Welcome back to the Journal Review — this is our walk-through of the December 2025 issue of the Journal of the American Academy of Dermatology. Four pieces this month: three entries from the Ethics Journal Club section, all in that "Dear Dr Dermatoethicist" advice-column format, and one original Delphi consensus study on cosmetic skincare ingredients. Let's get into it.

First up is an ethics letter on skin biopsies in patients with limited life expectancy. The setup is a resident's question about colleagues who insist on biopsying clinically and dermatoscopically obvious basal cell carcinomas even in patients whose life expectancy makes that diagnostic step arguably pointless. This isn't a study — it's an ethics consultation format, so there's no methods or results to walk through, just the reasoning itself, and it's worth following closely because this scenario comes up constantly in a Mohs practice with an aging referral base.

The core tension the authors lay out is beneficence versus nonmaleficence, mediated by autonomy. Biopsy is still the diagnostic gold standard, but it carries real downside in frail patients — infection risk, delayed healing — and the authors point out that dermatoscopy alone has reported sensitivity around ninety-one percent and specificity around ninety-five percent for basal cell carcinoma, which is high enough that a confirmatory biopsy is often clinically redundant for a classic-appearing lesion. Their broader argument is that treatment decisions, and by extension the diagnostic workup that precedes them, should be calibrated to the patient's remaining life expectancy and goals of care rather than defaulting to the full diagnostic-and-surgical pathway reflexively. They explicitly note that Mohs surgery, despite being first-line for many of these tumors, may not be necessary or beneficial for a slow-growing, asymptomatic lesion in a frail patient — the time, cost, and postoperative burden can outweigh any survival benefit for a tumor that was never going to be the thing that ends the patient's life. They also flag noninvasive alternatives worth having in your back pocket for exactly this conversation — reflectance confocal microscopy and optical coherence tomography — as ways to gain diagnostic confidence without a scalpel. And for lesions where treatment is still desired but a patient wants something lower-morbidity than surgery, they list watchful waiting, cryotherapy, electrodesiccation and curettage, topical chemotherapy, and topical immunotherapy as reasonable, patient-aligned options.

There's no data here to critique, no limitations section — this is a values-based argument, and the practical takeaway is really a communication mandate. The actionable piece for your practice is to build an explicit "does this biopsy or this excision change anything for this specific patient" checkpoint into your evaluation of geriatric and frail patients with classic BCCs, and to have the noninvasive-alternative conversation and the deintensified-treatment conversation as standard options on the table, not exceptions you reach for only when a patient pushes back.

Second piece, same format, different policy problem — this one's on the Multiple Procedure Payment Reduction policy, or MPPR, and its ethical friction in rural dermatology. The scenario is a rural patient with a melanoma history and comorbid limited mobility who needs several excisions for suspicious lesions, where doing them all in one session is clearly what's best for the patient, but MPPR reimburses the primary procedure at full rate and every subsequent same-day procedure at half rate. Again, this is a policy-ethics commentary, not a study, so there's no data to walk through beyond the background on the policy itself, which dates to nineteen ninety-five and was built on the premise that staff time and equipment overhead are duplicated when multiple procedures happen in one visit — an assumption the authors push back on directly, since additional tumors still require additional supplies, additional physician time, and additional cognitive and technical effort that isn't actually being duplicated for free.

The ethical argument here is that MPPR creates a perverse incentive: it financially penalizes exactly the consolidated, single-visit care that's best for a patient with a travel burden or limited mobility, pushing toward spreading excisions across multiple visits purely to protect reimbursement — which the authors note is particularly dangerous when you're dealing with a patient who has a melanoma history, since they cite data that delaying treatment of high-risk cutaneous squamous cell carcinoma by four to six weeks measurably increases local recurrence and metastatic risk. They frame this as a justice issue for rural practices specifically, since rural patients already face worse access from travel distance and thinner regional resources, and a blanket national reimbursement policy doesn't flex for that. Their proposed fix isn't to scrap MPPR but to build in documented exceptions — travel distance, mobility limitation, employment and caregiving constraints — auditable in the chart, so cost control and patient-centered consolidation of care aren't mutually exclusive.

Practically, there's nothing here that changes your surgical technique or your indications. What it should change, if you practice in or refer to rural settings, is your awareness that reimbursement structure itself can be a silent driver of care fragmentation, and it's worth this being part of any advocacy conversation your practice or academy engages in around Medicare policy reform.

Third ethics piece is a case-based dilemma around skin cancer management in solid organ transplant recipients — probably the most clinically textured of the three letters. The case is a transplant recipient with a high-risk squamous cell carcinoma on the penis alongside several lower-risk facial squamous cell carcinomas, who — after thorough multidisciplinary discussion including dermatology, urology, and transplant medicine, and after nonsurgical options like radiation were presented — continues to decline any intervention for the penile lesion because of the quality-of-life impact of penectomy on what the authors call a self-defining organ, and instead wants the facial lesions addressed first.

The ethical core is autonomy against beneficence, and the authors don't shy away from the clinical stakes: they cite data that a delay of just three months can double the risk of advanced disease, metastasis, and worse survival for penile carcinoma, which underscores real urgency, set against a patient's legitimate and deeply personal concern about sexual function and identity. They also situate this within the broader transplant context — solid organ transplant recipients carry a risk of squamous cell carcinoma reported at sixty-five to two hundred fifty times that of the general population, meaning these patients accumulate tumor burden requiring repeated, often disfiguring surgery, and treatment fatigue is a real and legitimate factor in a patient's decision-making, not a failure of compliance.

What I found useful here is that they don't just land on "respect autonomy and move on" — they lay out three concrete management strategies for the team to consider once the patient's decision is fixed: selective treatment of only the invasive components while leaving in-situ disease untreated to reduce surgical burden, aggressive resection pursuing clear margins on everything despite bigger defects, or deferring further surgery altogether given the patient's refusal on the higher-priority lesion. They also raise palliative care involvement as a legitimate framework here, not because the patient is terminal, but because palliative care specializes in exactly this kind of goals-of-care clarification under conflicting risk-benefit calculus. Again, no methods or limitations to report since this is a case-based ethics discussion — the practical takeaway for your practice is procedural: when a patient declines the objectively higher-risk lesion in favor of treating a lower-risk but more visible or symptomatic one, document that the discussion was multidisciplinary, document that alternatives including radiation were offered, and consider explicitly loop in palliative care or ethics consultation rather than treating it purely as a surgical scheduling problem.

Now the fourth article, and this one is a real original study — a Delphi consensus study on skincare ingredients recommended by cosmetic dermatologists, led by Alvarez and colleagues with senior author Murad Alam. This is worth more time because it actually has a methods section and results you can use.

The background problem: there's a huge and growing list of topical cosmetic ingredients on the market, and no clear expert consensus on which ones are actually worth recommending for the handful of complaints patients bring in every day — fine lines and wrinkles, acne, redness, dark spots, large pores, dry skin, oily skin. Patients and clinicians alike are essentially drowning in options without a curated, expert-vetted shortlist.

Methodologically, this is a qualitative consensus design, not a clinical trial, and that's the right tool for this question — you can't randomize patients to "niacinamide versus vitamin C" for a hundred different formulation and concentration variables, so instead the authors did a structured expert-elicitation process. They started with a literature search from nineteen ninety through twenty twenty to build a long list of generic ingredients in use in both over-the-counter and prescription products — that literature search produced three hundred eighteen candidate ingredients. That list was then handed to a first expert panel of seventeen board-certified cosmetic dermatologists, mostly cosmetic surgery fellowship program directors or internationally recognized experts, who were asked which ingredients they'd actually reach for, for each of the seven skin concerns. Anything named by two or more panelists survived — that pruned the list down to eighty-three ingredients.

Then came the actual Delphi process — a second, separate and larger panel of sixty-two dermatologists across forty-three institutions, members of the Association of Academic Cosmetic Dermatology, rated every ingredient on a nine-point Likert scale from "strongly discourage" to "strongly recommend," across two survey rounds with a virtual consensus discussion in between to hash out disagreement. The a priori bar for consensus was reasonably strict — an ingredient had to be rated seven-to-nine by at least seventy percent of the panel, with no more than fifteen percent rating it one-to-three, and then get confirmed at the live consensus meeting. That two-round structure with an intervening discussion is the classic Delphi design specifically because it lets outlier opinions get challenged with peer reasoning rather than just averaged away, which matters here since expert opinion, not RCT data, is doing a lot of the work.

On results: the first round actually expanded the list slightly, from eighty-three to eighty-nine ingredients, before the second round pruned it back down. Twenty-three unique ingredient-indication pairings ultimately reached consensus. Some of the notable, clinically unsurprising but now formally endorsed hits: retinoids came out as essentially the universal player, reaching consensus for fine lines and wrinkles, acne, dark spots, large pores, and oily skin, all with agreement in the mid-nineties percent range — about as strong a consensus as you'll see in any Delphi study. Mineral sunscreen also hit striking agreement, around ninety-five to ninety-seven percent, for both fine lines and wrinkles and redness. Hydroquinone was the single highest-consensus ingredient in the whole study at essentially universal agreement, just under ninety-nine percent, for dark spots. Benzoyl peroxide and salicylic acid clustered tightly around acne and oily skin, both in the low-to-mid nineties percent. Azelaic acid and glycolic acid both crossed threshold for acne and dark spots. Niacinamide made it for redness and dark spots, and vitamin C for fine lines and wrinkles and dark spots, both with strong but slightly more modest agreement than the top-tier ingredients. Interestingly, several ingredients that clinicians might assume are consensus favorites did not clear the bar — hyaluronic acid for fine lines and wrinkles, peptides, growth factors, and DNA repair enzymes all failed to reach the seventy percent threshold, suggesting the panel was fairly disciplined about not rubber-stamping popular but less differentiated ingredients.

The authors then did a second literature pass specifically on the consensus-winning ingredients and report that most of them are backed by level 1b or 2b evidence using Oxford Centre for Evidence-Based Medicine criteria — so this isn't consensus floating free of data, it's consensus that largely tracks with what's actually been published, with some ingredients admittedly resting more on expert opinion than trial evidence, which the authors state plainly as the main limitation.

Discussion-wise, the authors frame this as a starting point for building a skincare routine and a tool for more consistent clinician-patient communication, not a rigid formulary. The obvious limitation, which they own directly, is that a chunk of this consensus is expert opinion rather than head-to-head efficacy data, and Delphi consensus by design tells you what experts agree they'd reach for, not what's been proven superior to alternatives in a comparative trial.

Practically, for those of us doing reconstructive and post-surgical skin care counseling as much as tumor extirpation, this is a genuinely useful, low-effort reference — it gives you a vetted, short ingredient list you can hand to patients post-Mohs or in general cosmetic consults for pigmentary concerns, textural concerns, or barrier repair without having to litigate three hundred products on the shelf. I'd call this practice-useful rather than practice-changing — nothing here should alter your surgical decision-making, but it is a legitimate, citable reference the next time a patient asks what serum they should actually be using after their reconstruction has healed.

That covers all four pieces for December. The throughline across the three ethics letters is really the same tension wearing different clothes — patient-centered flexibility running up against rigid systems, whether that system is a payer policy, a diagnostic default, or a patient's own hierarchy of what matters to them — and the Delphi study is a nice practical counterweight, giving you something concrete to hand patients while those bigger ethical questions keep playing out case by case. Thanks for listening, and we'll see you next month.