Welcome to this month's journal review, covering the April 2026 issue of Dermatologic Surgery. We've got four pieces from the Communications section this time — a case series on rhinophyma, a methodology letter proposing a modified scar-scoring tool, a systematic review of a rare adnexal carcinoma, and a prospective study on surgical site infections in second-intention wounds. Let's get into it.

First up is a case series on high-frequency electrosurgery for severe rhinophyma. This is a small case series out of Istanbul — five patients, so treat the numbers accordingly, but the technique discussion is worth your attention. The background here is familiar to all of us: rhinophyma progresses from sebaceous and connective tissue hypertrophy to real disfigurement, and beyond the cosmetic burden, advanced cases can cause nasal obstruction and even sleep apnea. The authors are looking at high-frequency electrosurgery — essentially radiofrequency in the 2.5 to 3 megahertz range — as an accessible, lower-cost alternative to carbon dioxide laser or straight scalpel excision.

Methodologically, this is exactly what you'd expect for a rare, severe presentation: five patients, all graded as "major" by the El-Azhary system, treated under dorsal and lateral nasal nerve blocks with lidocaine and epinephrine, then layer-by-layer decortication with a blade-tip electrode down to the reticular dermis — identified by that classic yellowish hue and pinpoint bleeding. The key technical pearl, and this is the actual teaching point of the paper, is preserving the deepest third of the sebaceous glands to promote reepithelialization without atrophy. Outcomes were assessed at twelve weeks using paired Physician and Patient Global Assessment scores on a zero-to-three scale.

The results were about as good as you'd hope. All patients reepithelialized within ten to fourteen days, with only transient erythema lasting three to six weeks and no prolonged healing or significant crusting. Physicians rated outcomes excellent in three of the five and moderate in the other two — so a sixty–forty split. Patients, notably, rated their own outcomes as excellent across the board — all five. Mild scarring occurred in three patients but needed no treatment, one patient had persistent dilated pores, and there were no recurrences over a follow-up window ranging from six months to two years.

The discussion frames this against the alternatives: carbon dioxide laser has comparable efficacy but is expensive and maintenance-heavy; electrosurgery gets you there in a single session, at a fraction of the equipment cost, with the added benefit of built-in coagulation. The obvious limitation is the sample size — five patients is a case series, not a comparative trial — and there's no laser or scalpel control arm here, so any claims of superiority are really just consistency with prior literature rather than new comparative evidence. Practically speaking, this isn't practice-changing for anyone already comfortable treating rhinophyma with electrosurgical decortication — it's confirmatory. But the specific technical detail about preserving the deepest third of the pilosebaceous unit as your depth endpoint is a nice, concrete pearl to bank if you're not already anchoring your endpoint that way.

Next, a methodology letter proposing a clinician-only modification of the SCAR score — that's the Scar Cosmesis Assessment and Rating scale — specifically for retrospective photograph review. This is a validation letter rather than a full original study, but it's got real methodological substance, so it's worth walking through.

The problem they're solving: the original SCAR score is a fifteen-point scale, with thirteen points from clinician assessment — scar spread, erythema, dyspigmentation, track marks, and hypertrophy — and two points that require direct patient input, covering pain and pruritus. That's fine for prospective studies, but retrospective chart-and-photo reviews often don't have access to patients to ask about symptoms. So the authors strip out those two patient-reported points, leaving a thirteen-point, purely clinician-scored version, and then validate it.

Their design: they pulled fifty-six patients from a Mohs practice database — specifically linear closures greater than four centimeters on the medial cheek between 2017 and 2024 — and had three independent raters, a Mohs surgeon, a Mohs fellow, and a dermatologist, score follow-up photographs. They deliberately excluded the original operating surgeon from rating their own cases, which is a sensible bias-control move worth noting as good methodological practice. For statistics, they mirrored the original Kantor validation approach: Cronbach's alpha for internal consistency and an intraclass correlation coefficient using a two-way random-effects model for interrater reliability — using the same statistical framework as the original scale's validation lets you make a fair apples-to-apples comparison.

The results were solid: Cronbach's alpha came in at 0.90, which is excellent internal consistency, and the intraclass correlation coefficient was about 0.75, with a confidence interval spanning roughly 0.65 to 0.84 — that's good interrater reliability, and notably it held up despite the raters having different levels of training, from fellow to attending to general dermatologist. That reproducibility across experience levels is really the main selling point here.

The honest limitation, which the authors state themselves, is that this has only been validated on linear closures on the medial cheek. Whether it holds up for flaps, grafts, or other anatomic sites is simply unknown at this point. So the practical takeaway: if you're doing retrospective scar-outcomes research and don't have patient-reported data available, this is a reasonable, statistically validated tool to standardize your photographic scoring — genuinely useful for your own research methodology, but it's a research-infrastructure contribution, not something that changes how you counsel or treat a patient in clinic.

Third, a systematic review looking at recurrence rates after Mohs micrographic surgery versus wide local excision for squamoid eccrine ductal carcinoma — and this is billed as the largest review of this entity to date, pooling 85 cases.

Quick background refresher: squamoid eccrine ductal carcinoma is a rare adnexal tumor that looks like squamous cell carcinoma on the surface but has deeper eccrine ductal differentiation within a desmoplastic stroma, and perineural invasion is common. Because superficial or shave biopsies can miss the diagnostic deeper component, misdiagnosis as ordinary squamous cell carcinoma is a real and recurring problem in this literature.

For methods, this is a systematic review built from a PubMed search of case reports, case series, and review articles containing novel cases from 1997 through early 2025, supplemented with three new institutional cases, for a total of 85. They excluded anything that didn't use wide local excision or Mohs surgery, or that lacked follow-up data. The authors are upfront that while they generally followed a structured search and inclusion process consistent with PRISMA principles, they didn't formally apply a full PRISMA protocol or checklist — worth flagging since it affects how rigorously "systematic" this really is. Given how rare this tumor is, pooling published cases is really the only way to get a dataset with any statistical power at all — that's the authors' implicit rationale, and it's a reasonable one for an orphan diagnosis like this.

On to results: wide local excision was used in about two-thirds of cases, Mohs surgery in roughly one-third. Recurrence occurred in about one in five patients regardless of modality — eighteen and a half percent after wide excision, just over nineteen percent after Mohs — and a formal statistical test confirmed no significant difference between the two. Metastasis, though, showed a numeric gap: around nine percent after wide excision versus a single patient in the Mohs group. Follow-up averaged about two and a half years, but with a wide range, and notably nearly a third of all cases had less than a year of follow-up.

The discussion is really where this paper earns its value, because the authors contextualize these numbers against a striking historical fact: published recurrence rates for this tumor overall run seventy to eighty percent, dramatically higher than ordinary squamous cell carcinoma's low single digits to high teens, and metastatic rates have been reported as high as fifty percent — roughly ten times that of squamous cell carcinoma. So even though this analysis didn't find a significant modality difference, the disease itself remains far more aggressive than its histologic mimic would suggest. The authors are candid about why Mohs didn't show a clear advantage here: follow-up was often short, metastasis and immunosuppression status weren't consistently reported across source studies, there's likely publication bias since Mohs cases in the literature are disproportionately drawn from case reports — which tend to get published specifically because something went wrong — and there were simply more published wide-excision cases overall, introducing referral and reporting bias. They also note that misdiagnosis as squamous cell carcinoma before Mohs was even considered may have allowed some tumors to progress before appropriate margin control was applied.

Practical takeaway here: this doesn't give you evidence to prefer one surgical modality over the other on recurrence grounds — the data genuinely can't support that claim given its limitations. What it should reinforce is clinical suspicion and management intensity: any diagnosis of squamoid eccrine ductal carcinoma warrants adequate margin assessment, whichever technique you use, and given the disease's true aggressive potential — likely underestimated here because of short follow-up — these patients need longer-term surveillance than you'd typically apply to a similarly sized ordinary squamous cell carcinoma. That's the actionable point, not a modality preference.

Last, and probably the most immediately practice-relevant of the four, a prospective single-center study looking at surgical site infections and microbial shifts in wounds healing by second intention after Mohs surgery.

The clinical problem: second-intention wounds are thought to carry meaningful infection risk given delayed healing, and while gram-positive-targeted prophylaxis is commonly used, its actual efficacy has remained unclear. This study set out to characterize infection incidence, prescribing patterns, and — critically — the actual microbiology of infections when they occur.

Design-wise, this was a prospective, institutional-review-board-approved study from a single dermatologic surgeon at an academic center, running from January 2020 through mid-2024, capturing every Mohs case left to heal partially or fully by second intention. Every clinically diagnosed infection got a bacterial wound culture to guide antibiotic tailoring — which is really the methodological strength here, since it means the microbiology data reflects actual culture results rather than empiric assumption. Using a single surgeon likely controls for variability in wound care technique and threshold for diagnosing infection, though the authors don't state that explicitly — that's my inference, not theirs.

Now the numbers, and these are worth stating precisely because they change how you think about prophylaxis. Out of about sixty-six hundred Mohs cases over that four-and-a-half-year period, roughly thirteen percent — 846 wounds — were left to heal by second intention. Only twelve surgical site infections occurred in that group, giving an infection rate of about one and a half percent, which the authors note was actually the highest rate among all repair types at their institution. Here's the striking part: nine of those twelve infected patients had already received gram-positive-targeted prophylactic antibiotics, and of those nine, eight went on to grow gram-negative organisms on culture — predominantly Pseudomonas aeruginosa. In the three patients who received no prophylaxis at all, cultures showed a more mixed picture, majority gram-positive with a minority gram-negative. Across the whole second-intention cohort, antibiotic use — topical, oral, or both — was significantly more common in patients over 65, those with lower-extremity wounds, larger defects, and squamous cell carcinoma, though not associated with sex or immune status.

On the multivariate analysis, two factors independently predicted infection risk: a postoperative defect larger than about 400 square millimeters carried roughly a four-fold increased odds, and lower extremity or leg-and-foot location carried roughly a seven-fold increased odds — both statistically significant and, importantly, both clinically meaningful magnitudes, not just statistical noise. Age, sex, immune status, histology, and number of Mohs stages showed no independent association.

The discussion raises a genuinely important hypothesis: gram-positive prophylaxis may be disrupting native cutaneous flora and, by reducing competitive inhibition, opening the door for opportunistic gram-negative colonizers like Pseudomonas — a phenomenon the authors suggest is amplified on the lower extremity given routine environmental exposure during bathing and daily activity. They also note an institutional practice pattern that's a real confounder here: lower extremity wounds were preferentially left to heal by second intention at this center specifically because of poor skin laxity and higher dehiscence risk, meaning the second-intention cohort is inherently enriched for the anatomic site that also carries the highest infection risk — that's a selection effect baked into the cohort, not necessarily a property of second-intention healing itself. The authors are honest that with only twelve total infection events, this is a low-event-rate, single-center study, and statistical power for the microbiology subgroup findings is limited.

So what should you actually do with this. The recurrence-and-margin findings from the other papers aside, this one has a real, immediately usable signal: if you're reflexively prescribing gram-positive-only prophylaxis for large, lower-extremity second-intention wounds, this data suggests you may not be covering the organism most likely to actually cause a clinically relevant infection, and you might even be selecting for it. That's a reasonable trigger to reconsider antibiotic choice — or arguably to reconsider whether prophylaxis is even indicated at all — specifically for defects over 400 square millimeters on the leg or foot. I'd call this actionable but not yet definitive; twelve events is a small foundation for changing standard prescribing across the board, but it's exactly the kind of finding that should make you second-guess routine gram-positive prophylaxis in this specific high-risk subgroup while we wait for larger, multicenter confirmation.

That wraps up this month's four articles — a technique-affirming case series on rhinophyma, a useful new scoring tool for your own retrospective research, a sobering reminder about the true aggressiveness of squamoid eccrine ductal carcinoma regardless of surgical modality, and a genuinely practice-relevant signal about gram-negative shift in lower-extremity second-intention wounds. Thanks for listening, and we'll see you next month.