Evaluation of a pediatric dermatology electronic consult program in a rural state with subanalysis of infantile hemangioma cases.

An electronic consultation (e-Consult) store-and-forward teledermatology program was implemented to improve access to dermatologic care in Maine. While initially designed to triage potential skin cancers, we found this program to be heavily used for pediatric patients, especially infants. Our findings suggest e-Consult expedites care for pediatric dermatology patients, particularly those with infantile hemangiomas. The addition of dermoscopy to e-Consult platforms has the potential to expand e-Consult effectiveness.

Impact of Dermoscopy Training for Primary Care Practitioners on Number Needed to Biopsy to Detect Melanoma.

Introduction: The incidence of melanoma is on the rise. In trained hands, dermoscopy aids in the differentiation of melanoma from benign skin growths, including melanocytic nevi. This study evaluated the impact of dermoscopy training for primary care practitioners (PCPs) on the number of nevi needed to biopsy (NNB) to detect a melanoma. Methods: We conducted an educational intervention that included a foundational dermoscopy training workshop and subsequent monthly telementoring video conferences. We performed a retrospective observational study to evaluate the impact of this intervention on the number of nevi needed to biopsy to detect a melanoma. Results: The number of nevi biopsied to detect one melanoma decreased from 34.3 to 11.3 following the training intervention. Conclusion: Dermoscopy training for primary care practitioners resulted in a significant reduction in the NNB to detect melanoma.

Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care.

BACKGROUND: Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy. METHODS: A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither. RESULTS: Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features. CONCLUSIONS: This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection.

Dermoscopy for the Identification of Amelanotic Acral Melanoma.

Acral lentiginous melanoma is commonly misdiagnosed, and when detected late it portends a poor prognosis. Acral lentiginous melanoma can be mistaken for verruca, pyogenic granuloma, poroma, an ulcer, or other benign skin conditions. Patients with acral skin growths often present initially to a podiatric physician or their primary care physician. It is at this point when the growth is triaged as benign or potentially malignant. Dermoscopy aids in this decision making. Historically, dermoscopy training has been geared toward dermatologists, but there is increasing recognition of the need for dermoscopy training in primary care and podiatric medicine. Dermoscopy is particularly helpful in pink (amelanotic) growths, which can lack the traditional clinical findings of melanoma. A literature review of acral melanoma and dermoscopy was performed in PubMed. We also describe a case of amelanotic acral melanoma in a 58-year-old with a rapidly enlarging painful mass on her heel. The lesion was initially thought to be a pyogenic granuloma and was treated with debridement (curettage). She was ultimately seen in the dermatology clinic, and the findings under dermoscopy were worrisome for amelanotic melanoma. Biopsy confirmed the diagnosis. The cancer metastasized, and the patient died less than 2 years later.

Distance Learning and Spaced Review to Complement Dermoscopy Training for Primary Care.

BACKGROUND: Dermoscopy aids in skin cancer identification. For family physicians who use dermoscopy, there is higher sensitivity for melanoma detection than naked-eye examination. There is a shortage of dermoscopy training for primary care providers. The triage amalgamated dermoscopic algorithm (TADA) is designed for novice dermoscopists. While TADA can be taught in a short dermoscopy workshop, spaced review and blended learning strategies improve knowledge retention. OBJECTIVES: This study determined the impact that the addition of a distance learning platform has on clinical dermoscopy use. Moreover, it evaluated dermoscopic image identification (knowledge retention) following the addition of distance learning via Extension for Community Health Outcomes (ECHO) to a traditional TADA dermoscopy workshop. METHODS: Primary care providers voluntarily attended a 120-minute TADA dermoscopy workshop. Participants completed pre-intervention, post-TADA, and post-ECHO tests of 30 dermoscopic images of benign and malignant skin lesions. A survey was also administered to analyze clinical dermoscopy use and prior dermoscopy training. RESULTS: Twenty-seven residents, faculty, and advanced practice providers participated in this longitudinal observational cohort study. Mean test scores (out of 30) for images of benign and malignant lesions improved from 20.29 pre-intervention to 24.62 post-TADA and 27.63 post-ECHO (P < .001). On average, participants attended 4 ECHO sessions (out of 7 total) and there was a positive correlation (r = 0.77) between the number of ECHOs attended and post-ECHO scores. Dermoscope use increased from 37.0% to 96.3% (P < .001). CONCLUSION: Distance learning and spaced review complement dermoscopy workshop training for primary care.

Teaching Skin Cancer Detection to Medical Students Using a Dermoscopic Algorithm.

INTRODUCTION: Early detection of melanoma skin cancer improves survival rates. Training family physicians in dermoscopy with the triage amalgamated dermoscopic algorithm (TADA) has high sensitivity and specificity for identifying malignant skin neoplasms. In this study we evaluated the effectiveness of TADA training among medical students, compared with practicing clinicians. METHODS: We incorporated the TADA framework into 90-minute workshops that taught dermoscopy to family physicians, primary care residents, and first- and second-year medical students. The workshop reviewed the clinical and dermoscopic features of benign and malignant skin lesions and included a hands-on interactive session using a dermatoscope. All participants took a 30-image pretest and a different 30-image posttest. RESULTS: Forty-six attending physicians, 25 residents, and 48 medical students participated in the workshop. Mean pretest scores were 20.1, 20.3, and 15.8 for attending physicians, resident physicians and students, respectively (P<.001); mean posttest scores were 24.5, 25.9, and 24.1, respectively (P=.11). Pre/posttest score differences were significant ( P<.001) for all groups. The medical students showed the most gain in their pretest and posttest scores. CONCLUSION: After short dermoscopy workshop, medical students perform as well as trained physicians in identifying images of malignant skin lesions. Dermoscopy training may be a valuable addition to the medical school curriculum as this skill can be used by primary care physicians as well as multiple specialists including dermatologists, gynecologists, otolaryngologists, plastic surgeons, and ophthalmologists, who often encounter patients with concerning skin lesions.

Dermoscopic Lotus of Learning: Implementation and Dissemination of a Multimodal Dermoscopy Curriculum for Primary Care.

Dermoscopy is a cost-effective tool for detection of skin cancers yet there is limited training available for primary care. The goal of this project was to develop, implement, and disseminate a multimodal curriculum for primary care across a health system based on a previously validated algorithm (Triage Amalgamated Dermoscopic Algorithm; TADA). This cross-sectional study analyzes the dermoscopy workshop intervention of a dermoscopy multimodal curriculum. Volunteers attended one 120-minute dermoscopy workshop on benign and malignant growths using a validated algorithm. Participants took a 30-image pre- and posttest. Survey questions on dermoscopy use, preferences for learning, and skin biopsy performance were included to enhance curriculum development. About 96 participants completed both pre- and postintervention tests. The mean preintervention score (out of 30) was 18.6 and increased to 24.4 on the postintervention evaluation. There was a statistically significant improvement in scores for both benign and malignant skin growths after the intervention (P < .05). Short dermoscopy workshops have a positive intervention effect when training primary care providers to identify images of benign and malignant dermoscopic skin lesions. A multimodal dermoscopy curriculum allows learners to build on initial training using spaced review and blended learning strategies. The "Dermoscopic Lotus of Learning" has the potential to be a model for other primary care residency programs. A healthy partnership between dermatologists and primary care is essential.

Teaching Benign Skin Lesions as a Strategy to Improve the Triage Amalgamated Dermoscopic Algorithm (TADA).

INTRODUCTION: Dermoscopy aids family physicians (FPs) in skin cancer detection. The triage amalgamated dermoscopic algorithm (TADA) was created to simplify the dermoscopic evaluation of a skin growth. The purpose of this image-based study was to evaluate the effect of teaching the clinical and dermoscopic features of benign skin lesions on the diagnostic accuracy of skin cancer identification using TADA. We also sought to determine the best method to teach benign neoplasms. METHODS: In this cross-sectional study of an educational intervention, FPs participated in dermoscopy training. Participants were divided into 3 groups for teaching of common benign neoplasms (dermatofibroma, angioma, and seborrheic keratosis/lentigo): didactic + interactive, didactic + heuristic, and didactic. For each group, the benign teaching was followed by skin cancer identification training with TADA. All participants took a 30 image pre-test and 30 image post-test. RESULTS: Fifty-nine participants completed the study. The mean preintervention score (out of 30 correct responses) was 17.9 (SD, 4.5) and increased to 23.5 (SD, 3.0) on the postintervention evaluation (P < .001). Sensitivity for skin cancer increased from 62.5% to 88.1% following the intervention. Postintervention specificity for skin cancer was 87.8%. Sensitivity and specificity increased following the intervention for all 3 types of benign neoplasms. Diagnostic accuracy was not impacted by the method of benign teaching. CONCLUSION: Short dermoscopy training sessions with dedicated time for benign growths followed by TADA training for malignant growths are an effective means of teaching FPs dermoscopy and result in a high sensitivity and specificity for the identification of benign and malignant skin neoplasms.

Biopsies for skin cancer detection: Dispelling the myths.

This review debunks 5 myths and provides the information you need to perform rapid, high-quality biopsies to detect skin cancers at their earliest stages.

Ringed telangiectasias: an unusual presentation of telangiectasia macularis eruptiva perstans.

Telangiectasia macularis eruptiva perstans (TMEP) is a rare form of cutaneous mastocytosis. While most cutaneous mastocytoses occur in children and are asymptomatic, TMEP occurs predominantly in adults and is associated with systemic manifestations, requiring medical management. TMEP is typically characterised by scattered red-brown macules on the trunk and extremities, but must be differentiated from other telangiectatic conditions such as scleroderma, hereditary haemorrhagic telangiectasia and telangiectasias secondary to cirrhosis. Practitioners must be aware that variants to the classic presentation of TMEP exist, such as the ringed telangiectasias we describe. Diagnostic workup including tissue biopsy must be considered in such patients after a thorough history and physical have been performed and other telangiectatic processes have been ruled out. The treatment of cutaneous mastocytosis aims at controlling symptoms and preventing mast cell degranulation. Cosmetic treatment includes the use ofPsoralen and ultraviolet A (PUVA) therapy, total skin electron beam radiation and flashlamp pulsed-dye laser treatment.

Actinic Keratosis Clinical Practice Guidelines: An Appraisal of Quality.

Actinic keratosis (AK) is a common precancerous skin lesion and many AK management guidelines exist, but there has been limited investigation into the quality of these documents. The objective of this study was to assess the strengths and weaknesses of guidelines that address AK management. A systematic search for guidelines with recommendations for AK was performed. The Appraisal of Guidelines for Research and Evaluation (AGREE II) was used to appraise the quality of guidelines. Multiple raters independently reviewed each of the guidelines and applied the AGREE II tool and scores were calculated. Overall, 2,307 citations were identified and 7 fulfilled the study criteria. The Cancer Council of Australia/Australian Cancer Network guideline had the highest mean scores and was the only guideline to include a systematic review, include an evidence rating for recommendations, and report conflicts of interest and funding sources. High-quality, effective guidelines are evidence-based with recommendations that are concise and organized, so practical application is facilitated. Features such as concise tables, pictorial diagrams, and explicit links to evidence are helpful. However, the rigor and validity of some guidelines were weak. So, it is important for providers to be aware of the features that contribute to a high-quality, practical document.

Pruritis and palpable purpura from leeches in the Australian Rainforest.

Leeches are prevalent in the Australian Rainforest. We report two cases of leech bites resulting in pruritis and palpable purpura. The dermatologic sequelae of leech bites, differential diagnosis of pruritic palpable purpura, leech bite treatment, prevention, and complications are reviewed.