Welcome to this month's journal review, covering key articles from the Journal of the American Academy of Dermatology, July 2026 issue. Today we're reviewing four pieces relevant to dermatologic oncology and surgical practice: two melanoma prognostic biomarker studies, a phototherapy safety analysis, and a commentary piece proposing a unifying framework for nail unit malignancies. Let's get into it.

Our first article is a JAAD Game Changers summary by Jane Grant-Kels, covering the original work titled "Baseline serum neutrophil-to-lymphocyte ratio in acral melanoma compared with nonacral melanoma and its prognostic significance," by Choi, Jung, Kim, Won, Chang, Lee, and Lee.

The clinical question here is whether a simple, widely available lab value—the neutrophil-to-lymphocyte ratio, or N L R—can serve as a prognostic biomarker in acral lentiginous melanoma, a subtype already known to carry a worse prognosis than non-acral cutaneous melanoma. The study compared baseline serum N L R values between patients with acral melanoma and those with non-acral cutaneous melanoma, and then assessed whether N L R predicted progression-free survival within the acral melanoma cohort.

Key findings: in advanced-stage disease, baseline N L R was significantly higher in acral melanoma compared to non-acral cutaneous melanoma. Within the acral melanoma group, a high baseline N L R was independently associated with worse progression-free survival, and this association held up after adjusting for established adverse prognostic factors—ulceration, Breslow thickness of two millimeters or greater, and nodal invasion.

The evidence-based takeaway is that N L R may offer clinicians an inexpensive, readily obtainable adjunct for risk-stratifying acral melanoma patients at baseline, potentially informing conversations about prognosis and systemic therapy planning. That said, the summary provided doesn't detail the exact hazard ratios, confidence intervals, or the N L R cutoff value used to define "high" versus "low," nor does it specify cohort size—all of which would be necessary to judge the precision and generalizability of this finding before incorporating it into routine risk stratification. This is a single Game Changer synopsis rather than the full primary paper, so those granular statistics should be verified in the original text before altering practice.

Moving to our second article, another Game Changers summary from Doctor Grant-Kels, covering "Histopathologic regression in patients with primary cutaneous melanoma undergoing sentinel lymph node biopsy is associated with favorable survival and, after metastasis, with improved progression-free survival on immune checkpoint inhibitor therapy: A single-institutional cohort study," by Wagner, Knierim, Luttermann, Metzler, Yazdi, Bauer, Gassenmaier, Forschner, Leiter, Amaral, Garbe, Eigentler, Forchhammer, and Flatz.

The clinical question addresses a long-standing controversy: does histopathologic regression in a primary melanoma predict better or worse prognosis? Prior literature has been split on this point. This was a retrospective single-institution cohort study reviewing one thousand one hundred seventy-nine new melanomas that required sentinel lymph node biopsy, diagnosed between 2010 and 2015.

The key findings are notably consistent across multiple endpoints. Melanomas with histopathologic regression were associated with favorable relapse-free survival, favorable distant metastasis-free survival, and favorable melanoma-specific survival. Regression also correlated with a negative sentinel lymph node biopsy result. Perhaps most clinically interesting: even among patients who progressed to unresectable disease, those whose primary tumor showed regression had improved progression-free survival specifically when treated with immune checkpoint inhibitor therapy—this favorable association was not seen with targeted therapy or chemotherapy.

The evidence-based takeaway for practice is that regression should be viewed as a reassuring histopathologic feature rather than an ominous one—it correlates with lower nodal positivity and better survival outcomes across the disease spectrum, and it may even have relevance to predicting immunotherapy responsiveness in the metastatic setting. Limitations to note: this is a single-institution retrospective cohort, which limits generalizability and introduces potential selection and referral bias; specific effect sizes, hazard ratios, and confidence intervals are not enumerated in this summary and would need to be checked against the full original manuscript. The differential benefit by treatment modality—checkpoint inhibitors versus targeted therapy or chemotherapy—also warrants cautious interpretation given likely differences in patient selection for each therapy line.

Our third article is a Game Changers summary covering "Incidence and profile of skin cancers in patients following ultraviolet phototherapy without psoralens: A retrospective cohort study," by Wang, Ahad, Liu, Lee, Lui, Crawford, and Kalia.

The clinical question here is important for anyone managing chronic inflammatory skin disease: does non-psoralen ultraviolet phototherapy—broadband U V B, narrowband U V B, or combined U V A B—carry an increased risk of skin cancer, given that the carcinogenic risk of P U V A is already well established but data on these other modalities has been comparatively sparse.

This was a retrospective cohort study of over three thousand five hundred patients treated with broadband U V B, narrowband U V B, and or combined U V A B, predominantly for psoriasis or atopic dermatitis, spanning treatment dates from 1977 to 2018—a remarkably long follow-up window.

The key finding: compared to the general population, there was no significant difference in incidence of melanoma, squamous cell carcinoma, or basal cell carcinoma among phototherapy-treated patients. Furthermore, the authors did not identify a cumulative dose-response relationship between U V B exposure and skin cancer risk.

The evidence-based takeaway is that patients treated with non-psoralen phototherapy modalities do not appear to require enhanced dermatologic cancer screening beyond standard-of-care surveillance, in contrast to the established heightened vigilance warranted for P U V A-treated patients. As for limitations, this is a retrospective cohort design spanning over four decades of practice, which introduces heterogeneity in treatment protocols, dosimetry, and case ascertainment over time; the summary does not provide the actual incidence rates, confidence intervals, or standardized incidence ratios comparing the cohort to the general population, so the statistical strength of this null finding should be confirmed in the full paper before being cited as definitive reassurance.

Our fourth and final piece is not a Game Changers summary but an editorial commentary: "Onycho-oncology: A Useful Neologism," by Warren R. Heymann.

Doctor Heymann's commentary proposes the term "onycho-oncology" as a unifying framework to maintain clinical vigilance for nail unit malignancies, which are frequently mistaken for inflammatory or infectious conditions, leading to delayed biopsy and diagnosis. He references three original articles to make this case, each worth summarizing individually for surgical relevance.

The first is a multicenter retrospective study by Lipner and colleagues examining two hundred sixty-nine cases of nail squamous cell carcinoma in two hundred sixty-one patients, dividing cases into nail squamous cell carcinoma in situ, comprising one hundred forty-eight cases or fifty-five percent, and invasive nail squamous cell carcinoma, comprising one hundred twenty-one cases or forty-five percent. Anatomically, the tumors predominantly affected the right index and middle fingers and bilateral thumbs, accounting for sixty-two percent of cases, with a strong male predominance of seventy-two point four percent, typically presenting in the sixth decade of life. Koilocytosis, a histologic marker of human papillomavirus involvement, was identified in thirty-two point two percent of tumors, and was significantly more common in the in-situ subtype, with a p value of point zero one five. Clinically, subungual ooze independently predicted invasive disease, with an odds ratio of three point nine eight and a p value of point zero two five; pain, with a p value of point zero two two, and nail plate loss, with a p value of point zero zero four, were also associated with invasive disease. Regarding treatment, Mohs micrographic surgery was the most commonly used modality, employed in thirty-nine point five percent of cases. Overall recurrence across all treatment types was nine point seven percent, with no statistically significant difference in recurrence rates among treatment modalities. The authors' clinical takeaway, worth emphasizing for Mohs surgeons: nail squamous cell carcinoma presents either as a periungual papule or plaque with horizontal, warty growth, or as an oozing, ulcerating, dermally invasive subungual tumor; periungual cases are linked to human papillomavirus, often sexually transmitted, and these HPV-related cases tend to be in situ rather than invasive. Digit-sparing surgery remains first-line treatment, with comparable efficacy demonstrated across modalities, supporting continued use of Mohs micrographic surgery as a tissue-conserving option in this location.

The second referenced study, by Yonas, Chang, Tetzlaff, and Klufas, addresses nail unit acral melanoma, which is more prevalent among patients with skin of color and clinically distinct from non-nail unit acral melanoma. This retrospective review included two hundred eighty-one patients—fifty-eight with nail unit melanoma and two hundred twenty-three with non-nail unit acral melanoma. Ulceration was significantly more frequent in the nail unit group, at thirty-six point two percent versus eighteen point four percent in the non-nail unit group, a difference reaching statistical significance with a p value of point zero zero seven. The majority of nail unit melanomas were diagnosed at stage T2 or higher. The authors note this may reflect diagnostic delay, though inherent biological aggressiveness remains a consideration—an important reminder for maintaining a low threshold for biopsy of nail unit pigmented lesions.

The third referenced study is an international Delphi consensus statement on perioperative management in nail surgery, led by Sechi and colleagues. This consensus effort achieved agreement across a comprehensive set of perioperative domains: antibiotic prophylaxis, bleeding risk management, anesthesia technique, antisepsis, tourniquet use, postoperative analgesia, dressing selection, wound healing optimization, follow-up strategy, and prevention of long-term complications such as nail dystrophy and functional impairment. The output is an eight-step consensus flowchart intended to standardize perioperative practice and enhance patient safety in nail surgery—a practical tool for any surgeon regularly performing nail unit procedures.

Doctor Heymann's overarching point in coining "onycho-oncology" is to consolidate these threads—squamous cell carcinoma, melanoma, and perioperative technique—under one clinical mindset that promotes vigilance and reduces diagnostic delay in nail unit malignancy.

To close out this episode: this month's articles reinforce a common theme across melanoma and nail oncology—the search for accessible prognostic markers, whether serologic, like neutrophil-to-lymphocyte ratio, or histopathologic, like tumor regression, continues to refine risk stratification beyond traditional staging alone. Meanwhile, the phototherapy safety data offers practical reassurance for long-term UVB-based management of inflammatory dermatoses, and the nail unit literature underscores the ongoing need for biopsy vigilance and standardized perioperative protocols in this anatomically challenging surgical site. As always, we encourage review of the full original manuscripts for complete statistical detail before altering clinical protocols. Thank you for listening, and we'll see you next month.