Teledermatoscopy as a triage system for pigmented lesions: a pilot study

BACKGROUND: Skin-cancer screening should rely on simple, low-cost and high-sensitivity diagnostic procedures. AIMS: To compare diagnosis and management options after the evaluation of clinical and dermatoscopic teleconsultations with a store-and-forward teledermatology screening system for pigmented lesions. METHODS: Kappa values between telediagnoses and the gold standard (histological examination) were assessed. Referral rates, diagnostic confidence level (DCL), sensitivity and specificity were evaluated in both approaches. Picture quality and time and cost investments were also measured. In total, 61 teleconsultations were evaluated. RESULTS: Sensitivity of the clinical and dermatoscopic teleconsultations was 1 for both, whereas specificities were 0.65 and 0.78, respectively (P < 0.05). DCL was higher for the dermatoscopic teleconsultations (4.75 vs. 4.14, P < 0.05). Agreement between the clinical and dermatoscopic teleconsultation was kappa = 0.89 (95% CI 0.81-0.97). Agreement with the gold standard was 0.91 (95% CI 0.82-1.00) for the clinical teleconsultation and 0.94 (95% CI 0.88-1.00) for teledermatoscopy (P > 0.05). Teledermatoscopy increased the economic investment of a teledermatology facility by 2.4 times. The GP spent 1.5 times longer on dermatoscopic teleconsultations. CONCLUSIONS: Teledermatoscopy has improved the DCL, specificity and referral rates of a teledermatology-based screening system for pigmented lesions. A more detailed economic analysis remains to be performed before recommending teledermatoscopy as a routine screening procedure in pigmented-lesion clinics.     

Comparison of skin biopsy triage decisions in 49 patients with pigmented lesions and skin neoplasms: store-and-forward teledermatology vs face-to-face dermatology

OBJECTIVE: To determine the relative efficacy of store-and-forward teledermatology vs face-to-face dermatology consultations in triage decisions about the need for a biopsy of neoplastic skin changes. DESIGN: Prospective study of consecutive patients judged by an internist to require dermatologic consultation for a skin growth. SETTING: Private primary care and dermatology practices and an academic dermatology practice. PATIENTS: Patients requiring dermatology consultation for evaluation of skin growths. Patients were seen by a single primary care physician between July 10, 1998, and August 4, 2000. INTERVENTION: Digital photographs of skin growths were obtained by the primary care physician and evaluated by a teledermatologist. The patient was then seen face-to-face by a dermatologist. A biopsy was performed if either dermatologist favored biopsy. MAIN OUTCOME MEASURES: Decisions to perform a biopsy. Agreement between the dermatologists was assessed. RESULTS: Of the 49 patients with evaluable photographs, the face-to-face dermatologist and teledermatologist recommended a biopsy for the same 26 patients, yielding a sensitivity of the teledermatologist of 1.00 (95% confidence interval [CI], 0.87-1.00) and a specificity of 1.00 (95% CI, 0.85-1.00). The agreement between the dermatologists (kappa) was 1.00 (95% CI, 0.72-1.00). CONCLUSION: Store-and-forward teledermatology may provide an accurate and cost-effective method of determining whether skin growths in patients presenting to primary care physicians should undergo biopsy.     

Sunlight, keratotic skin lesions and skin cancer in renal transplant recipients

In a retrospective follow-up study, 36 renal transplant recipients with, and 101 without, skin cancer, who had received their first transplant before January 1981 and who were still alive with a functioning graft on 1 August 1989, were assessed to determine the risk of non-melanoma skin cancer in relation to exposure to sunlight during childhood and adolescence. The contribution of the number of keratotic skin lesions to the skin cancer risk was also assessed. The estimated relative risks (odds ratios) of skin cancer in relation to exposure to sunlight and the presence of keratotic skin lesions were calculated by maximum likelihood estimation in a logistic model. The majority of skin cancers and keratotic skin lesions were confined to sun-exposed skin. After adjustment for possible confounding variables, the odds ratios of skin cancer for moderate and high cumulative life-time exposure to sunlight, respectively, compared with low exposure, were 2·4 (95% confidence interval [CI] 0·64-9·3) and 47·6 (95% CI 5·4-418). Exposure to sunlight before the age of 30 contributed more to the risk of developing skin cancer later in life than exposure after the age of 30. No association was found between cumulative life-time exposure to sunlight and the number of keratotic skin lesions. Nevertheless, these lesions behaved as a strong independent risk factor in the development of skin cancer. The adjusted odds ratio of skin cancer for 50-99 lesions compared with >50 lesions was 4·5 (95% CI 1·1-18·2); the adjusted odds ratio for ≥100 lesions compared with >50 lesions was 20·8 (95% CI 5·3-81·7). We conclude that exposure to sunlight before the age of 30 contributes more to the risk of skin cancer in renal transplant recipients than exposure after the age of 30. Cumulative life-time exposure to sunlight does not appear to be associated with an increased number of keratotic skin lesions in these patients. The preferential localization of such lesions on sun-exposed skin suggests a possible role of recently received exposure to sunlight in the development of these lesions.     

Minor cutaneous ambulatory surgery and cryotherapy. Comparative study between a dermatologist and family physicians

IntroductionLack of diagnostic skill in cutaneous surgery may lead to erroneous and potentially detrimental therapies. This study compares the diagnosis and treatment in cutaneous surgery, including cryotherapy, between a dermatologist and family physicians.MethodsIt is an observational, prospective study on a random sample of patients that consulted the dermatologist for candidate lesions. Each lesion was independently evaluated by a dermatologist and a family physician, both of whom assigned the clinical diagnosis and therapeutic advice. Concordance for diagnosis, recommended treatment and indication for cryotherapy was calculated by Cohen's kappa coefficient.ResultsSix hundred forty-six lesions were evaluated. Global kappa indexes were 0.69 (95 % CI, 0.65-0.73) for diagnostic concordance, 0.62 (95% CI, 0.56-0.67) for recommended treatment and 0.73 (95 % CI, 0.67-0.78) for indication of cryotherapy. Diagnostic concordance was significantly better for melanocytic nevus, achrocordon and for lesions with multiple and monomorphous presentation, and worse for isolated pigmented lesions. For recommended treatment concordance was better for multiple and monomorphous lesions and worse for skin cancer and seborrheic keratosis. For indication of cryotherapy concordance was worse for skin cancer, melanocytic nevus, acrochordon and seborrheic keratosis. Family physicians made an erroneous indication for cryotherapy in 5.88 % of cases, including 3 non melanoma skin cancers.ConclusionsConcordance between dermatologists and family physicians for minor cutaneous surgery is generally good. Family physicians should be more careful in evaluating solitary pigmented lesions and patients at risk for skin cancer.     

A meta‐analysis of reflectance confocal microscopy for the diagnosis of malignant skin tumours

Early diagnosis is extremely important for treatment and prognosis of skin cancer. Reflectance confocal microscopy (RCM) is a recently developed technique used to diagnose skin cancer. This meta‐analysis was carried out to assess the accuracy of RCM for the diagnosis of malignant skin tumours. We conducted a systematic literature search of EMBASE, PubMed, the Cochrane Library and Web of Science database for relevant articles in English published up to 24 December 2015. The quality of the included studies was assessed using the QUADAS‐2 tool. Statistical analyses were conducted using the software Meta‐Disc version 1.4 and STATA version 12.0. A total of 21 studies involving 3108 patients with a total of 3602 lesions were included in the per‐lesion analysis. The corresponding pooled results for sensitivity and specificity were 93.6% (95% CI: 0.92–0.95) and 82.7% (95% CI: 0.81–0.84) respectively. Positive likelihood ratio and negative likelihood ratio were 5.84 (95% CI: 4.27–7.98) and 0.08 (95% CI: 0.07–0.10) respectively. Subgroup analysis showed that RCM had a sensitivity of 92.7% (95% CI: 0.90–0.95) and a specificity of 78.3% (95% CI: 0.76–0.81) for detecting melanoma. The pooled sensitivity and specificity of RCM for detecting basal cell carcinoma were 91.7% (95% CI: 0.87–0.95) and 91.3% (95% CI: 0.94–0.96) respectively. RCM is a valid method of identifying malignant skin tumours accurately.     

Five-year follow-up of a randomized, prospective trial of topical methyl aminolevulinate photodynamic therapy vs surgery for nodular basal cell carcinoma

OBJECTIVE: To compare 5-year lesion recurrence rates in primary nodular basal cell carcinoma treated with topical methyl aminolevulinate photodynamic therapy (PDT) or simple excision surgery. DESIGN: Prospective, randomized, multicenter study. SETTING: University hospital dermatology departments. PATIENTS: A total of 97 patients, 50 with 53 lesions treated with methyl aminolevulinate PDT and 47 with 52 lesions treated by excision surgery, were included in the per protocol analysis. Of the lesions treated with methyl aminolevulinate PDT and surgery, 49 and 52, respectively, showed complete clinical response at 3 months after treatment and were observed for long-term outcome evaluation. INTERVENTIONS: Topical methyl aminolevulinate cream, 160 mg/g, applied for 3 hours before illumination (75 J/cm(2) of red light at 570 to 670 nm) on 2 or 4 occasions (12 [23%] of 53 lesions); or excision surgery. MAIN OUTCOME MEASURES: Histologically confirmed lesion recurrence, sustained lesion complete response rate (time-to-event analysis), and investigator assessment of cosmetic outcome, 5 years after the last treatment. RESULTS: At 5 years, recurrence was documented in 7 (14%) of 49 lesions (95% confidence interval [CI], 6%-27%) treated with methyl aminolevulinate PDT vs 2 (4%) of 52 lesions (95% CI, 1%-13%) treated with excision surgery (P = .09). Estimated sustained lesion complete response rates were 76% (95% CI, 59%-87%) and 96% (95% CI, 84%-99%), respectively (P = .01). More patients treated with methyl aminolevulinate PDT than surgery had an excellent or good cosmetic outcome: 27 (87%) of 31 patients (95% CI, 70%-96%) vs 19 (54%) of 35 patients (95% CI, 37%-71%) (P = .007). CONCLUSIONS: Long-term follow-up indicates superior efficacy of surgery to methyl aminolevulinate PDT in nodular basal cell carcinoma. However, methyl aminolevulinate PDT is also an effective treatment for this indication and exhibits a more favorable cosmetic outcome.     

Teledermatology in the times of COVID‐19 – a systematic review

The COVID‐19 pandemic restricts the care of dermatological patients in many ways. Teledermatology such as video consultation or “store‐and‐forward” teledermatology could at least partly compensate for this. This systematic review summarizes all published studies on teledermatology during the COVID‐19 pandemic. It is based on a MEDLINE search for articles from 2020 in English and German. Two surveys among dermatologists from the USA and India showed that more than 80 % offered teledermatology. Among German dermatologists 17.5 % of 480 respondents offered online video consultation, 11.3 % offline consultation (store and forward) and 10.0 % both. Five cohort studies on teledermatology during the pandemic were identified. Three of them investigated teledermatology in chronic dermatoses (acne, inflammatory skin diseases), one dealt with the care of oncological patients with dermatological complications, and one analyzed teleconsultation in suspected COVID‐19 cases. In all studies, teledermatology largely reduced the number of personal consultations. The results indicate that the limitations of personal dermatological care of patients with skin diseases during the COVID‐19 pandemic can be at least partially compensated by an extension of teledermatology. Findings from the use of teledermatology during the pandemic should be employed to improve the use and acceptance of teledermatology by patients and dermatologists.     

Bowen disease and risk of subsequent malignant neoplasms: a population-based cohort study of 1147 patients.

OBJECTIVE: To address the long-standing question of whether patients with Bowen disease are at increased risk of internal malignant neoplasms. PATIENTS: A total of 1147 Danish patients diagnosed between 1978 and 1993 as having Bowen disease at nongenital sites were followed up for 6463 person-years for cancer occurrence up to 16 years after the skin lesion. MAIN OUTCOME MEASURE: Standardized incidence ratios (SIRs)--the ratios of observed-to-expected numbers of cancer--served as measures of relative risk. RESULTS: The observed number of noncutaneous cancers occurring in the cohort (n = 115) was close to expected (n = 103.0) (SIR = 1.1; 95% confidence interval, [CI], 0.9-1.3). However, nonmelanoma skin cancer (SIR = 4.3; 95% CI, 3.5-5.4; n = 83), lip cancer (SIR = 8.2; 95% CI, 2.6-19.1; n = 5), and, among men, leukemia (SIR = 3.2; 95% CI, 1.04-7.5; n = 5) occurred in excess. CONCLUSIONS: Patients with Bowen disease do not appear to constitutionally be at any unusually high general cancer risk. The increased risk of invasive skin and lip cancers is likely due to the common risk factor of UV light.     

Risk of second cancers after the diagnosis of non-melanoma skin cancer in Korean patients

Individuals with a personal history of non-melanoma skin cancer (NMSC) are known to have an increased risk of subsequent cancers. However, most of the studies regarding this fact were done on Caucasian populations. We investigated whether Korean patients with NMSC have an increased risk of developing second cancers compared to the general Korean population. Five hundred and thirty-two patients diagnosed with NMSC at the Department of Dermatology of Yonsei University Health System from 1999 to 2008 were assessed for development of second cancers. The overall second cancer incidence was increased among patients diagnosed with NMSC compared with the general population in Korea: 37 second cancer total (standardized incidence ratio [SIR] 1.38, 95% confidence interval [CI] 1.10-1.90); 23 second cancers in males (SIR 4.24, 95% CI 2.69-6.36); and 14 second cancers in females (SIR 2.28, 95% CI 1.25-3.83). There were significantly increased incidence ratios for NMSC (eight second cancers [SIR 9.52, 95% CI 4.11-18.77]), bladder cancer (four second cancers [SIR 4.21, 95% CI 1.15-10.78]) and nasopharyngeal cancer (one second cancer [SIR 20.00, 95% CI: 1.51-25.33]). Korean patients diagnosed with NMSC had more second cancers, particularly other skin cancers. This study provides additional evidence that NMSC may be a clinically significant and substantial risk factor for second cancers even in a Korean population, in which the incidence of NMSC is much lower than Caucasians.     

An evaluation of the role of a store-and-forward teledermatology system in skin cancer diagnosis and management

There is currently much interest in the potential role of telemedicine in improving the delivery of dermatological care in the UK. The two teledermatology systems available at present are divided into live video and store-and-forward technology. We investigated the value of a store-and-forward teledermatology system in the diagnosis and management of lesions suspicious of skin cancer. A total of 163 store-and-forward referrals of patients with one lesion each were assessed independently by a Consultant and a third-year trainee dermatologist. The accuracy of diagnosis and appropriateness of management from these assessments was compared to a subsequent face-to-face consultation with the Consultant. Analysis of the Consultants' diagnoses showed that 48% were identical for teledermatology and conventional face-to-face consultations. A further 17% of teledermatology diagnoses included the actual clinical diagnosis as a possibility but 20% were either incorrect or a diagnosis could not be made. In the remaining 15% of cases the digital image was of insufficient quality for assessment. Of the trainee's reports, 44% were identical to the clinical diagnoses and another 20% included the clinical diagnosis as a possibility. The management plan was appropriate in 55% of the total teledermatology referrals assessed by the Consultants and in 52% assessed by the trainee when compared with the conventional consultation. This study illustrates that the store-and forward type telemedicine system has limited diagnostic accuracy for skin lesions. However, our results suggest that store-and-forward teledermatology may be suitable and safe for screening out clearly benign lesions but the study casts doubt on its efficiency.     

Preliminary results of DERMATEL: prospective randomized study comparing synchronous and asynchronous modalities of teledermatology

IntroductionThere is considerable variability in the results of studies that evaluate diagnostic reliability in teledermatology. There are only two studies that compare the synchronous and asynchronous modalities of teleconsult in the same sample. We present the results of the pilot project DERMATEL, a study of diagnostic concordance that aims to increase the evidence of these aspects.Material and methodsOne-hundred-fifty.nine patients referred by the general practitioner in the first consult were randomized (algorithm 3:2:1) in three arms: asyncronous teledermatology (store-and-forward or SAF), synchronous teldermatology (real-time or VTC), and conventional consult (CC). We used high-quality, fixed digital images in all cases. The patients on the VTC teledermatology arm were also evaluated by videoconference. Finally all patients attended a face-to-face consult, considered the gold standard of patient care. A second dermatologist evaluated the diagnostic and management concordance between the teleconsults and the face-to-face consults.ResultsOne-hundred.forty-seven patients completed the study as follows: 74 in the SAF teledermatology arm, 47 in the VTC teledermatology arm and 26 in the conventional consult (control group). The teledermatological (SAF and VTC) and face-to-face evaluations were identical in 100 of 121 patients (82.6 %). The errors were mild in 14 cases (11.6 %) and severe in 7 (5,8 %). The diagnostic concordance was very high (kappa = 0,813). The errors grouped by diseases were as follows: 6/54 (11 %) for tumors, 10/30 (33.3 %) for inflammatory conditions, 1/20 (5 %) for infectious diseases, 3/12 (25 %) for alopecia/acne and 1/5 (20 %) for others. There were 15 errors in the SAF teledermatology arm (20.3 %) and 6 in the VTC teledermatology arm (12.8 %); these differences were not statistically significant (χ² 1.12; p = 0.288).ConclusionThe reliability of dermatological teleconsult is very high, especially for tumoral or infectious diseases. The synchronous interaction with audio requires more resources, is difficult to coordinate and its diagnostic efficacy is not superior to SAF teledermatology.     

Detection of human papillomavirus genotypes among high-risk women: a comparison of hybrid capture and linear array tests

OBJECTIVES: To assess the concordance and performance of 2 different assays in detection of human papillomavirus (HPV) genotypes among women with abnormal Pap smear. STUDY DESIGN: A series of 575 women referred for colposcopy due to an abnormal Pap smear were analyzed with the Linear Array HPV Genotyping test detecting 37 HPV types and compared with Hybrid Capture II (HCII) assay for detection of carcinogenic HPV. Histologic outcomes of cervical intraepithelial neoplasia grade 2 (CIN2) or worse (CIN2+) and CIN3+ were the primary endpoints. Clinical performance, including receiver operating characteristics, was determined for both tests. RESULTS: HCII and linear array (LA) were concordant in 88.1% (433/491; 95% CI 85.3%-91.0%), having a substantial agreement with regular kappa (kappa = 0.70, 95% CI 0.62-0.77) and almost perfect agreement with weighted kappa (ICC = 0.82, 95% CI 0.7-0.85). In detecting CIN2+ and CIN3+, LA is 5% and 6% more sensitive but 9.5% and 8.7% less specific than HCII (area under ROC curve; P = 0.317 and P = 0.875, respectively). CONCLUSIONS: Performance of HCII and LA does not significantly differ in detecting CIN2+ or CIN3+.     

Prognostic value of blood eosinophilia in primary cutaneous T-cell lymphomas

OBJECTIVE: To investigate the prognostic value of initial characteristics including blood eosinophilia in patients with primary cutaneous T-cell lymphoma. DESIGN: A retrospective inception cohort, patients included from date of diagnosis (1982-1998). SETTING: Two dermatology departments of a university hospital.Patients A total of 104 patients with cutaneous T-cell lymphoma, including patients with mycosis fungoides (n = 69), Sézary syndrome (n = 13), and nonepidermotropic cutaneous lymphoma (n = 22). The following variables were recorded: age, sex, diagnosis according to the European Organization for Research and Treatment of Cancer (EORTC) classification, type of skin involvement at the time of diagnosis, initial eosinophil absolute count, lactate dehydrogenase value, date of disease progression, and cause and date of death or date of last contact. MAIN OUTCOME MEASURES: Time from diagnosis to disease progression and to disease-specific death. RESULTS: The median follow-up was 43 months (range, 7-197 months). Estimated rates of disease progression and disease-specific death for 3 years were 19.5% (95% confidence interval [CI],11.3%-27.6%) and 9.9% (95% CI, 2.8%-13.6%), respectively. Univariable analysis of initial variables possibly influencing disease progression revealed significant prognostic value for diagnosis according to EORTC classification (hazard ratio [HR], 2.77; 95% CI, 1.04-7.41; P =.04), type of skin involvement (HR, 2.70; 95% CI, 1.00-7.25; P =.04), raised blood eosinophil absolute count (HR, 7.33; 95% CI, 2.84-18.91; P<.001), and raised serum level of lactate dehydrogenase (HR, 3.72; 95% CI, 1.58-8.78; P =.001).Concerning disease-specific death, significant prognostic indicators were diagnosis according to the EORTC classification (HR, 6.62; 95% CI, 1.68-26.12; P =.007) and a raised blood eosinophil absolute count (HR, 10.57; 95% CI, 2.28-49.0; P<.001). In multivariable analysis, only blood eosinophilia was associated with disease progression and disease-specific death. CONCLUSION: These results strongly suggest that blood eosinophilia at baseline is a prognostic factor in patients with primary cutaneous T-cell lymphoma.     

Reliability of self-reported willingness-to-pay and annual income in patients treated for toenail onychomycosis

BACKGROUND: Willingness-to-pay (WTP) is a health economics measure that has recently been used for skin diseases to evaluate patients' quality of life. However, the reliability of this measure has not been investigated in the dermatology literature and is essential in validating its use in health services research. OBJECTIVES: This study evaluated the test-retest reliability of self-reported annual income and WTP, a health economics measure of disease impact, in patients with toenail onychomycosis. METHODS: Forty-six patients enrolled in a randomized clinical trial comparing two different dosing regimens of terbinafine completed a self-administered questionnaire at baseline and 1 month later. The questionnaire asked: (i) how much patients would be willing to pay for a theoretical treatment with a cure rate of 85% for their current onychomycosis (10 categories: $0-50, $51-100, to > $800); and (ii) annual income (10 categories: $0-10,000 to > $200,000). RESULTS: Forty-four patients reported WTP at both visits, and 55% reported the same WTP. The quadratic-weighted (Fleiss-Cohen) kappa statistic indicated moderate agreement (kappa = 0.50, 95% confidence interval, CI 0.24-0.75, P < 0.01) as did the Spearman rank-order correlation coefficient (r(s) = 0.57, P < 0.01; median difference = 0, P = 0.50). Strong agreement was shown among the 42 patients who reported income at both visits; 71% reported the same annual income category (kappa = 0.72, 95% CI 0.47-0.96, P < 0.01; r(s) = 0.68, P < 0.01; median difference = 0, P = 0.77). Age, disease severity and duration, previous therapy, self-reported annual income, and medication side-effects were not statistically associated with the reliability of WTP. CONCLUSIONS: WTP and annual income demonstrated moderate and strong test-retest reliability, respectively. Self-reported WTP can serve as a reliable measure for future health economics research on onychomycosis.     

Factors predictive of complex Mohs surgery cases

Abstract Background: Mohs surgery allows excision of skin cancer in a tissue-sparing fashion that minimizes recurrence risk. While the indications for Mohs surgery are well established, factors predictive of complex Mohs cases are less studied. Objective: To determine patient, tumor, and surgeon characteristics associated with complex Mohs cases. Methods: A retrospective review was performed for a 3-year period (7/2006-6/2009) to identify Mohs cases requiring ≥4 stages ("complex"), and a control population requiring ≤3 stages ("non-complex"). Surgical logs for four fellowship-trained Mohs surgeons were reviewed. Results: 77 complex cases (51 academic practice vs. 26 private practice) were compared with 154 control cases (102 academic practice vs. 52 private practice). There were no significant differences in patient age, gender, immunosuppression, academic (2.7% complex) versus private practice (3.5% complex), or surgeons' years of experience. Factors associated with complexity included: recurrent tumors (p < 0.001; odds ratio (OR) 6.88; 95% confidence interval (CI) 2.8-17); basal cell carcinoma (BCC) with infiltrative or morpheaform histology (p = 0.0019; OR 3.0; 95% CI 1.5-6.3); tumors of the nose (p = 0.0168; OR 2.05; 95% CI 1.1-3.7), especially nasal tip (p = 0.0103; OR 3.68; 95% CI 1.3-10.6) and ear (p = 0.0178; OR 3.0; 95% CI 1.2-7.9), especially helix (p = 0.00744; OR 5.9; 95% CI 1.5-22.7); tumors with pre-operative size >1 cm (p = 0.018; OR 2.0; 95% CI 1.1-3.6); and tumors involving >1 cosmetic subunit (p = 0.0072; OR 5.0; 95% CI 1.5-16.7). Complex tumors had greater post-operative area (10.6 ± 1.3 vs. 3.6 ± 0.7 cm(2); p < 0.0001), and more often required flap/graft repair (p < 0.0001; OR 6.9; 95% CI 3.7-13.1). Limitations: A retrospective study representing a single geographic area. Conclusions: Mohs cases are similar in complexity whether in academic or private practice. Recurrent/aggressive histology tumors, tumors >1 cm, and tumors on the nose or ear are more likely to prove surgically complex. Advanced knowledge of these factors may be useful pre-operatively as Mohs surgeons plan their scheduled cases.     

Second lymphomas and other malignant neoplasms in patients with mycosis fungoides and Sezary syndrome: evidence from population-based and clinical cohorts

OBJECTIVE: To assess risks for developing second malignancies in patients with mycosis fungoides or Sézary syndrome. DESIGN: Retrospective study of 2 cohorts. SETTING: Nine population-based US cancer registries that constitute the Surveillance, Epidemiology, and End Results Program (SEER-9), and Stanford University referral center cohort of patients with cutaneous lymphoma. Patients with mycosis fungoides or Sézary syndrome from the SEER-9 registry diagnosed and followed up from 1984 through 2001 and from the Stanford University cohort diagnosed and followed up from 1973 through 2001. MAIN OUTCOME MEASURES: Relative risk was estimated using the standardized incidence ratio (SIR). The expected cancer incidence for both cohorts was calculated using age-, sex-, race-, and calendar year-specific SEER-9 incidence rates for the general population. Nonmelanoma skin cancers were excluded because these cancers are not routinely reported by the SEER database. RESULTS: In the SEER-9 cohort (n = 1798), there were 197 second instances of cancer (SIR = 1.32; 95% confidence interval [CI], 1.15-1.52) at all sites. Significantly elevated risk (P<.01) was observed for Hodgkin disease (6 cases; SIR = 17.14; 95% CI, 6.25-37.26) and non-Hodgkin lymphoma (27 cases; SIR = 5.08; 95% CI, 3.34-7.38). Elevated risk (P<.05) was also observed for melanoma (10 cases; SIR = 2.60; 95% CI, 1.25-4.79), and urinary cancer (21 cases; SIR = 1.74; 95% CI, 1.08-2.66). In the Stanford University cohort (n = 429), there were 37 second instances of cancer (SIR = 1.04; 95% CI, 0.76-1.44). Elevated risk (P<.01) was observed for Hodgkin disease (3 cases; SIR = 27.27; 95% CI, 5.35-77.54). Elevated risk (P<.05) was also observed for biliary cancer (2 cases; SIR = 11.76; 95% CI, 1.51-42.02). CONCLUSION: Updated SEER (population based) and Stanford (clinic based) data confirm the generalizability of earlier findings of increased risk of lymphoma in patients with mycosis fungoides or Sézary syndrome.     

The performance of SolarScan: an automated dermoscopy image analysis instrument for the diagnosis of primary melanoma

OBJECTIVE: To describe the diagnostic performance of SolarScan (Polartechnics Ltd, Sydney, Australia), an automated instrument for the diagnosis of primary melanoma. DESIGN: Images from a data set of 2430 lesions (382 were melanomas; median Breslow thickness, 0.36 mm) were divided into a training set and an independent test set at a ratio of approximately 2:1. A diagnostic algorithm (absolute diagnosis of melanoma vs benign lesion and estimated probability of melanoma) was developed and its performance described on the test set. High-quality clinical and dermoscopy images with a detailed patient history for 78 lesions (13 of which were melanomas) from the test set were given to various clinicians to compare their diagnostic accuracy with that of SolarScan. SETTING: Seven specialist referral centers and 2 general practice skin cancer clinics from 3 continents. Comparison between clinician diagnosis and SolarScan diagnosis was by 3 dermoscopy experts, 4 dermatologists, 3 trainee dermatologists, and 3 general practitioners. PATIENTS: Images of the melanocytic lesions were obtained from patients who required either excision or digital monitoring to exclude malignancy. MAIN OUTCOME MEASURES: Sensitivity, specificity, the area under the receiver operator characteristic curve, median probability for the diagnosis of melanoma, a direct comparison of SolarScan with diagnoses performed by humans, and interinstrument and intrainstrument reproducibility. RESULTS: The melanocytic-only diagnostic model was highly reproducible in the test set and gave a sensitivity of 91% (95% confidence interval [CI], 86%-96%) and specificity of 68% (95% CI, 64%-72%) for melanoma. SolarScan had comparable or superior sensitivity and specificity (85% vs 65%) compared with those of experts (90% vs 59%), dermatologists (81% vs 60%), trainees (85% vs 36%; P =.06), and general practitioners (62% vs 63%). The intraclass correlation coefficient of intrainstrument repeatability was 0.86 (95% CI, 0.83-0.88), indicating an excellent repeatability. There was no significant interinstrument variation (P = .80). CONCLUSIONS: SolarScan is a robust diagnostic instrument for pigmented or partially pigmented melanocytic lesions of the skin. Preliminary data suggest that its performance is comparable or superior to that of a range of clinician groups. However, these findings should be confirmed in a formal clinical trial.     

Tanning bed exposure increases the risk of malignant melanoma

BACKGROUND: Epidemiologic studies have associated tanning bed exposure and cutaneous melanoma. The relationship between the extent of tanning bed exposure and the risk of melanoma has not been elucidated in detail. METHODS: Surveys assessing the extent of tanning bed exposure and the history of skin cancer, including malignant melanoma, were collected from academic dermatology clinic patients (n = 1518). Of these, 551 (36.3%) completed all components of the survey. The available medical records, including pathology reports (n = 501; 33%), were reviewed to confirm cases of skin cancer. Data on potential confounding factors, including indoor vs. outdoor occupation and leisure activities, Fitzpatrick skin type, history of blistering sunburn, use of sunscreen and sun protective clothing, history of phototherapy, and level of education, were assessed and compared. RESULTS: Of the patients surveyed, 487 (32.1%) reported tanning bed exposure. Women aged 45 years or younger accounted for about 60% of all tanning bed users. Seventy-nine cases of malignant melanoma were reported, 22 in women aged 45 years or younger. In the entire cohort, the "ever-use" of tanning beds was found to be a significant risk factor for the development of melanoma [P < 0.05; odds ratio (OR), 1.64; 95% confidence interval (95% CI), 1.01-2.67]. The risk was greater in women aged 45 years or younger (P < 0.05; OR, 3.22; 95% CI, 1.01-11.46). Patients with a history of melanoma were significantly more likely to report tanning bed sessions exceeding 20 min (P < 0.01; OR, 3.18; 95% CI, 1.48-6.82); this association was even stronger for women aged 45 years or younger (OR, 4.12; 95% CI, 1.41-12.02). LIMITATIONS: The study was subject to recall bias, included only patients at a midwestern academic practice, and had a relatively low response rate. CONCLUSION: Exposure to tanning beds increases the risk of malignant melanoma, especially in women aged 45 years or younger. These findings reinforce the hazards of tanning bed exposure.     

Sociodemographic characteristics of spanish skin cancer patients

IntroductionMost epidemiological studies of skin cancer have been performed in countries with very different population and geographic characteristics to Spain. Investigation of this disease in the Spanish population would therefore be of interest.MethodOver a 12-month period, this prospective study recorded the types of skin cancer in consecutive patients who attended a dermatology clinic for the first time in health care area 3 of the health service of the Spanish autonomous community of Murcia. The demographic and social characteristics of these patients were determined. The results obtained were analyzed with the SPSS program, version 11.5, and compared withother studies conducted in other countries.ResultsMalignant tumors were the third most common presenting complaint (16.9 %) and the fourth most common secondary complaint (8%). The patients with skin cancer were older (69.52 years; 95% confidence interval [CI], 67.82-71.21 years) than the other patients in the sample (34.52 years; 95% CI, 33.23-33.81 years), and there were more men (51.7%) than women (48.3%). These individuals had a low level of schooling, which varied according to the type of tumor, and most had outdoor jobs, with a significantly higher exposure to sunlight (3.35 h/d; 95% CI, 3.08-3.62 h/d) than the other patients (2.72 h/d; 95% CI, 2.58-2.86 h/d). Furthermore, fewer malignant cutaneous tumors were found in patients with a higher phototype. The length of time since onset of the presenting complaints was shorter for skin cancer (11.37 months; 95% CI, 7.47-15.26 months) than for other skin diseases (25.83 months; 95% CI, 22.87-28.80). Also, there were no seasonal peaks in consultations for skin cancer, and treatment was essentially based on surgery and cryotherapy. In addition, more of these patients had follow-up visits (84%) than other dermatology patients (33%).ConclusionsMalignant or premalignant skin lesions are a common presenting skin complaint in the Mediterranean region, with differences in terms of attendance rates and predominant tumor type compared to other countries. This is probably due to the high sun exposure and predominance of skin phototype III. Similar studies for the whole of Spain would be of interest.     

Teledermatology applied following patient selection by general practitioners in daily practice improves efficiency and quality of care at lower cost

Background Teledermatology, the application of telemedicine in the field of dermatology, has similar accuracy and reliability as physical dermatology. Teledermatology has been widely used in daily practice in the Netherlands since 2005 and is fully reimbursed. Objectives This study prospectively investigated the effect of teledermatology on efficiency, quality and costs of care when integrated in daily practice and applied following patient selection by the general practitioner (GP). Methods Teledermatology consultations between GP and regional dermatologist were performed in daily GP practice in the Netherlands. Efficiency of care was measured by the decrease in the number of physical referrals to the dermatologist. Quality of care was measured by the percentage of teleconsultations for second opinion, physical referrals resulting from these teleconsultations, the response time of the dermatologists and educational effect experienced by the GP. Costs of conventional healthcare without teledermatology were compared with costs with teledermatology. Results One thousand, eight hundred and twenty GPs and 166 dermatologists performed teledermatology, and 37 207 teleconsultations performed from March 2007 to September 2010 were included. In the group of patients where the GP used teleconsultation to prevent a referral (n = 26 596), 74% of physical referrals were prevented. In the group of patients where the GP used teleconsultation for a second opinion (n = 10 611), 16% were physically referred after teleconsultation. The prevented referral rate in the total population was 68%. The mean response time of dermatologists was 4·6 h (median 2·0). GPs indicated that there was a beneficial educational effect in 85% of the teleconsultations. The estimated cost reduction was 18%. Conclusions Teledermatology can lead to efficient care probably at lower cost. We are therefore of the opinion that teledermatology following GP selection should be considered as a possible pathway of referral to secondary care.