Welcome back to the journal review. This episode covers the December 2025 issue of Dermatologic Surgery, and we've got four pieces worth your time — a quick-hit technique communication on smoke evacuation, a commentary on opioid prescribing patterns among Mohs surgeons, a full review on digital papillary adenocarcinoma, and an original retrospective study looking at transplant indication as a skin cancer risk factor. Let's get into it.

First up is a short communication — really a device description rather than a formal study — titled "A Flexible Smoke Evacuation Device: New Wine in an Old Bottle," out of Nanjing. The setup here is one you already know cold: electrocautery and CO2 laser treatment of warts generates plume, and that plume isn't just an odor nuisance — it's been shown to carry HPV subtypes 16 and 18, along with a cocktail of other chemicals from tissue ablation. The concern the authors raise is real occupational risk: viral particles depositing in the clinician's oropharynx with theoretical downstream carcinogenic risk, including oropharyngeal and lung cancer. Their practical problem is that a lot of clinics simply don't have adequate fixed smoke evacuation systems, often because of cost or infrastructure constraints.

Their solution, which they nickname the "Korean barbecue-style ventilator," is exactly what it sounds like — a flexible, extendable tube connected to an external exhaust fan, similar to the retractable hoods you see over grill tables, adapted for the OR. The tube can be positioned near the electrocautery tip, about five to ten centimeters away, and because it's flexible, it can follow the patient into whatever position the lesion demands — perianal, axillary, glans, wherever the wart happens to be — without the patient having to constantly reposition for a fixed hood. After the case, the tube retracts on its own, which is a nice practical touch compared with a permanently mounted rigid system. The stated suction capacity was reported as adequate for surgical use, and installation is described as straightforward — mount to the ceiling, connect the motor to power, tie into the smoke flue, done. The headline number here, and probably the one that matters most to anyone considering building their own, is cost: the entire system, motor and tubing included, came in at about 136 dollars, sourced through a consumer marketplace. There's no outcomes data, no comparative testing against commercial evacuators, and no quantification of actual smoke or viral particle reduction — this is purely a "here's how we built it and here's what it costs" description. The takeaway is practical rather than practice-changing: if your setting lacks a dedicated smoke evacuation system, this is a low-cost, physically simple option worth considering, but it hasn't been validated against established commercial units, so I'd treat it as a resourceful stopgap rather than a proven standard.

Next is a commentary — an invited discussion piece, not new primary data — responding to a retrospective study by Rossi and colleagues on opioid prescribing among Mohs surgeons operating on Medicare beneficiaries between 2014 and 2022. The commentary opens by reminding us of something we intuitively know but patients often don't expect: Mohs is tolerated remarkably well, with pain peaking on day one and usually manageable with acetaminophen or over-the-counter anti-inflammatories, yet opioids still get prescribed in a subset of cases. The underlying study the commentary discusses found that the overall percentage of Mohs surgeons prescribing opioids declined across that nine-year window, which the original authors attribute plausibly to heightened awareness of the opioid epidemic. The point the commentator really wants to draw out, though, is the comparison between surgeons who are members of the American College of Mohs Surgery — meaning fellowship-trained — versus those who are not. By raw percentage, more ACMS members prescribed opioids at all. But when you look closer, those same fellowship-trained prescribers used opioids more judiciously: shorter average days of supply, and a lower percentage of their overall cases involved an opioid prescription in the first place. The commentator's interpretation, clearly framed as their own extrapolation rather than something proven in the underlying data, is that ACMS members likely encounter more complex closures — flaps and grafts — that legitimately generate more postoperative pain, which would explain the higher raw prescribing rate, while their formal training presumably instills more disciplined stewardship once they do prescribe. There's no new data here to critique on methodological grounds since this is commentary, not original research, but it's worth flagging that this reasoning about case complexity is inference, not something the commentary demonstrates directly. Practically, this is more reassurance and framing than anything that changes your prescribing behavior — it reinforces that judicious, limited-duration opioid prescribing tied to genuinely painful repairs is the pattern to emulate, and it adds an evidence-based talking point for why fellowship training correlates with better stewardship, which might be useful if you're advocating for ACMS-accredited training within your institution.

Third, a full review article: "Digital Papillary Adenocarcinoma: An Updated Review of Epidemiology, Pathogenesis, and Management," synthesizing PubMed and MEDLINE literature with a deliberate emphasis on publications after 2010, given how rare this tumor is and how much has changed molecularly in the last decade. The authors are explicit that they included case reports and case series alongside larger cohort studies, which makes sense methodologically — you simply can't build a literature base on an entity this uncommon without pooling small numbers.

On epidemiology, digital papillary adenocarcinoma is vanishingly rare — think roughly one case per ten million person-years by the most recent SEER-based estimate, which also found the incidence rising over the past two decades, with an annual percent increase in the mid single digits. An English national registry study landed on a very similar incidence figure, so this isn't just an artifact of one database. It's clearly a male-predominant tumor, by roughly three or four to one, and it clusters in the fifth and sixth decades, though pediatric cases exist. Interestingly, when the tumor does show up off the digits — vulvar, perianal, forearm — those nonacral cases skew female, which is a nice clinical pearl if you're ever handed an odd-looking nodule in one of those locations.

The pathogenesis section is where this review earns its "updated" title. The biggest shift is the discovery of HPV42 DNA in the large majority of tumors tested — in one key study, essentially all cases were positive by sequencing and the large majority validated by in situ hybridization, while none of several other adnexal malignancies tested showed any HPV42 positivity at all. That specificity is striking and potentially diagnostically useful going forward. BRAF V600E mutations have also turned up in a meaningful subset of cases across several small series, though the authors flag real controversy here — some experts argue the BRAF-positive cases may actually represent misclassified acral hidradenomas rather than true digital papillary adenocarcinoma, so take that finding with some caution. FGFR2 overexpression has also been described, though its mechanistic role remains unclear.

On the histologic differential, the main mimicker is acral hidradenoma, and the review offers a useful discriminator: S100 and p63 staining pattern differs — restricted to the myoepithelial layer in digital papillary adenocarcinoma versus diffuse positivity in hidradenoma, which lacks S100 entirely — and NUT-1 expression, seen in the large majority of hidradenomas due to their characteristic gene fusion, has essentially never been described in digital papillary adenocarcinoma, giving you another immunohistochemical lever if a case is borderline.

Clinically, the course is genuinely bimodal — some tumors sit indolently for years, others grow rapidly over months. The management-relevant numbers are the ones to remember: incompletely or narrowly excised tumors recur at rates as high as half of cases, which is a strong argument for complete margin control up front. After adequate wide local excision or amputation, recurrence drops to somewhere in the range of five to ten percent, and critically, multiple studies — old and new — show no meaningful difference in recurrence between wide local excision and amputation, meaning digit-sparing surgery is a legitimate option and doesn't need to default to amputation. Metastatic potential is real, cited across studies at roughly five to twenty-five percent, with lung the most common site. Despite that, population-level survival is actually quite favorable — five-year disease-specific survival around ninety-eight percent and overall survival in the mid-nineties in the largest SEER analysis, with tumor size of two centimeters or more the one factor independently tied to worse disease-specific survival, while age, sex, and stage at presentation were not significant predictors in multivariate analysis.

For Mohs surgeons specifically, the review is candid that Mohs micrographic surgery is an emerging but genuinely understudied modality here — it's mentioned as a viable margin-control option given the comparable recurrence outcomes between wide excision and amputation, but the authors don't cite outcomes data specific to Mohs for this tumor, so that's an area flagged for future study rather than an established recommendation. Similarly, sentinel lymph node biopsy is mentioned only to say there isn't enough data to recommend it either way. Practical takeaway: this review doesn't change your surgical approach today, but it reinforces that margin-controlled, digit-preserving excision is defensible over amputation, it gives you two useful immunohistochemical tools — S100/p63 pattern and NUT-1 — for the hidradenoma differential, and it flags Mohs as a reasonable but not yet evidence-validated option worth documenting if you use it, since the field needs more outcomes data specifically on Mohs for this entity.

Last is an original retrospective cohort study: "The Association of Solid Organ and Hematopoietic Stem Cell Transplant Indication With Skin Cancer Risk," out of Vanderbilt. The background gap is well framed — we already know transplant recipients carry elevated skin cancer risk, and tools like the SUNTRAC calculator help stratify solid organ recipients using factors like race, pretransplant skin cancer history, age, sex, and thoracic transplant status. But thoracic transplant recipients in particular have generally been lumped together as one uniform high-risk group, and nobody had specifically asked whether the underlying reason for transplant — not just the organ type — independently predicts skin cancer risk. The authors also had a specific hypothesis going in: that transplant indications tied to high-risk behaviors, like smoking or alcohol or drug use, might correlate with higher-risk sun exposure habits and therefore more skin cancer. That's a testable and clinically intuitive idea.

Methodologically, this was a retrospective chart review using a single institution's deidentified research database, identifying transplant patients through a validated combination of diagnostic codes with manual chart review confirmation, and identifying skin cancer treatment through a paired diagnosis-and-procedure code algorithm rather than diagnosis codes alone — which is a smart design choice, since relying on diagnosis codes alone tends to overcount skin cancer, so pairing it with an actual treatment code tightens the outcome definition considerably. The authors don't fully spell out why retrospective design was necessary here, but it's a reasonable inference that a rare-exposure, rare-outcome combination like transplant indication and skin cancer development really requires a large existing clinical database rather than prospective enrollment, which would take years to accrue comparable numbers. They restricted analysis to indication categories with at least fifty patients specifically to avoid small-group outliers skewing the comparisons, which is a sensible a priori safeguard given how many different indications feed into transplant.

On results: they identified around thirty-four hundred solid organ recipients and roughly seventeen hundred stem cell recipients with documented indications. Stem cell recipients had a substantially lower average number of skin cancers per person than solid organ recipients, even after age-matching — the authors are appropriately cautious here, noting this is likely confounded by different conditioning regimens and shorter average follow-up in the stem cell group rather than reflecting a true biological difference in risk. Within the solid organ group, when indications were bucketed into genetic causes, autoimmune causes, exposure-related causes, and an other/unknown category, genetic causes stood out — youngest average age at transplant and the highest average number of skin cancers per person, a statistically significant difference specifically between the genetic and exposure groups. Here's the finding that actually cuts against their own hypothesis: the exposure-related group — things like hepatitis C, alcohol use, COPD — had the lowest average skin cancer burden of any category, which directly contradicts the idea that high-risk-behavior indications track with high-risk sun exposure. Men developed roughly two to three times as many skin cancers as women on average, consistent with prior literature. At the individual-diagnosis level, cystic fibrosis carried the lowest skin cancer burden, while interstitial pulmonary fibrosis, polycystic kidney disease, and ischemic cardiomyopathy carried the highest — an interesting detail since cystic fibrosis and interstitial pulmonary fibrosis are both thoracic indications, which directly undercuts the idea of treating all thoracic transplant recipients as a single risk category.

The authors are upfront about limitations: this is single-institution data, meaning the pretransplant skin cancer history was documented in a very small number of patients, too few to analyze further; there's no adjustment for skin type, detailed sun exposure, or other established risk factors; and electronic record documentation of transplant indication was inherently incomplete in places. They also made a deliberate choice to include basal cell carcinoma in their outcome definition, departing from SUNTRAC's methodology, reasoning that basal cell carcinoma can still generate significant morbidity and cumulative procedural burden in transplant patients — worth noting if you're mentally comparing these risk figures to SUNTRAC-based estimates.

Is this practice-changing? Not yet, and the authors themselves frame it as hypothesis-generating rather than definitive. But it is a genuinely interesting signal: transplant indication, and specifically genetic indications like cystic fibrosis relative to age-matched peers, may carry independent prognostic weight beyond organ type alone, which challenges the current practice of treating thoracic transplant recipients as a monolithic high-risk group. For now, the practical takeaway is soft — consider transplant indication as an additional data point when calibrating surveillance intensity, particularly for younger patients transplanted for genetic conditions, but recognize this needs validation in a larger, multi-institutional cohort with proper adjustment for skin type and sun exposure before it earns a place alongside validated tools like SUNTRAC.

That wraps our four articles for December. Bottom line across the issue: a genuinely cheap do-it-yourself smoke evacuation option worth considering if you lack a fixed system, a reassuring but non-actionable data point on opioid stewardship favoring fellowship training, a well-organized refresh on digital papillary adenocarcinoma with real diagnostic and prognostic pearls but no change yet to your surgical default, and a thought-provoking but early-stage signal that transplant indication — not just organ type — may deserve a place in how we risk-stratify our transplant patients. Thanks for listening, and we'll be back with the next issue.