Welcome back to the journal review. This is the December twenty twenty-five issue of Dermatologic Surgery, and we've got four pieces from the Communications section worth walking through together — a cross-sectional study on how patients rate Mohs surgeons online, a case report on an unusual complication of adjuvant radiation for keloids, a technique piece on stalled wound healing over exposed scalp bone, and a survey study on how Mohs surgeons actually manage rare cutaneous malignancies. Let's get into it.

First up is a cross-sectional study titled "An Assessment of Online Reviews for Mohs Surgeons Within the United States." The setup here is straightforward — patients increasingly use physician rating websites as a first step in choosing a doctor, something like seven in ten patients according to one of the surveys they cite, and Healthgrades in particular has already been studied across specialties like neurosurgery, oral and maxillofacial surgery, and radiation oncology, with average ratings clustering somewhere between four-point-one and four-point-five out of five. Nobody had done this for Mohs surgeons specifically, which is the gap this paper fills.

Methodologically, this is about as clean a cross-sectional design as you'll see — they pulled every Mohs surgeon listed on Healthgrades under a national search with the specialty filter set to Mohs micrographic surgery, all within a single five-day window in July twenty twenty-four to keep the data internally consistent, and supplemented with practice website data for anything missing. They calculated a weighted average rating to correct for the fact that some surgeons have a handful of reviews and others have hundreds, and they cross-referenced practice locations against Census Bureau data using the first three digits of the zip code — essentially a regional cluster — to look at population and median household income effects. The appeal of this design is obvious: it's a large, low-cost sample using entirely public data, no patient contact required, and it mirrors the methodology used in those other specialty studies closely enough to allow direct comparison.

The results: eight hundred nineteen Mohs surgeons included, roughly two-thirds male, mean age fifty-one. The overall weighted rating came out to four-point-six out of five, which is actually higher than what's been reported for other specialties, and the average surgeon had about fifty-six reviews attached to their profile. One in five surgeons had a perfect five-out-of-five rating. There was a real and statistically significant age gradient — surgeons under forty averaged four-point-seven, those between forty-one and sixty averaged four-point-four, and those over sixty averaged four-point-one — a stepwise decline that's both significant and, frankly, clinically noticeable if you're thinking about it from a practice-management standpoint. No difference by sex. Geographically, areas with more Mohs surgeons clustered together also had higher average ratings and more reviews per surgeon, though these correlations were fairly weak. Population size tracked with surgeon density, as did median household income, but interestingly, ratings trended slightly lower in wealthier zip codes — that particular finding didn't quite reach statistical significance, so I'd treat it as a hint rather than an established effect.

The authors' discussion ties the age-rating relationship to what's been proposed in other surgical specialties, namely that older, busier, more established surgeons may have longer wait times, which could be dragging down satisfaction scores — plausible, but speculative. They also flag a genuine access issue: lower-population, lower-income regions have fewer Mohs surgeons available at all, a maldistribution problem that's separate from the ratings question. Limitations are the ones inherent to any physician rating website analysis — selection into Healthgrades itself, a general tendency for online reviews to skew favorable, and no established correlation between star ratings and actual clinical outcomes.

Practically, I'd call this interesting rather than practice-changing. It's not going to alter how you manage a tumor, but it's a reasonable data point if you're thinking about practice growth, online reputation management, or benchmarking yourself against peers — and it's reassuring, at minimum, that Mohs surgeons as a group are rated above the norm for proceduralists generally.

Next is a case report: "Anagen Effluvium, A Rare Side Effect After Radiation Therapy for Auricular Keloids." An eighteen-year-old woman with a three-year history of left auricular keloids — a large pedunculated nodule on the superior helix plus smaller papules on the posterior lobule, previously treated with intralesional triamcinolone with only symptomatic improvement — opted for excision followed by adjuvant x-ray therapy. Excision went down to subcutaneous fat or perichondrium, reconstructed with a transposition flap for the helical defect and transposition plus linear closure for the lobule, followed by one cycle of postoperative x-ray therapy delivered as eighteen gray in three fractions every other day starting the day of surgery.

At two-month follow-up, she reported focal hair loss beginning about a week after radiation — a well-demarcated, roughly seven-by-six centimeter curvilinear patch adjacent to the treatment field, no scale or erythema, and critically, no exclamation-point hairs on dermoscopy, which argues against alopecia areata. The diagnosis of anagen effluvium was made clinically without biopsy — deliberately, since biopsying irradiated, keloid-prone skin carries its own healing and recurrence risks. She was started on topical minoxidil five percent twice daily, with regrowth beginning by three months and complete by six months.

The teaching point here is squarely about recognition and counseling. Anagen effluvium is classically a chemotherapy phenomenon, but it's also been described after interventional radiology procedures and even after intralesional five-fluorouracil injection into a keloid. Radiation-associated anagen effluvium can occur above roughly three gray, typically shows up one to three weeks after exposure, and presents as a sharply demarcated patch confined to the radiation field. Dermoscopically, both anagen effluvium and alopecia areata can show yellow and black dots, but broken hairs and exclamation-point hairs point specifically toward alopecia areata — that's your discriminator. Spontaneous regrowth is expected by around twelve months, and topical minoxidil is a reasonable adjunct if patients want to do something active. The authors believe this is the first reported case of anagen effluvium specifically following adjuvant radiation for a keloid. The actionable piece for anyone using adjuvant x-ray therapy after keloid excision, particularly on the ear or scalp margin, is to counsel patients preoperatively about possible transient hair loss at the field edge, and to coordinate directly with radiation oncology on shielding adjacent hair-bearing skin when feasible.

Third is a technique article — "Granulation Stimulation: A Technique for Secondary Intention Healing of the Scalp With Periosteal and Bone Exposure," presented as a small case series of four patients. The clinical problem is one every Mohs surgeon knows well: large scalp defects with periosteal or calvarial exposure are hard to reconstruct with local tissue in an outpatient, local-anesthesia-only setting, and second-intention healing, while often a good option, carries real risk — prolonged healing can desiccate exposed periosteum and predispose to osteomyelitis, and premature epithelialization at the wound edge can stall the whole process before the bone is ever covered.

The technique itself is deliberately simple. Using non-toothed forceps, the clinician gently sweeps and scrapes the granulating epithelial wound edge circumferentially to detach it from the wound base — some light bleeding is expected — and then lightly scrapes the forceps across the surface of the exposed bone itself. Standard moist wound dressings go back on afterward, and the whole process is repeated weekly, in their series performed by the practice nurse, until the bone is covered and healing completes.

The rationale, as the authors frame it, borrows from two existing concepts: sharp de-epithelialization techniques previously described for stalled second-intention healing on the nasal tip and ala, where de-epithelializing beyond the contracting edge delays basement membrane reconstitution and prevents rolled edges; and cortical craniectomy or burring of denuded calvarium to expose vascular medullary bone and stimulate granulation — though that more invasive approach carried a meaningful osteomyelitis rate, three out of seven patients in the series they cite. Their working hypothesis for why superficial periosteal scraping might help — and this is their own proposed mechanism, not something directly tested here — is that it releases platelet-derived growth factors and cytokines from the acute wounding itself, and they draw an analogy to a randomized trial of autologous whole blood clot dressings in diabetic foot ulcers, where the treated group healed meaningfully better than controls at twelve weeks.

Across their four patients — ages ranging from mid-seventies to early nineties, defects from Mohs surgery for basal cell carcinoma, atypical fibroxanthoma, squamous cell carcinoma, and melanoma in situ, with defect sizes spanning roughly three centimeters up to over ten centimeters — bony coverage was achieved in every case the technique was applied to, with a mean healing time around twenty-four weeks and no episodes of infection or osteomyelitis during the process. This is obviously a small, uncontrolled case series from a single practice, not a comparative trial, so the honest takeaway is that this is a genuinely practical, low-cost, low-risk adjunct — it requires no special equipment, has a low learning curow, and can be delegated to nursing staff — worth trying the next time you have a scalp wound stalling with premature epithelialization over exposed bone, but it hasn't been validated against the alternative strategies in any controlled way.

Last is the original survey study, "Treatment Preferences Among American College of Mohs Surgery Members for Rare Cutaneous Malignancies." Background here: rare cutaneous malignancies collectively account for something like fifty thousand cases a year in the US, only about one percent of all skin cancers, and this bucket includes entities like Merkel cell carcinoma, atypical fibroxanthoma, pleomorphic dermal sarcoma, dermatofibrosarcoma protuberans, sebaceous carcinoma, microcystic adnexal carcinoma, eccrine carcinoma, extramammary Paget disease, leiomyosarcoma, squamous cell carcinoma of the nail unit, mucinous carcinoma, and porocarcinoma, among others. Because these are individually so rare, there's essentially no consensus guideline for most of them, and real-world management — Mohs versus other modalities, immunohistochemistry use, adjuvant therapy — varies widely surgeon to surgeon. The goal was to map out what American College of Mohs Surgery members are actually doing, and whether training exposure predicts practice patterns.

This was done as a twenty-nine question anonymous survey built in REDCap and sent to the entire American College of Mohs Surgery listserv, analyzed with descriptive statistics and Fisher's exact test for associations. A survey is really the only feasible design here — the authors don't spell this out explicitly, but it follows directly from the problem they describe: these tumors are too rare and too heterogeneous in management for a registry or trial to easily capture nationwide practice variation, so asking surgeons directly is the pragmatic way to get a snapshot.

They had a hundred fifty-three people start the survey and a hundred forty-one complete it in full — a solid completion rate. Most respondents were in single-specialty private practice, with about a quarter in academics, and roughly a quarter involved in teaching an ACGME-accredited Micrographic Surgery and Dermatologic Oncology fellowship. Notably, practice setting itself — academic versus private — didn't significantly change treatment choice for any of the fifteen tumors surveyed.

On current practice, Mohs surgery was the preferred surgical modality for squamous cell carcinoma of the nail unit in the vast majority of respondents, similarly high preference for atypical fibroxanthoma, sebaceous carcinoma, and microcystic adnexal carcinoma, roughly seven in ten for dermatofibrosarcoma protuberans, eccrine carcinoma, and porocarcinoma, about two-thirds for mucinous carcinoma, and closer to a coin flip for extramammary Paget disease, pleomorphic dermal sarcoma, and leiomyosarcoma. Merkel cell carcinoma was the outlier, with only about three in ten favoring Mohs — which makes sense given how multidisciplinary its management is. Consistent with that, sentinel lymph node biopsy was considered essentially universally for Merkel cell carcinoma, but only in a minority for pleomorphic dermal sarcoma, sebaceous carcinoma, or periurethral penile squamous cell carcinoma, and radiation oncology referral followed the same pattern — near-universal for Merkel cell, much less common for the others.

On the education side, exposure during fellowship was highly variable by tumor type — nearly universal for atypical fibroxanthoma, over eighty percent for dermatofibrosarcoma protuberans, over seventy percent for sebaceous carcinoma, microcystic adnexal carcinoma, and nail unit squamous cell carcinoma, but under half for extramammary Paget disease and pleomorphic dermal sarcoma. The important finding is that fellowship exposure to a given tumor was strongly and significantly associated with treating that tumor later in practice, across fourteen of the fifteen entities surveyed — about as consistent a signal as you'll see in a survey study. The same pattern held for immunohistochemistry specifically: only about a third of respondents had any immunohistochemistry exposure during fellowship for Mohs generally, and less than a quarter had specific training on immunohistochemistry interpretation for rare tumors — but that smaller group was significantly more likely to be using immunohistochemistry in their current practice, with Mart-1, CK7, and multi-cytokeratin the most commonly taught stains.

The authors' discussion is candid about the underlying problem — a real lack of guidelines for most of these tumors, and genuine practice variation even among a specialized surgical society. Their bottom line is that among surgeons who do treat these tumors surgically at all, Mohs is the favored approach for eleven of the fifteen. And they lean fairly hard on the training-exposure correlation as an argument for standardizing rare-tumor and immunohistochemistry curricula across fellowship programs. Limitations are the expected ones for a survey — sample size, selection and recall bias, questions that couldn't capture case-by-case nuance, and a response reflecting only a small slice of the overall College membership, which the authors themselves flag as a reason for larger prospective work.

Practically, this one isn't practice-changing in the sense of new outcomes data, but it's genuinely useful as a benchmarking tool — it tells you how your own management of these rare tumors compares to your peers nationally, and it's a fairly compelling argument, if you're involved in fellowship education, for building deliberate exposure to rare-tumor management and immunohistochemistry interpretation into your training program, since exposure clearly and consistently predicts what these surgeons go on to do in practice.

That wraps up this month's rundown — a mix of practice-pattern data, a cautionary tale worth having in your adjuvant radiation counseling script, and a simple bedside technique worth trying the next time a scalp wound stalls over exposed bone. Thanks for listening, and we'll see you next month.