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How to explain physician compounding to legislators
In Ohio, new limits on drug compounding in physicians’ offices went into effect in April and have become a real hindrance to care for dermatology patients. The State of Ohio Board of Pharmacy has defined compounding as combining two or more prescription drugs and has required that physicians who perform this “compounding” must obtain a “Terminal Distributor of Dangerous Drugs” license. Ohio is the “test state,” and these rules, unless vigorously opposed, will be coming to your state.
[polldaddy:9779752]
The rules state that “compounded” drugs used within 6 hours of preparation must be prepared in a designated clean medication area with proper hand hygiene and the use of powder-free gloves. “Compounded” drugs that are used more than 6 hours after preparation, require a designated clean room with access limited to authorized personnel, environmental control devices such as a laminar flow hood, and additional equipment and training of personnel to maintain an aseptic environment. A separate license is required for each office location.
The state pharmacy boards are eager to restrict physicians – as well as dentists and veterinarians – and to collect annual licensing fees. Additionally, according to an article from the Ohio State Medical Association, noncompliant physicians can be fined by the pharmacy board.
We are talking big money, power, and dreams of clinical relevancy (and billable activities) here.
What can dermatologists do to prevent this regulatory overreach? I encourage you to plan a visit to your state representative, where you can demonstrate how these restrictions affect you and your patients – an exercise that should be both fun and compelling. All you need to illustrate your case is a simple kit that includes a syringe (but no needles in the statehouse!), a bottle of lidocaine with epinephrine, a bottle of 8.4% bicarbonate, alcohol pads, and gloves.
First, explain to your audience that there is a skin cancer epidemic with more than 5.4 million new cases a year and that, over the past 20 years, the incidence of skin cancer has doubled and is projected to double again over the next 20 years. Further, explain that dermatologists treat more than 70% of these cases in the office setting, under local anesthesia, at a huge cost savings to the public and government (it costs an average of 12 times as much to remove these cancers in the outpatient department at the hospital). Remember, states foot most of the bill for Medicaid and Medicare gap indigent coverage.
Take the bottle of lidocaine with epinephrine and open the syringe pack (Staffers love this demonstration; everyone is fascinated with shots.). Put on your gloves, wipe the top of the lidocaine bottle with an alcohol swab, and explain that this medicine is the anesthetic preferred for skin cancer surgery. Explain how it not only numbs the skin, but also causes vasoconstriction, so that the cancer can be easily and safely removed in the office.
Then explain that, in order for the epinephrine to be stable, the solution has to be very acidic (a pH of 4.2, in fact). Explain that this makes it burn like hell unless you add 0.1 cc per cc of 8.4% bicarbonate, in which case the perceived pain on a 10-point scale will drop from 8 to 2. Then pick up the bottle of bicarbonate and explain that you will no longer be able to mix these two components anymore without a “Terminal Distributor of Dangerous Drugs” license because your state pharmacy board considers this compounding. Your representative is likely to give you looks of astonishment, disbelief, and then a dawning realization of the absurdity of the situation.
Follow-up questions may include “Why can’t you buy buffered lidocaine with epinephrine from the compounding pharmacy?” Easy answer: because each patient needs an individual prescription, and you may not know in advance which patient will need it, and how much the patient will need, and it becomes unstable once it has been buffered. It also will cost the patient $45 per 5-cc syringe, and it will be degraded by the time the patient returns from the compounding pharmacy. Explain further that it costs you only 84 cents to make a 5-cc syringe of buffered lidocaine; that some patients may need as many as 10 syringes; and that these costs are all included in the surgery (free!) if the physician draws it up in the office.
A simple summary is – less pain, less cost – and no history of infections or complications.
It is an eye-opener when you demonstrate how ridiculous the compounding rules being imposed are for physicians and patients. I’ve used this demonstration at the state and federal legislative level, and more recently, at the Food and Drug Administration.
If you get the chance, when a state legislator is in your office, become an advocate for your patients and fellow physicians. Make sure physician offices are excluded from these definitions of com
This column was updated June 22, 2017.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@frontlinemedcom.com.
In Ohio, new limits on drug compounding in physicians’ offices went into effect in April and have become a real hindrance to care for dermatology patients. The State of Ohio Board of Pharmacy has defined compounding as combining two or more prescription drugs and has required that physicians who perform this “compounding” must obtain a “Terminal Distributor of Dangerous Drugs” license. Ohio is the “test state,” and these rules, unless vigorously opposed, will be coming to your state.
[polldaddy:9779752]
The rules state that “compounded” drugs used within 6 hours of preparation must be prepared in a designated clean medication area with proper hand hygiene and the use of powder-free gloves. “Compounded” drugs that are used more than 6 hours after preparation, require a designated clean room with access limited to authorized personnel, environmental control devices such as a laminar flow hood, and additional equipment and training of personnel to maintain an aseptic environment. A separate license is required for each office location.
The state pharmacy boards are eager to restrict physicians – as well as dentists and veterinarians – and to collect annual licensing fees. Additionally, according to an article from the Ohio State Medical Association, noncompliant physicians can be fined by the pharmacy board.
We are talking big money, power, and dreams of clinical relevancy (and billable activities) here.
What can dermatologists do to prevent this regulatory overreach? I encourage you to plan a visit to your state representative, where you can demonstrate how these restrictions affect you and your patients – an exercise that should be both fun and compelling. All you need to illustrate your case is a simple kit that includes a syringe (but no needles in the statehouse!), a bottle of lidocaine with epinephrine, a bottle of 8.4% bicarbonate, alcohol pads, and gloves.
First, explain to your audience that there is a skin cancer epidemic with more than 5.4 million new cases a year and that, over the past 20 years, the incidence of skin cancer has doubled and is projected to double again over the next 20 years. Further, explain that dermatologists treat more than 70% of these cases in the office setting, under local anesthesia, at a huge cost savings to the public and government (it costs an average of 12 times as much to remove these cancers in the outpatient department at the hospital). Remember, states foot most of the bill for Medicaid and Medicare gap indigent coverage.
Take the bottle of lidocaine with epinephrine and open the syringe pack (Staffers love this demonstration; everyone is fascinated with shots.). Put on your gloves, wipe the top of the lidocaine bottle with an alcohol swab, and explain that this medicine is the anesthetic preferred for skin cancer surgery. Explain how it not only numbs the skin, but also causes vasoconstriction, so that the cancer can be easily and safely removed in the office.
Then explain that, in order for the epinephrine to be stable, the solution has to be very acidic (a pH of 4.2, in fact). Explain that this makes it burn like hell unless you add 0.1 cc per cc of 8.4% bicarbonate, in which case the perceived pain on a 10-point scale will drop from 8 to 2. Then pick up the bottle of bicarbonate and explain that you will no longer be able to mix these two components anymore without a “Terminal Distributor of Dangerous Drugs” license because your state pharmacy board considers this compounding. Your representative is likely to give you looks of astonishment, disbelief, and then a dawning realization of the absurdity of the situation.
Follow-up questions may include “Why can’t you buy buffered lidocaine with epinephrine from the compounding pharmacy?” Easy answer: because each patient needs an individual prescription, and you may not know in advance which patient will need it, and how much the patient will need, and it becomes unstable once it has been buffered. It also will cost the patient $45 per 5-cc syringe, and it will be degraded by the time the patient returns from the compounding pharmacy. Explain further that it costs you only 84 cents to make a 5-cc syringe of buffered lidocaine; that some patients may need as many as 10 syringes; and that these costs are all included in the surgery (free!) if the physician draws it up in the office.
A simple summary is – less pain, less cost – and no history of infections or complications.
It is an eye-opener when you demonstrate how ridiculous the compounding rules being imposed are for physicians and patients. I’ve used this demonstration at the state and federal legislative level, and more recently, at the Food and Drug Administration.
If you get the chance, when a state legislator is in your office, become an advocate for your patients and fellow physicians. Make sure physician offices are excluded from these definitions of com
This column was updated June 22, 2017.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@frontlinemedcom.com.
In Ohio, new limits on drug compounding in physicians’ offices went into effect in April and have become a real hindrance to care for dermatology patients. The State of Ohio Board of Pharmacy has defined compounding as combining two or more prescription drugs and has required that physicians who perform this “compounding” must obtain a “Terminal Distributor of Dangerous Drugs” license. Ohio is the “test state,” and these rules, unless vigorously opposed, will be coming to your state.
[polldaddy:9779752]
The rules state that “compounded” drugs used within 6 hours of preparation must be prepared in a designated clean medication area with proper hand hygiene and the use of powder-free gloves. “Compounded” drugs that are used more than 6 hours after preparation, require a designated clean room with access limited to authorized personnel, environmental control devices such as a laminar flow hood, and additional equipment and training of personnel to maintain an aseptic environment. A separate license is required for each office location.
The state pharmacy boards are eager to restrict physicians – as well as dentists and veterinarians – and to collect annual licensing fees. Additionally, according to an article from the Ohio State Medical Association, noncompliant physicians can be fined by the pharmacy board.
We are talking big money, power, and dreams of clinical relevancy (and billable activities) here.
What can dermatologists do to prevent this regulatory overreach? I encourage you to plan a visit to your state representative, where you can demonstrate how these restrictions affect you and your patients – an exercise that should be both fun and compelling. All you need to illustrate your case is a simple kit that includes a syringe (but no needles in the statehouse!), a bottle of lidocaine with epinephrine, a bottle of 8.4% bicarbonate, alcohol pads, and gloves.
First, explain to your audience that there is a skin cancer epidemic with more than 5.4 million new cases a year and that, over the past 20 years, the incidence of skin cancer has doubled and is projected to double again over the next 20 years. Further, explain that dermatologists treat more than 70% of these cases in the office setting, under local anesthesia, at a huge cost savings to the public and government (it costs an average of 12 times as much to remove these cancers in the outpatient department at the hospital). Remember, states foot most of the bill for Medicaid and Medicare gap indigent coverage.
Take the bottle of lidocaine with epinephrine and open the syringe pack (Staffers love this demonstration; everyone is fascinated with shots.). Put on your gloves, wipe the top of the lidocaine bottle with an alcohol swab, and explain that this medicine is the anesthetic preferred for skin cancer surgery. Explain how it not only numbs the skin, but also causes vasoconstriction, so that the cancer can be easily and safely removed in the office.
Then explain that, in order for the epinephrine to be stable, the solution has to be very acidic (a pH of 4.2, in fact). Explain that this makes it burn like hell unless you add 0.1 cc per cc of 8.4% bicarbonate, in which case the perceived pain on a 10-point scale will drop from 8 to 2. Then pick up the bottle of bicarbonate and explain that you will no longer be able to mix these two components anymore without a “Terminal Distributor of Dangerous Drugs” license because your state pharmacy board considers this compounding. Your representative is likely to give you looks of astonishment, disbelief, and then a dawning realization of the absurdity of the situation.
Follow-up questions may include “Why can’t you buy buffered lidocaine with epinephrine from the compounding pharmacy?” Easy answer: because each patient needs an individual prescription, and you may not know in advance which patient will need it, and how much the patient will need, and it becomes unstable once it has been buffered. It also will cost the patient $45 per 5-cc syringe, and it will be degraded by the time the patient returns from the compounding pharmacy. Explain further that it costs you only 84 cents to make a 5-cc syringe of buffered lidocaine; that some patients may need as many as 10 syringes; and that these costs are all included in the surgery (free!) if the physician draws it up in the office.
A simple summary is – less pain, less cost – and no history of infections or complications.
It is an eye-opener when you demonstrate how ridiculous the compounding rules being imposed are for physicians and patients. I’ve used this demonstration at the state and federal legislative level, and more recently, at the Food and Drug Administration.
If you get the chance, when a state legislator is in your office, become an advocate for your patients and fellow physicians. Make sure physician offices are excluded from these definitions of com
This column was updated June 22, 2017.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@frontlinemedcom.com.
Study Compares Punch Excision vs. Core Excision for Recalcitrant Keloids
according to the results of a small retrospective study.
The method “offers similar efficacy, faster healing, and fewer complications,” one of the study authors, Jinwoong Jung, MD, said in an interview following the annual meeting of the American Society for Dermatologic Surgery, where he presented the study results during an oral abstract session.
For the study, Jung, a dermatologist at Yonsei University College of Medicine, Seoul, South Korea, and colleagues retrospectively analyzed 22 patients with recalcitrant keloids treated with cryotherapy immediately following either PE or CE between May 2019 and March 2024. They used the Vancouver Scar Scale (VSS) to assess treatment efficacy.
Of the 22 patients, 16 underwent treatment with CE and 6 underwent treatment with PE. Pretreatment VSS scores showed no significant differences between the groups (P = .535). The CE group had a reduction in the VSS score from 8.13 to 4.00, while the PE group had a reduction from 7.83 to 3.67, but these declines did not differ significantly (P = .737). The PE group exhibited a shorter healing time than the CE group (a mean of 43.5 vs 63.87 days, respectively), though this difference was not statistically significant (P = .129).
“The uniqueness of this work lies in its simplified use of PE for recalcitrant keloids, which demonstrated efficacy comparable to CE, with the potential advantage of faster healing times,” Jung said. “Future studies with larger sample sizes and extended follow-up periods could help establish this approach as a standard treatment method.”
He acknowledged certain limitations of the study, including its small sample size and the lack of long-term follow-up data. The researchers reported having no relevant disclosures.
A version of this article first appeared on Medscape.com.
according to the results of a small retrospective study.
The method “offers similar efficacy, faster healing, and fewer complications,” one of the study authors, Jinwoong Jung, MD, said in an interview following the annual meeting of the American Society for Dermatologic Surgery, where he presented the study results during an oral abstract session.
For the study, Jung, a dermatologist at Yonsei University College of Medicine, Seoul, South Korea, and colleagues retrospectively analyzed 22 patients with recalcitrant keloids treated with cryotherapy immediately following either PE or CE between May 2019 and March 2024. They used the Vancouver Scar Scale (VSS) to assess treatment efficacy.
Of the 22 patients, 16 underwent treatment with CE and 6 underwent treatment with PE. Pretreatment VSS scores showed no significant differences between the groups (P = .535). The CE group had a reduction in the VSS score from 8.13 to 4.00, while the PE group had a reduction from 7.83 to 3.67, but these declines did not differ significantly (P = .737). The PE group exhibited a shorter healing time than the CE group (a mean of 43.5 vs 63.87 days, respectively), though this difference was not statistically significant (P = .129).
“The uniqueness of this work lies in its simplified use of PE for recalcitrant keloids, which demonstrated efficacy comparable to CE, with the potential advantage of faster healing times,” Jung said. “Future studies with larger sample sizes and extended follow-up periods could help establish this approach as a standard treatment method.”
He acknowledged certain limitations of the study, including its small sample size and the lack of long-term follow-up data. The researchers reported having no relevant disclosures.
A version of this article first appeared on Medscape.com.
according to the results of a small retrospective study.
The method “offers similar efficacy, faster healing, and fewer complications,” one of the study authors, Jinwoong Jung, MD, said in an interview following the annual meeting of the American Society for Dermatologic Surgery, where he presented the study results during an oral abstract session.
For the study, Jung, a dermatologist at Yonsei University College of Medicine, Seoul, South Korea, and colleagues retrospectively analyzed 22 patients with recalcitrant keloids treated with cryotherapy immediately following either PE or CE between May 2019 and March 2024. They used the Vancouver Scar Scale (VSS) to assess treatment efficacy.
Of the 22 patients, 16 underwent treatment with CE and 6 underwent treatment with PE. Pretreatment VSS scores showed no significant differences between the groups (P = .535). The CE group had a reduction in the VSS score from 8.13 to 4.00, while the PE group had a reduction from 7.83 to 3.67, but these declines did not differ significantly (P = .737). The PE group exhibited a shorter healing time than the CE group (a mean of 43.5 vs 63.87 days, respectively), though this difference was not statistically significant (P = .129).
“The uniqueness of this work lies in its simplified use of PE for recalcitrant keloids, which demonstrated efficacy comparable to CE, with the potential advantage of faster healing times,” Jung said. “Future studies with larger sample sizes and extended follow-up periods could help establish this approach as a standard treatment method.”
He acknowledged certain limitations of the study, including its small sample size and the lack of long-term follow-up data. The researchers reported having no relevant disclosures.
A version of this article first appeared on Medscape.com.
FROM ASDS 2024
Do Cannabis Users Need More Anesthesia During Surgery?
TOPLINE:
However, the clinical relevance of this difference remains unclear.
METHODOLOGY:
- To assess if cannabis use leads to higher doses of inhalational anesthesia during surgery, the researchers conducted a retrospective cohort study comparing the average intraoperative minimum alveolar concentrations of volatile anesthetics (isoflurane and sevoflurane) between older adults who used cannabis products and those who did not.
- The researchers reviewed electronic health records of 22,476 patients aged 65 years or older who underwent surgery at the University of Florida Health System between 2018 and 2020.
- Overall, 268 patients who reported using cannabis within 60 days of surgery (median age, 69 years; 35% women) were matched to 1072 nonusers.
- The median duration of anesthesia was 175 minutes.
- The primary outcome was the intraoperative time-weighted average of isoflurane or sevoflurane minimum alveolar concentration equivalents.
TAKEAWAY:
- Cannabis users had significantly higher average minimum alveolar concentrations of isoflurane or sevoflurane than nonusers (mean, 0.58 vs 0.54; mean difference, 0.04; P = .021).
- The findings were confirmed in a sensitivity analysis that revealed higher mean average minimum alveolar concentrations of anesthesia in cannabis users than in nonusers (0.57 vs 0.53; P = .029).
- Although the 0.04 difference in minimum alveolar concentration between cannabis users and nonusers was statistically significant, its clinical importance is unclear.
IN PRACTICE:
“While recent guidelines underscore the importance of universal screening for cannabinoids before surgery, caution is paramount to prevent clinical bias leading to the administration of unnecessary higher doses of inhalational anesthesia, especially as robust evidence supporting such practices remains lacking,” the authors of the study wrote.
SOURCE:
This study was led by Ruba Sajdeya, MD, PhD, of the Department of Epidemiology at the University of Florida, Gainesville, and was published online in August 2024 in Anesthesiology.
LIMITATIONS:
This study lacked access to prescription or dispensed medications, including opioids, which may have introduced residual confounding. Potential underdocumentation of cannabis use in medical records could have led to exposure misclassification. The causality between cannabis usage and increased anesthetic dosing could not be established due to the observational nature of this study.
DISCLOSURES:
This study was supported by the National Institute on Aging, the National Institutes of Health, and in part by the University of Florida Clinical and Translational Science Institute. Some authors declared receiving research support, consulting fees, and honoraria and having other ties with pharmaceutical companies and various other sources.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
However, the clinical relevance of this difference remains unclear.
METHODOLOGY:
- To assess if cannabis use leads to higher doses of inhalational anesthesia during surgery, the researchers conducted a retrospective cohort study comparing the average intraoperative minimum alveolar concentrations of volatile anesthetics (isoflurane and sevoflurane) between older adults who used cannabis products and those who did not.
- The researchers reviewed electronic health records of 22,476 patients aged 65 years or older who underwent surgery at the University of Florida Health System between 2018 and 2020.
- Overall, 268 patients who reported using cannabis within 60 days of surgery (median age, 69 years; 35% women) were matched to 1072 nonusers.
- The median duration of anesthesia was 175 minutes.
- The primary outcome was the intraoperative time-weighted average of isoflurane or sevoflurane minimum alveolar concentration equivalents.
TAKEAWAY:
- Cannabis users had significantly higher average minimum alveolar concentrations of isoflurane or sevoflurane than nonusers (mean, 0.58 vs 0.54; mean difference, 0.04; P = .021).
- The findings were confirmed in a sensitivity analysis that revealed higher mean average minimum alveolar concentrations of anesthesia in cannabis users than in nonusers (0.57 vs 0.53; P = .029).
- Although the 0.04 difference in minimum alveolar concentration between cannabis users and nonusers was statistically significant, its clinical importance is unclear.
IN PRACTICE:
“While recent guidelines underscore the importance of universal screening for cannabinoids before surgery, caution is paramount to prevent clinical bias leading to the administration of unnecessary higher doses of inhalational anesthesia, especially as robust evidence supporting such practices remains lacking,” the authors of the study wrote.
SOURCE:
This study was led by Ruba Sajdeya, MD, PhD, of the Department of Epidemiology at the University of Florida, Gainesville, and was published online in August 2024 in Anesthesiology.
LIMITATIONS:
This study lacked access to prescription or dispensed medications, including opioids, which may have introduced residual confounding. Potential underdocumentation of cannabis use in medical records could have led to exposure misclassification. The causality between cannabis usage and increased anesthetic dosing could not be established due to the observational nature of this study.
DISCLOSURES:
This study was supported by the National Institute on Aging, the National Institutes of Health, and in part by the University of Florida Clinical and Translational Science Institute. Some authors declared receiving research support, consulting fees, and honoraria and having other ties with pharmaceutical companies and various other sources.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
However, the clinical relevance of this difference remains unclear.
METHODOLOGY:
- To assess if cannabis use leads to higher doses of inhalational anesthesia during surgery, the researchers conducted a retrospective cohort study comparing the average intraoperative minimum alveolar concentrations of volatile anesthetics (isoflurane and sevoflurane) between older adults who used cannabis products and those who did not.
- The researchers reviewed electronic health records of 22,476 patients aged 65 years or older who underwent surgery at the University of Florida Health System between 2018 and 2020.
- Overall, 268 patients who reported using cannabis within 60 days of surgery (median age, 69 years; 35% women) were matched to 1072 nonusers.
- The median duration of anesthesia was 175 minutes.
- The primary outcome was the intraoperative time-weighted average of isoflurane or sevoflurane minimum alveolar concentration equivalents.
TAKEAWAY:
- Cannabis users had significantly higher average minimum alveolar concentrations of isoflurane or sevoflurane than nonusers (mean, 0.58 vs 0.54; mean difference, 0.04; P = .021).
- The findings were confirmed in a sensitivity analysis that revealed higher mean average minimum alveolar concentrations of anesthesia in cannabis users than in nonusers (0.57 vs 0.53; P = .029).
- Although the 0.04 difference in minimum alveolar concentration between cannabis users and nonusers was statistically significant, its clinical importance is unclear.
IN PRACTICE:
“While recent guidelines underscore the importance of universal screening for cannabinoids before surgery, caution is paramount to prevent clinical bias leading to the administration of unnecessary higher doses of inhalational anesthesia, especially as robust evidence supporting such practices remains lacking,” the authors of the study wrote.
SOURCE:
This study was led by Ruba Sajdeya, MD, PhD, of the Department of Epidemiology at the University of Florida, Gainesville, and was published online in August 2024 in Anesthesiology.
LIMITATIONS:
This study lacked access to prescription or dispensed medications, including opioids, which may have introduced residual confounding. Potential underdocumentation of cannabis use in medical records could have led to exposure misclassification. The causality between cannabis usage and increased anesthetic dosing could not be established due to the observational nature of this study.
DISCLOSURES:
This study was supported by the National Institute on Aging, the National Institutes of Health, and in part by the University of Florida Clinical and Translational Science Institute. Some authors declared receiving research support, consulting fees, and honoraria and having other ties with pharmaceutical companies and various other sources.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Acne: Positive Outcomes Described With Laser Treatment
CARLSBAD, CALIF. — at 1 year.
“Combining the AviClear with medical therapy and energy-based devices provides the best outcomes,” Dr. Moradzadeh, who practices facial and plastic surgery in Beverly Hills, California, said at the Controversies & Conversations in Laser & Cosmetic Surgery annual symposium. “You have to do all 300 pulses per treatment, and you do need to use settings of 19.5-21.5 J/cm2 to get a great result.”
AviClear became the first 1726-nm laser cleared by the FDA for the treatment of mild to severe acne vulgaris, followed a few months later by clearance of the 1926-nm laser, the Accure Acne Laser System. But few long-term “real-world” studies of these two devices exist, according to Dr. Moradzadeh.
The protocol for Dr. Moradzadeh’s study included three AviClear treatments spaced 3-4 weeks apart combined with medical therapy and other energy-based devices such as a near-infrared Nd:YAG laser (Laser Genesis) and a non-ablative fractional laser (LaseMD Ultra), with follow-up at 1 month, 3 months, 6 months, 1 year, 1.5 years, and 2 years. Pain management options included acetaminophen, a numbing cream, and pre- and post-contact cooling.
Of the 100 patients, 90 were clear at 1 year, six patients were almost clear at 1 year, three patients were nonresponders, and one patient was lost to follow-up, Dr. Moradzadeh reported. “Two of the three nonresponders did not receive the full 300 pulses per treatment,” but all three cleared with isotretinoin treatment, he said. “What we now know from talking with other providers is that you really have to do all 300 pulses to get the best results.”
Of the 90 patients who achieved clearance, 80 remained clear at 1.5-2 years, and 10 are almost clear or have mild acne. “Of these, eight are adult females with hormonal acne and two are teenage males,” he said. “All 10 cleared with a fourth AviClear treatment and lifestyle modifications that included the elimination of whey, creatine, and skin care products containing vitamin E combined with vitamin C.”
During a question-and-answer session following the presentation, Jeffrey Dover, MD, director of SkinCare Physicians in Chestnut Hill, Massachusetts, said that general dermatologists have been slow to adopt the AviClear and Accure devices for treating patients with acne “because, for the most part, they are experts at treating acne with all the tools they have. They’re not used to using devices. They’re not used to having patients pay out of pocket for a treatment that is not covered by insurance. They don’t feel comfortable with that discussion.”
For example, the 14 dermatologists at SkinCare Physicians “almost never prescribe the 1726-nm devices for acne because it’s not in their sweet spot,” Dr. Dover continued, noting that one issue is that acne experts want more data.
In the experience of Nazanin Saedi, MD, clinical associate professor of dermatology at Thomas Jefferson University, Philadelphia, the 1726-nm laser devices for acne “fit nicely for women of childbearing age who have acne and don’t want to go on Accutane [isotretinoin], and also for teenagers who are either going to be noncompliant with Accutane or their parents are worried about side effects and the potential impacts on growth,” she said at the meeting. “That’s where we’ve found patients coming in wanting to do these treatments, and how it offers something that the medical treatments are lacking.”
Regarding concerns about out-of-pocket costs for AviClear or Accure treatments, Roy G. Geronemus, MD, who directs the Laser & Skin Surgery Center of New York, New York City, advised considering the long-term benefits. “If you calculate it out, it really is cost-effective to use the 1726-nm devices if you consider the copays, the cost of over-the-counter topicals, as well as the cost of prescription medications,” Dr. Geronemus said. “Over the long term, you are saving money for the patient.”
Dr. Dover acknowledged that was “a valid and important point,” but said that when the topic is discussed with general dermatologists who treat a lot of patients with acne, “they say patients are more willing to pay a copay [for a prescription] ... than write a check for $800 or $1000 per visit.”
The recently updated American Academy of Dermatology’s guidelines of care for the management of acne vulgaris, published in January 2024, characterized the available evidence as “insufficient” to develop a recommendation on the use of laser and light-based devices for the treatment of acne. Although the 1726-nm laser was cleared by the FDA for acne treatment in 2022, the authors of the guidelines wrote that “its evidence was not evaluated in the current guidelines due to lack of a randomized, controlled trial.”
Dr. Moradzadeh disclosed that he is a key opinion leader for Acclaro, Benev, Lutronic, Sofwave, and Cutera, the manufacturer for AviClear. Dr. Dover reported that he is a consultant for Cutera and performs research for the company. Dr. Saedi disclosed that she is a consultant to, a member of the advisory board for, and/or has received equipment and research support from many device and pharmaceutical companies. Dr. Geronemus disclosed that he is a member of the medical advisory board for and/or is an investigator for many device and pharmaceutical companies, including Accure. He also holds stock in the company.
A version of this article first appeared on Medscape.com.
CARLSBAD, CALIF. — at 1 year.
“Combining the AviClear with medical therapy and energy-based devices provides the best outcomes,” Dr. Moradzadeh, who practices facial and plastic surgery in Beverly Hills, California, said at the Controversies & Conversations in Laser & Cosmetic Surgery annual symposium. “You have to do all 300 pulses per treatment, and you do need to use settings of 19.5-21.5 J/cm2 to get a great result.”
AviClear became the first 1726-nm laser cleared by the FDA for the treatment of mild to severe acne vulgaris, followed a few months later by clearance of the 1926-nm laser, the Accure Acne Laser System. But few long-term “real-world” studies of these two devices exist, according to Dr. Moradzadeh.
The protocol for Dr. Moradzadeh’s study included three AviClear treatments spaced 3-4 weeks apart combined with medical therapy and other energy-based devices such as a near-infrared Nd:YAG laser (Laser Genesis) and a non-ablative fractional laser (LaseMD Ultra), with follow-up at 1 month, 3 months, 6 months, 1 year, 1.5 years, and 2 years. Pain management options included acetaminophen, a numbing cream, and pre- and post-contact cooling.
Of the 100 patients, 90 were clear at 1 year, six patients were almost clear at 1 year, three patients were nonresponders, and one patient was lost to follow-up, Dr. Moradzadeh reported. “Two of the three nonresponders did not receive the full 300 pulses per treatment,” but all three cleared with isotretinoin treatment, he said. “What we now know from talking with other providers is that you really have to do all 300 pulses to get the best results.”
Of the 90 patients who achieved clearance, 80 remained clear at 1.5-2 years, and 10 are almost clear or have mild acne. “Of these, eight are adult females with hormonal acne and two are teenage males,” he said. “All 10 cleared with a fourth AviClear treatment and lifestyle modifications that included the elimination of whey, creatine, and skin care products containing vitamin E combined with vitamin C.”
During a question-and-answer session following the presentation, Jeffrey Dover, MD, director of SkinCare Physicians in Chestnut Hill, Massachusetts, said that general dermatologists have been slow to adopt the AviClear and Accure devices for treating patients with acne “because, for the most part, they are experts at treating acne with all the tools they have. They’re not used to using devices. They’re not used to having patients pay out of pocket for a treatment that is not covered by insurance. They don’t feel comfortable with that discussion.”
For example, the 14 dermatologists at SkinCare Physicians “almost never prescribe the 1726-nm devices for acne because it’s not in their sweet spot,” Dr. Dover continued, noting that one issue is that acne experts want more data.
In the experience of Nazanin Saedi, MD, clinical associate professor of dermatology at Thomas Jefferson University, Philadelphia, the 1726-nm laser devices for acne “fit nicely for women of childbearing age who have acne and don’t want to go on Accutane [isotretinoin], and also for teenagers who are either going to be noncompliant with Accutane or their parents are worried about side effects and the potential impacts on growth,” she said at the meeting. “That’s where we’ve found patients coming in wanting to do these treatments, and how it offers something that the medical treatments are lacking.”
Regarding concerns about out-of-pocket costs for AviClear or Accure treatments, Roy G. Geronemus, MD, who directs the Laser & Skin Surgery Center of New York, New York City, advised considering the long-term benefits. “If you calculate it out, it really is cost-effective to use the 1726-nm devices if you consider the copays, the cost of over-the-counter topicals, as well as the cost of prescription medications,” Dr. Geronemus said. “Over the long term, you are saving money for the patient.”
Dr. Dover acknowledged that was “a valid and important point,” but said that when the topic is discussed with general dermatologists who treat a lot of patients with acne, “they say patients are more willing to pay a copay [for a prescription] ... than write a check for $800 or $1000 per visit.”
The recently updated American Academy of Dermatology’s guidelines of care for the management of acne vulgaris, published in January 2024, characterized the available evidence as “insufficient” to develop a recommendation on the use of laser and light-based devices for the treatment of acne. Although the 1726-nm laser was cleared by the FDA for acne treatment in 2022, the authors of the guidelines wrote that “its evidence was not evaluated in the current guidelines due to lack of a randomized, controlled trial.”
Dr. Moradzadeh disclosed that he is a key opinion leader for Acclaro, Benev, Lutronic, Sofwave, and Cutera, the manufacturer for AviClear. Dr. Dover reported that he is a consultant for Cutera and performs research for the company. Dr. Saedi disclosed that she is a consultant to, a member of the advisory board for, and/or has received equipment and research support from many device and pharmaceutical companies. Dr. Geronemus disclosed that he is a member of the medical advisory board for and/or is an investigator for many device and pharmaceutical companies, including Accure. He also holds stock in the company.
A version of this article first appeared on Medscape.com.
CARLSBAD, CALIF. — at 1 year.
“Combining the AviClear with medical therapy and energy-based devices provides the best outcomes,” Dr. Moradzadeh, who practices facial and plastic surgery in Beverly Hills, California, said at the Controversies & Conversations in Laser & Cosmetic Surgery annual symposium. “You have to do all 300 pulses per treatment, and you do need to use settings of 19.5-21.5 J/cm2 to get a great result.”
AviClear became the first 1726-nm laser cleared by the FDA for the treatment of mild to severe acne vulgaris, followed a few months later by clearance of the 1926-nm laser, the Accure Acne Laser System. But few long-term “real-world” studies of these two devices exist, according to Dr. Moradzadeh.
The protocol for Dr. Moradzadeh’s study included three AviClear treatments spaced 3-4 weeks apart combined with medical therapy and other energy-based devices such as a near-infrared Nd:YAG laser (Laser Genesis) and a non-ablative fractional laser (LaseMD Ultra), with follow-up at 1 month, 3 months, 6 months, 1 year, 1.5 years, and 2 years. Pain management options included acetaminophen, a numbing cream, and pre- and post-contact cooling.
Of the 100 patients, 90 were clear at 1 year, six patients were almost clear at 1 year, three patients were nonresponders, and one patient was lost to follow-up, Dr. Moradzadeh reported. “Two of the three nonresponders did not receive the full 300 pulses per treatment,” but all three cleared with isotretinoin treatment, he said. “What we now know from talking with other providers is that you really have to do all 300 pulses to get the best results.”
Of the 90 patients who achieved clearance, 80 remained clear at 1.5-2 years, and 10 are almost clear or have mild acne. “Of these, eight are adult females with hormonal acne and two are teenage males,” he said. “All 10 cleared with a fourth AviClear treatment and lifestyle modifications that included the elimination of whey, creatine, and skin care products containing vitamin E combined with vitamin C.”
During a question-and-answer session following the presentation, Jeffrey Dover, MD, director of SkinCare Physicians in Chestnut Hill, Massachusetts, said that general dermatologists have been slow to adopt the AviClear and Accure devices for treating patients with acne “because, for the most part, they are experts at treating acne with all the tools they have. They’re not used to using devices. They’re not used to having patients pay out of pocket for a treatment that is not covered by insurance. They don’t feel comfortable with that discussion.”
For example, the 14 dermatologists at SkinCare Physicians “almost never prescribe the 1726-nm devices for acne because it’s not in their sweet spot,” Dr. Dover continued, noting that one issue is that acne experts want more data.
In the experience of Nazanin Saedi, MD, clinical associate professor of dermatology at Thomas Jefferson University, Philadelphia, the 1726-nm laser devices for acne “fit nicely for women of childbearing age who have acne and don’t want to go on Accutane [isotretinoin], and also for teenagers who are either going to be noncompliant with Accutane or their parents are worried about side effects and the potential impacts on growth,” she said at the meeting. “That’s where we’ve found patients coming in wanting to do these treatments, and how it offers something that the medical treatments are lacking.”
Regarding concerns about out-of-pocket costs for AviClear or Accure treatments, Roy G. Geronemus, MD, who directs the Laser & Skin Surgery Center of New York, New York City, advised considering the long-term benefits. “If you calculate it out, it really is cost-effective to use the 1726-nm devices if you consider the copays, the cost of over-the-counter topicals, as well as the cost of prescription medications,” Dr. Geronemus said. “Over the long term, you are saving money for the patient.”
Dr. Dover acknowledged that was “a valid and important point,” but said that when the topic is discussed with general dermatologists who treat a lot of patients with acne, “they say patients are more willing to pay a copay [for a prescription] ... than write a check for $800 or $1000 per visit.”
The recently updated American Academy of Dermatology’s guidelines of care for the management of acne vulgaris, published in January 2024, characterized the available evidence as “insufficient” to develop a recommendation on the use of laser and light-based devices for the treatment of acne. Although the 1726-nm laser was cleared by the FDA for acne treatment in 2022, the authors of the guidelines wrote that “its evidence was not evaluated in the current guidelines due to lack of a randomized, controlled trial.”
Dr. Moradzadeh disclosed that he is a key opinion leader for Acclaro, Benev, Lutronic, Sofwave, and Cutera, the manufacturer for AviClear. Dr. Dover reported that he is a consultant for Cutera and performs research for the company. Dr. Saedi disclosed that she is a consultant to, a member of the advisory board for, and/or has received equipment and research support from many device and pharmaceutical companies. Dr. Geronemus disclosed that he is a member of the medical advisory board for and/or is an investigator for many device and pharmaceutical companies, including Accure. He also holds stock in the company.
A version of this article first appeared on Medscape.com.
Support for Laser Treatment to Reduce NMSC Risk is Increasing
CARLSBAD, CALIFORNIA — and a key 2017 publication laid the groundwork for current approaches, according to Elizabeth Tanzi, MD.
In the article, which was published in Molecules, Mike Kemp, PhD, and Jeffrey Bryant Travers, MD, PhD, at Wright State University, Dayton, Ohio, and Dan F. Spandau, PhD, at Indiana University School of Medicine, Indianapolis, demonstrated that geriatric skin responds to ultraviolet B (UVB) differently than young skin because of differences in insulin-like growth factor 1 (IGF-1) levels produced by dermal fibroblasts.
“As we age, our fibroblasts become senescent, inactive,” Dr. Tanzi, associate clinical professor of dermatology at George Washington University, Washington, DC, said at the Controversies and Conversations in Laser and Cosmetic Surgery symposium. “They don’t make as many growth factors, particularly IGF-1, and therefore we don’t stimulate the responses. We need more of our growth factors.”
In later, separate work, Dr. Travers, Dr. Spandau, and colleagues found that using dermabrasion or fractionated laser resurfacing to wound the skin can result in increased dermal IGF-1 levels and normalization of the abnormal pro-carcinogenic UV response associated with geriatric skin — a treatment that has the potential to prevent NMSC. That study “was the epiphany” for fostering interest among researchers in the field of lasers and medicine, Dr. Tanzi said.
In a retrospective cohort study, Mathew Avram, MD, JD, and colleagues reviewed patients with a history of facial keratinocyte carcinoma (KC) who were treated at Massachusetts General Hospital in Boston between 2005 and 2021. The study population included 43 patients treated with either the 1927- or the 1550-nm nonablative fractional laser (NAFL) and 52 matched controls. The rate of subsequent facial KC development was 20.9% in NAFL-treated patients and 40.4% in controls (relative risk, 0.52, P = .049). 
During a separate presentation at the meeting, Dr. Avram, director of lasers and cosmetics at Massachusetts General Hospital, Boston, said that, when he and his colleagues controlled for age, gender, and skin type, controls were 2.65 times more likely to develop new facial KC, compared with those treated with NAFL (P = .0169). “This enhanced effect was seen with the 1550-nm device, compared with the 1927-nm device. The study shows us that 1550-nm/1927-nm NAFL may have a protective effect for patients with a history of KC, but the role of each wavelength is to be determined. We also need a prospective, controlled study to verify the results.”
In an ongoing study first presented at the 2023 annual meeting of the American Society for Dermatologic Surgery, Dr. Tanzi and colleagues enrolled 15 patients aged ≥ 55 years to evaluate the restoration of physiologic features and biomarkers in skin treated with 25% trichloroacetic acid (TCA), plus the 1550-nm or 1927-nm NAFL. Four sites on the back were treated and biopsies were taken at baseline and at 3 months post treatment. The protocol involved TCA 25% to speckled frost, with the 1550-nm device set to level 6 at 70 mJ and the 1927-nm device set to level 8 at 20 mJ. Immunohistochemical stains are still pending; however, physiologic changes were noted.
Three months after a single treatment, the 1927-nm treated areas showed statistically significant elongation of fibroblasts (consistent with younger fibroblasts) on histology. “Although not a large study, it supports the growing body of research that demonstrates we are improving the health of our patients’ skin with certain types of laser treatments, not just beautifying it,” Dr. Tanzi said.
Dr. Tanzi disclosed being a member of the advisory board for AbbVie/Allergan and Sciton, and is a consultant for Alastin/Galderma, Candesant Biomedical, Cytrellis, Revance, and Solta Medical. Dr. Avram disclosed that he receives intellectual property royalties from and holds stock options in Cytrellis, and is a consultant to Allergan and holds stock options in BAI Biosciences, Sofwave, and La Jolla NanoMedical.
A version of this article first appeared on Medscape.com.
CARLSBAD, CALIFORNIA — and a key 2017 publication laid the groundwork for current approaches, according to Elizabeth Tanzi, MD.
In the article, which was published in Molecules, Mike Kemp, PhD, and Jeffrey Bryant Travers, MD, PhD, at Wright State University, Dayton, Ohio, and Dan F. Spandau, PhD, at Indiana University School of Medicine, Indianapolis, demonstrated that geriatric skin responds to ultraviolet B (UVB) differently than young skin because of differences in insulin-like growth factor 1 (IGF-1) levels produced by dermal fibroblasts.
“As we age, our fibroblasts become senescent, inactive,” Dr. Tanzi, associate clinical professor of dermatology at George Washington University, Washington, DC, said at the Controversies and Conversations in Laser and Cosmetic Surgery symposium. “They don’t make as many growth factors, particularly IGF-1, and therefore we don’t stimulate the responses. We need more of our growth factors.”
In later, separate work, Dr. Travers, Dr. Spandau, and colleagues found that using dermabrasion or fractionated laser resurfacing to wound the skin can result in increased dermal IGF-1 levels and normalization of the abnormal pro-carcinogenic UV response associated with geriatric skin — a treatment that has the potential to prevent NMSC. That study “was the epiphany” for fostering interest among researchers in the field of lasers and medicine, Dr. Tanzi said.
In a retrospective cohort study, Mathew Avram, MD, JD, and colleagues reviewed patients with a history of facial keratinocyte carcinoma (KC) who were treated at Massachusetts General Hospital in Boston between 2005 and 2021. The study population included 43 patients treated with either the 1927- or the 1550-nm nonablative fractional laser (NAFL) and 52 matched controls. The rate of subsequent facial KC development was 20.9% in NAFL-treated patients and 40.4% in controls (relative risk, 0.52, P = .049).
During a separate presentation at the meeting, Dr. Avram, director of lasers and cosmetics at Massachusetts General Hospital, Boston, said that, when he and his colleagues controlled for age, gender, and skin type, controls were 2.65 times more likely to develop new facial KC, compared with those treated with NAFL (P = .0169). “This enhanced effect was seen with the 1550-nm device, compared with the 1927-nm device. The study shows us that 1550-nm/1927-nm NAFL may have a protective effect for patients with a history of KC, but the role of each wavelength is to be determined. We also need a prospective, controlled study to verify the results.”
In an ongoing study first presented at the 2023 annual meeting of the American Society for Dermatologic Surgery, Dr. Tanzi and colleagues enrolled 15 patients aged ≥ 55 years to evaluate the restoration of physiologic features and biomarkers in skin treated with 25% trichloroacetic acid (TCA), plus the 1550-nm or 1927-nm NAFL. Four sites on the back were treated and biopsies were taken at baseline and at 3 months post treatment. The protocol involved TCA 25% to speckled frost, with the 1550-nm device set to level 6 at 70 mJ and the 1927-nm device set to level 8 at 20 mJ. Immunohistochemical stains are still pending; however, physiologic changes were noted.
Three months after a single treatment, the 1927-nm treated areas showed statistically significant elongation of fibroblasts (consistent with younger fibroblasts) on histology. “Although not a large study, it supports the growing body of research that demonstrates we are improving the health of our patients’ skin with certain types of laser treatments, not just beautifying it,” Dr. Tanzi said.
Dr. Tanzi disclosed being a member of the advisory board for AbbVie/Allergan and Sciton, and is a consultant for Alastin/Galderma, Candesant Biomedical, Cytrellis, Revance, and Solta Medical. Dr. Avram disclosed that he receives intellectual property royalties from and holds stock options in Cytrellis, and is a consultant to Allergan and holds stock options in BAI Biosciences, Sofwave, and La Jolla NanoMedical.
A version of this article first appeared on Medscape.com.
CARLSBAD, CALIFORNIA — and a key 2017 publication laid the groundwork for current approaches, according to Elizabeth Tanzi, MD.
In the article, which was published in Molecules, Mike Kemp, PhD, and Jeffrey Bryant Travers, MD, PhD, at Wright State University, Dayton, Ohio, and Dan F. Spandau, PhD, at Indiana University School of Medicine, Indianapolis, demonstrated that geriatric skin responds to ultraviolet B (UVB) differently than young skin because of differences in insulin-like growth factor 1 (IGF-1) levels produced by dermal fibroblasts.
“As we age, our fibroblasts become senescent, inactive,” Dr. Tanzi, associate clinical professor of dermatology at George Washington University, Washington, DC, said at the Controversies and Conversations in Laser and Cosmetic Surgery symposium. “They don’t make as many growth factors, particularly IGF-1, and therefore we don’t stimulate the responses. We need more of our growth factors.”
In later, separate work, Dr. Travers, Dr. Spandau, and colleagues found that using dermabrasion or fractionated laser resurfacing to wound the skin can result in increased dermal IGF-1 levels and normalization of the abnormal pro-carcinogenic UV response associated with geriatric skin — a treatment that has the potential to prevent NMSC. That study “was the epiphany” for fostering interest among researchers in the field of lasers and medicine, Dr. Tanzi said.
In a retrospective cohort study, Mathew Avram, MD, JD, and colleagues reviewed patients with a history of facial keratinocyte carcinoma (KC) who were treated at Massachusetts General Hospital in Boston between 2005 and 2021. The study population included 43 patients treated with either the 1927- or the 1550-nm nonablative fractional laser (NAFL) and 52 matched controls. The rate of subsequent facial KC development was 20.9% in NAFL-treated patients and 40.4% in controls (relative risk, 0.52, P = .049).
During a separate presentation at the meeting, Dr. Avram, director of lasers and cosmetics at Massachusetts General Hospital, Boston, said that, when he and his colleagues controlled for age, gender, and skin type, controls were 2.65 times more likely to develop new facial KC, compared with those treated with NAFL (P = .0169). “This enhanced effect was seen with the 1550-nm device, compared with the 1927-nm device. The study shows us that 1550-nm/1927-nm NAFL may have a protective effect for patients with a history of KC, but the role of each wavelength is to be determined. We also need a prospective, controlled study to verify the results.”
In an ongoing study first presented at the 2023 annual meeting of the American Society for Dermatologic Surgery, Dr. Tanzi and colleagues enrolled 15 patients aged ≥ 55 years to evaluate the restoration of physiologic features and biomarkers in skin treated with 25% trichloroacetic acid (TCA), plus the 1550-nm or 1927-nm NAFL. Four sites on the back were treated and biopsies were taken at baseline and at 3 months post treatment. The protocol involved TCA 25% to speckled frost, with the 1550-nm device set to level 6 at 70 mJ and the 1927-nm device set to level 8 at 20 mJ. Immunohistochemical stains are still pending; however, physiologic changes were noted.
Three months after a single treatment, the 1927-nm treated areas showed statistically significant elongation of fibroblasts (consistent with younger fibroblasts) on histology. “Although not a large study, it supports the growing body of research that demonstrates we are improving the health of our patients’ skin with certain types of laser treatments, not just beautifying it,” Dr. Tanzi said.
Dr. Tanzi disclosed being a member of the advisory board for AbbVie/Allergan and Sciton, and is a consultant for Alastin/Galderma, Candesant Biomedical, Cytrellis, Revance, and Solta Medical. Dr. Avram disclosed that he receives intellectual property royalties from and holds stock options in Cytrellis, and is a consultant to Allergan and holds stock options in BAI Biosciences, Sofwave, and La Jolla NanoMedical.
A version of this article first appeared on Medscape.com.
Safety Standards a Top Priority for ASLMS President
Arisa E. Ortiz, MD, began her term as president of the American Society for Laser Medicine and Surgery (ASLMS) during the organization’s annual meeting in April 2024.
After earning her medical degree from Albany Medical College, Albany, New York, Dr. Ortiz, a native of Los Angeles, completed her dermatology residency training at the University of California, Irvine, and the university’s Beckman Laser Institute. Next, she completed a laser and cosmetic dermatology fellowship at Massachusetts General Hospital, Harvard Medical School, and the Wellman Center for Photomedicine, all in Boston, and acquired additional fellowship training in Mohs micrographic surgery at the University of California, San Diego (UCSD). Dr. Ortiz is currently director of laser and cosmetic dermatology and a clinical professor of dermatology at UCSD.
She has authored more than 60 publications on new innovations in cutaneous surgery and is a frequent speaker at meetings of the American Academy of Dermatology, the American Society for Dermatologic Surgery (ASDS), and ASLMS, and she cochairs the annual Masters of Aesthetics Symposium in San Diego. Dr. Ortiz has received several awards, including the 2024 Castle Connolly Top Doctor Award and the Exceptional Women in Medicine Award; Newsweek America’s Best Dermatologists; the ASLMS Dr. Horace Furumoto Young Investigator Award, the ASLMS Best of Session Award for Cutaneous Applications, and the ASDS President’s Outstanding Service Award. Her primary research focuses on the laser treatment of nonmelanoma skin cancer.
In an interview, Dr. Ortiz spoke about her goals as ASLMS president and other topics related to dermatology.
Who inspired you most to become a doctor?
I’ve wanted to become a doctor for as long as I can remember. My fascination with science and the idea of helping people improve their health were driving forces. However, my biggest influence early on was my uncle, who was a pediatrician. His dedication and passion for medicine deeply inspired me and solidified my desire to pursue a career in healthcare.
I understand that a bout with chickenpox as a teenager influenced your decision to specialize in dermatology.
It’s an interesting and somewhat humorous story. When I was 18, I contracted chickenpox and ended up with scars on my face. It was a tough experience as a teenager, but it’s fascinating how such events can shape your life. In my quest for help, I opened the Yellow Pages and randomly chose a dermatologist nearby, who turned out to be Gary Lask, MD, director of lasers at UCLA [University of California, Los Angeles]. During our visit, I mentioned that I was premed, and he encouraged me to consider dermatology. About 6 years later, as a second-year medical student, I realized my passion for dermatology. I reached out to Dr. Lask and told him: “You were right. I want to be a dermatologist. Now, you have to help me get in!” Today, he remains my mentor, and I am deeply grateful for his guidance and support on this journey.
One of the initiatives for your term as ASLMS president includes a focus on safety standards for lasers and energy-based devices. Why is this important now?
Working at the university, I frequently encounter severe complications arising from the improper use of lasers and energy-based devices. As these procedures gain popularity, more providers are offering them, yet often without adequate training. As the world’s premier laser society, it is our duty to ensure patient safety. In the ever-evolving field of laser medicine, it is crucial that we continually strive to enhance the regulation of laser usage, ensuring that patients receive the highest standard of care with minimal risk.
One of the suggestions you have for the safety initiative is to offer a rigorous laser safety certification course with continuing education opportunities as a way foster a culture of heightened safety standards. Please explain what would be included in such a course and how it would align with current efforts to report adverse events such as the ASDS-Northwestern University Cutaneous Procedures Adverse Events Reporting (CAPER) registry and the Food and Drug Administration’s MedWatch Program.
A laser safety certification task force has been established to determine the best approach for developing a comprehensive course. The task force aims to assess the necessity of a formal safety certification in our industry, identify the resources needed to support such a certification, establish general safety protocols to form the content foundation, address potential legal concerns, and outline the process for formal certification program recognition. This exploratory work is expected to conclude by the end of the year. The proposed course may include modules on the fundamentals of laser physics, safe operation techniques, patient selection and management, and emergency protocols. Continuing education opportunities would be considered to keep practitioners updated on the latest advancements and safety protocols in laser medicine, thereby fostering a culture of heightened safety standards.
Another initiative for your term is the rollout of a tattoo removal program for former gang members based on the UCSD Clean Slate Tattoo Removal Program. Please tell us more about your vision for this national program.
UCSD Dermatology, in collaboration with UCSD Global Health, has been involved in the Clean Slate Tattoo Removal Program for the past decade. This initiative supports and rehabilitates former gang members by offering laser tattoo removal, helping them reintegrate into society. My vision is to equip our members with the necessary protocols to implement this outreach initiative in their own communities. By providing opportunities for reform and growth, we aim to foster safer and more inclusive communities nationwide.
You were one of the first clinicians to use a laser to treat basal cell carcinoma (BCC). Who are the ideal candidates for this procedure? Is the technique ready for wide clinical adoption? If not, what kind of studies are needed to make it so?
My research passion lies in optimizing laser treatments for BCC. During my fellowship with R. Rox Anderson, MD, and Mathew Avram, MD, at the MGH Wellman Center for Photomedicine, we conducted a pilot study using the 1064-nm Nd:YAG laser, achieving a 92% clearance rate after one treatment. Inspired by these results, we conducted a larger multicenter study, which demonstrated a 90% clearance rate after a single treatment. I now incorporate this technique into my daily practice. The ideal candidates for this procedure are patients with BCC that do not meet the Mohs Appropriate Use Criteria, such as those with nodular or superficial BCC subtypes on the body, individuals who are poor surgical candidates, or those who are surgically exhausted. However, I do not recommend this treatment for patients who are primarily concerned about facial scarring, particularly younger individuals; in such cases, Mohs surgery still remains the preferred option. While I believe this technique is ready for broader clinical adoption, it requires an understanding of laser endpoints. We are also exploring antibody-targeted gold nanorods to enhance the selectivity and standardization of the treatment.
Who inspires you most in your work today?
My patients are my greatest inspiration. Their trust and dedication motivate me to stay at the forefront of dermatologic advancements, ensuring I provide the most cutting-edge and safe treatments possible. Their commitment drives my relentless pursuit of continuous learning and innovation in the field.
What’s the best advice you can give to female dermatologists seeking leadership positions at the local, state, or national level?
My best advice is to have the courage to ask for what you seek. Societies are always looking for members who are eager to participate and contribute. If you express your interest in becoming more involved, there is likely a position available for you. The more you are willing to contribute to a society, the more likely you will be noticed and excel into higher leadership positions. Take initiative, show your commitment, and don’t hesitate to step forward when opportunities arise.
What’s the one tried-and-true laser- or energy-based procedure that you consider a “must” for your dermatology practice? And why?
Determining a single “must-have” laser- or energy-based procedure is a challenging question as it greatly depends on the specific needs of your patient population. However, one of the most common concerns among patients involves issues like redness and pigmentation. Therefore, having a versatile laser or an intense pulsed light device that effectively targets both red and brown pigmentation is indispensable for most practices.
In your view, what are the top three trends in aesthetic dermatology?
Over the years, I have observed several key trends in aesthetic dermatology:
- Minimally invasive procedures. There is a growing preference for less invasive treatments. Patients increasingly desire minimal downtime while still achieving significant results.
- Advancements in laser and energy-based devices for darker skin. There have been substantial advancements in technologies that are safer and more effective for darker skin tones. These developments play a crucial role in addressing diverse patient needs and providing inclusive dermatologic care.
- Natural aesthetic. I am hopeful that the trend toward an overdone appearance is fading. There seems to be a shift back towards a more natural and conservative aesthetic, emphasizing subtle enhancements over dramatic changes.
What development in dermatology are you most excited about in the next 5 years?
I am most excited to see how artificial intelligence and robotics play a role in energy-based devices.
Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies. She is also cochair of the MOAS.
Arisa E. Ortiz, MD, began her term as president of the American Society for Laser Medicine and Surgery (ASLMS) during the organization’s annual meeting in April 2024.
After earning her medical degree from Albany Medical College, Albany, New York, Dr. Ortiz, a native of Los Angeles, completed her dermatology residency training at the University of California, Irvine, and the university’s Beckman Laser Institute. Next, she completed a laser and cosmetic dermatology fellowship at Massachusetts General Hospital, Harvard Medical School, and the Wellman Center for Photomedicine, all in Boston, and acquired additional fellowship training in Mohs micrographic surgery at the University of California, San Diego (UCSD). Dr. Ortiz is currently director of laser and cosmetic dermatology and a clinical professor of dermatology at UCSD.
She has authored more than 60 publications on new innovations in cutaneous surgery and is a frequent speaker at meetings of the American Academy of Dermatology, the American Society for Dermatologic Surgery (ASDS), and ASLMS, and she cochairs the annual Masters of Aesthetics Symposium in San Diego. Dr. Ortiz has received several awards, including the 2024 Castle Connolly Top Doctor Award and the Exceptional Women in Medicine Award; Newsweek America’s Best Dermatologists; the ASLMS Dr. Horace Furumoto Young Investigator Award, the ASLMS Best of Session Award for Cutaneous Applications, and the ASDS President’s Outstanding Service Award. Her primary research focuses on the laser treatment of nonmelanoma skin cancer.
In an interview, Dr. Ortiz spoke about her goals as ASLMS president and other topics related to dermatology.
Who inspired you most to become a doctor?
I’ve wanted to become a doctor for as long as I can remember. My fascination with science and the idea of helping people improve their health were driving forces. However, my biggest influence early on was my uncle, who was a pediatrician. His dedication and passion for medicine deeply inspired me and solidified my desire to pursue a career in healthcare.
I understand that a bout with chickenpox as a teenager influenced your decision to specialize in dermatology.
It’s an interesting and somewhat humorous story. When I was 18, I contracted chickenpox and ended up with scars on my face. It was a tough experience as a teenager, but it’s fascinating how such events can shape your life. In my quest for help, I opened the Yellow Pages and randomly chose a dermatologist nearby, who turned out to be Gary Lask, MD, director of lasers at UCLA [University of California, Los Angeles]. During our visit, I mentioned that I was premed, and he encouraged me to consider dermatology. About 6 years later, as a second-year medical student, I realized my passion for dermatology. I reached out to Dr. Lask and told him: “You were right. I want to be a dermatologist. Now, you have to help me get in!” Today, he remains my mentor, and I am deeply grateful for his guidance and support on this journey.
One of the initiatives for your term as ASLMS president includes a focus on safety standards for lasers and energy-based devices. Why is this important now?
Working at the university, I frequently encounter severe complications arising from the improper use of lasers and energy-based devices. As these procedures gain popularity, more providers are offering them, yet often without adequate training. As the world’s premier laser society, it is our duty to ensure patient safety. In the ever-evolving field of laser medicine, it is crucial that we continually strive to enhance the regulation of laser usage, ensuring that patients receive the highest standard of care with minimal risk.
One of the suggestions you have for the safety initiative is to offer a rigorous laser safety certification course with continuing education opportunities as a way foster a culture of heightened safety standards. Please explain what would be included in such a course and how it would align with current efforts to report adverse events such as the ASDS-Northwestern University Cutaneous Procedures Adverse Events Reporting (CAPER) registry and the Food and Drug Administration’s MedWatch Program.
A laser safety certification task force has been established to determine the best approach for developing a comprehensive course. The task force aims to assess the necessity of a formal safety certification in our industry, identify the resources needed to support such a certification, establish general safety protocols to form the content foundation, address potential legal concerns, and outline the process for formal certification program recognition. This exploratory work is expected to conclude by the end of the year. The proposed course may include modules on the fundamentals of laser physics, safe operation techniques, patient selection and management, and emergency protocols. Continuing education opportunities would be considered to keep practitioners updated on the latest advancements and safety protocols in laser medicine, thereby fostering a culture of heightened safety standards.
Another initiative for your term is the rollout of a tattoo removal program for former gang members based on the UCSD Clean Slate Tattoo Removal Program. Please tell us more about your vision for this national program.
UCSD Dermatology, in collaboration with UCSD Global Health, has been involved in the Clean Slate Tattoo Removal Program for the past decade. This initiative supports and rehabilitates former gang members by offering laser tattoo removal, helping them reintegrate into society. My vision is to equip our members with the necessary protocols to implement this outreach initiative in their own communities. By providing opportunities for reform and growth, we aim to foster safer and more inclusive communities nationwide.
You were one of the first clinicians to use a laser to treat basal cell carcinoma (BCC). Who are the ideal candidates for this procedure? Is the technique ready for wide clinical adoption? If not, what kind of studies are needed to make it so?
My research passion lies in optimizing laser treatments for BCC. During my fellowship with R. Rox Anderson, MD, and Mathew Avram, MD, at the MGH Wellman Center for Photomedicine, we conducted a pilot study using the 1064-nm Nd:YAG laser, achieving a 92% clearance rate after one treatment. Inspired by these results, we conducted a larger multicenter study, which demonstrated a 90% clearance rate after a single treatment. I now incorporate this technique into my daily practice. The ideal candidates for this procedure are patients with BCC that do not meet the Mohs Appropriate Use Criteria, such as those with nodular or superficial BCC subtypes on the body, individuals who are poor surgical candidates, or those who are surgically exhausted. However, I do not recommend this treatment for patients who are primarily concerned about facial scarring, particularly younger individuals; in such cases, Mohs surgery still remains the preferred option. While I believe this technique is ready for broader clinical adoption, it requires an understanding of laser endpoints. We are also exploring antibody-targeted gold nanorods to enhance the selectivity and standardization of the treatment.
Who inspires you most in your work today?
My patients are my greatest inspiration. Their trust and dedication motivate me to stay at the forefront of dermatologic advancements, ensuring I provide the most cutting-edge and safe treatments possible. Their commitment drives my relentless pursuit of continuous learning and innovation in the field.
What’s the best advice you can give to female dermatologists seeking leadership positions at the local, state, or national level?
My best advice is to have the courage to ask for what you seek. Societies are always looking for members who are eager to participate and contribute. If you express your interest in becoming more involved, there is likely a position available for you. The more you are willing to contribute to a society, the more likely you will be noticed and excel into higher leadership positions. Take initiative, show your commitment, and don’t hesitate to step forward when opportunities arise.
What’s the one tried-and-true laser- or energy-based procedure that you consider a “must” for your dermatology practice? And why?
Determining a single “must-have” laser- or energy-based procedure is a challenging question as it greatly depends on the specific needs of your patient population. However, one of the most common concerns among patients involves issues like redness and pigmentation. Therefore, having a versatile laser or an intense pulsed light device that effectively targets both red and brown pigmentation is indispensable for most practices.
In your view, what are the top three trends in aesthetic dermatology?
Over the years, I have observed several key trends in aesthetic dermatology:
- Minimally invasive procedures. There is a growing preference for less invasive treatments. Patients increasingly desire minimal downtime while still achieving significant results.
- Advancements in laser and energy-based devices for darker skin. There have been substantial advancements in technologies that are safer and more effective for darker skin tones. These developments play a crucial role in addressing diverse patient needs and providing inclusive dermatologic care.
- Natural aesthetic. I am hopeful that the trend toward an overdone appearance is fading. There seems to be a shift back towards a more natural and conservative aesthetic, emphasizing subtle enhancements over dramatic changes.
What development in dermatology are you most excited about in the next 5 years?
I am most excited to see how artificial intelligence and robotics play a role in energy-based devices.
Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies. She is also cochair of the MOAS.
Arisa E. Ortiz, MD, began her term as president of the American Society for Laser Medicine and Surgery (ASLMS) during the organization’s annual meeting in April 2024.
After earning her medical degree from Albany Medical College, Albany, New York, Dr. Ortiz, a native of Los Angeles, completed her dermatology residency training at the University of California, Irvine, and the university’s Beckman Laser Institute. Next, she completed a laser and cosmetic dermatology fellowship at Massachusetts General Hospital, Harvard Medical School, and the Wellman Center for Photomedicine, all in Boston, and acquired additional fellowship training in Mohs micrographic surgery at the University of California, San Diego (UCSD). Dr. Ortiz is currently director of laser and cosmetic dermatology and a clinical professor of dermatology at UCSD.
She has authored more than 60 publications on new innovations in cutaneous surgery and is a frequent speaker at meetings of the American Academy of Dermatology, the American Society for Dermatologic Surgery (ASDS), and ASLMS, and she cochairs the annual Masters of Aesthetics Symposium in San Diego. Dr. Ortiz has received several awards, including the 2024 Castle Connolly Top Doctor Award and the Exceptional Women in Medicine Award; Newsweek America’s Best Dermatologists; the ASLMS Dr. Horace Furumoto Young Investigator Award, the ASLMS Best of Session Award for Cutaneous Applications, and the ASDS President’s Outstanding Service Award. Her primary research focuses on the laser treatment of nonmelanoma skin cancer.
In an interview, Dr. Ortiz spoke about her goals as ASLMS president and other topics related to dermatology.
Who inspired you most to become a doctor?
I’ve wanted to become a doctor for as long as I can remember. My fascination with science and the idea of helping people improve their health were driving forces. However, my biggest influence early on was my uncle, who was a pediatrician. His dedication and passion for medicine deeply inspired me and solidified my desire to pursue a career in healthcare.
I understand that a bout with chickenpox as a teenager influenced your decision to specialize in dermatology.
It’s an interesting and somewhat humorous story. When I was 18, I contracted chickenpox and ended up with scars on my face. It was a tough experience as a teenager, but it’s fascinating how such events can shape your life. In my quest for help, I opened the Yellow Pages and randomly chose a dermatologist nearby, who turned out to be Gary Lask, MD, director of lasers at UCLA [University of California, Los Angeles]. During our visit, I mentioned that I was premed, and he encouraged me to consider dermatology. About 6 years later, as a second-year medical student, I realized my passion for dermatology. I reached out to Dr. Lask and told him: “You were right. I want to be a dermatologist. Now, you have to help me get in!” Today, he remains my mentor, and I am deeply grateful for his guidance and support on this journey.
One of the initiatives for your term as ASLMS president includes a focus on safety standards for lasers and energy-based devices. Why is this important now?
Working at the university, I frequently encounter severe complications arising from the improper use of lasers and energy-based devices. As these procedures gain popularity, more providers are offering them, yet often without adequate training. As the world’s premier laser society, it is our duty to ensure patient safety. In the ever-evolving field of laser medicine, it is crucial that we continually strive to enhance the regulation of laser usage, ensuring that patients receive the highest standard of care with minimal risk.
One of the suggestions you have for the safety initiative is to offer a rigorous laser safety certification course with continuing education opportunities as a way foster a culture of heightened safety standards. Please explain what would be included in such a course and how it would align with current efforts to report adverse events such as the ASDS-Northwestern University Cutaneous Procedures Adverse Events Reporting (CAPER) registry and the Food and Drug Administration’s MedWatch Program.
A laser safety certification task force has been established to determine the best approach for developing a comprehensive course. The task force aims to assess the necessity of a formal safety certification in our industry, identify the resources needed to support such a certification, establish general safety protocols to form the content foundation, address potential legal concerns, and outline the process for formal certification program recognition. This exploratory work is expected to conclude by the end of the year. The proposed course may include modules on the fundamentals of laser physics, safe operation techniques, patient selection and management, and emergency protocols. Continuing education opportunities would be considered to keep practitioners updated on the latest advancements and safety protocols in laser medicine, thereby fostering a culture of heightened safety standards.
Another initiative for your term is the rollout of a tattoo removal program for former gang members based on the UCSD Clean Slate Tattoo Removal Program. Please tell us more about your vision for this national program.
UCSD Dermatology, in collaboration with UCSD Global Health, has been involved in the Clean Slate Tattoo Removal Program for the past decade. This initiative supports and rehabilitates former gang members by offering laser tattoo removal, helping them reintegrate into society. My vision is to equip our members with the necessary protocols to implement this outreach initiative in their own communities. By providing opportunities for reform and growth, we aim to foster safer and more inclusive communities nationwide.
You were one of the first clinicians to use a laser to treat basal cell carcinoma (BCC). Who are the ideal candidates for this procedure? Is the technique ready for wide clinical adoption? If not, what kind of studies are needed to make it so?
My research passion lies in optimizing laser treatments for BCC. During my fellowship with R. Rox Anderson, MD, and Mathew Avram, MD, at the MGH Wellman Center for Photomedicine, we conducted a pilot study using the 1064-nm Nd:YAG laser, achieving a 92% clearance rate after one treatment. Inspired by these results, we conducted a larger multicenter study, which demonstrated a 90% clearance rate after a single treatment. I now incorporate this technique into my daily practice. The ideal candidates for this procedure are patients with BCC that do not meet the Mohs Appropriate Use Criteria, such as those with nodular or superficial BCC subtypes on the body, individuals who are poor surgical candidates, or those who are surgically exhausted. However, I do not recommend this treatment for patients who are primarily concerned about facial scarring, particularly younger individuals; in such cases, Mohs surgery still remains the preferred option. While I believe this technique is ready for broader clinical adoption, it requires an understanding of laser endpoints. We are also exploring antibody-targeted gold nanorods to enhance the selectivity and standardization of the treatment.
Who inspires you most in your work today?
My patients are my greatest inspiration. Their trust and dedication motivate me to stay at the forefront of dermatologic advancements, ensuring I provide the most cutting-edge and safe treatments possible. Their commitment drives my relentless pursuit of continuous learning and innovation in the field.
What’s the best advice you can give to female dermatologists seeking leadership positions at the local, state, or national level?
My best advice is to have the courage to ask for what you seek. Societies are always looking for members who are eager to participate and contribute. If you express your interest in becoming more involved, there is likely a position available for you. The more you are willing to contribute to a society, the more likely you will be noticed and excel into higher leadership positions. Take initiative, show your commitment, and don’t hesitate to step forward when opportunities arise.
What’s the one tried-and-true laser- or energy-based procedure that you consider a “must” for your dermatology practice? And why?
Determining a single “must-have” laser- or energy-based procedure is a challenging question as it greatly depends on the specific needs of your patient population. However, one of the most common concerns among patients involves issues like redness and pigmentation. Therefore, having a versatile laser or an intense pulsed light device that effectively targets both red and brown pigmentation is indispensable for most practices.
In your view, what are the top three trends in aesthetic dermatology?
Over the years, I have observed several key trends in aesthetic dermatology:
- Minimally invasive procedures. There is a growing preference for less invasive treatments. Patients increasingly desire minimal downtime while still achieving significant results.
- Advancements in laser and energy-based devices for darker skin. There have been substantial advancements in technologies that are safer and more effective for darker skin tones. These developments play a crucial role in addressing diverse patient needs and providing inclusive dermatologic care.
- Natural aesthetic. I am hopeful that the trend toward an overdone appearance is fading. There seems to be a shift back towards a more natural and conservative aesthetic, emphasizing subtle enhancements over dramatic changes.
What development in dermatology are you most excited about in the next 5 years?
I am most excited to see how artificial intelligence and robotics play a role in energy-based devices.
Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies. She is also cochair of the MOAS.
Small Melanoma In Situ: Single Center Study Finds Recurrence Low With 5-mm Margin Excisions
. This approach has the potential to reduce morbidity and cost associated with treatment “without compromising patient outcomes in a selected population of lesions,” the authors say.
“Currently, there is uncertainty regarding the optimal excision margin for MIS, with different guidelines recommending a range between 5 and 10 mm,” corresponding author Cong Sun, MD, of Mater Hospital Brisbane Raymond Terrace, South Brisbane, Queensland, Australia, and colleagues wrote in the study, which was published in JAMA Dermatology. “In addition, studies using the Mohs micrographic surgery technique have suggested that wider margins, up to 18 mm, may be required for MIS in some settings.”
To further examine the use of 5-mm margins for excision of small MIS on low-risk sites, the researchers retrospectively evaluated 351 MIS lesions diagnosed in 292 patients between January 1, 2011, and November 30, 2018. Lesions were eligible for analysis if a 5-mm excisional margin was documented on the operation report and if there was more than 5 years of site-specific follow-up after wide local excision. Lesions with undocumented margins were excluded from analysis, as were those with fewer than 5 years of follow-up, and those that required more than one wide local excision.
The mean age of patients was 60.3 years, 55.5% were female, and the mean dimensions of the lesions was 6 × 5 mm. The most common subtype of melanoma diagnosed was superficial spreading melanoma (50.4% of lesions), followed by lentigo maligna (30.5%) and lentiginous MIS (19.1%). Nearly half of the lesions were on the trunk (47.9%), followed by the upper limb (27.4%), lower limb (16.8%), neck (4%), face (3.4%), and scalp (0.6%). As for the size of lesions, 78.1% were < 10 mm long and 88.9% were < 10 mm wide.
Nearly 71% (248) of the lesions were treated with an initial excisional biopsy, and 29.3% (103) underwent an initial shave excision. Median follow-up was 7 years.
Only three of the 351 lesions (0.9%) had a local recurrence, with no regional recurrence or metastatic spread, and 99.1% had no recurrence. The recurrences were reexcised “with clear margins” and after at least 5 years of follow-up, no further recurrences were reported, the authors said.
In Mohs surgery studies, reported recurrence rates for MIS have been “between 0.26% and 1.1%, with excisional margins between 6 and 12 mm required,” the authors noted. “This study demonstrated a comparable 0.9% recurrence rate achieved with a conservative 5-mm excisional margin. This shows that using a 5-mm margin for MIS of smaller size (< 10 mm) may reduce morbidity and cost associated with treatment without compromising patient outcomes in a selected population of lesions.”
The researchers recommended additional studies to confirm their findings and acknowledged certain limitations of their analysis, including its retrospective, single-center design and the predominantly small sizes of the lesions.
In an accompanying editorial, John A. Zitelli, MD, of the University of Pittsburgh, Pittsburgh, Pennsylvania, said that the margin measurement used by the researchers was another limitation. “Before the excision with a 5-mm margin was performed, the diagnosis of MIS was obtained by shave biopsy or excisional biopsy with a 2- to 3-mm margin of clinically normal skin,” Dr. Zitelli wrote. “Therefore, in patients without a 2- to 3-mm biopsy margin, a minimum surgical margin of 7-8 mm would be required to achieve a similar true negative excision margin.”
Also, he continued, the exclusion of lesions with wide subclinical extension that required wider margins “weakens the conclusion that 5 mm would be an effective treatment for all MIS.”
Hugh Greenway, MD, head of Mohs micrographic surgery and director of cutaneous oncology at Scripps Cancer Center, San Diego, who was asked to comment on the study, said that clinicians continue to search for the optimum smaller surgical margin for MIS. “This can be challenging with the variability of MIS based on location and other factors,” Dr. Greenway told this news organization. “This Australian retrospective study notes that for selected, well-defined 6 × 5 mm lesions of low-risk body sites (mainly torso and limbs), a 5-mm surgical margin can provide a high cure rate. The authors note further studies are indicated. Thus, for selected lesions in selected locations, the 5-mm surgical margin may be appropriate for MIS.”
The study authors, Dr. Zitelli, and Dr. Greenway reported no financial disclosures.
A version of this article appeared on Medscape.com.
. This approach has the potential to reduce morbidity and cost associated with treatment “without compromising patient outcomes in a selected population of lesions,” the authors say.
“Currently, there is uncertainty regarding the optimal excision margin for MIS, with different guidelines recommending a range between 5 and 10 mm,” corresponding author Cong Sun, MD, of Mater Hospital Brisbane Raymond Terrace, South Brisbane, Queensland, Australia, and colleagues wrote in the study, which was published in JAMA Dermatology. “In addition, studies using the Mohs micrographic surgery technique have suggested that wider margins, up to 18 mm, may be required for MIS in some settings.”
To further examine the use of 5-mm margins for excision of small MIS on low-risk sites, the researchers retrospectively evaluated 351 MIS lesions diagnosed in 292 patients between January 1, 2011, and November 30, 2018. Lesions were eligible for analysis if a 5-mm excisional margin was documented on the operation report and if there was more than 5 years of site-specific follow-up after wide local excision. Lesions with undocumented margins were excluded from analysis, as were those with fewer than 5 years of follow-up, and those that required more than one wide local excision.
The mean age of patients was 60.3 years, 55.5% were female, and the mean dimensions of the lesions was 6 × 5 mm. The most common subtype of melanoma diagnosed was superficial spreading melanoma (50.4% of lesions), followed by lentigo maligna (30.5%) and lentiginous MIS (19.1%). Nearly half of the lesions were on the trunk (47.9%), followed by the upper limb (27.4%), lower limb (16.8%), neck (4%), face (3.4%), and scalp (0.6%). As for the size of lesions, 78.1% were < 10 mm long and 88.9% were < 10 mm wide.
Nearly 71% (248) of the lesions were treated with an initial excisional biopsy, and 29.3% (103) underwent an initial shave excision. Median follow-up was 7 years.
Only three of the 351 lesions (0.9%) had a local recurrence, with no regional recurrence or metastatic spread, and 99.1% had no recurrence. The recurrences were reexcised “with clear margins” and after at least 5 years of follow-up, no further recurrences were reported, the authors said.
In Mohs surgery studies, reported recurrence rates for MIS have been “between 0.26% and 1.1%, with excisional margins between 6 and 12 mm required,” the authors noted. “This study demonstrated a comparable 0.9% recurrence rate achieved with a conservative 5-mm excisional margin. This shows that using a 5-mm margin for MIS of smaller size (< 10 mm) may reduce morbidity and cost associated with treatment without compromising patient outcomes in a selected population of lesions.”
The researchers recommended additional studies to confirm their findings and acknowledged certain limitations of their analysis, including its retrospective, single-center design and the predominantly small sizes of the lesions.
In an accompanying editorial, John A. Zitelli, MD, of the University of Pittsburgh, Pittsburgh, Pennsylvania, said that the margin measurement used by the researchers was another limitation. “Before the excision with a 5-mm margin was performed, the diagnosis of MIS was obtained by shave biopsy or excisional biopsy with a 2- to 3-mm margin of clinically normal skin,” Dr. Zitelli wrote. “Therefore, in patients without a 2- to 3-mm biopsy margin, a minimum surgical margin of 7-8 mm would be required to achieve a similar true negative excision margin.”
Also, he continued, the exclusion of lesions with wide subclinical extension that required wider margins “weakens the conclusion that 5 mm would be an effective treatment for all MIS.”
Hugh Greenway, MD, head of Mohs micrographic surgery and director of cutaneous oncology at Scripps Cancer Center, San Diego, who was asked to comment on the study, said that clinicians continue to search for the optimum smaller surgical margin for MIS. “This can be challenging with the variability of MIS based on location and other factors,” Dr. Greenway told this news organization. “This Australian retrospective study notes that for selected, well-defined 6 × 5 mm lesions of low-risk body sites (mainly torso and limbs), a 5-mm surgical margin can provide a high cure rate. The authors note further studies are indicated. Thus, for selected lesions in selected locations, the 5-mm surgical margin may be appropriate for MIS.”
The study authors, Dr. Zitelli, and Dr. Greenway reported no financial disclosures.
A version of this article appeared on Medscape.com.
. This approach has the potential to reduce morbidity and cost associated with treatment “without compromising patient outcomes in a selected population of lesions,” the authors say.
“Currently, there is uncertainty regarding the optimal excision margin for MIS, with different guidelines recommending a range between 5 and 10 mm,” corresponding author Cong Sun, MD, of Mater Hospital Brisbane Raymond Terrace, South Brisbane, Queensland, Australia, and colleagues wrote in the study, which was published in JAMA Dermatology. “In addition, studies using the Mohs micrographic surgery technique have suggested that wider margins, up to 18 mm, may be required for MIS in some settings.”
To further examine the use of 5-mm margins for excision of small MIS on low-risk sites, the researchers retrospectively evaluated 351 MIS lesions diagnosed in 292 patients between January 1, 2011, and November 30, 2018. Lesions were eligible for analysis if a 5-mm excisional margin was documented on the operation report and if there was more than 5 years of site-specific follow-up after wide local excision. Lesions with undocumented margins were excluded from analysis, as were those with fewer than 5 years of follow-up, and those that required more than one wide local excision.
The mean age of patients was 60.3 years, 55.5% were female, and the mean dimensions of the lesions was 6 × 5 mm. The most common subtype of melanoma diagnosed was superficial spreading melanoma (50.4% of lesions), followed by lentigo maligna (30.5%) and lentiginous MIS (19.1%). Nearly half of the lesions were on the trunk (47.9%), followed by the upper limb (27.4%), lower limb (16.8%), neck (4%), face (3.4%), and scalp (0.6%). As for the size of lesions, 78.1% were < 10 mm long and 88.9% were < 10 mm wide.
Nearly 71% (248) of the lesions were treated with an initial excisional biopsy, and 29.3% (103) underwent an initial shave excision. Median follow-up was 7 years.
Only three of the 351 lesions (0.9%) had a local recurrence, with no regional recurrence or metastatic spread, and 99.1% had no recurrence. The recurrences were reexcised “with clear margins” and after at least 5 years of follow-up, no further recurrences were reported, the authors said.
In Mohs surgery studies, reported recurrence rates for MIS have been “between 0.26% and 1.1%, with excisional margins between 6 and 12 mm required,” the authors noted. “This study demonstrated a comparable 0.9% recurrence rate achieved with a conservative 5-mm excisional margin. This shows that using a 5-mm margin for MIS of smaller size (< 10 mm) may reduce morbidity and cost associated with treatment without compromising patient outcomes in a selected population of lesions.”
The researchers recommended additional studies to confirm their findings and acknowledged certain limitations of their analysis, including its retrospective, single-center design and the predominantly small sizes of the lesions.
In an accompanying editorial, John A. Zitelli, MD, of the University of Pittsburgh, Pittsburgh, Pennsylvania, said that the margin measurement used by the researchers was another limitation. “Before the excision with a 5-mm margin was performed, the diagnosis of MIS was obtained by shave biopsy or excisional biopsy with a 2- to 3-mm margin of clinically normal skin,” Dr. Zitelli wrote. “Therefore, in patients without a 2- to 3-mm biopsy margin, a minimum surgical margin of 7-8 mm would be required to achieve a similar true negative excision margin.”
Also, he continued, the exclusion of lesions with wide subclinical extension that required wider margins “weakens the conclusion that 5 mm would be an effective treatment for all MIS.”
Hugh Greenway, MD, head of Mohs micrographic surgery and director of cutaneous oncology at Scripps Cancer Center, San Diego, who was asked to comment on the study, said that clinicians continue to search for the optimum smaller surgical margin for MIS. “This can be challenging with the variability of MIS based on location and other factors,” Dr. Greenway told this news organization. “This Australian retrospective study notes that for selected, well-defined 6 × 5 mm lesions of low-risk body sites (mainly torso and limbs), a 5-mm surgical margin can provide a high cure rate. The authors note further studies are indicated. Thus, for selected lesions in selected locations, the 5-mm surgical margin may be appropriate for MIS.”
The study authors, Dr. Zitelli, and Dr. Greenway reported no financial disclosures.
A version of this article appeared on Medscape.com.
Study Addresses Litigation Related to Cutaneous Energy-based Based Device Treatments
“The utilization of laser and energy-based devices (LEBD) has grown substantially,” corresponding author Scott Stratman, MD, MPH, and coauthors wrote in their study, which was published online in the Journal of the American Academy of Dermatology. “This has led to a rise in practitioners, both physicians and nonphysicians, who may lack the requisite training in LEBD procedures. Subsequently, procedures performed by these untrained practitioners have resulted in more lawsuits related to patient complications. As the demand for LEBD procedures and the number of practitioners performing these procedures increase, it remains paramount to characterize the trends of malpractice cases involving these procedures.”
Dr. Stratman, a dermatology resident at the Icahn School of Medicine at Mount Sinai, New York City, and colleagues queried the LexisNexis database from 1985 to Sept. 30, 2023, for all state, federal, and appellate cases that included the terms “negligence” or “malpractice” and “skin” and “laser.” After they removed duplicate cases and excluded cases that did not report dermatologic complications or cutaneous energy-based procedures, the final analysis included 75 cases.
Most of the appellants/plaintiffs (66; 88%) were women, a greater number of cases were in the Northeast (26; 34.7%) and the South (23; 30.7%), and the fewest cases were in the Midwest (12 [16%]). The most common anatomical sites were the face, head, and/or neck, and 43 of the cases (57.3%) were decided in favor of the appellee/defendant or the party defending against the appeal, while 29 (38.7%) were in favor of the appellant/plaintiff or the party appealing, and three cases (4%) did not report a verdict.
In other findings, plastic surgeons were the most litigated healthcare professionals (18; 24%), while 39 of the overall cases (52%) involved nonphysician operators (NPOs), 32 (42.7%) involved a physician operator, and 4 cases (5.3%) did not name a device operator. The most common procedure performed in the included cases was laser hair removal (33; 44%). Complications from energy-based devices included burns, scarring, and pigmentation changes. Statistically significant associations were neither found between verdict outcome and appellee/defendant type nor found between energy-device operator or anatomical site.
The authors acknowledged certain limitations of the study, including the fact that the LexisNexis database does not contain cases handled in out-of-court settlements and cases that underwent third-party arbitration.
“Physicians must recognize their responsibility when delegating procedures to NPOs and their role in supervision of these procedures,” they concluded. “Comprehensive training for physicians and their agents is necessary to diminish adverse outcomes and legal risks. Moreover, all practitioners should be held to the same standard of care. Familiarity with malpractice trends not only strengthens the patient-provider relationship but also equips providers with effective strategies to minimize the risk of legal repercussions.”
Mathew M. Avram, MD, JD, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, who was asked to comment on the study, said that it “reaffirms previous studies which show that laser hair removal continues to be the most litigated procedure in laser surgery, and that nonphysician operators are most commonly litigated against. It further reiterates the importance of close supervision and expert training of procedures delegated by physicians.”
Neither the authors nor Dr. Avram reported having relevant financial disclosures.
A version of this article first appeared on Medscape.com.
“The utilization of laser and energy-based devices (LEBD) has grown substantially,” corresponding author Scott Stratman, MD, MPH, and coauthors wrote in their study, which was published online in the Journal of the American Academy of Dermatology. “This has led to a rise in practitioners, both physicians and nonphysicians, who may lack the requisite training in LEBD procedures. Subsequently, procedures performed by these untrained practitioners have resulted in more lawsuits related to patient complications. As the demand for LEBD procedures and the number of practitioners performing these procedures increase, it remains paramount to characterize the trends of malpractice cases involving these procedures.”
Dr. Stratman, a dermatology resident at the Icahn School of Medicine at Mount Sinai, New York City, and colleagues queried the LexisNexis database from 1985 to Sept. 30, 2023, for all state, federal, and appellate cases that included the terms “negligence” or “malpractice” and “skin” and “laser.” After they removed duplicate cases and excluded cases that did not report dermatologic complications or cutaneous energy-based procedures, the final analysis included 75 cases.
Most of the appellants/plaintiffs (66; 88%) were women, a greater number of cases were in the Northeast (26; 34.7%) and the South (23; 30.7%), and the fewest cases were in the Midwest (12 [16%]). The most common anatomical sites were the face, head, and/or neck, and 43 of the cases (57.3%) were decided in favor of the appellee/defendant or the party defending against the appeal, while 29 (38.7%) were in favor of the appellant/plaintiff or the party appealing, and three cases (4%) did not report a verdict.
In other findings, plastic surgeons were the most litigated healthcare professionals (18; 24%), while 39 of the overall cases (52%) involved nonphysician operators (NPOs), 32 (42.7%) involved a physician operator, and 4 cases (5.3%) did not name a device operator. The most common procedure performed in the included cases was laser hair removal (33; 44%). Complications from energy-based devices included burns, scarring, and pigmentation changes. Statistically significant associations were neither found between verdict outcome and appellee/defendant type nor found between energy-device operator or anatomical site.
The authors acknowledged certain limitations of the study, including the fact that the LexisNexis database does not contain cases handled in out-of-court settlements and cases that underwent third-party arbitration.
“Physicians must recognize their responsibility when delegating procedures to NPOs and their role in supervision of these procedures,” they concluded. “Comprehensive training for physicians and their agents is necessary to diminish adverse outcomes and legal risks. Moreover, all practitioners should be held to the same standard of care. Familiarity with malpractice trends not only strengthens the patient-provider relationship but also equips providers with effective strategies to minimize the risk of legal repercussions.”
Mathew M. Avram, MD, JD, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, who was asked to comment on the study, said that it “reaffirms previous studies which show that laser hair removal continues to be the most litigated procedure in laser surgery, and that nonphysician operators are most commonly litigated against. It further reiterates the importance of close supervision and expert training of procedures delegated by physicians.”
Neither the authors nor Dr. Avram reported having relevant financial disclosures.
A version of this article first appeared on Medscape.com.
“The utilization of laser and energy-based devices (LEBD) has grown substantially,” corresponding author Scott Stratman, MD, MPH, and coauthors wrote in their study, which was published online in the Journal of the American Academy of Dermatology. “This has led to a rise in practitioners, both physicians and nonphysicians, who may lack the requisite training in LEBD procedures. Subsequently, procedures performed by these untrained practitioners have resulted in more lawsuits related to patient complications. As the demand for LEBD procedures and the number of practitioners performing these procedures increase, it remains paramount to characterize the trends of malpractice cases involving these procedures.”
Dr. Stratman, a dermatology resident at the Icahn School of Medicine at Mount Sinai, New York City, and colleagues queried the LexisNexis database from 1985 to Sept. 30, 2023, for all state, federal, and appellate cases that included the terms “negligence” or “malpractice” and “skin” and “laser.” After they removed duplicate cases and excluded cases that did not report dermatologic complications or cutaneous energy-based procedures, the final analysis included 75 cases.
Most of the appellants/plaintiffs (66; 88%) were women, a greater number of cases were in the Northeast (26; 34.7%) and the South (23; 30.7%), and the fewest cases were in the Midwest (12 [16%]). The most common anatomical sites were the face, head, and/or neck, and 43 of the cases (57.3%) were decided in favor of the appellee/defendant or the party defending against the appeal, while 29 (38.7%) were in favor of the appellant/plaintiff or the party appealing, and three cases (4%) did not report a verdict.
In other findings, plastic surgeons were the most litigated healthcare professionals (18; 24%), while 39 of the overall cases (52%) involved nonphysician operators (NPOs), 32 (42.7%) involved a physician operator, and 4 cases (5.3%) did not name a device operator. The most common procedure performed in the included cases was laser hair removal (33; 44%). Complications from energy-based devices included burns, scarring, and pigmentation changes. Statistically significant associations were neither found between verdict outcome and appellee/defendant type nor found between energy-device operator or anatomical site.
The authors acknowledged certain limitations of the study, including the fact that the LexisNexis database does not contain cases handled in out-of-court settlements and cases that underwent third-party arbitration.
“Physicians must recognize their responsibility when delegating procedures to NPOs and their role in supervision of these procedures,” they concluded. “Comprehensive training for physicians and their agents is necessary to diminish adverse outcomes and legal risks. Moreover, all practitioners should be held to the same standard of care. Familiarity with malpractice trends not only strengthens the patient-provider relationship but also equips providers with effective strategies to minimize the risk of legal repercussions.”
Mathew M. Avram, MD, JD, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, who was asked to comment on the study, said that it “reaffirms previous studies which show that laser hair removal continues to be the most litigated procedure in laser surgery, and that nonphysician operators are most commonly litigated against. It further reiterates the importance of close supervision and expert training of procedures delegated by physicians.”
Neither the authors nor Dr. Avram reported having relevant financial disclosures.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Treating High Stage cSCC: Better Results With Mohs Surgery vs Wide Local Excision, Study Finds
PHOENIX — . The benefit was seen across all outcome measures, including rates of recurrence, metastasis, and mortality.
These data support Mohs surgery as being the preferred surgical treatment option for high-stage cSCC, commented lead author David M. Wang, MD, Mohs Micrographic Surgery and Dermatologic Oncology Fellow, at Harvard’s Brigham and Women’s Hospital (BWH)/Dana-Farber Cancer Institute, Boston. “We found that across all outcomes, high-stage cSCC treated with WLE had a roughly twofold greater risk for recurrence, metastasis, or disease-specific death compared to Mohs,” he said at the annual meeting of the American College of Mohs Surgery (ACMS), where he presented the results.
External validation using data from a multicenter cSCC research collaboration from 12 contributing sites from across the United States, as well as international sites, was also conducted. “We performed the external validation by comparing results of the BWH-only cohort, which was the primary study, with the full multicenter data and with the full multicenter data minus the BWH cohort, and the findings were nearly identical in all three analyses,” Dr. Wang said.
Although patients diagnosed with cSCC usually have good outcomes, high-stage disease is associated with a higher risk for recurrence, metastasis, and death. Both Mohs surgery and WLE are used to treat cSCC, but a comparison of outcomes has not been well established in the setting of high-stage cSCC. Comparing the two surgical strategies can be problematic, as both patient and/or tumor characteristics can make it difficult to determine which outcomes can be attributed solely to the treatment type.
Mohs Superior Across the Board
In the retrospective cohort study, Dr. Wang and colleagues aimed to compare the results of Mohs surgery and WLE in patients with high-stage cSCC (BWH Staging System T2b or T3) and used statistical methods to balance baseline patient and tumor characteristics.
“To control for confounding by indication — differences in baseline patient or tumor characteristics — that are associated with both the treatment received and outcomes, we used propensity score weighting so that the baseline characteristics were balanced in the two treatment groups,” Dr. Wang told this news organization. “This statistical method aims to simulate randomization in a randomized controlled trial such that any differences in outcomes after propensity score weighting is attributed solely to the treatment received.”
The study used electronic medical records from a single tertiary care academic institution, and 216 patients with high-stage cSCC who had undergone surgery from January 2000 to December 2019 were included in the analysis. The median follow-up time was 33.1 months.
They found that overall, the risk for all adverse outcomes was lower among patients who had undergone Mohs surgery than among those treated with WLE, with the following results: Rates of local recurrence (5-year CI, 10.8% vs 22.1%, respectively; P = .003), nodal metastasis (11.9% vs 19.3%; P = .04), distant metastasis (4.7% vs 9.0%; P = .09), any recurrence (17.0% vs 34.2%; P < .001), and disease-specific death (8.5% vs 20.3%; P = .001).
“The data supports Mohs surgery as the preferred surgical treatment option for high-stage cSCC in accordance with NCCN [National Comprehensive Cancer Network] guidelines for very high-risk cSCC,” Dr. Wang said. He pointed out that the terminology “very high risk” in NCCN equates to “high stage” in other staging systems (BWH T2b or higher, AJCC T3 or higher).
There is still “a substantial proportion” of patients with high-stage cSCC who are eligible for Mohs but are treated with WLE, he added. “Our hope is that these findings provide additional data to support Mohs as the standard of care for primary surgical treatment of high-stage cSCC.”
Supports Benefits of Mohs
Weighing in on the research, Thomas E. Rohrer, MD, a dermatologic surgeon in Chestnut Hill, Massachusetts, noted that this was an excellent study that demonstrates benefits of Mohs surgery over straight excision on essentially all outcomes investigated and measured.
“The data clearly shows that Mohs should be used whenever possible,” he said. “There are some patients and facilities that do not have access or timely access to Mohs, so they would likely proceed with standard wide local excision. Otherwise, if there is the capability to perform Mohs, it would be preferred,” he added.
“There is no benefit to a standard excision over Mohs,” Dr. Rohrer emphasized. “If a surgeon is not sure if they have attained clear margins, they could and often do take a little more tissue to be certain.”
Also asked to comment on the data, Chad L. Prather, MD, a dermatologist in Baton Rouge, Louisiana, said, “We know that Mohs has been used for cancers that are not highly staged and we know it’s better than WLE, but this study shows that it is beneficial for higher stage cancers.”
However, he cautioned that unlike early-stage cancers, where Mohs is usually a definitive treatment, with higher stage disease it is a starting point. “As a takeaway, Mohs is superior, but it needs to be followed through,” he said. “These patients need to be closely followed as they are at a high risk for recurrence and metastasis and may need to be worked up for lymph node involvement and need additional therapy going forward.”
Dr. Prather also pointed out that there are circumstances when WLE may be a more suitable treatment. “Mohs is not very good if there is bony involvement,” he said. “This most often happens when the lesion is on the scalp and has invaded the skull. WLE may still be the preferred choice.”
Additionally, Mohs is not the best choice if the tumor is broken into multiple segments. “In these cases, WLE may be preferred,” Dr. Prather added. “But overall, Mohs is one of the best tools we have, and it stands to reason that it works well for high-risk tumors, as this study shows.”
The study was independently supported. Dr. Wang reported no relevant financial relationships. Dr. Rohrer and Dr. Prather had no relevant disclosures.
A version of this article appeared on Medscape.com.
PHOENIX — . The benefit was seen across all outcome measures, including rates of recurrence, metastasis, and mortality.
These data support Mohs surgery as being the preferred surgical treatment option for high-stage cSCC, commented lead author David M. Wang, MD, Mohs Micrographic Surgery and Dermatologic Oncology Fellow, at Harvard’s Brigham and Women’s Hospital (BWH)/Dana-Farber Cancer Institute, Boston. “We found that across all outcomes, high-stage cSCC treated with WLE had a roughly twofold greater risk for recurrence, metastasis, or disease-specific death compared to Mohs,” he said at the annual meeting of the American College of Mohs Surgery (ACMS), where he presented the results.
External validation using data from a multicenter cSCC research collaboration from 12 contributing sites from across the United States, as well as international sites, was also conducted. “We performed the external validation by comparing results of the BWH-only cohort, which was the primary study, with the full multicenter data and with the full multicenter data minus the BWH cohort, and the findings were nearly identical in all three analyses,” Dr. Wang said.
Although patients diagnosed with cSCC usually have good outcomes, high-stage disease is associated with a higher risk for recurrence, metastasis, and death. Both Mohs surgery and WLE are used to treat cSCC, but a comparison of outcomes has not been well established in the setting of high-stage cSCC. Comparing the two surgical strategies can be problematic, as both patient and/or tumor characteristics can make it difficult to determine which outcomes can be attributed solely to the treatment type.
Mohs Superior Across the Board
In the retrospective cohort study, Dr. Wang and colleagues aimed to compare the results of Mohs surgery and WLE in patients with high-stage cSCC (BWH Staging System T2b or T3) and used statistical methods to balance baseline patient and tumor characteristics.
“To control for confounding by indication — differences in baseline patient or tumor characteristics — that are associated with both the treatment received and outcomes, we used propensity score weighting so that the baseline characteristics were balanced in the two treatment groups,” Dr. Wang told this news organization. “This statistical method aims to simulate randomization in a randomized controlled trial such that any differences in outcomes after propensity score weighting is attributed solely to the treatment received.”
The study used electronic medical records from a single tertiary care academic institution, and 216 patients with high-stage cSCC who had undergone surgery from January 2000 to December 2019 were included in the analysis. The median follow-up time was 33.1 months.
They found that overall, the risk for all adverse outcomes was lower among patients who had undergone Mohs surgery than among those treated with WLE, with the following results: Rates of local recurrence (5-year CI, 10.8% vs 22.1%, respectively; P = .003), nodal metastasis (11.9% vs 19.3%; P = .04), distant metastasis (4.7% vs 9.0%; P = .09), any recurrence (17.0% vs 34.2%; P < .001), and disease-specific death (8.5% vs 20.3%; P = .001).
“The data supports Mohs surgery as the preferred surgical treatment option for high-stage cSCC in accordance with NCCN [National Comprehensive Cancer Network] guidelines for very high-risk cSCC,” Dr. Wang said. He pointed out that the terminology “very high risk” in NCCN equates to “high stage” in other staging systems (BWH T2b or higher, AJCC T3 or higher).
There is still “a substantial proportion” of patients with high-stage cSCC who are eligible for Mohs but are treated with WLE, he added. “Our hope is that these findings provide additional data to support Mohs as the standard of care for primary surgical treatment of high-stage cSCC.”
Supports Benefits of Mohs
Weighing in on the research, Thomas E. Rohrer, MD, a dermatologic surgeon in Chestnut Hill, Massachusetts, noted that this was an excellent study that demonstrates benefits of Mohs surgery over straight excision on essentially all outcomes investigated and measured.
“The data clearly shows that Mohs should be used whenever possible,” he said. “There are some patients and facilities that do not have access or timely access to Mohs, so they would likely proceed with standard wide local excision. Otherwise, if there is the capability to perform Mohs, it would be preferred,” he added.
“There is no benefit to a standard excision over Mohs,” Dr. Rohrer emphasized. “If a surgeon is not sure if they have attained clear margins, they could and often do take a little more tissue to be certain.”
Also asked to comment on the data, Chad L. Prather, MD, a dermatologist in Baton Rouge, Louisiana, said, “We know that Mohs has been used for cancers that are not highly staged and we know it’s better than WLE, but this study shows that it is beneficial for higher stage cancers.”
However, he cautioned that unlike early-stage cancers, where Mohs is usually a definitive treatment, with higher stage disease it is a starting point. “As a takeaway, Mohs is superior, but it needs to be followed through,” he said. “These patients need to be closely followed as they are at a high risk for recurrence and metastasis and may need to be worked up for lymph node involvement and need additional therapy going forward.”
Dr. Prather also pointed out that there are circumstances when WLE may be a more suitable treatment. “Mohs is not very good if there is bony involvement,” he said. “This most often happens when the lesion is on the scalp and has invaded the skull. WLE may still be the preferred choice.”
Additionally, Mohs is not the best choice if the tumor is broken into multiple segments. “In these cases, WLE may be preferred,” Dr. Prather added. “But overall, Mohs is one of the best tools we have, and it stands to reason that it works well for high-risk tumors, as this study shows.”
The study was independently supported. Dr. Wang reported no relevant financial relationships. Dr. Rohrer and Dr. Prather had no relevant disclosures.
A version of this article appeared on Medscape.com.
PHOENIX — . The benefit was seen across all outcome measures, including rates of recurrence, metastasis, and mortality.
These data support Mohs surgery as being the preferred surgical treatment option for high-stage cSCC, commented lead author David M. Wang, MD, Mohs Micrographic Surgery and Dermatologic Oncology Fellow, at Harvard’s Brigham and Women’s Hospital (BWH)/Dana-Farber Cancer Institute, Boston. “We found that across all outcomes, high-stage cSCC treated with WLE had a roughly twofold greater risk for recurrence, metastasis, or disease-specific death compared to Mohs,” he said at the annual meeting of the American College of Mohs Surgery (ACMS), where he presented the results.
External validation using data from a multicenter cSCC research collaboration from 12 contributing sites from across the United States, as well as international sites, was also conducted. “We performed the external validation by comparing results of the BWH-only cohort, which was the primary study, with the full multicenter data and with the full multicenter data minus the BWH cohort, and the findings were nearly identical in all three analyses,” Dr. Wang said.
Although patients diagnosed with cSCC usually have good outcomes, high-stage disease is associated with a higher risk for recurrence, metastasis, and death. Both Mohs surgery and WLE are used to treat cSCC, but a comparison of outcomes has not been well established in the setting of high-stage cSCC. Comparing the two surgical strategies can be problematic, as both patient and/or tumor characteristics can make it difficult to determine which outcomes can be attributed solely to the treatment type.
Mohs Superior Across the Board
In the retrospective cohort study, Dr. Wang and colleagues aimed to compare the results of Mohs surgery and WLE in patients with high-stage cSCC (BWH Staging System T2b or T3) and used statistical methods to balance baseline patient and tumor characteristics.
“To control for confounding by indication — differences in baseline patient or tumor characteristics — that are associated with both the treatment received and outcomes, we used propensity score weighting so that the baseline characteristics were balanced in the two treatment groups,” Dr. Wang told this news organization. “This statistical method aims to simulate randomization in a randomized controlled trial such that any differences in outcomes after propensity score weighting is attributed solely to the treatment received.”
The study used electronic medical records from a single tertiary care academic institution, and 216 patients with high-stage cSCC who had undergone surgery from January 2000 to December 2019 were included in the analysis. The median follow-up time was 33.1 months.
They found that overall, the risk for all adverse outcomes was lower among patients who had undergone Mohs surgery than among those treated with WLE, with the following results: Rates of local recurrence (5-year CI, 10.8% vs 22.1%, respectively; P = .003), nodal metastasis (11.9% vs 19.3%; P = .04), distant metastasis (4.7% vs 9.0%; P = .09), any recurrence (17.0% vs 34.2%; P < .001), and disease-specific death (8.5% vs 20.3%; P = .001).
“The data supports Mohs surgery as the preferred surgical treatment option for high-stage cSCC in accordance with NCCN [National Comprehensive Cancer Network] guidelines for very high-risk cSCC,” Dr. Wang said. He pointed out that the terminology “very high risk” in NCCN equates to “high stage” in other staging systems (BWH T2b or higher, AJCC T3 or higher).
There is still “a substantial proportion” of patients with high-stage cSCC who are eligible for Mohs but are treated with WLE, he added. “Our hope is that these findings provide additional data to support Mohs as the standard of care for primary surgical treatment of high-stage cSCC.”
Supports Benefits of Mohs
Weighing in on the research, Thomas E. Rohrer, MD, a dermatologic surgeon in Chestnut Hill, Massachusetts, noted that this was an excellent study that demonstrates benefits of Mohs surgery over straight excision on essentially all outcomes investigated and measured.
“The data clearly shows that Mohs should be used whenever possible,” he said. “There are some patients and facilities that do not have access or timely access to Mohs, so they would likely proceed with standard wide local excision. Otherwise, if there is the capability to perform Mohs, it would be preferred,” he added.
“There is no benefit to a standard excision over Mohs,” Dr. Rohrer emphasized. “If a surgeon is not sure if they have attained clear margins, they could and often do take a little more tissue to be certain.”
Also asked to comment on the data, Chad L. Prather, MD, a dermatologist in Baton Rouge, Louisiana, said, “We know that Mohs has been used for cancers that are not highly staged and we know it’s better than WLE, but this study shows that it is beneficial for higher stage cancers.”
However, he cautioned that unlike early-stage cancers, where Mohs is usually a definitive treatment, with higher stage disease it is a starting point. “As a takeaway, Mohs is superior, but it needs to be followed through,” he said. “These patients need to be closely followed as they are at a high risk for recurrence and metastasis and may need to be worked up for lymph node involvement and need additional therapy going forward.”
Dr. Prather also pointed out that there are circumstances when WLE may be a more suitable treatment. “Mohs is not very good if there is bony involvement,” he said. “This most often happens when the lesion is on the scalp and has invaded the skull. WLE may still be the preferred choice.”
Additionally, Mohs is not the best choice if the tumor is broken into multiple segments. “In these cases, WLE may be preferred,” Dr. Prather added. “But overall, Mohs is one of the best tools we have, and it stands to reason that it works well for high-risk tumors, as this study shows.”
The study was independently supported. Dr. Wang reported no relevant financial relationships. Dr. Rohrer and Dr. Prather had no relevant disclosures.
A version of this article appeared on Medscape.com.
FROM ACMS 2024
Study Finds Immunosuppression Affects Risk for Poor Outcomes in Patients with cSCC
PHOENIX — Immunosuppression is an independent risk factor for poorer outcomes in patients with cutaneous squamous cell carcinoma (cSCC), according to new research that was presented at the American College of Mohs Surgery (ACMS) 2024 annual meeting.
Even though immunosuppression is strongly associated with an increased risk for cSCC, studies to date have generally not shown it to be an independent risk factor for metastasis and disease-specific death (DSD), after accounting for primary tumor stage.
“Solid organ transplant puts patients at risk for developing cutaneous squamous cell carcinoma, and it’s more likely to have aggressive features,” said study author Jason Klein, MD, PhD, a dermatology resident at University of Texas Southwestern Medical Center, Dallas. “But it’s still not known if immunosuppression is an independent risk factor.”
Other groups “have tried to tackle this, but they have all primarily been single-institution data,” he noted, adding that “results so far have been tipping the scale towards immunosuppression not being an independent risk factor” for worse outcomes.
Immunosuppressed individuals face a greater risk for cSCC than the general population and often present with more aggressive, multifocal disease. However, Dr. Klein explained that a previous retrospective study comprising a cohort of approximately 7600 tumors from two centers reported that immunosuppression was not an independent risk factor for both tumor metastasis and cancer-specific death after adjusting for tumor characteristics.
Tipped the Scale
Therefore, the goal of the current study was to repeat this analysis but in a much larger retrospective cohort. Dr. Klein and his colleagues pooled cSCC data from 12 dermatology centers (11 academic and one private) that were located in the United States, Spain, and Brazil. The cohort included 4392 patients (3769 immunocompetent patients and 623 immunosuppressed patients) with 19,237 tumors (15,191 immunocompetent and 4046 immunosuppressed). Study endpoints included local recurrence, metastasis (nodal, satellite/in-transit, and distant), DSD, and “major poor outcomes” (defined as metastasis and DSD combined).
About 30% of the immunosuppressed patients were organ transplant recipients (OTR) and 10% had chronic lymphocytic leukemia (CLL). Half of the immunocompetent patients (50.3%) underwent Mohs surgery as the primary treatment, as did 58.2% of the immunosuppressed patients.
On multivariable analysis, significant predictors of “major poor outcomes” included immunosuppression (subdistribution hazard ratio [SHR], 1.3; P = .04), Brigham and Women’s Hospital tumor stage (SHR 6.7 for T2a, 18.1 for T2b, and 37.2 for T3; P < .001 for all), location on the head/neck (SHR, 2.1; P < .001), and adjuvant radiation (SHR, 1.6; P < .001).
But when metastasis and DSD were evaluated separately, immunosuppression was only predictive of DSD (SHR, 1.7; P = .008) but not metastasis (SHR, 1.2; P = .21). Dr. Klein explained that they also conducted a separate subanalysis limited to OTR and patients with CLL, which demonstrated that immunosuppression was no longer a significant predictor of “major poor outcomes” (SHR, 0.9; P = .66 for OTR; SHR, 1.4; P = .25 for CLL).
“Organ transplant status and CLL were not independent risk factors for major poor outcomes,” he said. “But in summary, we may be tipping the scale to immunosuppression being a risk factor.”
Asked to comment on the findings, Naissan O. Wesley, MD, director of Mohs surgery, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California, stated that “this larger scale study presented at this meeting was important to further confirm what we see in everyday practice, that immunosuppression may lead to poorer outcomes in patients with cutaneous squamous cell carcinoma.”
Also weighing in on the data, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery, at the Icahn School of Medicine at Mount Sinai, New York City, noted that the treatment of cSCC in high-risk patients has been challenging because of the historical lack of data and large studies to guide management.
“The authors provide a large cohort to help stratify which patients are most at risk for poor outcomes, which can inform our decision to refer for neoadjuvant or adjuvant treatment and multi-disciplinary management,” he said. “This is the first step in being able to optimize cure in these patients.”
The study was independently supported. Dr. Klein, Dr. Lewin, and Dr. Wesley reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
PHOENIX — Immunosuppression is an independent risk factor for poorer outcomes in patients with cutaneous squamous cell carcinoma (cSCC), according to new research that was presented at the American College of Mohs Surgery (ACMS) 2024 annual meeting.
Even though immunosuppression is strongly associated with an increased risk for cSCC, studies to date have generally not shown it to be an independent risk factor for metastasis and disease-specific death (DSD), after accounting for primary tumor stage.
“Solid organ transplant puts patients at risk for developing cutaneous squamous cell carcinoma, and it’s more likely to have aggressive features,” said study author Jason Klein, MD, PhD, a dermatology resident at University of Texas Southwestern Medical Center, Dallas. “But it’s still not known if immunosuppression is an independent risk factor.”
Other groups “have tried to tackle this, but they have all primarily been single-institution data,” he noted, adding that “results so far have been tipping the scale towards immunosuppression not being an independent risk factor” for worse outcomes.
Immunosuppressed individuals face a greater risk for cSCC than the general population and often present with more aggressive, multifocal disease. However, Dr. Klein explained that a previous retrospective study comprising a cohort of approximately 7600 tumors from two centers reported that immunosuppression was not an independent risk factor for both tumor metastasis and cancer-specific death after adjusting for tumor characteristics.
Tipped the Scale
Therefore, the goal of the current study was to repeat this analysis but in a much larger retrospective cohort. Dr. Klein and his colleagues pooled cSCC data from 12 dermatology centers (11 academic and one private) that were located in the United States, Spain, and Brazil. The cohort included 4392 patients (3769 immunocompetent patients and 623 immunosuppressed patients) with 19,237 tumors (15,191 immunocompetent and 4046 immunosuppressed). Study endpoints included local recurrence, metastasis (nodal, satellite/in-transit, and distant), DSD, and “major poor outcomes” (defined as metastasis and DSD combined).
About 30% of the immunosuppressed patients were organ transplant recipients (OTR) and 10% had chronic lymphocytic leukemia (CLL). Half of the immunocompetent patients (50.3%) underwent Mohs surgery as the primary treatment, as did 58.2% of the immunosuppressed patients.
On multivariable analysis, significant predictors of “major poor outcomes” included immunosuppression (subdistribution hazard ratio [SHR], 1.3; P = .04), Brigham and Women’s Hospital tumor stage (SHR 6.7 for T2a, 18.1 for T2b, and 37.2 for T3; P < .001 for all), location on the head/neck (SHR, 2.1; P < .001), and adjuvant radiation (SHR, 1.6; P < .001).
But when metastasis and DSD were evaluated separately, immunosuppression was only predictive of DSD (SHR, 1.7; P = .008) but not metastasis (SHR, 1.2; P = .21). Dr. Klein explained that they also conducted a separate subanalysis limited to OTR and patients with CLL, which demonstrated that immunosuppression was no longer a significant predictor of “major poor outcomes” (SHR, 0.9; P = .66 for OTR; SHR, 1.4; P = .25 for CLL).
“Organ transplant status and CLL were not independent risk factors for major poor outcomes,” he said. “But in summary, we may be tipping the scale to immunosuppression being a risk factor.”
Asked to comment on the findings, Naissan O. Wesley, MD, director of Mohs surgery, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California, stated that “this larger scale study presented at this meeting was important to further confirm what we see in everyday practice, that immunosuppression may lead to poorer outcomes in patients with cutaneous squamous cell carcinoma.”
Also weighing in on the data, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery, at the Icahn School of Medicine at Mount Sinai, New York City, noted that the treatment of cSCC in high-risk patients has been challenging because of the historical lack of data and large studies to guide management.
“The authors provide a large cohort to help stratify which patients are most at risk for poor outcomes, which can inform our decision to refer for neoadjuvant or adjuvant treatment and multi-disciplinary management,” he said. “This is the first step in being able to optimize cure in these patients.”
The study was independently supported. Dr. Klein, Dr. Lewin, and Dr. Wesley reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
PHOENIX — Immunosuppression is an independent risk factor for poorer outcomes in patients with cutaneous squamous cell carcinoma (cSCC), according to new research that was presented at the American College of Mohs Surgery (ACMS) 2024 annual meeting.
Even though immunosuppression is strongly associated with an increased risk for cSCC, studies to date have generally not shown it to be an independent risk factor for metastasis and disease-specific death (DSD), after accounting for primary tumor stage.
“Solid organ transplant puts patients at risk for developing cutaneous squamous cell carcinoma, and it’s more likely to have aggressive features,” said study author Jason Klein, MD, PhD, a dermatology resident at University of Texas Southwestern Medical Center, Dallas. “But it’s still not known if immunosuppression is an independent risk factor.”
Other groups “have tried to tackle this, but they have all primarily been single-institution data,” he noted, adding that “results so far have been tipping the scale towards immunosuppression not being an independent risk factor” for worse outcomes.
Immunosuppressed individuals face a greater risk for cSCC than the general population and often present with more aggressive, multifocal disease. However, Dr. Klein explained that a previous retrospective study comprising a cohort of approximately 7600 tumors from two centers reported that immunosuppression was not an independent risk factor for both tumor metastasis and cancer-specific death after adjusting for tumor characteristics.
Tipped the Scale
Therefore, the goal of the current study was to repeat this analysis but in a much larger retrospective cohort. Dr. Klein and his colleagues pooled cSCC data from 12 dermatology centers (11 academic and one private) that were located in the United States, Spain, and Brazil. The cohort included 4392 patients (3769 immunocompetent patients and 623 immunosuppressed patients) with 19,237 tumors (15,191 immunocompetent and 4046 immunosuppressed). Study endpoints included local recurrence, metastasis (nodal, satellite/in-transit, and distant), DSD, and “major poor outcomes” (defined as metastasis and DSD combined).
About 30% of the immunosuppressed patients were organ transplant recipients (OTR) and 10% had chronic lymphocytic leukemia (CLL). Half of the immunocompetent patients (50.3%) underwent Mohs surgery as the primary treatment, as did 58.2% of the immunosuppressed patients.
On multivariable analysis, significant predictors of “major poor outcomes” included immunosuppression (subdistribution hazard ratio [SHR], 1.3; P = .04), Brigham and Women’s Hospital tumor stage (SHR 6.7 for T2a, 18.1 for T2b, and 37.2 for T3; P < .001 for all), location on the head/neck (SHR, 2.1; P < .001), and adjuvant radiation (SHR, 1.6; P < .001).
But when metastasis and DSD were evaluated separately, immunosuppression was only predictive of DSD (SHR, 1.7; P = .008) but not metastasis (SHR, 1.2; P = .21). Dr. Klein explained that they also conducted a separate subanalysis limited to OTR and patients with CLL, which demonstrated that immunosuppression was no longer a significant predictor of “major poor outcomes” (SHR, 0.9; P = .66 for OTR; SHR, 1.4; P = .25 for CLL).
“Organ transplant status and CLL were not independent risk factors for major poor outcomes,” he said. “But in summary, we may be tipping the scale to immunosuppression being a risk factor.”
Asked to comment on the findings, Naissan O. Wesley, MD, director of Mohs surgery, Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California, stated that “this larger scale study presented at this meeting was important to further confirm what we see in everyday practice, that immunosuppression may lead to poorer outcomes in patients with cutaneous squamous cell carcinoma.”
Also weighing in on the data, Jesse M. Lewin, MD, chief of Mohs micrographic and dermatologic surgery, at the Icahn School of Medicine at Mount Sinai, New York City, noted that the treatment of cSCC in high-risk patients has been challenging because of the historical lack of data and large studies to guide management.
“The authors provide a large cohort to help stratify which patients are most at risk for poor outcomes, which can inform our decision to refer for neoadjuvant or adjuvant treatment and multi-disciplinary management,” he said. “This is the first step in being able to optimize cure in these patients.”
The study was independently supported. Dr. Klein, Dr. Lewin, and Dr. Wesley reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM ACMS 2024