Welcome back to the journal review. This is our walk-through of Dermatologic Surgery for March 2026, and we've got four pieces worth your time this month — a tricky case report, a single-center retrospective comparing Mohs against wide excision across five rare tumor types, a SEER-based mortality analysis in melanoma survivors, and a somewhat sobering look at what actually drives one-star online reviews of Mohs surgeons. Let's get into it.

First up is a case report — a communication piece — on acantholytic squamous cell carcinoma arising in a patient with Hailey-Hailey disease. The clinical setup is straightforward but the pathology is the whole point. A 64-year-old man with longstanding Hailey-Hailey disease, previously cleared on the face but with persistent, topically-treated truncal involvement, presented with a biopsy-proven acantholytic squamous cell carcinoma of the left mandible. Review of the original biopsy showed exactly what you'd expect to worry about — an atypical squamous proliferation with prominent acantholysis invading the dermis, sitting right next to epidermal acantholysis without atypia that was simply background Hailey-Hailey. During Mohs micrographic surgery, the surgeon encountered partial- to full-thickness acantholytic change on every stage, and by the third stage, similar-appearing acantholytic foci were still present peripherally without a clean read on whether this was residual tumor or just incidental Hailey-Hailey change. Rather than keep chasing margins blindly, the team stopped, consulted dermatopathology, and resumed later. On review, the frozen sections did show genuine full-thickness atypia with acantholysis and overlying parakeratosis consistent with squamous cell carcinoma in situ — but scattered throughout the periphery were separate foci of partial-thickness acantholysis without any atypia, which was just Hailey-Hailey. The patient came back, the remaining in-situ disease cleared in a single additional stage, and that was that.

The teaching point here is squarely about frozen-section pattern recognition. Acantholysis is not specific — it shows up in Hailey-Hailey, in acantholytic actinic keratoses, in acantholytic squamous cell carcinoma, and even as an incidental "microscopic Nikolsky" phenomenon in Hailey-Hailey patients at sites with no clinical disease at all, something previously described by Saggini and colleagues, possibly reactive to local trauma or possibly just biologically silent. The authors also remind us this same ambiguity could arise with any primary acantholytic dermatosis — pemphigus variants, Darier disease, Grover disease. Their practical message: when acantholytic change at the margin doesn't clearly read as tumor, get dermatopathology involved rather than assuming reflexively either way. Reported Mohs-to-dermatopathology concordance runs from the mid-nineties up to nearly 100 percent, but this is exactly the kind of case that sits in that small discordant tail. Nothing here changes your general Mohs technique, but it's a useful pattern to have banked mentally: a patient with a history of Hailey-Hailey and a squamous neoplasm with acantholytic features is a setup for frozen-section ambiguity, even in skin that looks clinically quiet.

Next is a retrospective analysis from a single academic center — Wake Forest — looking at 310 cases treated over fifteen years, comparing Mohs micrographic surgery against wide local excision across five genuinely rare cutaneous tumors: atypical fibroxanthoma, dermatofibrosarcoma protuberans, sebaceous carcinoma, extramammary Paget disease, and microcystic adnexal carcinoma. The rationale for even doing this study is that none of these five tumors has a well-established, guideline-level standard for surgical margin control, so real-world comparative data matters.

Methodologically, they used a natural-language-processing chart-search tool to flag any record containing these diagnostic terms between 2009 and 2024, then required histologic confirmation on permanent sections to actually qualify for inclusion — of 606 flagged patients, 310 met criteria. This is a pragmatic way to study rare tumors: you simply can't prospectively randomize a few hundred patients across five rare histologies, so a long-look-back single-center chart review, even with its limitations, is really the only feasible design here. They used odds ratios with confidence intervals for recurrence comparisons and Kaplan-Meier estimates for five-year recurrence-free and overall survival.

Across the whole cohort, five-year overall survival didn't differ significantly between Mohs and wide excision — not surprising, since overall survival in these tumors is driven mostly by disease biology rather than local margin technique. But recurrence-free survival told a different story, particularly for extramammary Paget disease, where wide excision patients had only a 41 percent five-year recurrence-free survival compared to essentially complete disease control with Mohs, a statistically significant and clearly clinically meaningful gap. Breaking it down by tumor: for atypical fibroxanthoma, this cohort actually saw a few more recurrences with Mohs than wide excision — 4 percent versus zero — but the wide excision group was tiny, only 21 patients, and 14 percent of those excisions had positive margins to begin with, so that's a fragile comparison; it also runs counter to the broader literature, where a prior meta-analysis found 2 percent recurrence with Mohs versus almost 9 percent with wide excision. For dermatofibrosarcoma protuberans, this series had zero recurrences with Mohs against 9 percent with wide excision, and the wide excision group had a striking 64 percent positive margin rate even using a two-centimeter median margin — reinforcing that Mohs should be strongly favored here. Sebaceous carcinoma showed low recurrence with both approaches in this cohort and no significant difference, though a larger systematic review the authors cite found a clear, significant advantage for Mohs. Extramammary Paget disease was the standout: zero recurrences with Mohs versus 33 percent with wide excision, and wide excision margins were positive four times out of five. Microcystic adnexal carcinoma had no recurrences in the ten Mohs-treated patients, with no internal wide-excision comparator, though historical data on wide excision for this tumor is poor.

The authors are upfront about the limitations — no standardized surveillance protocol across patients, small subgroup sample sizes, and wide-ranging, non-standardized excision margins that make apples-to-apples comparison difficult. For your practice, this is largely confirmatory rather than practice-changing on its own — it reinforces existing meta-analytic data that Mohs meaningfully reduces recurrence and positive-margin rates for dermatofibrosarcoma protuberans, extramammary Paget disease, and microcystic adnexal carcinoma, and probably sebaceous carcinoma given its typical periocular and facial locations. The atypical fibroxanthoma numbers here shouldn't move your practice at all — that's a small, margin-compromised comparator group, not a true signal against Mohs.

Third is a SEER-based cohort study looking at a genuinely important survivorship question: patients with cutaneous melanoma are already known to carry an increased risk of a second, noncutaneous melanoma — ocular, oral, or vaginal — but whether that second diagnosis actually shortens survival hadn't been well quantified. The authors queried SEER-17 data from 2000 to 2021, using pathology codes to identify microscopically confirmed cutaneous melanomas, then used the SEER multiple-primary standardized-incidence-ratio tool specifically to identify true subsequent noncutaneous primaries rather than metastatic spread misclassified as a new tumor. They built multivariate models adjusting for the usual demographic and tumor-level confounders — age, sex, marital status, income, rurality, anatomic site, Breslow depth, subtype, stage, and ulceration — and, importantly, modeled time to noncutaneous melanoma diagnosis as a time-varying covariate rather than a fixed baseline characteristic. That's a real methodologic strength worth flagging explicitly: if you don't do this, you introduce immortal time bias, because a patient has to survive long enough to even develop a second primary, which would artificially make the "second-melanoma" group look like it survives longer than it should. Treating it as time-varying corrects for that.

Out of over half a million cutaneous melanoma patients, 195 went on to develop a noncutaneous melanoma. Those patients were slightly older on average and more likely to be lower-income, both statistically significant differences, though the age gap of about three years is not itself clinically dramatic. The real finding is the survival hit: developing any noncutaneous melanoma after a cutaneous one was associated with nearly a three-fold increase in mortality hazard, a result that's both statistically significant and clinically substantial. When they stratified by site, oral melanomas stood out sharply — almost an eight-fold increase in mortality hazard, the worst of the group. Ocular melanomas also significantly worsened survival, at roughly a two-and-a-half-fold hazard increase. Vaginal melanomas trended toward worse survival but didn't reach statistical significance, most likely because of small numbers in that subgroup. Interestingly, when they stratified by age, patients under 50 who developed a second noncutaneous melanoma had the steepest mortality risk of any subgroup, at nearly a six-fold hazard increase. And in a nice bit of added context, the authors also compared cutaneous-plus-noncutaneous melanoma patients against patients who only ever had a noncutaneous melanoma alone — the combination group still fared significantly worse, suggesting there's something biologically or cumulatively worse about carrying both diagnoses rather than the noncutaneous melanoma simply being the dominant driver of mortality on its own.

The authors are honest about limitations — no comorbidity data available in SEER, which is a real potential confounder, and while they used the multiple-primary tool specifically to avoid it, they acknowledge some theoretical residual risk of a metastatic cutaneous melanoma being miscoded as a new noncutaneous primary. For your practice, this is squarely in the "important for survivorship conversations, not procedurally practice-changing" category. It doesn't change how you perform Mohs or manage a primary cutaneous melanoma, but it's a solid piece of data to have on hand when counseling melanoma survivors about surveillance — particularly reinforcing why persistent oral or ocular symptoms in a melanoma survivor deserve a low threshold for referral, given how disproportionately lethal those second primaries turn out to be.

Last is an original study, and it's less about surgical outcomes and more about practice management — a qualitative analysis of one-star Yelp reviews for Mohs surgeons. The premise is timely: online reviews increasingly feed into how patients choose physicians, and patient satisfaction metrics are formally tied to reimbursement through Medicare's Merit-based Incentive Payment System, so understanding what actually drives negative reviews has real financial relevance, not just reputational relevance.

The authors pulled Yelp listings for Mohs surgeons across the five largest US cities, cross-referenced them against Doximity and Healthgrades to confirm dermatology training and an actual Mohs practice, then isolated every one-star review for detailed coding. Two independent reviewers classified each discrete complaint within a review as clinical — things like scarring, recurrence, inadequate exam, uncontrolled pain — or nonclinical — cost and billing, staff professionalism, bedside manner, scheduling, and so on — with a third reviewer resolving disagreements, which is a solid inter-rater reliability approach for this kind of qualitative coding.

Of just over 7,000 total reviews pulled, about one in five were one-star, and after excluding non-Mohs providers, 670 one-star reviews remained, containing nearly 1,500 discrete coded complaints. The single most striking number in this paper: about 91 percent of those one-star reviews came from patients who never actually underwent a surgical procedure at all — these were consultation or office-visit encounters. And when you look at what people actually complained about, clinical issues made up less than one in five of all complaints, while roughly four out of every five complaints were nonclinical — cost, billing, and insurance issues were the single most common complaint category, followed closely by unprofessional staff behavior, poor physician bedside manner, and poor communication. Surgical patients were, understandably and significantly, more likely to complain about tangible clinical issues like scarring or pain control, while nonsurgical patients skewed heavily toward complaints about staff demeanor and time spent with the provider. Cosmetic-visit patients were significantly more likely than noncosmetic patients to flag poor cosmetic outcomes, billing problems, and bedside manner — consistent with this being an elective, expectation-heavy population.

The authors' own stated limitation is important: because they only analyzed one-star reviews, they may be missing patients who had real complaints but still rated the visit two or three stars, so this isn't a complete picture of dissatisfaction, just the most extreme end of it. There's also the obvious platform limitation — this is Yelp-specific behavior, not necessarily representative of Healthgrades or RateMDs reviewers. Practically speaking, this study won't change how you operate or how you manage margins, but it's genuinely actionable at the practice-management level: the consultation visit itself, not the surgical outcome, is where most reputational risk seems to concentrate, and investing in front-office training, billing transparency, and consistent communication — even for patients who never end up on your table — may do more for your online reputation and your patient-experience metrics than anything you do intraoperatively.

That wraps our four articles for March. A pathology pearl on acantholytic squamous cell carcinoma in Hailey-Hailey skin, reinforcing data favoring Mohs for several rare adnexal and mesenchymal tumors, a sobering survivorship signal on second noncutaneous melanomas, and a reminder that your waiting room and your billing office may matter more to your online reputation than your margins do. Thanks for listening, and we'll see you next month.