Mohs Micrographic Surgery effectively removes skin cancer while preserving healthy tissue. But what happens when the procedure that’s supposed to help maintain aesthetics leads to long-lasting and highly distressing cosmetic outcomes?
That’s the focus of an observational study published in the May issue of the Journal of Drugs in Dermatology. Researchers looked at the factors that contribute to the development of post-inflammatory hyperpigmentation (PIH) following Mohs surgery in patients with skin of color.
I interviewed the authors, Ramone F. Williams, MD, MPhil, FAAD, FACMS, of Harvard Medical School, and Onjona Hossain, MD, of Albert Einstein College of Medicine.
What led you to want to investigate the factors that lead to PIH in patients with skin of color who undergo Mohs surgery?
PIH can be highly distressing and occurs most noticeably in individuals with skin of color. It presents as hyperpigmentation of the skin following inflammation, injury or procedural intervention. Our research goal was to characterize patient and procedure-specific factors that contribute to PIH in order to educate dermatologists and surgeons on techniques that mitigate its development.
You note that PIH following cutaneous surgery is poorly studied. Why do you think this is the case?
While PIH has been studied following laser procedures, it is poorly studied following cutaneous surgery. Generally, PIH is not considered a worrisome condition by surgeons and dermatologists. However, data show that patients find PIH highly distressing, significantly impacting patients’ quality of life. Of note, PIH disproportionately affects individuals with skin of color, who are underrepresented in dermatology research.
You conducted a retrospective study of patients with skin of color who were treated with Mohs surgery. What were your key findings?
Our study found that among individuals with skin of color:
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- Fitzpatrick skin types IV to V were more likely to develop PIH following Mohs surgery.
- Grafts and granulation closures lead to PIH more often than linear repairs and flaps.
- Postoperative complications resulted in a higher rate of PIH.
- In a subset analysis of linear repairs, polyglactin 910 as a subcutaneous suture had a higher rate of PIH compared to poliglecaprone 25.
Did the results affirm your hypothesis or surprise you?
Our study is the first of its kind. Overall, the findings affirmed our hypotheses. We were surprised that risk factors that emerged as most significant were related to closure type. While no significant difference emerged in the use of absorbable versus nonabsorbable epidermal sutures, our study was underpowered to detect a significant difference. Larger studies are indicated.
PIH is just one of the functional and cosmetic negative outcomes that a patient with skin of color may experience after Mohs surgery. What other outcomes should dermatology clinicians be aware of?
PIH is a common negative cosmetic outcome in skin of color following Mohs surgery. Other negative outcomes in skin of color include hypopigmented atrophic scars and keloid formation.
Why is it important for Mohs surgeons to consider the distress caused by these negative outcomes, especially dyschromia?
PIH is often more troublesome to patients than the initiating disease. PIH may be long-lasting and treatment options are often considered cosmetic with high out-of-pocket costs without guarantee of success. Additionally, dyschromia is the most common patient outcome leading to liability claims against dermatologists.
What should Mohs surgeons consider in light of this study?
There are various modifiable factors considered during surgical planning. Mohs surgeons should consider linear repairs and flaps over grafts and granulation. Meticulous placement of buried vertical mattress sutures and strict patient adherence to postoperative activity restriction can reduce complications, such as wound dehiscence. Surgeons should opt for poliglecaprone 25 over polyglactin 910 as a subcutaneous suture. Additionally, nonabsorbable epidermal sutures are preferred over absorbable sutures. It would be prudent for surgeons to discuss the risk of PIH during informed consent.
Do you plan to conduct any additional studies based on these results?
Additional studies with larger sample size are needed to further characterize factors that contribute to PIH following Mohs surgery in skin of color. A prospective study would be ideal.
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