Patient-led teledermatology for skin lesion triage: a service evaluation of the DyplensTM dermoscope.

Despite the huge improvement in smartphone cameras, there has not been any real interest in the UK in pursuing patient-facing teledermatology within the sphere of skin lesion triage. High-specification dermoscopic images can be generated with smartphone attachments, but, to date, no formal clinical trial has been performed to establish the efficacy and feasibility of these consumer-level dermoscopes in skin lesion triage. The objectives of this study were to assess the ability of patients to capture dermoscopic images using a smartphone attachment, and to identify the safety and diagnostic accuracy of consumer-level dermoscopy in triaging out benign skin lesions from the 2-week-wait (2WW) cancer pathway. We recruited 78 patients already attending a face-to-face clinic at two locations. They were provided with instruction leaflets and asked to obtain dermoscopic and macroscopic images of their lesion(s) using their own smartphones. The images (and a brief history) were distributed to five experienced blinded assessors (consultants), who were asked to state their working diagnosis and outcome (reassurance, routine review or 2WW pathway), as they would in teledermatology. We compared their outcomes to the gold-standard in-person diagnosis and/or histological diagnosis, where available. The device achieved 100% sensitivity in diagnosing melanoma and squamous cell carcinoma (SCC). The specificity for the diagnoses of melanoma (89%) and SCC (83%) was high. The overall diagnostic accuracy was 77% for both benign and malignant lesions, The diagnostic accuracy was high for seborrhoeic keratosis (91%) and simple naevi (81%). Patient-captured dermoscopic images using bespoke smartphone attachments could be the future in safely triaging out benign lesions.

Artificial intelligence in dermatopathology: Diagnosis, education, and research.

Artificial intelligence (AI) utilizes computer algorithms to carry out tasks with human-like intelligence. Convolutional neural networks, a type of deep learning AI, can classify basal cell carcinoma, seborrheic keratosis, and conventional nevi, highlighting the potential for deep learning algorithms to improve diagnostic workflow in dermatopathology of highly routine diagnoses. Additionally, convolutional neural networks can support the diagnosis of melanoma and may help predict disease outcomes. Capabilities of machine learning in dermatopathology can extend beyond clinical diagnosis to education and research. Intelligent tutoring systems can teach visual diagnoses in inflammatory dermatoses, with measurable cognitive effects on learners. Natural language interfaces can instruct dermatopathology trainees to produce diagnostic reports that capture relevant detail for diagnosis in compliance with guidelines. Furthermore, deep learning can power computation- and population-based research. However, there are many limitations of deep learning that need to be addressed before broad incorporation into clinical practice. The current potential of AI in dermatopathology is to supplement diagnosis, and dermatopathologist guidance is essential for the development of useful deep learning algorithms. Herein, the recent progress of AI in dermatopathology is reviewed with emphasis on how deep learning can influence diagnosis, education, and research.

Patient education in Mohs surgery: a review and critical evaluation of techniques.

BACKGROUND: Traditional in-person discussion alone is often used for preoperative education in Mohs micrographic surgery (MMS). The appropriate use of more modern education techniques is not well defined in the MMS literature. OBJECTIVE: The authors aim to evaluate patient education techniques for MMS, address education in special populations, and highlight opportunities for improvement. METHODS AND MATERIALS: We performed a PubMed literature search with keywords "Mohs" and "education", "teaching", "understanding", "explanation", "preoperative", or "consent" with no restriction on publication time frame due to literature scarcity. RESULTS: Teledermatology consultation, MMS videos, 3D models, pamphlets/online materials, and shared medical appointments appear to be effective techniques (GRADE B). Analogies are also anecdotally helpful when integrated into traditional verbal education (GRADE C). The role of preoperative educational phone calls is more controversial (GRADE C). CONCLUSION: Regardless of the education technique utilized, no singular technique entirely replaces the traditional in-person discussion. Having access to multiple modalities can be beneficial for patients, allowing them options to choose their preferred method(s) of education. MMS is a difficult topic to conceptualize, and further research into educational techniques is needed to provide clear guidelines for Mohs surgeons.

Ablative fractional laser treatment of hypertrophic burn and traumatic scars: a systematic review of the literature.

Hypertrophic scars (HTS) following burns and other trauma and are associated with significant functional and psychosocial impairment. Ablative fractional lasers (AFLs) are increasingly being applied in the treatment of HTS supported by a rapidly expanding multidisciplinary base of literature. The multidisciplinary authors sought to evaluate existing literature, provide context and identify gaps, and make recommendations for a path forward. A systematic review was conducted to identify literature pertinent literature through September 2019. Retrospective cohort, randomized controlled trials, quasi-randomized controlled trials, observational prospective cohort, or case series with five or more subjects with hypertrophic scars incurred from burns and related trauma were considered. Twenty-two of the 23 evaluated studies documented statistically significant and/or meaningful qualitative improvements in nearly all outcome measures. Adverse events were generally infrequent and minor. Significant heterogeneity was observed among the studies included in this systematic review, precluding metaanalysis of pooled data. There is abundant existing literature on the use of AFLs in the management of HTS but study heterogeneity limits generalizability. Future studies should prioritize standardized protocols including assessments of function and quality of life.

Optical coherence tomography for fast bedside imaging, assessment and monitoring of autoimmune inflammatory skin diseases?

Optical coherence tomography (OCT) is a non-invasive, high-resolution imaging technique with a growing impact in dermatology. The principle of OCT is comparable to that of sonography, except that it uses infrared laser light instead of ultrasound waves. It has been clinically demonstrated that OCT is suitable for discriminating between different types of non-melanoma skin cancer at an early stage of disease. Optical coherence tomography generates two- or three-dimensional images of up to 2 mm penetration depth, a field of view of 6 mm × 6 mm, and an acquisition time of seconds. The resolution capability of OCT is more than 3 to 100 times higher than that of ultrasound imaging. It is of particular interest that the additional information on vasculature provided by OCT angiography enables the assessment and monitoring of inflammatory skin diseases. The use of OCT to locate exact blister levels was demonstrated for diagnosing autoimmune bullous diseases. It is anticipated that detection of subclinical lesions could indicate a relapse of the disease. In the future, this could enable intervention and early treatment. Furthermore, the development of high-speed OCT could allow fast scanning and bedside imaging of large body sites.

A Review of the Use of Telemedicine in Dermatologic Surgery.

BACKGROUND: Telemedicine is an emerging field with numerous applications within medicine. Previous review articles describe its use within plastic surgery and otolaryngology but none, to the authors' knowledge, within dermatologic surgery. OBJECTIVE: To provide a review of the applications of telemedicine within dermatologic surgery. MATERIALS AND METHODS: A PubMed search of articles published on teledermatology was conducted in July 2018. Articles were selected based on their relevance to dermatologic surgery and reviewed for their discussion of the applications of telemedicine in surgical and cosmetic dermatology. RESULTS: The initial search resulted in 156 articles. Eleven ultimately met inclusion criteria: 2 in referral and consultation, 5 in telepathology, 2 in intraoperative uses, and 2 in postprocedural care. CONCLUSION: For preoperative consultation, teledermatology enables the surgeon to plan ahead and increases access to care by reducing the number of clinic visits. Telepathology has the potential to allow intraoperative consultation with a dermatopathologist to achieve accurate tumor clearance without delay. Smartglasses represent a promising technology for greater care coordination and a teaching tool. Postprocedural monitoring via text messaging provides convenient access to expert advice and early detection of postoperative complications. With increasing technologic advancements, telemedicine holds great potential to augment the dermatologic surgeon's daily practice.

Radial shockwave therapy for male erectile rejuvenation in a dermatology and/or medical aesthetic practice.

INTRODUCTION: Erectile dysfunction is defined as the inability to achieve and maintain an erection to satisfactorily complete intercourse. Treatment depends on the cause and includes phosphodiesterase 5 inhibitor medications, penile pumps, implants, and surgery. Low-intensity shockwave therapy has been shown to be effective and safe for the treatment of erectile dysfunction. OBJECTIVE: We explored the role of low-intensity radial shockwave therapy for erectile dysfunction treatment in a dermatology and/or medical aesthetic practice setting. MATERIALS AND METHODS: A literature review was conducted on radial low-intensity shockwave technology in use for erectile rejuvenation to explore its positioning, safety, efficacy, tolerability, subject satisfaction, and usability in a dermatology and/or medical aesthetic setting. RESULTS: Low-intensity shockwave therapy was shown to be effective in subjects with organic erectile dysfunction, and the treatment effect was maintained for up to 2 years post-treatment. The treatment is reported to be safe and well-tolerated and have little downtime. Many dermatologists use low-intensity shockwave therapy for the treatment of cellulite and other conditions. This type of treatment is now available for erectile dysfunction and seems an attractive and safe option for subjects with organic vascular erectile dysfunction. CONCLUSIONS: Studies and clinical experience suggest that male erectile rejuvenation using low-intensity radial shockwave therapy seems an attractive option. The treatment can be safely, and effectively, delivered by trained staff as part of the total package that is available to men in a dermatology and/or medical aesthetic practice.

Expanding the applications of microneedles in dermatology.

Since the first patent for microneedles was filed in the 1970s, research on utilising microneedles as a drug delivery system has progressed significantly. In addition to the extensive research on microneedles for improving transdermal drug delivery, there is a growing interest in using these devices to manage dermatological conditions. This review aims to provide the background on microneedles, the clinical benefits, and challenges of the device along with the potential dermatological conditions that may benefit from the application of such a drug delivery system. The first part of the review provides an outline on benefits and challenges of translating microneedle-based drug delivery systems into clinical practice. The second part of the review covers the application of microneedles in treating dermatological conditions. The efficacy of microneedles along with the limitations of such a strategy to treat diseased skin shall be addressed.

Anestesia en dermatología / Anesthesia in dermatology

En la práctica dermatológica, se realizan diversos procedimientos quirúrgicos y estéticos que pueden causar dolor a los pacientes. Actualmente en el mercado se dispone, de un amplio arsenal de drogas que permiten lograr una anestesia segura y eficaz. Existen diferentes modalidades y técnicas de anestesia, según el tipo de intervención y el segmento corporal en el cual se va a realizar el procedimiento. Los efectos adversos de los diferentes anestésicos están bien definidos y se deben tomar ciertas precauciones en poblaciones especiales donde el riesgo de complicaciones es mayor. Es de fundamental importancia que el clínico posea un acabado conocimiento de los diversos fármacos utilizados en anestesia, para poder minimizar las complicaciones derivadas de su administración.

In dermatological practice, various surgical and cos-metic procedures are performed that can cause pain to patients. A large stock of drugs is now available on the market to provide safe and effective anesthesia. There are different modalities and techniques of anesthesia, depending on the type of intervention and the body segment in which the procedure will be performed. The adverse effects of different anesthe-tics are well defined and certain precautions should be taken in special populations where the risk of complications is greater. It is fundamental that the clinician has a thorough knowledge of the various drugs that can be used in anesthesia, in order to minimize complications arising from its administration

Noninvasive Imaging Tools in the Diagnosis and Treatment of Skin Cancers.

In the 1980s, the increasing incidence of skin cancers prompted the development of noninvasive medical devices to improve skin cancer diagnosis in daily dermatology practice. As a result of the development of these noninvasive techniques, diagnosis is now established earlier and with better accuracy. These advances are of great benefit to high-risk patients, who previously would have had to undergo several excisions. In this review, we focus on the classic technique of dermoscopy and the more recent digital version, as well as on advanced noninvasive imaging techniques, such as reflectance confocal microscopy and optical coherence tomography. On the basis of their specific features, these noninvasive medical devices can be used not only to diagnose and monitor melanoma and nonmelanoma skin cancers but also to choose the best therapy and follow the patient's response to treatment in vivo.

Wood's lamp for vitiligo disease stability and early recognition of initiative pigmentation after epidermal grafting.

The prerequisite for a successful vitiligo epidermal grafting surgery is the stable status of the disease. We used Wood's lamp to assess vitiligo activity to determine the disease stability, surgical grafting timing and the early recognition of re-pigmentation after grafting. Amelanotic lesions with sharply demarcated borders are typically stable and are good candidates for grafting. The re-pigmentation was first recognised under Wood's lamp as hypochromic islands, which progressed to normally pigmented islands. For patients more prone to relapse, follow up with Wood's lamp also provides more accurate surveillance.

Smartphone snapshot mapping of skin chromophores under triple-wavelength laser illumination.

Chromophore distribution maps are useful tools for skin malformation severity assessment and for monitoring of skin recovery after burns, surgeries, and other interactions. The chromophore maps can be obtained by processing several spectral images of skin, e.g., captured by hyperspectral or multispectral cameras during seconds or even minutes. To avoid motion artifacts and simplify the procedure, a single-snapshot technique for mapping melanin, oxyhemoglobin, and deoxyhemoglobin of in-vivo skin by a smartphone under simultaneous three-wavelength (448­532­659 nm) laser illumination is proposed and examined. Three monochromatic spectral images related to the illumination wavelengths were extracted from the smartphone camera RGB image data set with respect to crosstalk between the RGB detection bands. Spectral images were further processed accordingly to Beer's law in a three chromophore approximation. Photon absorption path lengths in skin at the exploited wavelengths were estimated by means of Monte Carlo simulations. The technique was validated clinically on three kinds of skin lesions: nevi, hemangiomas, and seborrheic keratosis. Design of the developed add-on laser illumination system, image-processing details, and the results of clinical measurements are presented and discussed.

Implementation of fluorescence confocal mosaicking microscopy by "early adopter" Mohs surgeons and dermatologists: recent progress.

Confocal mosaicking microscopy (CMM) enables rapid imaging of large areas of fresh tissue ex vivo without the processing that is necessary for conventional histology. When performed in fluorescence mode using acridine orange (nuclear specific dye), it enhances nuclei-to-dermis contrast that enables detection of all types of basal cell carcinomas (BCCs), including micronodular and thin strands of infiltrative types. So far, this technique has been mostly validated in research settings for the detection of residual BCC tumor margins with high sensitivity of 89% to 96% and specificity of 99% to 89%. Recently, CMM has advanced to implementation and testing in clinical settings by "early adopter" Mohs surgeons, as an adjunct to frozen section during Mohs surgery. We summarize the development of CMM guided imaging of ex vivo skin tissues from bench to bedside. We also present its current state of application in routine clinical workflow not only for the assessment of residual BCC margins in the Mohs surgical setting but also for some melanocytic lesions and other skin conditions in clinical dermatology settings. Last, we also discuss the potential limitations of this technology as well as future developments. As this technology advances further, it may serve as an adjunct to standard histology and enable rapid surgical pathology of skin cancers at the bedside.

Perception and Acceptability of Medical Photography in Chinese Dermatologic Patients: A Questionnaire Survey.

BACKGROUND: Medical photography is increasingly used by physicians, but studies assessing the perception and acceptability of medical photography by Chinese dermatologic patients are scarce. OBJECTIVE: To assess the perception and acceptability of medical photography in Chinese dermatologic patients. MATERIALS AND METHODS: From July to December 2014, adult patients visiting the Dermatology Clinic of The First Affiliated Hospital of Third Military Medical University were included in this study. They were required to fill an anonymous questionnaire regarding perception and acceptability of medical photography. RESULTS: A total of 509 consecutive patients completed the questionnaire, with 35 and 474 declining and undergoing medical photography, respectively. Meanwhile, 81.0% of the patients preferred to be photographed by attending physicians; 63.3% favored clinic-owned cameras, and 81.0% would rather have their photographs stored in the department's database. Besides, most patients allowed their photographs to be used in case studies (92.8%) or medical record keeping (90.3%). CONCLUSION: Most Chinese dermatologic patients accept medical photography. However, the principles of privacy protection and informed consent should be strictly enforced in clinical practice, and appropriate photographic devices and storage methods should be used, for better acceptance.

[LED lights in dermatology]. / LED en dermatologie.

The use in dermatology of light-emitting diodes (LEDs) continues to be surrounded by controversy. This is due mainly to poor knowledge of the physicochemical phases of a wide range of devices that are difficult to compare to one another, and also to divergences between irrefutable published evidence either at the level of in vitro studies or at the cellular level, and discordant clinical results in a variety of different indications: rejuvenation, acne, wound healing, leg ulcers, and cutaneous inflammatory or autoimmune processes. Therapeutic LEDs can emit wavelengths ranging from the ultraviolet, through visible light, to the near infrared (247-1300 nm), but only certain bands have so far demonstrated any real value. We feel certain that if this article remains factual, then readers will have a different, or at least more nuanced, opinion concerning the use of such LED devices in dermatology.

High frequency ultrasound with color Doppler in dermatology.

Ultrasonography is a method of imaging that classically is used in dermatology to study changes in the hypoderma, as nodules and infectious and inflammatory processes. The introduction of high frequency and resolution equipments enabled the observation of superficial structures, allowing differentiation between skin layers and providing details for the analysis of the skin and its appendages. This paper aims to review the basic principles of high frequency ultrasound and its applications in different areas of dermatology.