Mohs micrographic surgery (MMS) is considered the gold-standard treatment for basal cell carcinoma (BCC) particularly for sites with a high risk of incomplete excision such as the central face, for tumours with an aggressive growth pattern and consequent unpredictable subclinical extension and for recurrent tumours. However, the process is more time-consuming than for standard excision (SE), and the magnitude of benefit is uncertain. This article aims to provide a more complete picture of current evidence, including a review of cosmetic outcomes, tissue-sparing ability and cost-effectiveness of MMS. Although robust evidence is lacking, there is a large volume of observational data supporting a low recurrence rate after MMS. The risk of incomplete excision and higher recurrence rate of SE favours the use of MMS at high-risk sites. There is some low-certainty evidence that MMS results in a smaller defect size compared with SE, and that incomplete excision with SE results in larger defects. Larger defects may affect cosmetic outcome but there is no direct evidence that MMS improves cosmetic outcome compared with SE. There is conflicting evidence regarding the cost of MMS compared with SE, as some studies consider MMS less expensive than SE and others consider it more expensive, which may reflect the healthcare setting. A multicentre 10-year randomized controlled trial comparing MMS and SE in the treatment of high-risk BCC would be desirable, but is unlikely to be feasible or ethical. Collection of robust registry data capturing both MMS and SE outcomes would provide additional long-term outcomes.

We report a case of a 21-year-old man who was referred from the community with concern about persistent swollen and inflamed eyelids together with possible facial acne. He was known to have hypertrophic osteoarthropathy under the care of rheumatology for which he was on regular infliximab infusions. He had previously been treated with methotrexate (intolerant) azathioprine and adalimumab (lack of efficacy). He also had a long-standing history of inflammatory bowel disease and associated complications: iron-deficiency anaemia, previous choledochal cyst and biliary stricture, as well as previous deficiencies in vitamins B12, A and E. The patient was known to the genetics team, with prior genetic testing demonstrating that he is homozygous for a pathogenic SLC02A1 variant (c.1264_1265delAC). This gene encodes a prostaglandin transporter involved in mediating the uptake and clearance of prostaglandins in numerous tissues. On examination, he was found to have pronounced thickening of the facial skin, especially the forehead, alongside deep furrowing of the scalp. The eyelids were severely swollen and inflamed, with prominent straight eyelashes. There were milia present on the face predominantly on the brow and cheeks. There was clubbing of all digits on his hands and feet. The cutaneous findings were deemed all in keeping with pachydermoperiostosis. Pachydermoperiostosis, also known as primary/idiopathic hypertrophic osteoarthropathy, Touraine–Solente–Gole syndrome and Rosenfeld–Kloepfer syndrome, was first described by Friedrich in 1868. This is a rare condition, and both autosomal dominant and autosomal recessive modes of inheritance have been noted. The condition usually presents during puberty and the hallmark features are thickening and coarsening of the facial skin, periostosis and digital clubbing. Other cutaneous features can include seborrhoea with sebaceous hyperplasia, acne, hyperhidrosis and cutis verticis gyrata. Ocular manifestations include blepharoptosis, floppy eyelid syndrome, and hypertrophy of both the eyelids and palpebral conjunctiva. Crohn disease and multiple bone and joint issues are known features of the condition (Doshi D. Touraine–Solente–Gole syndrome. Orbit 2018; 37:97–101; Tabatabaei SA, Masoomi A, Soleimani M et al. Pachydermoperiostosis: a clinicopathological description. J Curr Ophthalmol 2019; 31:450–3). This reported case demonstrates both classic cutaneous and other organ system features of this rare genetic condition. It highlights the importance of being able to recognize all the associated findings when a patient presents with thickening of their facial skin and eyelids.

Teledermatology has become an essential tool in the triage and management of skin cancer referral pathways. The implementation of the process varies between dermatology departments. At a large multihospital trust, a retrospective service evaluation was conducted looking at the outcomes between two dermatology sites within the trust. Both use the same teledermatology platform to review all referrals made via a 2-week wait suspected cancer pathway for skin lesions. The main comparator was that one of the sites employs a straight to biopsy (STB) outcome as a potential pathway for referred lesions. The other site conducts face-to-face (F2F) review of suspicious lesions warranting biopsy first. Data were collected for all referrals made to both sites over a week in July 2021. A total of 506 lesions were referred across the two sites. Following teledermatology review at the site where STB was adopted, 32.2% (n = 96/298) of patients had a STB outcome and 33.9% (n = 101/298) had a F2F outcome. In comparison, 48.6% (n = 101/208) had a F2F outcome at the other site. Where STB was employed, biopsies were carried out for 13 intermediate lesions (actinic keratosis, superficial basal cell carcinoma, Bowen disease) vs. seven following F2F review at the other site. Rates of definitive surgery, for example wide local excision, were comparable between sites: 13.4% (STB) vs. 15.5%. Curettage and cautery was performed exclusively for lesions reviewed at the STB site, whereas at the other site, intermediate lesions were seen F2F and likely discharged following management with cryotherapy, topical treatments or conservative measures. The STB model can be appealing as it eliminates the need for a F2F review for lesions that require histological confirmation for diagnosis and management, saving valuable time and resources. However, the multiple stages involved in processing biopsies are costly and resource intensive when considering that many intermediate lesions can be treated from a clinical diagnosis alone. Biopsies are associated with increased morbidity and risk, unnecessary extra steps in patient care. With the Montgomery ruling, the process of consent must be robust and consider the individual values of each patient. Biopsies in more complex anatomical sites may pose additional difficulty when obtaining valid consent. The STB can have a role in the management of skin lesions and can streamline patient pathways. However, it does not replace good clinical acumen and, to remain cost-effective, needs to be employed in an appropriate manner.