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Mohs Surgery
by Ashley Cafferty
As a PA student, I distinctly remember a lecture during the dermatology module on Mohs surgery. I would never have predicted that several years later I would be very familiar with almost every aspect of this sub-specialty. For the past three years, I have worked under the supervision of Teri Cottingham, MD, a Fellowship Trained Mohs surgeon in Boise. While I do some general dermatology, the majority of my days are spent reviewing, preparing, assisting, and closing surgeries.
Mohs surgery was developed by Fredrick Mohs, MD, a general surgeon at the University of Wisconsin. The procedure involves surgical removal of a skin cancer in such a manner that the all of the skin edges and undersurface can be examined under the microscope. First, the lesion is identified, anesthetized, and scraped with a curette to better define the borders. Next, the specimen is removed with a scalpel and taken to the lab where it is cut into multiple sections and marked with ink according to the diagram drawn on the map of the site. The tissue is then frozen in a cryostat machine and cut into numerous thin layers that are placed on slides and dyed. Dr. Cottingham then reads the slides and indicates any positive margins on the map. The patient is then either prepared for another layer to be taken or for a repair. Most patients at our office clear after one or two layers but I have seen as many as six to ten.
Mohs surgery is indicated for the following situations:
• High risk anatomic location for recurrence. This includes the face, head, hands and feet.
• Aggressive tumor histology such as infiltrating or morpheaform BCCs and poorly differentiated SCCs.
• Large tumor size (anything over 2 cm).
• Need for tissue sparing (such as the lower legs in elderly patients).
• Recurrent lesion.
• Incompletely excised lesion.
• Indistinct clinical margins.
I would like to offer the following suggestions when you have made the decision to send a patient for Mohs surgery:
Tell your patients that Mohs surgery can take a long time. I cannot stress enough the importance of preparing your patient for that possibility. The most common statement we hear: "I just had no idea this would take so long." Patients are much more familiar with quick appointments and speedy outpatient surgeries. Mohs surgery is not a quick procedure.
Become familiar with the process and procedures of the clinic that you are referring to. Does the physician see the patient for a consultation prior to the surgery? Where will the patient be waiting between layers? Does the physician have nurses/PAs/NPs that will be assisting throughout the process? If it is at all possible, spend a couple hours observing some Mohs surgeries and repairs.
Talk to the patient briefly about their diagnosis and the need for referral to a Mohs surgeon. How is a BCC different from an SCC, etc? Why can you excise the one on the back but not the nose? I highly recommend when referring a patient that you personally talk to them about why they are being referred and briefly explain the process.
Mohs surgery is a very challenging but rewarding area of medicine. Despite the occasional long days, I thoroughly enjoy coming to work and am glad that this opportunity came my way. If you have any questions about Mohs surgery please contact me at: abcafferty@yahoo.com. 
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Beware Assumption
by Kent Whitaker
Two patients in recent history stand out as examples of the need in medicine, especially in dermatology, to not be led astray by assumption.
The first patient was a middle aged man seen with a chief complaint of a cyst on the scalp that had been previously drained by his family physician. The cyst had never totally cleared and he now wanted it excised. The examination seemed to confirm the diagnosis, however, the 2.5 cm nodule seemed deeper and more firmly attached to the underlying tissue than what would be expected with an epidermoid type cyst. The preliminary diagnosis was changed to possible lipoma and the patient was rescheduled in a week for excision. When the surgery was done, it became obvious quickly that this was neither a cyst, or lipoma, but a vascular fatty mass that turned out to be a desmoplastic melanoma.
The second patient was a 75 year-old gentleman who came in for a yearly examination, primarily to treat his considerable AK's. His history was negative for previous skin cancers. He had a thick head of pure white hair, with the exception of a dark plug of hair near the scalp vertex. The patient stated that it had been seen by other providers as well as his barber, who all told him that it was nothing to worry about. The diagnoses had ranged from a birthmark to vitiligo, piebaldism and poliosis. Regardless, the patient had been told by several trusted sources not to worry about it. The scalp under the dark hairs was also deeply pigmented.
Despite mild objections from the patient, the area was punch-biopsied and diagnosed as malignant melanoma.
The point of these cases is to reinforce the idea that we should never be lead to a diagnosis based on previous diagnoses or on the patient's own beliefs. Always approach each patient following the same model of a thorough history and examination.
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Delusions of Parasitosis
by Kent Whitaker
You've all had them. Patients who arrive at their appointment with a baggie full of small items that they claim were crawling out of their skin. You obligingly look at them under the microscope and find not bugs, but small crusts, pieces of skin and various pieces of lint, hair, or thread. The patient has the dreaded "delusions of parasitosis". Frustratingly, if you hint that it may be psychological, that there is no way that bugs could be living and breeding in their body, they immediately lump you into the category of non-believers and if you're not careful, they are off to their next provider to see if he/she will believe them.
At issue is the question of whether to treat the patient with a placebo cream, telling them that it's actually a very powerful bug killer, or do you treat it for what it is…a psychological disorder? Adding to the difficulty are shows on TV such as "Monsters Inside Me" which further cement the idea in these patients that they are infested. Often times, the spouse or significant other is also drawn into it, having to deal with the delusions on an ongoing basis. Personally, I have had roughly 5 of these patients during my career and none of them have been easy to treat. Most have ended up getting frustrated and moving on to other providers. This could be because I am reluctant to treat a patient with antipsychotics as I have very little experience with them.
Officially, it is labeled as a monosymptomatic hypochondriacal psychosis. It has been linked to schizophrenia, obsessive/compulsiveness, depression, anxiety and bipolar disorder. Some have found help by using the term "Morgellon disease" which was initially used to describe a condition characterized by fibers attached to the skin. It seems that term is better tolerated by the patient than "delusions". The name does seem to be a hindrance to treatment as others have also proposed different names for the condition that do not imply a psychogenic etiology.
Regarding treatment, most experts agree that you should never give a patient a medication telling them that "it will kill the bugs" as that only reinforces the delusion. Sometimes treatment can be as simple as a topical steroid to stop the itchy feeling. Resperidone (Resperdal) and olanzapine (Zyprexa) are the two current medications of choice. Pimozide (Orap) is also indicated, however it has an increased risk of extrapyramidal symptoms.
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Sunscreens
by Kent Whitaker
I've been following the state of sunscreens in the U.S. now for several years and like everyone, have been waiting for the new FDA monograph and changes in labeling which were supposed to be out in May, but have been postponed to later in the year (2010). We can only hope that there will finally be some sensible changes to take some of the confusion out of purchasing a good quality sunscreen.
In general, the debate around sunscreens does not appear to be dying down. There are several issues that continually come up in the literature regarding the safety of sunscreens in general. The primary issue is whether or not the chemicals used in sunscreens actually increase the risk for skin and other cancers. It is known that modern sunscreens effectively block both UVA and UVB, but research has shown that the same chemicals are powerful generators of free radicals. Free radicals are known to alter DNA which can then lead to cancer. Sunscreens easily penetrate into the skin and potentially into the bloodstream creating the possibility of free-radical formation in other organ systems.
A second concern is the "cosmetics" of sunscreens. I frequently have patients tell me they won't use sunscreens on their face because it gets in their eyes and burns. Another big issue is staining. I received a valuable tip from my brother, who did some home research and made a nice discovery. He couldn't remember the source of the article, but it discussed how sunscreens have a habit of turning white clothing an orange color. The basic problem is the ingredient avobenzone which is used as a UVA blocker. If the patient uses a sunscreen with avobenzone and it gets on white clothing and the garment is washed in water that has iron, the avobenzone oxidizes the iron during washing, leaving an orange stain where the sunscreen was on the clothing.
Conversely, if the water is low in iron, no staining occurs.
While the debate goes on regarding the safety of sunscreens, we should be continue to promote safe sun habits such as wide brimmed hats, protective clothing, and avoiding exposure during the most intense UV daylight hours of 10am to 4pm. I heard a nice pearl once, "If your shadow is shorter than you are, that's when you need to seek protection".
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Drug Review: Zyclara®
Zyclara® (imiquimod) 3.75% cream new option for the treatment of actinic keratoses
by Mariya Ostermiller
Topical Aldara® (imiquimod) 5% therapy, an interferon inducing immune stimulator used to treat actinic keratoses, has been implemented to produce the desired clearance of the lesions, however subsequently often results in varied degrees of localized erythema, crusting, pruritis, scaling, weeping, edema and tenderness of the skin at the application site. Less frequently, some experience fever, fatigue, headache, dizziness or nausea. Typically, the therapy is applied to the desired location three days a week for a period of 6-8 weeks.
While the clearance rates with this application method have proven to be effective, the lower strength formulation of the Zyclara® (imiquimod) 3.75% cream from Graceway Pharmaceuticals provides practitioners one more option for those patients who cannot seem to complete this regimen due to the typical local skin reactions listed above.
Zyclara® cream is generally applied to the desired areas daily for two weeks, and then the patient is allowed a two week break period from the Zyclara® therapy, allowing the skin to recover from localized reactions. This break period is then followed by another two weeks of daily Zyclara® application. The cream may be applied to large areas up to 25cm2.
The clearance rates of the Zyclara® are similar to that of the original Aldara (imiquimod) 5% cream, but for some patients the Zyclara® is better tolerated, and subsequently has the potential to produce better compliance to the therapy with improved overall results. Graceway pharmaceuticals has also issued a patient savings card available to those eligible, stating most patients pay $10 for the prescription.
Zyclara® is also being studied to treat external genital warts; however the cream is currently indicated for use on the face or balding scalp. On July 9th, 2010 Phase III clinical trials showed patients who applied Zyclara® once daily for eight weeks to external genital warts had a 33.8% clearance rate, compared to 11.5% with placebo. According to reports, the patients experienced minimal irritation and compliance to completion of therapy was high. While Zyclara® inevitably has its limitations; it does offer one more tool for practitioners to choose the right therapy for the appropriate patient, especially those who would prefer a two week recovery period during the imiquimod therapeutic process.
References:
1. Merion Matters. © 2010. May 28th, 2010. healthy-aging.advanceweb.com/News/News-Watch/FDA-Approves-Zyclara.aspx
2. Drugs.com/Zyclara.html. © 2000-2010. May 25th, 2010.
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