Aesthetic Dermatology

LOS CABOS, MEXICO — Dr. Mitchel P. Goldman doesn't accept insurance and says he believes that his cash-only acne patients get more for their money with one to three photodynamic therapy sessions than they do with years of prescriptions for medications, he said at the annual meeting of the Noah Worcester Dermatological Society.

Although he says he knows it sounds heretical—"and maybe you'll strip me of my derm boards"—he has been using the photosensitizing agent 5-aminolevulinic acid (ALA) followed by exposure to a blue-light laser for nearly 4 years and he thinks that there is nothing better for acne. "As soon as insurance companies wake up and realize it's a hell of a lot cheaper to do this than prescribe Accutane—they'll cover it," said Dr. Goldman, a dermatologist in private practice in La Jolla, Calif.

In the meantime, his patients pay $500-$600 for a treatment session that consists of a salicylic acid prep, microdermabrasion of the affected area, a scrub with acetone, 1-hour exposure to ALA (Levulan Kerastik, DUSA Pharmaceuticals), and 10–15 minutes' exposure to a blue light that is approved for the treatment of acne (BLU-U Photodynamic Therapy Illuminator, DUSA Pharmaceuticals Inc.), as well as long-pulse dye laser to individual acne lesions.

He said that he sees at least a 30% improvement in inflammatory acne after each treatment, spaced about 4 weeks apart. He has never done more than three treatments on a patient and he has never seen a patient's acne rebound, even years after a final treatment.

"Have I done controlled studies? No," he admitted. "It definitely lasts a long time."

Dr. Goldman explained that he is reassured by animal data, which show that exposure to photodynamic therapy (PDT) actually reduced, and did not increase, the risk of skin cancer ("Photodynamic Therapy" [London: Elsevier, 2005], pp. 53–64).

He says he has biopsied patients and seen a 90% decrease in the size of sebaceous glands after PDT.

He's read the studies that show that ALA-PDT kills bacteria and appears to normalize follicular shedding, and has participated in a study comparing blue light therapy with topical 1% clindamycin solution for inflammatory acne, in which lesions were reduced 34% after blue light therapy, compared with 14% with clindamycin (J. Drugs Dermatol. 2005;4:64–70).

"This is something the pharmaceutical companies do not want us to investigate, because they're going to lose a few billion dollars in acne treatment," he said.

Dr. Goldman disclosed that he has served as a consultant to DUSA Pharmaceuticals, the manufacturer of Levulan Kerastik (ALA) and the BLU-U light source.

LOS CABOS, MEXICO — Dr. Mitchel P. Goldman doesn't accept insurance and says he believes that his cash-only acne patients get more for their money with one to three photodynamic therapy sessions than they do with years of prescriptions for medications, he said at the annual meeting of the Noah Worcester Dermatological Society.

Although he says he knows it sounds heretical—"and maybe you'll strip me of my derm boards"—he has been using the photosensitizing agent 5-aminolevulinic acid (ALA) followed by exposure to a blue-light laser for nearly 4 years and he thinks that there is nothing better for acne. "As soon as insurance companies wake up and realize it's a hell of a lot cheaper to do this than prescribe Accutane—they'll cover it," said Dr. Goldman, a dermatologist in private practice in La Jolla, Calif.

In the meantime, his patients pay $500-$600 for a treatment session that consists of a salicylic acid prep, microdermabrasion of the affected area, a scrub with acetone, 1-hour exposure to ALA (Levulan Kerastik, DUSA Pharmaceuticals), and 10–15 minutes' exposure to a blue light that is approved for the treatment of acne (BLU-U Photodynamic Therapy Illuminator, DUSA Pharmaceuticals Inc.), as well as long-pulse dye laser to individual acne lesions.

He said that he sees at least a 30% improvement in inflammatory acne after each treatment, spaced about 4 weeks apart. He has never done more than three treatments on a patient and he has never seen a patient's acne rebound, even years after a final treatment.

"Have I done controlled studies? No," he admitted. "It definitely lasts a long time."

Dr. Goldman explained that he is reassured by animal data, which show that exposure to photodynamic therapy (PDT) actually reduced, and did not increase, the risk of skin cancer ("Photodynamic Therapy" [London: Elsevier, 2005], pp. 53–64).

He says he has biopsied patients and seen a 90% decrease in the size of sebaceous glands after PDT.

He's read the studies that show that ALA-PDT kills bacteria and appears to normalize follicular shedding, and has participated in a study comparing blue light therapy with topical 1% clindamycin solution for inflammatory acne, in which lesions were reduced 34% after blue light therapy, compared with 14% with clindamycin (J. Drugs Dermatol. 2005;4:64–70).

"This is something the pharmaceutical companies do not want us to investigate, because they're going to lose a few billion dollars in acne treatment," he said.

Dr. Goldman disclosed that he has served as a consultant to DUSA Pharmaceuticals, the manufacturer of Levulan Kerastik (ALA) and the BLU-U light source.

LOS CABOS, MEXICO — Dr. Mitchel P. Goldman doesn't accept insurance and says he believes that his cash-only acne patients get more for their money with one to three photodynamic therapy sessions than they do with years of prescriptions for medications, he said at the annual meeting of the Noah Worcester Dermatological Society.

Although he says he knows it sounds heretical—"and maybe you'll strip me of my derm boards"—he has been using the photosensitizing agent 5-aminolevulinic acid (ALA) followed by exposure to a blue-light laser for nearly 4 years and he thinks that there is nothing better for acne. "As soon as insurance companies wake up and realize it's a hell of a lot cheaper to do this than prescribe Accutane—they'll cover it," said Dr. Goldman, a dermatologist in private practice in La Jolla, Calif.

In the meantime, his patients pay $500-$600 for a treatment session that consists of a salicylic acid prep, microdermabrasion of the affected area, a scrub with acetone, 1-hour exposure to ALA (Levulan Kerastik, DUSA Pharmaceuticals), and 10–15 minutes' exposure to a blue light that is approved for the treatment of acne (BLU-U Photodynamic Therapy Illuminator, DUSA Pharmaceuticals Inc.), as well as long-pulse dye laser to individual acne lesions.

He said that he sees at least a 30% improvement in inflammatory acne after each treatment, spaced about 4 weeks apart. He has never done more than three treatments on a patient and he has never seen a patient's acne rebound, even years after a final treatment.

"Have I done controlled studies? No," he admitted. "It definitely lasts a long time."

Dr. Goldman explained that he is reassured by animal data, which show that exposure to photodynamic therapy (PDT) actually reduced, and did not increase, the risk of skin cancer ("Photodynamic Therapy" [London: Elsevier, 2005], pp. 53–64).

He says he has biopsied patients and seen a 90% decrease in the size of sebaceous glands after PDT.

He's read the studies that show that ALA-PDT kills bacteria and appears to normalize follicular shedding, and has participated in a study comparing blue light therapy with topical 1% clindamycin solution for inflammatory acne, in which lesions were reduced 34% after blue light therapy, compared with 14% with clindamycin (J. Drugs Dermatol. 2005;4:64–70).

"This is something the pharmaceutical companies do not want us to investigate, because they're going to lose a few billion dollars in acne treatment," he said.

Dr. Goldman disclosed that he has served as a consultant to DUSA Pharmaceuticals, the manufacturer of Levulan Kerastik (ALA) and the BLU-U light source.

LOS CABOS, MEXICO — Advances in photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) have led dermatologists to increasingly extol its virtues as a practical, versatile, and highly effective therapy for actinic keratoses, nonmelanoma skin cancer, acne, and photorejuvenation.

For example, at the annual meeting of the Noah Worcester Dermatological Society, several dermatologists described ALA-PDT with a degree of enthusiasm pointedly absent from presentations concerning many new lasers, skin smoothers, and nonablative, all-purpose devices.

"[It has] … changed the way I practice," Dr. C. William Hanke said at the meeting.

Dr. Hanke said he recalled hearing about ALA-PDT at an American Academy of Dermatology meeting 5 years ago. His impression of the therapy then was "how terrible it was. There was a lot of hand-holding … because the patient needed it."

Still, it seemed to work pretty well in eradicating actinic keratoses (AKs), and a 2003 study showed that it had the potential to be equal to 5-fluorouracil in efficacy and was preferred by most patients, despite the painful recovery required after a 14− to 18-hour ALA incubation period and subsequent exposure to a specialized light source (J. Drugs Dermatol. 2003;2:629–35).

Since then, ALA-PDT has changed dramatically in the following ways:

▸ Short-contact ALA-PDT is now standard. ALA remains on the skin just 15–60 minutes, profoundly affecting the side-effect profile and reducing pain. Instead of enduring a week of raw skin, erosions, and inflammation, most patients today note only minor stinging, erythema, and scaling that resolve within a few days. Many studies show that short-contact ALA-PDT does not reduce its effectiveness.

▸ Numerous light sources are being used. Although blue light emits a wavelength (405–420 nm) that conforms precisely to the absorption peak for ALA (marketed as the Levulan Kerastick by DUSA Pharmaceuticals Inc.), intense pulsed light (IPL), pulsed dye lasers, and other light sources also are proving effective.

▸ The versatility of ALA-PDT is expanding. Approved for nonhyperkeratotic AKs of the face and scalp, it also is being used on the trunk and extremities for AKs, nonmelanoma skin cancer, pigmented lesions, rosacea, and, especially, acne.

▸ Competition is on the horizon. An American launch is imminent for the photosensitizer methyl aminolevulinate, marketed as Metvix by the Norwegian company PhotoCure ASA. Widely used in Europe, Metvix is incubated for 3 hours under occlusion and activated by red light (630–660 nm) from a diode laser. Besides treating AKs and nonmelanoma skin cancer, the system is used to treat psoriasis.

Dr. Neil S. Sadick voiced a common complaint when he noted that nonablative therapies have now been used for 5 years to treat everything from rosacea to scars, "and we're still not sure [they're] effective or worth it."

In contrast, he said that IPL, which targets chromophores, has become a mainstay in his practice, "providing the greatest amount of clinical satisfaction, consistently, for [the] patients."

When he's treating more than telangiectasias, age spots, and minimal actinic damage, Dr. Sadick said he relies on ALA to amplify the impact of IPL.

"I can decrease five treatments to two [or] three treatments with IPL … for significant actinic damage. It's not nonablative; I would call it microablative," said Dr. Sadick, who practices in New York City and Great Neck, N.Y.

Dr. Mitchel P. Goldman said short-contact ALA-PDT using IPL is "incredibly impressive" for acne and a convenient and "very mildly painful" option for patients with actinic keratoses, telangiectasias, and skin texture problems. He even used the modality to treat his own facial squamous cell carcinoma.

He uses a pulsed dye laser rather than IPL on hair-bearing areas because IPL can remove hair.

Like Dr. Sadick, Dr. Goldman uses ALA-PDT to "boost" the effectiveness of IPL, reducing the number of treatments required.

After one or two treatments of ALA-PDT with IPL for actinic keratoses, "I think that's when you need to biopsy," said Dr. Goldman, who is in private practice in La Jolla, Calif.

Dr. Hanke, director of a dermatologic surgery practice in Carmel, Ind., says that ALA-PDT has become ever more useful in his practice over time, for cosmetic as well as medical dermatology.

If a patient's goal is to have smoother, clearer skin, with less blotchiness and redness, "we can do that," he said.

There are conditions, such as wrinkles, that do not respond well to ALA-PDT, the speakers agreed. In addition, Dr. Hanke said he was unimpressed by its results in a renal transplant patient with extreme sun damage that included a history of skin cancers and many keratoses.

It also doesn't work for disseminated superficial actinic porokeratosis or granulomatous rosacea, he concluded.

Its record in treating warts is erratic, he said, although he has had luck sometimes by paring the wart down, applying several coats of ALA, and then occluding the wart overnight prior to exposure to a light source.

Dr. Hanke has conducted clinical trials for DUSA Pharmaceuticals. Dr. Goldman has been a consultant for DUSA and for the Luminis LightSheer diode laser system, which can be used for phototherapy. Dr. Sadick has conducted research and/or consulted with Syneron, Thermage Inc., and Omnilux Inc., companies that manufacture lasers and light sources that can be used in phototherapy.

Getting the Most from PDT

The following steps can maximize the effects of ALA-PDT:

1Discontinue topical retinoids several weeks before treatment with 5-aminolevulinic acid photodynamic therapy (ALA-PDT).

2Prepare the skin using gentle microdermabrasion or acetone (to maximize the PDT reaction), or isopropyl alcohol (to minimize the PDT reaction).

3 Use a fresh ampule of Levulan Kerastick (ALA). The drug becomes inactive 4 hours after being opened.

4Apply two coats of ALA with a cotton swab. Take extra care to avoid getting the solution in the patient's eyes.

5Adjust exposure to ALA and to the light or laser source according to the patient's condition and severity. For example, the photosensitizer should remain on the skin 60 minutes prior to PDT for treatment of photoaging. Exposure time will vary: 22–25 minutes for an intense pulsed light source or 16 minutes and 40 seconds for a blue light source.

6Use cool airflow, rest periods, and, possibly, topical anesthesia or diazepam (5–10 mg) for pain management.

7Observe the patient post phototherapy, and wash the area thoroughly with soap and water to ensure that all of the photosensitizer has been removed. Apply sunscreen in the office.

8Be adamant in instructing the patient to avoid sun exposure altogether for 24 hours and to wear heavy sunscreen for 3–4 days. Patients can have extreme reactions to sun exposure in the days following phototherapy.

Source: Dr. Hanke

LOS CABOS, MEXICO — Advances in photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) have led dermatologists to increasingly extol its virtues as a practical, versatile, and highly effective therapy for actinic keratoses, nonmelanoma skin cancer, acne, and photorejuvenation.

For example, at the annual meeting of the Noah Worcester Dermatological Society, several dermatologists described ALA-PDT with a degree of enthusiasm pointedly absent from presentations concerning many new lasers, skin smoothers, and nonablative, all-purpose devices.

"[It has] … changed the way I practice," Dr. C. William Hanke said at the meeting.

Dr. Hanke said he recalled hearing about ALA-PDT at an American Academy of Dermatology meeting 5 years ago. His impression of the therapy then was "how terrible it was. There was a lot of hand-holding … because the patient needed it."

Still, it seemed to work pretty well in eradicating actinic keratoses (AKs), and a 2003 study showed that it had the potential to be equal to 5-fluorouracil in efficacy and was preferred by most patients, despite the painful recovery required after a 14− to 18-hour ALA incubation period and subsequent exposure to a specialized light source (J. Drugs Dermatol. 2003;2:629–35).

Since then, ALA-PDT has changed dramatically in the following ways:

▸ Short-contact ALA-PDT is now standard. ALA remains on the skin just 15–60 minutes, profoundly affecting the side-effect profile and reducing pain. Instead of enduring a week of raw skin, erosions, and inflammation, most patients today note only minor stinging, erythema, and scaling that resolve within a few days. Many studies show that short-contact ALA-PDT does not reduce its effectiveness.

▸ Numerous light sources are being used. Although blue light emits a wavelength (405–420 nm) that conforms precisely to the absorption peak for ALA (marketed as the Levulan Kerastick by DUSA Pharmaceuticals Inc.), intense pulsed light (IPL), pulsed dye lasers, and other light sources also are proving effective.

▸ The versatility of ALA-PDT is expanding. Approved for nonhyperkeratotic AKs of the face and scalp, it also is being used on the trunk and extremities for AKs, nonmelanoma skin cancer, pigmented lesions, rosacea, and, especially, acne.

▸ Competition is on the horizon. An American launch is imminent for the photosensitizer methyl aminolevulinate, marketed as Metvix by the Norwegian company PhotoCure ASA. Widely used in Europe, Metvix is incubated for 3 hours under occlusion and activated by red light (630–660 nm) from a diode laser. Besides treating AKs and nonmelanoma skin cancer, the system is used to treat psoriasis.

Dr. Neil S. Sadick voiced a common complaint when he noted that nonablative therapies have now been used for 5 years to treat everything from rosacea to scars, "and we're still not sure [they're] effective or worth it."

In contrast, he said that IPL, which targets chromophores, has become a mainstay in his practice, "providing the greatest amount of clinical satisfaction, consistently, for [the] patients."

When he's treating more than telangiectasias, age spots, and minimal actinic damage, Dr. Sadick said he relies on ALA to amplify the impact of IPL.

"I can decrease five treatments to two [or] three treatments with IPL … for significant actinic damage. It's not nonablative; I would call it microablative," said Dr. Sadick, who practices in New York City and Great Neck, N.Y.

Dr. Mitchel P. Goldman said short-contact ALA-PDT using IPL is "incredibly impressive" for acne and a convenient and "very mildly painful" option for patients with actinic keratoses, telangiectasias, and skin texture problems. He even used the modality to treat his own facial squamous cell carcinoma.

He uses a pulsed dye laser rather than IPL on hair-bearing areas because IPL can remove hair.

Like Dr. Sadick, Dr. Goldman uses ALA-PDT to "boost" the effectiveness of IPL, reducing the number of treatments required.

After one or two treatments of ALA-PDT with IPL for actinic keratoses, "I think that's when you need to biopsy," said Dr. Goldman, who is in private practice in La Jolla, Calif.

Dr. Hanke, director of a dermatologic surgery practice in Carmel, Ind., says that ALA-PDT has become ever more useful in his practice over time, for cosmetic as well as medical dermatology.

If a patient's goal is to have smoother, clearer skin, with less blotchiness and redness, "we can do that," he said.

There are conditions, such as wrinkles, that do not respond well to ALA-PDT, the speakers agreed. In addition, Dr. Hanke said he was unimpressed by its results in a renal transplant patient with extreme sun damage that included a history of skin cancers and many keratoses.

It also doesn't work for disseminated superficial actinic porokeratosis or granulomatous rosacea, he concluded.

Its record in treating warts is erratic, he said, although he has had luck sometimes by paring the wart down, applying several coats of ALA, and then occluding the wart overnight prior to exposure to a light source.

Dr. Hanke has conducted clinical trials for DUSA Pharmaceuticals. Dr. Goldman has been a consultant for DUSA and for the Luminis LightSheer diode laser system, which can be used for phototherapy. Dr. Sadick has conducted research and/or consulted with Syneron, Thermage Inc., and Omnilux Inc., companies that manufacture lasers and light sources that can be used in phototherapy.

Getting the Most from PDT

The following steps can maximize the effects of ALA-PDT:

1Discontinue topical retinoids several weeks before treatment with 5-aminolevulinic acid photodynamic therapy (ALA-PDT).

2Prepare the skin using gentle microdermabrasion or acetone (to maximize the PDT reaction), or isopropyl alcohol (to minimize the PDT reaction).

3 Use a fresh ampule of Levulan Kerastick (ALA). The drug becomes inactive 4 hours after being opened.

4Apply two coats of ALA with a cotton swab. Take extra care to avoid getting the solution in the patient's eyes.

5Adjust exposure to ALA and to the light or laser source according to the patient's condition and severity. For example, the photosensitizer should remain on the skin 60 minutes prior to PDT for treatment of photoaging. Exposure time will vary: 22–25 minutes for an intense pulsed light source or 16 minutes and 40 seconds for a blue light source.

6Use cool airflow, rest periods, and, possibly, topical anesthesia or diazepam (5–10 mg) for pain management.

7Observe the patient post phototherapy, and wash the area thoroughly with soap and water to ensure that all of the photosensitizer has been removed. Apply sunscreen in the office.

8Be adamant in instructing the patient to avoid sun exposure altogether for 24 hours and to wear heavy sunscreen for 3–4 days. Patients can have extreme reactions to sun exposure in the days following phototherapy.

Source: Dr. Hanke

LOS CABOS, MEXICO — Advances in photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA) have led dermatologists to increasingly extol its virtues as a practical, versatile, and highly effective therapy for actinic keratoses, nonmelanoma skin cancer, acne, and photorejuvenation.

For example, at the annual meeting of the Noah Worcester Dermatological Society, several dermatologists described ALA-PDT with a degree of enthusiasm pointedly absent from presentations concerning many new lasers, skin smoothers, and nonablative, all-purpose devices.

"[It has] … changed the way I practice," Dr. C. William Hanke said at the meeting.

Dr. Hanke said he recalled hearing about ALA-PDT at an American Academy of Dermatology meeting 5 years ago. His impression of the therapy then was "how terrible it was. There was a lot of hand-holding … because the patient needed it."

Still, it seemed to work pretty well in eradicating actinic keratoses (AKs), and a 2003 study showed that it had the potential to be equal to 5-fluorouracil in efficacy and was preferred by most patients, despite the painful recovery required after a 14− to 18-hour ALA incubation period and subsequent exposure to a specialized light source (J. Drugs Dermatol. 2003;2:629–35).

Since then, ALA-PDT has changed dramatically in the following ways:

▸ Short-contact ALA-PDT is now standard. ALA remains on the skin just 15–60 minutes, profoundly affecting the side-effect profile and reducing pain. Instead of enduring a week of raw skin, erosions, and inflammation, most patients today note only minor stinging, erythema, and scaling that resolve within a few days. Many studies show that short-contact ALA-PDT does not reduce its effectiveness.

▸ Numerous light sources are being used. Although blue light emits a wavelength (405–420 nm) that conforms precisely to the absorption peak for ALA (marketed as the Levulan Kerastick by DUSA Pharmaceuticals Inc.), intense pulsed light (IPL), pulsed dye lasers, and other light sources also are proving effective.

▸ The versatility of ALA-PDT is expanding. Approved for nonhyperkeratotic AKs of the face and scalp, it also is being used on the trunk and extremities for AKs, nonmelanoma skin cancer, pigmented lesions, rosacea, and, especially, acne.

▸ Competition is on the horizon. An American launch is imminent for the photosensitizer methyl aminolevulinate, marketed as Metvix by the Norwegian company PhotoCure ASA. Widely used in Europe, Metvix is incubated for 3 hours under occlusion and activated by red light (630–660 nm) from a diode laser. Besides treating AKs and nonmelanoma skin cancer, the system is used to treat psoriasis.

Dr. Neil S. Sadick voiced a common complaint when he noted that nonablative therapies have now been used for 5 years to treat everything from rosacea to scars, "and we're still not sure [they're] effective or worth it."

In contrast, he said that IPL, which targets chromophores, has become a mainstay in his practice, "providing the greatest amount of clinical satisfaction, consistently, for [the] patients."

When he's treating more than telangiectasias, age spots, and minimal actinic damage, Dr. Sadick said he relies on ALA to amplify the impact of IPL.

"I can decrease five treatments to two [or] three treatments with IPL … for significant actinic damage. It's not nonablative; I would call it microablative," said Dr. Sadick, who practices in New York City and Great Neck, N.Y.

Dr. Mitchel P. Goldman said short-contact ALA-PDT using IPL is "incredibly impressive" for acne and a convenient and "very mildly painful" option for patients with actinic keratoses, telangiectasias, and skin texture problems. He even used the modality to treat his own facial squamous cell carcinoma.

He uses a pulsed dye laser rather than IPL on hair-bearing areas because IPL can remove hair.

Like Dr. Sadick, Dr. Goldman uses ALA-PDT to "boost" the effectiveness of IPL, reducing the number of treatments required.

After one or two treatments of ALA-PDT with IPL for actinic keratoses, "I think that's when you need to biopsy," said Dr. Goldman, who is in private practice in La Jolla, Calif.

Dr. Hanke, director of a dermatologic surgery practice in Carmel, Ind., says that ALA-PDT has become ever more useful in his practice over time, for cosmetic as well as medical dermatology.

If a patient's goal is to have smoother, clearer skin, with less blotchiness and redness, "we can do that," he said.

There are conditions, such as wrinkles, that do not respond well to ALA-PDT, the speakers agreed. In addition, Dr. Hanke said he was unimpressed by its results in a renal transplant patient with extreme sun damage that included a history of skin cancers and many keratoses.

It also doesn't work for disseminated superficial actinic porokeratosis or granulomatous rosacea, he concluded.

Its record in treating warts is erratic, he said, although he has had luck sometimes by paring the wart down, applying several coats of ALA, and then occluding the wart overnight prior to exposure to a light source.

Dr. Hanke has conducted clinical trials for DUSA Pharmaceuticals. Dr. Goldman has been a consultant for DUSA and for the Luminis LightSheer diode laser system, which can be used for phototherapy. Dr. Sadick has conducted research and/or consulted with Syneron, Thermage Inc., and Omnilux Inc., companies that manufacture lasers and light sources that can be used in phototherapy.

Getting the Most from PDT

The following steps can maximize the effects of ALA-PDT:

1Discontinue topical retinoids several weeks before treatment with 5-aminolevulinic acid photodynamic therapy (ALA-PDT).

2Prepare the skin using gentle microdermabrasion or acetone (to maximize the PDT reaction), or isopropyl alcohol (to minimize the PDT reaction).

3 Use a fresh ampule of Levulan Kerastick (ALA). The drug becomes inactive 4 hours after being opened.

4Apply two coats of ALA with a cotton swab. Take extra care to avoid getting the solution in the patient's eyes.

5Adjust exposure to ALA and to the light or laser source according to the patient's condition and severity. For example, the photosensitizer should remain on the skin 60 minutes prior to PDT for treatment of photoaging. Exposure time will vary: 22–25 minutes for an intense pulsed light source or 16 minutes and 40 seconds for a blue light source.

6Use cool airflow, rest periods, and, possibly, topical anesthesia or diazepam (5–10 mg) for pain management.

7Observe the patient post phototherapy, and wash the area thoroughly with soap and water to ensure that all of the photosensitizer has been removed. Apply sunscreen in the office.

8Be adamant in instructing the patient to avoid sun exposure altogether for 24 hours and to wear heavy sunscreen for 3–4 days. Patients can have extreme reactions to sun exposure in the days following phototherapy.

Source: Dr. Hanke

KEVIN FOLEY, RESEARCH/SARAH L. G ALLANT, DESIGN

KEVIN FOLEY, RESEARCH/SARAH L. G ALLANT, DESIGN

KEVIN FOLEY, RESEARCH/SARAH L. G ALLANT, DESIGN

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.

Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.

The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.

Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.

"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.

The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.

The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."

Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.

"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.

Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.

In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.

When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.

Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.

"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.

He also shared tips for patient selection and scheduling.

There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.

Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."

Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.

Regardless of scheduling type, Dr. Yob suggests starting conservatively, with small defects, and scheduling more than enough time, and not hesitating to finish a patient's procedure the next day. The volume of patients will depend on the skill and speed of the surgeon, the experience of the surgical team, and the efficiency of the office setup.

Determine how the total number of patients with varying degrees of complexity fits with the workload. DR. YOB

Building a Mohs Surgery Practice Takes Planning and Hard Work

"When you are establishing a practice, consider how and whether you are willing to commit the time and resources—and it is a considerable commitment in the beginning—to develop a Mohs practice and do it right," Dr. Yob said. "You won't make money when you start, and you must be willing to work hard and train your staff."

When starting in a Mohs surgery practice, it is best to start small, allow extra time, not treat complex cases, avoid distractions, and pay attention to details, he said.

There are several other elements to consider:

Choosing Practice Type

Group or solo? Will patients be practice generated or referred?

Scouting Geographic Area

Research the local area and learn about the population: Is there a large population of retirees and suburban moms, or a lot of college students?

Determining Community Practice Patterns

Know the size of the community and the number of dermatologists in the area. If there are other dermatologists in the area, find out how they treat skin cancer and ask about their attitudes toward Mohs surgery. Find out whether primary care physicians treat skin cancer and how they feel about Mohs surgery. "Treat the family doctors with respect," Dr. Yob said. "The more you share with them, the more they respect you."

Evaluating Your Practice

How important is Mohs to you? Is it a focal point, or is it something you do in addition to general dermatology?

Generating Referrals

Talk to ENT surgeons and plastic surgeons. "If you can convince them that you can clean out the cancer and send them a tumor-free patient, they may appreciate that," he said.

Getting the Word Out

Other ways to generate business include giving lectures to physicians and participating in CME programs at hospitals and medical meetings, as well as giving community-based talks to church or civic groups. Pamphlets and Web sites are also helpful ways for Mohs surgeons to introduce themselves to the community.

Hiring Good Help

The lab technician is "the Mohs lifeline," Dr. Yob said. You can hire a full-time staff technician or contract with one. "If you plan to do Mohs only 2 days a week, you might be able to share a technician with another surgeon who does Mohs 3 days each week," he said. The advantages of an in-house technician are convenience, availability, and consistency, as well as faster communication. However, a contract technician is often more cost effective, usually experienced, and generally has a backup on call. A contracted technician also may have helpful insights into the community and sources of patients for surgeons who are in the early stages of establishing a Mohs practice. If a nurse or another member of your staff is eager to learn, consider training them. Their personality and willingness to learn is as important as previous background, he said.

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — When it comes to evaluating basal cell carcinomas for Mohs surgery, experience trumps criteria, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

The more slides that physicians review, the better they are at distinguishing basal cell carcinoma (BCC) from other conditions, said Dr. Rapini, professor and chair of dermatology at the University of Texas, Houston, and the M.D. Anderson Cancer Center.

The main problem with BCC as it relates to Mohs surgery is that the cancer tends to resemble follicles, sweat ducts, and sebaceous glands in Mohs sections, he explained.

To best evaluate histopathology slides for basal cell carcinoma, the surgeon should scan images on low power—the equivalent of flying over the tumor in a blimp and looking at it from a distance—and then zoom in for a closer look at anything that appears suspicious.

Get a special condenser for your microscope in order to have a 2x objective view, Dr. Rapini said. These condensers are more expensive but are worth it.

"You have to get in your blimp and look at the tumors from far away," he said. First find the tumor, then note the ink, then correlate it with the Mohs map of the problem area. "I prefer to look at the slide first and then look at the map. Even if the technician has flipped the sections by mistake, you can tell the orientation of the specimen from looking at the ink," Dr. Rapini said.

Looking for a BCC on a histopathology slide is sort of like finding a single black sheep in a herd of white sheep. "Look for bluish aggregates that don't look like they belong," he suggested.

Sometimes tumor cells will look like follicles, and sometimes they will clump together. When toluidine blue stain is used, purplish smudges of mucin are more apparent around tumors than around follicles, which can help distinguish between them.

"If you are unsure, scan on low power, and then get closer," Dr. Rapini said. Thick or fixed sections may have brownish areas that make tumor spotting more difficult, and these require a closer look with a higher-powered objective.

BCC often can be distinguished by looking for signs of an inflammatory reaction. Basaloid cells have the ability to differentiate toward sweat ducts, follicles, and sebaceous glands, but this rarely changes the prognosis.

The principal types of basal cell carcinoma are nodular, pigmented, superficial (also known as multicentric), and sclerosing (also known as morpheaform). The term "infiltrating BCC" is also used, but the definition depends on the user; the term has been used to describe any deeply invasive BCC and also has been used as a synonym for sclerosing or morpheaform BCC.

Micronodular BCC is a term currently in vogue in dermatology circles, even though its characteristics have been demonstrated in only one paper.

"It's supposed to be more aggressive than the average basal cell, but in my opinion, this definition is overrated," Dr. Rapini said. Any BCC can be aggressive or nonaggressive. Ordinary nodular BCC can get into bone, for instance, and sclerosing BCC can sometimes prove only a minor problem.

When the tumor does penetrate the bone, a multidisciplinary approach may be needed, including collaboration with a radiation therapist or orthopedist.

Folliculocentric basaloid proliferation is something else to consider in cases of potential BCC. Dr. Rapini cited the journal article that described funny-looking follicles (Arch. Dermatol. 1990;126:900–6). "These follicles are benign, but they just look strange," Dr. Rapini said. "There may be some sort of phenomenon where the nearby basal cell stimulates the follicular infundibulum," he added.

It's critical to remember that evidence of follicular differentiation does not rule out the possibility of BCC, Dr. Rapini noted. However, if papillary mesenchymal bodies, hair bulbs, or hair shafts are present, the area is more likely to be benign than cancerous.

Dr. Rapini recommends deeper cuts and a higher-powered examination to look for things like necrosis and stromal retraction. "The presence of lymphocytes can help distinguish BCC from follicles, but that isn't always reliable, especially in patients with rosacea," he said.

Even when there is follicular differentiation, physicians should not rule out BCC in a patient with a solitary tumor, especially in sun-damaged skin. A benign trichoepithelioma, for instance, can be confused with BCC. With regard to these tumors, Dr. Rapini said, "when in doubt, cut it out."

Dr. Rapini pointed out that breast cancer is the most common tumor to metastasize in the skin, and it can look like a basal cell or sclerosing basal cell carcinoma. A breast cancer tumor usually sits in the dermis, however, without connecting to the surface, and the patient usually mentions a history of breast cancer. Most of these metastases occur on the chest, he said.

Other conditions that simulate basal cell carcinoma include ameloblastoma (a dental tumor inside the mouth), cloacogenic carcinoma (anus), hair follicle tumors, sweat gland tumors, and sebaceous gland tumors.

The histopathology of metastatic breast cancer can resemble sclerosing or infiltrating basal cell carcinoma.

Pleomorphic basal cell carcinoma, which is essentially a BCC with giant atypical cells, behaves like any other BCC. Photos courtesy Dr. Ronald P. Rapini

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

SAN DIEGO — The art of treating skin cancer involves knowing which lesions are high risk and which are low risk, Dr. Ronald P. Rapini said at a meeting sponsored by the American Society for Mohs Surgery.

Patients with high-risk squamous cell carcinomas (SCCs) can be viable candidates for Mohs surgery. High-risk SCCs include those greater than 2 cm in size or 1 cm in depth or those in highly vascular areas such as the lips, said Dr. Rapini, professor and chairman of dermatology at the University of Texas, Houston.

"I think squamous cell is harder to see on slides than basal cell," Dr. Rapini said. When scanning with low power, remember that SCC tends to show up as the color pink, and it can be subtle within the dermis and muscle. For example, SCC often features atypical cells, but well-differentiated SCC might not show atypical cells.

Perineural invasion is present in approximately 10%–20% of SCCs and is more common when the tumor is recurrent or deeper than 2 cm, and approximately 40% of SCC patients report pain or nerve palsy.

Dr. Rapini said that "usually SCCs must be approximately 1 cm thick before they metastasize." Recurrent tumors, tumors that arise from burn scars, and postradiation tumors are additional examples of high-risk SCCs, as are poorly differentiated tumors, tumors with perineural invasion, and tumors in highly vascular locations, such as the lips or ears. SCCs in transplant patients and in those with pseudoglandular changes are also more likely to be severe.

Spindle cell tumors are a particular problem. The "big three" diagnoses on sun-fried skin are atypical fibroxanthoma, spindle cell squamous carcinoma, and spindle cell melanoma, he said.

Dr. Rapini also discussed other severe types of SCC:

▸ Keratoacanthoma. Specific criteria for a keratoacanthoma diagnosis—a central crater, lack of atypia in histology, and rapid growth—are worthless because they are so common to other cancers, he said. "The claim to fame of keratoacanthoma is spontaneous regression, but if you have a rapidly growing tumor you don't wait for it to regress," Dr. Rapini said, describing a keratoacanthoma as pale and glassy, with not a lot of atypia. "But if there are a lot of atypical cells, I'll just call it SCC," he said.

▸ Basosquamous cell carcinoma. This condition includes features of both SCC and basal cell carcinoma. Don't call it basosquamous simply because it is keratinizing under ulcers—that is just BCC, Dr. Rapini said. Some basosquamous cell carcinomas have clear cells as well, he added.

▸ Verrucous carcinoma. "I think of this as a wart that went amuck," Dr. Rapini said. This carcinoma appears pale and glassy, with minimal atypia. It does not metastasize, and it looks like a huge, nasty wart. The three most common variations occur on the sole of the foot (epithelioma cuniculatum), the genitals (Buschke-Lowenstein tumor), and mouth (oral florid papillomatosis).

Low-risk categories of SCC include actinic keratosis, Bowen's disease, and inverted follicular keratosis.

Some doctors call an actinic keratosis (AK) a superficial squamous cell carcinoma. AKs are often multifocal, and they can cause problems in the margins during Mohs surgery because they resemble SCC. Some surgeons use Mohs to get the invasive tumor out, and then treat the patient with imiquimod or freeze the edges of the wound after Mohs to treat any precancerous changes in the wound edge. On histopathology, an AK often alternates between pink and blue in the stratum corneum.

"In my opinion, Bowen's [squamous cell carcinoma in situ] is rarely an indication for Mohs surgery," Dr. Rapini said. Most states do not routinely cover Mohs surgery to treat Bowen's disease, and it is rarely necessary. He advised any surgeon who thinks that Mohs is indicated to document the reasons in the patient's chart and use code 173.8 (this depends upon the individual insurance carrier).

Inverted follicular keratosis, a downward-growing irritated seborrheic keratosis, has fewer clear cells than trichilemmoma (hair follicle tumor).

It has some AK features, but it is not as atypical as SCC.

SCC has many look-alikes, including hypertrophic lichen planus, hypertrophic lupus, prurigo nodularis, sweat duct metaplasia, and healing wounds.

Muscle degeneration also can mimic the squamous cell. "Damaged skeletal muscle may look bizarre, and it can be mistaken for SCC," Dr. Rapini said. "If you aren't sure, you can do a keratin stain."

Adnexal cell metaplasia, sweat ducts, and hair follicles can become metaplastic and strange looking, but none of these are SCC. A tangential section of epidermis—especially if it includes an AK—also can resemble a SCC if it is cut at a 45-degree angle. "A lot of people with squamous cell have AKs in the margins, and you may feel like you can't get clear because their whole face is one big AK," he noted.

When faced with a possible SCC, it's important to determine which lesions are superficial squamous cells and which ones are deep and aggressive. "I think the best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod, depending on the individual patient," Dr. Rapini said.

The patient on the left has recurrent squamous cell carcinoma with satellite nodules and would not be a good candidate for Mohs surgery. The image on the right shows pseudocarcinomatous hyperplasia in a previous biopsy site of a Spitz nevus. Photos courtesy Dr. Ronald P. Rapini

The best skin cancer surgeon uses multiple modalities, including Mohs, radiation, and imiquimod. DR. RAPINI

ATLANTA — Pretreatment preparation is key to uniform application and a good outcome with the Cook body peel, Dr. Sue Ellen Cox said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Patients should be pretreated with a retinoid, such as Tazorac (tazarotene), and an alpha hydroxy acid product, such as Lac-Hydrin. "You want the skin to turn over in advance of the procedure, but then you want to stop that about a week before the peel so that there is no irritation at the time of the peel," said Dr. Cox, a dermatologic surgeon in Chapel Hill, N.C.

Just before the peel, one should rub the skin with acetone to degrease the treatment area, then apply a "fairly uniform" thin layer of 70% glycolic acid gel, she advised. A gel formulation is important, because it serves as a partial barrier to the trichloracetic acid (TCA) that is also used as part of the Cook body peel. Too thick a layer of glycolic acid gel will prevent penetration of the TCA, she noted.

Typically, a 40% TCA concentration is applied over the glycolic acid gel. Dr. Cox said she gets the best results with 40% TCA but will try 35% first in those with very thin skin to gauge the development of the characteristic speckled white appearance that serves as the treatment end point.

The peel is stopped at this end point with a 10% sodium bicarbonate solution.

Immediately after the peel, the skin should be hydrated with Aquaphor or Vaseline, and the patient should apply a moisturizer such as Vanicream at home for long-term hydration.

Patients should be advised to use sun protection and to avoid rubbing or otherwise traumatizing the skin in the weeks after the peel, Dr. Cox said.

Skin flaking can occur for 2–4 weeks depending on the area treated. Hands, for example, will flake for about 2 weeks; legs will flake for about 4 weeks. Most patients will see about a 50% improvement after the first peel. Peels can be repeated every 1–4 months as necessary, but most patients are satisfied with the initial outcome, she said.

The Cook body peel is a safe, highly predictable peel that can be used almost anywhere on the body. Indications for this peel include actinic keratoses, lentigines, poikiloderma, hyperpigmentation, fine lines, and wrinkles. "Disseminated superficial actinic porokeratosis [DSAP] is my favorite indication; this is where I get all my referrals from my general dermatology friends," Dr. Cox said.

DSAP is very difficult to treat with other modalities, but it responds nicely to the Cook body peel, she said, noting, however, that multiple peels may be necessary in patients with this disease. The peel can be repeated every 2–4 months as needed in patients with DSAP. The lesions tend to recur, so even after achieving desired results, the peel may need to be repeated in about 2 years, she added.

This patient is shown at baseline and at 7.5 months post treatment, after receiving two Cook body peels. Photos courtesy Dr. Sue Ellen Cox

ATLANTA — Pretreatment preparation is key to uniform application and a good outcome with the Cook body peel, Dr. Sue Ellen Cox said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Patients should be pretreated with a retinoid, such as Tazorac (tazarotene), and an alpha hydroxy acid product, such as Lac-Hydrin. "You want the skin to turn over in advance of the procedure, but then you want to stop that about a week before the peel so that there is no irritation at the time of the peel," said Dr. Cox, a dermatologic surgeon in Chapel Hill, N.C.

Just before the peel, one should rub the skin with acetone to degrease the treatment area, then apply a "fairly uniform" thin layer of 70% glycolic acid gel, she advised. A gel formulation is important, because it serves as a partial barrier to the trichloracetic acid (TCA) that is also used as part of the Cook body peel. Too thick a layer of glycolic acid gel will prevent penetration of the TCA, she noted.

Typically, a 40% TCA concentration is applied over the glycolic acid gel. Dr. Cox said she gets the best results with 40% TCA but will try 35% first in those with very thin skin to gauge the development of the characteristic speckled white appearance that serves as the treatment end point.

The peel is stopped at this end point with a 10% sodium bicarbonate solution.

Immediately after the peel, the skin should be hydrated with Aquaphor or Vaseline, and the patient should apply a moisturizer such as Vanicream at home for long-term hydration.

Patients should be advised to use sun protection and to avoid rubbing or otherwise traumatizing the skin in the weeks after the peel, Dr. Cox said.

Skin flaking can occur for 2–4 weeks depending on the area treated. Hands, for example, will flake for about 2 weeks; legs will flake for about 4 weeks. Most patients will see about a 50% improvement after the first peel. Peels can be repeated every 1–4 months as necessary, but most patients are satisfied with the initial outcome, she said.

The Cook body peel is a safe, highly predictable peel that can be used almost anywhere on the body. Indications for this peel include actinic keratoses, lentigines, poikiloderma, hyperpigmentation, fine lines, and wrinkles. "Disseminated superficial actinic porokeratosis [DSAP] is my favorite indication; this is where I get all my referrals from my general dermatology friends," Dr. Cox said.

DSAP is very difficult to treat with other modalities, but it responds nicely to the Cook body peel, she said, noting, however, that multiple peels may be necessary in patients with this disease. The peel can be repeated every 2–4 months as needed in patients with DSAP. The lesions tend to recur, so even after achieving desired results, the peel may need to be repeated in about 2 years, she added.

This patient is shown at baseline and at 7.5 months post treatment, after receiving two Cook body peels. Photos courtesy Dr. Sue Ellen Cox

ATLANTA — Pretreatment preparation is key to uniform application and a good outcome with the Cook body peel, Dr. Sue Ellen Cox said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Patients should be pretreated with a retinoid, such as Tazorac (tazarotene), and an alpha hydroxy acid product, such as Lac-Hydrin. "You want the skin to turn over in advance of the procedure, but then you want to stop that about a week before the peel so that there is no irritation at the time of the peel," said Dr. Cox, a dermatologic surgeon in Chapel Hill, N.C.

Just before the peel, one should rub the skin with acetone to degrease the treatment area, then apply a "fairly uniform" thin layer of 70% glycolic acid gel, she advised. A gel formulation is important, because it serves as a partial barrier to the trichloracetic acid (TCA) that is also used as part of the Cook body peel. Too thick a layer of glycolic acid gel will prevent penetration of the TCA, she noted.

Typically, a 40% TCA concentration is applied over the glycolic acid gel. Dr. Cox said she gets the best results with 40% TCA but will try 35% first in those with very thin skin to gauge the development of the characteristic speckled white appearance that serves as the treatment end point.

The peel is stopped at this end point with a 10% sodium bicarbonate solution.

Immediately after the peel, the skin should be hydrated with Aquaphor or Vaseline, and the patient should apply a moisturizer such as Vanicream at home for long-term hydration.

Patients should be advised to use sun protection and to avoid rubbing or otherwise traumatizing the skin in the weeks after the peel, Dr. Cox said.

Skin flaking can occur for 2–4 weeks depending on the area treated. Hands, for example, will flake for about 2 weeks; legs will flake for about 4 weeks. Most patients will see about a 50% improvement after the first peel. Peels can be repeated every 1–4 months as necessary, but most patients are satisfied with the initial outcome, she said.

The Cook body peel is a safe, highly predictable peel that can be used almost anywhere on the body. Indications for this peel include actinic keratoses, lentigines, poikiloderma, hyperpigmentation, fine lines, and wrinkles. "Disseminated superficial actinic porokeratosis [DSAP] is my favorite indication; this is where I get all my referrals from my general dermatology friends," Dr. Cox said.

DSAP is very difficult to treat with other modalities, but it responds nicely to the Cook body peel, she said, noting, however, that multiple peels may be necessary in patients with this disease. The peel can be repeated every 2–4 months as needed in patients with DSAP. The lesions tend to recur, so even after achieving desired results, the peel may need to be repeated in about 2 years, she added.

This patient is shown at baseline and at 7.5 months post treatment, after receiving two Cook body peels. Photos courtesy Dr. Sue Ellen Cox

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — The decision for or against Mohs surgery must be based on a combination of criteria that includes histology, anatomy, type of patient, and type of tumor, Dr. Lynn Proctor Shipman said at a meeting sponsored by the American Society for Mohs Surgery.

Recurrent basal cell or squamous cell carcinomas are among the strongest indicators for Mohs surgery, said Dr. Shipman of the University of California, San Diego.

The advantages of Mohs surgery include a high cure rate and its status as an outpatient procedure (except in very difficult cases) that often preserves more tissue than do other cancer treatments. The disadvantages include the expense of staff and equipment and the need for specialized surgical training. Mohs also can be time consuming and tedious, and the procedure can be traumatic for the patient, she said.

There are no solid recurrence data comparing tumor treatment modalities. The differences among tumors, among patients, and among surgeons do not make for effective controlled studies, Dr. Shipman noted.

However, Mohs has demonstrated higher cure rates for primary and recurrent basal cell and squamous cell carcinoma compared with other treatments, including radiation.

Not all patients make good candidates for Mohs surgery. A frail or elderly patient, or a patient who would be too traumatized by the size of the defect in a Mohs procedure, should not receive the procedure (SKIN & ALLERGY NEWS, August 2005, p. 1).

Factors that make someone a good candidate for Mohs are the presence of infiltrating or micronodular tumors, aggressive tumors, or perineural invasion.

Dr. Shipman suggested that Mohs surgeons assessing patients should remember the five Cs:

Cure. The first treatment has the highest chance of cure, and Mohs cure rates are higher than those of other modalities.

Complications. Consider the medical status of the patients. Take a patient's blood pressure before you operate, and be aware of his or her medications.

Cosmesis. Mohs is often touted as tissue sparing, although preservation of function should be the most important goal. That said, a Mohs surgeon can often satisfy patients with a functional and cosmetically acceptable outcome.

Convenience. Although some waiting time is involved, Mohs is reasonably convenient for most patients.

Cost. Mohs is expensive, but radiation can be more expensive, and the cost of treating recurrent tumors can add up. Be sure to document the reasons for Mohs surgery in the patient's records to ensure Medicare coverage.

Certain anatomic sites with high recurrence rates are also indications for Mohs surgery.

The nose, for instance, is the bread and butter of Mohs. "There's almost never a day when I don't operate on the nose, especially the nasal tip," Dr. Shipman said. Mohs also is indicated for functionally significant sites, such as the finger, and in cases when a favorable cosmetic result is desired.

Immunocompromised patients are often candidates for Mohs surgery because of their increased susceptibility to tumors. "The longer they have been on immunosuppressant drugs, the greater the risk of tumor formation," Dr. Shipman noted. Unlike other patients, immunocompromised patients have a higher risk of squamous cell carcinoma than of basal cell carcinoma, particularly among cardiac patients, she added.

It is also important to remember that Mohs is not always successful, and is not recommended for oral, pharyngeal, or laryngeal tumors.

"Remember that many tumors require adjunctive therapy and a multidisciplinary approach for successful resolution," Dr. Shipman said.

Surgeons who are just beginning to perform Mohs surgery should consult colleagues from other disciplines before tackling multifocal or aggressive tumors, she emphasized.

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman

SAN DIEGO — Mohs surgery requires meticulous mapping.

A Mohs map preserves the integrity between the surgical wound and the histologic findings on the slides, Dr. Howard Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

An accurate, readable Mohs map must show the wound shape and the location of reference marks for correct orientation. It also must depict the location of tumor and other findings in the surgical area, such as scars, unrelated tumors, and incomplete margins, he said.

The map is essential for avoiding orientation errors and serves as a pictorial representation of the pathology report. It is also a medicolegal document, and surgeons can and will rely on it to help remember what they did in any given case. The map is critical for communication with lab technicians and consulting physicians, and it serves as part of the operative report. As such, it is vital in the event of a lawsuit.

"The map is the only pathology report you have," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif. "A good map will tell you what you did for a particular patient when you look at it years later."

In addition to tumor foci, the map must document incomplete surgical margins. "You want to be able to mark that there was an incomplete skin edge, to document why you needed to take another layer of tissue," Dr. Steinman pointed out.

Although mapping using digital photography is likely the wave of the future, it's worth developing a strategy for creating a functional Mohs map using other methods. Some surgeons use preprinted anatomic diagrams, whereas others use hand-drawn sketches or nondigital photographs. A representational shape of the wound is okay; it doesn't have to be precise. The map should be drawn larger than the actual size of the wound, however, so it will be easier to correlate findings between the microscope slides and the surgical wound, he said.

Before any tissue is processed, the Mohs map must include patient information, clinical information, the exact location of reference marks, and the wound shape. During tissue processing, the map depicts specimen subdivision patterns, tissue section-numbering schemes, and tissue inking patterns.

During the procedure, the Mohs map is essential for documenting the surgery, processing tissue, and maintaining orientation of the specimen and microscope slides to the wound. After the procedure, the map is an essential record of the work that was performed. When marking findings, most surgeons mark tumor foci in red and other findings in black on the map.

Tissue inking must be accurately drawn on the map and must appear the same both through the microscope and on the map. Inking orients and differentiates tissue specimens, and must be visible on the processed tissue wafers. Dr. Steinman recommends using a consistent drawing symbol for each color. "Pick one set of symbols and be consistent; use it for the rest of your career," he said. When subdividing large specimens, ink opposing cut edges the same color.

"I ink my specimens first and then mark the map, because if I mark the map first and do not ink the tissue accordingly, I have to go back and change the map," he said. Although Dr. Mohs used red as a tissue ink, many surgeons today favor blue, black, or green, because they are easier to see on the microscope slides.

Dr. Steinman tries to process the least number of tissue sections for each Mohs stage, processing specimens as one piece when possible. A consistent inking pattern should be developed for small, circular-shaped specimens, the most common first-stage specimen shape. Dr. Steinman uses blue ink from the 9:00–12:00 reference marks and black ink from 12:00–3:00. He places a green dot at the 6:00 mark on a specimen. Another method is to simply place ink into the four reference nicks of the specimen. "The important thing is to pick a method and be consistent," he said.

In addition, making a "Pac Man" incision to subdivide a specimen can offer an internal orientation. "When you cut a surgical specimen in half or quarters and use only two ink colors along their cut edges, you have created identically shaped pieces. You then need to place a third color on only one of each pair," Dr. Steinman said. "The third color is vital to preserve orientation."

Be aware of dense inflammation, which often masks tumor. "If you see dense inflammation on your first or second tissue wafers, tumor may be present in the wound base that requires another stage of Mohs surgery," Dr. Steinman said. Respect the dense inflammation and mark it on the Mohs map.

Establish orientation when examining slides by drawing a line radiating from the 12:00 point of the tissue wafer. Draw the line directly on the slide with a red pen. Also mark the tumor foci on appropriate wafers. This allows the slide to be held directly over the map, and findings can be oriented and drawn on the map more easily, he explained.

Subdividing a specimen with a 'Pac-Man' incision provides an internal orientation.

These images show a Mohs map and the wound that it documents. Note the complementary inking patterns between the map and wound. Photos courtesy Dr. Howard Steinman