Faculty Bibliography

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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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.

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.

Managing pregnant patients with a history of melanoma or with a melanoma diagnosis can be daunting and confusing for dermatologists. We present three clinical scenarios that raise questions about the safety of pregnancy in patients with a history of melanoma, skin biopsies during pregnancy, and excisions and sentinel lymph node biopsies during pregnancy. Our recommendations incorporate the most up-to-date clinical data to help guide clinicians when faced with pigmented lesions and melanoma in a pregnant patient.

Melanocytic lesions of acral sites are common, with an estimated prevalence of 28-36% in the USA. While the majority of these lesions are benign, differentiation from acral melanoma (AM) is often challenging. AM is a unique subtype of melanoma, with distinct molecular characteristics that are thought to contribute to its high rate of locoregional recurrence and worse prognosis. The advent of dermoscopy has since improved the diagnostic accuracy of AM, resulting in earlier detection and arguably improved survival. Additionally, the identification of unique genomic amplifications in AM invites the potential for future AM-specific targeted therapies. Herein, we discuss the importance of dermoscopy in the diagnosis of acral melanocytic lesions and review the treatment strategies for AM.

Throughout pregnancy, the body undergoes a variety of physiologic changes. The cutaneous findings can be most noticeable and often worrisome to both physicians and patients. Obstetricians and dermatologists must be able to differentiate between changes that are benign and those that may be pathologic. Most physicians recognize benign changes that are commonly described in literature such as hyperpigmentation, melasma, striae gravidarum, and telogen effluvium; however, they may be unaware of changes that tend to be less frequently discussed. This comprehensive review provides a broad overview of the physiologic cutaneous changes that occur during pregnancy as described in the literature over the past 10 years.

BACKGROUND: Complete removal of individual dysplastic nevi (DN) is often accomplished by a second surgical procedure after the initial biopsy. The choice to perform the second procedure is strongly influenced by histopathologic margin status of the initial biopsy specimen. OBJECTIVE: To evaluate the clinical and histopathologic outcomes of in toto biopsy of DN using a predetermined margin of normal skin. METHODS: We conducted a prospective study of a saucerization method using a defined 2-mm margin in patients undergoing biopsy of a pigmented skin lesion. RESULTS: We performed 151 biopsies in 138 patients. Overall, 137 of 151 lesions subjected to biopsy (90.7%) were melanocytic: 86 DN (57.0%), 40 nevi without atypia (26.5%), and 11 melanomas (7.3%). Of 78 DN, 68 (87.2%) were removed with clear histopathologic margins (8 DN were excluded because of inadequate processing). There was no clinical evidence of recurrence at any of the biopsy sites that were simply observed (i.e., not re-excised) over a median of 16.9 months. LIMITATIONS: There were few biopsies performed on the face. CONCLUSIONS: The complete histopathologic removal of nearly 9 of 10 DN using a peripheral margin of 2 mm of normal skin and a depth at the dermis and subcutaneous fat junction has the potential to decrease second procedures at DN biopsy sites, thereby decreasing patient morbidity and saving health care dollars.

Identifying new or changing melanocytic lesions, particularly in patients with numerous or atypical nevi, can be challenging. Total-body photography and sequential digital dermoscopy imaging, together known as digital follow-up, are 2 prominent forms of noninvasive imaging technology used in mole mapping that have been found to improve diagnostic accuracy, detect earlier-stage melanomas, and reduce costs. Digital follow-up, in combination with direct-to-consumer applications and teledermatology, is already revolutionizing the ways in which physicians and patients participate in melanoma surveillance and will likely continue to enhance early detection efforts.