LETTERS AND COMMUNICATIONS
It is theorized that cumulative sun exposure is the primary risk factor for BCC because of the strong relationship between solar radiation and the development of BCC. However, the pattern of sun exposure (intermittent concentrated vs long term) varies as the primary etiology of BCC, from head to trunk. It is reasonable to say that our patient was exposed to intermittent concentrated patterns of non-solar UV radiation over a long-term period.
a subject of daily importance, UV-B exposure. This case demonstrates the clinical importance for obtaining a thorough history of all risks and contributing factors to fully understand, educate, and treat patients.
It is important to highlight that a certain amount of error naturally exists with UV exposure. Solar UV exposure can depend on many factors including altitude, latitude, cloud cover, time of day, season, and individual traits of an exposed person (i.e., skin type, ethnicity, age, exposure history, clothing, etc.).2 One limitation in this study is that the least-squares regression model does not take into account cloud cover, variation in seasons, and latitude.
References
Acknowledgments The authors thanks to Steven Turley, PhD, Physicist, BYU.
1. Uguccini O. An integrating sphere spectroradiometer for solar simulator measurements. Cleveland, OH: Lewis Research Center, 1968. 2. Rigel D, Rigel E, Rigel A. Effects of altitude and latitude on ambient UVB radiation. J Am Acad Dermatol 1999;40:114–6. 3. National Toxicology Program. Department of Heath and Human Services. Available from: http://ntp.niehs.nih.gov/ntp/roc/eleventh/ profiles/s183uvrr. Accessed April 1, 2008. 4. Wolfe C, Green W, Cognetta A, Hatfield H. Multiple squamous cell carcinomas and eruptive keratoacanthomas in an arc welder. Dermatol Surg 2013;39:328–30.
Carbon arc lamp UV-B exposure calculations can also vary depending on the type and power of carbon arc lamp movie projector, operator handling procedures, operator distance from UV source, time of exposure, pattern of exposure, and other factors such as spectral irradiance curves and estimations. From our mathematical calculations, it is conceivable that carbon arc lamp exposure could have been a significant factor contributing to an increased burden of BCCs. A review of the literature resulted in no significant studies of carbon arc lamps and BCC. It is believed by the authors that this is a rare source that encompasses
Marcus Harris, DO Family Medicine, Intermountain Clinics Ephraim, Utah Chris Cook, DO Lloyd Cleaver, DO, FAOCD Northeast Regional Medical Center Still University Kirksville, Missouri Chris Weyer, DO Dermatology and Plastic Surgery of Arizona Sierra Vista, Arizona
Antiseptic Use in Mohs and Reconstructive Surgery: An American College of Mohs Surgery Member Survey There are many antiseptic preparations available for cutaneous surgery, and studies to date have demonstrated significant variation in the steps taken by surgeons to prevent infection.1 The authors sought to determine the antiseptic practices of members of the American College of Mohs Surgery (ACMS) and to identify scrub preparation preference based on
164
surgeon demographics, anatomic site, and stage of surgery (Mohs vs reconstruction).
Methods An anonymous web-based 10-question survey was e-mailed to the members of the ACMS. Five questions
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
TABLE 1. Respondent Demographics N (%) Age, years #35
20 (11.8)
36–46
76 (45.0)
46–55
42 (25.4)
>56
30 (17.8)
anatomic sites. The remaining questions surveyed the associated side effects, changes made to the scrub preparation in the last year, and the use of perioperative intralesional antibiotic injections. Correlation between perioperative antiseptic preferences and demographic variables was evaluated using Fisher’s exact test with p < .05 being considered significant.
Gender Male
109 (64.9)
Female
Results
59 (35.1)
Practice environment Single private practice
35 (20.8)
Multispecialty group
22 (13.1)
Single-specialty group
68 (40.5)
Academic medical center
43 (25.6)
Year of fellowship training Before 1999
57 (34.3)
2000–2003
23 (13.9)
2004–2008 2009 or after
48 (28.9) 38 (22.9)
No. of Mohs surgeries per year 0–500
27 (16.0)
501–1,000
81 (47.9)
1,001–1,500
30 (17.8)
1,500+
30 (18.3)
were regarding the demographics of the surgeon including age, gender, practice environment, year of fellowship training, and annual number of surgeries. Two questions examined the antiseptic use when taking a Mohs layer and repairing the defect at various
Within the 2-month response time, 168 ACMS members responded to the survey. The majority of responders were between the ages of 36 and 55 years (70.4%) and were male (64.9%). The most common practice environment was a single-specialty group (40.5%) followed by an academic medical center (25.6%). Fellowship training was most commonly completed before 1999 (34.3%), and the majority of surgeons performed between 501 and 1,000 surgeries annually (47.9%) (Table 1). Except in the periocular area, the most common antiseptic used when taking a Mohs layer was Hibiclens (Mölnlycke Health Care, Norcross, GA) (4.0% chlorhexidine gluconate). Hibiclens was used by 67.3% of the responders on the head and neck and 73.5% on the torso or extremities. Povidone–iodine of 7.5% to 10% was the most commonly reported antiseptic used in the periocular area both when taking a Mohs layer and during defect reconstruction (58.7% and 65.0%, respectively). For defect reconstruction, Hibiclens
TABLE 2. Antiseptic for Mohs Layer and Defect Repair 7.5%–10% Povidone– Iodine, N (%)
5% Opthalmic Povidone–Iodine, N (%)
Hibiclens, N (%)
70% Isopropyl Alcohol, N (%)
Layer
25 (16.3)
1 (0.7)
103 (67.3)
17 (11.1)
7 (4.6)
Repair
34 (22.7)
1 (0.7)
105 (70.0)
3 (2.0)
7 (4.7)
Periocular Layer
84 (58.7)
13 (9.1)
25 (17.5)
21 (14.7)
0 (0)
Repair
93 (65.0)
16 (11.2)
26 (18.2)
7 (4.9)
1 (0.7)
Layer
20 (13.3)
0 (0)
111 (73.5)
13 (8.6)
7 (4.6)
Repair
24 (15.9)
0 (0)
114 (75.5)
1 (0.7)
12 (8.0)
ChloraPrep, N (%)
Head and neck, not periocular
Torso or extremities
pHisoHex was not included in the table because it was not reported by any of the responders.
41:1:JANUARY 2015
165
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
was also the most common antiseptic used on the head and neck, excluding the periocular area, and on the torso or extremities (70.0% and 75.5%, respectively) (Table 2). The majority of responders have not recently changed their scrub preparation (92.3%). Keratitis was reported as a side effect associated with Hibiclens by 2 responders. One responder reported keratitis associated with ChloraPrep (CareFusion, El Paso, TX). Nine responders reported hypersensitivity with Hibiclens and 5 with 7.5% to 10% povidone– iodine. The use of perioperative intralesional antibiotic injections was reported by 6.5% of the responders. The type of antiseptic used significantly differed by practice type only. Single-specialty groups were more likely than others to use 70% isopropyl alcohol instead of Hibiclens (head and neck, p = .004; and torso, p = .005).
and during defect reconstruction for all locations excluding the periocular area. Povidone–iodine of 7.5% to 10% is safely being used in the periocular area both when taking a Mohs layer and during defect reconstruction. The most commonly reported side effect associated with the use of Hibiclens was hypersensitivity, and the most serious side effect was keratitis. Similarly, hypersensitivity was the most common side effect associated with povidone–iodine. Acknowledgments The authors thank Emily Scherer, PhD, for her assistance in the statistical analysis.
Reference 1. Eisen D, Warshawski L, Zloty D, Azari R. Results of a survey regarding perioperative antiseptic practices. J Cutan Med Surg 2009; 13:134–9.
Discussion Several trends regarding the use of antiseptics by Mohs surgeons are evident. Although there are a variety of antiseptic techniques available, the majority of members of the ACMS who responded to the survey are safely using Hibiclens when taking a Mohs layer
Lindsey K. Collins, MD Thomas J. Knackstedt, MD Faramarz H. Samie, MD, PhD Section of Dermatology Dartmouth–Hitchcock Medical Center Lebanon, New Hampshire
Myxoid Neurofibroma Treated With Mohs Micrographic Surgery Myxoid neurofibroma is a rare variant of neurofibromas. Myxoid neurofibroma commonly presents as a solitary flesh-colored to pink or blue nodule.1 Lesions typically occur in adults with a predilection for the face, shoulders, and arms.1 Histologically, myxoid neurofibromas are composed mainly of S100 positive Schwann cells in a myxoid-rich matrix with focal delicate collagen fibers.2 Myxoid neurofibromas are usually treated with a standard excision. The authors report the first case treated with Mohs micrographic surgery (MMS).
The patient denied any pain or sensitivity. Over this 10-year course, the patient underwent 2 excisions of the lesion but had recurrences after
History and Course A 72-year-old man presented with a 10-year history of a slow-growing lesion on his dorsal nose.
166
Figure 1. Myxoid neurofibroma. Preoperative photograph.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
It is theorized that cumulative sun exposure is the primary risk factor for BCC because of the strong relationship between solar radiation and the development of BCC. However, the pattern of sun exposure (intermittent concentrated vs long term) varies as the primary etiology of BCC, from head to trunk. It is reasonable to say that our patient was exposed to intermittent concentrated patterns of non-solar UV radiation over a long-term period.
a subject of daily importance, UV-B exposure. This case demonstrates the clinical importance for obtaining a thorough history of all risks and contributing factors to fully understand, educate, and treat patients.
It is important to highlight that a certain amount of error naturally exists with UV exposure. Solar UV exposure can depend on many factors including altitude, latitude, cloud cover, time of day, season, and individual traits of an exposed person (i.e., skin type, ethnicity, age, exposure history, clothing, etc.).2 One limitation in this study is that the least-squares regression model does not take into account cloud cover, variation in seasons, and latitude.
References
Acknowledgments The authors thanks to Steven Turley, PhD, Physicist, BYU.
1. Uguccini O. An integrating sphere spectroradiometer for solar simulator measurements. Cleveland, OH: Lewis Research Center, 1968. 2. Rigel D, Rigel E, Rigel A. Effects of altitude and latitude on ambient UVB radiation. J Am Acad Dermatol 1999;40:114–6. 3. National Toxicology Program. Department of Heath and Human Services. Available from: http://ntp.niehs.nih.gov/ntp/roc/eleventh/ profiles/s183uvrr. Accessed April 1, 2008. 4. Wolfe C, Green W, Cognetta A, Hatfield H. Multiple squamous cell carcinomas and eruptive keratoacanthomas in an arc welder. Dermatol Surg 2013;39:328–30.
Carbon arc lamp UV-B exposure calculations can also vary depending on the type and power of carbon arc lamp movie projector, operator handling procedures, operator distance from UV source, time of exposure, pattern of exposure, and other factors such as spectral irradiance curves and estimations. From our mathematical calculations, it is conceivable that carbon arc lamp exposure could have been a significant factor contributing to an increased burden of BCCs. A review of the literature resulted in no significant studies of carbon arc lamps and BCC. It is believed by the authors that this is a rare source that encompasses
Marcus Harris, DO Family Medicine, Intermountain Clinics Ephraim, Utah Chris Cook, DO Lloyd Cleaver, DO, FAOCD Northeast Regional Medical Center Still University Kirksville, Missouri Chris Weyer, DO Dermatology and Plastic Surgery of Arizona Sierra Vista, Arizona
Antiseptic Use in Mohs and Reconstructive Surgery: An American College of Mohs Surgery Member Survey There are many antiseptic preparations available for cutaneous surgery, and studies to date have demonstrated significant variation in the steps taken by surgeons to prevent infection.1 The authors sought to determine the antiseptic practices of members of the American College of Mohs Surgery (ACMS) and to identify scrub preparation preference based on
164
surgeon demographics, anatomic site, and stage of surgery (Mohs vs reconstruction).
Methods An anonymous web-based 10-question survey was e-mailed to the members of the ACMS. Five questions
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
TABLE 1. Respondent Demographics N (%) Age, years #35
20 (11.8)
36–46
76 (45.0)
46–55
42 (25.4)
>56
30 (17.8)
anatomic sites. The remaining questions surveyed the associated side effects, changes made to the scrub preparation in the last year, and the use of perioperative intralesional antibiotic injections. Correlation between perioperative antiseptic preferences and demographic variables was evaluated using Fisher’s exact test with p < .05 being considered significant.
Gender Male
109 (64.9)
Female
Results
59 (35.1)
Practice environment Single private practice
35 (20.8)
Multispecialty group
22 (13.1)
Single-specialty group
68 (40.5)
Academic medical center
43 (25.6)
Year of fellowship training Before 1999
57 (34.3)
2000–2003
23 (13.9)
2004–2008 2009 or after
48 (28.9) 38 (22.9)
No. of Mohs surgeries per year 0–500
27 (16.0)
501–1,000
81 (47.9)
1,001–1,500
30 (17.8)
1,500+
30 (18.3)
were regarding the demographics of the surgeon including age, gender, practice environment, year of fellowship training, and annual number of surgeries. Two questions examined the antiseptic use when taking a Mohs layer and repairing the defect at various
Within the 2-month response time, 168 ACMS members responded to the survey. The majority of responders were between the ages of 36 and 55 years (70.4%) and were male (64.9%). The most common practice environment was a single-specialty group (40.5%) followed by an academic medical center (25.6%). Fellowship training was most commonly completed before 1999 (34.3%), and the majority of surgeons performed between 501 and 1,000 surgeries annually (47.9%) (Table 1). Except in the periocular area, the most common antiseptic used when taking a Mohs layer was Hibiclens (Mölnlycke Health Care, Norcross, GA) (4.0% chlorhexidine gluconate). Hibiclens was used by 67.3% of the responders on the head and neck and 73.5% on the torso or extremities. Povidone–iodine of 7.5% to 10% was the most commonly reported antiseptic used in the periocular area both when taking a Mohs layer and during defect reconstruction (58.7% and 65.0%, respectively). For defect reconstruction, Hibiclens
TABLE 2. Antiseptic for Mohs Layer and Defect Repair 7.5%–10% Povidone– Iodine, N (%)
5% Opthalmic Povidone–Iodine, N (%)
Hibiclens, N (%)
70% Isopropyl Alcohol, N (%)
Layer
25 (16.3)
1 (0.7)
103 (67.3)
17 (11.1)
7 (4.6)
Repair
34 (22.7)
1 (0.7)
105 (70.0)
3 (2.0)
7 (4.7)
Periocular Layer
84 (58.7)
13 (9.1)
25 (17.5)
21 (14.7)
0 (0)
Repair
93 (65.0)
16 (11.2)
26 (18.2)
7 (4.9)
1 (0.7)
Layer
20 (13.3)
0 (0)
111 (73.5)
13 (8.6)
7 (4.6)
Repair
24 (15.9)
0 (0)
114 (75.5)
1 (0.7)
12 (8.0)
ChloraPrep, N (%)
Head and neck, not periocular
Torso or extremities
pHisoHex was not included in the table because it was not reported by any of the responders.
41:1:JANUARY 2015
165
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
was also the most common antiseptic used on the head and neck, excluding the periocular area, and on the torso or extremities (70.0% and 75.5%, respectively) (Table 2). The majority of responders have not recently changed their scrub preparation (92.3%). Keratitis was reported as a side effect associated with Hibiclens by 2 responders. One responder reported keratitis associated with ChloraPrep (CareFusion, El Paso, TX). Nine responders reported hypersensitivity with Hibiclens and 5 with 7.5% to 10% povidone– iodine. The use of perioperative intralesional antibiotic injections was reported by 6.5% of the responders. The type of antiseptic used significantly differed by practice type only. Single-specialty groups were more likely than others to use 70% isopropyl alcohol instead of Hibiclens (head and neck, p = .004; and torso, p = .005).
and during defect reconstruction for all locations excluding the periocular area. Povidone–iodine of 7.5% to 10% is safely being used in the periocular area both when taking a Mohs layer and during defect reconstruction. The most commonly reported side effect associated with the use of Hibiclens was hypersensitivity, and the most serious side effect was keratitis. Similarly, hypersensitivity was the most common side effect associated with povidone–iodine. Acknowledgments The authors thank Emily Scherer, PhD, for her assistance in the statistical analysis.
Reference 1. Eisen D, Warshawski L, Zloty D, Azari R. Results of a survey regarding perioperative antiseptic practices. J Cutan Med Surg 2009; 13:134–9.
Discussion Several trends regarding the use of antiseptics by Mohs surgeons are evident. Although there are a variety of antiseptic techniques available, the majority of members of the ACMS who responded to the survey are safely using Hibiclens when taking a Mohs layer
Lindsey K. Collins, MD Thomas J. Knackstedt, MD Faramarz H. Samie, MD, PhD Section of Dermatology Dartmouth–Hitchcock Medical Center Lebanon, New Hampshire
Myxoid Neurofibroma Treated With Mohs Micrographic Surgery Myxoid neurofibroma is a rare variant of neurofibromas. Myxoid neurofibroma commonly presents as a solitary flesh-colored to pink or blue nodule.1 Lesions typically occur in adults with a predilection for the face, shoulders, and arms.1 Histologically, myxoid neurofibromas are composed mainly of S100 positive Schwann cells in a myxoid-rich matrix with focal delicate collagen fibers.2 Myxoid neurofibromas are usually treated with a standard excision. The authors report the first case treated with Mohs micrographic surgery (MMS).
The patient denied any pain or sensitivity. Over this 10-year course, the patient underwent 2 excisions of the lesion but had recurrences after
History and Course A 72-year-old man presented with a 10-year history of a slow-growing lesion on his dorsal nose.
166
Figure 1. Myxoid neurofibroma. Preoperative photograph.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
