Welcome to this journal-review episode covering Dermatologic Surgery, May twenty twenty-six. We've got four pieces this month — a letter on biopsy-site documentation, an original split-face trial comparing a topical antibacterial to a chemical peel for acne, a meta-analysis on cutaneous angiosarcoma survival, and a scoping review on topical vitamin C for actinic keratoses and nonmelanoma skin cancer. Let's get into it.

First up is a letter to the editor, essentially a commentary piece responding to a prior "How We Do It" article on biopsy-site documentation protocols. The authors, writing from a referral-only Mohs practice, are building on a piece by Bawany and colleagues that laid out a comprehensive preoperative checklist for preventing wrong-site surgery — consultation exams, pathology review, staff cross-verification, that kind of thing. This letter isn't presenting new data of its own; it's proposing one additional, low-cost safeguard layered onto that existing protocol. The core idea: at the time of biopsy scheduling, ask the patient, or a family member, to photograph the biopsy site with their smartphone, ideally soon after the procedure, and then bring that photo — or a printed copy — to the Mohs consultation or reminder call. The rationale they lay out is straightforward. Referring practices vary wildly in whether and how well they photograph biopsy sites, so this bypasses that inconsistency. The patient's own photo is time-stamped and instantly available for real-time comparison. And it engages the patient directly in verifying their own surgical site, which matters because the literature they cite indicates patients misidentify their own biopsy site nearly one in three times, even shortly after the procedure. The authors are honest about the assumptions this rests on — the patient needs smartphone access, needs to actually know which lesion is the cancer, the site needs to still be visible or at least recognizable as a healing wound or scar, the photo needs to be in reasonable focus with visible anatomic landmarks, and it needs to actually be retrievable at the visit. They frame this explicitly as a complementary checkpoint, not a replacement for clinical photography at the time of biopsy, which they still consider the gold standard. For your practice, this is a genuinely low-effort addition — asking your scheduling staff to build in one extra instruction to patients — that plugs a real gap, particularly for urgent referrals or practices where a formal consultation visit isn't happening before the surgical date.

Next, an original clinical trial: a split-face, comparative study out of Assiut University in Egypt looking at dapsone seven-and-a-half percent gel versus twenty percent trichloroacetic acid peels for mild to moderate acne vulgaris. The background here is fairly simple — acne treatment selection is multifactorial, TCA peeling is an established resurfacing option, and topical dapsone has been used for years in its five percent formulation requiring twice-daily dosing; the newer seven-and-a-half percent formulation is designed for once-daily use, which the authors hoped would improve adherence. Their stated gap is that no prior Egyptian trial had directly compared these two modalities. Methodologically, this was a quasi-experimental split-face design in thirty patients — TCA on the right side of the face every two weeks for three months, dapsone gel nightly on the left side for the same duration, with a one-month follow-up after treatment ended. The split-face approach makes good sense here, since it uses each patient as their own control and removes a lot of the interpatient variability in acne severity and skin type that would otherwise muddy a parallel-group comparison with only thirty subjects. They assessed outcomes using the Global Acne Grading Score and straightforward lesion counts, both graded by two evaluators with standardized photography.

On results: both treatments produced a meaningful and statistically significant drop in acne severity. The Global Acne Grading Score fell from about twelve down to around six on both sides — so roughly a fifty percent reduction with either treatment. When they compared the relative percent improvement between sides, dapsone came out slightly ahead numerically, around fifty percent versus about forty-five percent for TCA, but that difference was not statistically significant, so read that as essentially a tie. Lesion counts told a similar story — both non-inflammatory and inflammatory lesion counts dropped significantly on both sides, and again the side-to-side difference in the degree of improvement wasn't statistically significant. When they broke down response categories, both arms had similar rates of good, moderate, and mild responders — roughly a third to forty percent of patients had a good response regardless of which treatment they got. The authors' conclusion, that dapsone appeared more effective specifically for inflammatory lesions, comes from the raw lesion count trajectories rather than a formally significant interaction test, so I'd treat that as a descriptive observation rather than a proven differential effect.

Limitations worth flagging: this is a small, single-center cohort, overwhelmingly female, with a short one-month post-treatment follow-up, so we have no read on durability or long-term recurrence. It's also a quasi-experimental rather than a randomized design — sidedness wasn't concealed or blinded, which matters for a subjective outcome like acne grading, even with photographic documentation. For your practice, the real takeaway isn't practice-changing in a Mohs or oncology context, obviously, but if you or your practice offers cosmetic and medical acne treatment, this supports dapsone seven-and-a-half percent gel as a reasonable once-daily home alternative to serial in-office TCA peels, with roughly comparable efficacy and presumably better convenience, though the evidence base remains thin and short-term.

Third, a meta-analysis on survival outcomes in cutaneous angiosarcoma — and this one's much more relevant to our day-to-day. The background is familiar: angiosarcoma is rare, aggressive, historically quoted with a five-year survival around thirty-five percent and a recurrence rate of about seventy-five percent within two years of local treatment, and there's never been a randomized trial to guide therapy because the disease is just too uncommon. The authors set out to pool existing individual patient data to get more statistical power than any single case series could offer. Methodologically, they ran a systematic PubMed search across combinations of anatomic sites and treatment modalities, ultimately identifying sixteen eligible studies, nine of which had tumor-node-metastasis staging data usable for their analysis — a total of a hundred fifty-nine patients. They stratified everyone into early-stage, meaning T1N0M0, versus mid-to-late-stage disease, and ran Kaplan-Meier survival curves, Cox regression for hazard ratios, and subgroup comparisons. Extracting patient-level rather than aggregate data is the key methodological choice here — it's what lets them run individual-patient survival modeling instead of just comparing summary statistics across studies, which is genuinely the right approach for a rare-disease meta-analysis, though it's also labor-intensive and dependent on how completely the original papers reported their cases.

On results: early-stage patients trended toward longer survival, later recurrence, and later metastasis compared with mid-to-late-stage patients, but none of those differences reached statistical significance — worth sitting with, because it suggests the studies were underpowered rather than that stage doesn't matter clinically. What did emerge as significant: in early-stage disease, older age independently predicted worse survival, with each additional year of age carrying roughly a seven percent increase in mortality risk. In mid-to-late-stage disease, tumor location was the dominant prognostic factor — scalp tumors carried almost a three-fold increased risk of death compared to other sites, and that was statistically significant. Critically, treatment modality — surgery alone, surgery plus radiation, chemoradiation, multimodal combinations — showed no independent association with survival, recurrence, or metastasis in either stage group, even though early-stage patients were much more likely to get surgery alone and advanced-stage patients were pushed toward chemoradiation. Overall recurrence was seen in about seven in ten patients with available data, and metastasis in around four in ten, with no significant difference between stage groups on either measure.

The authors are appropriately cautious in their discussion, attributing much of the null treatment finding to underpowering rather than true equivalence, and they note their scalp-location finding aligns with prior literature describing scalp angiosarcoma as particularly aggressive, with distant spread in up to half of cases. They also flag emerging immunotherapy data — a phase two trial of cabozantinib plus nivolumab reporting a response rate above sixty percent — as a promising direction their own cohort was too small to evaluate, since so few patients had received immunotherapy. Limitations are the ones you'd expect from any retrospective pooled analysis of a rare tumor: heterogeneous source studies, no randomization, potential selection and reporting bias in which cases even made it into the literature, and real risk of the whole analysis being underpowered to detect true treatment effects even though none appeared. For your practice, this isn't practice-changing regarding treatment selection — it doesn't tell you surgery-plus-radiation is equivalent to surgery alone, it tells you the existing literature can't yet distinguish between them. What is clinically useful is the prognostic signal: scalp location in more advanced disease and older age in early-stage disease both deserve to shape your counseling and surveillance intensity, even if they don't yet dictate a specific treatment algorithm.

Last, a systematic scoping review on topical vitamin C for actinic keratoses and nonmelanoma skin cancer. This is a synthesis piece, PRISMA-guided and PROSPERO-registered, searching four databases through twenty twenty-four for prospective clinical studies using vitamin C concentrations of at least five percent. The yield was strikingly small — out of over three thousand initial results and a hundred forty-eight full-text reviews, only four studies actually qualified: two randomized trials, one prospective observational study, and one case report, covering forty patients with actinic keratoses, twenty-one with basal cell carcinoma, and a single squamous cell carcinoma case.

Walking through what's actually there: for actinic keratoses, a split-forearm randomized trial applied a fifteen percent vitamin C, one percent vitamin E, and ferulic acid combination cream against vehicle for eight weeks, under sunscreen. Complete clearance was rare and not significantly different between groups, but partial clearance was significantly more common with the active cream, roughly half of treated forearms versus about a quarter of vehicle-treated ones. Worth flagging: one participant actually developed a squamous cell carcinoma on the vitamin C-treated forearm during the study, and another had a basal cell carcinoma noted on treated skin — neither proves causation, but it's a caution you'd want to mention if a patient asks about this as prevention. For basal cell carcinoma, two small studies used much higher concentrations with penetration enhancers — one used thirty-three percent vitamin C under twelve-hour occlusion in six patients, achieving complete response in the nodular case and in four of six superficial BCCs, though one superficial case recurred. The second, a randomized trial, compared thirty percent vitamin C in dimethyl sulfoxide against five percent imiquimod and found a complete response rate around eighty-seven percent with vitamin C versus about fifty-seven percent with imiquimod, a significant difference, with no recurrences over a median follow-up of two and a half years and notably better cosmetic outcomes — no residual hypopigmentation with vitamin C compared to seventy percent of imiquimod-treated patients. Finally, a single case report describes complete resolution of a well-differentiated squamous cell carcinoma on the ear using a supersaturated forty-to-seventy percent vitamin C solution under occlusion.

Pooling the two BCC studies, the authors calculate a combined complete response rate around seventy-eight percent for superficial and nodular BCC treated with high-concentration vitamin C under occlusion or in DMSO, without recurrence in that pooled group. They frame the proposed mechanism as oxidative — vitamin C generating reactive hydroxyl radicals extracellularly, plus intracellular uptake of its oxidized form via the GLUT1 transporter, depleting glycolytic cofactors that cancer cells depend on more heavily than normal keratinocytes. Evidence quality here is genuinely thin — two studies rated level two by Oxford Centre criteria, the others level three and four, and notably, no studies at all were found evaluating topical vitamin C as a preventive agent against AK or skin cancer development, despite that being one of the review's stated aims. The authors are appropriately restrained in their own conclusion, stating this is insufficient to generate clinical recommendations. For your practice, this is interesting and mechanistically plausible, but squarely in the "not yet actionable" category — we're talking about a total of twenty-two BCCs and one SCC across the entire treatment literature, no comparison against standard destructive or surgical modalities beyond the one imiquimod trial, and no prevention data whatsoever. It's not something to offer patients in place of standard excision, curettage, or Mohs for anything beyond the lowest-risk superficial lesions in a research context, and even there, only with a clear discussion of the limited evidence base.

That wraps up this month's four articles — a practical safeguard for wrong-site surgery, a reasonably solid split-face comparison in acne therapy, a sobering but useful prognostic meta-analysis in angiosarcoma, and a hypothesis-generating but still very early look at topical vitamin C in skin cancer. Thanks for listening, and I'll see you next issue.