Citations

BACKGROUND Guidelines and evidence related to antibiotic prophylaxis in dermatologic surgery have evolved since the authors' previously published advisory statement. OBJECTIVE To provide an updated advisory statement on antibiotic prophylaxis in dermatologic surgery as guided by updated recommendations from the American Heart Association and the American Dental Association with the American Academy of Orthopaedic Surgeons guidelines. METHODS A structured literature review was performed. A multidisciplinary team of specialists from dermatologic surgery, infectious diseases, and pharmacy were convened to review up-to-date data and develop updated comprehensive evidence-based recommendations. RESULTS Consistent with the previous advisory statement, prophylactic antibiotics are recommended for patients with high-risk cardiac or prosthetic joint conditions, when the dermatologic surgical site is infected or if the procedure breaches the mucosa. Significant changes were made for prophylaxis of surgical site infection. Updated recommendations were made regarding antibiotic selection in penicillin-allergic patients and intraoperative use of intraincisional clindamycin in the local anesthetic. LIMITATIONS Reviewed data are predominantly limited to retrospective data. CONCLUSION Recommendations regarding antibiotic prophylaxis around dermatologic surgery are evolving as new data and practices are introduced. The 2025 advisory statement provides the latest recommendations for appropriate use of antibiotic prophylaxis in dermatologic surgery.

This study used semi-structured interviews with 11 key opinion leaders to explore why dermatologist involvement in innovation remains limited despite growing investment in the field. It found that barriers such as limited early exposure to industry, time constraints and goal misalignment hinder engagement, but also highlighted solutions like integrating industry exposure into training and fostering new funding models. These findings suggest actionable strategies to bridge gaps between clinicians and industry and promote dermatological innovation.

BACKGROUND Approximately 10% of patients report penicillin allergy. Based on historical guidelines, patients with a penicillin allergy should receive an alternative to cephalexin for prophylaxis in dermatologic surgery. OBJECTIVE To determine, based on evidence, if cephalexin should be used as a first-line prophylactic antibiotic in dermatologic surgery for patients with penicillin allergy. METHODS Systematic review of the literature was performed with defined search terms. RESULTS Less than 5% of those with penicillin allergy labels have a true penicillin allergy. For patients with true, persistent penicillin allergy, there is an overall low cross-reactivity with cephalosporins, especially with cephalosporins that do not share identical R1 side chain. The first-generation cephalosporins, including cephalexin, have a slightly higher risk of cross-reactivity in patients with reported allergy to amino-penicillins (amoxicillin, ampicillin) but not other penicillins. The risk of severe cross-reactivity of cephalosporins in patients with low-risk penicillin allergies is extremely low. Cephalexin has a superior side effect profile and efficacy compared to alternatives. CONCLUSION Cephalexin should be used as the first-line prophylactic antibiotic in dermatologic surgery for patients with documented penicillin allergy, including anaphylaxis. There may be a higher risk of cross-reactivity with cephalexin in patients with a confirmed amino-penicillin allergy.

BACKGROUND Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.

BACKGROUND Limited data exist on sentinel lymph node biopsy (SLNB) for cutaneous squamous cell carcinoma (cSCC) of the head and neck. OBJECTIVE To review the results of SLNB for patients with cSCC of the head and neck at the authors’ institution. MATERIALS AND METHODS A retrospective review was completed for patients who underwent SLNB for cSCC of the head and neck over 19 years. Patient demographics, immune status, tumor stage, total patients with positive SLNB, local recurrence, nodal recurrence, in-transit metastasis, and disease-specific death were recorded. RESULTS Sixty patients underwent lymphoscintigraphy, and an SLN was identified in 58 patients. The mean follow-up was 3.2 years (range, 15 days–16 years). Four patients (6.9%) had a positive SLNB. All were Brigham and Women's Hospital (BWH) stage T2b tumors. Three of these patients were immunosuppressed, 3 patients underwent neck dissection, and 2 patients received adjuvant radiation. None developed local or regional recurrence. Of the 53 patients with a negative SLNB, there were 4 local recurrences, 2 in-transit metastases, and no nodal recurrences. CONCLUSION Immunosuppressed patients with tumors BWH stage T2b or greater may be a reasonable cohort to focus future prospective studies on the utility of SLNB in cSCC of the head and neck.

BACKGROUND Perioperative anxiety can negatively impact patient satisfaction and can complicate outpatient dermatologic procedures. OBJECTIVE Evaluate adverse events associated with oral midazolam as a perioperative anxiolytic during dermatologic surgery and assess whether an enhanced monitoring approach is associated with an increased detection rate. MATERIALS AND METHODS Five hundred cases (250 before and after change in monitoring) where patients were administered oral midazolam between July 2015 and May 2017 were retrospectively reviewed. The number of procedures, type of procedures, dose in milligrams, number of doses, major and minor adverse events, and vital signs were recorded. RESULTS The difference in number of treatment sites, types of procedures, and total dose administered was not significant. There were minor but significant differences in the mean change in blood pressure, heart rate, respiratory rate, and Richmond Agitation and Sedation Scale score before and after the procedure but not oxygen saturation. These vital sign changes were not clinically significant. There were zero major adverse events in both groups. There were 2 patients who became transiently hypoxic. CONCLUSION Oral midazolam administration was not associated with major adverse events including in the more intensively monitored group. This supports its use as an anxiolytic for outpatient dermatologic procedures.

Background Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy, but to the authors' knowledge, limited data exist regarding the safety and efficacy of these agents in transplant recipients. Herein, the authors have reported their experience with 17 patients who were treated with ICIs for metastatic malignancies after undergoing solid organ transplantation. Methods Data were abstracted for solid organ transplant recipients who received ICIs for the treatment of malignancy between January 1, 2016, and September 30, 2019. The authors identified 7 kidney, 8 liver, and 2 heart transplant recipients. Outcomes of interest were adverse drug reactions, cancer progression, and patient survival. Results The most common malignancies treated with ICIs were metastatic squamous cell carcinoma (5 patients; 29%) and hepatocellular carcinoma (5 patients; 29%), which were noted exclusively among liver transplant recipients. The median duration on ICIs was 1.7 months (interquartile range, 0.4‐7.6 months). Five patients (29%) developed adverse reactions, including 4 patients (24%) with immune‐related adverse events(irAEs), 3 patients (18%) with acute allograft rejections, 1 patient (6%) with autoimmune colitis, and 1 patient (6%) with ICI‐induced cardiotoxicity (the patient was a heart transplant recipient). The cumulative incidence of cancer progression was 50% and 69%, respectively, at 6 months and 12 months. Eleven patients (65%) died over the median follow‐up period of 4.6 months (interquartile range, 1.5‐13.2 months) from the time of ICI initiation, with cancer progression being the most common cause of death. Conclusions ICIs can be used as individualized therapy in selected patients who have undergone solid organ transplantation but more studies are needed to determine how best to use these agents to improve outcomes further.