When Mohs Is Appropriate

Summary and Comment |
November 16, 2012

When Mohs Is Appropriate

  1. Murad Alam, MD, MSCI

2012 appropriate use criteria for Mohs micrographic surgery

  1. Murad Alam, MD, MSCI

Four major dermatology societies that represent dermatologists active in surgery collectively convened a large number of experts to develop appropriate use criteria for Mohs surgery in 270 scenarios involving basal cell carcinomas (BCCs), squamous cell carcinomas (SCCs), melanoma in situ, and rare cutaneous malignancies.

To rate appropriate use in these scenarios, the experts used a process based on a method developed by the RAND Corporation/University of California–Los Angeles. The year-long, complex effort was designed to be as systematic and objective as possible and included literature review, data extraction, development of clinical indications, and face-to-face and conference-call discussions during which ratings were assigned until consensus was reached. The ratings were designed to guide management of the typical patient, not unusual or exceptional cases. To minimize bias, more than half of the 17 physician rating panel were non-Mohs dermatologists.

This definition of appropriate use was applied to each indication: . . . anticipated clinical benefit (e.g., high cure rate re total margin assessment, low recurrence, small defect size, range of reconstructive possibilities, retention of functional capacity, low morbidity and mortality). . . exceeds the possible negative consequences (e.g., extended surgical procedure under local anesthesia, incorrectly interpreted margins, and risks associated with office-based surgery). Consensus was reached in all of the evaluated scenarios. Mohs was rated as appropriate in 200 scenarios (74%), its appropriateness was rated as uncertain in 24 situations (9%), and its use as inappropriate in 46 (17%). The authors note that further study is needed for the scenarios where appropriate Mohs use was uncertain.


To best use limited medical resources and maximize patient benefit, it is important to use all medical procedures where they are best indicated. Dermatologists who perform Mohs can use this document to guide treatment selection. The details are too many to list, but in general, the collaborative found that smaller, more superficial tumors located off the head and neck are less likely to be appropriate indications for Mohs.


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