Quality of Life in a Vitiligo Support Group.

BACKGROUND: No study has examined the impact of vitiligo support group membership on vitiligo patient quality of life (QoL).

OBJECTIVE: We sought to examine the QoL impact of vitiligo support groups by comparing QoL and associated patient characteristics between vitiligo patients who are and are not members of a vitiligo support group.

METHODS: Members of a Henry Ford Hospital-sponsored, Southeast Michigan Vitiligo Support Group were compared to non-member vitiligo patients recruited from a previous study cohort.17 Eligible patients were asked to complete the Dermatology Life Quality Index (DLQI) and a study-specific questionnaire designed to collect relevant patient characteristics.

RESULTS: The mean DLQI scores for the support group members and non-members were similar (7.1 ± 5.4 and 6.0 ± 6.5, respectively; P-value 0.2), despite the support group members reporting more severe overall disease and increased disease severity in exposed portions of the body. The African-American: Caucasian ratio and the prevalence of unemployment were both significantly higher among the support group participants. LIMITATIONS: Small sample size may have limited the study's ability to demonstrate the differences between the support group participants and the controls.

CONCLUSIONS: The similar QoL despite an increased prevalence of poorer QoL indicators among the support group participants suggests a protective effect of support group membership.

J Drugs Dermatol. 2017;16(4):344-350.

Providers' Experiences with a Melanoma Web-Based Course: a Discussion on Barriers and Intentions.

Primary care visits provide an opportunity for skin examinations with the potential to reduce melanoma mortality. The INFORMED (INternet curriculum FOR Melanoma Early Detection) Group developed a Web-based curriculum to improve primary care providers' (PCPs') skin cancer detection skills. This study details feedback obtained from participant focus groups, including the feasibility of implementing in other PCP practices. Practicing PCPs at Henry Ford Health System and Kaiser Permanente Northern California completed the curriculum. Feedback sessions were conducted with standardized questions focusing on four domains: (1) overall impressions of the curriculum, (2) recommendations for improvement, (3) current skin examination practices, and (4) suggestions for increasing skin screening by PCPs. Discussions at each site were audio recorded, transcribed verbatim, and de-identified. Providers (N = 54) had a positive impression of the Web-based curriculum, with suggestions to provide offline teaching aids and request assistance. Despite having improved confidence in diagnosing malignant lesions, many providers felt a lack of confidence in performing the screening and time constraints affected their current practices, as did institutional constraints. Providers intended to increase discussion with patients about skin cancer. The accessibility, effectiveness, and popularity of the curriculum indicate potential for implementation in the primary care setting. Participating providers noted that institutional barriers remain which must be addressed for successful dissemination and implementation.

Squamous cell carcinoma originating from cutaneous cysts: The Henry Ford Experience and review of the literature.

PURPOSE: Malignant transformation to squamous cell carcinoma (SCC) arising within cutaneous epidermal cysts is a very rare phenomenon. We provide a series of new cases and an overview of the literature. We sought to define the prevalence of and characterize SCC arising within epidermal and pilar cysts. PATIENT AND METHODS: We searched Henry Ford Health System (HFHS) non-melanoma skin cancer (NMSC) registry from 2005 to 2009 to identify cases of SCC arising from epidermal cysts. RESULTS: We identified 1904 cases of epidermal cysts at our institution between 2005 and 2014. Of these, three cases of SCC arose from an epidermal cyst and one case of SCC developed from a pilar cyst. All lesions occurred below the waist with the exception of the pilar cyst on the scalp. CONCLUSIONS: Given the extremely low incidence, propensity of malignant lesions to become symptomatic and efficacy of treatment, we do not recommend routine excision of all epidermal cysts. Instead, we recommend excision and pathology for all symptomatic epidermal cysts, or those that rapidly grow, or do not respond to medical therapy.

Identification of Stevens-Johnson syndrome and toxic epidermal necrolysis in electronic health record databases.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) carry a high mortality risk. While identifying clinical and genetic risk factors for these conditions has been hindered by their rarity, large electronic health databases hold promise for identifying large numbers of cases for study, especially with the introduction in 2008 of ICD-9 codes more specific for these conditions. OBJECTIVE: The objective of this study is to estimate the validity of ICD-9 codes for ascertaining SJS/TEN in 12 collaborating research units in the USA, covering almost 60 million lives. METHODS: From the electronic databases at each site, we ascertained potential cases of SJS/TEN using ICD-9 codes. At five sites, a subset of medical records was abstracted and standardized criteria applied by board-certified dermatologists to adjudicate diagnoses. Multivariate logistic regression was used to identify factors independently associated with validated SJS/TEN cases. RESULTS: A total of 56 591 potential cases of SJS/TEN were identified. A subset of 276 charts was selected for adjudication and 39 (of the 276) were confirmed as SJS/TEN. Patients with the ICD-9 codes introduced after 2008 were more likely to be confirmed as cases (OR 3.32; 95%CI 0.82, 13.47) than those identified in earlier years. Likelihood of case status increased with length of hospitalization. Applying the probability of case status to the 56 591 potential cases, we estimated 475-875 to be valid SJS/TEN cases. CONCLUSION: Newer ICD-9 codes, along with length of hospitalization, identified patients with a high likelihood of SJS/TEN. This is important for identification of subjects for future pharmacogenomics studies.

Self-reported quality of life after skin cancer in young adults.

INTRODUCTION: Skin cancer incidence is increasing in younger adults. Patient satisfaction and quality of life surveys are limited, and more information is needed on the unique perspectives of these younger patients who may be affected differently. We sought to explore how skin cancer has affected quality of life in younger adults. METHODS: A self-reported questionnaire was administered to patients with skin cancer aged 20-50 years diagnosed from 2007 to 2008. Quality of life was measured using the Skin Cancer Index (SCI) and Skindex-16 with a transformed scale. Descriptive statistics with standard deviations were calculated. RESULTS: One-hundred sixty-one patients were identified; 62 completed surveys (38.5%), with 47 patients eligible for inclusion. Forty participants (85%) reported having made lifestyle changes since being diagnosed with non-melanoma skin cancers, most commonly habitual use of sunscreen (n = 34; 77.3%). Quality of life was most impacted by worries about their skin cancer (Skindex-16 score 24.5 (34.4 standard deviation)), including their future risk of developing further cancers (58.5 (31.8)). LIMITATIONS: Limitations include small sample size and possible response bias. CONCLUSIONS: There is a modest impact on quality of life in young patients with skin cancer based on the Skindex-16 and SCI. Young skin cancer survivors may benefit from patient counseling, which addresses risk assessment and future risk reduction.

Photocarcinogenesis: an epidemiologic perspective on ultraviolet light and skin cancer.

Photocarcinogenesis is the result of a complex interplay between ultraviolet radiation, DNA damage, mutation formation, DNA repair, apoptosis, and the immune system. Recent trends show an increase in incidence of both melanoma and nonmelanoma skin cancers. Some individuals have a genetic predisposition toward increased risk for skin cancer, whereas others experience increased risk through ultraviolet exposure and subsequent mutation formation. The initiation and propagation pathways of melanoma and nonmelanoma skin cancers differ but have some elements in common. The increase in incidence of skin cancer has been discovered to vary among age groups and gender.

Comparing characteristics of melanoma cases arising in health maintenance organizations with state and national registries.

Datasets from large health maintenance organizations (HMOs), particularly those with established cancer registries that report to the Surveillance, Epidemiology, and End Results program, are potentially excellent resources for studying melanoma epidemiology and outcomes. However, generalizability of the findings beyond HMO-based populations has not been well studied. We compared melanoma patient, tumor, and treatment characteristics at Kaiser Permanente Northern California and Henry Ford Healthcare Systems with those of corresponding regional, state, and national registry-reported melanoma databases. We identified all melanoma cases diagnosed at Kaiser Permanente Northern California (1996-2009) and Henry Ford Healthcare Systems (1996-2007) and ascertained patient (age, sex, race, and ethnicity), tumor (site, size, laterality, invasiveness, depth, ulceration, subtype, and stage), and treatment (surgery and radiation) variables from health system cancer registries. Registry data were obtained from Surveillance, Epidemiology, and End Results databases for the reporting period ending in November 2011. We found that melanoma cases arising in HMO settings generally have comparable patient, tumor, and treatment characteristics to regional, state, and national cases. An important difference included improved reporting of race information at HMO sites. Melanoma studies using data derived from select HMOs are potentially generalizable to local, state, and national populations, and may be better situated for studying racial-ethnic disparities.

What increased registry outreach may mean for cutaneous melanoma surveillance: impact of changes in Iowa.

BACKGROUND: Cutaneous melanoma (CM) is underreported to cancer registries, in part due to insufficient reporting in the nonhospital setting. The objective of this study was to better understand the impact of dermatologist and private pathology laboratory reporting on CM rates. METHODS: We examined the impact of targeted casefinding in private pathology laboratories and dermatology offices by the State Health Registry of Iowa (SHRI) on CM incidence, as well as the characteristics of nonhospital reported cases. RESULTS: Over the 39-year period (1973-2011), 22,541 cases of CM were captured by the SHRI; 16,183 (72%) were invasive melanoma cases and 6,358 (28%) were in situ cases. The incidence of invasive melanoma increased 3.6 fold between the time periods of 1973-1975 and 2009-2011 (6.6 vs. 24 per 100,000 person-years, respectively). If case reporting from private pathology laboratories and dermatology offices was not conducted, the 2009-2011 invasive CM rate would have decreased to 19.1. The ratio of invasive to in situ cases declined from 8:1 from 1973-1987 to less 2:1 from 2007-2011. Age at diagnosis also significantly increased across time periods, while the proportion of females declined. From 2007-2011, the majority (55%) of nonhospital cases were in situ, and 90% of the invasive cases were localized. A higher percentage of urban residents were attributed to nonhospital-based reporting sources compared to hospital-based sources (57% vs 45%, P < .0001) CONCLUSIONS: Electronic health records and incentivized Meaningful Use for reporting may provide an efficient method for nonhospital based providers to easily and accurately report CM cases to registries.

Effects on skills and practice from a web-based skin cancer course for primary care providers.

BACKGROUND: Melanoma incidence and mortality is a growing concern. Better recognition and management of skin cancer by primary care providers (PCPs) could help, but studies suggest they would benefit from additional education. Effective educational programs are needed. METHODS: We developed and conducted a voluntary before-and-after evaluation of a 1- to 2-hour interactive, web-based course in skin cancer detection for practicing, board-certified PCPs (http://www.skinsight.com/info/for_professionals/dermatology-education-resources). Voluntary participants' ability to diagnose and manage skin cancer was assessed using pretests, immediate tests, and 6-month posttests. The effect on actual practice patterns was assessed using participants' patient panels: referrals or visits to dermatology and skin biopsies during the 6 months after the course were compared with those during the same period before the course. RESULTS: The mean age of the 54 participants was 50.5 years (standard deviation, 11.1); 54% were women and 52% were Asian. The mean score for appropriate diagnosis and management increased from 36.1% to 46.7% (odds ratio, 1.6; 95% confidence interval, 1.4-1.9), with greatest improvement in benign lesions, from 32.1% to 46.3% (odds ratio, 1.9; 95% confidence interval, 1.6-2.4). Dermatology referrals for suspicious lesions or new visits by participants' patients decreased at both sites after the course (from 630 to 607 and from 726 to 266, respectively). CONCLUSIONS: This course improved skills in practicing PCPs. Improvement was greatest in the diagnosis and appropriate management of benign lesions and dermatology utilization decreased.

Validation of a large basal cell carcinoma registry.

BACKGROUND: The epidemiological study of basal cell carcinomas (BCCs) is difficult because BCCs lack distinct disease codes and are excluded from most cancer registries. OBJECTIVE: To develop and validate a large BCC registry based on electronically assigned Systematized Nomenclature of Medicine (SNOMED) codes and text-string searches of electronic pathology reports from Kaiser Permanente Northern California. METHODS AND MATERIALS: Potential BCCs were identified from electronic pathology reports (n=39,026) in 2005 and were reviewed by a dermatologist who assigned case/non-case status (gold-standard). A subset of the records (n=9,428) was independently reviewed by a second dermatologist to ascertain reliability of case assignment. In addition, a subset of excluded electronic pathology reports from 2005 (n=2,700) was reviewed to determine whether inclusion criteria had missed potential BCCs. We calculated the positive predictive value (PPV) of 3 different algorithms for identifying BCCs from electronic pathology data. RESULTS: BCC-specific SNOMED codes had the highest PPV for identifying BCCs, 0.992 (95 percent CI: 0.991-0.993). Inter-rater reliability for case assignment was high (kappa=0.92, 95 percent CI: 0.91-0.93). Standardized incidence rates were consistent with previously published rates in the United States. CONCLUSIONS: We created and validated a large BCC registry to serve as a unique resource for studying BCCs.

Bendamustine-induced "flagellate dermatitis".

BACKGROUND: The term "flagellate erythema" after bleomycin therapy was described as bleomycin-induced linear hyperpigmentation. Since then, this pattern has not been related to any other chemotherapeutic regimen. OBSERVATION: We report a rare patient with chronic lymphocytic leukemia who developed "flagellate dermatitis" induced by bendamustine. CONCLUSION: Chemotherapy induced "Flagellate Dermatitis" is a rare finding reported only after bleomycin therapy. We describe the first case with this characteristic eruption pattern after administration of bendamustine.

Photoprotection counseling of non-white ethno-racial groups: a survey of the practice of expert dermatologists.

The morbidity of skin cancer in non-white, ethno-racial populations is well established, yet no specific guidelines exist addressing the manner in which this population should be counseled on photoexposure. We conducted a 20-item survey to assess the behavior of specialized dermatologists when providing photoprotection recommendations to non-white, ethno-racial patients as well as the perceived relevance of counseling for this group. Our study demonstrated that key opinion leaders within the fields of photodermatology and ethnic dermatology believe that photoprotection counseling is beneficial for ethno-racial minorities. Based on these preliminary data and other recently published reports, the development of photoprotection guidelines specific to non-white, ethno-racial groups may be warranted.

Perception of xeroderma pigmentosum support group members of xeroderma pigmentosum lifestyle impact.

Xeroderma pigmentosum (XP) is a genetic condition, which can cause an extreme sensitivity to sunlight and an increased risk of skin cancer due to errors in DNA repair. An online survey was administered to a convenience sample of participants who were members of an online support group for XP patients and their families to determine common symptoms and quality of life. The Dermatologic Life Quality Index (DLQI) or the Children's Dermatologic Life Quality Index (CDLQI) was used depending on patient age. A total of four patients and two parents of young patients completed our survey. Quality of life as measured through the DLQI and CDLQI was moderately affected.

Update on the current state of melanoma incidence.

The incidence of melanoma is rising worldwide, and in the United States has increased by approximately 2.8% annually since 1981. Melanoma is more common in whites, and is generally more prevalent in men. However, there is a 6.1% annual increase in US incidence of melanomas in white women younger than age 44, with growing concern that increases in skin cancer in younger women may reflect recent trends in indoor tanning. Melanoma incidence is also greater in higher economic groups. Globally, melanoma incidence is highest in Australia, followed by the United States and parts of Europe.

Skin-of-color epidemiology: a report of the most common skin conditions by race.

To quantify and compare diagnoses according to race in pediatric Health Maintenance Organization (HMO) health plan patients seen in a general dermatology clinic over a 10-year period. Retrospective cohort of health plan pediatric patients seen in the dermatology clinic between 1997 and 2007 was established using an electronic medical record database. Diagnoses and diagnostic codes were recorded according to International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes grouped on their first three digits. The proportion of patients with each diagnosis was determined according to race and sex, and the 10 most common diagnoses were determined. The most common diagnoses observed in all pediatric patients were acne (28.6%), dermatitis (19.4%), and warts (16.2%), accounting for more than 60% of dermatologic visits by children. Although acne (29.9%), warts (22.6%), and dermatitis (13.1%) were also the most common diagnoses for Caucasian children, African American pediatric patients were most commonly seen for dermatitis (29.0%), acne (27.5%), and dermatophytosis (10.2%). The three most common diagnoses for Asian patients were dermatitis (29.1%), acne (22.2%), and warts (12.6%). Acne remains one of the most common dermatologic diagnoses in children of all races. Differences in frequency of office visits for dermatitis, warts, and dermatophytosis were seen when comparing children of other races with Caucasian children.

Developing an interactive web-based learning program on skin cancer: the learning experiences of clinical educators.

Web-based learning in medical education is rapidly growing. However, there are few firsthand accounts on the rationale for and development of web-based learning programs. We present the experience of clinical educators who developed an interactive online skin cancer detection and management course in a time-efficient and cost-efficient manner without any prior skills in computer programming or technical construction of web-based learning programs. We review the current state of web-based learning including its general advantages and disadvantages as well as its specific utility in dermatology. We then detail our experience in developing an interactive online skin cancer curriculum for primary care clinicians. Finally, we describe the main challenges faced and lessons learned during the process. This report may serve medical educators who possess minimal computer programming and web design skills but want to employ the many strengths of web-based learning without the huge costs associated with hiring a professional development team.

Validation of claims data algorithms to identify nonmelanoma skin cancer.

Health maintenance organization (HMO) administrative databases have been used as sampling frames for ascertaining nonmelanoma skin cancer (NMSC). However, because of the lack of tumor registry information on these cancers, these ascertainment methods have not been previously validated. NMSC cases arising from patients served by a staff model medical group and diagnosed between 1 January 2007 and 31 December 2008 were identified from claims data using three ascertainment strategies. These claims data cases were then compared with NMSC identified using natural language processing (NLP) of electronic pathology reports (EPRs), and sensitivity, specificity, positive and negative predictive values were calculated. Comparison of claims data-ascertained cases with the NLP demonstrated sensitivities ranging from 48 to 65% and specificities from 85 to 98%, with ICD-9-CM ascertainment demonstrating the highest case sensitivity, although the lowest specificity. HMO health plan claims data had a higher specificity than all-payer claims data. A comparison of EPR and clinic log registry cases showed a sensitivity of 98% and a specificity of 99%. Validation of administrative data to ascertain NMSC demonstrates respectable sensitivity and specificity, although NLP ascertainment was superior. There is a substantial difference in cases identified by NLP compared with claims data, suggesting that formal surveillance efforts should be considered.

Racial and ethnic variations in incidence and survival of cutaneous melanoma in the United States, 1999-2006.

BACKGROUND: Most melanoma studies use data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program or individual cancer registries. Small numbers of melanoma cases have limited in-depth analyses for all racial and ethnic groups. OBJECTIVE: We sought to describe racial and ethnic variations in melanoma incidence and survival. METHODS: Incidence for invasive melanoma and 5-year melanoma-specific survival were calculated for whites, blacks, American Indians/Alaskan Natives, Asians/Pacific Islanders (API), and Hispanics using data from 38 population-based cancer registries. RESULTS: Incidence rates of melanoma were significantly higher for females than males among whites and Hispanics under 50 years of age and APIs under 40 years of age. White and black patients were older (median age: 59-63 years) compared with Hispanics, American Indians/Alaskan Natives, and API (median age: 52-56 years). The most common histologic type was acral lentiginous melanoma among blacks and superficial spreading melanoma among all other racial and ethnic groups. Hispanics had the highest incidence rate of acral lentiginous melanoma, significantly higher than whites and API. Nonwhites were more likely to have advanced and thicker melanomas at diagnosis and lower melanoma-specific survival compared with whites. LIMITATIONS: Over 50% of melanoma cases did not have specified histology. The numbers of nonwhite patients were still relatively small despite broad population coverage (67% of United States). CONCLUSIONS: Racial and ethnic differences in age at melanoma diagnosis, anatomic sites, and histologic types suggest variations in etiologic pathways. The high percentages of advanced and thicker melanomas among nonwhites highlight the need to improve melanoma awareness for all race and ethnicity in the United States.

Association between cutaneous melanoma incidence rates among white US residents and county-level estimates of solar ultraviolet exposure.

BACKGROUND: Recent US studies have raised questions as to whether geographic differences in cutaneous melanoma incidence rates are associated with differences in solar ultraviolet (UV) exposure. OBJECTIVES: We sought to assess the association of solar UV exposure with melanoma incidence rates among US non-Hispanic whites. METHODS: We assessed the association between county-level estimates of average annual solar UV exposure for 1961 to 1990 and county-level melanoma incidence rates during 2004 to 2006. We used Poisson multilevel mixed models to calculate incidence density ratios by cancer stage at diagnosis while controlling for individuals' age and sex and for county-level estimates of solar UV exposure, socioeconomic status, and physician density. RESULTS: Age-adjusted rates of early- and late-stage melanoma were both significantly higher in high solar UV counties than in low solar UV counties. Rates of late-stage melanoma incidence were generally higher among men, but younger women had a higher rate of early-stage melanoma than their male counterparts. Adjusted rates of early-stage melanoma were significantly higher in high solar UV exposure counties among men aged 35 years or older and women aged 65 years or older. LIMITATIONS: The relationship between individual-level UV exposure and risk for melanoma was not evaluated. CONCLUSIONS: County-level solar UV exposure was associated with the incidence of early-stage melanoma among older US adults but not among younger US adults. Additional studies are needed to determine whether exposure to artificial sources of UV exposure or other factors might be mitigating the relationship between solar UV exposure and risk for melanoma.