Welcome back to the Dermatologic Surgery journal review. This is the May twenty twenty-six issue, and we've got four pieces worth your time today — a rapid review and meta-analysis on a topic most of us have never formally quantified, a nice retrospective case series out of Brussels on a pediatric nail dystrophy, a case report on a genuinely rare porokeratosis variant, and a clinical review synthesizing decades of histology on chemical peels. Let's get into it.

First up is a review article: "Adverse Psychological Events Associated With Mohs Micrographic Surgery: A Rapid Review and Meta-Analysis," out of Washington State and the Zucker School of Medicine at Hofstra Northwell. This is a PROSPERO-registered rapid review with two linked components, and the background question is one that's easy to overlook clinically — we obsess over infection rates, flap necrosis, and hematoma in our informed consent conversations, but do we ever mention anxiety or psychological distress as a procedural risk? A prior audit of UK National Health Service consent forms for dermatologic surgery found zero mention of psychological adverse events, and these authors wanted to know whether that gap exists in the US as well, and whether the underlying literature actually supports treating psychological distress as a real, quantifiable adverse event of Mohs.

Methodologically, this is a nice teaching case for how to handle a genuinely heterogeneous literature. They searched MEDLINE and PsycINFO for any study quantifying psychological status in adults perioperatively during Mohs, then pulled thirteen different psychological measures — mostly anxiety visual analog scales, but also State-Trait Anxiety Inventory subscales, the Zung scale, quality-of-life instruments like the Skindex and Skin Cancer Index, and even a depression measure, the PHQ-8. Because you can't meta-analyze a ten-point anxiety VAS against a Skindex score directly, they standardized everything onto a zero-to-one-hundred distress scale — a reasonable, if imperfect, solution the authors themselves flag as a limitation of comparing apples to oranges. They also ran a second, parallel analysis using original unstandardized scores grouped by identical scales, essentially as a sensitivity check on their own standardization method. Separately, and this is the more novel piece, they Googled US Mohs consent forms the way a motivated patient might, to see what real-world documents actually disclose.

The results: twenty-nine studies, sixty-four hundred patients total, average age around sixty-five, slight male majority. Pooled standardized distress came out to about twenty-five out of one hundred — so a mild-to-moderate level on average — but the heterogeneity was essentially total, with an I-squared of one hundred percent and a wide confidence interval stretching from roughly ten up into the sixties. The clinically important detail here isn't the point estimate, it's that every single included study's confidence interval excluded zero — meaning in every study population, patients experienced measurable distress, full stop. Individual studies ranged from a low of about five out of one hundred, in a study specifically measuring depressive symptoms, up to nearly seventy-five out of one hundred in a trial that had enrolled patients specifically because they wanted anxiolytics before surgery — so selection matters enormously here. And notably, depressive symptoms didn't just occur but in some cohorts actually worsened over time in about a third of patients, which is a finding that deserves more attention than it usually gets. On the consent form side: twenty forms identified, zero mentioning any psychological risk. Three forms obliquely implied sedation might be offered, but none framed anxiety or distress as a disclosed risk of the procedure itself.

Limitations are real and the authors are transparent about them: no study used random sampling, most didn't control for confounders like anxiolytic use, prior psychiatric history, or whether the patient had a support person present, and fewer than half the psychological measures used even had citations provided for their validity. This is a rapid review of quite disparate small studies, not a tightly controlled trial, so the pooled number is more of a signal than a precise estimate.

Practically, here's the takeaway: this isn't practice-changing in the sense of altering your surgical technique, but it is a legitimate prompt to reconsider your informed consent language. The evidence says psychological distress during Mohs is close to universal and occasionally clinically significant, and essentially no consent form anywhere addresses it. Adding a line about anxiety being common and manageable, and asking proactively about anxiety history or interest in anxiolytics, costs you nothing and closes a documented gap between patient experience and disclosed risk.

Next, an original article out of three university hospitals in Brussels: "Congenital Malalignment of the Great Toenail: Spontaneous Regression Rate and Limiting Factors for Surgical Outcome." The clinical gap here is straightforward — congenital malalignment of the great toenail is rare enough that the literature consists of small case series, the largest prior one being thirty cases from nineteen eighty-three, and the conventional teaching has been that about half of cases resolve spontaneously by age ten, that surgery works best when done young — say between two and ten — and in milder disease. This group wanted a real dataset to actually test those assumptions.

This is a retrospective, comparative, descriptive study pulling eleven years of records, sixty patients and ninety-four affected nails, comparing a wait-and-see cohort against a surgical cohort — the unguodermal rotation flap technique is described in detail with an accompanying video. Why retrospective and comparative rather than a trial? The authors don't spell out their reasoning explicitly, but given how rare this condition is — well under one hundred cases in the literature since its first description — a prospective randomized design comparing surgery to observation simply isn't feasible; a retrospective chart and photograph review across three referral centers over a decade is the only realistic way to accumulate a cohort this size. To get objective outcomes, they had three blinded nail-expert dermatologists independently score standardized photographs using a severity index the authors built themselves, covering onycholysis, angle of deviation, hyperkeratosis, transverse ridges, and pulp hypertrophy — that blinded multi-rater objective scoring, paired with a separate patient self-report, is a nice methodological touch that lets them cross-check subjective satisfaction against measured disease severity.

Results: median age at diagnosis was five and a half, onset typically before age two, roughly two-thirds of patients female, disease bilateral in over half. Two-thirds of patients had already seen another physician before the correct diagnosis was made, and only dermatologists got it right — a good reminder that this remains widely misdiagnosed. Twenty-seven patients elected surgery, thirty-three nails operated, mostly around age four to five. On self-report, both groups reported improvement, but the objective severity score told a more useful story: the wait-and-see group showed no measurable improvement in severity scores over long-term follow-up, while the surgical group showed a highly significant drop across all six severity items, with particular improvement in degree of malalignment, transverse ridges, pulp hypertrophy, and nail thickness. Complication-wise, early infection occurred in about one in five operated nails, all resolved with oral antibiotics, and lateral ingrowing developed later in about one in eight, managed with phenolization. A handful had late relapse, averaging six and a half years out, but all did well again after one year. And critically, no relationship was found between age at diagnosis, age at surgery, and degree of improvement — directly challenging the old dogma that you need to operate young for a good result.

Limitations are the ones you'd expect from this design: substantial loss to follow-up, especially for subjective assessment, non-standardized photography for angle measurements, variable follow-up intervals from six months to eleven years, and no randomization between surgical and observational arms — patients weren't assigned, they were offered surgery based on lack of improvement or severity, so there's inherent selection bias baked into the comparison.

The practical takeaway here is genuinely practice-relevant if you or your pediatric dermatology colleagues see this entity: the data argue against the traditional teaching that surgery should be reserved for young children with mild disease. Wait-and-see nails simply didn't improve objectively regardless of age, while surgical nails improved regardless of age or severity at baseline. If you're counseling a family on an older child or an adult with longstanding malalignment, this study supports offering surgical correction rather than assuming the window has closed.

Third, a case report: "High-Frequency Electrocautery and Photodynamic Therapy for Porokeratosis Ptychotropica," from Wuhan. Porokeratosis ptychotropica is a rare variant presenting as symmetric, erythematous-to-brown, hyperkeratotic, wart-like plaques localized to the perianal and buttock region, and it's notoriously treatment-resistant — no single modality has been reliably effective across the literature, with surgery, dermabrasion, cryotherapy, laser, and topicals all reported with inconsistent results.

The case is a thirty-eight-year-old man with lesions since childhood, unresponsive to corticosteroid injections, topical retinoids, and oral therapy, biopsy-confirmed with the classic cornoid lamellae. The technique combined high-frequency electrocautery to create superficial erosion of the plaques, under intravenous anesthesia, followed the next day by five-ALA photodynamic therapy — the rationale being that pretreating with electrocautery lets the photosensitizer penetrate more deeply and boosts PDT efficacy, an approach with some precedent in disseminated superficial actinic porokeratosis. PDT was repeated at weekly intervals; after two additional sessions the eroded areas healed, and later sessions were tolerated without anesthesia at all. At twelve-month follow-up, lesions were flatter and smoother with marked reduction in pruritus, though with some residual hypopigmentation and a few palpable scars — so a good functional result with a trade-off in cosmesis.

The teaching points here are practical rather than statistical, since this is a single case with no comparator. First, this combination approach — cautery to debulk and create erosion, followed by PDT to consolidate and promote controlled healing — is a reasonable option to keep in your back pocket for a condition that otherwise has no reliable standard of care. Second, and this is the detail worth remembering for long-term management: porokeratosis ptychotropica carries a reported malignant transformation risk on the order of seven to twelve percent, plausibly driven in part by chronic scratching and trauma, so regardless of which treatment you choose, these patients need durable long-term surveillance, not just symptomatic control.

Last, a review article: "Histologic Changes After Chemical Peeling: A Clinical Review," pulling together thirty studies and about five hundred patients total, organized by peel depth. This isn't a meta-analysis with pooled statistics — it's a narrative synthesis, so there's no single effect size to report, but the organizing framework is genuinely useful for treatment selection.

For superficial peels — tretinoin, salicylic acid, TCA under thirty-five percent, Jessner's, glycolic and lactic acid — the consistent theme is epidermal necrosis followed by regeneration, with mild epidermal thickening in several agents, most clearly with tretinoin, TCA, and glycolic acid, but dermal effects were equivocal to absent across most agents. Interestingly, lower-strength TCA peels also reduced melanin and melanosome content, supporting their use specifically for epidermal pigmentary problems, and effects generally didn't persist beyond about three to six months — useful when you're setting expectations with a patient about maintenance intervals.

Medium-depth peels — the Brody, Monheit, and Coleman combination peels, TCA above thirty-five percent, and eighty-eight percent phenol — showed a more consistent signal: all five caused increased epidermal thickness with Grenz zone formation, and critically, all showed increased dermal thickness as well, something superficial peels largely didn't achieve. Collagen quality improved across most of these, though elastin findings were mixed, with some studies showing improved elastin arrangement and others showing no change or even decline — so don't oversell elastin remodeling as a guaranteed effect at this depth.

Deep peels — specifically phenol-croton oil, in both Baker's and Hetter's formulations — showed the most robust and durable findings: increased epidermal and Grenz zone thickness, better keratinocyte organization, more even melanocyte distribution with fewer melanin granules, and in the dermis, increased thickness, increased collagen, fibroblasts, and glycosaminoglycans, plus evidence of decreased abnormal elastin with regeneration of normal elastic fibers — findings that in one study persisted at twenty-year follow-up.

Since this is a narrative review of heterogeneous case series and small studies rather than original data, the honest limitation is exactly what you'd expect — wide variation in peel concentrations, follow-up intervals, biopsy technique, and study species, since some of the superficial peel data came from irradiated mouse models rather than human skin, which the authors flag explicitly when interpreting conflicting results.

The practical takeaway is really a framework rather than a single actionable number: histology confirms the clinical hierarchy you already use — superficial peels for epidermal problems like pigment and texture with an expected effect window of months, medium-depth peels when you need actual dermal remodeling for actinic damage or acne scarring, and deep phenol-croton oil peels when you need the most durable structural change, at the cost of a longer recovery and the pigmentary risk profile that comes with it. Not a new indication for anyone, but a nice mechanistic anchor the next time you're counseling a patient on why you're recommending one peel depth over another.

That's the May issue — a call to rethink our consent conversations around psychological risk, solid evidence against restricting toenail malalignment surgery to young children, a workable salvage approach for a stubborn porokeratosis variant, and a tidy histologic roadmap for chemical peel selection. Thanks for listening, and we'll see you next month.