Uso profiláctico de cremas antifungicas tópicas, para prevenir reinfección en onicomicosis.

Topical antifungal treatment prevents recurrence of toenail onychomycosis following cure

Authors

• First published: 30 August 2017 DOI: 10.1111/dth.12545  
• 
  

Abstract

Recurrence rates are high for onychomycosis, with prophylactic topical antifungal use proposed to counter recurrence. Although this is a reasonable action for many clinicians, few studies have been conducted on the efficacy of topical prophylaxis. A retrospective chart review (2010–2015) was conducted in patients receiving oral terbinafine or itraconazole for toenail onychomycosis. Following complete cure, a topical antifungal (amorolfine, bifonazole, ciclopirox olamine, or terbinafine spray) was used weekly as prophylaxis. Recurrence was recorded along with patient characteristics including demographics and concomitant medical conditions. Data from 320 patients were collected. Recurrence was significantly lower in patients receiving topical antifungal prophylaxis than in no prophylactic treatment following oral terbinafine (p < .001), but not itraconazole (p = .185). Regardless of oral treatment, the use of topical antifungals as prophylaxis (p < .001) decreased, and the number of affected toenails (p = .048) and family history of fungal infections (p < .001) increased the likelihood that recurrence would occur. This study supports the use of topical antifungal medications as prophylactic treatment to help prevent recurrence of toenail onychomycosis and suggests that those with a family history of fungal infections should be closely monitored.

No solo en Estados Unidos decae el sistema de salud, basándonos en métricas no adecuadas...

A Corrosive Force in Medical Care

It comes in a large white envelope each month. It's marked confidential.

When I hold it up to the light, I can see through the envelope. I can't see the details, but the colored graphs give it away.

It's my monthly productivity report based on relative value units (RVUs). Most employed doctors get these graphs.

These "dashboards" of value include your own productivity as well as many other graphs showing how you stack up with other doctors across the country. It tells your employer if you are a hard worker.

Doing an ablation, catheterization, or stent or valve replacement earns a bunch of RVUs.

Listening to patients, examining patients, counseling patients, or hugging patients earns very few RVUs.

Doing important research, teaching colleagues, and reading the medical evidence earns zero RVUs.

Too often, in too many medical systems, RVUs have become the primary unit of success.

No, you can't be a mean and nasty doctor. And no, you can't be a totally unskilled doctor who has too many complications.

But short of those extremes, if you make few waves, have good templates on your electronic health record so documentation is complete, and do tons of procedures, you are valuable.

If, on the other hand, you like slow, conservative medicine, or narrative notes rather than templates, or worse, if you are thoughtful and frank about silly policies, you become an outlier. If you do these things, your RVU tally usually does not reach the 75% of standard bar. Then trouble can come to you.

These trends are not so problematic for people close to the end of their career.

What's really scary, though, is that this is the milieu in which a younger generation of clinicians is learning the craft. I was shocked to learn that a major teaching center (which will remain nameless) compensates its teaching faculty solely on the basis of productivity. Imagine that. Educators whose paychecks are determined by the number of RVUs they generate rather than the bedside skills they impart to learners.

This, my friends, is happening in many of the places you go to get healthcare.

It's why I tweeted this recently.

Productivity and the RVU have no place in medical care. There needs to be a different system of valuing the care of people with disease.

Follow John Mandrola on Twitter.

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Alopecia, que hay de nuevo

Articulo de Doc check:

Alopecia: Hair Follicles, Wake Up!

Hair loss is more than just a cosmetic problem. People suffer mentally from having lack of hair. At present only a few medications exist for treating it. Biologists are now trying to manipulate the metabolism involved and to develop implants from stem cells.

An estimated 80 per cent of all men and 42 per cent of all women have to battle various versions of androgenetic alopecia. Whereas in the beginning men usually watch their hairline recede, women lose their hair predominantly in the middle crest region.

Currently hardly any space in which to work

Dermatologists have cast a critical eye over the already yellowing pages of the S3 guideline which deals with treatments for androgenetic alopecia. In their evaluation of literature sources, the authors found 396 articles, 85 papers of which fulfilled the methodological inclusion criteria. Ultimately only minoxidil and finasteride received good reviews.

Minoxidil is equally suitable for women and men. The prodrug minoxidil ends up, through the action of the enzyme sulfotransferase, becoming minoxidil sulfate in the follicles during anaphase. Blood circulation improves and cells increasingly excrete growth producing factors such as vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF). Moreover, protective prostaglandins are increasingly produced. In men the 5% formulation is more effective, the same formulation in women yields no significant added value when compared to 2% minoxidil. If patients discontinue using this preparation, their hair will increasingly fall out once again in the medium term.

For men suffering from hair loss, there is still another option. In the male metabolism dihydrotestosterone(DHT) is a centrally important molecule. DHT-sensitive follicles react by shortening their anagen phase, and the hair falls out faster. In addition there are indications of upregulation of the insulin-like growth factor 1 (IGF-1). Finasteride comes into the picture here. In being a 5α-reductase inhibitor it brings down the DHT level in the blood. Dutasteride has a similar effect, but has not been approved for use against androgenetic alopecia.

Association with erectile dysfunction

New studies have put finasteride and dutasteride in a bad light when used in men. Tina Kiguradze and William H. Temps from Northwestern University, Chicago, have found correlations with persistent erectile dysfunction (PED) for both pharmaceuticals. The US Food and Drug Administration had issued appropriate warnings earlier, albeit with a much poorer body of data. A large part of all studies had methodological distortions.

Kiguradze and Temps evaluated data from 11,909 men who for various reasons had been prescribed 5α-reductase inhibitor by a doctor. Their subjects were between 16 to 89 years of age. PED occurred with 167 people (1.4 percent). After discontinuation of the preparation, it took an average of 1,348 days for normal erections to return. This pharmacotherapy is therefore an individual and independent risk factor, according to the authors. They compare the effect to that of the negative consequences of type 2 diabetes, obesity, alcohol abuse or severe nicotine consumption. As far as physicians and pharmacists are concerned, it is a possible further limitation for pharmacotherapies.

New targets, new opportunity

This is why scientists are eagerly looking for new target structures. A working group led by Aimee Flores from the Department of Molecular Cell and Developmental Biology at UCLA succeeded in activating hair follicle stem cells. The focus of her experiments was the question of which factors move quiescent follicles from the telogen phase into the anagen phase with renewed growth. The results were surprising. If cells convert glucose into pyruvate and metabolise it in their mitochondria, the cells remain in their arrested sleep phase. If lactate however is formed from the sugar, hair follicle stem cells are stimulated into hair production.

Flores immediately identified two suitable candidate molecules in order to intervene in regulation. RCGD423 acts as an inhibitor in the intracellular JAK-STAT signalling pathway, which leads to more lactate in the stem cells. Alternatively, UK5099 prevents pyruvate uptake in mitochondria of the hair follicle stem cells. In an animal experiment both molecules initiated hair growth.

Untreated mice and those treated with UK5099 in comparison (vl.). New hair grew through use of the pharmaceutical agent. © UCLA Broad Stem Cell Center

Transplanting one's own building blocks

Stem cells are also interesting in other respects. In the laboratory Japanese researchers produced so-called "embryoid bodies", that is three-dimensional tissue lumps, from induced pluripotent stem cells (iPS cells) derived from wild-type mice. Administering signal proteins such as Wnt10b resulted in skin layers with hair follicles. They then transplanted small tissue portions onto hairless naked mice. These animals, due to genetic anomalies, have no thymus and no body hair. After 14 days, hair grew in this area. What's more no anatomical anomalies appeared:

Cross-section through normal skin and through an implant of iPS cells following transplantation © RIKEN Center for Developmental Biology

According to co-author Takashi Tsuji the method is generally also suitable for humans. He works at the RIKEN Center for Developmental Biology in the Japanese city Kobe. Whether Tsuji is proven correct remains to be seen in new studies. Opportunities for finding new treatment methods look good.

Article byMichael van den Heuvel

Medical journalist

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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2208-8206

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Mayor susceptibilidad para Sifilis en ptes HIV+ y con HAART.

Comportamiento, farmaco y enfermedad se combinan para incrementar la incidencia de Sífilis en esta población.

A Double-Edged Sword

Does Highly Active Antiretroviral Therapy Contribute to Syphilis Incidence by Impairing Immunity to Treponema Pallidum?

Michael L Rekart; Wilfred Ndifon; Robert C Brunham; Jonathan Dushoff; Sang Woo Park; Sanjana Rawat; Caroline E Cameron

DISCLOSURES 

Sex Transm Infect. 2017;93(5):374-378. 

Discussion 

Biological Plausibility

Protection against the extracellular pathogen T. pallidum, the causative agent of syphilis, is dependent upon T cell expansion and the generation of an early Th1-stimulating, interferon γ (IFN γ)-producing host proinflammatory response that potentiates the primary clearance mechanism of T. pallidum, macrophage-mediated opsonophagocytosis.^[25] The latter process is dependent on unperturbed mitochondrial function to ensure peak metabolic activity within macrophages,^[26] opsonic antibody production and IFN γ-mediated macrophage activation.^[27] Opsonic antibody quality is reduced in individuals infected with HIV-1^[28] and certain HAART agents significantly suppress mitochondrial function,^[26] the proinflammatory response^[29] and macrophage activation,^[30]leading to reduced treponemal clearance via opsonophagocytosis. InSTIs have been shown to suppress the proinflammatory response in cohort studies^[29] and opsonophagocytosis is reduced in vitro following treatment of macrophages with NRTIs, consistent with mitochondrial damage.^[26]

Further, the well-documented depletion of CD4⁺ memory T cells in individuals infected with HIV-1^[30] would enhance their susceptibility to syphilis reinfection. NRTIs, especially TDF, have been shown to inhibit telomerase activity leading to accelerated shortening of telomerase length in peripheral blood mononuclear cells (PBMCs),^[31] which may lead to the accumulation of replicative senescent cells^[32] with limited ability to protect against pathogens such as T. pallidum. Reciprocally, upregulation of monocyte expression of CCR5 receptors by treponemal lipoproteins enhances the susceptibility of monocytes to HIV-1 infection,^[33]further weakening the innate and adaptive immune responses to T. pallidum.

Collectively, these observations provide viable explanations for (1) an enhanced susceptibility of individuals infected with HIV-1, especially those on HAART, to syphilis infection and reinfection and (2) higher syphilis incidence among individuals treated with HAART compared with chlamydia and gonorrhoea, infections caused by pathogens that are less reliant on opsonophagocytosis for clearance.

Debemos cutlivar antes de tratar... las onicomicosis.

Published in Dermatology

Journal Scan / Research · October 09, 2017

Confirming Onychomycosis Before Treatment Is Cost-Effective

Journal of cutaneous medicine and surgery

Abstract:

BACKGROUND

Onychomycosis can be investigated by sampling. Information gleaned includes nail bed involvement, nail plate penetration, fungal viability, and species identification. Testing samples can confirm a diagnosis. While diagnostic testing is considered useful in directing therapy, a substantial number of clinicians do not confirm diagnosis prior to treatment.

OBJECTIVES

The aim of this study is to quantify the benefit of confirmatory testing prior to treating toenail onychomycosis.

METHODS

The cost of mycological cure (negative potassium hydroxide and negative culture) and the cost-effectiveness of confirmatory testing were determined using the average cost of potassium hydroxide (KOH), culture, periodic acid-Schiff (PAS), efinaconazole, ciclopirox, terbinafine, and itraconazole. Costs were obtained through literature searches, public domain websites, and telephone surveys to local pharmacies and laboratories. To represent the potential risks of prescribing onychomycosis treatment, the costs associated with liver monitoring, potential life-threatening adverse events, and drug-drug interactions were obtained through public domain websites, published studies, and product inserts.

RESULTS

PAS was determined to be the most sensitive confirmatory test and KOH the least expensive. The overall cost of an incorrect diagnosis (no confirmatory test used) ranged between $350 and $1175 CAD per patient for treatment of 3 infected toenails. Comparatively, performing confirmatory testing prior to treatment decreases the overall cost to $320 to $930, depending on the therapy, physician, and test.

CONCLUSIONS

It is preferred to diagnose onychomycosis prior to treatment. Furthermore, there are cost savings when confirmatory testing is performed before initiating treatment with both topical and oral antifungals in Canada.

Journal of cutaneous medicine and surgery

Confirmatory Testing Prior to Initiating Onychomycosis Therapy Is Cost-Effective

J Cutan Med Surg 2017 Sep 27;[EPub Ahead of Print], AK Gupta, SG Versteeg, NH Shear 

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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2208-8206

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Basofilos y posible resolución de urticaria cronica en niños...

Un poco contradictorio, pero si interesante sobre el mejor pronostico si el test de suero autologo es positivo...

IN THE JOURNALS
Basophil count associated with spontaneous chronic urticaria resolution
Maurer M, et al. JAMA Dermatol. 2017;doi:10.1001/jamadermatol.2017.3183. Netchiporouk E, et al. JAMA Dermatol. 2017;doi:10.1001/jamadermatol.2017.3182.
October 6, 2017
A positive basophil activation test result may be a prognostic factor of pediatric chronic urticaria resolution, according to new research published in JAMA Dermatology.
Because the etiology of chronic urticaria remains unknown and little is understood about why as many as half of cases resolve spontaneously within 5 years in adults, the researchers followed a cohort of 139 children (aged, < 18 years) with the disease to gain further understanding of the comorbidities, natural history and subtypes, and predictors of resolution.
Eligible participants were accrued at a single tertiary center between 2013 and 2015. Criteria included hives lasting at least 6 weeks. Factors undergoing assessment included disease activity, comorbidities, physical triggers, basophil activation test results, complete blood cell count, C-reactive protein levels, thyroid-stimulating hormone levels and thyroid peroxidase antibodies, according to study background.
Inducible urticaria was reported in 20% of the cohort, which the researchers suggested was most commonly induced by cold.
An autoimmune comorbidity was observed in six children. These cases included thyroiditis and type 1 diabetes.
Family members of the patients frequently reported autoimmune disorders (17%) and chronic urticaria (12%).

The researchers defined a positive basophil activation test as CD63 levels > 1.8% and observed this outcome in 58% of the cohort. Resolution after 1 year occurred more than twice as frequently in children with a positive basophil activation test result than in those with a negative result (HR = 2.33; 95% CI, 1.08-5.05).
However, the presence of basophils carried a negative association with resolution (HR = 0.40; 95% CI, 0.20-0.99).
Age carried no association with resolution.
There were 43 cases of chronic urticaria resolution, according to the findings. The yearly resolution rate was 10.3%.
In an accompanying editorial, Marcus Maurer, MD, Martin K. Church, PhD, DSc, and Karsten Weller, MD, of the department of dermatology and allergy at Charité–Universitätsmedizin Berlin, wrote that the findings by Netchiporouk et al. may allow clinicians to provide an educated guess to parents and children about the likelihood and timing of spontaneous resolution.
"While we still do not have good predictors for the duration of [chronic urticaria] in individual children, we are beginning to understand that clinical features (eg, good response to antihistamine treatment) and laboratory markers (eg, basophil numbers and serum auto reactivity) can help to distinguish between subpopulations of pediatric patients with [chronic urticaria] that differ in the duration of their disease," they wrote. "Although this observation is new, it is hardly surprising."
The editorialists suggested that a number of factors have long been known to predict spontaneous response in adults. "What comes as a surprise is that, in children with [chronic urticaria], basophil-activating serum activity and basopenia, which are both linked to the presence of mast cell-activating autoantibodies and high disease activity, are associated with earlier, not later, disease resolution," they wrote. "This seems to contradict the findings that high disease activity, that is, failure to respond to a standard-dosed antihistamine or high urticaria activity scores, predict longer disease duration."

Another take-home message from the paper, according to the editorialists, is that
"type 2 autoimmune urticaria (driven by IgG autoantibodies) is of shorter duration than type 1 autoimmune urticaria (driven by IgE autoantibodies), in children as well as in adults with [chronic spontaneous urticaria]," they wrote.
They suggested that basopenia, as well as other markers of autoimmune chronic spontaneous urticaria, should be directions of future study. "Such studies should be performed in children and adults with [chronic spontaneous urticaria]," they wrote. "They should include, aside from blood basophil levels and serum auto reactivity, clinical features of [chronic spontaneous urticaria] previously linked to 'autoimmune' [chronic spontaneous urticaria], such as comorbid autoimmune disorders, concomitant angioedema, and levels of disease activity, impact and control, as well as blood levels of IgG-anti-FceRI, IgG-anti-IgE, IgE-anti-self, other autoantibodies (e.g., IgG-anti-TPO), autologous serum skin testing, total IgE, and response to antihistamines and omalizumab."
Disease severity, age at onset and gender information also should undergo clinical study, the editorialists added.
"Other questions that emerge from the present findings include the following," they wrote. "What is the reason for the basopenia seen in some but not all patients with [chronic spontaneous urticaria]? How is this linked to basophil activating serum activity? Do basopenia and serum auto-reactivity precede the development of clinical signs and symptoms, or do they result from them? Both antihistaminic therapy and treatment with omalizumab have been shown to normalize blood basophil levels in patients who benefit from these treatments. Is the same true for serum auto-reactivity, and is spontaneous remission in patients with [chronic spontaneous urticaria] linked to the loss of serum auto-reactivity?" – by Rob Volansky
Disclosures: The authors report no relevant financial disclosures.


Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica
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2208-8206
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Nuevas terapias nuevos, efectos adversos sobre la piel.

Anti-Cancer Therapies, Pigmentary Changes Linked

J Am Acad Dermatol; ePub 2017 Sep 14; Dai, Belum, et al

September 27, 2017

There is a significant risk of development of pigmentary changes during treatment with targeted anti-cancer therapies, according to a recent study. Therefore, appropriate counseling and management are critical to minimize psychosocial impairment and deterioration in quality of life. A comprehensive search was conducted to identify studies reporting targeted therapy–induced pigmentary changes. The incidence and relative risk were calculated and case reports and series were reviewed to understand clinical characteristics. A total of 8,052 patients from 36 clinical trials were included. Researchers found:

• The calculated overall incidences of targeted cancer therapy-induced all-grade pigmentary changes in the skin and hair were 17.7% and 21.5%, respectively.
• The relative risk of all-grade pigmentary changes of skin and hair were 93.7 and 20.1.
• Across 53 case reports/series (n=75 patients), epidermal growth factor receptor and breakpoint cluster region-abelson inhibitors were the most common offending agents.

Citation:

Dai J, Belum VR, Wu S, Sibaud V, Lacouture ME. Pigmentary changes in patients treated with targeted anticancer agents: A systematic review and meta-analysis. [Published online ahead of print September 14, 2017]. J Am Acad Dermatol. doi:10.1016/j.jaad.2017.06.044.

Si nota más manchas, debe evitar más el sol y más filtro solar.

Hyperpigmentation Patients: Less Sunscreen Usage

J Am Acad Dermatol; ePub 2017 Feb 15; Maymone, et al

March 1, 2017

Patients diagnosed with post-inflammatory hyperpigmentation, men, and those with disease duration <1 year reported lower sunscreen usage, a recent study found. These groups might benefit from increased counseling on sun-protective behaviors. Researchers conducted a cross-sectional study with 404 adults who complained of cutaneous hyperpigmentation. They found:

• About 67.5% reported using a product containing sunscreen, and 91% endorsed using one with a sun protection factor of ≥21.
• Among the participants, 48.5% were not sure if their sunscreen provided broad-spectrum protection, and only 7.6% reapplied every 2 hours.
• The odds of a patient with melasma using sunscreen were 6.7 times the odds of a patient with post-inflammatory hyperpigmentation using sunscreen.
• Additional predictors for sunscreen use were female sex and disease duration of ≥1 year.
• In a multivariate analysis, the odds ratio of sunscreen use among African Americans compared to whites was 0.31.

Citation:

Maymone MBC, Neamab HH, Wirya SA, et al. Sun-protective behaviors in patients with cutaneous hyperpigmentation: A cross-sectional study. [Published online ahead of print February 15, 2017]. J Am Acad Dermatol. doi:10.1016/j.jaad.2016.12.018.

Recomendaciones para reducir exposición solar desde los 6 meses a 24 años.

USPSTF Draft Statement Recommends Sun-Safe Behavioral Counseling for More Fair-Skinned Youth

By Kelly Young

Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

The U.S. Preventive Services Task Force has expanded the age range of patients who should receive behavioral counseling to reduce their risk for skin cancer. 

In a draft recommendation, the group now recommends that fair-skinned patients aged 6 months to 24 years and their caregivers be advised about reducing their exposure to ultraviolet radiation (grade B recommendation). Previously, the task force recommended behavioral counseling beginning at age 10 years.

Clinicians may selectively counsel older fair-skinned patients based on their existing risk factors since the net benefit is likely small (grade C). Patients at higher risk include those with a history of sunburns or tanning bed use, freckling, a compromised immune system, and more nevi, including atypical nevi.

The group declined to make a recommendation for or against skin self-examination given the mixed evidence (grade I).

USPSTF draft recommendation (Free)

USPSTF draft evidence review (Free)

USPSTF grade definitions (Free)

Background: Physician's First Watch coverage of USPSTF's 2012 recommendation (Free)

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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Remover nevus atipicos con margen de 2 mm.

Study Defines Safe, Effective Margins for Complete Removal of Individual Dysplastic Nevi

NEW YORK -- October 2, 2017 -- By carefully tracing a line of at least 2 mm outside of and around the edges of individual dysplastic nevi, physicians can remove all of its cells and avert the need for a second surgery.

The recommendation for such a tightly defined surgical margin is published in the Journal of the American Academy of Dermatology.

Such margin guidelines are needed because as many as two-thirds of the hundreds of thousands of suspicious skin moles removed each year in the United States require re-excision. Second procedures introduce more risk of infection, bleeding, and scarring, as well as inconvenience and unnecessary costs.

"Although the vast majority of suspicious-looking skin moles do not turn out to be cancerous melanomas, once a decision has been made to remove a mole, there should be a clearer standard margin," said David Polsky, MD, Perlmutter Cancer Center at NYU Langone Health, New York, New York.

He noted that most physicians cut out either just the darkest portion of a suspicious mole, or when removing the entire mole, opt for a very small, imprecise 1 mm margin around the mole's edge.

"Our study shows that a 'one and done' approach with a clearly defined, slightly larger margin is safer and more effective in completely removing suspicious moles with a single procedure than the current non-standardised approach," said Dr. Polsky.

For the study, researchers removed 151 suspicious skin moles in 138 men and women, all patients at NYU Langone, which provided all supplies and funding for the study. Most biopsies came from the arms, legs, and backs.

All patients underwent the biopsy procedure, involving complete mole removal with a 2 mm margin, between January and August 2015. Researchers then monitored the patients for about 1.5 years after their procedures and found that none had any further suspicious growths at their biopsy sites.

Lab testing showed that more than 90% of biopsied moles were completely removed by using the single procedure, with 11 (7%) diagnosed as melanoma.

"While our study did not directly compare use of the wider margin to a narrower margin, the common practice of removing moles with narrow margins and performing a second 'clean-up' procedure suggests a need to move toward wider margins during the initial procedure," said Dr. Polsky.

If further data support the current findings, he hopes that other cancer centres will also adopt his "one and done" approach, and, if so, he will recommend changes to the next edition of practice guidelines issued by the American Academy of Dermatology.

Reference: http://dx.doi.org/10.1016/j.jaad.2017.07.016

SOURCE: NYU Langone Health

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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Nueva estratificación de Carcinoma Epidermoide Cutáneo...

Published in Dermatology

Journal Scan / Review · October 03, 2017

A New Risk-Stratification System for Cutaneous Squamous Cell Carcinoma

Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• The authors of this review propose a new evidence-based risk stratification system for cutaneous squamous cell carcinoma (cSCC) that divides tumors into low-, intermediate-, and high-risk subsets, taking into account both tumor and patient characteristics. The authors define low-, intermediate-, and high-risk cSCC based on both the Brigham and Women's Hospitals (BWH) cSCC staging system and the absolute risk for local recurrence and nodal metastases. Low-risk cSCC comprises BWH T1 and T2a tumors and has an absolute risk of local recurrence and nodal metastases of 5% and 3%, respectively. In contrast, high-risk cSCC comprises BWH T2b and T3 tumors and has >20% absolute risk of local recurrence and nodal metastases. Low-risk cSCC should be followed annually, intermediate-risk cSCC every 6 to 12 months for 2 years, then annually, and high-risk cSCC every 2 to 4 months for 2 years, then annually.

• A small percentage of cSCC are associated with local recurrence, nodal metastases, and death, and an evidence-based risk-stratification system that identifies patients at highest risk for these outcomes may improve patient management.

  – Jeffrey Scott, MD

Journal of the American Academy of Dermatology

Abstract:

Most primary cutaneous squamous cell carcinomas are cured with surgery. A subset, however, may develop local and nodal metastasis that may eventuate in disease-specific; death. This subset has been variably termed high risk. Herein, we review; an emerging body of data on the risks of these outcomes and propose an evidence-based; risk stratification for low-, intermediate-, and high-risk tumors that takes into; account both tumor and patient characteristics. Finally, we discuss a framework for; management of these tumors on the basis of data, when available, and our; recommendations when data are sparse.

A New Evidence-Based Risk Stratification System for Cutaneous Squamous Cell Carcinoma Into Low, Intermediate, and High Risk Groups With Implications for Management

J Am Acad Dermatol 2017 Sep 13;[EPub Ahead of Print], CL Baum, AC Wright, JC Martinez, CJ Arpey, JD Brewer, RK Roenigk, CC Otley