Welcome to this month's journal review — we're covering the April twenty twenty-six issue of Dermatologic Surgery, four articles this time, ranging from a nail surgery technique paper to three reviews touching seborrheic keratosis, incidental Mohs pathology, and pigmentary laser therapy. Let's get into it.

First up is an original article, though it comes out of an orthopedic surgery group rather than dermatology proper — a modified Heifetz method with a new suture technique for ingrown toenails. Worth including here because Mohs surgeons and dermatologic oncologists absolutely see and treat onychocryptosis, and this journal apparently thought it relevant too.

The background is straightforward: the classic Heifetz technique — partial matricectomy plus excision of the hypertrophic lateral fold — is a mainstay for stage two and three ingrown toenails, but it has two recognized weak points. First, incomplete excision of the lateral matrix horn can leave a nidus for recurrence. Second, and this is the crux of the paper, the classic technique closes the wound by passing suture directly through the nail plate, which the authors argue causes nail deformation and postoperative pain. So they developed a modification: instead of suturing through the nail, they place two transverse sutures through the proximal soft tissue only, sparing the nail plate entirely, and they also curette the proximal phalanx periosteum to more completely ablate the germinal matrix.

Methodologically, this is a retrospective cohort, and the way it was assembled is worth flagging plainly: it isn't a randomized or even a concurrently-enrolled comparison. All patients treated before a certain date got the classic technique; once the surgeons became dissatisfied with nail deformity and pain, they switched entirely to the modified technique, and everyone after that point got the new method. So this is a historical, before-and-after cohort — one hundred four classic, one hundred ten modified. The authors don't explicitly discuss this as a limitation of design choice, but it's the obvious explanation for why they didn't randomize: the modification arose organically out of clinical dissatisfaction with the original method, and retrospective comparison was simply the practical way to capture that natural experiment. The problem, which I'll come back to, is that time itself is a confounder here — general perioperative care, surgeon experience, and patient selection could all have drifted between the two eras.

Onto results. Recurrence was significantly lower with the modified technique — two point seven percent versus ten point six percent — and that's a clinically meaningful difference, not just a statistical one; a four-fold reduction in recurrence for a common outpatient procedure matters. Cosmetic satisfaction was also higher, ninety-six percent versus seventy-nine percent, again both significant and clinically relevant. Postoperative pain on the visual analog scale was lower in the modified group, essentially near zero versus roughly three-quarters of a point — statistically significant, and although the absolute pain scores in both groups were low, avoiding suture-through-nail pain is a plausible, mechanistically sensible benefit. Return to activity was faster with the modified technique, about twenty-one days versus twenty-three and a half — this one reached statistical significance, but a two-day difference in returning to daily activity is not something you'd call clinically transformative. Superficial infection rates were similar between groups and not significantly different, and there were no deep infections, no necrosis, no neurovascular complications in either arm.

The discussion positions the technique against other published methods — Winograd-based approaches in the literature report recurrence in the mid-single digits, so the modified Heifetz recurrence rate here compares favorably, though obviously these are all different patient populations and different eras, not head-to-head data.

The honest limitations: this is a single-institution, retrospective, sequential-cohort design without randomization, which means the encouraging results could partly reflect a general improvement in perioperative technique or surgeon experience over time rather than the suture modification alone. There's also no blinding of the cosmetic satisfaction assessment, which is inherently prone to bias when patients know which era of technique they received.

Practical takeaway: this is a genuinely low-risk, easy-to-adopt technical tweak — keeping suture out of the nail plate makes intuitive sense and costs nothing to implement — so if you perform matricectomies in your practice, it's reasonable to consider. But I'd call this "interesting and plausible" rather than definitively practice-changing, given the historical-cohort design; a prospective or randomized comparison would be needed to fully trust the magnitude of the recurrence benefit.

Next, a scoping review on laser treatments for seborrheic keratosis. This is a review article, PRISMA-guided, aiming to map the existing evidence on laser-based management of these ubiquitous benign epidermal lesions rather than to answer one specific efficacy question — hence "scoping" rather than systematic-with-meta-analysis.

The clinical gap they're addressing: seborrheic keratoses are extremely common, traditional destructive treatments like cryotherapy, curettage, and electrosurgery carry real risk of dyspigmentation and scarring — especially in darker skin — and laser therapy has proliferated as an alternative without any synthesis of what actually works, at what parameters, and how safely.

Methodologically, they searched six databases, screened over seven hundred records down to twenty-two included studies covering just under fifteen hundred patients, and explicitly state that a meta-analysis wasn't feasible given how heterogeneous the laser types and protocols were — so this stays descriptive and narrative, which is the right call when you're pooling case series across eight different laser modalities with wildly different reporting standards.

On results, the studies split into ablative and pigment-selective nonablative categories. Ablative platforms — carbon dioxide at ten thousand six hundred nanometers and erbium:YAG at twenty-nine forty nanometers — achieved single-session clearance in the majority of studies, up to about ninety percent of lesions, with recurrence essentially at zero to six percent depending on the series. Carbon dioxide laser studies reported around eighty-seven percent patient satisfaction and no scarring at all across the pooled cohort, though erythema and some postinflammatory pigment change occurred in a meaningful minority. Erbium:YAG did even better on satisfaction, around ninety-five percent, again with high single-session clearance, though one study did report a six percent recurrence at six months and there was some reported scarring in a small fraction of patients.

The nonablative, pigment-selective lasers — long-pulsed alexandrite, Nd:YAG at ten sixty-four nanometers, frequency-doubled Nd:YAG or KTP at five thirty-two, pulsed-dye, and the newer titanium-sapphire picosecond devices — generally needed multiple sessions, on the order of one to three, rather than single-session clearance. Recurrence was again low across the board. But I'd flag one thing the authors' own data surfaces without much editorial alarm: the alexandrite laser subset, small as it was, showed strikingly high rates of adverse pigmentary change and scarring — roughly three-quarters of those patients experienced hyper- or hypopigmentation, and about seventy percent had scarring reported. That's a small numerator, only a handful of patients across three studies, but it's a signal worth knowing before reaching for that device.

The limitation the authors are most forthright about, and it's the central point of the whole review: Fitzpatrick skin typing was reported in only about two-thirds of studies, and where it was reported, it clustered in types one through four — types five and six were essentially absent. Given that traditional destructive therapies cause disproportionate dyspigmentation risk in darker skin, and that's precisely the population where a gentler alternative would matter most, this is a real evidence gap, not a minor footnote. Sample sizes per laser type were often tiny — some modalities represented by a single study of a handful of patients — so precision around adverse event rates for anything other than carbon dioxide and erbium:YAG should be held loosely.

Practical takeaway: for routine, cosmetically-motivated seborrheic keratosis removal, ablative carbon dioxide or erbium:YAG remains a reasonably well-supported, single-session option with high satisfaction. Pigment-selective nonablative options are plausible alternatives especially where scarring risk is a concern, but the evidence quality is thin, protocols aren't standardized, and — critically — there is essentially no direct evidence to guide you in Fitzpatrick five or six skin. This is useful context, not yet a protocol you can lift wholesale into darker-skinned patients with confidence.

Third article: a systematic review of incidental histologic findings during Mohs micrographic surgery. This is squarely in our wheelhouse. The premise is simple — during real-time margin assessment, pathology unrelated to the index tumor sometimes turns up, and there's no standardized approach to reporting or managing it.

Methods: PRISMA-guided search across four databases, screened down from roughly twenty-five hundred records to twenty-nine included studies, twenty-two individual case reports and seven case series, spanning publications from nineteen eighty-four to twenty twenty-five. This is exactly the right design for the question — you're trying to characterize the spectrum of a rare, heterogeneously-reported phenomenon, and a systematic review of case-level literature is the only way to aggregate that.

Here's where you need to watch the denominators carefully, because the authors are upfront about this distorting their own headline numbers. Of six hundred eighty total patients with incidental findings, six hundred ten came from a single large retrospective study that only characterized incidental basal cell and squamous cell carcinomas — essentially, tumors found incidentally while treating a different index tumor. That one study dominates the aggregate statistics. Strip that out, and you're left with seventy genuinely "other" incidental findings from the remaining twenty-eight studies. Among those seventy, the categories break down as iatrogenic or artifactual findings — mostly filler material, hyaluronic acid and calcium hydroxylapatite — at just over half; benign adnexal neoplasms like syringomas and syringomatous hyperplasia at around sixteen percent; other malignant neoplasms, including three Merkel cell carcinomas, two melanomas, and isolated cases of chronic lymphocytic leukemia, B-cell lymphoma, multiple myeloma, and spiradenocarcinoma, at fourteen percent; and smaller slices for infectious, metabolic, inflammatory, and ectopic tissue findings.

This is where the headline statistic in the abstract needs unpacking rather than repeating at face value: the paper states ninety-one percent of all reported incidental findings required further treatment, but that figure is almost entirely driven by the six hundred ten incidental carcinomas from that one dominant study, which by definition need treatment. Among the seventy "true" miscellaneous incidental findings — the syringomas, the fillers, the rare malignancies — only about sixteen percent required further intervention. That's a much more clinically honest number, and the authors themselves acknowledge that including the large study likely inflated the overall treatment-required percentage.

Anatomically, most incidental findings turned up in Mohs Appropriate Use Criteria zone H — the head, high-risk zone — at just under fifty-eight percent, which makes sense given both tumor burden and biopsy density in that region.

The discussion adds some genuinely useful pearls beyond the raw tally: conjunctival concretions on eyelid Mohs can mimic the keratin pearls of squamous cell carcinoma; background MART-1 staining can highlight benign nevi and lentigines alongside melanoma and create diagnostic confusion during melanoma-in-situ Mohs; tophaceous gout can produce pseudoepitheliomatous hyperplasia mimicking squamous cell carcinoma; and frozen-section artifacts — tissue undulation, freeze-induced vacuolization, staining irregularities, and "floaters" displaced during sectioning — remain a persistent technical pitfall worth actively guarding against.

Limitations are the ones you'd expect from a case-report-driven review: significant publication bias toward unusual or severe findings, heterogeneous reporting with inconsistent follow-up, and the distorting effect of that one large study, which the authors explicitly name as a limitation of their own aggregate numbers. Their honest conclusion is that the true incidence of incidental findings during Mohs is probably underreported, since only the interesting cases make it into print.

Practical takeaway: nothing here is practice-changing in terms of a hard number to memorize, but it's a genuinely useful vigilance reminder — keep a high index of suspicion for unexpected histology even when the index tumor's margins are clear, particularly for adnexal mimickers and staining pitfalls like MART-1 background positivity, and don't hesitate to loop in dermatopathology when something doesn't fit the expected picture, especially in zone H where density of incidental findings appears highest.

Last article: a systematic review of laser therapy for lichen planus pigmentosus and erythema dyschromicum perstans — two dermal hyperpigmentation disorders, often grouped together as acquired dermal macular hyperpigmentation, that disproportionately affect patients with darker skin and are notoriously resistant to topical and systemic therapy.

The gap here is that laser therapy is emerging as an option via selective photothermolysis of dermal melanin, but there's no consensus on parameters or safety, particularly given the elevated risk of dyspigmentation and scarring when treating pigmented lesions in skin of color.

Methods: PRISMA-guided search of three databases through the end of twenty twenty-four, yielding fifteen studies and only fifty-six total patients — this is a small evidence base, and worth noting up front that ten of the fifteen studies were Oxford level-four evidence, meaning mostly case reports and small case series, with zero level-one studies. One methodological detail is genuinely worth explaining because it shapes how much confidence to place in the results: many of the included studies didn't report a standardized outcome measure like melanin index, so the reviewers themselves retrospectively graded pretreatment and post-treatment clinical photographs using a Physician's Global Assessment scale from zero to six. That's a reasonable workaround given the state of the literature, but it does mean a meaningful chunk of the "results" you're about to hear are the reviewers' own subjective photographic interpretation rather than the original authors' reported outcome — an important caveat on precision.

Results: lichen planus pigmentosus accounted for forty-six of the fifty-six patients, erythema dyschromicum perstans for ten. Q-switched Nd:YAG at ten sixty-four nanometers was by far the most-used laser, applied in forty patients across six studies, averaging six sessions at a fluence around three joules per square centimeter. By the reviewers' PGA grading, about thirty percent achieved near-complete to complete clearance, sixty percent had partial improvement, and roughly ten percent had minimal or no response — so the large majority saw at least some benefit, though true "complete clearance" was the minority outcome. Adverse events were generally mild — transient erythema, some post-laser hyperpigmentation — but there was one case of koebnerized vitiligo that developed after the treating fluence was increased from two and a half up to three joules per square centimeter, which is a useful, specific safety signal: complications appear fluence-dependent, and pushing energy up in search of faster clearance carries real risk in this population.

Fractional erbium at fifteen fifty nanometers was tried in nine patients with erythema dyschromicum perstans and performed poorly — only about eleven percent achieved good clearance, with the remaining nearly ninety percent showing little to no improvement at eighteen weeks. One case that had failed Q-switched Nd:YAG monotherapy went on to complete clearance after adding fractional erbium plus topical tazarotene and fluticasone — a single case, promising but obviously not generalizable. Picosecond Nd:YAG, carbon dioxide fractional ablative, and thulium fractional lasers were each reported in only one or two patients apiece, with results ranging from mild improvement to near-complete clearance — interesting anecdotes, not yet a dataset. Q-switched ruby laser was tried once for erythema dyschromicum perstans and showed no response at all.

The authors' discussion offers a genuine clinical pearl that goes against typical dermal-lesion laser dogma: standard teaching for treating dermal pigment usually aims for an endpoint of immediate frosting, but the authors note their own clinical experience — and that reflected across several included studies — favors stopping at faint erythema with a conservative, low-fluence, multi-pass "toning" approach, specifically to minimize the risk of post-inflammatory hyperpigmentation and vitiligo induction in these patients.

Limitations are substantial and the authors don't dodge them: this is an overwhelmingly low level-of-evidence literature, total patient numbers are tiny, follow-up averaged only around seven months, outcome measures were inconsistent enough to require the reviewers' own retrospective photographic grading, and there are no controlled trials at all — so everything here is hypothesis-generating rather than confirmatory.

Practical takeaway: for a patient with biopsy-confirmed lichen planus pigmentosus or erythema dyschromicum perstans who has failed topical therapy, conservative low-fluence Q-switched Nd:YAG with a multi-session toning approach is a reasonable option to discuss, with explicit counseling that response is often partial rather than complete and that fluence should be escalated cautiously given the fluence-linked vitiligo signal. Fractional erbium looks less promising specifically for erythema dyschromicum perstans based on this data. Overall, call this evidence-informed but not evidence-proven — worth having in your toolkit for a genuinely hard-to-treat population, but not something to treat as an established, standardized protocol yet.

That wraps our four articles for this issue — a technical nail surgery refinement worth a low-risk trial in your own hands, two review articles mapping laser evidence for seborrheic keratosis and for pigmentary disorders in skin of color that both converge on the same message of promising but underpowered data, and a systematic review of incidental Mohs pathology that's less about new numbers and more about sustaining the diagnostic vigilance you already bring to the microscope. Thanks for listening, and I'll see you next month.