Dermatologic Surgery

DENVER – Simultaneous use of high intensity focused electromagnetic field (HIFEM) and radiofrequency (RF) was safe and effective for muscle toning and fat reduction in the upper arm area, according to results from a study that analyzed results with MRI and other measures at two dermatology practices.

Simultaneous use of HIFEM and RF has been shown to be safe and effective “for fat reduction and muscle toning in various body parts,” lead study author Carolyn Jacob, MD, founder and director of Chicago Cosmetic Surgery and Dermatology, wrote in an abstract presented at the annual meeting of the American Society for Dermatologic Surgery. This study investigated the effect of the HIFEM and RF procedure on muscle toning and adipose tissue in the upper arms.

In what Dr. Jacob described as the first study of its kind because magnetic resonance imaging (MRI) was used to evaluate results, she and her coauthors enrolled 34 patients aged 23-72 years at two centers who had a BMI in the range of 18.5-33.9 kg/m². The patients underwent four 30-minute bilateral procedures over the upper arms spaced 1 week apart with the Emsculpt NEO (BTL Aesthetics), which simultaneously delivers HIFEM and RF therapy.

NEO small sized applicators were used, which at the time of the study were under investigation but have since been cleared for use with the device. According to the manufacturer’s website, Emsculpt NEO is indicated for noninvasive lipolysis of the abdomen and thighs and reduction in the circumference of the abdomen and thighs in patients with skin types I-VI; and for noninvasive lipolysis of the upper arms “limited to skin types II and III and BMI 30 or under.”

The investigators measured changes in fat and triceps muscle tissue via MRI at baseline, 1-month, and 3-month follow-up visits. They also obtained digital photographs, administered patient questionnaires regarding comfort and satisfaction, and monitored safety of the treatments.

Of the 28 patients who completed their 1-month follow-up visit, analysis of MRI images showed a 22.3% average decrease in fat tissue from baseline MRIs (a decrease of 4.0 ± 1.2 mm; P < .01) and a 21.5% average increase in muscle mass (an increase of 8.2 ± 2.3 mm; P < .001). For the 25 patients who completed their 3-month follow-up visit, analysis of MRI images showed a 25.5% average decrease in fat tissue (a decrease of 4.9 ± 1.5 mm; P < .01) and a 23.9% average increase in muscle mass (an increase of 8.9 ± 2.0 mm; P < .001).

The analysis of questionnaires revealed high patient satisfaction with the results (87.1%), high comfort during the treatment (91.2%), and a low Visual Analogue Scale (VAS) score (1.6 ± 2.0) used to evaluate pain.

“This study shows that HIFEM and RF consistently increases muscle and decreases fat,” Dr. Jacob said in an interview. “It’s the only study on the triceps showing MRI evidence of fat loss with a nonsurgical body shaping device.”

She characterized the learning curve for the Emsculpt NEO as “small, as the previous Emsculpt small applicators have a similar fit.”

Pooja Sodha, MD, director of the center for laser and cosmetic dermatology at George Washington University, Washington, who was asked to comment on the study, said that the combination of radiofrequency energy and high-intensity focused electromagnetic technology triggers heat-induced damage of adipose tissue and muscle strengthening, respectively, to improve overall appearance and tone.

“Simultaneous delivery is the key here, and the real technological superhero, allowing us to take advantage of the synergistic effects of the muscle contractions and the tissue heating,” Dr. Sodha told this news organization. “Earlier this year, we saw published data on success with abdominal contouring with similar fat reduction and muscle enhancement as reported in this study, and these results persisted at 6 months,” with some declines noted at that time, she said.

“It is very encouraging and exciting to have similar effectiveness and safety for the arms, with such high satisfaction and comfort,” she added.

Dr. Jacob disclosed that she has conducted research studies for BTL Aesthetics since 2017 and is a member of the company’s advisory board. Dr. Sodha reported having no financial disclosures.

DENVER – Simultaneous use of high intensity focused electromagnetic field (HIFEM) and radiofrequency (RF) was safe and effective for muscle toning and fat reduction in the upper arm area, according to results from a study that analyzed results with MRI and other measures at two dermatology practices.

Simultaneous use of HIFEM and RF has been shown to be safe and effective “for fat reduction and muscle toning in various body parts,” lead study author Carolyn Jacob, MD, founder and director of Chicago Cosmetic Surgery and Dermatology, wrote in an abstract presented at the annual meeting of the American Society for Dermatologic Surgery. This study investigated the effect of the HIFEM and RF procedure on muscle toning and adipose tissue in the upper arms.

In what Dr. Jacob described as the first study of its kind because magnetic resonance imaging (MRI) was used to evaluate results, she and her coauthors enrolled 34 patients aged 23-72 years at two centers who had a BMI in the range of 18.5-33.9 kg/m². The patients underwent four 30-minute bilateral procedures over the upper arms spaced 1 week apart with the Emsculpt NEO (BTL Aesthetics), which simultaneously delivers HIFEM and RF therapy.

NEO small sized applicators were used, which at the time of the study were under investigation but have since been cleared for use with the device. According to the manufacturer’s website, Emsculpt NEO is indicated for noninvasive lipolysis of the abdomen and thighs and reduction in the circumference of the abdomen and thighs in patients with skin types I-VI; and for noninvasive lipolysis of the upper arms “limited to skin types II and III and BMI 30 or under.”

The investigators measured changes in fat and triceps muscle tissue via MRI at baseline, 1-month, and 3-month follow-up visits. They also obtained digital photographs, administered patient questionnaires regarding comfort and satisfaction, and monitored safety of the treatments.

Of the 28 patients who completed their 1-month follow-up visit, analysis of MRI images showed a 22.3% average decrease in fat tissue from baseline MRIs (a decrease of 4.0 ± 1.2 mm; P < .01) and a 21.5% average increase in muscle mass (an increase of 8.2 ± 2.3 mm; P < .001). For the 25 patients who completed their 3-month follow-up visit, analysis of MRI images showed a 25.5% average decrease in fat tissue (a decrease of 4.9 ± 1.5 mm; P < .01) and a 23.9% average increase in muscle mass (an increase of 8.9 ± 2.0 mm; P < .001).

The analysis of questionnaires revealed high patient satisfaction with the results (87.1%), high comfort during the treatment (91.2%), and a low Visual Analogue Scale (VAS) score (1.6 ± 2.0) used to evaluate pain.

“This study shows that HIFEM and RF consistently increases muscle and decreases fat,” Dr. Jacob said in an interview. “It’s the only study on the triceps showing MRI evidence of fat loss with a nonsurgical body shaping device.”

She characterized the learning curve for the Emsculpt NEO as “small, as the previous Emsculpt small applicators have a similar fit.”

Pooja Sodha, MD, director of the center for laser and cosmetic dermatology at George Washington University, Washington, who was asked to comment on the study, said that the combination of radiofrequency energy and high-intensity focused electromagnetic technology triggers heat-induced damage of adipose tissue and muscle strengthening, respectively, to improve overall appearance and tone.

“Simultaneous delivery is the key here, and the real technological superhero, allowing us to take advantage of the synergistic effects of the muscle contractions and the tissue heating,” Dr. Sodha told this news organization. “Earlier this year, we saw published data on success with abdominal contouring with similar fat reduction and muscle enhancement as reported in this study, and these results persisted at 6 months,” with some declines noted at that time, she said.

“It is very encouraging and exciting to have similar effectiveness and safety for the arms, with such high satisfaction and comfort,” she added.

Dr. Jacob disclosed that she has conducted research studies for BTL Aesthetics since 2017 and is a member of the company’s advisory board. Dr. Sodha reported having no financial disclosures.

DENVER – Simultaneous use of high intensity focused electromagnetic field (HIFEM) and radiofrequency (RF) was safe and effective for muscle toning and fat reduction in the upper arm area, according to results from a study that analyzed results with MRI and other measures at two dermatology practices.

Simultaneous use of HIFEM and RF has been shown to be safe and effective “for fat reduction and muscle toning in various body parts,” lead study author Carolyn Jacob, MD, founder and director of Chicago Cosmetic Surgery and Dermatology, wrote in an abstract presented at the annual meeting of the American Society for Dermatologic Surgery. This study investigated the effect of the HIFEM and RF procedure on muscle toning and adipose tissue in the upper arms.

In what Dr. Jacob described as the first study of its kind because magnetic resonance imaging (MRI) was used to evaluate results, she and her coauthors enrolled 34 patients aged 23-72 years at two centers who had a BMI in the range of 18.5-33.9 kg/m². The patients underwent four 30-minute bilateral procedures over the upper arms spaced 1 week apart with the Emsculpt NEO (BTL Aesthetics), which simultaneously delivers HIFEM and RF therapy.

NEO small sized applicators were used, which at the time of the study were under investigation but have since been cleared for use with the device. According to the manufacturer’s website, Emsculpt NEO is indicated for noninvasive lipolysis of the abdomen and thighs and reduction in the circumference of the abdomen and thighs in patients with skin types I-VI; and for noninvasive lipolysis of the upper arms “limited to skin types II and III and BMI 30 or under.”

The investigators measured changes in fat and triceps muscle tissue via MRI at baseline, 1-month, and 3-month follow-up visits. They also obtained digital photographs, administered patient questionnaires regarding comfort and satisfaction, and monitored safety of the treatments.

Of the 28 patients who completed their 1-month follow-up visit, analysis of MRI images showed a 22.3% average decrease in fat tissue from baseline MRIs (a decrease of 4.0 ± 1.2 mm; P < .01) and a 21.5% average increase in muscle mass (an increase of 8.2 ± 2.3 mm; P < .001). For the 25 patients who completed their 3-month follow-up visit, analysis of MRI images showed a 25.5% average decrease in fat tissue (a decrease of 4.9 ± 1.5 mm; P < .01) and a 23.9% average increase in muscle mass (an increase of 8.9 ± 2.0 mm; P < .001).

The analysis of questionnaires revealed high patient satisfaction with the results (87.1%), high comfort during the treatment (91.2%), and a low Visual Analogue Scale (VAS) score (1.6 ± 2.0) used to evaluate pain.

“This study shows that HIFEM and RF consistently increases muscle and decreases fat,” Dr. Jacob said in an interview. “It’s the only study on the triceps showing MRI evidence of fat loss with a nonsurgical body shaping device.”

She characterized the learning curve for the Emsculpt NEO as “small, as the previous Emsculpt small applicators have a similar fit.”

Pooja Sodha, MD, director of the center for laser and cosmetic dermatology at George Washington University, Washington, who was asked to comment on the study, said that the combination of radiofrequency energy and high-intensity focused electromagnetic technology triggers heat-induced damage of adipose tissue and muscle strengthening, respectively, to improve overall appearance and tone.

“Simultaneous delivery is the key here, and the real technological superhero, allowing us to take advantage of the synergistic effects of the muscle contractions and the tissue heating,” Dr. Sodha told this news organization. “Earlier this year, we saw published data on success with abdominal contouring with similar fat reduction and muscle enhancement as reported in this study, and these results persisted at 6 months,” with some declines noted at that time, she said.

“It is very encouraging and exciting to have similar effectiveness and safety for the arms, with such high satisfaction and comfort,” she added.

Dr. Jacob disclosed that she has conducted research studies for BTL Aesthetics since 2017 and is a member of the company’s advisory board. Dr. Sodha reported having no financial disclosures.

DENVER – Successful treatment of superficial and nodular basal cell cancers can be achieved using apoptosis induced by controlled hyperthermia, preliminary results from an ongoing study suggest.

At the annual meeting of the American Society for Dermatologic Surgery, Christopher Zachary, MD, and colleagues described a novel, noninvasive standardized controlled hyperthermia and mapping protocol (CHAMP) designed to help clinicians with margin assessment and treatment of superficial and nodular basal cell cancers (BCCs). “There’s considerable interest on the part of the public in having CHAMP treatment for their BCCs,” Dr. Zachary, professor and chair emeritus, University of California, Irvine, told this news organization in advance of the meeting.

In both study arms, the majority of patients enrolled to date have been found to be free of tumor at 3 months by clinical and OCT examination. “The study is ongoing, but the current numbers indicate that 9 out of 10 superficial and nodular BCCs are free of tumor at 3-12 months after the last treatment,” Dr. Zachary said. The standard-treatment arm, where tissue was treated to a gray color with tissue contraction, generally resulted in more blistering and tissue necrosis with prolonged healing, compared with the Low and Slow–controlled hyperthermia arm. BCC lesions treated in the controlled hyperthermia arm had a lilac gray color with “a surprising increase” in the Doppler blood flow rate, compared with those in the standard-treatment arm, he noted.

“Blood flow following the standard technique is dramatically reduced immediately post treatment, which accounts in part for the frequent ulceration and slow healing in that group,” Dr. Zachary said.

He acknowledged certain limitations of the study, including its relatively small sample size and the fact that the optimal treatment parameters of the Low and Slow technique have yet to be realized. “It could be that we will achieve better results at 50º C for 70 seconds or similar,” he said. “While this technique will not in any way reduce the great benefits of Mohs surgery for complex BCCs, it will benefit those with simpler superficial and nodular BCCs, particularly in those who are not good surgical candidates.”

As an aside, Dr. Zachary supports the increased use of OCT scanners to improve the ability to diagnose and assess the lateral and deep margins of skin cancers. “I think that all dermatology residents should understand how to use these devices,” he said. “I’m convinced they are going to be useful in their clinical practice in the future.”

Keith L. Duffy, MD, who was asked to comment on the work, said that the study demonstrates novel ways to use existing and developing technologies in dermatology and highlights the intersection of aesthetic, surgical, and medical dermatology. “CHAMP is promising as shown by the data in the abstract and I am eager to see the final results of the study with an eye toward final cure rate and cosmesis,” said Dr. Duffy, associate professor of dermatology at the University of Utah, Salt Lake City.

“In my estimation, this technology will need to prove to be superior in one or both of these parameters in order to be considered a first- or second-line therapy,” he added. “My practice for these types of basal cell carcinomas is a simple one pass of curettage with aluminum chloride or pressure for hemostasis. The healing is fast, the cosmesis is excellent, and the cure rate is more than 90% for this simple in-office destruction. However, for those with access to this technology and proficiency with its use, CHAMP may become a viable alternative to our existing destructive methods. I look forward to seeing the published results of this multicenter trial.”

This study is being funded by Michelson Diagnostics. Sciton provided the long-pulsed 1,064-nm lasers devices being used in the trial. Neither Dr. Zachary nor Dr. Duffy reported having relevant disclosures.
 

DENVER – Successful treatment of superficial and nodular basal cell cancers can be achieved using apoptosis induced by controlled hyperthermia, preliminary results from an ongoing study suggest.

At the annual meeting of the American Society for Dermatologic Surgery, Christopher Zachary, MD, and colleagues described a novel, noninvasive standardized controlled hyperthermia and mapping protocol (CHAMP) designed to help clinicians with margin assessment and treatment of superficial and nodular basal cell cancers (BCCs). “There’s considerable interest on the part of the public in having CHAMP treatment for their BCCs,” Dr. Zachary, professor and chair emeritus, University of California, Irvine, told this news organization in advance of the meeting.

In both study arms, the majority of patients enrolled to date have been found to be free of tumor at 3 months by clinical and OCT examination. “The study is ongoing, but the current numbers indicate that 9 out of 10 superficial and nodular BCCs are free of tumor at 3-12 months after the last treatment,” Dr. Zachary said. The standard-treatment arm, where tissue was treated to a gray color with tissue contraction, generally resulted in more blistering and tissue necrosis with prolonged healing, compared with the Low and Slow–controlled hyperthermia arm. BCC lesions treated in the controlled hyperthermia arm had a lilac gray color with “a surprising increase” in the Doppler blood flow rate, compared with those in the standard-treatment arm, he noted.

“Blood flow following the standard technique is dramatically reduced immediately post treatment, which accounts in part for the frequent ulceration and slow healing in that group,” Dr. Zachary said.

He acknowledged certain limitations of the study, including its relatively small sample size and the fact that the optimal treatment parameters of the Low and Slow technique have yet to be realized. “It could be that we will achieve better results at 50º C for 70 seconds or similar,” he said. “While this technique will not in any way reduce the great benefits of Mohs surgery for complex BCCs, it will benefit those with simpler superficial and nodular BCCs, particularly in those who are not good surgical candidates.”

As an aside, Dr. Zachary supports the increased use of OCT scanners to improve the ability to diagnose and assess the lateral and deep margins of skin cancers. “I think that all dermatology residents should understand how to use these devices,” he said. “I’m convinced they are going to be useful in their clinical practice in the future.”

Keith L. Duffy, MD, who was asked to comment on the work, said that the study demonstrates novel ways to use existing and developing technologies in dermatology and highlights the intersection of aesthetic, surgical, and medical dermatology. “CHAMP is promising as shown by the data in the abstract and I am eager to see the final results of the study with an eye toward final cure rate and cosmesis,” said Dr. Duffy, associate professor of dermatology at the University of Utah, Salt Lake City.

“In my estimation, this technology will need to prove to be superior in one or both of these parameters in order to be considered a first- or second-line therapy,” he added. “My practice for these types of basal cell carcinomas is a simple one pass of curettage with aluminum chloride or pressure for hemostasis. The healing is fast, the cosmesis is excellent, and the cure rate is more than 90% for this simple in-office destruction. However, for those with access to this technology and proficiency with its use, CHAMP may become a viable alternative to our existing destructive methods. I look forward to seeing the published results of this multicenter trial.”

This study is being funded by Michelson Diagnostics. Sciton provided the long-pulsed 1,064-nm lasers devices being used in the trial. Neither Dr. Zachary nor Dr. Duffy reported having relevant disclosures.
 

DENVER – Successful treatment of superficial and nodular basal cell cancers can be achieved using apoptosis induced by controlled hyperthermia, preliminary results from an ongoing study suggest.

At the annual meeting of the American Society for Dermatologic Surgery, Christopher Zachary, MD, and colleagues described a novel, noninvasive standardized controlled hyperthermia and mapping protocol (CHAMP) designed to help clinicians with margin assessment and treatment of superficial and nodular basal cell cancers (BCCs). “There’s considerable interest on the part of the public in having CHAMP treatment for their BCCs,” Dr. Zachary, professor and chair emeritus, University of California, Irvine, told this news organization in advance of the meeting.

In both study arms, the majority of patients enrolled to date have been found to be free of tumor at 3 months by clinical and OCT examination. “The study is ongoing, but the current numbers indicate that 9 out of 10 superficial and nodular BCCs are free of tumor at 3-12 months after the last treatment,” Dr. Zachary said. The standard-treatment arm, where tissue was treated to a gray color with tissue contraction, generally resulted in more blistering and tissue necrosis with prolonged healing, compared with the Low and Slow–controlled hyperthermia arm. BCC lesions treated in the controlled hyperthermia arm had a lilac gray color with “a surprising increase” in the Doppler blood flow rate, compared with those in the standard-treatment arm, he noted.

“Blood flow following the standard technique is dramatically reduced immediately post treatment, which accounts in part for the frequent ulceration and slow healing in that group,” Dr. Zachary said.

He acknowledged certain limitations of the study, including its relatively small sample size and the fact that the optimal treatment parameters of the Low and Slow technique have yet to be realized. “It could be that we will achieve better results at 50º C for 70 seconds or similar,” he said. “While this technique will not in any way reduce the great benefits of Mohs surgery for complex BCCs, it will benefit those with simpler superficial and nodular BCCs, particularly in those who are not good surgical candidates.”

As an aside, Dr. Zachary supports the increased use of OCT scanners to improve the ability to diagnose and assess the lateral and deep margins of skin cancers. “I think that all dermatology residents should understand how to use these devices,” he said. “I’m convinced they are going to be useful in their clinical practice in the future.”

Keith L. Duffy, MD, who was asked to comment on the work, said that the study demonstrates novel ways to use existing and developing technologies in dermatology and highlights the intersection of aesthetic, surgical, and medical dermatology. “CHAMP is promising as shown by the data in the abstract and I am eager to see the final results of the study with an eye toward final cure rate and cosmesis,” said Dr. Duffy, associate professor of dermatology at the University of Utah, Salt Lake City.

“In my estimation, this technology will need to prove to be superior in one or both of these parameters in order to be considered a first- or second-line therapy,” he added. “My practice for these types of basal cell carcinomas is a simple one pass of curettage with aluminum chloride or pressure for hemostasis. The healing is fast, the cosmesis is excellent, and the cure rate is more than 90% for this simple in-office destruction. However, for those with access to this technology and proficiency with its use, CHAMP may become a viable alternative to our existing destructive methods. I look forward to seeing the published results of this multicenter trial.”

This study is being funded by Michelson Diagnostics. Sciton provided the long-pulsed 1,064-nm lasers devices being used in the trial. Neither Dr. Zachary nor Dr. Duffy reported having relevant disclosures.
 

DENVER – Highly purified liquid injectable silicone is a safe and effective permanent treatment for acne scarring in all skin types, including darker skin types, results from a recent study showed.

“Acne is pervasive, and acne scarring disproportionately affects darker skin types,” lead study author Nicole Salame, MD, told this news organization in advance of the annual meeting of the American Society for Dermatologic Surgery, where she presented the results of the study. “Treatment of acne scarring in darker skin is also particularly challenging since resurfacing can be problematic. Numerous treatment options exist but vary in effectiveness, sustainability, and side-effect profile, especially for patients with darker skin.”

Highly purified liquid injectable silicone (also known as LIS) is approved by the Food and Drug Administration for treating intraocular tamponade of retinal detachment, and has been used off label for skin augmentation. A 2005 study of LIS for five patients with acne scarring, with up to 30 years of follow-up, showed efficacy and preservation of product without complications for depressed, broad-based acne scars .

“Use of LIS as a permanent treatment for acne scarring in darker skin types has yet to be evaluated,” said Dr. Salame, a 4th-year dermatology resident at Emory University, Atlanta. “Our study is the first to retrospectively evaluate the safety and efficacy of highly purified LIS for the treatment of acne scars in all skin types.”

Dr. Salame and coauthor Harold J. Brody, MD, evaluated the charts of 96 patients with a mean age of 51 years who received highly purified LIS for the treatment of acne scars at Dr. Brody’s Atlanta-based private dermatology practice between July 2010 and March 2021. Of the 96 patients, 31 had darker skin types (20 were Fitzpatrick skin type IV and 11 were Fitzpatrick skin type V). Dr. Brody performed all treatments: a total of 206 in the 96 patients.

The average time of follow-up was 6.31 years; 19 patients had a follow-up of 1-3 years, 25 had a follow-up of 3-5 years, and 52 had a follow-up of greater than 5 years. The researchers did not observe any complications along the course of the patients’ treatments, and no patients reported complications or dissatisfaction with treatment.

“Among the most impressive findings of our study was the permanence of effectiveness of LIS for acne scarring in patients who had treatment over a decade before,” Dr. Salame said. “Our longest follow up was 12 years. These patients continued to show improvement in their acne scarring years after treatment with LIS, even as they lost collagen and volume in their face with advancing age.”

In addition, she said, none of the patients experienced complications of granulomatous reactions, migration, or extrusion of product, which were previously documented with the use of macrodroplet injectable silicone techniques. “This is likely due to the consistent use of the microdroplet injection technique in our study – less than 0.01 cc per injection at minimum 6- to 8-week intervals or more,” Dr. Salame said.

Lawrence J. Green, MD, of the department of dermatology at George Washington University, Washington, who was asked to comment on the study, said that the findings “show safety and durability of highly purified microdroplet liquid silicone to treat acne scars. The numbers of patients reviewed are small and selective (one highly skilled dermatologist), but with the right material (highly purified liquid silicone) and in a qualified and experienced physician’s hand, this treatment seems like a great option.”

Dr. Salame acknowledged certain limitations of the study, including its single-center, retrospective design. “Future prospective studies with larger patient populations of all skin types recruited from multiple centers may be needed,” she said.

The researchers reported having no relevant conflicts of interest or funding sources to disclose. Dr. Green disclosed that he is a speaker, consultant, or investigator for numerous pharmaceutical companies.

DENVER – Highly purified liquid injectable silicone is a safe and effective permanent treatment for acne scarring in all skin types, including darker skin types, results from a recent study showed.

“Acne is pervasive, and acne scarring disproportionately affects darker skin types,” lead study author Nicole Salame, MD, told this news organization in advance of the annual meeting of the American Society for Dermatologic Surgery, where she presented the results of the study. “Treatment of acne scarring in darker skin is also particularly challenging since resurfacing can be problematic. Numerous treatment options exist but vary in effectiveness, sustainability, and side-effect profile, especially for patients with darker skin.”

Highly purified liquid injectable silicone (also known as LIS) is approved by the Food and Drug Administration for treating intraocular tamponade of retinal detachment, and has been used off label for skin augmentation. A 2005 study of LIS for five patients with acne scarring, with up to 30 years of follow-up, showed efficacy and preservation of product without complications for depressed, broad-based acne scars .

“Use of LIS as a permanent treatment for acne scarring in darker skin types has yet to be evaluated,” said Dr. Salame, a 4th-year dermatology resident at Emory University, Atlanta. “Our study is the first to retrospectively evaluate the safety and efficacy of highly purified LIS for the treatment of acne scars in all skin types.”

Dr. Salame and coauthor Harold J. Brody, MD, evaluated the charts of 96 patients with a mean age of 51 years who received highly purified LIS for the treatment of acne scars at Dr. Brody’s Atlanta-based private dermatology practice between July 2010 and March 2021. Of the 96 patients, 31 had darker skin types (20 were Fitzpatrick skin type IV and 11 were Fitzpatrick skin type V). Dr. Brody performed all treatments: a total of 206 in the 96 patients.

The average time of follow-up was 6.31 years; 19 patients had a follow-up of 1-3 years, 25 had a follow-up of 3-5 years, and 52 had a follow-up of greater than 5 years. The researchers did not observe any complications along the course of the patients’ treatments, and no patients reported complications or dissatisfaction with treatment.

“Among the most impressive findings of our study was the permanence of effectiveness of LIS for acne scarring in patients who had treatment over a decade before,” Dr. Salame said. “Our longest follow up was 12 years. These patients continued to show improvement in their acne scarring years after treatment with LIS, even as they lost collagen and volume in their face with advancing age.”

In addition, she said, none of the patients experienced complications of granulomatous reactions, migration, or extrusion of product, which were previously documented with the use of macrodroplet injectable silicone techniques. “This is likely due to the consistent use of the microdroplet injection technique in our study – less than 0.01 cc per injection at minimum 6- to 8-week intervals or more,” Dr. Salame said.

Lawrence J. Green, MD, of the department of dermatology at George Washington University, Washington, who was asked to comment on the study, said that the findings “show safety and durability of highly purified microdroplet liquid silicone to treat acne scars. The numbers of patients reviewed are small and selective (one highly skilled dermatologist), but with the right material (highly purified liquid silicone) and in a qualified and experienced physician’s hand, this treatment seems like a great option.”

Dr. Salame acknowledged certain limitations of the study, including its single-center, retrospective design. “Future prospective studies with larger patient populations of all skin types recruited from multiple centers may be needed,” she said.

The researchers reported having no relevant conflicts of interest or funding sources to disclose. Dr. Green disclosed that he is a speaker, consultant, or investigator for numerous pharmaceutical companies.

DENVER – Highly purified liquid injectable silicone is a safe and effective permanent treatment for acne scarring in all skin types, including darker skin types, results from a recent study showed.

“Acne is pervasive, and acne scarring disproportionately affects darker skin types,” lead study author Nicole Salame, MD, told this news organization in advance of the annual meeting of the American Society for Dermatologic Surgery, where she presented the results of the study. “Treatment of acne scarring in darker skin is also particularly challenging since resurfacing can be problematic. Numerous treatment options exist but vary in effectiveness, sustainability, and side-effect profile, especially for patients with darker skin.”

Highly purified liquid injectable silicone (also known as LIS) is approved by the Food and Drug Administration for treating intraocular tamponade of retinal detachment, and has been used off label for skin augmentation. A 2005 study of LIS for five patients with acne scarring, with up to 30 years of follow-up, showed efficacy and preservation of product without complications for depressed, broad-based acne scars .

“Use of LIS as a permanent treatment for acne scarring in darker skin types has yet to be evaluated,” said Dr. Salame, a 4th-year dermatology resident at Emory University, Atlanta. “Our study is the first to retrospectively evaluate the safety and efficacy of highly purified LIS for the treatment of acne scars in all skin types.”

Dr. Salame and coauthor Harold J. Brody, MD, evaluated the charts of 96 patients with a mean age of 51 years who received highly purified LIS for the treatment of acne scars at Dr. Brody’s Atlanta-based private dermatology practice between July 2010 and March 2021. Of the 96 patients, 31 had darker skin types (20 were Fitzpatrick skin type IV and 11 were Fitzpatrick skin type V). Dr. Brody performed all treatments: a total of 206 in the 96 patients.

The average time of follow-up was 6.31 years; 19 patients had a follow-up of 1-3 years, 25 had a follow-up of 3-5 years, and 52 had a follow-up of greater than 5 years. The researchers did not observe any complications along the course of the patients’ treatments, and no patients reported complications or dissatisfaction with treatment.

“Among the most impressive findings of our study was the permanence of effectiveness of LIS for acne scarring in patients who had treatment over a decade before,” Dr. Salame said. “Our longest follow up was 12 years. These patients continued to show improvement in their acne scarring years after treatment with LIS, even as they lost collagen and volume in their face with advancing age.”

In addition, she said, none of the patients experienced complications of granulomatous reactions, migration, or extrusion of product, which were previously documented with the use of macrodroplet injectable silicone techniques. “This is likely due to the consistent use of the microdroplet injection technique in our study – less than 0.01 cc per injection at minimum 6- to 8-week intervals or more,” Dr. Salame said.

Lawrence J. Green, MD, of the department of dermatology at George Washington University, Washington, who was asked to comment on the study, said that the findings “show safety and durability of highly purified microdroplet liquid silicone to treat acne scars. The numbers of patients reviewed are small and selective (one highly skilled dermatologist), but with the right material (highly purified liquid silicone) and in a qualified and experienced physician’s hand, this treatment seems like a great option.”

Dr. Salame acknowledged certain limitations of the study, including its single-center, retrospective design. “Future prospective studies with larger patient populations of all skin types recruited from multiple centers may be needed,” she said.

The researchers reported having no relevant conflicts of interest or funding sources to disclose. Dr. Green disclosed that he is a speaker, consultant, or investigator for numerous pharmaceutical companies.

PORTLAND, ORE. – In his nearly 2 decades of dermatology practice, Keith L. Duffy, MD, has seen his share of cases where Mohs surgery was misused or misappropriated.

“Appropriate use criteria in Mohs are near and dear to my heart,” Dr. Duffy, associate professor of dermatology at the University of Utah, Salt Lake City, said at the annual meeting of the Pacific Dermatologic Association. “I want to protect our specialty. I see patients who have dozens of skin cancers. I want to emphasize the long game of management in those patients. You have to think about the tumors in terms of decades.”

In 2012, an ad hoc task force from the American Academy of Dermatology (AAD), the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery developed appropriate use criteria (AUC) for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered. The task force used a 9-point scale to rate each indication, as follows:

• A score of 7 to 9: The use of MMS is appropriate for the specific indication and is generally considered acceptable.
• A score of 4 to 6: The use of MMS is uncertain for the specific indication, although its use may be appropriate and acceptable.
• A score of 1 to 3: The use of MMS is inappropriate for the specific indication and is generally not considered acceptable.

These ratings were translated into a free Mohs Surgery Appropriate Use Criteria App developed by the AAD.

Subsequently, Dr. Duffy and colleagues retrospectively examined the University of Utah’s adherence to the Mohs AUC over the course of 3 months. Their analysis, published in 2015, included 1,026 nonmelanoma skin cancers in 724 patients. Of the 1,026 cancers, 350 (34.1%) were treated with MMS. Of these, 339 (96.9%) were deemed appropriate based on the AUC guidelines, 4 (1.1%) were deemed uncertain, and 7 (2%) were deemed inappropriate.

There were also 611 skin cancers that were not treated with Mohs but met criteria for treatment with Mohs. “Most of these were AUC 7 tumors,” Dr. Duffy said. “When I see an AUC 7 tumor, I give high consideration for certain anatomic locations, especially the lower leg, scalp, eyelid, genitalia, ear, hands, and feet. I also think about the patient’s age, the number of skin cancers, and histological characteristics. Consider the long game in management and remember that skin cancer patients can make a near infinite amount of skin cancers, so be conservative when excising skin cancers to preserve precious skin.”

In his opinion, full thickness wounds requiring sutures should be avoided on the scalp and lower leg, if possible. “Most carcinomas in these locations are superficial and not aggressive in immunocompetent patients,” said Dr. Duffy, who said he has had one patient in 12 years who was not a transplant patient who had a metastatic squamous cell carcinoma on the lower leg. “Postop complications can be totally avoided. I don’t worry about these patients bleeding or [about] dehiscence. They can go back and play golf the next day, so you save valuable skin where the real estate is precious. This underscores a practice pearl: Incorporate the Mohs AUC and consideration of anatomic location when considering the most appropriate treatment of skin cancers.”

He also advises dermatologists to consider the histopathologic characteristics of the tumor when treating skin cancers to reduce complications and save tissue, so that patients can resume their lifestyle. “When you read the pathology report, really think about what the dermatopathologist saw under the microscope,” said Dr. Duffy, who is an investigator at the University of Utah’s Huntsman Cancer Institute. He said that he is able to review the slides for 90% of his own cases before surgery. “I’m lucky that way, but if you have any questions, your dermatopathologist should be on speed dial.”

Ultimately, he concluded, proper selection of a treatment modality for a specific tumor and patient rules the day. “Tumors should be thought about in the context of the patient and not as a single or isolated cancer,” he said.

Dr. Duffy reported having no relevant disclosures.

PORTLAND, ORE. – In his nearly 2 decades of dermatology practice, Keith L. Duffy, MD, has seen his share of cases where Mohs surgery was misused or misappropriated.

“Appropriate use criteria in Mohs are near and dear to my heart,” Dr. Duffy, associate professor of dermatology at the University of Utah, Salt Lake City, said at the annual meeting of the Pacific Dermatologic Association. “I want to protect our specialty. I see patients who have dozens of skin cancers. I want to emphasize the long game of management in those patients. You have to think about the tumors in terms of decades.”

In 2012, an ad hoc task force from the American Academy of Dermatology (AAD), the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery developed appropriate use criteria (AUC) for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered. The task force used a 9-point scale to rate each indication, as follows:

• A score of 7 to 9: The use of MMS is appropriate for the specific indication and is generally considered acceptable.
• A score of 4 to 6: The use of MMS is uncertain for the specific indication, although its use may be appropriate and acceptable.
• A score of 1 to 3: The use of MMS is inappropriate for the specific indication and is generally not considered acceptable.

These ratings were translated into a free Mohs Surgery Appropriate Use Criteria App developed by the AAD.

Subsequently, Dr. Duffy and colleagues retrospectively examined the University of Utah’s adherence to the Mohs AUC over the course of 3 months. Their analysis, published in 2015, included 1,026 nonmelanoma skin cancers in 724 patients. Of the 1,026 cancers, 350 (34.1%) were treated with MMS. Of these, 339 (96.9%) were deemed appropriate based on the AUC guidelines, 4 (1.1%) were deemed uncertain, and 7 (2%) were deemed inappropriate.

There were also 611 skin cancers that were not treated with Mohs but met criteria for treatment with Mohs. “Most of these were AUC 7 tumors,” Dr. Duffy said. “When I see an AUC 7 tumor, I give high consideration for certain anatomic locations, especially the lower leg, scalp, eyelid, genitalia, ear, hands, and feet. I also think about the patient’s age, the number of skin cancers, and histological characteristics. Consider the long game in management and remember that skin cancer patients can make a near infinite amount of skin cancers, so be conservative when excising skin cancers to preserve precious skin.”

In his opinion, full thickness wounds requiring sutures should be avoided on the scalp and lower leg, if possible. “Most carcinomas in these locations are superficial and not aggressive in immunocompetent patients,” said Dr. Duffy, who said he has had one patient in 12 years who was not a transplant patient who had a metastatic squamous cell carcinoma on the lower leg. “Postop complications can be totally avoided. I don’t worry about these patients bleeding or [about] dehiscence. They can go back and play golf the next day, so you save valuable skin where the real estate is precious. This underscores a practice pearl: Incorporate the Mohs AUC and consideration of anatomic location when considering the most appropriate treatment of skin cancers.”

He also advises dermatologists to consider the histopathologic characteristics of the tumor when treating skin cancers to reduce complications and save tissue, so that patients can resume their lifestyle. “When you read the pathology report, really think about what the dermatopathologist saw under the microscope,” said Dr. Duffy, who is an investigator at the University of Utah’s Huntsman Cancer Institute. He said that he is able to review the slides for 90% of his own cases before surgery. “I’m lucky that way, but if you have any questions, your dermatopathologist should be on speed dial.”

Ultimately, he concluded, proper selection of a treatment modality for a specific tumor and patient rules the day. “Tumors should be thought about in the context of the patient and not as a single or isolated cancer,” he said.

Dr. Duffy reported having no relevant disclosures.

PORTLAND, ORE. – In his nearly 2 decades of dermatology practice, Keith L. Duffy, MD, has seen his share of cases where Mohs surgery was misused or misappropriated.

“Appropriate use criteria in Mohs are near and dear to my heart,” Dr. Duffy, associate professor of dermatology at the University of Utah, Salt Lake City, said at the annual meeting of the Pacific Dermatologic Association. “I want to protect our specialty. I see patients who have dozens of skin cancers. I want to emphasize the long game of management in those patients. You have to think about the tumors in terms of decades.”

In 2012, an ad hoc task force from the American Academy of Dermatology (AAD), the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery developed appropriate use criteria (AUC) for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered. The task force used a 9-point scale to rate each indication, as follows:

• A score of 7 to 9: The use of MMS is appropriate for the specific indication and is generally considered acceptable.
• A score of 4 to 6: The use of MMS is uncertain for the specific indication, although its use may be appropriate and acceptable.
• A score of 1 to 3: The use of MMS is inappropriate for the specific indication and is generally not considered acceptable.

These ratings were translated into a free Mohs Surgery Appropriate Use Criteria App developed by the AAD.

Subsequently, Dr. Duffy and colleagues retrospectively examined the University of Utah’s adherence to the Mohs AUC over the course of 3 months. Their analysis, published in 2015, included 1,026 nonmelanoma skin cancers in 724 patients. Of the 1,026 cancers, 350 (34.1%) were treated with MMS. Of these, 339 (96.9%) were deemed appropriate based on the AUC guidelines, 4 (1.1%) were deemed uncertain, and 7 (2%) were deemed inappropriate.

There were also 611 skin cancers that were not treated with Mohs but met criteria for treatment with Mohs. “Most of these were AUC 7 tumors,” Dr. Duffy said. “When I see an AUC 7 tumor, I give high consideration for certain anatomic locations, especially the lower leg, scalp, eyelid, genitalia, ear, hands, and feet. I also think about the patient’s age, the number of skin cancers, and histological characteristics. Consider the long game in management and remember that skin cancer patients can make a near infinite amount of skin cancers, so be conservative when excising skin cancers to preserve precious skin.”

In his opinion, full thickness wounds requiring sutures should be avoided on the scalp and lower leg, if possible. “Most carcinomas in these locations are superficial and not aggressive in immunocompetent patients,” said Dr. Duffy, who said he has had one patient in 12 years who was not a transplant patient who had a metastatic squamous cell carcinoma on the lower leg. “Postop complications can be totally avoided. I don’t worry about these patients bleeding or [about] dehiscence. They can go back and play golf the next day, so you save valuable skin where the real estate is precious. This underscores a practice pearl: Incorporate the Mohs AUC and consideration of anatomic location when considering the most appropriate treatment of skin cancers.”

He also advises dermatologists to consider the histopathologic characteristics of the tumor when treating skin cancers to reduce complications and save tissue, so that patients can resume their lifestyle. “When you read the pathology report, really think about what the dermatopathologist saw under the microscope,” said Dr. Duffy, who is an investigator at the University of Utah’s Huntsman Cancer Institute. He said that he is able to review the slides for 90% of his own cases before surgery. “I’m lucky that way, but if you have any questions, your dermatopathologist should be on speed dial.”

Ultimately, he concluded, proper selection of a treatment modality for a specific tumor and patient rules the day. “Tumors should be thought about in the context of the patient and not as a single or isolated cancer,” he said.

Dr. Duffy reported having no relevant disclosures.

Treating keloid scars by combining excision and contact cryosurgery is a plausible way to decrease the volume of scars, results from a single-center observational study suggest.

“There is currently no consensus regarding the best treatment of keloid scars,” corresponding author Manon Artz, of the department of plastic, reconstructive, and aesthetic surgery at University Hospital of Brest (France), and colleagues wrote in a research letter published online in JAMA Dermatology.

Prompilove/Getty Images

“Earlier studies report a decreased scar volume and a substantial reduction of recurrence in keloid scars treated by cryosurgery,” they wrote. “In this study, our objective was to assess whether intramarginal excision (shaving) of the keloid scar followed by an immediate single session of contact cryosurgery is associated with decreased scar volume.”

Between March 2014 and May 2020, the researchers evaluated the approach in 31 patients with 40 keloid scars who were treated at University Hospital of Brest. Of these study participants, four were lost to follow-up, leaving 27 patients with 35 keloid scars in the final analysis. Their mean age was 24 years, 60% were female, and there was fairly even distribution of Fitzpatrick skin types II-VI.

Most of the keloid scars were located on the ear (69%) and the chest (23%), while the rest were on the head and neck. The primary outcome was reduction of keloid scar volume after 12 months, which was measured with the Vancouver scar scale. The researchers defined 80%-100% reduction in scar volume as “major,” a 50%-80% reduction as “substantial,” and a 0%-50% reduction or recurrence as “moderate.”

After 12 months, 19 scars (54%) showed a major reduction in volume, while 6 (17%) had a substantial reduction, and seven (20%) experienced no reduction. Across all keloid scars, the median scar volume decreased significantly by 81.9%.

Scar volume reduction differed by anatomical location. Specifically, 84% of ear scars showed major or substantial reduction, while 60% of scars on the chest showed a moderate reduction in scar volume or recurrence. In another key finding, the Vancouver scar scale score was reduced overall in 25 scars by 71.4%, from 7 before treatment to 5 after treatment.

“There remains no silver bullet for the treatment of keloids, but this study adds invaluable evidence that tangential excision followed by contact cryosurgery can be a viable treatment regimen with low recurrence rates,” said Marcus G. Tan, MD, who recently completed his dermatology residency at the University of Ottawa and who was asked to comment on the study. “Clinicians should exercise caution especially when treating individuals with darker skin phototypes due to their increased risk of scarring and dyspigmentation.”

Limitations of this study, he said, include a smaller study population with some patient dropouts and a lack of adverse effects reported.

The researchers and Dr. Tan reported having no financial conflicts.

Treating keloid scars by combining excision and contact cryosurgery is a plausible way to decrease the volume of scars, results from a single-center observational study suggest.

“There is currently no consensus regarding the best treatment of keloid scars,” corresponding author Manon Artz, of the department of plastic, reconstructive, and aesthetic surgery at University Hospital of Brest (France), and colleagues wrote in a research letter published online in JAMA Dermatology.

Prompilove/Getty Images

“Earlier studies report a decreased scar volume and a substantial reduction of recurrence in keloid scars treated by cryosurgery,” they wrote. “In this study, our objective was to assess whether intramarginal excision (shaving) of the keloid scar followed by an immediate single session of contact cryosurgery is associated with decreased scar volume.”

Between March 2014 and May 2020, the researchers evaluated the approach in 31 patients with 40 keloid scars who were treated at University Hospital of Brest. Of these study participants, four were lost to follow-up, leaving 27 patients with 35 keloid scars in the final analysis. Their mean age was 24 years, 60% were female, and there was fairly even distribution of Fitzpatrick skin types II-VI.

Most of the keloid scars were located on the ear (69%) and the chest (23%), while the rest were on the head and neck. The primary outcome was reduction of keloid scar volume after 12 months, which was measured with the Vancouver scar scale. The researchers defined 80%-100% reduction in scar volume as “major,” a 50%-80% reduction as “substantial,” and a 0%-50% reduction or recurrence as “moderate.”

After 12 months, 19 scars (54%) showed a major reduction in volume, while 6 (17%) had a substantial reduction, and seven (20%) experienced no reduction. Across all keloid scars, the median scar volume decreased significantly by 81.9%.

Scar volume reduction differed by anatomical location. Specifically, 84% of ear scars showed major or substantial reduction, while 60% of scars on the chest showed a moderate reduction in scar volume or recurrence. In another key finding, the Vancouver scar scale score was reduced overall in 25 scars by 71.4%, from 7 before treatment to 5 after treatment.

“There remains no silver bullet for the treatment of keloids, but this study adds invaluable evidence that tangential excision followed by contact cryosurgery can be a viable treatment regimen with low recurrence rates,” said Marcus G. Tan, MD, who recently completed his dermatology residency at the University of Ottawa and who was asked to comment on the study. “Clinicians should exercise caution especially when treating individuals with darker skin phototypes due to their increased risk of scarring and dyspigmentation.”

Limitations of this study, he said, include a smaller study population with some patient dropouts and a lack of adverse effects reported.

The researchers and Dr. Tan reported having no financial conflicts.

Treating keloid scars by combining excision and contact cryosurgery is a plausible way to decrease the volume of scars, results from a single-center observational study suggest.

“There is currently no consensus regarding the best treatment of keloid scars,” corresponding author Manon Artz, of the department of plastic, reconstructive, and aesthetic surgery at University Hospital of Brest (France), and colleagues wrote in a research letter published online in JAMA Dermatology.

Prompilove/Getty Images

“Earlier studies report a decreased scar volume and a substantial reduction of recurrence in keloid scars treated by cryosurgery,” they wrote. “In this study, our objective was to assess whether intramarginal excision (shaving) of the keloid scar followed by an immediate single session of contact cryosurgery is associated with decreased scar volume.”

Between March 2014 and May 2020, the researchers evaluated the approach in 31 patients with 40 keloid scars who were treated at University Hospital of Brest. Of these study participants, four were lost to follow-up, leaving 27 patients with 35 keloid scars in the final analysis. Their mean age was 24 years, 60% were female, and there was fairly even distribution of Fitzpatrick skin types II-VI.

Most of the keloid scars were located on the ear (69%) and the chest (23%), while the rest were on the head and neck. The primary outcome was reduction of keloid scar volume after 12 months, which was measured with the Vancouver scar scale. The researchers defined 80%-100% reduction in scar volume as “major,” a 50%-80% reduction as “substantial,” and a 0%-50% reduction or recurrence as “moderate.”

After 12 months, 19 scars (54%) showed a major reduction in volume, while 6 (17%) had a substantial reduction, and seven (20%) experienced no reduction. Across all keloid scars, the median scar volume decreased significantly by 81.9%.

Scar volume reduction differed by anatomical location. Specifically, 84% of ear scars showed major or substantial reduction, while 60% of scars on the chest showed a moderate reduction in scar volume or recurrence. In another key finding, the Vancouver scar scale score was reduced overall in 25 scars by 71.4%, from 7 before treatment to 5 after treatment.

“There remains no silver bullet for the treatment of keloids, but this study adds invaluable evidence that tangential excision followed by contact cryosurgery can be a viable treatment regimen with low recurrence rates,” said Marcus G. Tan, MD, who recently completed his dermatology residency at the University of Ottawa and who was asked to comment on the study. “Clinicians should exercise caution especially when treating individuals with darker skin phototypes due to their increased risk of scarring and dyspigmentation.”

Limitations of this study, he said, include a smaller study population with some patient dropouts and a lack of adverse effects reported.

The researchers and Dr. Tan reported having no financial conflicts.

SAN DIEGO – The risk of laser or intense-pulsed light–induced vitiligo from treating vitiligo with either modality appears to be low, but caution is recommended until further studies are carried out.

Those are the preliminary conclusions from a systematic review and survey of experts that Albert Wolkerstorfer, MD, presented during a clinical abstract session at the annual conference of the American Society for Laser Medicine and Surgery.

According to Dr. Wolkerstorfer, a dermatologist at Amsterdam University Medical Center, clinicians are reluctant to perform laser/intense pulsed light (IPL) treatments in patients with vitiligo because of the absence of clear guidelines, so he and his colleagues set out to investigate the risks of laser/IPL-induced vitiligo in patients with vitiligo and to seek out international consensus on recommendations from experts. “There is hardly any literature about it and certainly no guidelines,” he pointed out.

Dr. Wolkerstorfer and his colleagues designed three consecutive studies: A systematic review of laser/IPL-induced vitiligo; an international survey among 14 vitiligo experts from 10 countries about the occurrence of laser‐induced vitiligo, and a Delphi technique aimed at establishing a broad consensus about recommendations for safe use of lasers in vitiligo patients. At the time of the meeting, the Delphi process was still being carried out, so he did not discuss that study.

For the systematic review, the researchers found 11,073 unique hits on PubMed, Embase, and CINAHL using the terms “vitiligo,” “depigmentation,” “hypopigmentation,” and “leukoderma.” Only six case reports of laser/IPL-induced vitiligo were included in the final analysis. Of these, three had de novo vitiligo and three had vitiligo/halo nevi. These cases included two that occurred following treatment of port wine stains with the 585-nm laser; one that occurred following treatment of dyspigmentation with IPL; one that occurred following treatment of hypertrichosis with the 1,064-nm laser, one that occurred following treatment of hypertrichosis with the 755-nm laser, and one case that occurred following treatment of melasma with the ablative laser.

For the international survey of 14 experts from 10 countries, respondents said they had 10,670 new face-to-face vitiligo consultations in the past year. They reported that 30 of the vitiligo cases (0.3%) were likely caused by laser/IPL. Of these 30 cases, 18 (60%) had de novo vitiligo.

Of these cases, vitiligo occurred most frequently after laser hair reduction (47%), followed by use of the fractional laser (17%), and the ablative laser (13%). The interval between laser/IPL treatment and onset of vitiligo was 0-4 weeks in 27% of cases and 4-12 weeks in 57% of cases. Direct complications such as blistering, crusting, and erosions occurred in 57% of cases.

“Our conclusion is that laser and IPL-induced vitiligo is a rare phenomenon, and it often affects patients without prior vitiligo, which was really a surprise to us,” Dr. Wolkerstorfer said. “Complications seem to increase the risk,” he added.

“Despite the apparently low risk, we recommend caution [in patients with vitiligo], especially with aggressive laser procedures,” he said. “We recommend using conservative settings, not to treat active vitiligo patients ... and to perform test spots prior to treating large areas.” But he characterized this recommendation as “totally preliminary” pending results of the Delphi technique aimed at building consensus about laser/IPL treatments in vitiligo.

In an interview at the meeting, one of the session moderators, Oge Onwudiwe, MD, a dermatologist who practices in Alexandria, Va., said that as clinicians await results of the study’s Delphi consensus, current use of lasers and IPL in patients with vitiligo “is based on your clinical judgment and whether the vitiligo is active or inactive. If the patient has vitiligo and you’re doing laser hair removal in the armpit, they may get active lesions in that area, but they can cover it. So, they may take that as a ‘win’ with the risk. But if it can erupt in other areas, that’s a risk they must be willing to take.”

Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical. He is an advisory board member for Incyte. Dr. Onwudiwe reported having no disclosures.

SAN DIEGO – The risk of laser or intense-pulsed light–induced vitiligo from treating vitiligo with either modality appears to be low, but caution is recommended until further studies are carried out.

Those are the preliminary conclusions from a systematic review and survey of experts that Albert Wolkerstorfer, MD, presented during a clinical abstract session at the annual conference of the American Society for Laser Medicine and Surgery.

According to Dr. Wolkerstorfer, a dermatologist at Amsterdam University Medical Center, clinicians are reluctant to perform laser/intense pulsed light (IPL) treatments in patients with vitiligo because of the absence of clear guidelines, so he and his colleagues set out to investigate the risks of laser/IPL-induced vitiligo in patients with vitiligo and to seek out international consensus on recommendations from experts. “There is hardly any literature about it and certainly no guidelines,” he pointed out.

Dr. Wolkerstorfer and his colleagues designed three consecutive studies: A systematic review of laser/IPL-induced vitiligo; an international survey among 14 vitiligo experts from 10 countries about the occurrence of laser‐induced vitiligo, and a Delphi technique aimed at establishing a broad consensus about recommendations for safe use of lasers in vitiligo patients. At the time of the meeting, the Delphi process was still being carried out, so he did not discuss that study.

For the systematic review, the researchers found 11,073 unique hits on PubMed, Embase, and CINAHL using the terms “vitiligo,” “depigmentation,” “hypopigmentation,” and “leukoderma.” Only six case reports of laser/IPL-induced vitiligo were included in the final analysis. Of these, three had de novo vitiligo and three had vitiligo/halo nevi. These cases included two that occurred following treatment of port wine stains with the 585-nm laser; one that occurred following treatment of dyspigmentation with IPL; one that occurred following treatment of hypertrichosis with the 1,064-nm laser, one that occurred following treatment of hypertrichosis with the 755-nm laser, and one case that occurred following treatment of melasma with the ablative laser.

For the international survey of 14 experts from 10 countries, respondents said they had 10,670 new face-to-face vitiligo consultations in the past year. They reported that 30 of the vitiligo cases (0.3%) were likely caused by laser/IPL. Of these 30 cases, 18 (60%) had de novo vitiligo.

Of these cases, vitiligo occurred most frequently after laser hair reduction (47%), followed by use of the fractional laser (17%), and the ablative laser (13%). The interval between laser/IPL treatment and onset of vitiligo was 0-4 weeks in 27% of cases and 4-12 weeks in 57% of cases. Direct complications such as blistering, crusting, and erosions occurred in 57% of cases.

“Our conclusion is that laser and IPL-induced vitiligo is a rare phenomenon, and it often affects patients without prior vitiligo, which was really a surprise to us,” Dr. Wolkerstorfer said. “Complications seem to increase the risk,” he added.

“Despite the apparently low risk, we recommend caution [in patients with vitiligo], especially with aggressive laser procedures,” he said. “We recommend using conservative settings, not to treat active vitiligo patients ... and to perform test spots prior to treating large areas.” But he characterized this recommendation as “totally preliminary” pending results of the Delphi technique aimed at building consensus about laser/IPL treatments in vitiligo.

In an interview at the meeting, one of the session moderators, Oge Onwudiwe, MD, a dermatologist who practices in Alexandria, Va., said that as clinicians await results of the study’s Delphi consensus, current use of lasers and IPL in patients with vitiligo “is based on your clinical judgment and whether the vitiligo is active or inactive. If the patient has vitiligo and you’re doing laser hair removal in the armpit, they may get active lesions in that area, but they can cover it. So, they may take that as a ‘win’ with the risk. But if it can erupt in other areas, that’s a risk they must be willing to take.”

Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical. He is an advisory board member for Incyte. Dr. Onwudiwe reported having no disclosures.

SAN DIEGO – The risk of laser or intense-pulsed light–induced vitiligo from treating vitiligo with either modality appears to be low, but caution is recommended until further studies are carried out.

Those are the preliminary conclusions from a systematic review and survey of experts that Albert Wolkerstorfer, MD, presented during a clinical abstract session at the annual conference of the American Society for Laser Medicine and Surgery.

According to Dr. Wolkerstorfer, a dermatologist at Amsterdam University Medical Center, clinicians are reluctant to perform laser/intense pulsed light (IPL) treatments in patients with vitiligo because of the absence of clear guidelines, so he and his colleagues set out to investigate the risks of laser/IPL-induced vitiligo in patients with vitiligo and to seek out international consensus on recommendations from experts. “There is hardly any literature about it and certainly no guidelines,” he pointed out.

Dr. Wolkerstorfer and his colleagues designed three consecutive studies: A systematic review of laser/IPL-induced vitiligo; an international survey among 14 vitiligo experts from 10 countries about the occurrence of laser‐induced vitiligo, and a Delphi technique aimed at establishing a broad consensus about recommendations for safe use of lasers in vitiligo patients. At the time of the meeting, the Delphi process was still being carried out, so he did not discuss that study.

For the systematic review, the researchers found 11,073 unique hits on PubMed, Embase, and CINAHL using the terms “vitiligo,” “depigmentation,” “hypopigmentation,” and “leukoderma.” Only six case reports of laser/IPL-induced vitiligo were included in the final analysis. Of these, three had de novo vitiligo and three had vitiligo/halo nevi. These cases included two that occurred following treatment of port wine stains with the 585-nm laser; one that occurred following treatment of dyspigmentation with IPL; one that occurred following treatment of hypertrichosis with the 1,064-nm laser, one that occurred following treatment of hypertrichosis with the 755-nm laser, and one case that occurred following treatment of melasma with the ablative laser.

For the international survey of 14 experts from 10 countries, respondents said they had 10,670 new face-to-face vitiligo consultations in the past year. They reported that 30 of the vitiligo cases (0.3%) were likely caused by laser/IPL. Of these 30 cases, 18 (60%) had de novo vitiligo.

Of these cases, vitiligo occurred most frequently after laser hair reduction (47%), followed by use of the fractional laser (17%), and the ablative laser (13%). The interval between laser/IPL treatment and onset of vitiligo was 0-4 weeks in 27% of cases and 4-12 weeks in 57% of cases. Direct complications such as blistering, crusting, and erosions occurred in 57% of cases.

“Our conclusion is that laser and IPL-induced vitiligo is a rare phenomenon, and it often affects patients without prior vitiligo, which was really a surprise to us,” Dr. Wolkerstorfer said. “Complications seem to increase the risk,” he added.

“Despite the apparently low risk, we recommend caution [in patients with vitiligo], especially with aggressive laser procedures,” he said. “We recommend using conservative settings, not to treat active vitiligo patients ... and to perform test spots prior to treating large areas.” But he characterized this recommendation as “totally preliminary” pending results of the Delphi technique aimed at building consensus about laser/IPL treatments in vitiligo.

In an interview at the meeting, one of the session moderators, Oge Onwudiwe, MD, a dermatologist who practices in Alexandria, Va., said that as clinicians await results of the study’s Delphi consensus, current use of lasers and IPL in patients with vitiligo “is based on your clinical judgment and whether the vitiligo is active or inactive. If the patient has vitiligo and you’re doing laser hair removal in the armpit, they may get active lesions in that area, but they can cover it. So, they may take that as a ‘win’ with the risk. But if it can erupt in other areas, that’s a risk they must be willing to take.”

Dr. Wolkerstorfer disclosed that he has received grant or research funding from Lumenis, Novartis, and Avita Medical. He is an advisory board member for Incyte. Dr. Onwudiwe reported having no disclosures.

Patients who are immunocompromised showed no increased risk of surgical site infection when undergoing Mohs micrographic surgery, regardless of whether or not they received antibiotics, suggesting that antibiotic prophylaxis, which is often used for these patients, may not be necessary, according to new research.

The retrospective cohort study found that “immunosuppressed patients had similar infection rates as immunocompetent patients following Mohs micrographic surgery,” first author Tuyet A. Nguyen, MD, of the department of dermatology, Cedars-Sinai Medical Center, Los Angeles, told this news organization.

“Therefore, antibiotic prescribing patterns should not change simply due to immunosuppression. Furthermore, immunosuppressed patients appear to respond well to antibiotics and recover similarly to immunocompetent patients,” she said.

Dr. Nguyen

Overall, postprocedural infections occurred in 1.6% (95) of patients, a rate that mirrors that of the general population, Dr. Nguyen noted. No significant differences in surgical site infection rates were observed between immunocompromised patients (2.1%, n = 15) and those who were immunocompetent (1.6%, n = 80; P = .30).

Importantly, among those who were immunocompromised, the rates of infection were not significantly different between those who did receive antibiotics (3.0%, n = 8) and those who did not receive antibiotics (1.5%, n = 7; P = .19).

The lack of a difference in surgical site infection rates among those who did and those who did not receive antibiotics extended to the entire study population (2.0% vs. 1.4%; P = .12).

The study cohort mainly comprised immunosuppressed transplant patients, notably, heart, lung, and kidney transplant patients. However, “even in this population, we did not see a higher rate of infection,” senior author Nima M. Gharavi, MD, PhD, director of dermatologic surgery and Mohs micrographic surgery and associate professor of medicine and pathology and laboratory medicine at Cedars-Sinai Medical Center, said in an interview.

Dr. Nima M. Gharavi

A version of this article first appeared on Medscape.com.

Patients who are immunocompromised showed no increased risk of surgical site infection when undergoing Mohs micrographic surgery, regardless of whether or not they received antibiotics, suggesting that antibiotic prophylaxis, which is often used for these patients, may not be necessary, according to new research.

The retrospective cohort study found that “immunosuppressed patients had similar infection rates as immunocompetent patients following Mohs micrographic surgery,” first author Tuyet A. Nguyen, MD, of the department of dermatology, Cedars-Sinai Medical Center, Los Angeles, told this news organization.

“Therefore, antibiotic prescribing patterns should not change simply due to immunosuppression. Furthermore, immunosuppressed patients appear to respond well to antibiotics and recover similarly to immunocompetent patients,” she said.

Dr. Nguyen

Overall, postprocedural infections occurred in 1.6% (95) of patients, a rate that mirrors that of the general population, Dr. Nguyen noted. No significant differences in surgical site infection rates were observed between immunocompromised patients (2.1%, n = 15) and those who were immunocompetent (1.6%, n = 80; P = .30).

Importantly, among those who were immunocompromised, the rates of infection were not significantly different between those who did receive antibiotics (3.0%, n = 8) and those who did not receive antibiotics (1.5%, n = 7; P = .19).

The lack of a difference in surgical site infection rates among those who did and those who did not receive antibiotics extended to the entire study population (2.0% vs. 1.4%; P = .12).

The study cohort mainly comprised immunosuppressed transplant patients, notably, heart, lung, and kidney transplant patients. However, “even in this population, we did not see a higher rate of infection,” senior author Nima M. Gharavi, MD, PhD, director of dermatologic surgery and Mohs micrographic surgery and associate professor of medicine and pathology and laboratory medicine at Cedars-Sinai Medical Center, said in an interview.

Dr. Nima M. Gharavi

A version of this article first appeared on Medscape.com.

Patients who are immunocompromised showed no increased risk of surgical site infection when undergoing Mohs micrographic surgery, regardless of whether or not they received antibiotics, suggesting that antibiotic prophylaxis, which is often used for these patients, may not be necessary, according to new research.

The retrospective cohort study found that “immunosuppressed patients had similar infection rates as immunocompetent patients following Mohs micrographic surgery,” first author Tuyet A. Nguyen, MD, of the department of dermatology, Cedars-Sinai Medical Center, Los Angeles, told this news organization.

“Therefore, antibiotic prescribing patterns should not change simply due to immunosuppression. Furthermore, immunosuppressed patients appear to respond well to antibiotics and recover similarly to immunocompetent patients,” she said.

Dr. Nguyen

Overall, postprocedural infections occurred in 1.6% (95) of patients, a rate that mirrors that of the general population, Dr. Nguyen noted. No significant differences in surgical site infection rates were observed between immunocompromised patients (2.1%, n = 15) and those who were immunocompetent (1.6%, n = 80; P = .30).

Importantly, among those who were immunocompromised, the rates of infection were not significantly different between those who did receive antibiotics (3.0%, n = 8) and those who did not receive antibiotics (1.5%, n = 7; P = .19).

The lack of a difference in surgical site infection rates among those who did and those who did not receive antibiotics extended to the entire study population (2.0% vs. 1.4%; P = .12).

The study cohort mainly comprised immunosuppressed transplant patients, notably, heart, lung, and kidney transplant patients. However, “even in this population, we did not see a higher rate of infection,” senior author Nima M. Gharavi, MD, PhD, director of dermatologic surgery and Mohs micrographic surgery and associate professor of medicine and pathology and laboratory medicine at Cedars-Sinai Medical Center, said in an interview.

Dr. Nima M. Gharavi

A version of this article first appeared on Medscape.com.

As increasing numbers of patients in their 80s, 90s, and even 100s present for possible Mohs micrographic surgery, surgeons are confronted with deciding when the risks of treatment may outweigh the benefits.

In one of two presentations at the annual meeting of the American College of Mohs Surgery that addressed this topic, Howard W. Rogers, MD, of Advanced Dermatology in Norwich, Conn., said that the crux of the issue is the concern not to undertreat. He noted that reduced access to dermatologic care during the pandemic has provided a stark lesson in the risks of delaying treatment in all age groups. “Mohs surgeons have all seen the consequences of delayed treatment due to the pandemic with enormous, destructive, and sometimes fatal cancers coming to the office in the last year,” he told this news organization.

“Pandemic-related treatment delay has caused increased suffering and morbidity for countless skin cancer patients across the U.S.,” he said. “In general, not treating skin cancer and hoping it’s not going to grow or having significant delays in treatment are a recipe for disastrous outcomes.”

That said, active monitoring may be appropriate “for select small cancers that tend to grow slowly in the very elderly,” added Dr. Rogers, the incoming ACMS president. Among the key situations where the benefits of active monitoring may outweigh the risks of surgery are small, slowly growing cancers, when frailty is an issue.

Frailty has been equated to compromised functionality, which can increase the risk of an array of complications, including prolonged wound healing and secondary complications stemming from immobility. The toll those issues can take on patients’ quality of life can be considerable, Dr. Rogers said.

When weighing treatment options with elderly patients, he emphasized that careful consideration should be given to whether the “time needed to benefit from a Mohs procedure is longer than the patient’s life expectancy.” Furthermore, a decision not to treat does not have to be the last word. “We need to have an honest dialogue on the consequences of nontreatment, but part of that should be that just because we don’t treat today, doesn’t mean we can’t treat it tomorrow, if necessary.”

Of note, he added, “more than 100,00 patients have surgery for basal cell carcinoma [BCC] in their last year of life.” And that figure will likely rise exponentially if population projections come to fruition, considering that the population of people over the age of 85 is predicted to increase to nearly 18 million in 2050, from 5.8 million in 2012, Dr. Rogers said.

Until more research emerges on how to best treat this age group, Dr. Rogers noted that experts recommend that for elderly patients, “treatment should be individualized with consideration of active monitoring of primary BCC that is not in the H-zone, asymptomatic, smaller than 1 cm, with treatment initiated if there is substantial growth or symptoms.” Ultimately, he urged surgeons to “be sensitive and treat our patients like ourselves or our family members.”
 

When appropriate – Mohs is safe in the very elderly

Taking on the issue in a separate presentation, Deborah MacFarlane, MD, professor of dermatology and head and neck surgery at MD Anderson Cancer Center, Houston, said that for skin cancer cases that warrant treatment, clinicians should not let age alone stand in the way of Mohs surgery.

The evidence of its safety in the elderly dates back to a paper published in 1997 that Dr. MacFarlane coauthored, describing Mohs surgery of BCCs, squamous cell cancers (SCCs), and melanomas among 115 patients aged 90 and older (average, 92.4 years) who had an average of 1.9 comorbid medical conditions, and were taking an average of 2.3 medications. “Overall, we had just one complication among the patients,” she said.

In a subsequent paper, Dr. MacFarlane and her colleagues found that age at the time of Mohs surgery, even in older patients, was unrelated to survival, stage of cancer, or the type of repair. “We have concluded that this rapidly growing segment of the population can undergo Mohs surgery and should not be relegated to less effective treatment out of fear of its affecting their survival,” Dr. MacFarlane said.

She agreed with the concern about frailty and hence functionality, which may need to be factored in when making a decision to perform Mohs surgery. “I think this is something we do intuitively anyway,” she added. “We’re going to offer Mohs to someone who we think will survive and who is in relatively good health,” Dr. MacFarlane noted.

The point is illustrated in a new multicenter study of 1,181 patients at 22 U.S. sites, aged 85 years and older with nonmelanoma skin cancer referred for Mohs surgery. In the study, published in JAMA Dermatology after the ACMS meeting, patients who had Mohs surgery were almost four times more likely to have high functional status (P < .001) and were more likely to have facial tumors (P < .001), compared with those who had an alternate surgery.

The main reasons provided by the surgeons for opting to treat with Mohs included a patient’s desire for treatment with a high cure rate (66%), good/excellent patient functional status for age (57%), and a high risk associated with the tumor based on histology (40%), noted Dr. MacFarlane, one of the authors.

She reiterated the point raised by Dr. Rogers that “this is something we’re going to increasingly face,” noting that people over 85 represent the fastest growing segment of the population. “I have more patients over the age of 100 than I’ve ever had before,” she said.

Nevertheless, her own experience with elderly patients speaks to the safety of Mohs surgery in this population: Dr. MacFarlane reported a review of her practice’s records of 171 patients aged 85 years and older between May 2016 and May 2022, who received 414 separate procedures, without a single complication.

Sharing many of Dr. Rogers’ concerns about using caution in at-risk patients, Dr. MacFarlane offered recommendations for the optimal treatment of elderly patients receiving Mohs, including handling tissue delicately, and “keep undermining to a minimum.” She noted that intermediate closures and full thickness skin grafts are ideal closures for the elderly, while flaps may be performed in selected robust skin. It is also important to involve caretakers from the onset, talk and listen to patients – and play their choice of music during treatment, she said.

Commenting on the debate, comoderator Nahid Y. Vidal, MD, of the department of dermatology, Mayo Clinic, Rochester, Minn., noted that the expanding older population is accompanied by increases in skin cancer, in addition to more immunosenescence that is related to development of infections, autoimmune disease, and malignant tumors.

“In our academic practice, as with both the reference speakers, we do frequently see elderly, and not uncommonly the super-elderly,” she told this news organization. “The take-home point for me is to treat your whole patient, not just the tumor,” considering social factors, frailty/spry factor, and preferences, “and to do the humanistic thing, while also remaining evidence based,” she said.

“Don’t assume that increased age translates to morbidity, worse outcomes, or futility of treatment,” she added. “Chances are, if [a patient] made it to 90 years old with only a few medications and few medical problems, they may make it to 100, so why put the patient at risk for metastasis and death from a treatable/curable skin cancer,” in the case of SCC, she said.

“By the same token, why not perform more conservative treatments such as ED&C [electrodesiccation and curettage] for very low-risk skin cancers in low-risk locations, such as a superficial basal cell carcinoma on the trunk?” Overall, instead of trying to determine how long a super-elderly individual will live, Dr. Vidal said that “it’s better to educate the patient, engage in a discussion about goals of care, and to make few assumptions.”

Dr. Rogers, Dr. MacFarlane, and Dr. Vidal report no disclosures.

A version of this article first appeared on Medscape.com.

As increasing numbers of patients in their 80s, 90s, and even 100s present for possible Mohs micrographic surgery, surgeons are confronted with deciding when the risks of treatment may outweigh the benefits.

In one of two presentations at the annual meeting of the American College of Mohs Surgery that addressed this topic, Howard W. Rogers, MD, of Advanced Dermatology in Norwich, Conn., said that the crux of the issue is the concern not to undertreat. He noted that reduced access to dermatologic care during the pandemic has provided a stark lesson in the risks of delaying treatment in all age groups. “Mohs surgeons have all seen the consequences of delayed treatment due to the pandemic with enormous, destructive, and sometimes fatal cancers coming to the office in the last year,” he told this news organization.

“Pandemic-related treatment delay has caused increased suffering and morbidity for countless skin cancer patients across the U.S.,” he said. “In general, not treating skin cancer and hoping it’s not going to grow or having significant delays in treatment are a recipe for disastrous outcomes.”

That said, active monitoring may be appropriate “for select small cancers that tend to grow slowly in the very elderly,” added Dr. Rogers, the incoming ACMS president. Among the key situations where the benefits of active monitoring may outweigh the risks of surgery are small, slowly growing cancers, when frailty is an issue.

Frailty has been equated to compromised functionality, which can increase the risk of an array of complications, including prolonged wound healing and secondary complications stemming from immobility. The toll those issues can take on patients’ quality of life can be considerable, Dr. Rogers said.

When weighing treatment options with elderly patients, he emphasized that careful consideration should be given to whether the “time needed to benefit from a Mohs procedure is longer than the patient’s life expectancy.” Furthermore, a decision not to treat does not have to be the last word. “We need to have an honest dialogue on the consequences of nontreatment, but part of that should be that just because we don’t treat today, doesn’t mean we can’t treat it tomorrow, if necessary.”

Of note, he added, “more than 100,00 patients have surgery for basal cell carcinoma [BCC] in their last year of life.” And that figure will likely rise exponentially if population projections come to fruition, considering that the population of people over the age of 85 is predicted to increase to nearly 18 million in 2050, from 5.8 million in 2012, Dr. Rogers said.

Until more research emerges on how to best treat this age group, Dr. Rogers noted that experts recommend that for elderly patients, “treatment should be individualized with consideration of active monitoring of primary BCC that is not in the H-zone, asymptomatic, smaller than 1 cm, with treatment initiated if there is substantial growth or symptoms.” Ultimately, he urged surgeons to “be sensitive and treat our patients like ourselves or our family members.”
 

When appropriate – Mohs is safe in the very elderly

Taking on the issue in a separate presentation, Deborah MacFarlane, MD, professor of dermatology and head and neck surgery at MD Anderson Cancer Center, Houston, said that for skin cancer cases that warrant treatment, clinicians should not let age alone stand in the way of Mohs surgery.

The evidence of its safety in the elderly dates back to a paper published in 1997 that Dr. MacFarlane coauthored, describing Mohs surgery of BCCs, squamous cell cancers (SCCs), and melanomas among 115 patients aged 90 and older (average, 92.4 years) who had an average of 1.9 comorbid medical conditions, and were taking an average of 2.3 medications. “Overall, we had just one complication among the patients,” she said.

In a subsequent paper, Dr. MacFarlane and her colleagues found that age at the time of Mohs surgery, even in older patients, was unrelated to survival, stage of cancer, or the type of repair. “We have concluded that this rapidly growing segment of the population can undergo Mohs surgery and should not be relegated to less effective treatment out of fear of its affecting their survival,” Dr. MacFarlane said.

She agreed with the concern about frailty and hence functionality, which may need to be factored in when making a decision to perform Mohs surgery. “I think this is something we do intuitively anyway,” she added. “We’re going to offer Mohs to someone who we think will survive and who is in relatively good health,” Dr. MacFarlane noted.

The point is illustrated in a new multicenter study of 1,181 patients at 22 U.S. sites, aged 85 years and older with nonmelanoma skin cancer referred for Mohs surgery. In the study, published in JAMA Dermatology after the ACMS meeting, patients who had Mohs surgery were almost four times more likely to have high functional status (P < .001) and were more likely to have facial tumors (P < .001), compared with those who had an alternate surgery.

The main reasons provided by the surgeons for opting to treat with Mohs included a patient’s desire for treatment with a high cure rate (66%), good/excellent patient functional status for age (57%), and a high risk associated with the tumor based on histology (40%), noted Dr. MacFarlane, one of the authors.

She reiterated the point raised by Dr. Rogers that “this is something we’re going to increasingly face,” noting that people over 85 represent the fastest growing segment of the population. “I have more patients over the age of 100 than I’ve ever had before,” she said.

Nevertheless, her own experience with elderly patients speaks to the safety of Mohs surgery in this population: Dr. MacFarlane reported a review of her practice’s records of 171 patients aged 85 years and older between May 2016 and May 2022, who received 414 separate procedures, without a single complication.

Sharing many of Dr. Rogers’ concerns about using caution in at-risk patients, Dr. MacFarlane offered recommendations for the optimal treatment of elderly patients receiving Mohs, including handling tissue delicately, and “keep undermining to a minimum.” She noted that intermediate closures and full thickness skin grafts are ideal closures for the elderly, while flaps may be performed in selected robust skin. It is also important to involve caretakers from the onset, talk and listen to patients – and play their choice of music during treatment, she said.

Commenting on the debate, comoderator Nahid Y. Vidal, MD, of the department of dermatology, Mayo Clinic, Rochester, Minn., noted that the expanding older population is accompanied by increases in skin cancer, in addition to more immunosenescence that is related to development of infections, autoimmune disease, and malignant tumors.

“In our academic practice, as with both the reference speakers, we do frequently see elderly, and not uncommonly the super-elderly,” she told this news organization. “The take-home point for me is to treat your whole patient, not just the tumor,” considering social factors, frailty/spry factor, and preferences, “and to do the humanistic thing, while also remaining evidence based,” she said.

“Don’t assume that increased age translates to morbidity, worse outcomes, or futility of treatment,” she added. “Chances are, if [a patient] made it to 90 years old with only a few medications and few medical problems, they may make it to 100, so why put the patient at risk for metastasis and death from a treatable/curable skin cancer,” in the case of SCC, she said.

“By the same token, why not perform more conservative treatments such as ED&C [electrodesiccation and curettage] for very low-risk skin cancers in low-risk locations, such as a superficial basal cell carcinoma on the trunk?” Overall, instead of trying to determine how long a super-elderly individual will live, Dr. Vidal said that “it’s better to educate the patient, engage in a discussion about goals of care, and to make few assumptions.”

Dr. Rogers, Dr. MacFarlane, and Dr. Vidal report no disclosures.

A version of this article first appeared on Medscape.com.

As increasing numbers of patients in their 80s, 90s, and even 100s present for possible Mohs micrographic surgery, surgeons are confronted with deciding when the risks of treatment may outweigh the benefits.

In one of two presentations at the annual meeting of the American College of Mohs Surgery that addressed this topic, Howard W. Rogers, MD, of Advanced Dermatology in Norwich, Conn., said that the crux of the issue is the concern not to undertreat. He noted that reduced access to dermatologic care during the pandemic has provided a stark lesson in the risks of delaying treatment in all age groups. “Mohs surgeons have all seen the consequences of delayed treatment due to the pandemic with enormous, destructive, and sometimes fatal cancers coming to the office in the last year,” he told this news organization.

“Pandemic-related treatment delay has caused increased suffering and morbidity for countless skin cancer patients across the U.S.,” he said. “In general, not treating skin cancer and hoping it’s not going to grow or having significant delays in treatment are a recipe for disastrous outcomes.”

That said, active monitoring may be appropriate “for select small cancers that tend to grow slowly in the very elderly,” added Dr. Rogers, the incoming ACMS president. Among the key situations where the benefits of active monitoring may outweigh the risks of surgery are small, slowly growing cancers, when frailty is an issue.

Frailty has been equated to compromised functionality, which can increase the risk of an array of complications, including prolonged wound healing and secondary complications stemming from immobility. The toll those issues can take on patients’ quality of life can be considerable, Dr. Rogers said.

When weighing treatment options with elderly patients, he emphasized that careful consideration should be given to whether the “time needed to benefit from a Mohs procedure is longer than the patient’s life expectancy.” Furthermore, a decision not to treat does not have to be the last word. “We need to have an honest dialogue on the consequences of nontreatment, but part of that should be that just because we don’t treat today, doesn’t mean we can’t treat it tomorrow, if necessary.”

Of note, he added, “more than 100,00 patients have surgery for basal cell carcinoma [BCC] in their last year of life.” And that figure will likely rise exponentially if population projections come to fruition, considering that the population of people over the age of 85 is predicted to increase to nearly 18 million in 2050, from 5.8 million in 2012, Dr. Rogers said.

Until more research emerges on how to best treat this age group, Dr. Rogers noted that experts recommend that for elderly patients, “treatment should be individualized with consideration of active monitoring of primary BCC that is not in the H-zone, asymptomatic, smaller than 1 cm, with treatment initiated if there is substantial growth or symptoms.” Ultimately, he urged surgeons to “be sensitive and treat our patients like ourselves or our family members.”
 

When appropriate – Mohs is safe in the very elderly

Taking on the issue in a separate presentation, Deborah MacFarlane, MD, professor of dermatology and head and neck surgery at MD Anderson Cancer Center, Houston, said that for skin cancer cases that warrant treatment, clinicians should not let age alone stand in the way of Mohs surgery.

The evidence of its safety in the elderly dates back to a paper published in 1997 that Dr. MacFarlane coauthored, describing Mohs surgery of BCCs, squamous cell cancers (SCCs), and melanomas among 115 patients aged 90 and older (average, 92.4 years) who had an average of 1.9 comorbid medical conditions, and were taking an average of 2.3 medications. “Overall, we had just one complication among the patients,” she said.

In a subsequent paper, Dr. MacFarlane and her colleagues found that age at the time of Mohs surgery, even in older patients, was unrelated to survival, stage of cancer, or the type of repair. “We have concluded that this rapidly growing segment of the population can undergo Mohs surgery and should not be relegated to less effective treatment out of fear of its affecting their survival,” Dr. MacFarlane said.

She agreed with the concern about frailty and hence functionality, which may need to be factored in when making a decision to perform Mohs surgery. “I think this is something we do intuitively anyway,” she added. “We’re going to offer Mohs to someone who we think will survive and who is in relatively good health,” Dr. MacFarlane noted.

The point is illustrated in a new multicenter study of 1,181 patients at 22 U.S. sites, aged 85 years and older with nonmelanoma skin cancer referred for Mohs surgery. In the study, published in JAMA Dermatology after the ACMS meeting, patients who had Mohs surgery were almost four times more likely to have high functional status (P < .001) and were more likely to have facial tumors (P < .001), compared with those who had an alternate surgery.

The main reasons provided by the surgeons for opting to treat with Mohs included a patient’s desire for treatment with a high cure rate (66%), good/excellent patient functional status for age (57%), and a high risk associated with the tumor based on histology (40%), noted Dr. MacFarlane, one of the authors.

She reiterated the point raised by Dr. Rogers that “this is something we’re going to increasingly face,” noting that people over 85 represent the fastest growing segment of the population. “I have more patients over the age of 100 than I’ve ever had before,” she said.

Nevertheless, her own experience with elderly patients speaks to the safety of Mohs surgery in this population: Dr. MacFarlane reported a review of her practice’s records of 171 patients aged 85 years and older between May 2016 and May 2022, who received 414 separate procedures, without a single complication.

Sharing many of Dr. Rogers’ concerns about using caution in at-risk patients, Dr. MacFarlane offered recommendations for the optimal treatment of elderly patients receiving Mohs, including handling tissue delicately, and “keep undermining to a minimum.” She noted that intermediate closures and full thickness skin grafts are ideal closures for the elderly, while flaps may be performed in selected robust skin. It is also important to involve caretakers from the onset, talk and listen to patients – and play their choice of music during treatment, she said.

Commenting on the debate, comoderator Nahid Y. Vidal, MD, of the department of dermatology, Mayo Clinic, Rochester, Minn., noted that the expanding older population is accompanied by increases in skin cancer, in addition to more immunosenescence that is related to development of infections, autoimmune disease, and malignant tumors.

“In our academic practice, as with both the reference speakers, we do frequently see elderly, and not uncommonly the super-elderly,” she told this news organization. “The take-home point for me is to treat your whole patient, not just the tumor,” considering social factors, frailty/spry factor, and preferences, “and to do the humanistic thing, while also remaining evidence based,” she said.

“Don’t assume that increased age translates to morbidity, worse outcomes, or futility of treatment,” she added. “Chances are, if [a patient] made it to 90 years old with only a few medications and few medical problems, they may make it to 100, so why put the patient at risk for metastasis and death from a treatable/curable skin cancer,” in the case of SCC, she said.

“By the same token, why not perform more conservative treatments such as ED&C [electrodesiccation and curettage] for very low-risk skin cancers in low-risk locations, such as a superficial basal cell carcinoma on the trunk?” Overall, instead of trying to determine how long a super-elderly individual will live, Dr. Vidal said that “it’s better to educate the patient, engage in a discussion about goals of care, and to make few assumptions.”

Dr. Rogers, Dr. MacFarlane, and Dr. Vidal report no disclosures.

A version of this article first appeared on Medscape.com.

SAN DIEGO – Twelve years ago, Merete Haedersdal, MD, PhD, and colleagues published data from a swine study, which showed for the first time that the ablative fractional laser can be used to boost the uptake of drugs into the skin.

That discovery paved the way for what are now well-established clinical applications of laser-assisted drug delivery for treating actinic keratoses and scars. According to Dr. Haedersdal, professor of dermatology at the University of Copenhagen, evolving clinical indications for laser-assisted drug delivery include rejuvenation, local anesthesia, melasma, onychomycosis, hyperhidrosis, alopecia, and vitiligo, while emerging indications include treatment of skin cancer with PD-1 inhibitors and combination chemotherapy regimens, and vaccinations.

During a presentation at the annual conference of the American Society for Laser Medicine and Surgery, she said that researchers have much to learn about laser-assisted drug delivery, including biodistribution of the drug being delivered. Pointing out that so far, “what we have been dealing with is primarily looking at the skin as a black box,” she asked, “what happens when we drill the holes and drugs are applied on top of the skin and swim through the tiny channels?”

By using high-performance liquid chromatography (HPLC) and HPLC mass spectrometry to measure drug concentration in the skin, she and her colleagues have observed enhanced uptake of drugs – 4-fold to 40-fold greater – primarily in ex vivo pig skin. “We do know from ex vivo models that it’s much easier to boost the uptake in the skin” when compared with in vivo human use, where much lower drug concentrations are detected, said Dr. Haedersdal, who, along with Emily Wenande, MD, PhD, and R. Rox Anderson, MD, at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston, authored a clinical review, published in 2020, on the basics of laser-assisted drug delivery.

“What we are working on now is visualizing what’s taking place when we apply the holes and the drugs in the skin. This is the key to tailoring laser-assisted uptake to specific dermatologic diseases being treated,” she said. To date, she and her colleagues have examined the interaction with tissue using different devices, including ex vivo confocal microscopy, to view the thermal response to ablative fractional laser and radiofrequency. “We want to take that to the next level and look at the drug biodistribution.”

Efforts are underway to compare the pattern of drug distribution with different modes of delivery, such as comparing ablative fractional laser to intradermal needle injection. “We are also working on pneumatic jet injection, which creates a focal drug distribution,” said Dr. Haedersdal, who is a visiting scientist at the Wellman Center. “In the future, we may take advantage of device-tailored biodistribution, depending on which clinical indication we are treating.”

Another important aspect to consider is drug retention in the skin. In a study presented as an abstract at the meeting, led by Dr. Wenande, she, Dr. Haedersdal, and colleagues used a pig model to evaluate the effect of three vasoregulative interventions on ablative fractional laser-assisted 5-fluororacil concentrations in in vivo skin. The three interventions were brimonidine 0.33% solution, epinephrine 10 mcg/mL gel, and a 595-nm pulsed dye laser (PDL) in designated treatment areas.

“What we learned from that was in the short term – 1-4 hours – the ablative fractional laser enhanced the uptake of 5-FU, but it was very transient,” with a twofold increased concentration of 5-FU, Dr. Haedersdal said. Over 48-72 hours, after PDL, there was “sustained enhancement of drug in the skin by three to four times,” she noted.

The synergy of systemic drugs with ablative fractional laser therapy is also being evaluated. In a mouse study led by Dr. Haedersdal’s colleague, senior researcher Uffe H. Olesen, PhD, the treatment of advanced squamous cell carcinoma tumors with a combination of ablative fractional laser and systemic treatment with PD-1 inhibitors resulted in the clearance of more tumors than with either treatment as monotherapy. “What we want to explore is the laser-induced tumor immune response in keratinocyte cancers,” she added.

“When you shine the laser on the skin, there is a robust increase of neutrophilic granulocytes.” Combining this topical immune-boosting response with systemic delivery of PD-1 inhibitors in a mouse model with basal cell carcinoma, she said, “we learned that, when we compare systemic PD-1 inhibitors alone to the laser alone and then with combination therapy, there was an increased tumor clearance of basal cell carcinomas and also enhanced survival of the mice” with the combination, she said. There were also “enhanced neutrophilic counts and both CD4- and CD8-positive cells were increased,” she added.

Dr. Haedersdal disclosed that she has received grants or research funding from Lutronic, Venus Concept, Leo Pharma, and Mirai Medical.

SAN DIEGO – Twelve years ago, Merete Haedersdal, MD, PhD, and colleagues published data from a swine study, which showed for the first time that the ablative fractional laser can be used to boost the uptake of drugs into the skin.

That discovery paved the way for what are now well-established clinical applications of laser-assisted drug delivery for treating actinic keratoses and scars. According to Dr. Haedersdal, professor of dermatology at the University of Copenhagen, evolving clinical indications for laser-assisted drug delivery include rejuvenation, local anesthesia, melasma, onychomycosis, hyperhidrosis, alopecia, and vitiligo, while emerging indications include treatment of skin cancer with PD-1 inhibitors and combination chemotherapy regimens, and vaccinations.

During a presentation at the annual conference of the American Society for Laser Medicine and Surgery, she said that researchers have much to learn about laser-assisted drug delivery, including biodistribution of the drug being delivered. Pointing out that so far, “what we have been dealing with is primarily looking at the skin as a black box,” she asked, “what happens when we drill the holes and drugs are applied on top of the skin and swim through the tiny channels?”

By using high-performance liquid chromatography (HPLC) and HPLC mass spectrometry to measure drug concentration in the skin, she and her colleagues have observed enhanced uptake of drugs – 4-fold to 40-fold greater – primarily in ex vivo pig skin. “We do know from ex vivo models that it’s much easier to boost the uptake in the skin” when compared with in vivo human use, where much lower drug concentrations are detected, said Dr. Haedersdal, who, along with Emily Wenande, MD, PhD, and R. Rox Anderson, MD, at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston, authored a clinical review, published in 2020, on the basics of laser-assisted drug delivery.

“What we are working on now is visualizing what’s taking place when we apply the holes and the drugs in the skin. This is the key to tailoring laser-assisted uptake to specific dermatologic diseases being treated,” she said. To date, she and her colleagues have examined the interaction with tissue using different devices, including ex vivo confocal microscopy, to view the thermal response to ablative fractional laser and radiofrequency. “We want to take that to the next level and look at the drug biodistribution.”

Efforts are underway to compare the pattern of drug distribution with different modes of delivery, such as comparing ablative fractional laser to intradermal needle injection. “We are also working on pneumatic jet injection, which creates a focal drug distribution,” said Dr. Haedersdal, who is a visiting scientist at the Wellman Center. “In the future, we may take advantage of device-tailored biodistribution, depending on which clinical indication we are treating.”

Another important aspect to consider is drug retention in the skin. In a study presented as an abstract at the meeting, led by Dr. Wenande, she, Dr. Haedersdal, and colleagues used a pig model to evaluate the effect of three vasoregulative interventions on ablative fractional laser-assisted 5-fluororacil concentrations in in vivo skin. The three interventions were brimonidine 0.33% solution, epinephrine 10 mcg/mL gel, and a 595-nm pulsed dye laser (PDL) in designated treatment areas.

“What we learned from that was in the short term – 1-4 hours – the ablative fractional laser enhanced the uptake of 5-FU, but it was very transient,” with a twofold increased concentration of 5-FU, Dr. Haedersdal said. Over 48-72 hours, after PDL, there was “sustained enhancement of drug in the skin by three to four times,” she noted.

The synergy of systemic drugs with ablative fractional laser therapy is also being evaluated. In a mouse study led by Dr. Haedersdal’s colleague, senior researcher Uffe H. Olesen, PhD, the treatment of advanced squamous cell carcinoma tumors with a combination of ablative fractional laser and systemic treatment with PD-1 inhibitors resulted in the clearance of more tumors than with either treatment as monotherapy. “What we want to explore is the laser-induced tumor immune response in keratinocyte cancers,” she added.

“When you shine the laser on the skin, there is a robust increase of neutrophilic granulocytes.” Combining this topical immune-boosting response with systemic delivery of PD-1 inhibitors in a mouse model with basal cell carcinoma, she said, “we learned that, when we compare systemic PD-1 inhibitors alone to the laser alone and then with combination therapy, there was an increased tumor clearance of basal cell carcinomas and also enhanced survival of the mice” with the combination, she said. There were also “enhanced neutrophilic counts and both CD4- and CD8-positive cells were increased,” she added.

Dr. Haedersdal disclosed that she has received grants or research funding from Lutronic, Venus Concept, Leo Pharma, and Mirai Medical.

SAN DIEGO – Twelve years ago, Merete Haedersdal, MD, PhD, and colleagues published data from a swine study, which showed for the first time that the ablative fractional laser can be used to boost the uptake of drugs into the skin.

That discovery paved the way for what are now well-established clinical applications of laser-assisted drug delivery for treating actinic keratoses and scars. According to Dr. Haedersdal, professor of dermatology at the University of Copenhagen, evolving clinical indications for laser-assisted drug delivery include rejuvenation, local anesthesia, melasma, onychomycosis, hyperhidrosis, alopecia, and vitiligo, while emerging indications include treatment of skin cancer with PD-1 inhibitors and combination chemotherapy regimens, and vaccinations.

During a presentation at the annual conference of the American Society for Laser Medicine and Surgery, she said that researchers have much to learn about laser-assisted drug delivery, including biodistribution of the drug being delivered. Pointing out that so far, “what we have been dealing with is primarily looking at the skin as a black box,” she asked, “what happens when we drill the holes and drugs are applied on top of the skin and swim through the tiny channels?”

By using high-performance liquid chromatography (HPLC) and HPLC mass spectrometry to measure drug concentration in the skin, she and her colleagues have observed enhanced uptake of drugs – 4-fold to 40-fold greater – primarily in ex vivo pig skin. “We do know from ex vivo models that it’s much easier to boost the uptake in the skin” when compared with in vivo human use, where much lower drug concentrations are detected, said Dr. Haedersdal, who, along with Emily Wenande, MD, PhD, and R. Rox Anderson, MD, at the Wellman Center for Photomedicine, at Massachusetts General Hospital, Boston, authored a clinical review, published in 2020, on the basics of laser-assisted drug delivery.

“What we are working on now is visualizing what’s taking place when we apply the holes and the drugs in the skin. This is the key to tailoring laser-assisted uptake to specific dermatologic diseases being treated,” she said. To date, she and her colleagues have examined the interaction with tissue using different devices, including ex vivo confocal microscopy, to view the thermal response to ablative fractional laser and radiofrequency. “We want to take that to the next level and look at the drug biodistribution.”

Efforts are underway to compare the pattern of drug distribution with different modes of delivery, such as comparing ablative fractional laser to intradermal needle injection. “We are also working on pneumatic jet injection, which creates a focal drug distribution,” said Dr. Haedersdal, who is a visiting scientist at the Wellman Center. “In the future, we may take advantage of device-tailored biodistribution, depending on which clinical indication we are treating.”

Another important aspect to consider is drug retention in the skin. In a study presented as an abstract at the meeting, led by Dr. Wenande, she, Dr. Haedersdal, and colleagues used a pig model to evaluate the effect of three vasoregulative interventions on ablative fractional laser-assisted 5-fluororacil concentrations in in vivo skin. The three interventions were brimonidine 0.33% solution, epinephrine 10 mcg/mL gel, and a 595-nm pulsed dye laser (PDL) in designated treatment areas.

“What we learned from that was in the short term – 1-4 hours – the ablative fractional laser enhanced the uptake of 5-FU, but it was very transient,” with a twofold increased concentration of 5-FU, Dr. Haedersdal said. Over 48-72 hours, after PDL, there was “sustained enhancement of drug in the skin by three to four times,” she noted.

The synergy of systemic drugs with ablative fractional laser therapy is also being evaluated. In a mouse study led by Dr. Haedersdal’s colleague, senior researcher Uffe H. Olesen, PhD, the treatment of advanced squamous cell carcinoma tumors with a combination of ablative fractional laser and systemic treatment with PD-1 inhibitors resulted in the clearance of more tumors than with either treatment as monotherapy. “What we want to explore is the laser-induced tumor immune response in keratinocyte cancers,” she added.

“When you shine the laser on the skin, there is a robust increase of neutrophilic granulocytes.” Combining this topical immune-boosting response with systemic delivery of PD-1 inhibitors in a mouse model with basal cell carcinoma, she said, “we learned that, when we compare systemic PD-1 inhibitors alone to the laser alone and then with combination therapy, there was an increased tumor clearance of basal cell carcinomas and also enhanced survival of the mice” with the combination, she said. There were also “enhanced neutrophilic counts and both CD4- and CD8-positive cells were increased,” she added.

Dr. Haedersdal disclosed that she has received grants or research funding from Lutronic, Venus Concept, Leo Pharma, and Mirai Medical.

Patients receiving treatment with ibrutinib for chronic lymphocytic leukemia (CLL) show significant increases in the risk for bleeding when undergoing Mohs micrographic surgery for skin cancer, indicating the need for temporary treatment interruptions, new research shows.

“Our cohort of CLL patients on ibrutinib had a two-times greater risk of bleeding complications relative to those on anticoagulants and a nearly 40-times greater risk of bleeding complications relative to those patients on no anticoagulants or CLL therapy,” Kelsey E. Hirotsu, MD, first author of one of two studies on the issue presented at the American College of Mohs Surgery annual meeting, told this news organization.

“It was definitely surprising to see this doubled risk with ibrutinib relative to anticoagulants, and certainly highlights the clinically relevant increased bleeding risk in patients on ibrutinib,” said Dr. Hirotsu, a Mohs micrographic surgery fellow in the department of dermatology, University of California, San Diego (UCSD).

With CLL associated with an increased risk for aggressive skin cancers, particularly squamous cell carcinoma, Mohs surgeons may commonly find themselves treating patients with these unique considerations. Surgical treatment of those cancers can be complicated not only because of potential underlying thrombocytopenia, which occurs in about 5% of untreated CLL patients, but also because of the increased risk for bleeding that is associated with the use of the Bruton tyrosine kinase inhibitor ibrutinib, commonly used for CLL.

While the nature of the increased bleeding-related complications among patients with CLL undergoing Mohs surgery has been documented in some case reports, evidence from larger studies has been lacking.

In one of the studies presented at the ACMS meeting, Dr. Hirotsu and her colleagues evaluated data on patients with CLL who underwent at least one Mohs surgery procedure at UCSD Dermatologic Surgery over 10 years. Of the 362 Mohs cases among 98 patients with CLL, 32 cases had at least one complication. Patients on anticoagulants, including antiplatelet agents, Coumadin, and direct oral anticoagulants (DOACs), not surprisingly, had higher rates of complications, particularly bleeding.

However, those treated with ibrutinib had the highest rates of complications among all of the patients (40.6%), with all of their complications involving bleeding-related events. In comparison, the complication rates, for instance, of patients treated with antiplatelets were 21.9%; Coumadin, 6.2%; and DOACs, 15.6%.

The incidence of bleeding-related complications among the cases in the ibrutinib-treated patients was 30.2% compared with 13.2% among those on blood thinners and no CLL therapy (relative risk [RR], 2.08; 95% confidence interval [CI], 0.85-5.11; P = .11). “Although not statistically significant, these results could trend toward significance with larger sample sizes,” Dr. Hirotsu said.

The risk for bleeding among patients on ibrutinib compared with patients on no medications, however, was significant, with a relative risk of 39.0 (95% CI, 2.35-646; P = .011).

Of note, among 12 patients on ibrutinib who experienced bleeding complications, 7 had previously undergone Mohs surgeries when they were not taking ibrutinib and no bleeding complications had occurred in those procedures. “This may further implicate ibrutinib as a cause of the bleeding-related complications,” Dr. Hirotsu said.

In investigating the role of thrombocytopenia at the time of Mohs surgery, the authors found that, among ibrutinib-treated patients who had no complications, 30% had thrombocytopenia, compared with 70% of those who did have bleeding while on ibrutinib at the time of surgery.

“It was interesting that thrombocytopenia is more common in ibrutinib patients with bleeding-related complications, but further research needs to be done to determine the clinical relevance and possible management implications,” Dr. Hirotsu said.

In a separate study presented at the meeting, 37 patients treated with ibrutinib for CLL while undergoing cutaneous surgery that included Mohs surgery and excisions had a significantly increased bleeding complication rate compared with a control group of 64 age- and sex-matched patients with CLL undergoing cutaneous surgery: 6 of 75 procedures (8%) versus 1 of 115 procedures (0.9%; P = .02).

Those with bleeding complications while on ibrutinib were all male, older (mean age, 82.7 vs. 73.0; P = .01), and had lower mean platelet counts (104 K/mcL vs. 150.5 K/mcL; P = .03).

There were no significant differences between the case and control groups in terms of anatomic site, type of procedure (Mohs versus excision), tumor diagnosis, lesion size, or type of reconstruction, while the control group was more likely to be on aspirin or other anticoagulants (P < .0001).

In an interview, senior author Nahid Y. Vidal, MD, a Mohs surgeon and dermatologic oncologist at the Mayo Clinic, Rochester, Minn., said that “the take-home message is that patients on ibrutinib should be considered higher risk for bleeding events, regardless of whether they are having a simpler surgery [excision] or more involved skin surgery procedure [Mohs with flap].”

Holding treatment

To offset the bleeding risk, Dr. Vidal notes that holding the treatment is considered safe and that the manufacturer recommends holding ibrutinib for at least 3-7 days pre- and post surgery, “depending on type of surgery and risk of bleeding.”

“In our institution, with the hematologist/oncologist’s input, we hold ibrutinib for 5 days preop and 3 days post op, and have not had bleed complications in these patients,” she said, noting that there were no bleeding events in the patients in the study when ibrutinib was held.

Likewise, Dr. Hirotsu noted that at her center at UCSD, patients on ibrutinib are asked during the preop call to hold treatment for 3 days before and after Mohs surgery – but are advised to discuss the decision with their hematologist/oncologist for approval.

The measure isn’t always successful in preventing bleeding, however, as seen in a case study describing two patients who experienced bleeding complications following Mohs surgery despite being taken off ibrutinib 3 days prior to the procedure.

The senior author of that study, Kira Minkis, MD, PhD, department of dermatology, Weill Cornell/New York Presbyterian, New York, told this news organization that her team concluded that in those cases ibrutinib perhaps should have been held longer than 3 days.

“In some cases, especially if the Mohs surgery is a large procedure with a more advanced reconstruction, such as a large flap, it might be more prudent to continue it longer than 3 days,” Dr. Minkis said. She noted that the high bleeding risk observed in the studies at ACMS was notable – but not unexpected.

“I’m not that surprised because if you look at the hematologic literature, the risk is indeed pretty significant, so it makes sense that it would also occur with Mohs surgeries,” she said.

She underscored that a 3-day hold of ibrutinib should be considered the minimum, “and in some cases, it should be held up to 7 days prior to surgery, depending on the specific surgery,” with the important caveat of consulting with the patient’s hematology team.

“Multidisciplinary decision-making is necessary for these cases, and the interruption of therapy should always be discussed with their hematology team,” she added. That said, Dr. Minkis noted that “I’ve never had a hematologist who had any concerns for withholding ibrutinib even for a week around the time of a surgery.”

Dr. Hirotsu, Dr. Vidal, and Dr. Minkis reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patients receiving treatment with ibrutinib for chronic lymphocytic leukemia (CLL) show significant increases in the risk for bleeding when undergoing Mohs micrographic surgery for skin cancer, indicating the need for temporary treatment interruptions, new research shows.

“Our cohort of CLL patients on ibrutinib had a two-times greater risk of bleeding complications relative to those on anticoagulants and a nearly 40-times greater risk of bleeding complications relative to those patients on no anticoagulants or CLL therapy,” Kelsey E. Hirotsu, MD, first author of one of two studies on the issue presented at the American College of Mohs Surgery annual meeting, told this news organization.

“It was definitely surprising to see this doubled risk with ibrutinib relative to anticoagulants, and certainly highlights the clinically relevant increased bleeding risk in patients on ibrutinib,” said Dr. Hirotsu, a Mohs micrographic surgery fellow in the department of dermatology, University of California, San Diego (UCSD).

With CLL associated with an increased risk for aggressive skin cancers, particularly squamous cell carcinoma, Mohs surgeons may commonly find themselves treating patients with these unique considerations. Surgical treatment of those cancers can be complicated not only because of potential underlying thrombocytopenia, which occurs in about 5% of untreated CLL patients, but also because of the increased risk for bleeding that is associated with the use of the Bruton tyrosine kinase inhibitor ibrutinib, commonly used for CLL.

While the nature of the increased bleeding-related complications among patients with CLL undergoing Mohs surgery has been documented in some case reports, evidence from larger studies has been lacking.

In one of the studies presented at the ACMS meeting, Dr. Hirotsu and her colleagues evaluated data on patients with CLL who underwent at least one Mohs surgery procedure at UCSD Dermatologic Surgery over 10 years. Of the 362 Mohs cases among 98 patients with CLL, 32 cases had at least one complication. Patients on anticoagulants, including antiplatelet agents, Coumadin, and direct oral anticoagulants (DOACs), not surprisingly, had higher rates of complications, particularly bleeding.

However, those treated with ibrutinib had the highest rates of complications among all of the patients (40.6%), with all of their complications involving bleeding-related events. In comparison, the complication rates, for instance, of patients treated with antiplatelets were 21.9%; Coumadin, 6.2%; and DOACs, 15.6%.

The incidence of bleeding-related complications among the cases in the ibrutinib-treated patients was 30.2% compared with 13.2% among those on blood thinners and no CLL therapy (relative risk [RR], 2.08; 95% confidence interval [CI], 0.85-5.11; P = .11). “Although not statistically significant, these results could trend toward significance with larger sample sizes,” Dr. Hirotsu said.

The risk for bleeding among patients on ibrutinib compared with patients on no medications, however, was significant, with a relative risk of 39.0 (95% CI, 2.35-646; P = .011).

Of note, among 12 patients on ibrutinib who experienced bleeding complications, 7 had previously undergone Mohs surgeries when they were not taking ibrutinib and no bleeding complications had occurred in those procedures. “This may further implicate ibrutinib as a cause of the bleeding-related complications,” Dr. Hirotsu said.

In investigating the role of thrombocytopenia at the time of Mohs surgery, the authors found that, among ibrutinib-treated patients who had no complications, 30% had thrombocytopenia, compared with 70% of those who did have bleeding while on ibrutinib at the time of surgery.

“It was interesting that thrombocytopenia is more common in ibrutinib patients with bleeding-related complications, but further research needs to be done to determine the clinical relevance and possible management implications,” Dr. Hirotsu said.

In a separate study presented at the meeting, 37 patients treated with ibrutinib for CLL while undergoing cutaneous surgery that included Mohs surgery and excisions had a significantly increased bleeding complication rate compared with a control group of 64 age- and sex-matched patients with CLL undergoing cutaneous surgery: 6 of 75 procedures (8%) versus 1 of 115 procedures (0.9%; P = .02).

Those with bleeding complications while on ibrutinib were all male, older (mean age, 82.7 vs. 73.0; P = .01), and had lower mean platelet counts (104 K/mcL vs. 150.5 K/mcL; P = .03).

There were no significant differences between the case and control groups in terms of anatomic site, type of procedure (Mohs versus excision), tumor diagnosis, lesion size, or type of reconstruction, while the control group was more likely to be on aspirin or other anticoagulants (P < .0001).

In an interview, senior author Nahid Y. Vidal, MD, a Mohs surgeon and dermatologic oncologist at the Mayo Clinic, Rochester, Minn., said that “the take-home message is that patients on ibrutinib should be considered higher risk for bleeding events, regardless of whether they are having a simpler surgery [excision] or more involved skin surgery procedure [Mohs with flap].”

Holding treatment

To offset the bleeding risk, Dr. Vidal notes that holding the treatment is considered safe and that the manufacturer recommends holding ibrutinib for at least 3-7 days pre- and post surgery, “depending on type of surgery and risk of bleeding.”

“In our institution, with the hematologist/oncologist’s input, we hold ibrutinib for 5 days preop and 3 days post op, and have not had bleed complications in these patients,” she said, noting that there were no bleeding events in the patients in the study when ibrutinib was held.

Likewise, Dr. Hirotsu noted that at her center at UCSD, patients on ibrutinib are asked during the preop call to hold treatment for 3 days before and after Mohs surgery – but are advised to discuss the decision with their hematologist/oncologist for approval.

The measure isn’t always successful in preventing bleeding, however, as seen in a case study describing two patients who experienced bleeding complications following Mohs surgery despite being taken off ibrutinib 3 days prior to the procedure.

The senior author of that study, Kira Minkis, MD, PhD, department of dermatology, Weill Cornell/New York Presbyterian, New York, told this news organization that her team concluded that in those cases ibrutinib perhaps should have been held longer than 3 days.

“In some cases, especially if the Mohs surgery is a large procedure with a more advanced reconstruction, such as a large flap, it might be more prudent to continue it longer than 3 days,” Dr. Minkis said. She noted that the high bleeding risk observed in the studies at ACMS was notable – but not unexpected.

“I’m not that surprised because if you look at the hematologic literature, the risk is indeed pretty significant, so it makes sense that it would also occur with Mohs surgeries,” she said.

She underscored that a 3-day hold of ibrutinib should be considered the minimum, “and in some cases, it should be held up to 7 days prior to surgery, depending on the specific surgery,” with the important caveat of consulting with the patient’s hematology team.

“Multidisciplinary decision-making is necessary for these cases, and the interruption of therapy should always be discussed with their hematology team,” she added. That said, Dr. Minkis noted that “I’ve never had a hematologist who had any concerns for withholding ibrutinib even for a week around the time of a surgery.”

Dr. Hirotsu, Dr. Vidal, and Dr. Minkis reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Patients receiving treatment with ibrutinib for chronic lymphocytic leukemia (CLL) show significant increases in the risk for bleeding when undergoing Mohs micrographic surgery for skin cancer, indicating the need for temporary treatment interruptions, new research shows.

“Our cohort of CLL patients on ibrutinib had a two-times greater risk of bleeding complications relative to those on anticoagulants and a nearly 40-times greater risk of bleeding complications relative to those patients on no anticoagulants or CLL therapy,” Kelsey E. Hirotsu, MD, first author of one of two studies on the issue presented at the American College of Mohs Surgery annual meeting, told this news organization.

“It was definitely surprising to see this doubled risk with ibrutinib relative to anticoagulants, and certainly highlights the clinically relevant increased bleeding risk in patients on ibrutinib,” said Dr. Hirotsu, a Mohs micrographic surgery fellow in the department of dermatology, University of California, San Diego (UCSD).

With CLL associated with an increased risk for aggressive skin cancers, particularly squamous cell carcinoma, Mohs surgeons may commonly find themselves treating patients with these unique considerations. Surgical treatment of those cancers can be complicated not only because of potential underlying thrombocytopenia, which occurs in about 5% of untreated CLL patients, but also because of the increased risk for bleeding that is associated with the use of the Bruton tyrosine kinase inhibitor ibrutinib, commonly used for CLL.

While the nature of the increased bleeding-related complications among patients with CLL undergoing Mohs surgery has been documented in some case reports, evidence from larger studies has been lacking.

In one of the studies presented at the ACMS meeting, Dr. Hirotsu and her colleagues evaluated data on patients with CLL who underwent at least one Mohs surgery procedure at UCSD Dermatologic Surgery over 10 years. Of the 362 Mohs cases among 98 patients with CLL, 32 cases had at least one complication. Patients on anticoagulants, including antiplatelet agents, Coumadin, and direct oral anticoagulants (DOACs), not surprisingly, had higher rates of complications, particularly bleeding.

However, those treated with ibrutinib had the highest rates of complications among all of the patients (40.6%), with all of their complications involving bleeding-related events. In comparison, the complication rates, for instance, of patients treated with antiplatelets were 21.9%; Coumadin, 6.2%; and DOACs, 15.6%.

The incidence of bleeding-related complications among the cases in the ibrutinib-treated patients was 30.2% compared with 13.2% among those on blood thinners and no CLL therapy (relative risk [RR], 2.08; 95% confidence interval [CI], 0.85-5.11; P = .11). “Although not statistically significant, these results could trend toward significance with larger sample sizes,” Dr. Hirotsu said.

The risk for bleeding among patients on ibrutinib compared with patients on no medications, however, was significant, with a relative risk of 39.0 (95% CI, 2.35-646; P = .011).

Of note, among 12 patients on ibrutinib who experienced bleeding complications, 7 had previously undergone Mohs surgeries when they were not taking ibrutinib and no bleeding complications had occurred in those procedures. “This may further implicate ibrutinib as a cause of the bleeding-related complications,” Dr. Hirotsu said.

In investigating the role of thrombocytopenia at the time of Mohs surgery, the authors found that, among ibrutinib-treated patients who had no complications, 30% had thrombocytopenia, compared with 70% of those who did have bleeding while on ibrutinib at the time of surgery.

“It was interesting that thrombocytopenia is more common in ibrutinib patients with bleeding-related complications, but further research needs to be done to determine the clinical relevance and possible management implications,” Dr. Hirotsu said.

In a separate study presented at the meeting, 37 patients treated with ibrutinib for CLL while undergoing cutaneous surgery that included Mohs surgery and excisions had a significantly increased bleeding complication rate compared with a control group of 64 age- and sex-matched patients with CLL undergoing cutaneous surgery: 6 of 75 procedures (8%) versus 1 of 115 procedures (0.9%; P = .02).

Those with bleeding complications while on ibrutinib were all male, older (mean age, 82.7 vs. 73.0; P = .01), and had lower mean platelet counts (104 K/mcL vs. 150.5 K/mcL; P = .03).

There were no significant differences between the case and control groups in terms of anatomic site, type of procedure (Mohs versus excision), tumor diagnosis, lesion size, or type of reconstruction, while the control group was more likely to be on aspirin or other anticoagulants (P < .0001).

In an interview, senior author Nahid Y. Vidal, MD, a Mohs surgeon and dermatologic oncologist at the Mayo Clinic, Rochester, Minn., said that “the take-home message is that patients on ibrutinib should be considered higher risk for bleeding events, regardless of whether they are having a simpler surgery [excision] or more involved skin surgery procedure [Mohs with flap].”

Holding treatment

To offset the bleeding risk, Dr. Vidal notes that holding the treatment is considered safe and that the manufacturer recommends holding ibrutinib for at least 3-7 days pre- and post surgery, “depending on type of surgery and risk of bleeding.”

“In our institution, with the hematologist/oncologist’s input, we hold ibrutinib for 5 days preop and 3 days post op, and have not had bleed complications in these patients,” she said, noting that there were no bleeding events in the patients in the study when ibrutinib was held.

Likewise, Dr. Hirotsu noted that at her center at UCSD, patients on ibrutinib are asked during the preop call to hold treatment for 3 days before and after Mohs surgery – but are advised to discuss the decision with their hematologist/oncologist for approval.

The measure isn’t always successful in preventing bleeding, however, as seen in a case study describing two patients who experienced bleeding complications following Mohs surgery despite being taken off ibrutinib 3 days prior to the procedure.

The senior author of that study, Kira Minkis, MD, PhD, department of dermatology, Weill Cornell/New York Presbyterian, New York, told this news organization that her team concluded that in those cases ibrutinib perhaps should have been held longer than 3 days.

“In some cases, especially if the Mohs surgery is a large procedure with a more advanced reconstruction, such as a large flap, it might be more prudent to continue it longer than 3 days,” Dr. Minkis said. She noted that the high bleeding risk observed in the studies at ACMS was notable – but not unexpected.

“I’m not that surprised because if you look at the hematologic literature, the risk is indeed pretty significant, so it makes sense that it would also occur with Mohs surgeries,” she said.

She underscored that a 3-day hold of ibrutinib should be considered the minimum, “and in some cases, it should be held up to 7 days prior to surgery, depending on the specific surgery,” with the important caveat of consulting with the patient’s hematology team.

“Multidisciplinary decision-making is necessary for these cases, and the interruption of therapy should always be discussed with their hematology team,” she added. That said, Dr. Minkis noted that “I’ve never had a hematologist who had any concerns for withholding ibrutinib even for a week around the time of a surgery.”

Dr. Hirotsu, Dr. Vidal, and Dr. Minkis reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.