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Mohs underutilized for melanoma of head and neck
CHICAGO – Contemporary national guidelines undervalue the benefits of Mohs micrographic surgery for patients with melanoma of the head and neck, William C. Fix asserted at the annual meeting of the American College of Mohs Surgery.
Mr. Fix, a medical student at the University of Pennsylvania, Philadelphia, presented a single-center retrospective study of 13,644 cases of head and neck skin cancer treated with Mohs micrographic surgery (MMS) for margin control. The cohort included 1,065 melanomas in situ, 410 invasive melanomas, more than 8,700 basal cell carcinomas, and 3,343 squamous cell carcinomas.
Mr. Fix and his coinvestigators undertook this observational study because they identified a gap in current guidelines for treatment of skin cancers of the head and neck. For example, the National Comprehensive Cancer Network recommends margin control at the time of primary surgery for BCCs and SCCs deemed at high risk for local recurrence and defines what those high-risk features are. For melanomas, however, the guidelines recommend wide local excision, even though that approach has roughly a 10% recurrence rate, compared with less than 1% for MMS.
Moreover, the 2012 appropriate use criteria for MMS put forth by the American Academy of Dermatology in concert with several other medical societies are unclear about invasive melanoma. As a result of this lack of guidance, the use of margin control in primary surgery for melanoma is applied in less than 4% of cases, according to Mr. Fix.
The University of Pennsylvania data he presented showed that melanomas of the head and neck were significantly more likely to be large in size, to be poorly defined, and to have other high-risk features for local recurrence than were the BCCs and SCCs. In a multivariate logistic regression analysis controlling for high-risk characteristics, melanomas were independently associated with a twofold increased likelihood of requiring flap reconstruction compared with BCCs and SCCs of the head and neck.
“We’ve shown that melanomas have high-risk features for local recurrence, possibly to a greater extent than BCCs and SCCs. These features help us triage resource use for BCC and SCC. Could these same features help us make decisions for melanomas?” he asked rhetorically.
Mr. Fix reported having no financial conflicts of interest regarding his study, which was conducted free of commercial support.
CHICAGO – Contemporary national guidelines undervalue the benefits of Mohs micrographic surgery for patients with melanoma of the head and neck, William C. Fix asserted at the annual meeting of the American College of Mohs Surgery.
Mr. Fix, a medical student at the University of Pennsylvania, Philadelphia, presented a single-center retrospective study of 13,644 cases of head and neck skin cancer treated with Mohs micrographic surgery (MMS) for margin control. The cohort included 1,065 melanomas in situ, 410 invasive melanomas, more than 8,700 basal cell carcinomas, and 3,343 squamous cell carcinomas.
Mr. Fix and his coinvestigators undertook this observational study because they identified a gap in current guidelines for treatment of skin cancers of the head and neck. For example, the National Comprehensive Cancer Network recommends margin control at the time of primary surgery for BCCs and SCCs deemed at high risk for local recurrence and defines what those high-risk features are. For melanomas, however, the guidelines recommend wide local excision, even though that approach has roughly a 10% recurrence rate, compared with less than 1% for MMS.
Moreover, the 2012 appropriate use criteria for MMS put forth by the American Academy of Dermatology in concert with several other medical societies are unclear about invasive melanoma. As a result of this lack of guidance, the use of margin control in primary surgery for melanoma is applied in less than 4% of cases, according to Mr. Fix.
The University of Pennsylvania data he presented showed that melanomas of the head and neck were significantly more likely to be large in size, to be poorly defined, and to have other high-risk features for local recurrence than were the BCCs and SCCs. In a multivariate logistic regression analysis controlling for high-risk characteristics, melanomas were independently associated with a twofold increased likelihood of requiring flap reconstruction compared with BCCs and SCCs of the head and neck.
“We’ve shown that melanomas have high-risk features for local recurrence, possibly to a greater extent than BCCs and SCCs. These features help us triage resource use for BCC and SCC. Could these same features help us make decisions for melanomas?” he asked rhetorically.
Mr. Fix reported having no financial conflicts of interest regarding his study, which was conducted free of commercial support.
CHICAGO – Contemporary national guidelines undervalue the benefits of Mohs micrographic surgery for patients with melanoma of the head and neck, William C. Fix asserted at the annual meeting of the American College of Mohs Surgery.
Mr. Fix, a medical student at the University of Pennsylvania, Philadelphia, presented a single-center retrospective study of 13,644 cases of head and neck skin cancer treated with Mohs micrographic surgery (MMS) for margin control. The cohort included 1,065 melanomas in situ, 410 invasive melanomas, more than 8,700 basal cell carcinomas, and 3,343 squamous cell carcinomas.
Mr. Fix and his coinvestigators undertook this observational study because they identified a gap in current guidelines for treatment of skin cancers of the head and neck. For example, the National Comprehensive Cancer Network recommends margin control at the time of primary surgery for BCCs and SCCs deemed at high risk for local recurrence and defines what those high-risk features are. For melanomas, however, the guidelines recommend wide local excision, even though that approach has roughly a 10% recurrence rate, compared with less than 1% for MMS.
Moreover, the 2012 appropriate use criteria for MMS put forth by the American Academy of Dermatology in concert with several other medical societies are unclear about invasive melanoma. As a result of this lack of guidance, the use of margin control in primary surgery for melanoma is applied in less than 4% of cases, according to Mr. Fix.
The University of Pennsylvania data he presented showed that melanomas of the head and neck were significantly more likely to be large in size, to be poorly defined, and to have other high-risk features for local recurrence than were the BCCs and SCCs. In a multivariate logistic regression analysis controlling for high-risk characteristics, melanomas were independently associated with a twofold increased likelihood of requiring flap reconstruction compared with BCCs and SCCs of the head and neck.
“We’ve shown that melanomas have high-risk features for local recurrence, possibly to a greater extent than BCCs and SCCs. These features help us triage resource use for BCC and SCC. Could these same features help us make decisions for melanomas?” he asked rhetorically.
Mr. Fix reported having no financial conflicts of interest regarding his study, which was conducted free of commercial support.
REPORTING FROM THE ACMS ANNUAL MEETING
Key clinical point: Margin control at the time of primary surgery for melanoma of the head and neck makes sense.
Major finding: Patients with a melanoma of the head and neck were twice as likely to require secondary flap reconstruction compared with patients with a basal cell carcinoma or squamous cell carcinoma of the head and neck.
Study details: A retrospective single-center study of 13,644 cases of skin cancer of the head and neck treated with Mohs surgery.
Disclosures: The presenter reported having no financial conflicts regarding the study, which was conducted free of commercial support.
Taking the sting out of nail surgery: Postoperative pain pearls
CHICAGO – In a busy clinic it can be hard to find the time to stop, talk, and listen. But doing so will “pay dividends in time spent later – and in reduced complications” of nail surgery, according to Molly A. Hinshaw, MD.
Dr. Hinshaw, director of the nail clinic at the University of Wisconsin–Madison, shared her
“One pearl is the importance of patient education before we start,” Dr. Hinshaw said. Preoperatively, she takes time to talk through the entire surgery and expected postoperative course. Critically, she reassures patients that pain will be controlled; she also reviews in detail what the pharmacologic and nonpharmacologic pain control strategies will be.
In addition, it’s important to address patients’ natural anxiety about what the surgical site will look and feel like and how healing will progress, particularly in those first few days after surgery. “I offer a first dressing change in my practice, either at 24 or 48 hours. This can be very anxiolytic for the patient,” she said.
At the preoperative stage, Dr. Hinshaw also tells patients that, from a healing and pain management standpoint, to make sure they plan “to have a restful 48 hours after surgery.” Her patient instructions for the immediate postoperative period include keeping the limb elevated and avoiding unnecessary activity with the affected limb while the digit, whether a finger or toe, is still anesthetized. To stay on top of the pain, the appropriate oral pain medication should be started once sensation starts to return to the digit. She recommends patients also take a dose of their pain medication at bedtime, as this will help them get a restful night of sleep.
“One thing that I’ve learned over the years is that throbbing and a little bit of swelling after surgery is not uncommon,” said Dr. Hinshaw, who uses elastic self-adherent wrap for the top layer of wound dressings after nail surgery. She tells her patients, “if you’re feeling throbbing, you’re welcome to unwrap it and rewrap it more loosely.” Just giving the patient the ability to find a comfortable level of pressure on the affected digit is often enough to alleviate the throbbing, as opposed to treating that throbbing with pain medication.
Dr. Hinshaw said she’s learned to tailor her postoperative analgesia to the surgery and to the patient. With all patients, she is sure to make medication and dosing choices that take comorbidities and potential drug-drug interactions into account. She does not ask patients to stop anticoagulation before nail procedures.
For phenolization procedures and punch biopsies, she’ll advise patients to use acetaminophen or NSAIDs. Some procedures are going to have a more painful recovery course, said Dr. Hinshaw, so she’ll use an opioid such as hydrocodone with acetaminophen for shave excisions and fusiform longitudinal excisions.
The physician and patient can also plan ahead for a brief course of more potent opioids for some procedures. “Certainly for lateral longitudinal excisions, they will need narcotic pain management for at least 48 hours after surgery,” she noted. “It’s a painful surgery.”
Other procedures that will need more postoperative analgesia include flaps and nail unit grafts, she said. In general, NSAIDs are useful to add after the first 24 hours. In addition, “I always call my patients the day after surgery to see how they’re doing. This helps identify any issues and questions early and is comforting to the patient,” she added.
Dr. Hinshaw disclosed that she has an ownership stake in and sits on the board of directors of Accure Medical.
CHICAGO – In a busy clinic it can be hard to find the time to stop, talk, and listen. But doing so will “pay dividends in time spent later – and in reduced complications” of nail surgery, according to Molly A. Hinshaw, MD.
Dr. Hinshaw, director of the nail clinic at the University of Wisconsin–Madison, shared her
“One pearl is the importance of patient education before we start,” Dr. Hinshaw said. Preoperatively, she takes time to talk through the entire surgery and expected postoperative course. Critically, she reassures patients that pain will be controlled; she also reviews in detail what the pharmacologic and nonpharmacologic pain control strategies will be.
In addition, it’s important to address patients’ natural anxiety about what the surgical site will look and feel like and how healing will progress, particularly in those first few days after surgery. “I offer a first dressing change in my practice, either at 24 or 48 hours. This can be very anxiolytic for the patient,” she said.
At the preoperative stage, Dr. Hinshaw also tells patients that, from a healing and pain management standpoint, to make sure they plan “to have a restful 48 hours after surgery.” Her patient instructions for the immediate postoperative period include keeping the limb elevated and avoiding unnecessary activity with the affected limb while the digit, whether a finger or toe, is still anesthetized. To stay on top of the pain, the appropriate oral pain medication should be started once sensation starts to return to the digit. She recommends patients also take a dose of their pain medication at bedtime, as this will help them get a restful night of sleep.
“One thing that I’ve learned over the years is that throbbing and a little bit of swelling after surgery is not uncommon,” said Dr. Hinshaw, who uses elastic self-adherent wrap for the top layer of wound dressings after nail surgery. She tells her patients, “if you’re feeling throbbing, you’re welcome to unwrap it and rewrap it more loosely.” Just giving the patient the ability to find a comfortable level of pressure on the affected digit is often enough to alleviate the throbbing, as opposed to treating that throbbing with pain medication.
Dr. Hinshaw said she’s learned to tailor her postoperative analgesia to the surgery and to the patient. With all patients, she is sure to make medication and dosing choices that take comorbidities and potential drug-drug interactions into account. She does not ask patients to stop anticoagulation before nail procedures.
For phenolization procedures and punch biopsies, she’ll advise patients to use acetaminophen or NSAIDs. Some procedures are going to have a more painful recovery course, said Dr. Hinshaw, so she’ll use an opioid such as hydrocodone with acetaminophen for shave excisions and fusiform longitudinal excisions.
The physician and patient can also plan ahead for a brief course of more potent opioids for some procedures. “Certainly for lateral longitudinal excisions, they will need narcotic pain management for at least 48 hours after surgery,” she noted. “It’s a painful surgery.”
Other procedures that will need more postoperative analgesia include flaps and nail unit grafts, she said. In general, NSAIDs are useful to add after the first 24 hours. In addition, “I always call my patients the day after surgery to see how they’re doing. This helps identify any issues and questions early and is comforting to the patient,” she added.
Dr. Hinshaw disclosed that she has an ownership stake in and sits on the board of directors of Accure Medical.
CHICAGO – In a busy clinic it can be hard to find the time to stop, talk, and listen. But doing so will “pay dividends in time spent later – and in reduced complications” of nail surgery, according to Molly A. Hinshaw, MD.
Dr. Hinshaw, director of the nail clinic at the University of Wisconsin–Madison, shared her
“One pearl is the importance of patient education before we start,” Dr. Hinshaw said. Preoperatively, she takes time to talk through the entire surgery and expected postoperative course. Critically, she reassures patients that pain will be controlled; she also reviews in detail what the pharmacologic and nonpharmacologic pain control strategies will be.
In addition, it’s important to address patients’ natural anxiety about what the surgical site will look and feel like and how healing will progress, particularly in those first few days after surgery. “I offer a first dressing change in my practice, either at 24 or 48 hours. This can be very anxiolytic for the patient,” she said.
At the preoperative stage, Dr. Hinshaw also tells patients that, from a healing and pain management standpoint, to make sure they plan “to have a restful 48 hours after surgery.” Her patient instructions for the immediate postoperative period include keeping the limb elevated and avoiding unnecessary activity with the affected limb while the digit, whether a finger or toe, is still anesthetized. To stay on top of the pain, the appropriate oral pain medication should be started once sensation starts to return to the digit. She recommends patients also take a dose of their pain medication at bedtime, as this will help them get a restful night of sleep.
“One thing that I’ve learned over the years is that throbbing and a little bit of swelling after surgery is not uncommon,” said Dr. Hinshaw, who uses elastic self-adherent wrap for the top layer of wound dressings after nail surgery. She tells her patients, “if you’re feeling throbbing, you’re welcome to unwrap it and rewrap it more loosely.” Just giving the patient the ability to find a comfortable level of pressure on the affected digit is often enough to alleviate the throbbing, as opposed to treating that throbbing with pain medication.
Dr. Hinshaw said she’s learned to tailor her postoperative analgesia to the surgery and to the patient. With all patients, she is sure to make medication and dosing choices that take comorbidities and potential drug-drug interactions into account. She does not ask patients to stop anticoagulation before nail procedures.
For phenolization procedures and punch biopsies, she’ll advise patients to use acetaminophen or NSAIDs. Some procedures are going to have a more painful recovery course, said Dr. Hinshaw, so she’ll use an opioid such as hydrocodone with acetaminophen for shave excisions and fusiform longitudinal excisions.
The physician and patient can also plan ahead for a brief course of more potent opioids for some procedures. “Certainly for lateral longitudinal excisions, they will need narcotic pain management for at least 48 hours after surgery,” she noted. “It’s a painful surgery.”
Other procedures that will need more postoperative analgesia include flaps and nail unit grafts, she said. In general, NSAIDs are useful to add after the first 24 hours. In addition, “I always call my patients the day after surgery to see how they’re doing. This helps identify any issues and questions early and is comforting to the patient,” she added.
Dr. Hinshaw disclosed that she has an ownership stake in and sits on the board of directors of Accure Medical.
EXPERT ANALYSIS FROM SUMMER AAD 2018
Cost-effective wound healing described with fetal bovine collagen matrix
CHICAGO – A novel, commercially available fetal bovine collagen matrix provides “an ideal wound healing environment” for outpatient treatment of partial and full thickness wounds, ulcers, burns, and surgical wounds, Katarina R. Kesty, MD, declared at the annual meeting of the American College of Mohs Surgery.
“. We applied this product to 46 patients over 10 months and have observed favorable healing times and good cosmesis,” said Dr. Kesty, a dermatology resident at Wake Forest University, Winston-Salem, N.C.
She shared the clinical experience she and her colleagues have accrued with this product, which is called PriMatrix and is manufactured by Integra LifeSciences. She also explained how to successfully code and bill for its use.
“In-office application of this product is cost-effective when compared to similar products applied in the operating room by plastic surgeons and other specialists,” Dr. Kesty noted.
How cost-effective? She provided one example of a patient with a 12.6-cm2 defect on the scalp repaired with fetal bovine collagen matrix. Upon application of the appropriate billing codes, this repair was reimbursed by Medicare to the tune of $1,208. In contrast, another patient at Wake Forest had a 16.6-cm2 Mohs defect on the scalp repaired in the operating room by an oculoplastic surgeon who used split thickness skin grafts. For this procedure, Medicare was billed $30,805.11, and the medical center received $9,241.53 in reimbursement.
“An office repair using this fetal bovine collagen matrix is much more cost-effective,” she observed. “It also saves the patient from the risks of general anesthesia or conscious sedation.”
PriMatrix is a porous acellular collagen matrix derived from fetal bovine dermis. It contains type I and type III collagen, with the latter being particularly effective at attracting growth factors, blood, and angiogenic cytokines in support of dermal regeneration and revascularization. The product is available in solid sheets, mesh, and fenestrated forms in a variety of sizes. It needs to be rehydrated for 1 minute in room temperature saline. It can then be cut to the size of the wound and secured to the wound bed, periosteum, fascia, or cartilage with sutures or staples. The site is then covered with a thick layer of petrolatum and a tie-over bolster.
Dr. Kesty and her dermatology colleagues have applied the matrix to surgical defects ranging in size from 0.2 cm2 to 70 cm2, with an average area of 19 cm2. They have utilized the mesh format most often in order to allow drainage. They found the average healing time when the matrix was applied to exposed bone, periosteum, or perichondrium was 13.8 weeks, compared with 10.8 weeks for subcutaneous wounds.
With the use of the fetal bovine collagen matrix, wounds less than 10 cm2 in size healed in an average of 9.3 weeks, those from 10 cm2 to 25 cm2 in size healed in an average of 10.4 weeks, and wounds larger than 25 cm2 healed in an average of 15.7 weeks.
Coding and reimbursement
PriMatrix has been available for outpatient office use and reimbursement by Medicare since January 2017. Successful reimbursement requires completion of a preauthorization form, which is typically approved on the same day by Medicare and other payers. The proper CPT codes are 1527x, signifying a skin substitute graft less than 100 cm2 in size; Q4110 times the number of 1-cm2 units of PriMatrix utilized; and, when appropriate, ICD10 code Z85.828, for personal history of nonmelanoma skin cancer.
Dr. Kesty reported no financial conflicts of interest.
CHICAGO – A novel, commercially available fetal bovine collagen matrix provides “an ideal wound healing environment” for outpatient treatment of partial and full thickness wounds, ulcers, burns, and surgical wounds, Katarina R. Kesty, MD, declared at the annual meeting of the American College of Mohs Surgery.
“. We applied this product to 46 patients over 10 months and have observed favorable healing times and good cosmesis,” said Dr. Kesty, a dermatology resident at Wake Forest University, Winston-Salem, N.C.
She shared the clinical experience she and her colleagues have accrued with this product, which is called PriMatrix and is manufactured by Integra LifeSciences. She also explained how to successfully code and bill for its use.
“In-office application of this product is cost-effective when compared to similar products applied in the operating room by plastic surgeons and other specialists,” Dr. Kesty noted.
How cost-effective? She provided one example of a patient with a 12.6-cm2 defect on the scalp repaired with fetal bovine collagen matrix. Upon application of the appropriate billing codes, this repair was reimbursed by Medicare to the tune of $1,208. In contrast, another patient at Wake Forest had a 16.6-cm2 Mohs defect on the scalp repaired in the operating room by an oculoplastic surgeon who used split thickness skin grafts. For this procedure, Medicare was billed $30,805.11, and the medical center received $9,241.53 in reimbursement.
“An office repair using this fetal bovine collagen matrix is much more cost-effective,” she observed. “It also saves the patient from the risks of general anesthesia or conscious sedation.”
PriMatrix is a porous acellular collagen matrix derived from fetal bovine dermis. It contains type I and type III collagen, with the latter being particularly effective at attracting growth factors, blood, and angiogenic cytokines in support of dermal regeneration and revascularization. The product is available in solid sheets, mesh, and fenestrated forms in a variety of sizes. It needs to be rehydrated for 1 minute in room temperature saline. It can then be cut to the size of the wound and secured to the wound bed, periosteum, fascia, or cartilage with sutures or staples. The site is then covered with a thick layer of petrolatum and a tie-over bolster.
Dr. Kesty and her dermatology colleagues have applied the matrix to surgical defects ranging in size from 0.2 cm2 to 70 cm2, with an average area of 19 cm2. They have utilized the mesh format most often in order to allow drainage. They found the average healing time when the matrix was applied to exposed bone, periosteum, or perichondrium was 13.8 weeks, compared with 10.8 weeks for subcutaneous wounds.
With the use of the fetal bovine collagen matrix, wounds less than 10 cm2 in size healed in an average of 9.3 weeks, those from 10 cm2 to 25 cm2 in size healed in an average of 10.4 weeks, and wounds larger than 25 cm2 healed in an average of 15.7 weeks.
Coding and reimbursement
PriMatrix has been available for outpatient office use and reimbursement by Medicare since January 2017. Successful reimbursement requires completion of a preauthorization form, which is typically approved on the same day by Medicare and other payers. The proper CPT codes are 1527x, signifying a skin substitute graft less than 100 cm2 in size; Q4110 times the number of 1-cm2 units of PriMatrix utilized; and, when appropriate, ICD10 code Z85.828, for personal history of nonmelanoma skin cancer.
Dr. Kesty reported no financial conflicts of interest.
CHICAGO – A novel, commercially available fetal bovine collagen matrix provides “an ideal wound healing environment” for outpatient treatment of partial and full thickness wounds, ulcers, burns, and surgical wounds, Katarina R. Kesty, MD, declared at the annual meeting of the American College of Mohs Surgery.
“. We applied this product to 46 patients over 10 months and have observed favorable healing times and good cosmesis,” said Dr. Kesty, a dermatology resident at Wake Forest University, Winston-Salem, N.C.
She shared the clinical experience she and her colleagues have accrued with this product, which is called PriMatrix and is manufactured by Integra LifeSciences. She also explained how to successfully code and bill for its use.
“In-office application of this product is cost-effective when compared to similar products applied in the operating room by plastic surgeons and other specialists,” Dr. Kesty noted.
How cost-effective? She provided one example of a patient with a 12.6-cm2 defect on the scalp repaired with fetal bovine collagen matrix. Upon application of the appropriate billing codes, this repair was reimbursed by Medicare to the tune of $1,208. In contrast, another patient at Wake Forest had a 16.6-cm2 Mohs defect on the scalp repaired in the operating room by an oculoplastic surgeon who used split thickness skin grafts. For this procedure, Medicare was billed $30,805.11, and the medical center received $9,241.53 in reimbursement.
“An office repair using this fetal bovine collagen matrix is much more cost-effective,” she observed. “It also saves the patient from the risks of general anesthesia or conscious sedation.”
PriMatrix is a porous acellular collagen matrix derived from fetal bovine dermis. It contains type I and type III collagen, with the latter being particularly effective at attracting growth factors, blood, and angiogenic cytokines in support of dermal regeneration and revascularization. The product is available in solid sheets, mesh, and fenestrated forms in a variety of sizes. It needs to be rehydrated for 1 minute in room temperature saline. It can then be cut to the size of the wound and secured to the wound bed, periosteum, fascia, or cartilage with sutures or staples. The site is then covered with a thick layer of petrolatum and a tie-over bolster.
Dr. Kesty and her dermatology colleagues have applied the matrix to surgical defects ranging in size from 0.2 cm2 to 70 cm2, with an average area of 19 cm2. They have utilized the mesh format most often in order to allow drainage. They found the average healing time when the matrix was applied to exposed bone, periosteum, or perichondrium was 13.8 weeks, compared with 10.8 weeks for subcutaneous wounds.
With the use of the fetal bovine collagen matrix, wounds less than 10 cm2 in size healed in an average of 9.3 weeks, those from 10 cm2 to 25 cm2 in size healed in an average of 10.4 weeks, and wounds larger than 25 cm2 healed in an average of 15.7 weeks.
Coding and reimbursement
PriMatrix has been available for outpatient office use and reimbursement by Medicare since January 2017. Successful reimbursement requires completion of a preauthorization form, which is typically approved on the same day by Medicare and other payers. The proper CPT codes are 1527x, signifying a skin substitute graft less than 100 cm2 in size; Q4110 times the number of 1-cm2 units of PriMatrix utilized; and, when appropriate, ICD10 code Z85.828, for personal history of nonmelanoma skin cancer.
Dr. Kesty reported no financial conflicts of interest.
EXPERT ANALYSIS FROM THE ACMS ANNUAL MEETING
Stress balls, hand-holding no help during dermatology procedures
according to a randomized trial of 135 patients at Northwestern University, Chicago.
In all three groups, anxiety levels were a little over 3 points on a 10-point Visual Analog Scale (VAS) before surgery and around 2 points during it. The 6-item State Trait Anxiety Inventory score was just under 9 in all three groups right after the procedure, meaning patients weren’t very anxious. Physiological measures did not change from before to after the procedure or between groups. Postoperative pain scores were all under 1 on a 10-point scale, and patients in all three groups were highly satisfied with their encounter, the researchers said in JAMA Dermatology.
“Many patients commented anecdotally on the calming effect of hand-holding or stress ball use,” so “it was surprising that the total data did not show these interventions to preferentially decrease anxiety or alleviate pain,” Arianna F. Yanes, a medical student at Northwestern University, and her coinvestigators said.
It could be that standard measures – giving patients an opportunity to ask questions, making sure they feel comfortable, and the like – are enough. However, “hand-holding and stress balls may still provide stress relief in patients who are particularly anxious before the procedure.” Perhaps patients would have preferred having their hand held by a loved one instead of a stranger, the investigators said.
Meanwhile, patients who researched their operation online beforehand had higher preoperative anxiety scores (3.84 vs. 2.62 points on the VAS; P = .04), but they could have been more anxious from the start.
The mean subject age was 66 years, and 62% were men.
The work was funded by Northwestern University and a grant from Merz. The investigators had no relevant disclosures.
SOURCE: Yanes AF et al. JAMA Dermatol. 2018 Jul 18. doi:10.1001/jamadermatol.2018.1783.
according to a randomized trial of 135 patients at Northwestern University, Chicago.
In all three groups, anxiety levels were a little over 3 points on a 10-point Visual Analog Scale (VAS) before surgery and around 2 points during it. The 6-item State Trait Anxiety Inventory score was just under 9 in all three groups right after the procedure, meaning patients weren’t very anxious. Physiological measures did not change from before to after the procedure or between groups. Postoperative pain scores were all under 1 on a 10-point scale, and patients in all three groups were highly satisfied with their encounter, the researchers said in JAMA Dermatology.
“Many patients commented anecdotally on the calming effect of hand-holding or stress ball use,” so “it was surprising that the total data did not show these interventions to preferentially decrease anxiety or alleviate pain,” Arianna F. Yanes, a medical student at Northwestern University, and her coinvestigators said.
It could be that standard measures – giving patients an opportunity to ask questions, making sure they feel comfortable, and the like – are enough. However, “hand-holding and stress balls may still provide stress relief in patients who are particularly anxious before the procedure.” Perhaps patients would have preferred having their hand held by a loved one instead of a stranger, the investigators said.
Meanwhile, patients who researched their operation online beforehand had higher preoperative anxiety scores (3.84 vs. 2.62 points on the VAS; P = .04), but they could have been more anxious from the start.
The mean subject age was 66 years, and 62% were men.
The work was funded by Northwestern University and a grant from Merz. The investigators had no relevant disclosures.
SOURCE: Yanes AF et al. JAMA Dermatol. 2018 Jul 18. doi:10.1001/jamadermatol.2018.1783.
according to a randomized trial of 135 patients at Northwestern University, Chicago.
In all three groups, anxiety levels were a little over 3 points on a 10-point Visual Analog Scale (VAS) before surgery and around 2 points during it. The 6-item State Trait Anxiety Inventory score was just under 9 in all three groups right after the procedure, meaning patients weren’t very anxious. Physiological measures did not change from before to after the procedure or between groups. Postoperative pain scores were all under 1 on a 10-point scale, and patients in all three groups were highly satisfied with their encounter, the researchers said in JAMA Dermatology.
“Many patients commented anecdotally on the calming effect of hand-holding or stress ball use,” so “it was surprising that the total data did not show these interventions to preferentially decrease anxiety or alleviate pain,” Arianna F. Yanes, a medical student at Northwestern University, and her coinvestigators said.
It could be that standard measures – giving patients an opportunity to ask questions, making sure they feel comfortable, and the like – are enough. However, “hand-holding and stress balls may still provide stress relief in patients who are particularly anxious before the procedure.” Perhaps patients would have preferred having their hand held by a loved one instead of a stranger, the investigators said.
Meanwhile, patients who researched their operation online beforehand had higher preoperative anxiety scores (3.84 vs. 2.62 points on the VAS; P = .04), but they could have been more anxious from the start.
The mean subject age was 66 years, and 62% were men.
The work was funded by Northwestern University and a grant from Merz. The investigators had no relevant disclosures.
SOURCE: Yanes AF et al. JAMA Dermatol. 2018 Jul 18. doi:10.1001/jamadermatol.2018.1783.
FROM JAMA DERMATOLOGY
Unlikely mentors
Mentorship is a hot topic. Mentors are generally perceived as knowledgeable, kind, generous souls who will guide mentees through tough challenges and be your pal. I suggest to you that while such encounters are marvelous, and to be sought out, some of the most important lessons are taught by members of the opposite cast.
The presiding secretary of the Ohio state medical board was a brigadier general, still active reserve, tall with a bristling countenance. I was president of the Ohio Dermatological Association and was accompanied by Mark Bechtel, MD, who was our chair of state legislation. We had been invited to , and that there had not been any deaths related to local anesthesia administered by dermatologists in Ohio (or anywhere else). We expected to tell the medical board there was nothing to worry about, and we could all go home. This was 17 years ago.
It quickly became apparent that there had been an extensive prior dialogue between the medical board and representatives of the American College of Surgeons and the American Society of Anesthesiologists. They sat at the head table with the secretary of the medical board.
“In our experience, there are really some dangerous procedures going on in the office setting under local anesthesia, and this area desperately needs regulation,” the anesthesiologist’s representative said. The surgeon’s representative chimed in: “From what I’ve heard, office surgery is a ticking time bomb and needs regulation, and as soon as possible.” This prattle went on and on, with the medical board secretary sympathetically nodding his head. I raised my hand and was ignored – and ignored. It became apparent that this was a show trial, and our opinion was not really wanted, just our attendance noted in the minutes. Finally, I stood up and protested, and pointed out that all of this “testimony” was conjecture and personal opinion, and that there was no factual basis for their claims. The president stiffened, stood up, and started barking orders.He told me to “sit down and not speak unless I was called on.” I sat down and shut up. And I was never called on. Mark Bechtel put a calming hand on my arm. Goodness, I had not been treated like that since junior high.
I soon realized that dermatologists were not at all important to the medical board, and that the medical board had no idea about our safety and efficiency and really did not care.
Following the meeting, I was told by Larry Lanier (the American Academy of Dermatology state legislative liaison at the time) that Ohio was to be the test state to restrict local anesthesia and tumescent anesthesia nationwide. He explained that some widely reported liposuction-related deaths in Florida had given the medical board the “justification” to act. He went on to explain that yes, there were no data either way, but we had better hire a lobbyist and hope for the best.
I was stunned by what I now call (in this case, rough) “mentorship” by the medical board secretary. I understood I could meekly go along – or get angry. I chose the latter, and it has greatly changed my career.
Now, this was not a hot, red, foam-at-the-mouth mad, but a slow burn, the kind that sustains, not consumes.
I went home and did a literature review and was disheartened to find absolutely nothing in the literature on the safety record of dermatologists in the office setting or on the safety of office surgery in general under local anesthesia. We had nothing to back us up.
I looked up the liposuction deaths in Florida and discovered the procedures were all done under general anesthesia or deep sedation by surgeons of one type or another. I also discovered that Florida had enacted mandatory reporting, and the reports could be had for copying costs. I ordered all available, 9 months of data.
We dermatologists passed a special assessment and hired a lobbyist who told us we were too late to have any impact on the impending restrictions. We took a resolution opposing the medical board rules – which would have eliminated using any sedation in the office, even haloperidol and tumescent anesthesia – to the state medical society and got it passed despite the medical board secretary (who was a former president of the society) testifying against us. The Florida data showed no deaths or injuries from using local anesthesia in the office by anyone, and I succeeded in getting a letter addressing that data published expeditiously in the Journal of the American Medical Association (JAMA 2001;285[20]:2582).
The president of the American Society for Dermatologic Surgery at that time, Stephen Mandy, MD, came to town and testified against the proposed restrictions along with about 60 physicians, including dermatologists, plastic surgeons, and other physicians who perform office-based surgery who we had rallied to join us from across the state. So many colleagues joined us, in fact, that some of us had to sit on the floor during the proceedings.
The proposed restrictions evaporated. I and many others have since devoted our research efforts to solidifying dermatology’s safety and quality record. Dr. Bechtel, professor of dermatology at Ohio State University, Columbus, is now secretary of the state medical board. At the last annual state meeting, I thanked the brigadier general, the former secretary of the medical board, for his unlikely mentorship. He smiled and we got our picture taken together.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Mentorship is a hot topic. Mentors are generally perceived as knowledgeable, kind, generous souls who will guide mentees through tough challenges and be your pal. I suggest to you that while such encounters are marvelous, and to be sought out, some of the most important lessons are taught by members of the opposite cast.
The presiding secretary of the Ohio state medical board was a brigadier general, still active reserve, tall with a bristling countenance. I was president of the Ohio Dermatological Association and was accompanied by Mark Bechtel, MD, who was our chair of state legislation. We had been invited to , and that there had not been any deaths related to local anesthesia administered by dermatologists in Ohio (or anywhere else). We expected to tell the medical board there was nothing to worry about, and we could all go home. This was 17 years ago.
It quickly became apparent that there had been an extensive prior dialogue between the medical board and representatives of the American College of Surgeons and the American Society of Anesthesiologists. They sat at the head table with the secretary of the medical board.
“In our experience, there are really some dangerous procedures going on in the office setting under local anesthesia, and this area desperately needs regulation,” the anesthesiologist’s representative said. The surgeon’s representative chimed in: “From what I’ve heard, office surgery is a ticking time bomb and needs regulation, and as soon as possible.” This prattle went on and on, with the medical board secretary sympathetically nodding his head. I raised my hand and was ignored – and ignored. It became apparent that this was a show trial, and our opinion was not really wanted, just our attendance noted in the minutes. Finally, I stood up and protested, and pointed out that all of this “testimony” was conjecture and personal opinion, and that there was no factual basis for their claims. The president stiffened, stood up, and started barking orders.He told me to “sit down and not speak unless I was called on.” I sat down and shut up. And I was never called on. Mark Bechtel put a calming hand on my arm. Goodness, I had not been treated like that since junior high.
I soon realized that dermatologists were not at all important to the medical board, and that the medical board had no idea about our safety and efficiency and really did not care.
Following the meeting, I was told by Larry Lanier (the American Academy of Dermatology state legislative liaison at the time) that Ohio was to be the test state to restrict local anesthesia and tumescent anesthesia nationwide. He explained that some widely reported liposuction-related deaths in Florida had given the medical board the “justification” to act. He went on to explain that yes, there were no data either way, but we had better hire a lobbyist and hope for the best.
I was stunned by what I now call (in this case, rough) “mentorship” by the medical board secretary. I understood I could meekly go along – or get angry. I chose the latter, and it has greatly changed my career.
Now, this was not a hot, red, foam-at-the-mouth mad, but a slow burn, the kind that sustains, not consumes.
I went home and did a literature review and was disheartened to find absolutely nothing in the literature on the safety record of dermatologists in the office setting or on the safety of office surgery in general under local anesthesia. We had nothing to back us up.
I looked up the liposuction deaths in Florida and discovered the procedures were all done under general anesthesia or deep sedation by surgeons of one type or another. I also discovered that Florida had enacted mandatory reporting, and the reports could be had for copying costs. I ordered all available, 9 months of data.
We dermatologists passed a special assessment and hired a lobbyist who told us we were too late to have any impact on the impending restrictions. We took a resolution opposing the medical board rules – which would have eliminated using any sedation in the office, even haloperidol and tumescent anesthesia – to the state medical society and got it passed despite the medical board secretary (who was a former president of the society) testifying against us. The Florida data showed no deaths or injuries from using local anesthesia in the office by anyone, and I succeeded in getting a letter addressing that data published expeditiously in the Journal of the American Medical Association (JAMA 2001;285[20]:2582).
The president of the American Society for Dermatologic Surgery at that time, Stephen Mandy, MD, came to town and testified against the proposed restrictions along with about 60 physicians, including dermatologists, plastic surgeons, and other physicians who perform office-based surgery who we had rallied to join us from across the state. So many colleagues joined us, in fact, that some of us had to sit on the floor during the proceedings.
The proposed restrictions evaporated. I and many others have since devoted our research efforts to solidifying dermatology’s safety and quality record. Dr. Bechtel, professor of dermatology at Ohio State University, Columbus, is now secretary of the state medical board. At the last annual state meeting, I thanked the brigadier general, the former secretary of the medical board, for his unlikely mentorship. He smiled and we got our picture taken together.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Mentorship is a hot topic. Mentors are generally perceived as knowledgeable, kind, generous souls who will guide mentees through tough challenges and be your pal. I suggest to you that while such encounters are marvelous, and to be sought out, some of the most important lessons are taught by members of the opposite cast.
The presiding secretary of the Ohio state medical board was a brigadier general, still active reserve, tall with a bristling countenance. I was president of the Ohio Dermatological Association and was accompanied by Mark Bechtel, MD, who was our chair of state legislation. We had been invited to , and that there had not been any deaths related to local anesthesia administered by dermatologists in Ohio (or anywhere else). We expected to tell the medical board there was nothing to worry about, and we could all go home. This was 17 years ago.
It quickly became apparent that there had been an extensive prior dialogue between the medical board and representatives of the American College of Surgeons and the American Society of Anesthesiologists. They sat at the head table with the secretary of the medical board.
“In our experience, there are really some dangerous procedures going on in the office setting under local anesthesia, and this area desperately needs regulation,” the anesthesiologist’s representative said. The surgeon’s representative chimed in: “From what I’ve heard, office surgery is a ticking time bomb and needs regulation, and as soon as possible.” This prattle went on and on, with the medical board secretary sympathetically nodding his head. I raised my hand and was ignored – and ignored. It became apparent that this was a show trial, and our opinion was not really wanted, just our attendance noted in the minutes. Finally, I stood up and protested, and pointed out that all of this “testimony” was conjecture and personal opinion, and that there was no factual basis for their claims. The president stiffened, stood up, and started barking orders.He told me to “sit down and not speak unless I was called on.” I sat down and shut up. And I was never called on. Mark Bechtel put a calming hand on my arm. Goodness, I had not been treated like that since junior high.
I soon realized that dermatologists were not at all important to the medical board, and that the medical board had no idea about our safety and efficiency and really did not care.
Following the meeting, I was told by Larry Lanier (the American Academy of Dermatology state legislative liaison at the time) that Ohio was to be the test state to restrict local anesthesia and tumescent anesthesia nationwide. He explained that some widely reported liposuction-related deaths in Florida had given the medical board the “justification” to act. He went on to explain that yes, there were no data either way, but we had better hire a lobbyist and hope for the best.
I was stunned by what I now call (in this case, rough) “mentorship” by the medical board secretary. I understood I could meekly go along – or get angry. I chose the latter, and it has greatly changed my career.
Now, this was not a hot, red, foam-at-the-mouth mad, but a slow burn, the kind that sustains, not consumes.
I went home and did a literature review and was disheartened to find absolutely nothing in the literature on the safety record of dermatologists in the office setting or on the safety of office surgery in general under local anesthesia. We had nothing to back us up.
I looked up the liposuction deaths in Florida and discovered the procedures were all done under general anesthesia or deep sedation by surgeons of one type or another. I also discovered that Florida had enacted mandatory reporting, and the reports could be had for copying costs. I ordered all available, 9 months of data.
We dermatologists passed a special assessment and hired a lobbyist who told us we were too late to have any impact on the impending restrictions. We took a resolution opposing the medical board rules – which would have eliminated using any sedation in the office, even haloperidol and tumescent anesthesia – to the state medical society and got it passed despite the medical board secretary (who was a former president of the society) testifying against us. The Florida data showed no deaths or injuries from using local anesthesia in the office by anyone, and I succeeded in getting a letter addressing that data published expeditiously in the Journal of the American Medical Association (JAMA 2001;285[20]:2582).
The president of the American Society for Dermatologic Surgery at that time, Stephen Mandy, MD, came to town and testified against the proposed restrictions along with about 60 physicians, including dermatologists, plastic surgeons, and other physicians who perform office-based surgery who we had rallied to join us from across the state. So many colleagues joined us, in fact, that some of us had to sit on the floor during the proceedings.
The proposed restrictions evaporated. I and many others have since devoted our research efforts to solidifying dermatology’s safety and quality record. Dr. Bechtel, professor of dermatology at Ohio State University, Columbus, is now secretary of the state medical board. At the last annual state meeting, I thanked the brigadier general, the former secretary of the medical board, for his unlikely mentorship. He smiled and we got our picture taken together.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].
Ropivacaine called top anesthesia for nail surgery
CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.
“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.
Lidocaine has a fast onset – less than 1 minute – but a problematic short duration of 30-120 minutes. Bupivacaine has the disadvantage of a slow onset of up to 5 minutes, albeit with a longer duration of anesthesia at 2-4 hours. Ropivacaine has a fast onset, plus a duration of up to 8 hours. And unlike lidocaine and bupivacaine, which are vasodilatory, ropivacaine is vasoconstrictive.
“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.
Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.
Achieving smooth sailing with local anesthesia
Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.
The distal digital block
This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.
Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.
“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.
Dr. Cressey reported no financial conflicts regarding her presentation.
CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.
“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.
Lidocaine has a fast onset – less than 1 minute – but a problematic short duration of 30-120 minutes. Bupivacaine has the disadvantage of a slow onset of up to 5 minutes, albeit with a longer duration of anesthesia at 2-4 hours. Ropivacaine has a fast onset, plus a duration of up to 8 hours. And unlike lidocaine and bupivacaine, which are vasodilatory, ropivacaine is vasoconstrictive.
“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.
Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.
Achieving smooth sailing with local anesthesia
Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.
The distal digital block
This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.
Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.
“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.
Dr. Cressey reported no financial conflicts regarding her presentation.
CHICAGO – Ropivacaine has a fast onset of action, longer duration than either lidocaine or bupivacaine, and it’s the only one of the three that’s inherently vasoconstrictive. For Brienne Cressey, MD, those features make ropivacaine the local anesthetic of choice in performing nail surgery.
“Local anesthesia is really key for nail surgery. If you don’t have good anesthesia it’s not a good experience for either the surgeon or the patient,” she observed at the annual meeting of the American College of Mohs Surgery.
Lidocaine has a fast onset – less than 1 minute – but a problematic short duration of 30-120 minutes. Bupivacaine has the disadvantage of a slow onset of up to 5 minutes, albeit with a longer duration of anesthesia at 2-4 hours. Ropivacaine has a fast onset, plus a duration of up to 8 hours. And unlike lidocaine and bupivacaine, which are vasodilatory, ropivacaine is vasoconstrictive.
“With lidocaine, you get a lot of blood right after you take off your tourniquet. With ropivacaine, you get really nice reperfusion, but it’s not too much. You take off the tourniquet, check to see you’ve got reperfusion, then you add a little ropivacaine – about 0.5 mL – on either side of the base of the distal phalanx. It stops the bleeding immediately and you can easily put on a pressure dressing. It’s a nice way to get the patient over the hump of those first hours of pain and lets them drive home in comfort,” explained Dr. Cressey, a dermatologist working in a group practice at Dermatology Professionals in East Greenwich, R.I.
Ropivacaine is less cardiotoxic than bupivacaine. And ropivacaine offers an additional advantage: Its pH is such that no buffering is necessary. “Ropivacaine doesn’t require any compounding. You can just use it at 1% straight out of the bottle. That’s what we do in our office, and we’ve had very good experience with it,” according to the dermatologist.
Achieving smooth sailing with local anesthesia
Dr. Cressey delivers ropivacaine slowly through a 30-gauge needle, which makes for a smaller, less painful puncture. She utilizes a topical cold spray, and places a vibrating machine as a distractant proximal to where she is injecting. She keeps the anesthetic at room temperature or warms it to body temperature in a water bath as another means of reducing the pain of injection.
The distal digital block
This is a cross between a traditional proximal digital block and a wing block. It works well for the second, third, and fourth digits, which are mostly volar dominant. The block bathes the volar nerve branch in anesthesia at the midline of the finger or toe.
Dr. Cressey begins by injecting ropivacaine proximal and lateral to the junction of the proximal nail fold and lateral nail fold. After creating a dermal wheal, she directs her needle perpendicularly downward toward the finger or toe pad, injecting 1-4 mL of anesthesia, depending upon digit size. Visible blanching will progress digitally. If resistance is encountered, it suggests the needle has penetrated a ligament or other fibrous tissue. Simply withdraw the needle and continue injecting.
“What’s nice about the distal digital block is you get an immediate effect, and there’s good hemostasis during the procedure as well,” she said.
Dr. Cressey reported no financial conflicts regarding her presentation.
EXPERT ANALYSIS FROM THE ACMS ANNUAL MEETING
Mask provides effective, cheap protection from hazardous electrocautery plumes
CHICAGO – Routine use of an N95 mask during electrocautery is an effective and inexpensive way for dermatologic surgeons to protect themselves from toxic, airborne particulate matter in the smoke generated during the procedure, Emily de Golian, MD, said at the annual meeting of the American College of Mohs Surgery.
“Our data suggest clear as well as superiority to the laser masks that are used in hair removal procedures and ablative procedures in cosmetic clinics,” commented Dr. de Golian, a Mohs micrographic surgery fellow at the University of California, San Diego.
This matter of self-protection from the effects of electrocautery smoke plumes deserves greater attention from the dermatologic community, according to Dr. de Golian. There is solid evidence that these plumes contain high concentrations of known carcinogens, including benzene, acetonitrile, and butadiene – indeed, concentrations far in excess of what’s found in second-hand cigarette smoke. Moreover, many of these airborne carcinogens and other toxins have been linked to leukemia, neurologic disorders, lung cancer, thrombotic disorders, lung disease, and infectious disease transmission, albeit not convincingly so to date in dermatologic surgeons. But why wait for definitive evidence to accrue?
“In light of these hazards – and according to governmental guidelines – dermatologic surgeons would be wise to adopt protective measures during surgical procedures,” Dr. de Golian said.
But they haven’t. She cited a national survey conducted several years ago by a colleague in which 79% of the 316 responding dermatologic surgeons indicated they use no smoke management whatsoever, neither masks nor a local exhaust evacuation system. Only 10% employed smoke management 25%-50% of the time during electrocautery, and a scant 11% of dermatologic surgeons did so at least 75% of the time (Dermatol Surg. 2014 Dec;40[12]:1373-7).
Given the far more substantial expense of installing an office smoke evacuation system, mask filtration becomes an attractive alternative. But the relative efficacy of the various types of masks in blocking fine and ultrafine particulate matter contained in electrocautery plumes hadn’t previously been systematically studied. This created the impetus for Dr. de Golian’s study.
The N95 masks were the clear winner, particularly when it came to filtering the ultrafine particles, which are of greatest concern because they remain suspended in air longer and penetrate deeper into the respiratory tract than larger particles. The N95 masks proved superior to procedural masks, which in turn were significantly more effective than the laser masks. The differences between mask performance for larger particle filtration were smaller, although the N95 remained number one. She noted that the study results probably underestimate the true filtration efficacy of N95 masks, since they form a tighter seal with the face in clinical practice than with the other two mask types.
Mask self-protection “is easily applicable in your own practice, and it meets NIOSH-recommended [National Institute for Occupational Safety and Health] standards for safety in the workplace,” the dermatologist noted.
In the next phase of her research, she plans to evaluate the optimal technology and techniques of smoke evacuation in the surgical suite. That’s an attractive method because it protects everyone in the room, not just the surgeon. And while the practitioner survey indicates this technology isn’t widely used by dermatologic surgeons on a routine basis at present, that could change, particularly in the current era in which patient-reported outcomes and satisfaction surveys have taken on added weight.
“Patients prefer not smelling their own tissue burning,” Dr. de Golian said.
She reported no financial conflicts regarding her study, which was conducted free of commercial support.
CHICAGO – Routine use of an N95 mask during electrocautery is an effective and inexpensive way for dermatologic surgeons to protect themselves from toxic, airborne particulate matter in the smoke generated during the procedure, Emily de Golian, MD, said at the annual meeting of the American College of Mohs Surgery.
“Our data suggest clear as well as superiority to the laser masks that are used in hair removal procedures and ablative procedures in cosmetic clinics,” commented Dr. de Golian, a Mohs micrographic surgery fellow at the University of California, San Diego.
This matter of self-protection from the effects of electrocautery smoke plumes deserves greater attention from the dermatologic community, according to Dr. de Golian. There is solid evidence that these plumes contain high concentrations of known carcinogens, including benzene, acetonitrile, and butadiene – indeed, concentrations far in excess of what’s found in second-hand cigarette smoke. Moreover, many of these airborne carcinogens and other toxins have been linked to leukemia, neurologic disorders, lung cancer, thrombotic disorders, lung disease, and infectious disease transmission, albeit not convincingly so to date in dermatologic surgeons. But why wait for definitive evidence to accrue?
“In light of these hazards – and according to governmental guidelines – dermatologic surgeons would be wise to adopt protective measures during surgical procedures,” Dr. de Golian said.
But they haven’t. She cited a national survey conducted several years ago by a colleague in which 79% of the 316 responding dermatologic surgeons indicated they use no smoke management whatsoever, neither masks nor a local exhaust evacuation system. Only 10% employed smoke management 25%-50% of the time during electrocautery, and a scant 11% of dermatologic surgeons did so at least 75% of the time (Dermatol Surg. 2014 Dec;40[12]:1373-7).
Given the far more substantial expense of installing an office smoke evacuation system, mask filtration becomes an attractive alternative. But the relative efficacy of the various types of masks in blocking fine and ultrafine particulate matter contained in electrocautery plumes hadn’t previously been systematically studied. This created the impetus for Dr. de Golian’s study.
The N95 masks were the clear winner, particularly when it came to filtering the ultrafine particles, which are of greatest concern because they remain suspended in air longer and penetrate deeper into the respiratory tract than larger particles. The N95 masks proved superior to procedural masks, which in turn were significantly more effective than the laser masks. The differences between mask performance for larger particle filtration were smaller, although the N95 remained number one. She noted that the study results probably underestimate the true filtration efficacy of N95 masks, since they form a tighter seal with the face in clinical practice than with the other two mask types.
Mask self-protection “is easily applicable in your own practice, and it meets NIOSH-recommended [National Institute for Occupational Safety and Health] standards for safety in the workplace,” the dermatologist noted.
In the next phase of her research, she plans to evaluate the optimal technology and techniques of smoke evacuation in the surgical suite. That’s an attractive method because it protects everyone in the room, not just the surgeon. And while the practitioner survey indicates this technology isn’t widely used by dermatologic surgeons on a routine basis at present, that could change, particularly in the current era in which patient-reported outcomes and satisfaction surveys have taken on added weight.
“Patients prefer not smelling their own tissue burning,” Dr. de Golian said.
She reported no financial conflicts regarding her study, which was conducted free of commercial support.
CHICAGO – Routine use of an N95 mask during electrocautery is an effective and inexpensive way for dermatologic surgeons to protect themselves from toxic, airborne particulate matter in the smoke generated during the procedure, Emily de Golian, MD, said at the annual meeting of the American College of Mohs Surgery.
“Our data suggest clear as well as superiority to the laser masks that are used in hair removal procedures and ablative procedures in cosmetic clinics,” commented Dr. de Golian, a Mohs micrographic surgery fellow at the University of California, San Diego.
This matter of self-protection from the effects of electrocautery smoke plumes deserves greater attention from the dermatologic community, according to Dr. de Golian. There is solid evidence that these plumes contain high concentrations of known carcinogens, including benzene, acetonitrile, and butadiene – indeed, concentrations far in excess of what’s found in second-hand cigarette smoke. Moreover, many of these airborne carcinogens and other toxins have been linked to leukemia, neurologic disorders, lung cancer, thrombotic disorders, lung disease, and infectious disease transmission, albeit not convincingly so to date in dermatologic surgeons. But why wait for definitive evidence to accrue?
“In light of these hazards – and according to governmental guidelines – dermatologic surgeons would be wise to adopt protective measures during surgical procedures,” Dr. de Golian said.
But they haven’t. She cited a national survey conducted several years ago by a colleague in which 79% of the 316 responding dermatologic surgeons indicated they use no smoke management whatsoever, neither masks nor a local exhaust evacuation system. Only 10% employed smoke management 25%-50% of the time during electrocautery, and a scant 11% of dermatologic surgeons did so at least 75% of the time (Dermatol Surg. 2014 Dec;40[12]:1373-7).
Given the far more substantial expense of installing an office smoke evacuation system, mask filtration becomes an attractive alternative. But the relative efficacy of the various types of masks in blocking fine and ultrafine particulate matter contained in electrocautery plumes hadn’t previously been systematically studied. This created the impetus for Dr. de Golian’s study.
The N95 masks were the clear winner, particularly when it came to filtering the ultrafine particles, which are of greatest concern because they remain suspended in air longer and penetrate deeper into the respiratory tract than larger particles. The N95 masks proved superior to procedural masks, which in turn were significantly more effective than the laser masks. The differences between mask performance for larger particle filtration were smaller, although the N95 remained number one. She noted that the study results probably underestimate the true filtration efficacy of N95 masks, since they form a tighter seal with the face in clinical practice than with the other two mask types.
Mask self-protection “is easily applicable in your own practice, and it meets NIOSH-recommended [National Institute for Occupational Safety and Health] standards for safety in the workplace,” the dermatologist noted.
In the next phase of her research, she plans to evaluate the optimal technology and techniques of smoke evacuation in the surgical suite. That’s an attractive method because it protects everyone in the room, not just the surgeon. And while the practitioner survey indicates this technology isn’t widely used by dermatologic surgeons on a routine basis at present, that could change, particularly in the current era in which patient-reported outcomes and satisfaction surveys have taken on added weight.
“Patients prefer not smelling their own tissue burning,” Dr. de Golian said.
She reported no financial conflicts regarding her study, which was conducted free of commercial support.
REPORTING FROM THE ACMS ANNUAL MEETING
Key clinical point: Electrocautery smoke is bad news, and wearing an N95 mask affords protection.
Major finding: The N95 mask was significantly more effective than basic procedural or laser masks at filtering particulate matter less than 1 mcm in size contained in electrocautery smoke.
Study details: This study utilized highly sensitive airborne particle counting devices to assess the relative protective filtration afforded by three types of masks.
Disclosures: The presenter reported no financial conflicts regarding this study, which was conducted free of commercial support.
Keloids: Cutting is never enough
KAUAI, HAWAII – The truth about keloids is that most affected patients are not surgical candidates and thus, need to be convinced to pursue nonsurgical options, according to Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in Morristown, N.J.
“Virtually all patients arrive saying, ‘I want this cut off. I want this gone today, or even better, yesterday,’ ” she said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
“Removal without adjunctive therapy is a guaranteed failure – about 100% of the time in my experience. ‘I don’t want injections’ is not the answer. They always say they don’t want injections, but regardless of what else I do, they’re going to get shots,” stressed Dr. Baldwin, who is also a dermatologist at the Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.
With earlobe keloid surgery alone, the recurrence rate is less than 50%. With surgery, followed by a program of corticosteroid injections, the recurrence rate plummets to 1%-3%. And, with surgery followed by adjunctive radiotherapy, the rate is close to zero.
In contrast, keloid surgery at sites other than the earlobe has roughly a 50% recurrence rate if followed up with corticosteroid injections and 20% with radiotherapy. Patients need to understand this upfront. They also need to be told that, while treatment can improve appearance, the site will never look normal.
Pedunculated lesions are quite amenable to surgery. They are often mushroom shaped, with a narrow base that doesn’t contain keloidal tissue. “Pedunculated lesions are the maximum benefit with least risk scenario,” Dr. Baldwin commented.
Mature brownish keloids are less likely to recur than younger red ones. “There are no data for that, just my experience,” she continued. Keloids on the jaw, upper back, mid-chest, and deltoid are the ones most likely to recur.
During her presentation, Dr. Baldwin provided the following points about different treatments:
- Postsurgical adjunctive therapy. The options include corticosteroid injections, injectable interferon, and pressure dressings. Which to chose? Urge patients to opt for all of them. “Go for the whole kit and caboodle. There’s no reason to stop at just one. I can tell you that if you do all of these things on an earlobe keloid, no matter how big it is, that sucker’s not coming back. On the body, sometimes yes, sometimes no. That’s a much harder area to treat,” Dr. Baldwin said.
- Corticosteroids. Her personal recipe is 40 mg/cc of triamcinolone injected to the base and walls of the excision site immediately postsurgically and again every 2 weeks for 2 months, regardless of the site’s clinical appearance. “If they come in absolutely dead flat, I don’t care. I’m injecting it anyway. I have no data behind this, but I can tell you that when I do it that way, the chances of recurrence are much less,” she noted. After the first 2 months of steroid injections, she switches to a once-monthly schedule for another 6 months, with the dose and concentration selected based upon appearance.
- Radiation therapy. “Many of you don’t use it and many patients refuse it, but if you’ve got a patient who’ll do it, it’s by far the single best adjunctive therapy for the treatment of keloids,” Dr. Baldwin said. This is ineffective on existing keloids, and she advises to cut first, then irradiate the base. All forms of radiotherapy are effective, she added, so she leaves the details to the radiotherapist. “I say, ‘Here’s the patient, do your thing.’ Most of them do it immediately postop, others do it a day or 2 or a week later,” she said.
- Interferon. The regimen is 1.5 million U/linear cm injected into the base and walls of the excision site on days 1 and 7. The maximum is 5 million U/session in order to minimize the interferon-induced flulike syndrome. Pretreatment with 1 g of acetaminophen before the interferon injections and every 4 hours for 24 hours posttreatment is also helpful in preventing the flulike symptoms, which can sometimes be formidable. “I tell patients to be able to take the next day off from work if they have to and also not to have any obligations that night for child or elderly care,” Dr. Baldwin noted.
- Pressure dressings. For these to be effective, they have to exert considerable pressure, and they must be worn 24/7 for 4-6 months. The only location in which pressure dressings make sense is on the earlobes. Dr. Baldwin mentioned two producers: Delasco makes silicone pressure earrings, and NBN Products makes a variety of the devices.
- The nonsurgical alternatives. For the many patients who aren’t good surgical candidates, the workhorse therapy for existing keloids is intralesional triamcinolone at 40 mg/cc. This works best for sessile lesions. Dr. Baldwin doesn’t hesitate to give 50-100 mg/treatment session. “Ask, ‘Where do you want to start?’ We do a tiny area with a huge amount of triamcinolone and then that spot will get better. If you spread it around over a large area, nothing’s going get better,” she advised. 5-fluorouracil is a less attractive alternative. It’s painful, less effective, and it can cause ulceration.
“I’ve found [5-fluorouracil] to be of limited use. I think corticosteroid is the heavy lifter. I’d prefer not to be injecting an antimetabolite into somebody if I can help it,” Dr. Baldwin said.
She reported receiving research funding from Dermira, Galderma, La Roche-Posay, Novan, and Valeant; and serving as a consultant and/or on a speakers’ bureau for Allergan, Bayer, Encore, Johnson & Johnson, Mayne, and Sun.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
KAUAI, HAWAII – The truth about keloids is that most affected patients are not surgical candidates and thus, need to be convinced to pursue nonsurgical options, according to Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in Morristown, N.J.
“Virtually all patients arrive saying, ‘I want this cut off. I want this gone today, or even better, yesterday,’ ” she said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
“Removal without adjunctive therapy is a guaranteed failure – about 100% of the time in my experience. ‘I don’t want injections’ is not the answer. They always say they don’t want injections, but regardless of what else I do, they’re going to get shots,” stressed Dr. Baldwin, who is also a dermatologist at the Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.
With earlobe keloid surgery alone, the recurrence rate is less than 50%. With surgery, followed by a program of corticosteroid injections, the recurrence rate plummets to 1%-3%. And, with surgery followed by adjunctive radiotherapy, the rate is close to zero.
In contrast, keloid surgery at sites other than the earlobe has roughly a 50% recurrence rate if followed up with corticosteroid injections and 20% with radiotherapy. Patients need to understand this upfront. They also need to be told that, while treatment can improve appearance, the site will never look normal.
Pedunculated lesions are quite amenable to surgery. They are often mushroom shaped, with a narrow base that doesn’t contain keloidal tissue. “Pedunculated lesions are the maximum benefit with least risk scenario,” Dr. Baldwin commented.
Mature brownish keloids are less likely to recur than younger red ones. “There are no data for that, just my experience,” she continued. Keloids on the jaw, upper back, mid-chest, and deltoid are the ones most likely to recur.
During her presentation, Dr. Baldwin provided the following points about different treatments:
- Postsurgical adjunctive therapy. The options include corticosteroid injections, injectable interferon, and pressure dressings. Which to chose? Urge patients to opt for all of them. “Go for the whole kit and caboodle. There’s no reason to stop at just one. I can tell you that if you do all of these things on an earlobe keloid, no matter how big it is, that sucker’s not coming back. On the body, sometimes yes, sometimes no. That’s a much harder area to treat,” Dr. Baldwin said.
- Corticosteroids. Her personal recipe is 40 mg/cc of triamcinolone injected to the base and walls of the excision site immediately postsurgically and again every 2 weeks for 2 months, regardless of the site’s clinical appearance. “If they come in absolutely dead flat, I don’t care. I’m injecting it anyway. I have no data behind this, but I can tell you that when I do it that way, the chances of recurrence are much less,” she noted. After the first 2 months of steroid injections, she switches to a once-monthly schedule for another 6 months, with the dose and concentration selected based upon appearance.
- Radiation therapy. “Many of you don’t use it and many patients refuse it, but if you’ve got a patient who’ll do it, it’s by far the single best adjunctive therapy for the treatment of keloids,” Dr. Baldwin said. This is ineffective on existing keloids, and she advises to cut first, then irradiate the base. All forms of radiotherapy are effective, she added, so she leaves the details to the radiotherapist. “I say, ‘Here’s the patient, do your thing.’ Most of them do it immediately postop, others do it a day or 2 or a week later,” she said.
- Interferon. The regimen is 1.5 million U/linear cm injected into the base and walls of the excision site on days 1 and 7. The maximum is 5 million U/session in order to minimize the interferon-induced flulike syndrome. Pretreatment with 1 g of acetaminophen before the interferon injections and every 4 hours for 24 hours posttreatment is also helpful in preventing the flulike symptoms, which can sometimes be formidable. “I tell patients to be able to take the next day off from work if they have to and also not to have any obligations that night for child or elderly care,” Dr. Baldwin noted.
- Pressure dressings. For these to be effective, they have to exert considerable pressure, and they must be worn 24/7 for 4-6 months. The only location in which pressure dressings make sense is on the earlobes. Dr. Baldwin mentioned two producers: Delasco makes silicone pressure earrings, and NBN Products makes a variety of the devices.
- The nonsurgical alternatives. For the many patients who aren’t good surgical candidates, the workhorse therapy for existing keloids is intralesional triamcinolone at 40 mg/cc. This works best for sessile lesions. Dr. Baldwin doesn’t hesitate to give 50-100 mg/treatment session. “Ask, ‘Where do you want to start?’ We do a tiny area with a huge amount of triamcinolone and then that spot will get better. If you spread it around over a large area, nothing’s going get better,” she advised. 5-fluorouracil is a less attractive alternative. It’s painful, less effective, and it can cause ulceration.
“I’ve found [5-fluorouracil] to be of limited use. I think corticosteroid is the heavy lifter. I’d prefer not to be injecting an antimetabolite into somebody if I can help it,” Dr. Baldwin said.
She reported receiving research funding from Dermira, Galderma, La Roche-Posay, Novan, and Valeant; and serving as a consultant and/or on a speakers’ bureau for Allergan, Bayer, Encore, Johnson & Johnson, Mayne, and Sun.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
KAUAI, HAWAII – The truth about keloids is that most affected patients are not surgical candidates and thus, need to be convinced to pursue nonsurgical options, according to Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in Morristown, N.J.
“Virtually all patients arrive saying, ‘I want this cut off. I want this gone today, or even better, yesterday,’ ” she said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
“Removal without adjunctive therapy is a guaranteed failure – about 100% of the time in my experience. ‘I don’t want injections’ is not the answer. They always say they don’t want injections, but regardless of what else I do, they’re going to get shots,” stressed Dr. Baldwin, who is also a dermatologist at the Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.
With earlobe keloid surgery alone, the recurrence rate is less than 50%. With surgery, followed by a program of corticosteroid injections, the recurrence rate plummets to 1%-3%. And, with surgery followed by adjunctive radiotherapy, the rate is close to zero.
In contrast, keloid surgery at sites other than the earlobe has roughly a 50% recurrence rate if followed up with corticosteroid injections and 20% with radiotherapy. Patients need to understand this upfront. They also need to be told that, while treatment can improve appearance, the site will never look normal.
Pedunculated lesions are quite amenable to surgery. They are often mushroom shaped, with a narrow base that doesn’t contain keloidal tissue. “Pedunculated lesions are the maximum benefit with least risk scenario,” Dr. Baldwin commented.
Mature brownish keloids are less likely to recur than younger red ones. “There are no data for that, just my experience,” she continued. Keloids on the jaw, upper back, mid-chest, and deltoid are the ones most likely to recur.
During her presentation, Dr. Baldwin provided the following points about different treatments:
- Postsurgical adjunctive therapy. The options include corticosteroid injections, injectable interferon, and pressure dressings. Which to chose? Urge patients to opt for all of them. “Go for the whole kit and caboodle. There’s no reason to stop at just one. I can tell you that if you do all of these things on an earlobe keloid, no matter how big it is, that sucker’s not coming back. On the body, sometimes yes, sometimes no. That’s a much harder area to treat,” Dr. Baldwin said.
- Corticosteroids. Her personal recipe is 40 mg/cc of triamcinolone injected to the base and walls of the excision site immediately postsurgically and again every 2 weeks for 2 months, regardless of the site’s clinical appearance. “If they come in absolutely dead flat, I don’t care. I’m injecting it anyway. I have no data behind this, but I can tell you that when I do it that way, the chances of recurrence are much less,” she noted. After the first 2 months of steroid injections, she switches to a once-monthly schedule for another 6 months, with the dose and concentration selected based upon appearance.
- Radiation therapy. “Many of you don’t use it and many patients refuse it, but if you’ve got a patient who’ll do it, it’s by far the single best adjunctive therapy for the treatment of keloids,” Dr. Baldwin said. This is ineffective on existing keloids, and she advises to cut first, then irradiate the base. All forms of radiotherapy are effective, she added, so she leaves the details to the radiotherapist. “I say, ‘Here’s the patient, do your thing.’ Most of them do it immediately postop, others do it a day or 2 or a week later,” she said.
- Interferon. The regimen is 1.5 million U/linear cm injected into the base and walls of the excision site on days 1 and 7. The maximum is 5 million U/session in order to minimize the interferon-induced flulike syndrome. Pretreatment with 1 g of acetaminophen before the interferon injections and every 4 hours for 24 hours posttreatment is also helpful in preventing the flulike symptoms, which can sometimes be formidable. “I tell patients to be able to take the next day off from work if they have to and also not to have any obligations that night for child or elderly care,” Dr. Baldwin noted.
- Pressure dressings. For these to be effective, they have to exert considerable pressure, and they must be worn 24/7 for 4-6 months. The only location in which pressure dressings make sense is on the earlobes. Dr. Baldwin mentioned two producers: Delasco makes silicone pressure earrings, and NBN Products makes a variety of the devices.
- The nonsurgical alternatives. For the many patients who aren’t good surgical candidates, the workhorse therapy for existing keloids is intralesional triamcinolone at 40 mg/cc. This works best for sessile lesions. Dr. Baldwin doesn’t hesitate to give 50-100 mg/treatment session. “Ask, ‘Where do you want to start?’ We do a tiny area with a huge amount of triamcinolone and then that spot will get better. If you spread it around over a large area, nothing’s going get better,” she advised. 5-fluorouracil is a less attractive alternative. It’s painful, less effective, and it can cause ulceration.
“I’ve found [5-fluorouracil] to be of limited use. I think corticosteroid is the heavy lifter. I’d prefer not to be injecting an antimetabolite into somebody if I can help it,” Dr. Baldwin said.
She reported receiving research funding from Dermira, Galderma, La Roche-Posay, Novan, and Valeant; and serving as a consultant and/or on a speakers’ bureau for Allergan, Bayer, Encore, Johnson & Johnson, Mayne, and Sun.
SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Hyaluronic acid filler preferred for infraorbital hollowing
Most patients who responded to surveys reported being satisfied after off-label treatment with Juvéderm Voluma XC hyaluronic acid filler for infraorbital hollowing, a study finds.
Adverse effects were reported in 12% of patients.
The treatment’s “high patient satisfaction profile and a similar safety profile among other soft-tissue fillers make it an excellent adjunct in the plastic surgeon’s armamentarium,” reported Michael B. Hall, MD, and his associates at their private, ambulatory facial plastic and reconstructive surgery practice in Austin, Texas, in JAMA Facial Plastic Surgery.
According to the researchers, the Food and Drug Administration has not approved any soft-tissue fillers for the periorbital complex. At their practice, Dr. Hall and his associates treat infraorbital hollows with Juvéderm Voluma XC, which is approved by the FDA for certain types of cheek augmentation. Other studies have examined Belotero or Restylane as treatments for building volume in the periorbital area, the authors wrote, but research into cosmetic injections of Juvéderm Voluma XC is lacking.
For the new study, the researchers retrospectively analyzed the cases of 101 patients (aged 32-75 years, with average age of 54 years; 89% female; 54% Fitzpatrick skin type II; racial breakdown not reported) who were electively treated with the filler for infraorbital hollowing in 2016 and 2017. The patients received an average 1 mL of the treatment gel.
The patients were photographed and answered surveys, and they were evaluated using the Allergan Infraorbital Hollows Scale. Follow-up time averaged 12 months.
A total of 18 patients (18%) required touch-up within 3 months, and 2 required multiple touch-ups. A total of 12 subjects (12%) had adverse effects (including 3 who had more than one), which included bruising (10%), contour irregularities (2%), edema (3%) and Tyndall effect (1%). Hyaluronidase was required in 3 patients (3%), and 24 patients sought further treatment after 3 months.
The researchers sent two satisfaction surveys to the participants. A total of 41% responded to the FACE-Q Satisfaction With Eyes survey, and 42% responded to the FACE-Q Satisfaction With Decision survey.
Depending on the question, 70%-85% of the respondents to the Satisfaction With Eyes survey said they were “definitely” or “somewhat” satisfied with the treatment outcome.
The highest levels of dissatisfaction came in response to a questions about whether the subjects felt their eyes looked alert (not tired) or youthful. The highest levels of satisfaction were in response to questions about whether the subjects were happy with the shape, attractiveness, and openness of their eyes.
Depending on the question, 73%-85% of the subjects who took the Satisfaction With Decision survey reported that they “definitely” or “somewhat” agree with positive statements about the treatment. While differences were small, they agreed the most with a statement saying the procedure was “worth the time and effort.”
No external funding or remuneration was received. The study authors reported no relevant disclosures.
SOURCE: Hall MB et al. JAMA Facial Plast Surg. 2018 Apr 5. doi:10.1001/jamafacial.2018.0230.
Most patients who responded to surveys reported being satisfied after off-label treatment with Juvéderm Voluma XC hyaluronic acid filler for infraorbital hollowing, a study finds.
Adverse effects were reported in 12% of patients.
The treatment’s “high patient satisfaction profile and a similar safety profile among other soft-tissue fillers make it an excellent adjunct in the plastic surgeon’s armamentarium,” reported Michael B. Hall, MD, and his associates at their private, ambulatory facial plastic and reconstructive surgery practice in Austin, Texas, in JAMA Facial Plastic Surgery.
According to the researchers, the Food and Drug Administration has not approved any soft-tissue fillers for the periorbital complex. At their practice, Dr. Hall and his associates treat infraorbital hollows with Juvéderm Voluma XC, which is approved by the FDA for certain types of cheek augmentation. Other studies have examined Belotero or Restylane as treatments for building volume in the periorbital area, the authors wrote, but research into cosmetic injections of Juvéderm Voluma XC is lacking.
For the new study, the researchers retrospectively analyzed the cases of 101 patients (aged 32-75 years, with average age of 54 years; 89% female; 54% Fitzpatrick skin type II; racial breakdown not reported) who were electively treated with the filler for infraorbital hollowing in 2016 and 2017. The patients received an average 1 mL of the treatment gel.
The patients were photographed and answered surveys, and they were evaluated using the Allergan Infraorbital Hollows Scale. Follow-up time averaged 12 months.
A total of 18 patients (18%) required touch-up within 3 months, and 2 required multiple touch-ups. A total of 12 subjects (12%) had adverse effects (including 3 who had more than one), which included bruising (10%), contour irregularities (2%), edema (3%) and Tyndall effect (1%). Hyaluronidase was required in 3 patients (3%), and 24 patients sought further treatment after 3 months.
The researchers sent two satisfaction surveys to the participants. A total of 41% responded to the FACE-Q Satisfaction With Eyes survey, and 42% responded to the FACE-Q Satisfaction With Decision survey.
Depending on the question, 70%-85% of the respondents to the Satisfaction With Eyes survey said they were “definitely” or “somewhat” satisfied with the treatment outcome.
The highest levels of dissatisfaction came in response to a questions about whether the subjects felt their eyes looked alert (not tired) or youthful. The highest levels of satisfaction were in response to questions about whether the subjects were happy with the shape, attractiveness, and openness of their eyes.
Depending on the question, 73%-85% of the subjects who took the Satisfaction With Decision survey reported that they “definitely” or “somewhat” agree with positive statements about the treatment. While differences were small, they agreed the most with a statement saying the procedure was “worth the time and effort.”
No external funding or remuneration was received. The study authors reported no relevant disclosures.
SOURCE: Hall MB et al. JAMA Facial Plast Surg. 2018 Apr 5. doi:10.1001/jamafacial.2018.0230.
Most patients who responded to surveys reported being satisfied after off-label treatment with Juvéderm Voluma XC hyaluronic acid filler for infraorbital hollowing, a study finds.
Adverse effects were reported in 12% of patients.
The treatment’s “high patient satisfaction profile and a similar safety profile among other soft-tissue fillers make it an excellent adjunct in the plastic surgeon’s armamentarium,” reported Michael B. Hall, MD, and his associates at their private, ambulatory facial plastic and reconstructive surgery practice in Austin, Texas, in JAMA Facial Plastic Surgery.
According to the researchers, the Food and Drug Administration has not approved any soft-tissue fillers for the periorbital complex. At their practice, Dr. Hall and his associates treat infraorbital hollows with Juvéderm Voluma XC, which is approved by the FDA for certain types of cheek augmentation. Other studies have examined Belotero or Restylane as treatments for building volume in the periorbital area, the authors wrote, but research into cosmetic injections of Juvéderm Voluma XC is lacking.
For the new study, the researchers retrospectively analyzed the cases of 101 patients (aged 32-75 years, with average age of 54 years; 89% female; 54% Fitzpatrick skin type II; racial breakdown not reported) who were electively treated with the filler for infraorbital hollowing in 2016 and 2017. The patients received an average 1 mL of the treatment gel.
The patients were photographed and answered surveys, and they were evaluated using the Allergan Infraorbital Hollows Scale. Follow-up time averaged 12 months.
A total of 18 patients (18%) required touch-up within 3 months, and 2 required multiple touch-ups. A total of 12 subjects (12%) had adverse effects (including 3 who had more than one), which included bruising (10%), contour irregularities (2%), edema (3%) and Tyndall effect (1%). Hyaluronidase was required in 3 patients (3%), and 24 patients sought further treatment after 3 months.
The researchers sent two satisfaction surveys to the participants. A total of 41% responded to the FACE-Q Satisfaction With Eyes survey, and 42% responded to the FACE-Q Satisfaction With Decision survey.
Depending on the question, 70%-85% of the respondents to the Satisfaction With Eyes survey said they were “definitely” or “somewhat” satisfied with the treatment outcome.
The highest levels of dissatisfaction came in response to a questions about whether the subjects felt their eyes looked alert (not tired) or youthful. The highest levels of satisfaction were in response to questions about whether the subjects were happy with the shape, attractiveness, and openness of their eyes.
Depending on the question, 73%-85% of the subjects who took the Satisfaction With Decision survey reported that they “definitely” or “somewhat” agree with positive statements about the treatment. While differences were small, they agreed the most with a statement saying the procedure was “worth the time and effort.”
No external funding or remuneration was received. The study authors reported no relevant disclosures.
SOURCE: Hall MB et al. JAMA Facial Plast Surg. 2018 Apr 5. doi:10.1001/jamafacial.2018.0230.
FROM JAMA FACIAL PLASTIC SURGERY
Key clinical point:
Major finding: Adverse effects occurred at a rate of 12%, and most who responded to surveys reported satisfaction postprocedure (70%-85%).
Study details: A retrospective observational study of 101 patients.
Disclosures: No external funding or remuneration was received. The study authors reported no relevant disclosures.
Source: Hall MB et al. JAMA Facial Plast Surg. 2018 Apr 5. doi:10.1001/jamafacial.2018.0230.
Surgical excision essential in severe hidradenitis suppurativa
KAUAI, HAWAII – Medical therapy alone is never sufficient in Hurley stage III hidradenitis suppurativa (HS), Iltefat H. Hamzavi, MD, observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“Even with the advances in biologics and antibiotic therapy, you still have to excise once you’re in full-blown Hurley stage III disease. Surgery has to be part of your protocol,” according to Dr. Hamzavi, a dermatologist at Henry Ford Hospital in Detroit, which runs one of the nation’s largest hidradenitis suppurativa clinics, with roughly 1,600 patients.
“Of course we’re biased. But until the data can set us free, you’re stuck with me,” the dermatologist quipped.
A core principle of the Henry Ford algorithm is this: “Medical therapy [for patients with advanced HS] stabilizes them and reduces their draining and pain, then you try to bring them back to a lower stage with surgical options,” he explained.
Although other HS staging systems exist, Dr. Hamzavi and his colleagues rely on the Hurley staging system to guide their treatment. Basically, Hurley stage I consists of follicular nodules and abscesses. When the nodules connect to form sinus tracts with scarring, that’s stage II. And if the sinus tracts interconnect throughout an entire area, that’s stage III.
Hurley stage I
First-line treatment of localized Hurley stage I disease at Henry Ford is a 10% topical benzoyl peroxide wash left on for 5 minutes before bathing, followed by postbathing topical clindamycin 1% lotion or solution applied to the nodules. If this maintenance regimen isn’t sufficient to prevent formation of new and worsening nodules, Dr. Hamzavi supplements it with up to three once-monthly 1064-nm Nd:YAG laser sessions aimed at follicular ablation. It’s a laser application he and his colleagues pioneered (Dermatol Surg. 2009 Aug;35[8]:1188-98). They subsequently documented the histopathologic basis of the procedure’s efficacy, which entails selective thermolysis of follicles, destruction of inflammatory lesions in the superficial to mid-dermis, followed by fibrosis and scarring (Arch Dermatol. 2011 Jan;147[1]:21-8).
In generalized Hurley stage I HS, the Henry Ford approach is to supplement the topical regimen and laser sessions with oral doxycycline at 100-150 mg daily for 1-6 months.
“The theory here is this is a dysbiotic event. The antibiotics reduce commensal bacteria, which ultimately reduces the reactive inflammatory response. But when you stop the antibiotics, the inflammatory response returns. So antibiotics can help stabilize the disease state but really can’t reverse the disease state. For that we have to turn to ablative treatment options: laser, surgery,” the dermatologist continued.
Hurley stage II
“At this point you’re looking at procedures,” according to Dr. Hamzavi. “Once you have sinus tracts it’s critical to remove them.”
The treatment backbone in stage II disease is 8-10 weeks of oral clindamycin and rifampin, both at 300 mg twice daily.
“This is one of the fundamental building blocks of HS clinics throughout the world,” he noted.
Clostridium difficile infection is exceedingly rare in HS patients on this regimen, for reasons still unclear.
If this dual-antibiotic regimen doesn’t dramatically reduce drainage and pain, he adds levofloxacin at 500 mg twice daily for up to 2 weeks in an effort to calm down unstable, decompensating disease.
Dapsone at 50-150 mg/day for up to 12 weeks is an additional option. It’s most useful in patients with nodules that are disproportionately painful, in Dr. Hamzavi’s experience.
Deroofing is a simple procedure that should be considered for all sinus tracts. It entails numbing the area with a ring block then introducing a curette or surgical probe into the sinus tract to open it up and get rid of the gelatinous material within. Dutch investigators have detailed the technique (J Am Acad Dermatol. 2010 Sep;63[3]:475-80).
Tumor necrosis factor–inhibitor therapy has been a major advance in Hurley stage II and III disease. “It doesn’t work in everybody, but a lot of patients can be stabilized,” Dr. Hamzavi observed.
Efficacy has been amply demonstrated for adalimumab (Humira) and infliximab (Remicade). In Dr. Hamzavi’s experience infliximab works better, probably because it offers more dosing options.
Assuming medical therapy has resulted in disease stabilization, CO2 laser excision of sinus tracts under local anesthesia can then be employed as an office procedure to turn back the clock and return to an earlier stage of disease. Dermatologists at the Cleveland Clinic have described the technique in detail (Dermatol Surg. 2010 Feb;36[2]:208-13).
Hurley stage III
If biologic therapy doesn’t bring disease stabilization, the patient is likely headed for surgical excision using the CO2 laser. The Henry Ford team favors a specific regimen of surgical preparation using wide-spectrum antibiotics. The program begins with 6 weeks of IV ertapenem at 1 g/day delivered by a peripherally inserted central catheter managed by infectious disease colleagues.
“IV ertapenem is a drug you may not know much about. We find it works really well as a great way to bridge patients towards surgery,” the dermatologist explained.
The IV ertapenem is followed by 6 weeks of oral triple therapy with rifampin, moxifloxacin, and metronidazole then another 6 weeks of rifampin plus moxifloxacin. Next it’s surgical excision time.
Lifestyle modification
Lifestyle modification deserves to be a major priority in all HS patients, regardless of Hurley stage. Smoking cessation results in significantly greater likelihood of favorable response to first-line therapy. In obese patients, greater than 15% weight loss has been associated with significant reduction in disease severity. A sartorial shift to loose-fitting clothing can quiet down skin lesions through decreased friction and pressure. And proper utilization of warm compression will rapidly decrease acute lesional pain.
Dr. Hamzavi and his coinvestigators have described the Henry Ford Hospital treatment algorithm in a review of HS published in an open-access journal meant to serve as a resource for patients and physicians alike (F1000Res. 2017 Jul 28;6:1272. doi: 10.12688/f1000research.11337.1. eCollection 2017).
He reported serving as a consultant to AbbVie, Incyte, and UCB.
The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.
KAUAI, HAWAII – Medical therapy alone is never sufficient in Hurley stage III hidradenitis suppurativa (HS), Iltefat H. Hamzavi, MD, observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“Even with the advances in biologics and antibiotic therapy, you still have to excise once you’re in full-blown Hurley stage III disease. Surgery has to be part of your protocol,” according to Dr. Hamzavi, a dermatologist at Henry Ford Hospital in Detroit, which runs one of the nation’s largest hidradenitis suppurativa clinics, with roughly 1,600 patients.
“Of course we’re biased. But until the data can set us free, you’re stuck with me,” the dermatologist quipped.
A core principle of the Henry Ford algorithm is this: “Medical therapy [for patients with advanced HS] stabilizes them and reduces their draining and pain, then you try to bring them back to a lower stage with surgical options,” he explained.
Although other HS staging systems exist, Dr. Hamzavi and his colleagues rely on the Hurley staging system to guide their treatment. Basically, Hurley stage I consists of follicular nodules and abscesses. When the nodules connect to form sinus tracts with scarring, that’s stage II. And if the sinus tracts interconnect throughout an entire area, that’s stage III.
Hurley stage I
First-line treatment of localized Hurley stage I disease at Henry Ford is a 10% topical benzoyl peroxide wash left on for 5 minutes before bathing, followed by postbathing topical clindamycin 1% lotion or solution applied to the nodules. If this maintenance regimen isn’t sufficient to prevent formation of new and worsening nodules, Dr. Hamzavi supplements it with up to three once-monthly 1064-nm Nd:YAG laser sessions aimed at follicular ablation. It’s a laser application he and his colleagues pioneered (Dermatol Surg. 2009 Aug;35[8]:1188-98). They subsequently documented the histopathologic basis of the procedure’s efficacy, which entails selective thermolysis of follicles, destruction of inflammatory lesions in the superficial to mid-dermis, followed by fibrosis and scarring (Arch Dermatol. 2011 Jan;147[1]:21-8).
In generalized Hurley stage I HS, the Henry Ford approach is to supplement the topical regimen and laser sessions with oral doxycycline at 100-150 mg daily for 1-6 months.
“The theory here is this is a dysbiotic event. The antibiotics reduce commensal bacteria, which ultimately reduces the reactive inflammatory response. But when you stop the antibiotics, the inflammatory response returns. So antibiotics can help stabilize the disease state but really can’t reverse the disease state. For that we have to turn to ablative treatment options: laser, surgery,” the dermatologist continued.
Hurley stage II
“At this point you’re looking at procedures,” according to Dr. Hamzavi. “Once you have sinus tracts it’s critical to remove them.”
The treatment backbone in stage II disease is 8-10 weeks of oral clindamycin and rifampin, both at 300 mg twice daily.
“This is one of the fundamental building blocks of HS clinics throughout the world,” he noted.
Clostridium difficile infection is exceedingly rare in HS patients on this regimen, for reasons still unclear.
If this dual-antibiotic regimen doesn’t dramatically reduce drainage and pain, he adds levofloxacin at 500 mg twice daily for up to 2 weeks in an effort to calm down unstable, decompensating disease.
Dapsone at 50-150 mg/day for up to 12 weeks is an additional option. It’s most useful in patients with nodules that are disproportionately painful, in Dr. Hamzavi’s experience.
Deroofing is a simple procedure that should be considered for all sinus tracts. It entails numbing the area with a ring block then introducing a curette or surgical probe into the sinus tract to open it up and get rid of the gelatinous material within. Dutch investigators have detailed the technique (J Am Acad Dermatol. 2010 Sep;63[3]:475-80).
Tumor necrosis factor–inhibitor therapy has been a major advance in Hurley stage II and III disease. “It doesn’t work in everybody, but a lot of patients can be stabilized,” Dr. Hamzavi observed.
Efficacy has been amply demonstrated for adalimumab (Humira) and infliximab (Remicade). In Dr. Hamzavi’s experience infliximab works better, probably because it offers more dosing options.
Assuming medical therapy has resulted in disease stabilization, CO2 laser excision of sinus tracts under local anesthesia can then be employed as an office procedure to turn back the clock and return to an earlier stage of disease. Dermatologists at the Cleveland Clinic have described the technique in detail (Dermatol Surg. 2010 Feb;36[2]:208-13).
Hurley stage III
If biologic therapy doesn’t bring disease stabilization, the patient is likely headed for surgical excision using the CO2 laser. The Henry Ford team favors a specific regimen of surgical preparation using wide-spectrum antibiotics. The program begins with 6 weeks of IV ertapenem at 1 g/day delivered by a peripherally inserted central catheter managed by infectious disease colleagues.
“IV ertapenem is a drug you may not know much about. We find it works really well as a great way to bridge patients towards surgery,” the dermatologist explained.
The IV ertapenem is followed by 6 weeks of oral triple therapy with rifampin, moxifloxacin, and metronidazole then another 6 weeks of rifampin plus moxifloxacin. Next it’s surgical excision time.
Lifestyle modification
Lifestyle modification deserves to be a major priority in all HS patients, regardless of Hurley stage. Smoking cessation results in significantly greater likelihood of favorable response to first-line therapy. In obese patients, greater than 15% weight loss has been associated with significant reduction in disease severity. A sartorial shift to loose-fitting clothing can quiet down skin lesions through decreased friction and pressure. And proper utilization of warm compression will rapidly decrease acute lesional pain.
Dr. Hamzavi and his coinvestigators have described the Henry Ford Hospital treatment algorithm in a review of HS published in an open-access journal meant to serve as a resource for patients and physicians alike (F1000Res. 2017 Jul 28;6:1272. doi: 10.12688/f1000research.11337.1. eCollection 2017).
He reported serving as a consultant to AbbVie, Incyte, and UCB.
The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.
KAUAI, HAWAII – Medical therapy alone is never sufficient in Hurley stage III hidradenitis suppurativa (HS), Iltefat H. Hamzavi, MD, observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“Even with the advances in biologics and antibiotic therapy, you still have to excise once you’re in full-blown Hurley stage III disease. Surgery has to be part of your protocol,” according to Dr. Hamzavi, a dermatologist at Henry Ford Hospital in Detroit, which runs one of the nation’s largest hidradenitis suppurativa clinics, with roughly 1,600 patients.
“Of course we’re biased. But until the data can set us free, you’re stuck with me,” the dermatologist quipped.
A core principle of the Henry Ford algorithm is this: “Medical therapy [for patients with advanced HS] stabilizes them and reduces their draining and pain, then you try to bring them back to a lower stage with surgical options,” he explained.
Although other HS staging systems exist, Dr. Hamzavi and his colleagues rely on the Hurley staging system to guide their treatment. Basically, Hurley stage I consists of follicular nodules and abscesses. When the nodules connect to form sinus tracts with scarring, that’s stage II. And if the sinus tracts interconnect throughout an entire area, that’s stage III.
Hurley stage I
First-line treatment of localized Hurley stage I disease at Henry Ford is a 10% topical benzoyl peroxide wash left on for 5 minutes before bathing, followed by postbathing topical clindamycin 1% lotion or solution applied to the nodules. If this maintenance regimen isn’t sufficient to prevent formation of new and worsening nodules, Dr. Hamzavi supplements it with up to three once-monthly 1064-nm Nd:YAG laser sessions aimed at follicular ablation. It’s a laser application he and his colleagues pioneered (Dermatol Surg. 2009 Aug;35[8]:1188-98). They subsequently documented the histopathologic basis of the procedure’s efficacy, which entails selective thermolysis of follicles, destruction of inflammatory lesions in the superficial to mid-dermis, followed by fibrosis and scarring (Arch Dermatol. 2011 Jan;147[1]:21-8).
In generalized Hurley stage I HS, the Henry Ford approach is to supplement the topical regimen and laser sessions with oral doxycycline at 100-150 mg daily for 1-6 months.
“The theory here is this is a dysbiotic event. The antibiotics reduce commensal bacteria, which ultimately reduces the reactive inflammatory response. But when you stop the antibiotics, the inflammatory response returns. So antibiotics can help stabilize the disease state but really can’t reverse the disease state. For that we have to turn to ablative treatment options: laser, surgery,” the dermatologist continued.
Hurley stage II
“At this point you’re looking at procedures,” according to Dr. Hamzavi. “Once you have sinus tracts it’s critical to remove them.”
The treatment backbone in stage II disease is 8-10 weeks of oral clindamycin and rifampin, both at 300 mg twice daily.
“This is one of the fundamental building blocks of HS clinics throughout the world,” he noted.
Clostridium difficile infection is exceedingly rare in HS patients on this regimen, for reasons still unclear.
If this dual-antibiotic regimen doesn’t dramatically reduce drainage and pain, he adds levofloxacin at 500 mg twice daily for up to 2 weeks in an effort to calm down unstable, decompensating disease.
Dapsone at 50-150 mg/day for up to 12 weeks is an additional option. It’s most useful in patients with nodules that are disproportionately painful, in Dr. Hamzavi’s experience.
Deroofing is a simple procedure that should be considered for all sinus tracts. It entails numbing the area with a ring block then introducing a curette or surgical probe into the sinus tract to open it up and get rid of the gelatinous material within. Dutch investigators have detailed the technique (J Am Acad Dermatol. 2010 Sep;63[3]:475-80).
Tumor necrosis factor–inhibitor therapy has been a major advance in Hurley stage II and III disease. “It doesn’t work in everybody, but a lot of patients can be stabilized,” Dr. Hamzavi observed.
Efficacy has been amply demonstrated for adalimumab (Humira) and infliximab (Remicade). In Dr. Hamzavi’s experience infliximab works better, probably because it offers more dosing options.
Assuming medical therapy has resulted in disease stabilization, CO2 laser excision of sinus tracts under local anesthesia can then be employed as an office procedure to turn back the clock and return to an earlier stage of disease. Dermatologists at the Cleveland Clinic have described the technique in detail (Dermatol Surg. 2010 Feb;36[2]:208-13).
Hurley stage III
If biologic therapy doesn’t bring disease stabilization, the patient is likely headed for surgical excision using the CO2 laser. The Henry Ford team favors a specific regimen of surgical preparation using wide-spectrum antibiotics. The program begins with 6 weeks of IV ertapenem at 1 g/day delivered by a peripherally inserted central catheter managed by infectious disease colleagues.
“IV ertapenem is a drug you may not know much about. We find it works really well as a great way to bridge patients towards surgery,” the dermatologist explained.
The IV ertapenem is followed by 6 weeks of oral triple therapy with rifampin, moxifloxacin, and metronidazole then another 6 weeks of rifampin plus moxifloxacin. Next it’s surgical excision time.
Lifestyle modification
Lifestyle modification deserves to be a major priority in all HS patients, regardless of Hurley stage. Smoking cessation results in significantly greater likelihood of favorable response to first-line therapy. In obese patients, greater than 15% weight loss has been associated with significant reduction in disease severity. A sartorial shift to loose-fitting clothing can quiet down skin lesions through decreased friction and pressure. And proper utilization of warm compression will rapidly decrease acute lesional pain.
Dr. Hamzavi and his coinvestigators have described the Henry Ford Hospital treatment algorithm in a review of HS published in an open-access journal meant to serve as a resource for patients and physicians alike (F1000Res. 2017 Jul 28;6:1272. doi: 10.12688/f1000research.11337.1. eCollection 2017).
He reported serving as a consultant to AbbVie, Incyte, and UCB.
The Global Academy for Medical Education/SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR