8598
Intralesional methotrexate for treatment of keratoacanthoma
and well-differentiated squamous cell carcinoma
Rachael C. Saporito, MD, Department of Dermatology, Baylor Scott &
White Health, Temple, TX; Meagan O. Harris, MD, Department of
Dermatology, Baylor Scott & White Health, Temple, TX; Chad D. Housewright,
MD, Department of Dermatology, Baylor Scott & White Health, Temple, TX
In the most recent ‘‘Guidelines of care for the management of cutaneous squamous
cell carcinoma’’ by Kim et al published in the Journal of the American Academy of
Dermatology, intralesional methotrexate was not included as a potential alternative
to surgical excision. This case series presents three patients with keratoacanthoma
and well-differentiated squamous cell carcinomas that showed complete clinical
resolution with two to three injections of 25 mg/mL methotrexate, each
approximately two weeks apart. We propose consideration of intralesional
methotrexate for primary treatment for nonsurgical candidates or neoadjuvant
therapy prior to Mohs micrographic surgery. Biopsy should first be obtained to
ensure that the lesion is a well-differentiated squamous cell carcinoma. Due to the
risk of pancytopenia and hepatotoxicity, a complete blood count and a compre-
hensive metabolic panel should be obtained prior to administration and one week
after the initial injection. Caution is advised in patients with significant abnormalities
at baseline or alterations following treatment. No patients in this case series
developed lab abnormalities following injection or adverse events.
Commercial support: None identified.
8661
Invasive melanoma depth increases with decreasing total body
photography frequency
Rebecca Sarac, BS, Tulane University School of Medicine, New Orleans,
LA; Elizabeth Drugge, PhD, MPH, New York Medical College, Valhalla,
NY
Introduction: Total body photography (TBP) is a screening tool shown to enhance
melanoma detection and reduce benign nevus biopsies. Such practices are usually
limited to individuals with a personal or family history of atypical nevi, melanoma, or
nonmelanoma skin cancers. Melanoma depth is the most important prognostic
indicator of mortality and early detection improves survival. We previously
demonstrated that computer-assisted serial comparison of TBP images can yield
small malignant lesions which may be in their initial growth phase. Currently, there
are no widely accepted guidelines for TBP use, and data on the recommended
interval between TBP sessions are lacking.
Methods: A retrospective chart review was performed on patients in a private
practice dermatology office between January 1, 2015 and July 1, 2016. Comparison
of serial TBP images was performed using a semi-automated computer-assisted
model. Lesions were categorized as new or changed if the patient underwent at least
two sessions of TBP prior to biopsy. For lesions detected with TBP, the scan interval
was determined as the difference in years between TBP sessions prior to biopsy of
the lesion.
Results: 2,473 patients underwent TBP at least once and 1,655 patients at least
twice. A total of 268 pigmented lesions were biopsied, of which 225 were new or
changed. 67 of these lesions were malignant, 44 were melanoma in situ (MIS) and 23
were invasive melanoma (INV) (MIS:INV ratio 1.9). The average scan interval was
2.36 years (SD 1.34) for malignant lesions and 2.41 years (SD 1.29) for benign
lesions. The difference between the average scan interval for these two groups was
not statistically significant. However, among invasive lesions, the duration between
TBP scans was significantly correlated with depth of invasion (rho ¼ 0.562, P ¼
.0053). Three of the 23 invasive lesions were noted to be new, and there was a very
high correlation between depth of invasive melanoma and duration of TBP interval
(rho ¼ 1.000, P \.05). C
Conclusion: The duration between TBP sessions may not aide in predicting lesion
outcome, however there is a relationship between the length of time between
successive scans and depth of invasive melanoma. Although the sample size is small,
there was an extremely high correlation between depth and TBP scan interval for
new invasive lesions. This preliminary data are promising; however, further
evaluation with a larger sample size and more consistent scanning practices are
needed and may be able to help shed light on future TBP practices and
recommendations.
Commercial support: None identified.
October 2019
9794
Investigation of electrosurgery and interference with implant-
able cardiac devices
Sima Amin, BS, Texas A&M College of Medicine, College Station, TX;
Katie Homan, MD, Department of Dermatology, Baylor Scott and White
Hospital, Temple, TX; Mary Lee, DO, Department of Internal Medicine, Baylor
Scott and White Hospital, Temple, TX; Chad Housewright, MD, Department of
Dermatology, Baylor Scott and White Hospital, Temple, TX
Introduction: Electrodessication is a form of electrosurgery used commonly in the
dermatologic setting to achieve hemostasis. It is important to distinguish electro-
dessication from electrocoagulation as they utilize different energy parameters.
Electrocoagulation uses low voltage, high amplitude current while electrodessica-
tion uses high voltage, low amplitude current. Electrocoagulation is well docu-
mented to cause interference with implanted cardiac devices such as implantable
cardioverter defibrillators (ICDs), cardiac resynchronization therapy (CRTs), and
pacemakers. However, according to in-vitro studies, electrodessication is consid-
ered safe in patients with implanted cardiac devices. To our knowledge, there is no
in-vivo data to support this claim. Mohs micrographic surgery, excisional surgery,
and electrodessication and curettage (ED&C) are common dermatologic procedures
performed to treat skin cancer that often employ electrodessication to achieve
hemostasis. In this study, we aim to describe the outcomes of electrodessication
during dermatologic procedures in patients with pacemakers, CRTs and ICDs.
Methods: Retrospective chart review was done from March 2014-April 2018 at a
single center (Baylor Scott & White Temple Dermatology Clinic). Forty-five patients
met criteria of having a pacemaker, CRT or ICD device and having undergone Mohs
micrographic surgery, excisional surgery or ED&C procedure. Patients with
pacemakers, ICDs, or CRTs that have a history of surgery involving other forms of
electrosurgery after the insertion of cardiac device were excluded from the study.
Adverse peri- and postoperative outcomes, as well as device malfunction were
evaluated.
Results: Forty-five patients (4 women, 41 men) with mean age of 79 met the
inclusion criteria. Thirty-two patients underwent Mohs surgery, nine underwent
excisional surgery and four had ED&C. No perioperative adverse effects were
recorded. Device reports were examined for inappropriate firing of the defibrillator,
loss of capture, temporary inhibition of pacing, battery drainage, pacing at an
elevated or erratic rate, failure to deliver antitachycardia, reversion to asynchronous
pacing, induction of arrhythmias, or tissue damage at lead tissue, but no such issues
were found.
Conclusion: The lack of complications associated with pacemakers, ICDs, and CRT
devices with electrodessication is reassuring, however prospective and larger
retrospective studies are warranted.
Commercial support: None identified.
9938
Is topical treatment effective for psoriasis in patients who failed
topical treatment?
Nwanneka Okwundu, DO, Center for Dermatology Research,
Department of Dermatology, Wake Forest School of Medicine,
Winston-Salem, NC; Leah Cardwell, MD, Center for Dermatology Research,
Department of Dermatology, Wake Forest School of Medicine, Winston-Salem,
NC; Abigail Cline, MD, PhD, Center for Dermatology Research, Department of
Dermatology, Wake Forest School of Medicine, Winston-Salem, NC; Irma
Richardson, MHA, Center for Dermatology Research, Department of
Dermatology, Wake Forest School of Medicine, Winston-Salem, NC; Steven R.
Feldman, MD, PhD, Center for Dermatology Research, Department of
Dermatology, Wake Forest School of Medicine, Winston-Salem, NC
Background: Topical corticosteroids may lose efficacy over time. Poor treatment
outcomes may be due to poor adherence. We evaluated how frequently patients
with psoriasis resistant to topical treatment respond to topical corticosteroids
Objective: To determine how frequently psoriasis resistant to topical corticosteroids
can be effectively treated with topical corticosteroids under conditions promoting
good adherence.
Methods: Twelve patients with topical corticosteroid resistant psoriasis were treated
with topical 0.25% desoximetasone spray. In addition, half the subjects also received
twice daily phone call reminders to further promote good adherence. Pruritus Visual
Analog Scale (VAS), Psoriasis Area and Severity Index (PASI), Total Lesion Severity
Score (TLSS), and, Investigator Global Assessment (IGA) assessed disease severity.
Patients had follow-up visits at baseline, Day 3, Day 7, and Day 14 to further help
assure good adherence to the treatment regimen.
Results: 10 of the 12 subjects had failed previous treatment with topical clobetasol.
Nevertheless, most subjects improved in most scoring parameters. 100%, 91.7%,
83.3%, and 58.3% had improvements in itching, PASI, TLSS, and IGA, respectively.
The percent reduction in itching ranged from 67-100% and 50-86% and PASI
improvement ranged from 18-63% and 0-55% for the phone call and no phone call
groups, respectively. TLSS and IGA improvements were of lower magnitude but
showed a similar pattern with numerically greater improvements in the phone call
reminder group. No subject had worsening itching, PASI, TLSS, or IGA.
Conclusion: Psoriasis resistant to topical treatments is often due to poor adherence
rather than ineffectiveness of applied topical corticosteroids. When plaque psoriasis
appears resistant to topical corticosteroids, addressing adherence issues may be
critical. Intervention to improve treatment adherence may lead to better health
outcomes.
Commercial support: None identified.
J AM ACAD DERMATOL AB85