To determine if the complete response rates of lentigo maligna (LM) to imiquimod, 5%, cream can be improved by the addition of a topical retinoid. Design: Prospective randomized study of patients treated with imiquimod alone vs imiquimod plus a topical retinoid, followed by conservative staged excisions. Setting: Mohs surgical clinic in an academic institution. Patients: Ninety patients with biopsy-confirmed LM. Interventions: Ninety patients with 91 LMs were randomized into 2 groups. One group received imiquimod, 5%, cream 5 d/wk for 3 months, while the other group also received tazarotene, 0.1%, gel 2 d/wk for 3 months. Following topical therapy, all patients underwent staged excisions and frozen section analysis with Melan-A immunostaining to confirm negative margins. Main Outcome Measure: The presence or absence of residual LM at the time of staged excision. Results: Forty-six patients with 47 LMs were randomized to receive monotherapy: 42 of 47 LMs reached the intended treatment duration, with 27 complete responses (64%). Forty-four patients with 44 LMs were randomized to receive combined therapy: 37 of 44 LMs reached the intended treatment duration, with 29 complete responses (78%). This difference did not reach statistical significance (P =.17). There have been no recurrences to date, with a mean follow-up period of 42 months. Conclusions: Among patients who received topical imiquimod with vs without tazarotene, 22% (8 of 37) of lesions vs 36% (15 of 42) of lesions showed residual LM on staged excisions. Pretreating LM with imiquimod, 5%, cream may decrease surgical defect sizes; however, total reliance on topical imiquimod as an alternative to surgery may put the patient at increased risk of a local recurrence.

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Objective: To better understand postoperative opioid use after dermatologic surgery.Design: Prospective observational study.Setting: Academic dermatology department. Patients:The study included 212 adults (1) who were undergoing a single skin excision (including Mohs micrographic surgery), (2) who consented to participate, and (3) who were able to be reached by telephone on postoperative day 3 or 4. Patients who did not meet these criteria and those referred to another physician for further surgical treatment or repair were excluded. Main Outcome Measures:The study examined (1) the incidence of opioid prescription after dermatologic surgery, (2) the percentage of prescribed opioid pain medications used in the postoperative period, and (3) patient and surgical characteristics associated with opioid pain medication prescription and use.Results: Opioids were prescribed to 72 of the 212 patients (34%). Twenty-five of the 72 patients (35%) who were prescribed opioids did not use them. Forty-nine of 57 patients (86%) who filled an opioid prescription had leftover pills, and 26 of the 49 patients (53%) planned to keep them. Only maximum pain score was significantly associated with opioid use.Conclusions: Opioids were overprescribed after dermatologic surgery. Patients who had leftover opioids did not dispose of them properly, which could lead to potential misuse and abuse.

Pigmented purpuric eruptions comprise a group of benign dermatoses that are characterized clinically by pinpoint petechiae and purpura on a hyperpigmented base and histologically by capillaritis. The etiology of this group of disorders is unknown, although aberrant cell-mediated immunity has been proposed. Pigmented purpuric eruptions are well characterized in the pediatric population. In this case series we present three children with these disorders and review the clinical subtypes of pigmented purpuric eruptions that have been described in the literature.

The retrospective review suggests that opioid prescribing is predicted by characteristics of the surgery (i.e., size, defect repair type, and anatomic location) and characteristics of the surgeon (i.e., age, sex, and practice location) with significant heterogeneity in prescribing habits. The national survey results raise the possibility that patients might not take all prescribed opioid pills after dermatologic surgery. Further investigation is warranted to determine how patients are actually using prescription pain pills to balance pain control with patient safety.