns, trauma, or surgery. Unlike hyaluronic acid and other options, fat grafts last; about half of injected adipocytes remain indefinitely. Fat grafting might also help soften scars, he said.

To get the most out of the procedure, of course, it has to be done correctly, so Dr. Levi took a few minutes at the annual clinical congress of the American College of Surgeons to share his tips on harvesting and spinning down fat grafts, injecting adipocytes, and other matters. Although the concepts of fat grafting are straightforward, the techniques are a bit tricky. Dr. Levi hoped his treatment pearls would help other physicians, especially those considering adding fat grafting to their practice.
 

[email protected]

BOSTON – Fat grafting has taken off in recent years, especially for breast reconstruction, but it’s become clear that it also has a role in scar treatment, according to Benjamin Levi, MD, director of the burn/wound and regenerative medicine laboratory at the University of Michigan, Ann Arbor.

Some corners of the Internet tout it as “some sort of magic stem cell surgery,” Dr. Levi said, but in reality, for scar surgeons, it’s just another useful tool in the armamentarium, one that excels at filling skin depressions due to underlying tissue loss, whether from burns, trauma, or surgery. Unlike hyaluronic acid and other options, fat grafts last; about half of injected adipocytes remain indefinitely. Fat grafting might also help soften scars, he said.

To get the most out of the procedure, of course, it has to be done correctly, so Dr. Levi took a few minutes at the annual clinical congress of the American College of Surgeons to share his tips on harvesting and spinning down fat grafts, injecting adipocytes, and other matters. Although the concepts of fat grafting are straightforward, the techniques are a bit tricky. Dr. Levi hoped his treatment pearls would help other physicians, especially those considering adding fat grafting to their practice.
 

[email protected]

ORLANDO – Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States.

M. Alexander Otto/MDedge News

Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases, said Elizabeth G. Berry, MD, of Emory University, Atlanta, and Atlanta Veterans Administration Medical Center, one of the study investigators.

The finding “really has the potential to change how we manage these lesions. You don’t need to cut [these patients] again. You can watch them. Close observation with routine skin surveillance is reasonable,” Dr. Berry said at the International Investigative Dermatology meeting.

Routine skin exams are essential for patients with a history of dysplastic nevi as these patients are at risk for developing melanoma. Indeed, in this study, 100 patients (22.8%) subsequently developed melanomas at a site other than the location of their biopsy.

The study included 438 patients who had 467 biopsies that indicated incomplete excision of a moderately dysplastic nevus from 1990 to 2014. Patients were at least 18 years old and were an average of 47 years old. About half had a history of dysplastic nevi, and a third had a history of melanoma.

All of their biopsies for moderately dysplastic nevi had positive margins, but patients had no clinically apparent residual pigment at their excision sites. Lesions were equally as likely to be removed by shave and punch biopsies, and the majority of the nevi were located on the trunk. Complete excision was the intent in all cases.

To control for interobserver variability, the centers submitted a total of 40 slides for central dermatopathology review, which found agreement in 35 cases (87.8%). Two of the remaining five cases were downgraded to mild dysplasia, two were upgraded to severe, and one patient was upgraded to melanoma in situ, but hasn’t had a recurrence after 5 years of follow-up.

Controlling for age, sex, and family history, a patient history of dysplastic nevus prior to the biopsy doubled the risk of a subsequent melanoma (P = .017), and a history of melanoma increased it almost eightfold (P less than .001).

Knowing these risk factors, patients with a history of dysplastic nevi “need to have more frequent total body skin exams. What that frequency is, we don’t know,” Dr. Berry said.

The investigators reported they had no relevant disclosures.

[email protected]

SOURCE: Kim CC et al. IID 2018, Abstract 571.

ORLANDO – Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States.

M. Alexander Otto/MDedge News

Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases, said Elizabeth G. Berry, MD, of Emory University, Atlanta, and Atlanta Veterans Administration Medical Center, one of the study investigators.

The finding “really has the potential to change how we manage these lesions. You don’t need to cut [these patients] again. You can watch them. Close observation with routine skin surveillance is reasonable,” Dr. Berry said at the International Investigative Dermatology meeting.

Routine skin exams are essential for patients with a history of dysplastic nevi as these patients are at risk for developing melanoma. Indeed, in this study, 100 patients (22.8%) subsequently developed melanomas at a site other than the location of their biopsy.

The study included 438 patients who had 467 biopsies that indicated incomplete excision of a moderately dysplastic nevus from 1990 to 2014. Patients were at least 18 years old and were an average of 47 years old. About half had a history of dysplastic nevi, and a third had a history of melanoma.

All of their biopsies for moderately dysplastic nevi had positive margins, but patients had no clinically apparent residual pigment at their excision sites. Lesions were equally as likely to be removed by shave and punch biopsies, and the majority of the nevi were located on the trunk. Complete excision was the intent in all cases.

To control for interobserver variability, the centers submitted a total of 40 slides for central dermatopathology review, which found agreement in 35 cases (87.8%). Two of the remaining five cases were downgraded to mild dysplasia, two were upgraded to severe, and one patient was upgraded to melanoma in situ, but hasn’t had a recurrence after 5 years of follow-up.

Controlling for age, sex, and family history, a patient history of dysplastic nevus prior to the biopsy doubled the risk of a subsequent melanoma (P = .017), and a history of melanoma increased it almost eightfold (P less than .001).

Knowing these risk factors, patients with a history of dysplastic nevi “need to have more frequent total body skin exams. What that frequency is, we don’t know,” Dr. Berry said.

The investigators reported they had no relevant disclosures.

[email protected]

SOURCE: Kim CC et al. IID 2018, Abstract 571.

ORLANDO – Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States.

M. Alexander Otto/MDedge News

Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases, said Elizabeth G. Berry, MD, of Emory University, Atlanta, and Atlanta Veterans Administration Medical Center, one of the study investigators.

The finding “really has the potential to change how we manage these lesions. You don’t need to cut [these patients] again. You can watch them. Close observation with routine skin surveillance is reasonable,” Dr. Berry said at the International Investigative Dermatology meeting.

Routine skin exams are essential for patients with a history of dysplastic nevi as these patients are at risk for developing melanoma. Indeed, in this study, 100 patients (22.8%) subsequently developed melanomas at a site other than the location of their biopsy.

The study included 438 patients who had 467 biopsies that indicated incomplete excision of a moderately dysplastic nevus from 1990 to 2014. Patients were at least 18 years old and were an average of 47 years old. About half had a history of dysplastic nevi, and a third had a history of melanoma.

All of their biopsies for moderately dysplastic nevi had positive margins, but patients had no clinically apparent residual pigment at their excision sites. Lesions were equally as likely to be removed by shave and punch biopsies, and the majority of the nevi were located on the trunk. Complete excision was the intent in all cases.

To control for interobserver variability, the centers submitted a total of 40 slides for central dermatopathology review, which found agreement in 35 cases (87.8%). Two of the remaining five cases were downgraded to mild dysplasia, two were upgraded to severe, and one patient was upgraded to melanoma in situ, but hasn’t had a recurrence after 5 years of follow-up.

Controlling for age, sex, and family history, a patient history of dysplastic nevus prior to the biopsy doubled the risk of a subsequent melanoma (P = .017), and a history of melanoma increased it almost eightfold (P less than .001).

Knowing these risk factors, patients with a history of dysplastic nevi “need to have more frequent total body skin exams. What that frequency is, we don’t know,” Dr. Berry said.

The investigators reported they had no relevant disclosures.

[email protected]

SOURCE: Kim CC et al. IID 2018, Abstract 571.

A combination of low-dose isotretinoin and nonablative fractional laser (NAFL) was a safe and effective treatment for moderate to severe acne and also improved acne scars in a small Chinese study, investigators reported.

In the randomized, split-face, controlled study of 18 adult Asian patients with moderate to severe acne, low-dose isotretinoin alone effectively controlled papule and pustule acne lesions, whereas NAFL had the additional effect of reducing the number of comedones and improving boxcar atrophic scars, reported Weihui Zeng, MD, and associates from the department of dermatology at the Second Affiliated Hospital of Xi’an Jiaotong University, Shanxi, China.

The authors noted that many patients seen at their clinic cannot tolerate a 20 mg/day dose of isotretinoin because of severe mucocutaneous side effects and that treatment with nonablative lasers, which – in contrast to ablative lasers – use infrared radiation to penetrate the skin deeply and thereby selectively heat dermal tissue while sparing the epidermis, could be a treatment option for these patients.

Therefore, they set out to investigate a treatment plan combining 1,550-nm NAFL with low-dose isotretinoin (10 mg/day) in the 18 patients (mean age, 24 years; skin types II-IV) attending their outpatient dermatology clinic. Three laser treatments were administered at monthly intervals to one side of the face, with the other side of the face serving as a control. Each patient was on low-dose isotretinoin for 30-45 days before laser treatment. A revised Leeds acne-grading system was used.

At follow-up after the third treatment – 3 months after the first laser treatment – both sides of the face showed significant recovery in all participants, but there was greater improvement on the laser-treated side. The mean Leeds acne-grading scores decreased from 10.6 at baseline to 5.8 on the control side of the face, and from 10.4 at baseline to 3.5 on the laser-treated side. The changes in scores differed significantly between sides (P less than .05), and the number of comedones decreased more on the laser-treated side of the face than it did the control side.

Significant improvements were also seen with superficial scars (P less than .05) and deep boxcar atrophic scars (P less than .01) on the laser-treated sides of patients’ faces, compared with the control sides, but significant improvements were not seen with the number of papules and nodules or with icepick or rolling scars.

Patients reported discomfort after NAFL treatment, including pain (100%), sensation of heat (100%), erythema (94.5%), and edema (88.9%), which resolved spontaneously within 24 hours.

Most of the patients (n = 12; 66.7%) were satisfied after the last treatment, two (11.1%) were “very satisfied,” and four (22.2%) were neutral; none were dissatisfied.

“Low-dose isotretinoin effectively controlled papule and pustule acne lesions, whereas use of 1,550-nm Er:glass NAFL may significantly reduce the number of comedones and improve boxcar atrophic scars,” the authors wrote.

They authors reported no significant interest with commercial supporters.

SOURCE: Xia J et al. Dermatol Surg. 2018 Sep;44(9):1201-8.

A combination of low-dose isotretinoin and nonablative fractional laser (NAFL) was a safe and effective treatment for moderate to severe acne and also improved acne scars in a small Chinese study, investigators reported.

In the randomized, split-face, controlled study of 18 adult Asian patients with moderate to severe acne, low-dose isotretinoin alone effectively controlled papule and pustule acne lesions, whereas NAFL had the additional effect of reducing the number of comedones and improving boxcar atrophic scars, reported Weihui Zeng, MD, and associates from the department of dermatology at the Second Affiliated Hospital of Xi’an Jiaotong University, Shanxi, China.

The authors noted that many patients seen at their clinic cannot tolerate a 20 mg/day dose of isotretinoin because of severe mucocutaneous side effects and that treatment with nonablative lasers, which – in contrast to ablative lasers – use infrared radiation to penetrate the skin deeply and thereby selectively heat dermal tissue while sparing the epidermis, could be a treatment option for these patients.

Therefore, they set out to investigate a treatment plan combining 1,550-nm NAFL with low-dose isotretinoin (10 mg/day) in the 18 patients (mean age, 24 years; skin types II-IV) attending their outpatient dermatology clinic. Three laser treatments were administered at monthly intervals to one side of the face, with the other side of the face serving as a control. Each patient was on low-dose isotretinoin for 30-45 days before laser treatment. A revised Leeds acne-grading system was used.

At follow-up after the third treatment – 3 months after the first laser treatment – both sides of the face showed significant recovery in all participants, but there was greater improvement on the laser-treated side. The mean Leeds acne-grading scores decreased from 10.6 at baseline to 5.8 on the control side of the face, and from 10.4 at baseline to 3.5 on the laser-treated side. The changes in scores differed significantly between sides (P less than .05), and the number of comedones decreased more on the laser-treated side of the face than it did the control side.

Significant improvements were also seen with superficial scars (P less than .05) and deep boxcar atrophic scars (P less than .01) on the laser-treated sides of patients’ faces, compared with the control sides, but significant improvements were not seen with the number of papules and nodules or with icepick or rolling scars.

Patients reported discomfort after NAFL treatment, including pain (100%), sensation of heat (100%), erythema (94.5%), and edema (88.9%), which resolved spontaneously within 24 hours.

Most of the patients (n = 12; 66.7%) were satisfied after the last treatment, two (11.1%) were “very satisfied,” and four (22.2%) were neutral; none were dissatisfied.

“Low-dose isotretinoin effectively controlled papule and pustule acne lesions, whereas use of 1,550-nm Er:glass NAFL may significantly reduce the number of comedones and improve boxcar atrophic scars,” the authors wrote.

They authors reported no significant interest with commercial supporters.

SOURCE: Xia J et al. Dermatol Surg. 2018 Sep;44(9):1201-8.

A combination of low-dose isotretinoin and nonablative fractional laser (NAFL) was a safe and effective treatment for moderate to severe acne and also improved acne scars in a small Chinese study, investigators reported.

In the randomized, split-face, controlled study of 18 adult Asian patients with moderate to severe acne, low-dose isotretinoin alone effectively controlled papule and pustule acne lesions, whereas NAFL had the additional effect of reducing the number of comedones and improving boxcar atrophic scars, reported Weihui Zeng, MD, and associates from the department of dermatology at the Second Affiliated Hospital of Xi’an Jiaotong University, Shanxi, China.

The authors noted that many patients seen at their clinic cannot tolerate a 20 mg/day dose of isotretinoin because of severe mucocutaneous side effects and that treatment with nonablative lasers, which – in contrast to ablative lasers – use infrared radiation to penetrate the skin deeply and thereby selectively heat dermal tissue while sparing the epidermis, could be a treatment option for these patients.

Therefore, they set out to investigate a treatment plan combining 1,550-nm NAFL with low-dose isotretinoin (10 mg/day) in the 18 patients (mean age, 24 years; skin types II-IV) attending their outpatient dermatology clinic. Three laser treatments were administered at monthly intervals to one side of the face, with the other side of the face serving as a control. Each patient was on low-dose isotretinoin for 30-45 days before laser treatment. A revised Leeds acne-grading system was used.

At follow-up after the third treatment – 3 months after the first laser treatment – both sides of the face showed significant recovery in all participants, but there was greater improvement on the laser-treated side. The mean Leeds acne-grading scores decreased from 10.6 at baseline to 5.8 on the control side of the face, and from 10.4 at baseline to 3.5 on the laser-treated side. The changes in scores differed significantly between sides (P less than .05), and the number of comedones decreased more on the laser-treated side of the face than it did the control side.

Significant improvements were also seen with superficial scars (P less than .05) and deep boxcar atrophic scars (P less than .01) on the laser-treated sides of patients’ faces, compared with the control sides, but significant improvements were not seen with the number of papules and nodules or with icepick or rolling scars.

Patients reported discomfort after NAFL treatment, including pain (100%), sensation of heat (100%), erythema (94.5%), and edema (88.9%), which resolved spontaneously within 24 hours.

Most of the patients (n = 12; 66.7%) were satisfied after the last treatment, two (11.1%) were “very satisfied,” and four (22.2%) were neutral; none were dissatisfied.

“Low-dose isotretinoin effectively controlled papule and pustule acne lesions, whereas use of 1,550-nm Er:glass NAFL may significantly reduce the number of comedones and improve boxcar atrophic scars,” the authors wrote.

They authors reported no significant interest with commercial supporters.

SOURCE: Xia J et al. Dermatol Surg. 2018 Sep;44(9):1201-8.

SAN DIEGO – The development of ablative fractional lasers has revolutionized how dermatologists treat scars, according to Jill S. Waibel, MD.

“I tell patients it’s like boiling water in a tea kettle and watching the vapor form,” Dr. Waibel, a dermatologist with the Miami Dermatology and Laser Institute, said at the annual Masters of Aesthetics Symposium. “You literally ‘steam off’ their bad scar and the human body will heal that wound to almost normal skin. It’s the closest thing we have to a magic wand.”

In the not-too-distant past, dermatologists “were treating scars just to make them look better,” she said. However, thanks to groundbreaking work by clinicians at Naval Medical Center San Diego, the use of ablative fractional lasers to treat scars was found to improve range of motion in patients, as well as their pain and pruritus. “It represents a major innovation that heals in ways not previously possible,” said Dr. Waibel, who is also chief of dermatology at Baptist Hospital in Miami. “We’re not just healing the scar; we’re healing the skin back to its physiological normal place. A lot of these patients suffer quite a bit.”

Dr. Waibel likened her scar treatment approach to a three-course meal. Lesion color drives her choice of what device to use as an “appetizer” treatment. Most scars are either red (erythematous), brown (hyperpigmented), or white (hypopigmented). Though every scar is unique and individually evaluated for treatment, typically she uses pulsed dye laser, intense pulsed light, or broadband light therapy to treat erythematous/early scars; nonablative fractional lasers to treat atrophic scars, and the thulium or 1,470-nm laser to treat hyperpigmented scars. The “main course” device in her practice is an ablative fractional erbium or CO₂ laser.

“Once I treat the scar three to five times, I might switch to a nonablative laser, but I’m really an ablative fractional user,” Dr. Waibel said. “Dessert” can be whatever adjunctive therapies you need, she continued. This may include triamcinolone acetonide, 5-fluorouracil, poly-l-lactic acid, hyaluronidase, Z-plasty, punch biopsies, shave biopsies, compression, chemical reconstruction of skin scars (CROSS), and subcision.

For erythematous surgical and trauma scars, she uses a combination of pulsed dye laser and ablative fractional laser. “Same day, same treatment; one after each other,” she said. She favors using intense pulsed light for donor sites because it has filters that address both melanin and hemosiderin, superiority for scar erythema, and deeper penetration with greater speed to treat large surface areas.

One recent advance in the vascular arena is the new 595-nm pulsed dye laser by Candela, known as the VBeam Prima. It features increased energy, a 15-nm spot size, a zoom hand piece, once-a-day calibration, and contact cooling, which may be better for pigmented and possibly microvascular structures. The device is cleared for treating conditions like rosacea, acne, spider veins, port-wine stains, wrinkles, warts and stretch marks, as well as photoaging and benign pigmented lesions.

Dr. Waibel’s go-to device for treating a hypertrophic, hyperpigmented surgical scar is a 1927-nm or 1470-nm nonablative fractional laser, followed by a fractional ablative laser and injection of 1-2 ccs of 5-fluorouracil only to elevated areas. Hypopigmented scars are “by far the toughest to treat,” she said. However, she has a formula for these, too, and recently conducted a trial comparing the efficacy of nonablative fractional laser, ablative fractional laser, and ablative fractional laser followed by laser-assisted delivery of bimatoprost (Latisse) to treat hypopigmentation.

Surgical scars get better on their own in many cases, but sometimes early intervention is warranted. “Most surgeons will tell patients, ‘Wait a year. What you have [in terms of scar formation] is what you have,’” Dr. Waibel said. “If a surgical scar becomes hypertrophic, it does so within a month of surgery. I don’t prophylactically treat surgical scars unless the patient has had multiple surgeries in the same location with trouble healing. But if it’s been 6 months to a year, or if the patient is developing hypertrophic scars, then I will treat.”

Acne scars are challenging, because patients want to look good right away. “With deep scars, it takes several treatments to see good improvements,” she said. “I tell all my acne scar patients it takes a year [to get good results].”

Most burn patients require three to six treatment sessions, “but sometimes you get remarkable improvement sooner,” she said. “That’s due to the patient’s healing.” She and her associates recently completed an unpublished study that examined early intervention of fractional ablative laser versus control in 20 subjects with acute burn injuries who ranged in age from 18 to 80 years. The subjects underwent treatment with an ablative fractional CO₂ laser within 3 months of sustaining the burn injury, leaving an untreated control area for comparison. According to Dr. Waibel, 100% of the blinded physician evaluators graded the laser-treated area correctly, compared with the control area. In addition, a significant improvement in all points of the Manchester Scar Scale was observed in the laser-treated area. “The earlier you treat burn and trauma patients, the easier it is to get them back to normal,” she said.

Dr. Waibel disclosed that she has conducted clinical research for Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.

[email protected]

SAN DIEGO – The development of ablative fractional lasers has revolutionized how dermatologists treat scars, according to Jill S. Waibel, MD.

“I tell patients it’s like boiling water in a tea kettle and watching the vapor form,” Dr. Waibel, a dermatologist with the Miami Dermatology and Laser Institute, said at the annual Masters of Aesthetics Symposium. “You literally ‘steam off’ their bad scar and the human body will heal that wound to almost normal skin. It’s the closest thing we have to a magic wand.”

In the not-too-distant past, dermatologists “were treating scars just to make them look better,” she said. However, thanks to groundbreaking work by clinicians at Naval Medical Center San Diego, the use of ablative fractional lasers to treat scars was found to improve range of motion in patients, as well as their pain and pruritus. “It represents a major innovation that heals in ways not previously possible,” said Dr. Waibel, who is also chief of dermatology at Baptist Hospital in Miami. “We’re not just healing the scar; we’re healing the skin back to its physiological normal place. A lot of these patients suffer quite a bit.”

Dr. Waibel likened her scar treatment approach to a three-course meal. Lesion color drives her choice of what device to use as an “appetizer” treatment. Most scars are either red (erythematous), brown (hyperpigmented), or white (hypopigmented). Though every scar is unique and individually evaluated for treatment, typically she uses pulsed dye laser, intense pulsed light, or broadband light therapy to treat erythematous/early scars; nonablative fractional lasers to treat atrophic scars, and the thulium or 1,470-nm laser to treat hyperpigmented scars. The “main course” device in her practice is an ablative fractional erbium or CO₂ laser.

“Once I treat the scar three to five times, I might switch to a nonablative laser, but I’m really an ablative fractional user,” Dr. Waibel said. “Dessert” can be whatever adjunctive therapies you need, she continued. This may include triamcinolone acetonide, 5-fluorouracil, poly-l-lactic acid, hyaluronidase, Z-plasty, punch biopsies, shave biopsies, compression, chemical reconstruction of skin scars (CROSS), and subcision.

For erythematous surgical and trauma scars, she uses a combination of pulsed dye laser and ablative fractional laser. “Same day, same treatment; one after each other,” she said. She favors using intense pulsed light for donor sites because it has filters that address both melanin and hemosiderin, superiority for scar erythema, and deeper penetration with greater speed to treat large surface areas.

One recent advance in the vascular arena is the new 595-nm pulsed dye laser by Candela, known as the VBeam Prima. It features increased energy, a 15-nm spot size, a zoom hand piece, once-a-day calibration, and contact cooling, which may be better for pigmented and possibly microvascular structures. The device is cleared for treating conditions like rosacea, acne, spider veins, port-wine stains, wrinkles, warts and stretch marks, as well as photoaging and benign pigmented lesions.

Dr. Waibel’s go-to device for treating a hypertrophic, hyperpigmented surgical scar is a 1927-nm or 1470-nm nonablative fractional laser, followed by a fractional ablative laser and injection of 1-2 ccs of 5-fluorouracil only to elevated areas. Hypopigmented scars are “by far the toughest to treat,” she said. However, she has a formula for these, too, and recently conducted a trial comparing the efficacy of nonablative fractional laser, ablative fractional laser, and ablative fractional laser followed by laser-assisted delivery of bimatoprost (Latisse) to treat hypopigmentation.

Surgical scars get better on their own in many cases, but sometimes early intervention is warranted. “Most surgeons will tell patients, ‘Wait a year. What you have [in terms of scar formation] is what you have,’” Dr. Waibel said. “If a surgical scar becomes hypertrophic, it does so within a month of surgery. I don’t prophylactically treat surgical scars unless the patient has had multiple surgeries in the same location with trouble healing. But if it’s been 6 months to a year, or if the patient is developing hypertrophic scars, then I will treat.”

Acne scars are challenging, because patients want to look good right away. “With deep scars, it takes several treatments to see good improvements,” she said. “I tell all my acne scar patients it takes a year [to get good results].”

Most burn patients require three to six treatment sessions, “but sometimes you get remarkable improvement sooner,” she said. “That’s due to the patient’s healing.” She and her associates recently completed an unpublished study that examined early intervention of fractional ablative laser versus control in 20 subjects with acute burn injuries who ranged in age from 18 to 80 years. The subjects underwent treatment with an ablative fractional CO₂ laser within 3 months of sustaining the burn injury, leaving an untreated control area for comparison. According to Dr. Waibel, 100% of the blinded physician evaluators graded the laser-treated area correctly, compared with the control area. In addition, a significant improvement in all points of the Manchester Scar Scale was observed in the laser-treated area. “The earlier you treat burn and trauma patients, the easier it is to get them back to normal,” she said.

Dr. Waibel disclosed that she has conducted clinical research for Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.

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SAN DIEGO – The development of ablative fractional lasers has revolutionized how dermatologists treat scars, according to Jill S. Waibel, MD.

“I tell patients it’s like boiling water in a tea kettle and watching the vapor form,” Dr. Waibel, a dermatologist with the Miami Dermatology and Laser Institute, said at the annual Masters of Aesthetics Symposium. “You literally ‘steam off’ their bad scar and the human body will heal that wound to almost normal skin. It’s the closest thing we have to a magic wand.”

In the not-too-distant past, dermatologists “were treating scars just to make them look better,” she said. However, thanks to groundbreaking work by clinicians at Naval Medical Center San Diego, the use of ablative fractional lasers to treat scars was found to improve range of motion in patients, as well as their pain and pruritus. “It represents a major innovation that heals in ways not previously possible,” said Dr. Waibel, who is also chief of dermatology at Baptist Hospital in Miami. “We’re not just healing the scar; we’re healing the skin back to its physiological normal place. A lot of these patients suffer quite a bit.”

Dr. Waibel likened her scar treatment approach to a three-course meal. Lesion color drives her choice of what device to use as an “appetizer” treatment. Most scars are either red (erythematous), brown (hyperpigmented), or white (hypopigmented). Though every scar is unique and individually evaluated for treatment, typically she uses pulsed dye laser, intense pulsed light, or broadband light therapy to treat erythematous/early scars; nonablative fractional lasers to treat atrophic scars, and the thulium or 1,470-nm laser to treat hyperpigmented scars. The “main course” device in her practice is an ablative fractional erbium or CO₂ laser.

“Once I treat the scar three to five times, I might switch to a nonablative laser, but I’m really an ablative fractional user,” Dr. Waibel said. “Dessert” can be whatever adjunctive therapies you need, she continued. This may include triamcinolone acetonide, 5-fluorouracil, poly-l-lactic acid, hyaluronidase, Z-plasty, punch biopsies, shave biopsies, compression, chemical reconstruction of skin scars (CROSS), and subcision.

For erythematous surgical and trauma scars, she uses a combination of pulsed dye laser and ablative fractional laser. “Same day, same treatment; one after each other,” she said. She favors using intense pulsed light for donor sites because it has filters that address both melanin and hemosiderin, superiority for scar erythema, and deeper penetration with greater speed to treat large surface areas.

One recent advance in the vascular arena is the new 595-nm pulsed dye laser by Candela, known as the VBeam Prima. It features increased energy, a 15-nm spot size, a zoom hand piece, once-a-day calibration, and contact cooling, which may be better for pigmented and possibly microvascular structures. The device is cleared for treating conditions like rosacea, acne, spider veins, port-wine stains, wrinkles, warts and stretch marks, as well as photoaging and benign pigmented lesions.

Dr. Waibel’s go-to device for treating a hypertrophic, hyperpigmented surgical scar is a 1927-nm or 1470-nm nonablative fractional laser, followed by a fractional ablative laser and injection of 1-2 ccs of 5-fluorouracil only to elevated areas. Hypopigmented scars are “by far the toughest to treat,” she said. However, she has a formula for these, too, and recently conducted a trial comparing the efficacy of nonablative fractional laser, ablative fractional laser, and ablative fractional laser followed by laser-assisted delivery of bimatoprost (Latisse) to treat hypopigmentation.

Surgical scars get better on their own in many cases, but sometimes early intervention is warranted. “Most surgeons will tell patients, ‘Wait a year. What you have [in terms of scar formation] is what you have,’” Dr. Waibel said. “If a surgical scar becomes hypertrophic, it does so within a month of surgery. I don’t prophylactically treat surgical scars unless the patient has had multiple surgeries in the same location with trouble healing. But if it’s been 6 months to a year, or if the patient is developing hypertrophic scars, then I will treat.”

Acne scars are challenging, because patients want to look good right away. “With deep scars, it takes several treatments to see good improvements,” she said. “I tell all my acne scar patients it takes a year [to get good results].”

Most burn patients require three to six treatment sessions, “but sometimes you get remarkable improvement sooner,” she said. “That’s due to the patient’s healing.” She and her associates recently completed an unpublished study that examined early intervention of fractional ablative laser versus control in 20 subjects with acute burn injuries who ranged in age from 18 to 80 years. The subjects underwent treatment with an ablative fractional CO₂ laser within 3 months of sustaining the burn injury, leaving an untreated control area for comparison. According to Dr. Waibel, 100% of the blinded physician evaluators graded the laser-treated area correctly, compared with the control area. In addition, a significant improvement in all points of the Manchester Scar Scale was observed in the laser-treated area. “The earlier you treat burn and trauma patients, the easier it is to get them back to normal,” she said.

Dr. Waibel disclosed that she has conducted clinical research for Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.

[email protected]

CHICAGO – The future looks bright for reflectance confocal microscopy (RCM) as a tie breaker to decide whether skin lesions that are equivocal on dermoscopy warrant biopsy to rule out malignancy, Ann M. John, MD, asserted at the annual meeting of the American College of Mohs Surgery.

“With the advent of dermoscopy, dermatologists were able to elucidate both benign and malignant patterns to help further guide their decision to biopsy or not. This increased diagnostic accuracy of suspicious lesions by 30%, while reducing the benign to malignant ratio of biopsies performed from 18:1 to 4:1. However, there are still lesions that are equivocal on dermoscopy, as we all know, and for this, there’s reflectance confocal microscopy,” observed Dr. John, of Robert Wood Johnson Medical School, New Brunswick, N.J.

RCM is a device technology that’s been cleared by the Food and Drug Administration since 2008 for the imaging of clinically suspicious lesions. It employs laser scanning to assess the light-scattering properties of cells in the epidermis and dermis, generating images with resolution comparable to histology.

RCM took a back seat initially while American dermatologists were gradually coming to embrace dermoscopy, which their European colleagues had done years earlier. Now, with the availability of handheld RCM for use in the dermatology clinic, expect RCM to assume a growing role in daily practice.

To illustrate the power of RCM as a diagnostic aid, she presented a single-center retrospective study of 1,189 clinically suspicious skin lesions that were equivocal on dermoscopy and then assessed using RCM with 1 year of subsequent patient follow-up. Overall, 155 lesions were deemed positive for cancer or atypia by RCM, while 1,034 were determined to be benign. Of those 155, 46 lesions were considered false positives because of their benign appearance on histologic inspection of the biopsy sample. Only 2 of the 1,034 lesions identified as negative by RCM proved to be false negatives on the basis of clinical changes within 1 year.

The overall sensitivity and specificity of RCM was 98.2% and 99.8%, respectively, with a positive predictive value of 70.3% and a negative predictive value of 99.8%.

The entire RCM procedure takes a skilled technician 15-20 minutes per lesion. As a practical matter, other investigators have estimated that RCM results in a cost savings of about $308,000 per million health plan members per year by reducing the need for biopsies (Dermatol Clin. 2016 Oct;34[4]:367-75).

In addition to evaluating clinically suspicious lesions, other situations in which RCM offers practical value include its use directly before the first cut during Mohs surgery in order to determine the margins of atypia; ex vivo imaging of Mohs margins, which has been shown to be comparable with frozen sections in accuracy but takes only one-third of the time; and imaging of biopsied lesions in order to determine the diagnosis relatively quickly, Dr. John noted.

She reported having no financial conflicts regarding her study.

[email protected]

CHICAGO – The future looks bright for reflectance confocal microscopy (RCM) as a tie breaker to decide whether skin lesions that are equivocal on dermoscopy warrant biopsy to rule out malignancy, Ann M. John, MD, asserted at the annual meeting of the American College of Mohs Surgery.

“With the advent of dermoscopy, dermatologists were able to elucidate both benign and malignant patterns to help further guide their decision to biopsy or not. This increased diagnostic accuracy of suspicious lesions by 30%, while reducing the benign to malignant ratio of biopsies performed from 18:1 to 4:1. However, there are still lesions that are equivocal on dermoscopy, as we all know, and for this, there’s reflectance confocal microscopy,” observed Dr. John, of Robert Wood Johnson Medical School, New Brunswick, N.J.

RCM is a device technology that’s been cleared by the Food and Drug Administration since 2008 for the imaging of clinically suspicious lesions. It employs laser scanning to assess the light-scattering properties of cells in the epidermis and dermis, generating images with resolution comparable to histology.

RCM took a back seat initially while American dermatologists were gradually coming to embrace dermoscopy, which their European colleagues had done years earlier. Now, with the availability of handheld RCM for use in the dermatology clinic, expect RCM to assume a growing role in daily practice.

To illustrate the power of RCM as a diagnostic aid, she presented a single-center retrospective study of 1,189 clinically suspicious skin lesions that were equivocal on dermoscopy and then assessed using RCM with 1 year of subsequent patient follow-up. Overall, 155 lesions were deemed positive for cancer or atypia by RCM, while 1,034 were determined to be benign. Of those 155, 46 lesions were considered false positives because of their benign appearance on histologic inspection of the biopsy sample. Only 2 of the 1,034 lesions identified as negative by RCM proved to be false negatives on the basis of clinical changes within 1 year.

The overall sensitivity and specificity of RCM was 98.2% and 99.8%, respectively, with a positive predictive value of 70.3% and a negative predictive value of 99.8%.

The entire RCM procedure takes a skilled technician 15-20 minutes per lesion. As a practical matter, other investigators have estimated that RCM results in a cost savings of about $308,000 per million health plan members per year by reducing the need for biopsies (Dermatol Clin. 2016 Oct;34[4]:367-75).

In addition to evaluating clinically suspicious lesions, other situations in which RCM offers practical value include its use directly before the first cut during Mohs surgery in order to determine the margins of atypia; ex vivo imaging of Mohs margins, which has been shown to be comparable with frozen sections in accuracy but takes only one-third of the time; and imaging of biopsied lesions in order to determine the diagnosis relatively quickly, Dr. John noted.

She reported having no financial conflicts regarding her study.

[email protected]

CHICAGO – The future looks bright for reflectance confocal microscopy (RCM) as a tie breaker to decide whether skin lesions that are equivocal on dermoscopy warrant biopsy to rule out malignancy, Ann M. John, MD, asserted at the annual meeting of the American College of Mohs Surgery.

“With the advent of dermoscopy, dermatologists were able to elucidate both benign and malignant patterns to help further guide their decision to biopsy or not. This increased diagnostic accuracy of suspicious lesions by 30%, while reducing the benign to malignant ratio of biopsies performed from 18:1 to 4:1. However, there are still lesions that are equivocal on dermoscopy, as we all know, and for this, there’s reflectance confocal microscopy,” observed Dr. John, of Robert Wood Johnson Medical School, New Brunswick, N.J.

RCM is a device technology that’s been cleared by the Food and Drug Administration since 2008 for the imaging of clinically suspicious lesions. It employs laser scanning to assess the light-scattering properties of cells in the epidermis and dermis, generating images with resolution comparable to histology.

RCM took a back seat initially while American dermatologists were gradually coming to embrace dermoscopy, which their European colleagues had done years earlier. Now, with the availability of handheld RCM for use in the dermatology clinic, expect RCM to assume a growing role in daily practice.

To illustrate the power of RCM as a diagnostic aid, she presented a single-center retrospective study of 1,189 clinically suspicious skin lesions that were equivocal on dermoscopy and then assessed using RCM with 1 year of subsequent patient follow-up. Overall, 155 lesions were deemed positive for cancer or atypia by RCM, while 1,034 were determined to be benign. Of those 155, 46 lesions were considered false positives because of their benign appearance on histologic inspection of the biopsy sample. Only 2 of the 1,034 lesions identified as negative by RCM proved to be false negatives on the basis of clinical changes within 1 year.

The overall sensitivity and specificity of RCM was 98.2% and 99.8%, respectively, with a positive predictive value of 70.3% and a negative predictive value of 99.8%.

The entire RCM procedure takes a skilled technician 15-20 minutes per lesion. As a practical matter, other investigators have estimated that RCM results in a cost savings of about $308,000 per million health plan members per year by reducing the need for biopsies (Dermatol Clin. 2016 Oct;34[4]:367-75).

In addition to evaluating clinically suspicious lesions, other situations in which RCM offers practical value include its use directly before the first cut during Mohs surgery in order to determine the margins of atypia; ex vivo imaging of Mohs margins, which has been shown to be comparable with frozen sections in accuracy but takes only one-third of the time; and imaging of biopsied lesions in order to determine the diagnosis relatively quickly, Dr. John noted.

She reported having no financial conflicts regarding her study.

[email protected]