Faculty Bibliography

BACKGROUND:Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience an increased skin cancer-associated in morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. METHODS:We conducted three rounds of Delphi-method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. RESULTS:The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance post-transplant. High-risk patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. CONCLUSION/CONCLUSIONS:We propose a standardized approach to skin cancer screening in SOTR based on multi-disciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

Acral lentiginous melanoma (ALM) is a rare but aggressive subtype of melanoma often associated with poor prognosis. Although overall incidence is rare, ALM accounts for a larger proportion of melanomas among black, Asian, and Hispanic individuals than among white individuals. Similarly, the proportion of acral melanocytic nevi tends to be greater in ethnic skin despite a lower overall nevi count. Dermoscopy can help differentiate between benign and malignant acral melanocytic lesions. Herein, we discuss the population trends of acral melanocytic lesions in patients with skin of color. We also examine the diagnostic challenges of acral lesions and review the dermoscopic patterns unique to acral volar skin.

BACKGROUND:The role of female sex hormones in the pathogenesis of malignant melanoma (MM) remains controversial. While melanocytes appear to be hormonally responsive, the effect of estrogen on MM cells is less clear. Available clinical data does not consistently demonstrate that increased endogenous hormones from pregnancy, or increased exogenous hormones from oral contraceptive pills and hormone replacement, impact MM prevalence and outcome. OBJECTIVE:We sought to examine potential associations between in vitro fertilization (IVF) and melanoma. METHODS:A literature review was conducted. Primary outcomes were reported as associations between IVF and melanoma risk, as compared to the general population. Secondary outcomes included associations stratified by type of IVF regimen and subgroup, such as parous versus nulliparous patients. RESULTS:Eleven studies met our inclusion criteria. Five studies found no increased risk of MM among IVF users as compared to the general population. Two studies found an increase in MM in clomiphene users. Four studies found an increase in MM among patients who were gravid or parous either before or after IVF. CONCLUSIONS:The reviewed studies do not reveal consistent patterns of association between IVF and MM among all infertile women. However, the data indicates that there may be an increased risk of MM in ever-parous patients treated with IVF. High-quality studies, which include a large number of MM cases and control for well-established MM risk factors, are needed to adequately assess the relationship between IVF and MM, particularly among ever-parous women.

Importance/UNASSIGNED:As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce. Objective/UNASSIGNED:To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme. Design, Setting, and Participants/UNASSIGNED:This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists. Main Outcomes and Measures/UNASSIGNED:Active US dermatologist and physician density. Results/UNASSIGNED:In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities. Conclusions and Relevance/UNASSIGNED:Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

The clinically atypical nevus (CAN) has long been a contentious entity in the dermatologic community, largely owing to its ability to clinically and histologically resemble melanoma. This has led some to assert that CAN are melanoma precursors. While studies have indicated that CAN mark persons at increased risk for melanoma, the lifetime risk of transformation of an individual nevus into a melanoma has been estimated to be far less than 1 in 1,000, with at least half of melanomas suggested to arise de novo rather than within a preexisting nevus. Despite this evidence, differing attitudes toward the biologic significance and malignant potential of CAN have resulted in substantial variation in management among clinicians. We conducted an IRB-approved survey to assess differences in the attitudes and practices among newly trained dermatologists compared with pigmented lesion specialists regarding the management of CAN. We surveyed 295 specialists from the International Dermoscopy Society (IDS) and 139 U.S. dermatology chief residents, with response rates of 57% (n = 168/295) and 59% (n = 82/139), respectively. Sixty-one percent of chief residents believe dermoscopy helps differentiate melanomas from benign lesions, yet only 39% believe they perform fewer biopsies with dermoscopy. Lacking evidence-based guidelines, most chief residents (68%) use <=1-mm margins in the initial biopsy of CAN, which may be suboptimal, while most IDS members (60%) use >=2-mm margins. There were substantial differences between IDS members and chief residents with respect to management of CAN after biopsy. For biopsies in which the margins came back free, 67% of chief residents would reexcise the site depending on the degree of histologic atypia, in contrast to only 11% of IDS members who would reexcise. The results of our survey noted considerable variability in the clinical management of CAN among specialist and novice dermatologists. The use of educational guidelines may assist in narrowing these practice gaps.
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