Vulval dermatoses: A review of referrals to dermatology.

We undertook a retrospective observational review of patients referred to a tertiary dermatology department with vulval complaints over 12 months. The most common provisional diagnoses made by the referrer and final dermatology diagnoses were lichen sclerosus (54% and 38%), dermatitis (12.7% and 16.5%) and psoriasis (5.1% and 6.3%). Referrers may benefit from further education about skin diseases of the vulva, topical steroids for vulval complaints and the importance of clinical photography.

Using Artificial Intelligence as a Melanoma Screening Tool in Self-Referred Patients.

INTRODUCTION: Early detection of melanoma requires timely access to medical care. In this study, we examined the feasibility of using artificial intelligence (AI) to flag possible melanomas in self-referred patients concerned that a skin lesion might be cancerous. METHODS: Patients were recruited for the study through advertisements in 2 hospitals in Halifax, Nova Scotia, Canada. Lesions of concern were initially examined by a trained medical student and if the study criteria were met, the lesions were then scanned using the FotoFinder System®. The images were analyzed using their proprietary computer software. Macroscopic and dermoscopic images were evaluated by 3 experienced dermatologists and a senior dermatology resident, all blinded to the AI results. Suspicious lesions identified by the AI or any of the 3 dermatologists were then excised. RESULTS: Seventeen confirmed malignancies were found, including 10 melanomas. Six melanomas were not flagged by the AI. These lesions showed ambiguous atypical melanocytic proliferations, and all were diagnostically challenging to the dermatologists and to the dermatopathologists. Eight malignancies were seen in patients with a family history of melanoma. The AI's ability to diagnose malignancy is not inferior to the dermatologists examining dermoscopic images. CONCLUSION: AI, used in this study, may serve as a practical skin cancer screening aid. While it does have technical and diagnostic limitations, its inclusion in a melanoma screening program, directed at those with a concern about a particular lesion would be valuable in providing timely access to the diagnosis of skin cancer.

Cutaneous adverse reactions following the Pfizer/BioNTech COVID-19 vaccine.

A growing number of cutaneous adverse reactions have been reported following the administration of a COVID-19 vaccine. We describe a series of twenty patients who developed a variety of cutaneous conditions within two weeks of receiving the Pfizer/ BioNTech BNT162b2 vaccine.

PASI vs PO-PASI: Patient-Oriented PASI (PO-PASI) is comparable to clinician score PASI.

This comparative observational study aimed to validate an online Patient-oriented Psoriasis Area and Severity Index (PO-PASI) by comparing it against the Psoriasis Area and Severity Index (PASI), of 97 adult participants with chronic plaque psoriasis. Pearson's correlation coefficient of 0.866 (P-value = 0.0001) showed a strong positive linear correlation, and interclass correlation coefficients [ICC scores = 0.864 [95% confidence intervals (CIs) (0.803 < ICC < 0.907)]] suggest an interrater reliability of 'good' to 'excellent' when comparing PO-PASI to the PASI score. Additionally, we compared PO-PASI and PASI with DLQI and demonstrated an overall stronger positive correlation between PO-PASI and DLQI when compared to PASI.

Virtual lesion clinic - Evaluation of a teledermatology triage system for referrals for suspected melanoma.

INTRODUCTION: The Virtual Lesion Clinic (VLC) of Waitemata District Health Board (WDHB) improves melanoma assessment and treatment using teledermatology. The VLC is reserved for pigmented lesions referred as suspected melanoma from primary care but indeterminate at the initial triage. OBJECTIVES: To assess the efficacy of the VLC diagnosis of melanoma. METHODS: A retrospective audit of suspected melanoma referrals (1 January 2012 to 31 December 2016) was conducted. Lesions were referred to the VLC if diagnostic uncertainty remained at the initial triage. VLC patients attended MoleMap imaging centres, a dermatologist reviewed history and images remotely and suggested a diagnosis and management plan. Post VLC provisional diagnosis of melanoma, all lesions subsequently excised were reviewed. A positive predictive value (PPV) was calculated using concordance between VLC diagnosis of melanoma and histopathological diagnosis of melanoma. Number needed to excise (NNE) for melanoma was derived, as well as an invasive to in-situ melanoma ratio (IM:MIS) and false negative rate (FNR). RESULTS: The VLC received 1874 referrals for 3546 lesions during the 5-year study period. Six hundred and seventy-nine lesions were recommended excision/biopsy or specialist face-to-face assessment, and 504 lesions were subsequently excised. The PPV was 62%, NNE 1.62 and IM:MIS 0.76 for lesions suspected to be melanoma at VLC assessment. The VLC had a melanoma-specific FNR of 7%. CONCLUSIONS: The VLC is effective in early diagnosis of melanoma with a high positive predictive value, low number needed to excise and low false negative rate amongst lesions referred as suspected melanoma.

The use of noninvasive imaging techniques in the diagnosis of melanoma: a prospective diagnostic accuracy study.

BACKGROUND: Early detection of melanoma is crucial to improving the detection of thin curable melanomas. Noninvasive, computer-assisted methods have been developed to use at the bedside to aid in diagnoses but have not been compared directly in a clinical setting. OBJECTIVE: We conducted a prospective diagnostic accuracy study comparing a dermatologist's clinical examination at the bedside, teledermatology, and noninvasive imaging techniques (FotoFinder, MelaFind, and Verisante Aura). METHODS: A total of 184 patients were recruited prospectively from an outpatient dermatology clinic, with lesions imaged, assessed, and excised. Skin specimens were assessed by 2 blinded pathologists, providing the gold standard comparison. RESULTS: Fifty-nine lesions from 56 patients had a histopathologic diagnosis of melanoma, whereas 150 lesions from 128 patients were diagnosed as benign. Sensitivities and specificities were, respectively, MelaFind (82.5%, 52.4%), Verisante Aura (21.4%, 86.2%), and FotoFinder Moleanalyzer Pro (88.1%, 78.8%). The sensitivity and specificity of the teledermoscopist (84.5% and 82.6%, respectively) and local dermatologist (96.6% and 32.2%, respectively) were also compared. LIMITATIONS: There are inherent limitations in using pathology as the gold standard to compare sensitivities and specificities. CONCLUSION: This study demonstrates that the highest sensitivity and specificity of the instruments were established with the FotoFinder Moleanalyzer Pro, which could be a valuable tool to assist with, but not replace, clinical decision making.

A baseline patch test series for New Zealand.

BACKGROUND: Patch testing is the gold standard diagnostic test for allergic contact dermatitis and needs to be relevant to the region and the population being tested. The aim of this study was to develop a specific New Zealand baseline series (NZBS). METHOD: We performed a retrospective case note review of patients attending four regional patch test centres between 2008 and 2020. Demographic and diagnostic information was collected for each patient along with results of patch testing. Using the results of this review, a group of 11 dermatologists with an interest in contact dermatitis agreed on a core group of allergens for inclusion in an NZBS, based on the frequency of positive reactions and allergens of interest. The remaining potential allergens were ranked by each dermatologist using an online questionnaire, with inclusion in the final NZBS by consensus. RESULTS: Results from 2402 patients (67% female, mean age 44 years) from Auckland, Wellington, Palmerston North and Christchurch were collated. The 10 most frequent positive (relevant and non-relevant) allergens were nickel sulfate (22.0%), fragrance mix I (8.6%), cobalt chloride (7.3%), Myroxylon pereirae (5.6%), colophonium (5.1%), p-phenylenediamine (4.9%), methylisothiazolinone/methylchloroisothiazolinone (4.1%), fragrance mix II (3.9%), potassium dichromate (3.5%) and methylisothiazolinone (3.4%). Based on these results, a core series of 30 allergens was developed, with an additional 30 allergens added to form the extended series (total 60 allergens). CONCLUSION: The baseline series of patch test allergens for routine use in New Zealand (NZBS) is based on national patch test data and expert consensus.

Vulval lichen sclerosus: An Australasian management consensus.

BACKGROUND/OBJECTIVES: Vulval lichen sclerosus (VLS) is a chronic inflammatory skin condition predominantly affecting the anogenital region in women and children. To date, there is lack of agreement amongst experts on a severity scale to aid assessment, research and treatment stratification on VLS. Furthermore, literature on best practice for long-term management of VLS is lacking. The aim of this consensus is to provide broad guidelines on the short and long-term management of VLS. METHODS: An initial focus group of Australasian experts in vulval dermatology developed a draft consensus statement for the management of VLS. Based on the results of the draft statement, a consensus panel of 22 Australasian experts, comprised of the initial and additional members, participated in an anonymous four-stage eDelphi process. Round 1 involved generation and voting on statements from the draft consensus statement developed by the focus group. In Rounds 2, 3 & 4, panel members were presented formal feedback from previous rounds and asked to indicate their level of agreement. Consensus was reached if there was ≥70% agreement on the importance of an item in the 4 (agree) to 5 (strongly agree) range. RESULTS: The expert panel, with a total of 504 collective years of experience in the field of VLS, reached consensus on a core set of 51 management statements related to diagnosis, severity, initial and long-term management, follow-up, and complications of VLS. CONCLUSIONS: This study has identified a set of management statements for VLS that may be useful in clinical practice in the Australasian population.

How strong is the relationship between scabies and acute rheumatic fever? An analysis of neighbourhood factors.

AIM: Recent studies have linked scabies with acute rheumatic fever (ARF). We explored the relationship, by neighbourhood, between permethrin dispensing as an indicator of scabies prevalence and ARF cases over the same period. METHODS: Incident cases of ARF notified to public health between September 2015 and June 2018 and the annual incidence of prescribing by neighbourhood over the same period were analysed. Evidence of an association between permethrin and ARF was obtained by carrying out Poisson regression of the rate of ARF in terms of permethrin rate at the census area unit level, with adjustment for ethnicity and socio-economic deprivation. RESULTS: A total of 413 neighbourhoods were included. The incidence of ARF varied between 0 and 102 per 100 000 people per year (mean 4.3). In contrast, the annual incidence of dispensing of permethrin varied between 0 and 3201 per 100 000 people per year (mean 771). A strong association was observed between the two variables. In an adjusted quasi-Poisson model, permethrin-dispensing rates were strongly associated with ARF incidence, with a change from the 16th to the 84th centile associated with a 16.5-fold increase in incidence (95% confidence interval: 3.82-71.6). CONCLUSIONS: Permethrin prescribing as an indicator of scabies is strongly associated with the incidence of ARF. Considered together with other studies, this evidence suggests that improving scabies control may reduce the burden of ARF in New Zealand.

Growth rate of clinically diagnosed superficial basal cell carcinoma and changes in dermoscopic features over time.

BACKGROUND/OBJECTIVES: Basal cell carcinoma (BCC) is the most commonly occurring skin cancer. BCCs have been found to generally grow slowly. Data are limited on how the dermoscopic characteristics of BCCs evolve. We set out to determine the growth rate of superficial BCCs (sBCC) and assess the change in dermoscopic features over time. METHODS: A retrospective review was performed of clinically diagnosed sBCC. Images, demographic and dermoscopic data were collected by a melanographer. Mixed effects linear regression models were used to investigate sBCC growth and associations between size and dermoscopic/demographic variables. We tested differences in trends over time in dermoscopic features using non-parametric trend tests. RESULTS: 100 individual sBCC were evaluated in 70 patients (mean age 62; 59% male), 69% had Fitzpatrick skin phototype 1 or 2, and 81% had some degree of actinic damage. sBCC were present on the back in 58% and 22% of men and women, respectively. The median surface area was 41.9 mm2 with a growth rate of 0.81 mm2 /month. Males had larger sBCC than females. There was no association between sBCC size and Fitzpatrick skin phototype, history of skin cancer or family history of melanoma. There is some evidence larger sBCC gain shiny white structures (P = 0.053) over time. CONCLUSIONS: sBCC grow at a rate unlikely to adversely affect patient outcomes associated with long wait times. Our data suggest that dermoscopy can aid in appropriate treatment selection for sBCC.

E-referrals and teledermatoscopy grading for melanoma: a successful model of care.

BACKGROUND/OBJECTIVES: An e-referral system was developed at a tertiary care hospital in Auckland, New Zealand in 2014 for suspected cutaneous malignancy. E-referrals include patient information, a description of the lesion(s), biopsy results and/or attached photograph(s). Experienced surgical oncologists prioritised the referrals and selected a management option or referred them for a teledermatoscopy opinion. Our aim was to review the efficacy of e-referrals for improving diagnostic accuracy for melanoma. METHODS: Referrals received in 2016 including images and categorisation as confirmed, likely or suspected melanoma by the triage specialist were evaluated. Concordance of the pathological diagnosis with the triage diagnosis and teledermatoscopy diagnosis was determined for each referral. RESULTS: 809 of 3470 e-referrals for skin cancer were categorised as confirmed, likely or suspected melanoma. 230 (28.4%) of these included a referral histopathology confirming melanoma/melanoma in situ. Of the remaining 579 referrals, 315 were sent for urgent diagnostic excision and 264 were referred for teledermatoscopy. 120 of the 315 sent for urgent excision were confirmed as melanoma (53) or melanoma in situ (67) on histopathology: a positive predictive value (PPV) of 38.1% and number needed to excise (NNE) of 2.6. Less than 10% of referrals triaged for teledermatoscopy were confirmed as melanoma (24/264). Almost half of all referrals (374/809, 45.6%) included melanoma/melanoma in situ. The melanoma: melanoma in situ ratio was 1: 1.18. CONCLUSIONS: The e-referral and teledermatoscopy service for suspected melanoma has proven fewer unnecessary excisions of benign lesions than previously reported.

Comparison of the accuracy of human readers versus machine-learning algorithms for pigmented skin lesion classification: an open, web-based, international, diagnostic study.

BACKGROUND: Whether machine-learning algorithms can diagnose all pigmented skin lesions as accurately as human experts is unclear. The aim of this study was to compare the diagnostic accuracy of state-of-the-art machine-learning algorithms with human readers for all clinically relevant types of benign and malignant pigmented skin lesions. METHODS: For this open, web-based, international, diagnostic study, human readers were asked to diagnose dermatoscopic images selected randomly in 30-image batches from a test set of 1511 images. The diagnoses from human readers were compared with those of 139 algorithms created by 77 machine-learning labs, who participated in the International Skin Imaging Collaboration 2018 challenge and received a training set of 10 015 images in advance. The ground truth of each lesion fell into one of seven predefined disease categories: intraepithelial carcinoma including actinic keratoses and Bowen's disease; basal cell carcinoma; benign keratinocytic lesions including solar lentigo, seborrheic keratosis and lichen planus-like keratosis; dermatofibroma; melanoma; melanocytic nevus; and vascular lesions. The two main outcomes were the differences in the number of correct specific diagnoses per batch between all human readers and the top three algorithms, and between human experts and the top three algorithms. FINDINGS: Between Aug 4, 2018, and Sept 30, 2018, 511 human readers from 63 countries had at least one attempt in the reader study. 283 (55·4%) of 511 human readers were board-certified dermatologists, 118 (23·1%) were dermatology residents, and 83 (16·2%) were general practitioners. When comparing all human readers with all machine-learning algorithms, the algorithms achieved a mean of 2·01 (95% CI 1·97 to 2·04; p<0·0001) more correct diagnoses (17·91 [SD 3·42] vs 19·92 [4·27]). 27 human experts with more than 10 years of experience achieved a mean of 18·78 (SD 3·15) correct answers, compared with 25·43 (1·95) correct answers for the top three machine algorithms (mean difference 6·65, 95% CI 6·06-7·25; p<0·0001). The difference between human experts and the top three algorithms was significantly lower for images in the test set that were collected from sources not included in the training set (human underperformance of 11·4%, 95% CI 9·9-12·9 vs 3·6%, 0·8-6·3; p<0·0001). INTERPRETATION: State-of-the-art machine-learning classifiers outperformed human experts in the diagnosis of pigmented skin lesions and should have a more important role in clinical practice. However, a possible limitation of these algorithms is their decreased performance for out-of-distribution images, which should be addressed in future research. FUNDING: None.

In situ and invasive melanoma in a high-risk, New Zealand, population: A population-based study.

BACKGROUND: Few population-based studies assess both invasive and in situ melanoma. We document all patients with a first biopsied melanoma in a general population in New Zealand (NZ). METHODS: All residents in a defined area of New Zealand with a biopsy showing a new primary invasive or in situ melanoma from 2010 to 2012 were identified, 974 patients; analysis used multivariate methods. RESULTS: Age-standardised incidence rates were 34.3 in females (F) and 41.4 in males (M) for invasive, 20.9 F and 27.6 M for in situ, and 55.2 F and 69.0 M for total melanoma. More in situ melanoma occurred in older patients and on the head and neck. Geometric mean Breslow thickness for invasive was 0.78 mm F and 0.85 mm M, with thicker lesions at ages over 60 and on the lower limb; there was no significant relationship with sex, distance from care or social deprivation assessed from residential address. Nodular melanomas (15%) were more frequent in older and male patients, and on the limbs, and were thicker. The estimated cumulative risk for melanoma is 4.4% F and 4.6% M by age 70. The body site distribution and sex differences were consistent with sun exposure patterns. Estimated incidence of melanoma in New Zealand in 2018 is 2500 invasive and 1700 in situ cases. CONCLUSIONS: Assessing both in situ and invasive melanoma expands the clinical picture, better estimating health care demand and costs. Results suggest that in situ disease is a more slowly growing lesion than the early phase of invasive disease. The features of thicker or nodular melanoma show priorities for prevention and early detection.

Dermoscopic 'Chaos and Clues' in the diagnosis of melanoma in situ.

BACKGROUND/OBJECTIVE: To describe the dermoscopic features of melanoma in situ using the Chaos and Clues method. METHOD: Histologically proven primary melanoma in situ (MIS) diagnosed through a specialist teledermoscopy clinic were reviewed by three dermatologists. By consensus they agreed on the global dermoscopic pattern, colours, presence of chaos (asymmetry of colour and structure and more than one pattern), and each of the nine clues described for malignancy. RESULTS: One hundred MIS in 92 patients of European ethnicity (45 males) were assessed. Mean age was 67.3 years (range 20-95). The mean dimensions of the lesions were 11.1 × 12.0 mm (range 2.5-31.3 × 2.3-32.3 mm). Using pattern analysis, 82% of the lesions had three or more patterns (multicomponent) and the rest had 2 patterns. Colours included light brown (100%), dark brown (98%) and grey (75%). All MIS demonstrated chaos. The most prevalent clues were thick lines (88%), eccentric structureless areas (88%), and grey or blue structures (75%). CONCLUSION: Dermoscopy can be very helpful in the early diagnosis of melanoma and MIS. The Chaos and Clues method is simple to use. Its unambiguous descriptors can be successfully used to describe MIS. The presence of chaos and clues to malignancy (including thick lines, eccentric structureless areas, and blue/grey structures) should raise a red flag and lead to referral or excision.

Quality of Life and Sexual Distress in Women With Erosive Vulvovaginal Lichen Planus.

OBJECTIVES: Erosive vulvovaginal lichen planus (EVLP) is a chronic and painful genital dermatosis. Little is published about its impact on quality of life. This study aimed to evaluate quality of life and sexual function in women with EVLP. MATERIALS AND METHODS: Women with genital dermatoses were surveyed using the Dermatology Life Quality Index (DLQI) and Hospital Depression and Anxiety Scales. A subgroup completed the Female Sexual Distress Scale and Female Sexual Function Index subscales. Patient characteristics including age, diagnosis, and current treatment were recorded. Results from women with EVLP were compared with other diagnoses. RESULTS: Data from 77 women who participated between March 2013 and March 2014 were analyzed. Of these, 17 had EVLP. Comparator groups included women with vulval lichen sclerosus (n = 48) and vulval dermatitis (n = 12). In women with EVLP, 59% reported at least moderate impact on quality of life; mean DLQI scores: EVLP, 7.18; lichen sclerosus, 3.79; dermatitis, 8.67; p = .008. Overall, scores suggested depression in 14% and anxiety in 16% of participants. Sexual distress scores 11 or higher were recorded by 69% of women with EVLP, 63% of women with lichen sclerosus, and 56% of women with dermatitis. In those completing all sections of the survey (n = 40), DLQI was significantly correlated with depression (p = .004), sexual distress (p = .001), and sexual satisfaction (p = .01). CONCLUSIONS: Sixty-nine percent of women with EVLP reported sexual distress. Women with EVLP reported lesser quality of life than those with lichen sclerosus. Quality of life, anxiety and depression, sexual distress, and sexual function were all related in these participants.

Sucrose replacement in high ratio white layer cakes.

BACKGROUND: Several commercially available alternative sweeteners have potential in reducing the caloric content of baked products. Sugar alcohols and natural sweeteners have similar bulk as sucrose and can replace sucrose directly. High intensity sweeteners have high potency but light weight so bulking agents are often added. This study determined alternative sweeteners and combinations of alternative sweetener and a bulking agent that produced good quality white layer cakes. RESULTS: Cakes made with maltitol were acceptable but erythritol and fructose produced undesirable cakes. Maltodextrin and polydextrose were acceptable bulking agents, producing cakes that were similar to control cakes. The flavor of cakes sweetened with sucralose was acceptable but those with stevia had a disagreeable metallic aftertaste. Cakes made with sucralose plus maltodextrin were preferred over those containing sucralose plus polydextrose. Consumer acceptance of flavor, texture and overall liking of cakes containing maltitol was similar to sucrose and both were preferred over cakes containing maltodextrin plus sucralose. CONCLUSION: Replacing sucrose with maltitol in white layer cakes reduced the caloric content by 16% with no loss in quality. © 2016 Society of Chemical Industry.

Teledermoscopy in High-risk Melanoma Patients: A Comparative Study of Face-to-face and Teledermatology Visits.

Teledermoscopy is considered a reliable tool for the evaluation of pigmented skin lesions. We compared the management decision in face-to-face visits vs. teledermatology in a high-risk melanoma cohort using total-body photography, macroscopic and dermoscopic images of single lesions. Patients were assessed both face-to face and by 4 remote teledermatologists. Lesions identified as suspicious for skin cancer by face-to-face evaluation underwent surgical excision. The teledermatologists recommended "self-monitoring", "short-term monitoring", or "excision". A 4-year monitoring was completed in a cohort of participating subjects. The general agreement, calculated by prevalence and bias-adjusted κ (PABAK), showed almost perfect agreement (PABAK 0.9-0.982). A total of 23 lesions were excised; all teledermatologists identified the 9 melanomas. The greatest discrepancy was detected in "short-term monitoring". During 4-year monitoring one melanoma was excised that had been considered benign. In conclusion, melanoma identification by experts in pigmented lesions appears to be equivalent between face-to-face and teledermatological consultation.

An observational case series on dermatoscopic patterns of fading melanocytic naevi.

BACKGROUND/OBJECTIVES: The prevalence of melanocytic naevi falls with age. It has been postulated that this could be due to spontaneous involution (fading). Our objective was to provide dermatoscopic evidence of fading naevi and to describe the patterns of fading observed. METHODS: Serial dermatoscopic images of naevi demonstrating fading were collected from a set of 25 000 images. Any naevi that showed significant fading, as compared to previous imaging of the same lesion, were included in the analysis. RESULTS: A total of 47 naevi in 21 patients were found to have significantly faded over a span of 2-11 years. The dermatoscopic fading was observed to occur in two patterns. The most common pattern observed was generalised fading (n = 45), where fading was present over all the naevus. There were two cases of focal fading (n = 2) where fading was present only over one area of the naevus. CONCLUSIONS: Fading melanocytic naevi are uncommon. Melanocytic naevi fade in recognisable patterns, with generalised fading most commonly observed in our series.