Welcome back to the journal review. This month we're working through the September 2026 issue of Dermatologic Surgery, and I've pulled four pieces worth your time — a case series on an old drug used in a slightly unconventional way, a cautionary case report about a piercing tract you don't want to miss, a workforce and training landscape piece for anyone involved in fellowship selection, and a retrospective chart review testing whether a five-dollar black light can help you get cleaner melanoma margins. Let's get into it.

First up is a communication — really a small case series — on eruptive keratoacanthomas successfully treated with intralesional corticosteroids. You know the diagnostic headache here: keratoacanthomas sit on a spectrum with squamous cell carcinoma, many pathologists just call them SCC-keratoacanthoma type, and while the individual lesion usually behaves indolently, when patients develop them in an eruptive, multiple fashion, your standard toolkit — excision, destruction, topical fluorouracil, intralesional chemotherapeutic agents — gets cumbersome fast, especially when someone has twenty or more lesions.

The authors from Cleveland Clinic present four patients. One was a woman with metastatic lung adenocarcinoma on an EGFR inhibitor who developed numerous keratoacanthomas on her extremities that had already failed photodynamic therapy, topical steroids, and topical fluorouracil — she responded to serial intralesional triamcinolone injections with flattening or complete resolution of all lesions. The second had eruptive keratoacanthomas arising within a radiation field after Mohs surgery and radiation for a lip SCC, and after exhausting acitretin, intralesional fluorouracil, cryotherapy, topical fluorouracil, photodynamic therapy, and multiple rounds of Mohs, her remaining lesions cleared with intralesional triamcinolone. The third, a rheumatoid arthritis patient on immunosuppressive therapy who'd already had seven Mohs surgeries on her legs, had complete resolution of seven keratoacanthomas within six weeks of a single triamcinolone treatment. The fourth developed recurrent, isolated keratoacanthomas at prior Mohs surgery sites over nearly two years, and each new lesion resolved completely with intralesional triamcinolone injected at the time it appeared.

There's no formal study design here — this is a case series, so there's no statistical test to walk through, just an accumulation of anecdote-level evidence. What's interesting is the proposed mechanism the authors discuss: keratoacanthomas are thought to arise from the hair follicle, and corticosteroids suppress the anagen phase, which may inhibit keratoacanthoma growth the same way it inhibits normal follicular cycling. There may also be a direct antimitotic effect through altered DNA synthesis and cytokine signaling, including transforming growth factor alpha. The authors also raise a more selective hypothesis worth remembering clinically — that intralesional steroids may work best in keratoacanthomas with an inflammatory driver, since two of their four patients were on immunomodulating drugs and two developed their lesions reactively at prior surgical or radiation sites. That's a reasonable framework for deciding who might respond.

The honest caveat here is that the literature on intralesional corticosteroids for keratoacanthoma is described by the authors themselves as showing lower success rates than other intralesional agents like fluorouracil, methotrexate, or bleomycin. This is four patients, uncontrolled, selected because it worked. The practical takeaway is not that this replaces your existing algorithm — it's that intralesional triamcinolone belongs in your back pocket as a low-cost, low-risk option specifically for patients where surgery is undesirable, where destructive treatments have already failed, or where the eruptive burden makes procedural approaches impractical. Interesting and clinically usable as a salvage option, not something that changes your first-line approach.

Next, a case report: extensive basal cell carcinoma tracking along the nasal mucosa at the site of a nose piercing. This one is a good reminder to slow down on scar-like plaques with an unusual history. A 76-year-old woman had a firm plaque at a longstanding nasal piercing site that she and, implicitly, prior examiners had attributed to scarring from the piercing itself — she'd had it for a decade. Biopsy showed basal cell carcinoma with micronodular and follicular differentiation, and on exam the nodule extended into the nares with evident mucosal involvement.

Here's the part that should stick with you: Mohs sectioning showed tumor tracking circumferentially around the piercing tract itself, following the dermis through to the nasal mucosa — essentially using the epithelialized piercing channel as a conduit between the cutaneous and mucosal surfaces. It took five stages to clear, and the final defect was substantial, nearly five centimeters, full thickness through the nasal tip, ala, dorsum, and sidewall, extending onto the medial cheek — requiring a multidisciplinary reconstruction with facial plastics, an auricular cartilage graft, and a prelaminated paramedian forehead flap.

The discussion frames body piercing as an underappreciated risk factor for occult subclinical extension, distinct from the more familiar aggressive-histology-and-ala-location risk factors for full-thickness nasal defects. The authors' practical suggestion is straightforward and worth adopting: any time you're evaluating a tumor at a piercing site — nasal, lip, or even ear — examine both the cutaneous and the opposing mucosal or posterior surface before you start, because the tract can carry tumor to a surface you wouldn't otherwise be inspecting, and that changes how you counsel the patient on anticipated defect size and reconstruction complexity before you ever pick up a blade. This is a single case, so it's not practice-changing in the sense of an algorithm, but it is a concrete, low-cost habit — bidirectional exam at piercing sites — that costs you nothing and could save you an intraoperative surprise.

Third is a different kind of piece — an overview article on Micrographic Surgery and Dermatologic Oncology fellowship selection, aimed at prospective applicants but genuinely useful for anyone serving as a fellowship director or mentor. There's no primary data collection here; this is a synthesis of existing survey and match data, so I'll walk through the landscape rather than a methods-and-results structure.

The field has grown substantially, from sixty-three programs and sixty-eight trainees a decade ago to eighty-four programs with around a hundred fellows now, and board certification through the American Board of Dermatology now requires the ACGME-accredited fellowship pathway, since the practice pathway sunset in 2025. The match itself is competitive — roughly one hundred fifty applicants a year competing for spots, with about sixty percent matching. Notably, having more interviews improved an applicant's odds, but submitting more applications did not — a detail worth passing along to anyone mentoring an applicant who thinks quantity of applications is the lever to pull. Almost half of matched applicants stayed near their residency program, and about a third matched at their actual home institution, which tells you something about how heavily "fit" and familiarity weigh in this process. Match exemptions, which let programs fill spots outside the formal process, have fallen sharply since 2018 guidelines restricted them largely to military and international candidates — from thirty a year down to fewer than five annually.

On the selection side, fellowship directors remain predominantly male, though female representation has risen to about a quarter over the past few decades, and female directors were more likely to bring in female fellows and to reach leadership roles faster despite comparable credentials. Perhaps the most practically important point for anyone advising an applicant: directors seem to weight personality and work ethic more heavily than board scores or advanced degrees, assessed mainly through interviews and letters of recommendation — and a strong letter from a fellowship-trained Mohs surgeon who directly supervised the applicant carries outsized influence, especially when that mentoring relationship has been sustained over time. Research productivity during residency functions as a proxy for the same trait, valued even above subspecialty-specific research. Internal candidates are favored, which reinforces the value of a home program, though away rotations have not been shown to reliably move the needle. And geographically, the field is concentrated in metropolitan areas — over eighty percent of US counties lack a Mohs surgeon — while most graduates settle near where they trained and gravitate toward private practice in urban or suburban settings, leaving workforce maldistribution as an open problem the authors flag for candidates willing to consider underserved markets.

There's no statistical methodology to teach here since this is a narrative synthesis of prior survey work, not new data analysis. The practical takeaway is mostly for those on the mentoring and fellowship director side: if you're advising a resident, steer them toward accumulating strong, durable mentor relationships and demonstrable research effort rather than papering their application with volume, and recognize that your letter carries more weight than almost anything else you can offer them.

Last, and the one real analytic paper of the four: a retrospective chart review on utilizing a Wood's lamp to demarcate excisional margins for melanoma. This is a single-institution, single-surgeon retrospective review conducted from 2012 to 2023, addressing a genuine clinical problem — clinical exam alone under white light regularly underestimates the subclinical extension of melanoma, particularly melanoma in situ, and the literature has repeatedly shown that a meaningful fraction of these tumors need margins well beyond the standard five to ten millimeters recommended by NCCN guidelines to actually clear.

The method here is simple and worth understanding precisely because it's simple: every lesion was examined under a Wood's lamp preoperatively, the border of illuminated, presumably melanocytic pigment was marked, and then a standard margin — five millimeters — was measured outward from that Wood's-lamp-defined border rather than from the clinically visible border under normal light, following NCCN-based margin guidance for the tumor thickness in question. All cases were done by one dermatologist, which the authors note was intentional — it removes interobserver variability in both the Wood's lamp interpretation and surgical technique as a confounder, which matters a great deal for a technique this operator-dependent, though of course it also means you're looking at one person's skill and interpretation, not a generalizable technique reliably reproduced across examiners.

I'll flag something about the statistics, or rather the near-absence of them, because it's a useful teaching point in itself. This paper reports descriptive proportions — margin clearance rates as simple fractions — rather than any comparative inferential test. There's no regression, no confidence interval, no p-value anywhere in this analysis, and that's actually appropriate for what the question is: what fraction of lesions cleared with this technique, full stop, compared narratively against clearance rates reported in other published series using standard excision. But it does mean you should read the subgroup numbers with real caution. When they report an 84.6 percent clearance rate for the nose, ear, eyelid, and periorbital region, that's eleven out of thirteen cases — move one single case from cleared to noncleared and that rate swings by nearly eight points. Small denominators produce unstable percentages, and that's true throughout the subgroup breakdown here, not a flaw unique to this paper, just something to keep in mind whenever a case series reports a rate to one decimal place off a denominator under twenty.

With that caveat, the headline numbers are genuinely interesting. Across a hundred ninety excisions, overall margin clearance was about ninety-five percent — 180 of 190. By location, clearance was strongest on the trunk and extremities at roughly ninety-seven percent, weaker on the head and neck generally around ninety-three percent, and weakest, as you'd expect given anatomic constraints and higher baseline subclinical extension risk, in the nose-eyelid-ear-periorbital group at that eighty-five percent figure. By subtype, lentigo maligna, lentigo maligna melanoma, and melanoma without a specified histologic subtype all cleared at one hundred percent, superficial spreading cleared at about ninety-eight percent, and melanoma in situ — the subtype most notorious for subclinical spread — still cleared at close to ninety-two percent.

The authors lean on that melanoma in situ and lentigo maligna performance as their strongest argument, and the comparison numbers they cite from prior literature are worth repeating because they're the clinically meaningful figures here: a staged excision series without Wood's lamp guidance cleared only about fifty-four percent of lentigo maligna cases with a standard five-millimeter margin, needing an average margin over a centimeter for the ones that didn't clear initially. Another series found forty-five percent of melanoma in situ cases needed more than five millimeters, with almost twelve millimeters required to clear ninety-three percent of cases. Against that backdrop, getting one hundred percent clearance on lentigo maligna and lentigo maligna melanoma, and over ninety percent on melanoma in situ, using a straightforward five-millimeter margin off a Wood's-lamp-marked border, is a meaningfully better result than unaided clinical margining.

The limitations are honestly stated and matter clinically. This is retrospective, single-institution, single-operator, which limits generalizability — you're really testing one experienced dermatologist's interpretation of Wood's lamp fluorescence, and that skill may not transfer uniformly. There's also a real counterpoint the authors cite directly: a separate prospective study found that when all clinically suspicious pigment under standard white light was already biopsied before excision, adding Wood's lamp examination didn't improve subclinical detection and in some cases just increased wound size — meaning the benefit may be concentrated in scenarios where the initial clinical delineation was incomplete, not a universal upgrade over careful white-light exam and biopsy practice. There's also the inherent difficulty of the tool itself: it doesn't distinguish melanoma from background melanocytic hyperplasia, so the authors rely on contiguous versus noncontiguous pigmentation patterns to decide what to include in the marked margin, which is somewhat subjective.

Practically, here's where I'd land: this is interesting and plausible, not yet a mandate to change your standard margining protocol. If you already own a Wood's lamp, and particularly for lentigo maligna or melanoma in situ on the head and neck where subclinical extension is your biggest enemy, using it as an adjunct to mark your intended margin before you cut is low-cost, low-risk, and has decent supporting rationale from this and prior series. It is not a substitute for careful clinical exam and appropriate biopsy of any suspicious satellite pigment, and it hasn't been validated across multiple operators, so I wouldn't treat a five-millimeter Wood's-lamp margin as inherently sufficient just because this series achieved good numbers — particularly not in that periorbital and nasal-ear subgroup where their own data showed the weakest performance.

That's the September issue. A modest but genuinely useful case series on intralesional steroids for refractory eruptive keratoacanthomas, a sharp reminder to examine both sides of any piercing tract before you commit to a surgical plan, a comprehensive look at what actually drives fellowship selection for anyone mentoring the next generation of Mohs surgeons, and a retrospective series suggesting the humble Wood's lamp may earn a spot in your melanoma margining toolkit. Thanks for listening, and I'll see you next month.