According to a recent study, there is great variation from one Mohs’ surgeon to another when having Mohs’ surgery. In this study, they found that the mean number of stages per case was 1.47 (range, 1.09-4.11). The variation in range is huge!!! Thirty-five percent of surgeons were persistent outliers (performed more stages than the mean) in all three years of this study. Physicians in solo practice had a 2.35-times likelihood of a persistent high outlier status (OR = 2.35; 95% CI, 1.25-4.35). Now this does not make sense! Think about it, often the most difficult cases are referred to tertiary care centers (academic institutions), yet they were more likely to clear a patient in fewer stages.
Why the great variation? In an academic center, there are residents and fellows assisting on cases. What does that mean for patients? There is less risk for “funny business”–surgeons intentionally taking smaller pieces so that they they will require more stages (in a fee-for-service model, the surgeon is paid for each stage taken).
In my practice, approximately 80% of patients are cleared within the first stage. This falls well within the mean average of 1.47 average stages per patient. Unfortunately, many surgeons fall outside of this mean. This increases cost, may adversely affect cosmetic outcome, increases surgical time for patients, and may lead to increased patient discomfort as additional anesthetic may be needed.
How do you choose a Mohs’ surgeon? That is a difficult question. According to this study, a Mohs’ surgeon in Private Practice is more likely to perform more layers than is necessary than a surgeon who is a full-time academic surgeon. That being said, I know of great surgeons who are in private practice and many who rarely clear a patient in one stage. In fact, some of the best surgeons are in private practice.
What do I recommend? When choosing a Mohs’ Surgeon, one must be more cautious when choosing one who is in Private Practice. In my over 2 decades of performing Mohs’, I can count on one hand how many patients during the initial consultation have asked me what the likelihood of clearing them on the first stage is.
Melanoma in situ is a common tumor, and often affects the elderly. In some cases, surgery can be extremely extensive and/or patients are not good surgical candidates. For years, Dermatogists have been offering topical imiquimod (Aldara) to these patients as an alternative to surgery, with the full understanding that it is not as good as surgery, but better than nothing.
A recent study published in Dermatologic Surgery looked at long-term recurrence rates for patients who were treated with Aldara. They found that 17% of patients had a recurrence of their tumor, which is far higher than surgical recurrence rates.
In short, some publications talk about a “new” “alternative” to surgery. This is simply not the case. Surgery is the best option and topical treatment with imiquimod, as it has been, should only be considered for those who are not surgical candidates or those who are not expected to outlive their disease.
According to a recent article, all treatments that were evaluated were effective in treating hair loss.
For men, 2% minoxidil, 5% minoxidil, low light therapy, and finasteride were all effective.
For women, 2% minoxidil was effective. Unfortunately, other treatments were not evaluated for women.
Recommendations from Dr. Bader: In my experience finasteride is most effective in men with a high compliance rate. The original 1mg dose was actually pulled out of thin air–no studies to find the most effective dose with the least amount of side effects was used to come up with this dose. I have found that 1mg may not be enough for some patients. 1.25mg (a quarter of a 5mg tablet) works well and some require a 2.5mg dose once or twice a week. I have found that this higher dosing has a greater effect on those who do not get the desired result with a minimal increase in side effects.
For women, I recommend that 5% minoxidil used once daily. This dosing schedule was recently FDA approved, not that this matters. One can buy the 5% minoxidil for men or women, whichever is cheaper. The product is the same. The only difference is the instructions that come with the product. Men are instructed to use the product twice daily. Studies have shown that 5% minoxidil twice a day is no more effective than 2% minoxidil twice a day. For this reason, once a day dosing is recommended for women, not that there is substantially greater risk of using the product twice a day. Side effects from this product include low blood pressure and increased facial hair growth in some. I recommend using the product at night, when one is less affected by lower blood pressure. One should get out of bed slowly to ensure they do not get lightheaded.