Letters 195


Cynthia O. Anyanwu, BS,a,b and Jules B. Lipoff, MDa Department of Dermatology, University of Pennsylvania, Philadelphiaa; and Georgetown University School of Medicine, Washington, District of Columbiab Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jules B. Lipoff, MD, Department of Dermatology, University of Pennsylvania, Penn Presbyterian Medical Center, Medical Arts Bldg, Suite 106, 51 N 39 St, Philadelphia, PA 19104 E-mail: [email protected] REFERENCES 1. Accetta P, Accetta J, Kostecki J. The use of digital cameras by US dermatologists. J Am Acad Dermatol. 2013;69:837-838. 2. Hubbard VG, Goddard DJ, Walker SL. An online survey of the use of digital cameras by members of the British Association of Dermatologists. Clin Exp Dermatol. 2009;34:492-494. 3. Kunde L, McMeniman E, Parker M. Clinical photography in dermatology: ethical and medico-legal considerations in the age of digital and smartphone technology. Australas J Dermatol. 2013;54:192-197.


Mohs micrographic surgery in the treatment of trichilemmal carcinoma: The Mayo Clinic experience To the Editor: Trichilemmal carcinoma is a rare cutaneous adnexal tumor of the outer root sheath. A majority of the reported cases arise in the sun-exposed, hair-bearing anatomic sites of older Caucasians.1 Clinically, trichilemmal carcinomas are unremarkable solitary papules that often resemble

basal cell carcinomas.1 Histologically, they often exhibit lobular proliferation of atypical, glycogenheavy clear cells lacking mucin and palisading around a follicular unit.1 Although historical data suggest benign clinical courses of these tumors, recent literature implies a locoregionally aggressive course and even metastatic potential after wide local excision.2 Wide local excision is the usual therapeutic modality, and radical resection with neck dissection and postoperative radiotherapy for high-risk cases has been suggested. Mohs micrographic surgery (MMS) has been successfully used for an increasing variety of nonmelanoma skin cancers. Although cases and a review of MMS utility for trichilemmal carcinomas are available,3-6 we report the largest series of trichilemmal carcinomas treated with MMS to our knowledge. Approval for this study was obtained from the Mayo Clinic Institutional Review Board. We identified all trichilemmal carcinomas from 2002 to 2014 from the Mayo Clinic electronic pathology database. Two board-certified dermatopathologists (T. L. H. and M. J. C.) reviewed the original histopathology slides. Trichilemmomas, trichoblastomas, and trichoblastic carcinomas were excluded. For all patients with a confirmed trichilemmal carcinoma, the following data were collected from clinic notes and operative reports: age at diagnosis, gender, race, anatomic location of tumor, tumor size, treatment modality, recurrence, metastasis, death caused by disease, and follow-up duration. Only trichilemmal carcinomas treated with MMS were included. Seven cases of trichilemmal carcinoma treated with MMS were identified, and all clinical data were reviewed. The average age of diagnosis was 70 years. All 7 cases were located on the head and neck, with 3 of 7 (43%) located around the ear. There was a strong male predominance with the male to female ratio being 5:2. All patients were Caucasian. Average

Table I. Trichilemmal carcinomas treated with Mohs micrographic surgery at Mayo Clinic between 2002 and 2014 Case no. Age, y Gender Race

1 2 3 4 5 6 7

69 58 71 72 59 67 93



Anatomic site

Nasal dorsum Right ear Vertex scalp Left retroauricular Forehead Left cheek Right preauricular

Preoperative size, cm

0.5 1.0 2.4 2.8 2.0 2.0

3 3 3 3 3 3 e

Patient 7: treated at outside Mohs micrographic surgery facility. Patient 5: defect to periosteum. F, Female; M, male; W, white.

0.6 1.0 2.5 1.9 3.0 0.8

Postoperative size, cm

No. of Mohs stages

Follow-up, mo

3 3 3 3 3 3 e

1 2 1 1 3 1 e

4 56 13 37 50 19 12

0.6 2.6 2.2 3.2 2.7 3.1

0.7 2.0 3.0 2.1 3.5 1.6

Recurrence Metastasis

No No No No No No No

No No No No No No No


196 Letters


number of MMS stages to tumor clearance was 1.3; however, in case of 3 MMS layers, the defect is taken to periosteum of the scalp. This depth is attributed to large debulking layers typically used in our practice. One patient had MMS at an outside facility. Average follow-up time was 2.5 years for 6 patients treated at Mayo Clinic and 2.3 years overall. None of the cases treated with MMS recurred or metastasized (Table I). To our knowledge, our study represents the largest single-center series of trichilemmal carcinoma treated with MMS. Trichilemmal carcinoma is an adnexal tumor with no statistical data on outcomes or mortality, yet recurrences and metastases have been reported in the literature.2,3 To our knowledge, no clear recommendation regarding treatment is present in the literature.3 Although our study concurs with a favorable outcome of these tumors if appropriately treated, MMS could be considered in the region of the head and neck for definitive tumor eradication and preservation of tissue. This study is limited by the rarity of this tumor, short follow-up, and retrospective nature of the data. A meta-analysis of MMS versus wide local excision would be ideal.

Medicine and Pathology,c Mayo Clinic, Rochester, Minnesota Funding sources: None. Conflicts of interest: None declared. Correspondence to: Stanislav N. Tolkachjov, MD, Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 E-mail: [email protected]

Stanislav N. Tolkachjov, MD,a Thomas L. Hocker, MD,a,b Michael J. Camilleri, MD,a,c and Christian L. Baum, MDa,b

REFERENCES 1. Wong TY, Suster S. Tricholemmal carcinoma: a clinicopathologic study of 13 cases. Am J Dermatopathol. 1994;16:463-473. 2. Jung J, Cho SB, Yun M, Lee KH, Chung KY. Metastatic malignant proliferating trichilemmal tumor detected by positron emission tomography. Dermatol Surg. 2003;29:872-874. 3. Hamman MS, Brian Jiang SI. Management of trichilemmal carcinoma: an update and comprehensive review of the literature. Dermatol Surg. 2014;40:711-717. 4. Tierney E, Ochoa MT, Rudkin G, Soriano TT. Mohs’ micrographic surgery of a proliferating trichilemmal tumor in a young black man. Dermatol Surg. 2005;31:359-363. 5. Cecchi R, Rapicano V, De Gaudio C. Malignant proliferating trichilemmal tumor of the scalp managed with micrographic surgery and sentinel lymph node biopsy. J Eur Acad Dermatol Venereol. 2008;22:1258-1259. 6. Kim YH, Lee YK, Choi KW, Lee CY, Kim KH. A case of trichilemmal carcinoma treated with Mohs micrographic surgery. Ann Dermatol. 2008;20:157-161.

Department of Dermatology,a Division of Dermatologic Surgery,b and Division of Laboratory




Comments on ‘‘Lack of efficacy with 1064-nm neodymium:yttrium-aluminum-garnet laser for the treatment of onychomycosis: A randomized controlled trial’’ To the Editor: Recently, the use of laser devices has become an emerging treatment option for onychomycosis. We read with great interest the article by Hollmig et al.1 Although the study was mostly well designed and analyzed, we have the following questions and comments regarding the statistical analyses. Firstly, the sample size was calculated in order to detect the minimal proximal nail plate difference between the 2 groups. The proximal nail plate clearance was designated as the secondary end point by the authors. However, the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) guideline states that the number of

subjects is usually determined based on the primary objective end point of the trial; if not, the reason should be made clear and justified.2 Another statistical inconsistency is that the sample size (n ¼ 24) was calculated as number of patients in whom the minimal nail plate difference was observed; however, the clinical proximal nail plate clearance was compared with regard to number of nail plates not number of patients. Secondly, the protocol was violated that 27 patients were randomly allocated 17 vs 10 patients, not 18 vs 9 patients to be a 2:1 ratio. Thirdly, the proximal nail plate clearance was calculated from multiple nail plates of the same patients (39 nail plates from 6 control patients and 39 nail plates from 10 laser patients), thus the data were not independent and not suitable for use with a nonparametric t-test. Lastly, the results in Fig 2 would be convincing if the overall significance level were controlled by statistical methods in order to

Mohs micrographic surgery in the treatment of trichilemmal carcinoma: the Mayo Clinic experience.

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