Diagnosis of Skin Disease in Moderately to Highly Pigmented Skin by Artificial Intelligence.

BACKGROUND: Triage of patients with skin diseases often includes an initial assessment by a nurse or general practitioner, followed by a dermatologist. Artificial intelligence (AI) systems have been reported to improve clinician ability to diagnose and triage skin conditions. Previous studies have also shown that diagnosis in patients with skin of color can be more challenging. PURPOSE: This study seeks to determine the performance of AI in the screening and triage of benign-neoplastic, malignant-neoplastic, and non-neoplastic skin conditions for Fitzpatrick skin types IV-VI. METHODS: A set of 163 non-standardized clinical photographs of skin disease manifestations from patients with Fitzpatrick skin types IV-VI were obtained through a publicly available dataset (Scale AI and MIT Research Lab, “Fitzpatrick 17 Dataset”). All photos were diagnosed by a specialist and categorized into three disease classes: benign-neoplastic, malignant-neoplastic, or non-neoplastic. There were 23, 14, and 122 cases of each disease class, respectively. RESULTS: Overall, the AI was able to classify the disease classes with a high degree of accuracy for the Top 1 diagnosis (86.50%). Based on its first prediction, the AI demonstrated the greatest accuracy when classifying non-neoplastic conditions (90.98%), high accuracy in detecting malignant-neoplastic conditions (77.78%), and moderate accuracy of classifying benign-neoplastic conditions (69.57%). CONCLUSION: The AI had an overall accuracy of 86.50% in diagnosing skin disease in Fitzpatrick skin types IV to VI. This is an improvement over reported clinician diagnostic accuracy of 44.3% in darker skin types. Incorporating AI into front-line screening of skin conditions could thereby assist in patient triage and shorten the time to accurate diagnosis. Schneider LG, Mamelak AJ, Tejani I, et al. Diagnosis of skin disease in moderately to highly pigmented skin by artificial intelligence. J Drugs Dermatol. 2023;22(7):647-652. doi:10.36849/JDD.7581.

Tumor characteristics of Mohs surgery patients in Ottawa, Canada versus Houston, Texas--a consequence of access to care?

BACKGROUND: Ontario is one of the most underserved provinces in Canada for providing Mohs micrographic surgery (MMS). A new MMS clinic was opened in Ottawa, Ontario, in June 2009 to help combat the increasing incidence of nonmelanoma skin cancer (NMSC) in this region. OBJECTIVE: To prospectively compare MMS cases completed in Ottawa with cases completed in Houston, Texas, and examine the differences in tumor characteristics. MATERIALS AND METHODS: The first 150 cases performed in Ottawa were prospectively compared with 150 consecutive cases performed at a Mohs surgery clinic in Houston, Texas. Patient demographics, tumor diagnosis, primary or recurrent disease, tumor dimension, number of surgical stages, defect size, complexity of the procedure, and closure method were compared. RESULTS: The average preoperative tumor area was three times as great in Ottawa as in Houston. Almost one entire additional stage was required to clear the tumors treated in Ottawa. Postoperative defects were 87% larger in Ottawa. The number of advanced reconstructive repairs was significantly higher in Ottawa (93%) than Houston (14%). CONCLUSIONS: A significantly higher NMSC disease burden and greater surgical complexity was observed in the tumors treated in Ottawa than in Houston.

An analysis of pain and analgesia after Mohs micrographic surgery.

BACKGROUND: Pain characteristics and analgesia in patients undergoing Mohs micrographic surgery have not been systematically studied. It is important to know about pain after Mohs micrographic surgery to better serve patient needs. OBJECTIVE: We sought to measure pain in patients after Mohs micrographic surgery, and to investigate the relationship among postoperative pain, surgical characteristics, patient characteristics, and analgesics used. METHODS: The Wong-Baker 0-to-10 pain scale was prospectively administered postoperatively to all patients presenting for Mohs micrographic surgery in a private practice setting between October 1, 2007, and December 31, 2008. Patients recorded their pain level from the day of surgery through postoperative day 4. The age, sex, location of surgery, number of lesions operated on, postoperative size, type of repair, severity of pain, and oral analgesics consumed and dosages used were recorded. RESULTS: A total of 433 patients were included in the final analysis. The highest pain scores were found on the day of surgery and steadily declined until postoperative day 4 (P < .000). In all, 52% of patients took pain medication on the day of surgery, which declined successively with each postoperative day. The highest mean pain scores were statistically significantly associated with repair type (flaps), age (<66 years), number of lesions, and consumption of narcotics for pain relief. No statistically significant differences existed for sex or postoperative defect size. LIMITATIONS: The instrument used to measure pain relied on patient self-report in a private practice surgery center. Only the validated Wong-Baker pain scale was used to assess pain in this study. CONCLUSION: Approximately half of the patients after Mohs micrographic surgery take medication for pain control. Type of closure, location of surgery, age, and type of pain medication taken were significantly associated with postoperative pain.

Desmoplastic trichoepithelioma.

BACKGROUND: Desmoplastic trichoepithelioma (DTE) is an uncommon adnexal tumor usually found on the face of young women. OBJECTIVE: We sought to describe the clinical and histologic characteristics of DTE and discuss management strategies for these tumors. METHODS: We conducted a retrospective case series and review of the literature. RESULTS: A series of 17 cases of DTE is reported. Of our patients, 82% were female and half of all these cases occurred on the cheek. Unlike previous reports, the patients in our study were slightly older, with 53% older than 51 years and 71% between the ages of 31 and 60 years at the time of surgery (mean age 49 years, median age 52 years, range 14-81 years). Approximately 38% of the tumors had been present for 1 to 2 years before presentation. The average size of the tumors at the time of surgery was 0.8 x 0.6 cm. All cases were treated with Mohs micrographic surgery. To date, none of the tumors have recurred. LIMITATIONS: This is a small case series. The referral patterns of our predominantly Mohs micrographic surgery clinic might further bias this study. CONCLUSION: DTE is a benign tumor that has a predilection for the face. With its rapid growth, aggressive histologic features that may be confused with basal cell carcinoma, and tendency to arise in cosmetically and functionally sensitive areas, these tumors should be removed in a manner that assures clear surgical margins, such as Mohs micrographic surgery.

Review ofactinic keratosis. Part I: etiology, epidemiology and clinical presentation.

Clinically, actinic keratoses (solar keratoses) are keratotic lesions that occur on chronically sunlight-exposed skin. Histologically, they are epidermal tumors. Presenting with a spectrum of clinical features, actinic keratoses are believed to be predictors and precursors of invasive squamous cell carcinoma. This, the first of a two-part overview, examines the etiology and epidemiology of actinic keratoses, their clinical and histological features and their role in the development of nonmelanoma skin cancer.

Vertical undermining for the closure of partial thickness surgical defects.

Vertical undermining for repair of partial thickness defects is a new effective technique that allows the wound edges of partial thickness defects to be freed and mobilized so that they can be repaired primarily. This technique does not call for the removal of the residual dermis at the base of the wound, allowing for conservation of the healthy tissues. By leaving the partial thickness dermis in place, this technique significantly decreases wound- healing times, as well as leads to improved cosmetic outcomes and increased patient satisfaction.

Leech therapy in cutaneous surgery and disease.

BACKGROUND: Over the ages, the use of leeches in medicine has evolved from haphazard bloodletting to a well-understood physiologic process with defined, rational applications. OBJECTIVE: The authors describe the current role of leech therapy in cutaneous surgery and medicine. METHODS: Case series and review of the literature. RESULTS: Leech saliva contains anticoagulative, anti-aggregative and vasodilatory components. Combined with the annelid's mechanical ability to extract blood, leeches can contribute to patients' health with minimal risks. CONCLUSION: Leeches should be considered as novel therapies for disorders of coagulation and venous congestion. Implementation of leech treatment should be tempered with the potential adverse effects, including Aeromonas infection and a drop in hematocrit that might require a blood transfusion.

Changes in skin tanning attitudes. Fashion articles and advertisements in the early 20th century.

Historical reviews suggest that tanning first became fashionable in the 1920s or 1930s. To quantitatively and qualitatively examine changes in tanning attitudes portrayed in the popular women's press during the early 20th century, we reviewed summer issues of Vogue and Harper's Bazaar for the years 1920, 1927, 1928, and 1929. We examined these issues for articles and advertisements promoting skin tanning or skin bleaching and protection. We found that articles and advertisements promoting the fashionable aspects of tanned skin were more numerous in 1928 and 1929 than in 1927 and 1920, whereas those promoting pale skin (by bleaching or protection) were less numerous. These findings demonstrate a clear shift in attitudes toward tanned skin during this period.

Linear closure for nasal defects after Mohs micrographic surgery.

BACKGROUND: Skin cancers on the nose are very common. Excision of these tumors results in surgical defects that can pose a challenge to repair. OBJECTIVE: To present the authors' experience of using linear closures (LC) to repair surgical defects on the nose in patients who underwent Mohs micrographic surgery (MMS). METHODS: A retrospective analysis was conducted of 4765 patients with skin malignancies on the nose that were treated with MMS between July 1997 and January 2006. The following variables were examined: type of repair, age, and sex of the patients, postoperative size of the defect, type of malignancy, location of the defect, and final length of the closure. Short-term and long-term complications were evaluated and discussed. In a second study arm, a limited prospective cosmetic outcome assessment of patients with nasal defects repaired by LC compared to flaps and grafts was also conducted. RESULTS: There were 2053 patients (1020 men and 1033 women) who underwent LC of nasal defects after MMS. The average postoperative defect size was 1.7 x 0.9 cm, with an average closure length of 2.7 cm (range: 0.6 cm to 8.5 cm). The 2 major malignancies treated were basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Short-term complications were minimal. Nasal asymmetry and/or raising of the nasal alae were occasionally seen, which improved over time. The cosmetic outcomes of the LC group were rated higher than the flap/graft group for lesions on the nose, although this was not statistically significant. CONCLUSIONS: A vertical or slightly vertical linear closure for nasal defects after Mohs micrographic surgery is a robust and reliable method to deliver excellent cosmetic and functional results. Linear closure should be considered for small and mid-sized cutaneous nasal defects whenever possible.

Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings.

UNLABELLED: Chronic wounds are a major healthcare problem costing the United States billions of dollars a year. The American Academy of Dermatology has underscored the significance of wound care in dermatological practice. It is critical for all dermatologists to understand the elements of diagnosis and therapy. We emphasize major aspects of diagnosis and present a simple classification of wound dressings with guidelines for usage and relative cost data. LEARNING OBJECTIVE: After completing this learning activity, participants should be able to diagnose common types of chronic wounds, formulate a therapeutic plan, and describe the major classes of topical therapies and dressings for the chronic wound.

Basal cell carcinoma arising in a patient with vitiligo.

Patients with vitiligo are predisposed to solar damage, often suffering from actinic keratoses (AK) and squamous cell carcinoma (SCC). However, never have these patients been noted to have an increased risk for basal cell carcinoma (BCC). In fact, no case reports of these 2 diseases occurring together exist in the literature. Here, the authors report a case of basal cell carcinoma arising in a patient with vitiligo. This rare occurrence gives question to the nature of these tumors and their pathogenesis.

Lower extremity positioning to relieve tension during surgical reconstruction.

Surgical wounds on the lower extremity often suffer from prolonged and poor healing secondary to decreased blood flow, the effects of gravity, and excessive tension placed on the wound. Ensuring perfect apposition of wound edges free of tension during the surgical repair can augment this healing process. The authors detail a simple and effective technique for improving repairs and outcomes when operating on the lower limb by relieving tension on the wound through leg positioning.

Frontalis muscle plication and imbrication in reconstruction of forehead defects.

The forehead is a common site for nonmelanoma skin cancer. For medium to large sized defects, the primary reconstructive challenge is the paucity of loose adjacent donor skin. The authors describe frontalis muscle plication, imbrication, and related surgical techniques utilized in reconstructing forehead defects. With these techniques, one can significantly reduce wound tension and increase the volume of tissue recruited to the defect site as necessary.

Port-wine-stain-associated dermatitis: implications for cutaneous vascular laser therapy.

Port-wine stains are congenital vascular malformations affecting 0.3% to 0.5% of infants. Dermatitis occurring exclusively or most severely within port-wine stains has been described in the literature. Traditionally, topical corticosteroid therapy has been used for the treatment of dermatitis, while pulseddye laser treatment is considered a safe and effective means of lightening the appearance of congenital port-wine stains. To describe the development of port-wine stain-associated dermatitis as well as a rational treatment approach to these patients, we studied three children with facial, limb, or truncal port-wine stains who developed dermatitis within the congenital vascular malformation either prior to or during treatment with pulseddye laser. Laser therapy of dermatitis-affected areas was subsequently deferred pending resolution of the dermatitis with topical corticosteroid or topical calcineurin inhibitor treatment. While pulseddye laser therapy is an effective means of lightening port-wine stains and achieving lasting resolution of any associated dermatitis, this therapy to dermatitis-affected areas should be postponed until the inflammation resolves to minimize the risk of laser-associated adverse effects.

Occlusive wound dressings in emergency medicine and acute care.

One of the great misconceptions in wound care is that a wound heals best when permitted to form a dry scab. By contrast, moisture has repeatedly been shown to significantly accelerate wound healing. Emergency physicians and other acute care providers are encouraged to incorporate occlusive moisture-retentive dressings into their regular practice to expedite healing, reduce pain and scarring, improve wound care convenience and patient compliance, and minimize wound contamination and infection.

Rituximab therapy in severe juvenile pemphigus vulgaris.

Juvenile pemphigus vulgaris (PV) is a rare and often misdiagnosed condition. Although PV frequently is severe in children, a substantial portion of the morbidity and mortality associated with juvenile PV has been attributed to treatment. This report demonstrates the efficacy of rituximab therapy in juvenile PV. We report 2 cases and review the literature. Rituximab treatment was effective in helping to control 2 recalcitrant cases of juvenile PV without inducing the adverse effects associated with other adjuvant therapies. Rituximab should be considered when treating resistant cases of PV in pediatric populations to avoid the long-term side effects of other immunosuppressive treatments.

Overexpression of claudin proteins in esophageal adenocarcinoma and its precursor lesions.

Claudins are components of tight junctions important in intercellular barriers and cell polarity. The authors identified upregulation of Claudins 3, 4, and 7 in gastric adenocarcinoma using Affymetrix U-133 oligonucleotide microarrays and immunohistochemistry (IHC). While normal gastric mucosa lacked Claudin 3, 4, and 7 expression, intestinal metaplasia and dysplasia showed these proteins. The authors hypothesized that Claudins would be similarly overexpressed in Barrett's esophagus (BE)/adenocarcinoma. Claudins 3, 4, and 7 gene expression was analyzed by Affymetrix U-133 microarrays in three esophageal adenocarcinomas, one case of BE, and three normal esophagi. IHC validation was performed using tissue microarrays constructed from esophageal resection specimens containing squamous (44 cases), gastric (40 cases), and non-dysplastic BE (16 cases), low-grade and high-grade dysplasia (16 and 26 cases), adenocarcinoma (58 cases), and nodal metastases (27 cases). IHC staining was scored semiquantitatively (0+ to 4+). By microarray analysis, Claudin 3 showed a marked increase in mRNA expression compared with normal esophagus (approximately 100-fold). Claudins 4 and 7 were modestly increased (2.2- and 1.3-fold). By IHC, Claudin 3 expression was 1+ in most (>95%) normal squamous or gastric tissues and 2+ to 4+ in more than 80% of high-grade dysplasia, adenocarcinoma, and metastases specimens. Claudin 4 protein expression was 2+ or less in most squamous and gastric mucosa (>90%) but 3+ or 4+ in BE, low- and high-grade dysplasia, adenocarcinoma, and metastases specimens (>90%). Claudin 7 expression was minimal in squamous and gastric mucosa but strong (3+ to 4+) in BE and low-grade dysplasia. In high-grade dysplasia, adenocarcinoma, and metastases, Claudin 7 was less intense, with 60% to 70% staining 3+ or 4+ and 30% to 40% staining weakly (1+ or 2+). The findings suggest that alterations in Claudin proteins are an early event in tumorigenesis and may provide targets for diagnosis and directed therapy for esophageal adenocarcinoma and its precursors.

Photoaging: mechanisms and repair.

UNLABELLED: Aging is a complex, multifactorial process resulting in several functional and esthetic changes in the skin. These changes result from intrinsic as well as extrinsic processes, such as ultraviolet radiation. Recent advances in skin biology have increased our understanding of skin homeostasis and the aging process, as well as the mechanisms by which ultraviolet radiation contributes to photoaging and cutaneous disease. These advances in skin biology have led to the development of a diversity of treatments aimed at preventing aging and rejuvenating the skin. The focus of this review is the mechanism of photoaging and the pathophysiology underlying the treatments specifically designed for its prevention and treatment. LEARNING OBJECTIVES: At the conclusion of this learning activity, participants should be familiar with the mechanism of photoaging, the treatments for photoaging, and the data that supports the use of these treatments.

Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience.

BACKGROUND: Widespread introduction of highly active antiretroviral therapy (HAART) in the mid 1990s has altered the presentation of the cutaneous manifestations associated with HIV infection. OBJECTIVE: Our purpose was to evaluate the use of HAART on the prevalence and spectrum of cutaneous manifestations in HIV-infected patients. METHODS: A study of the initial visits of 897 HIV-infected patients at an urban dermatology clinic between 1996 and 2002 was performed. RESULTS: Folliculitis was the most common cutaneous disorder identified. Patients with CD4-positive cell counts less than 200 cells/mm3 had an increased prevalence of folliculitis and prurigo nodularis, whereas those with HIV viral loads higher than 55,000 copies/mL had a higher prevalence of idiopathic pruritus and candidiasis. Patients not receiving HAART had increased rates of folliculitis and prurigo nodularis. Patients receiving HAART had increased rates of photosensitivity and molluscum contagiosum. LIMITATIONS: This was a cross-sectional study in which temporality was unable to be determined. CONCLUSION: With ongoing therapeutic advancements, the cutaneous manifestations associated with HIV infection will continue to evolve.

Microarray profiles of human basal cell carcinoma: insights into tumor growth and behavior.

PURPOSE: Basal cell carcinoma (BCC) is the most common human neoplasm. Much interest lies in determining the genetic basis of BCC to explain the unique locally invasive phenotype and infrequent metastatic behavior of these skin tumors. OBJECTIVE: We sought to examine a gene expression profile for BCC to elucidate new molecules responsible for its unique growth characteristics. METHODS: We analyzed gene expression patterns of 50 BCC tumors using spotted cDNA microarrays of 1718 characterized human genes related to cancer and immunity. This is the largest and most comprehensive gene expression study ever performed for BCC. Nodular and sclerosing histological subtypes of BCC were examined and compared to normal control skin. After statistical filtering, 374 significantly dysregulated genes were sorted by hierarchical clustering to determine trends of gene expression and similarities between patient gene expression profiles. RESULTS: A total of 165 upregulated genes and 115 downregulated genes were identified. These covered a range of categories, including extracellular matrix, cell junctions, motility, metastasis, oncogenes, tumor suppressors, DNA repair, cell cycle, immune regulation and angiogenesis. Clusters of genes were either commonly dysregulated across the 50 patient sample, or selectively affected in subsets of tumors. Histological subtypes were not distinguishable by hierarchical clustering. Many of the genes elucidated, including collagen type IV subunits and other novel candidates, possess functions related to extracellular matrix remodeling and metastasis. CONCLUSION: These results suggest a gene profile which may explain the invasive growth yet rarely metastatic behavior of BCC. The genes identified may also be potential targets for therapeutics aimed at further controlling invasiveness and local destruction of BCC.