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.

Lymphangiosarcoma of the scalp.

BACKGROUND: Lymphangiosarcoma is a rare, aggressive malignancy that originates from the endothelial cells lining lymphatic vessels and carries an extremely poor prognosis. Its clinical and histologic features are often indistinguishable from angiosarcoma. OBJECTIVE: We sought to better characterize the clinical and histologic features of lymphangiosarcoma. METHODS: Case report and review of the literature. RESULTS: A number of immunohistochemical markers, including Von Willebrand factor, Ulex europaeus agglutinin 1, CD31, VEGFR-3, D2-40, Prox-1, can be used to help differentiate lymphatic from vascular tissue. CONCLUSIONS: Recent characterization of several new biologic markers has allowed greater differentiation between these tumors and may provide new therapeutic targets for treatment.

Wait times for Mohs micrographic surgery in Ottawa, Ontario.

BACKGROUND: The Ministry of Health and Long-Term Care, in coordination with Cancer Care Ontario, records and analyzes wait times for cancer surgery in the province of Ontario. However, this strategy does not include wait times for skin cancer surgery. PURPOSE: The wait times and referral patterns of patients undergoing Mohs micrographic surgery at The Ottawa Hospital (TOH) were examined to better assess the adequacy of access to skin cancer treatment in Ontario. METHOD: The records of 101 Mohs surgeries (96 patients) consecutively performed at TOH between June 14, 2010, and October 19, 2010, were reviewed. The interval between the date the referral for Mohs surgery was first received and the date of surgery was calculated for each case. The specialty of the referring physician and the postal code of each patient treated were also recorded. RESULTS: The average wait time between the date of referral and the date of surgery was 122.6 days or 17.5 weeks (median 124 days, 17.7 weeks). Over 75% of patients waited over 12 weeks (84 days) for cancer surgery. All Mohs surgery patients treated at TOH resided within postal districts in eastern and northern Ontario. CONCLUSION: The current wait time for Mohs surgery in the Ottawa region is beyond the standard for cancer treatment. Improving access to care and incorporating Mohs surgery into the Ministry of Health and Long-Term Care's Wait Time Strategy might significantly improve this.

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.

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.

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.

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.

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.

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.

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.

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.

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.