Dermatoscopic patterns of cutaneous metastases: A multicentre cross-sectional study of the International Dermoscopy Society.

BACKGROUND: The detection of cutaneous metastases (CMs) from various primary tumours represents a diagnostic challenge. OBJECTIVES: Our aim was to evaluate the general characteristics and dermatoscopic features of CMs from different primary tumours. METHODS: Retrospective, multicentre, descriptive, cross-sectional study of biopsy-proven CMs. RESULTS: We included 583 patients (247 females, median age: 64 years, 25%-75% percentiles: 54-74 years) with 632 CMs, of which 52.2% (n = 330) were local, and 26.7% (n = 169) were distant. The most common primary tumours were melanomas (n = 474) and breast cancer (n = 59). Most non-melanoma CMs were non-pigmented (n = 151, 95.6%). Of 169 distant metastases, 54 (32.0%) appeared on the head and neck region. On dermatoscopy, pigmented melanoma metastases were frequently structureless blue (63.6%, n = 201), while amelanotic metastases were typified by linear serpentine vessels and a white structureless pattern. No significant difference was found between amelanotic melanoma metastases and CMs of other primary tumours. CONCLUSIONS: The head and neck area is a common site for distant CMs. Our study confirms that most pigmented melanoma metastasis are structureless blue on dermatoscopy and may mimic blue nevi. Amelanotic metastases are typified by linear serpentine vessels and a white structureless pattern, regardless of the primary tumour.

Clinical Features Associated with the Demand of In-Person Care by Dermatologists: An Observational Cross-Sectional Study.

Background: The factors necessitating the need for referrals for in-person evaluations by a dermatologist are not adequately understood and have not been studied using automated text mining so far. The objective of this study was to compare the prevalence of required in-person dermatologist care in the presence or absence of certain clinical features. Methods: Observational cross-sectional study of 11,661 teledermatology reports made from February 2017 to March 2020. Results: The need for dermoscopy was associated with a 348% increase in the possibility of referral for in-person dermatologist evaluations (prevalence ratio [PR]: 4.48, 95% confidence interval [CI]: 4.17-4.82). Infectious diseases were associated with a 64% lower possibility of referral (PR: 0.36, 95% CI: 0.30-0.43). Discussion: Some lesions and poorly documented cases are challenging to assess remotely. This study presents a different approach to research more detailed data from teledermatology reports, using text mining, and points out the risk magnitude for demanding dermatologic in-person care of which feature analyzed. As limitations, the variables related to lesion location, size, and extension were not analyzed and the dictionaries used were originally in Brazilian Portuguese. Conclusions: Teledermatology seems sufficient for the management of 75% of clinical cases, especially acute in young patients with inflammatory or infectious lesions. Referrals for in-person dermatologist consultations were not only strongly associated with the need for dermoscopy, but also for therapeutic reasons like surgical procedures, phototherapy, and the use of some systemic medications.

Dermoscopic Nevus Patterns Associated with Melanoma Patients.

BACKGROUND: The quantitative and qualitative presence of melanocytic nevi is considered a significant risk factor for melanoma. Little is known whether patients showing any of the recognized global dermoscopic nevus patterns might also be considered at increased risk for the disease. OBJECTIVES: We aimed to investigate the frequency of global dermoscopic patterns of common nevi among melanoma patients and compare them to controls, as well as the dermoscopic patterns of atypical nevi between the groups. METHODS: We included consecutive melanoma patients and age- and sex-matched controls who presented to our Department with at least 10 melanocytic nevi. Total body examination was performed, and all nevi had their dermoscopic pattern described. Global dermoscopic patterns of nevi were compared between groups, as well as atypical nevus patterns. Finally, nevus patterns were stratified by their location and also compared between groups. RESULTS: We included 120 melanoma patients and 120 controls. Melanoma patients presented a larger number of common (p = 0.002) and atypical melanocytic nevi (p < 0.001) and more variability of dermoscopic nevus patterns (p < 0.001). No difference in the global dermatoscopic pattern of common nevi was observed between groups. The complex pattern of atypical nevi was associated with melanoma (OR = 2.87). Melanoma patients also showed more common nevi with a reticular pattern on the back (p = 0.014) and lower limbs (p = 0.041) as well as atypical nevi on the back with reticular pattern (p = 0.01), with reticular-homogeneous pattern (p = 0.001), and with reticular-globular pattern (p = 0.048) than controls. Nevi with multifocal pigmentation were also more frequent among melanoma patients (OR = 2.61). CONCLUSION: Melanoma patients tend to present a higher number of common reticular nevi on the back and lower limbs, as well as atypical nevi with a complex pattern, especially reticular, reticular-homogeneous, and reticular-globular on the back.

Short-Term Follow-Up of a Randomized Controlled Trial of 0.5% and 5% 5-Fluorouracil After Microneedling for Treatment of Facial Actinic Keratoses.

INTRODUCTION: Topical 5-fluorouracil (5-FU) is used to treat actinic keratosis, although side effects limit treatment. Microneedling might be a tool for reducing treatment duration. OBJECTIVE: To evaluate microneedling to promote 5-FU delivery at different concentrations (0.5% and 5%) for actinic keratoses (AKs) treatment. METHODS: Forty-four patients with facial AKs subjected to 1.0 mm microneedling on 1 side of the face were randomized into 5% 5-FU or 0.5% 5-FU groups. Evaluations of efficacy and safety were conducted on days 21 and 111. RESULTS: Forty-four patients aged 47 to 85 years were enrolled. Complete clearance of AKs was similar within groups for the side of the face treated with microneedling and 5-FU and the side treated with 5-FU alone in both the 5% and 0.5% 5-FU groups. Microneedling and 5% 5-FU was superior to microneedling and 0.5% 5-FU to reduce AKs (p = .025). Microneedling and 5% 5-FU resulted in fewer adverse effects than 5% 5-FU alone (p = .011). CONCLUSION: Topical 5% and 0.5% 5-FU delivery for 3 days after microneedling was effective for treating facial AKs and equivalent to 5% and 0.5% 5-FU alone for 15 days after 3 months of follow-up. Microneedling may potentiate 5-FU treatment, reducing treatment time without losing efficacy.

Dermoscopic Aspects of Traumatized Nevi After Dermabrasion.

BACKGROUND: Melanocytic nevi submitted to trauma can undergo clinical, dermoscopic, and even histological changes, making it difficult to differentiate them from a melanoma. OBJECTIVE: The aim of this study is to evaluate the dermoscopic changes of traumatized nevi after dermabrasion. METHODS: Dermoscopic images of acquired melanocytic nevi were compared before and 4 weeks after half of their area had undergone dermabrasion. RESULTS: The sample consisted of 50 lesions from 15 patients. The homogeneous pattern was the most frequent, followed by the reticular, cobblestone, and globular patterns. After dermabrasion, nearly half of the lesions (46%) became dermatoscopically asymmetric. Among all lesions, structureless areas, dotted vessels and erythema were the most frequent new dermoscopic structures. CONCLUSION: Trauma after dermabrasion may induce significant dermoscopic changes in melanocytic nevi. Although the global pattern did not change, most of the lesions became asymmetric, with the appearance or fading of dermoscopic structures and colors. A history of recent trauma should be investigated when evaluating pigmented lesions.

Stromal α-Smooth Muscle Actin Positivity Is Associated With High-Risk Basal Cell Carcinomas.

ABSTRACT: The presence of myofibroblast differentiation has been proposed as an invading mechanism in basal cell carcinomas. However, small studies regarding α-smooth muscle actin positivity have led to conflicting results. This review of 100 cases examines the association between α-smooth muscle actin positivity on immunohistochemical studies and the clinical and histopathological characteristics of the tumor, including tumor size, thickness, subtype, topography, ulceration, 5-year recurrence rate, and age at diagnosis.

Skin pigmentation polymorphisms associated with increased risk of melanoma in a case-control sample from southern Brazil.

BACKGROUND: Melanoma is the most aggressive type of skin cancer and is associated with environmental and genetic risk factors. It originates in melanocytes, the pigment-producing cells. Single nucleotide polymorphisms (SNPs) in pigmentation genes have been described in melanoma risk modulation, but knowledge in the field is still limited. METHODS: In a case-control approach (107 cases and 119 controls), we investigated the effect of four pigmentation gene SNPs (TYR rs1126809, HERC2 rs1129038, SLC24A5 rs1426654, and SLC45A2 rs16891982) on melanoma risk in individuals from southern Brazil using a multivariate logistic regression model and multifactor dimensionality reduction (MDR) analysis. RESULTS: Two SNPs were associated with an increased risk of melanoma in a dominant model: rs1129038AA and rs1426654AA [OR = 2.094 (95% CI: 1.106-3.966), P = 2.3 10- 2 and OR = 7.126 (95% CI: 1.873-27.110), P = 4.0 10- 3, respectively]. SNP rs16891982CC was associated with a lower risk to melanoma development in a log-additive model when the allele C was inherited [OR = 0.081 (95% CI: 0.008-0.782), P = 3 10- 2]. In addition, MDR analysis showed that the combination of the rs1426654AA and rs16891982GG genotypes was associated with a higher risk for melanoma (P = 3 10- 3), with a redundant effect. CONCLUSIONS: These results contribute to the current knowledge and indicate that epistatic interaction of these SNPs, with an additive or correlational effect, may be involved in modulating the risk of melanoma in individuals from a geographic region with a high incidence of the disease.

Tropomyosin-Related Kinase Receptor and Neurotrophin Expression in Cutaneous Melanoma Is Associated with a Poor Prognosis and Decreased Survival.

OBJECTIVE: Normally, activation of tropomyosin-related kinase (TRK) receptors by neurotrophins (NTs) stimulates intracellular pathways involved in cell survival and proliferation. Dysregulation of NT/TRK signaling may affect neoplasm prognosis. Data on NT and TRK expression in melanomas are limited, and it is unclear whether NT/TRK signaling pathways are involved in the origin and progression of this neoplasm. METHODS: We examined whether NT/TRK expression differs across different cutaneous melanoma grades and subtypes, and whether it is associated with melanoma prognosis and survival. A cross-sectional study was performed in which the expression of TrkA, TrkB, nerve growth factor (NGF), and brain-derived neurotrophic factor (BDNF) was analyzed by immunohistochemistry of 154 melanoma samples. We investigated NT/TRK expression associations with prognostic factors for melanoma, relapse-free survival (RFS), and overall survival (OS). RESULTS: Of the 154 melanoma samples, 77 (55.4%) were TrkA immunopositive, 81 (58.3%) were TrkB immunopositive, 113 (81.3%) were BDNF immunopositive, and 104 (75.4%) were NGF immunopositive. We found NT/TRK expression associated strongly with several clinical prognostic factors, including the tumor-node-metastasis stage (p < 0.001), histological subtype (p < 0.001), and Clark level (p < 0.05), as well as with a worse OS (p < 0.05 for all, except TrkB) and RFS (p < 0.05 for all). CONCLUSIONS: Our results show strong associations of NT/TRK expression with melanoma stage progression and a poor prognosis.

Man against machine: diagnostic performance of a deep learning convolutional neural network for dermoscopic melanoma recognition in comparison to 58 dermatologists.

Background: Deep learning convolutional neural networks (CNN) may facilitate melanoma detection, but data comparing a CNN's diagnostic performance to larger groups of dermatologists are lacking. Methods: Google's Inception v4 CNN architecture was trained and validated using dermoscopic images and corresponding diagnoses. In a comparative cross-sectional reader study a 100-image test-set was used (level-I: dermoscopy only; level-II: dermoscopy plus clinical information and images). Main outcome measures were sensitivity, specificity and area under the curve (AUC) of receiver operating characteristics (ROC) for diagnostic classification (dichotomous) of lesions by the CNN versus an international group of 58 dermatologists during level-I or -II of the reader study. Secondary end points included the dermatologists' diagnostic performance in their management decisions and differences in the diagnostic performance of dermatologists during level-I and -II of the reader study. Additionally, the CNN's performance was compared with the top-five algorithms of the 2016 International Symposium on Biomedical Imaging (ISBI) challenge. Results: In level-I dermatologists achieved a mean (±standard deviation) sensitivity and specificity for lesion classification of 86.6% (±9.3%) and 71.3% (±11.2%), respectively. More clinical information (level-II) improved the sensitivity to 88.9% (±9.6%, P = 0.19) and specificity to 75.7% (±11.7%, P < 0.05). The CNN ROC curve revealed a higher specificity of 82.5% when compared with dermatologists in level-I (71.3%, P < 0.01) and level-II (75.7%, P < 0.01) at their sensitivities of 86.6% and 88.9%, respectively. The CNN ROC AUC was greater than the mean ROC area of dermatologists (0.86 versus 0.79, P < 0.01). The CNN scored results close to the top three algorithms of the ISBI 2016 challenge. Conclusions: For the first time we compared a CNN's diagnostic performance with a large international group of 58 dermatologists, including 30 experts. Most dermatologists were outperformed by the CNN. Irrespective of any physicians' experience, they may benefit from assistance by a CNN's image classification. Clinical trial number: This study was registered at the German Clinical Trial Register (DRKS-Study-ID: DRKS00013570; https://www.drks.de/drks_web/).

Dermatoscopic Patterns of Nonfacial Actinic Keratosis: Characterization of Pigmented and Nonpigmented Lesions.

BACKGROUND: Actinic keratoses (AKs) are dysplastic proliferations of keratinocytes. Studies evaluating nonfacial dermatoscopic pattern of AKs are scarce. OBJECTIVE: This study aimed to evaluate the dermatoscopic patterns of AKs located in nonfacial sites and to compare their patterns with facial lesions. MATERIALS AND METHODS: Patients with concomitant facial and nonfacial AKs were recruited to participate and evaluated by clinical and dermatoscopic images of their AKs. RESULTS: Sixty-eight patients were included in the study. A total of 258 nonfacial AKs and 68 facial AKs were analyzed. The most frequent nonfacial AK dermatoscopic structures were white opaque scales (97.3%) and erythema (57.4%). When analyzed in combination, white scales plus erythema were found in 55.4% of nonfacial AKs. Pigmented structures were observed in 22.5% nonfacial AKs. Homogeneous brown pigmentation was the most prevalent pigmented structure in nonfacial pigmented AK (pAK) (93.1%). There was a positive association between patients having concomitant pigmented facial and nonfacial AKs (p < .001). CONCLUSION: The combinations of erythema and white opaque scales or yellow opaque scales and homogeneous pigmentation are suggestive, respectively of nonpigmented and pigmented nonfacial AKs. Pigmented AKs occur concomitantly in facial and nonfacial areas.

Characterization of individuals at high risk of developing melanoma in Latin America: bases for genetic counseling in melanoma.

PURPOSE: CDKN2A is the main high-risk melanoma-susceptibility gene, but it has been poorly assessed in Latin America. We sought to analyze CDKN2A and MC1R in patients from Latin America with familial and sporadic multiple primary melanoma (SMP) and compare the data with those for patients from Spain to establish bases for melanoma genetic counseling in Latin America. METHODS: CDKN2A and MC1R were sequenced in 186 Latin American patients from Argentina, Brazil, Chile, Mexico, and Uruguay, and in 904 Spanish patients. Clinical and phenotypic data were obtained. RESULTS: Overall, 24 and 14% of melanoma-prone families in Latin America and Spain, respectively, had mutations in CDKN2A. Latin American families had CDKN2A mutations more frequently (P = 0.014) than Spanish ones. Of patients with SMP, 10% of those from Latin America and 8.5% of those from Spain had mutations in CDKN2A (P = 0.623). The most recurrent CDKN2A mutations were c.-34G>T and p.G101W. Latin American patients had fairer hair (P = 0.016) and skin (P < 0.001) and a higher prevalence of MC1R variants (P = 0.003) compared with Spanish patients. CONCLUSION: The inclusion criteria for genetic counseling of melanoma in Latin America may be the same criteria used in Spain, as suggested in areas with low to medium incidence, SMP with at least two melanomas, or families with at least two cases among first- or second-degree relatives.Genet Med 18 7, 727-736.

Dermoscopic Features of Pigmented Bowen Disease: A Multicenter Study on Behalf of the Ibero-Latin American College of Dermatology (CILAD).

INTRODUCTION: Studies focused on dermoscopic aspects of pigmented Bowen disease (pBD) in Latin American population are scarce and limited to only case reports or small series. OBJECTIVES: To report dermoscopic findings in a large series of 147 pBD diagnosed in Ibero-Latin American population. METHODS: We conducted a multicentric, retrospective study on 147 histologically proven pBD under the auspices of the Dermoscopy Chapter of the Ibero-Latin American College of Dermatology. RESULTS: The study population consisted of 77 females (52%) and 70 males (48%) with a mean age of 68.6 years. 70.1% of patients had skin phototype 3, 15.6% to skin phototype 2, and 14.3% to skin phototype 4. On clinical examination, near 60% of pBD were flat, 70% presented with scales, and 90% were asymmetric. Under dermoscopy, structureless hypopigmented areas, dots brown and pink color were the most frequently observed. Regarding specific dermoscopic clues to pBD, the most prevalent were structureless hypopigmented areas, vessels arranged in linear fashion at the periphery, and pigmented lines or pigmented dots distributed in a linear fashion. Clustered, coiled, and dotted vessels were observed in 55.8%, 45.6%, and 45.6% of the cases, respectively. CONCLUSIONS: We report a large series of cases of pBD in Latin American patients, with most patients being skin phototype 3 and 4. Distinctively in our study, the pigmented structures and the clues derived from the presence of melanin were much more frequent than in previous reports in fair skin.

Skin cancer characteristics during the first year of the COVID-19 pandemic at a tertiary hospital in Latin America.

BACKGROUND: The influence of the novel human coronavirus disease (COVID-19) pandemic on skin cancer characteristics in Latin America is still poorly elucidated. METHODS: This was a cross-sectional study which included patients diagnosed with skin cancer (basal cell carcinoma [BCC], cutaneous squamous cell carcinoma [cSCC], and primary cutaneous melanoma [cMM]) during the first year of the COVID-19 pandemic (from March 1, 2020, to February 28, 2021) and the preceding year at our institution. The total number of skin cancer diagnoses and surgeries, as well as their topography, clinicopathological staging at diagnosis, and treatment delay were compared between the two periods. RESULTS: There was a 31.8% reduction in skin cancer diagnoses during the first year of the COVID-19 pandemic at our institution. There was an increase in the proportion of low-risk cancers according to the NCCN guidelines for BCCs (40.8-49%, P < 0.001) and cSCCs (41.7-49.6%, P = 0.03), but there was no difference in the distribution of other staging systems for the three types of cancer. We also found a significant reduction in surgeries for BCCs (-57.6%, P < 0.001) and cSCCs (-44.7%, P < 0.001) but not for cMM. CONCLUSIONS: The first year of the COVID-19 pandemic was associated with reduced numbers of skin cancer diagnoses and surgeries at our institution. This study provides an assessment of skin cancer characteristics during the first year of the pandemic in the Latin American population.

Dermoscopy in Selected Latin American Countries: A Preliminary Look into Current Trends and Future Opportunities Among Dermatology Residency Programs.

INTRODUCTION: Skin cancer remains a global public health burden. Dermoscopy is a useful technique that aids in early detection and increases diagnostic accuracy with adequate training. However, dermoscopy is not uniformly taught to residents worldwide. Dermoscopy training in Latin American dermatology residency programs has not been explored. OBJECTIVES: To assess current dermoscopy training among dermatology residency programs in Latin America (eg training modalities, preferred/most effective modalities per residents, diseases/pathologies taught). METHODS: Cross-sectional survey distributed via e-mail between March and May 2021. Chief residents from Argentina, Brazil, Colombia, Costa Rica, Chile, Ecuador, Guatemala, Mexico, Panama, and Uruguay were invited to participate. RESULTS: 81 chief residents completed the questionnaire (81/126, 64.2%). Seventy-two percent of programs had an established dermoscopy curriculum, with dedicated hours of training varying greatly by program. Institutions commonly utilized sessions with "unknown" dermoscopy images and direct teaching by experts in the clinical setting as supplements to lectures, also described by residents as most effective. The most commonly taught methods included pattern analysis (74.1%), the two-step algorithm (61.7%), and the ABCD rule (59.3%). Almost all respondents reported desiring additional training during residency and believe that dermoscopy training should be a requirement to graduate from residency. CONCLUSIONS: This study highlights a preliminary look into current landscape in dermoscopy training among selected Latin American dermatology residency programs, demonstrating room for improvement and standardization in dermoscopic education and training. Our results serve as a baseline reference and provide valuable information to guide future educational initiatives incorporating successful teaching strategies (eg. spaced education/repetition, flipped classroom model) used in dermatology and other fields.

Total body skin examination for skin cancer screening in patients with focused symptoms.

BACKGROUND: The value of total body skin examination (TBSE) for skin cancer screening is controversial. OBJECTIVE: We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE. METHODS: In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE. RESULTS: We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas. LIMITATIONS: The impact of TBSE on skin cancer mortality was not evaluated. CONCLUSIONS: TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.

Accuracy in melanoma detection: a 10-year multicenter survey.

BACKGROUND: Early excision is the only strategy to reduce melanoma mortality, but unnecessary excision of benign lesions increases morbidity and healthcare costs. OBJECTIVE: To assess accuracy in melanoma detection based on number-needed-to-excise (NNE) values over a 10-year period. METHODS: Information was retrieved on all histopathologically confirmed cutaneous melanomas or melanocytic nevi that were excised between 1998 and 2007 at participating clinics. NNE values were calculated by dividing the total number of excised lesions by the number of melanomas. Analyses included changes in NNE over time, differences in NNE between specialized clinical settings (SCS) versus non-specialized clinical settings (NSCS), and patient factors influencing NNE. RESULTS: The participating clinics contributed a total of 300,215 cases, including 17,172 melanomas and 283,043 melanocytic nevi. The overall NNE values achieved in SCS and NSCS in the 10-year period were 8.7 and 29.4, respectively. The NNE improved over time in SCS (from 12.8 to 6.8), but appeared unchanged in NSCS. Most of the effect on NNE in SCS was due to a greater number of excised melanomas. Higher NNE values were observed in patients younger than 40 years and for lesions located on the trunk. LIMITATIONS: No data concerning the use of dermatoscopy and digital monitoring procedures were collected from the participating centers. CONCLUSION: Over the 10-year study period, accuracy in melanoma detection improved only in specialized clinics maybe because of a larger use of new diagnostic techniques such as dermatoscopy.

Indications for Digital Monitoring of Patients With Multiple Nevi: Recommendations from the International Dermoscopy Society.

Introduction: In patients with multiple nevi, sequential imaging using total body skin photography (TBSP) coupled with digital dermoscopy (DD) documentation reduces unnecessary excisions and improves the early detection of melanoma. Correct patient selection is essential for optimizing the efficacy of this diagnostic approach. Objectives: The purpose of the study was to identify, via expert consensus, the best indications for TBSP and DD follow-up. Methods: This study was performed on behalf of the International Dermoscopy Society (IDS). We attained consensus by using an e-Delphi methodology. The panel of participants included international experts in dermoscopy. In each Delphi round, experts were asked to select from a list of indications for TBSP and DD. Results: Expert consensus was attained after 3 rounds of Delphi. Participants considered a total nevus count of 60 or more nevi or the presence of a CDKN2A mutation sufficient to refer the patient for digital monitoring. Patients with more than 40 nevi were only considered an indication in case of personal history of melanoma or red hair and/or a MC1R mutation or history of organ transplantation. Conclusions: Our recommendations support clinicians in choosing appropriate follow-up regimens for patients with multiple nevi and in applying the time-consuming procedure of sequential imaging more efficiently. Further studies and real-life data are needed to confirm the usefulness of this list of indications in clinical practice.