Faculty Bibliography

A 31-gene expression profile (GEP) test to predict metastasis risk has been validated with over 900 cutaneous melanoma (CM) tumor samples. The test generates Class 1 (low-risk) or 2 (highrisk) results, which are associated with significantly different 5- year distant metastasis free survival rates (91% versus 57%, resp). 157 dermatologists who attended a national educational dermatology conference were presented with the clinical validity evidence for the 31-GEP test, followed by a description of a 30- year-old male with a thigh lesion that was biopsy confirmed melanoma, without ulceration or atypical features and no family or personal history of skin cancer. They were asked to provide the Breslow thickness (BT; ranging from 0.7-1.5 mm) at which they would recommend sentinel lymph node biopsy (SLNB), oncology referral, or imaging. The majority of respondents (62%, 57%, and 55%, resp) indicated a BT of 1.0 mm as the thickness to manage a patient with each modality, reflecting an adherence to current management guidelines. Respondents were then asked the same question in the context of a Class 1 or Class 2 result. After inclusion of a Class 1 result, responses reflecting the BT inflection points for guiding SLNB, oncology referral and imaging were changed in 23%, 18% and 19% of cases, resp, with risk-appropriate changes (increased BT) of 87%, 83% and 59%. Following addition of a Class 2 outcome to patient characteristics, the initial BT used to guide SLNB, medical oncology referral, and imaging was changed in 47%, 50% and 47% of the responses, resp, with 95%, 84% and 97% of the cases changed in a risk-appropriate direction (decreased BT). The results indicate that the 31-GEP test may have a significant and appropriate impact upon CM patient management while remaining within the context of the established practice guidelines that exist today

BACKGROUND: Guidelines exist for the management of cutaneous malignant melanoma, but their adoption, prevalence, and impact have not yet been determined. OBJECTIVE: To determine current melanoma clinical management practices of US dermatologists and the variance from guidelines that might exist. METHODS: A cross-sectional e-mail survey study assessing preferred biopsy methods for lesions suspicious for melanoma, margins used for excision, and recommended follow-up intervals were sent to 6177 US dermatologists (540 responding). The representative nature of the responding subset was verified by comparing their demographics to that from the American Academy of Dermatology (AAD) membership. RESULTS: Management varied from published guidelines. Shave biopsy (35%) was the most commonly used method followed by narrow excisional biopsy (31%), saucerization/scoop shave (12%), punch (11%), and wide excision (3%). Excisional margins narrower than recommended were noted and follow-up intervals varied. There were significant management differences noted for dermatologists by practice setting and by years in practice. LIMITATIONS: The impact of patient history, lesion anatomic site, and size of lesion were not assessed. Recall and nonresponder sampling bias may exist. CONCLUSION: Variations in dermatologists' approaches to melanoma management and variance from current guidelines suggest that a knowledge gap may exist representing an educational opportunity. However, emerging data may also justify deviations from existing guidelines, suggesting a reassessment of the guidelines may be indicated.

The American Academy of Dermatology and dermatologists' themselves, have recommended public education and patient counseling regarding sunscreen. The purpose of this study was to determine US dermatologists' actual sunscreen perceptions as well as their recommendations and personal usage. 540 practicing US dermatologists responded to an online survey that assessed each physician's perception of safety and efficacy of sunscreen, recommendation factors, and personal usage. Dermatologists have an overall positive view of sunscreen. 99% of dermatologists agree that regular sunscreen use helps lower skin cancer risk, reduces subsequent photoaging, and recommend their family/friends use sunscreen. Most dermatologists believe that oxybenzone and retinyl palmitate are safe in sunscreen (86% and 85%, respectively). Dermatologists used multiple sunscreen recommendation criteria including Sun Protection Factor (SPF) level, broad spectrum protection, cosmetic elegance/feel, and photostability (96%, 98%, 85%, and 68%, respectively). The use of sunscreen remains a critical part of sun protection. Therefore, it is important to assess and understand the perspective and patient recommendations provided by dermatologists.

J Drugs Dermatol 2016;15(9):1121-1123.

Spectators at baseball games may receive a considerable amount of exposure to solar UV radiation (UVR). The purpose of this study was to evaluate if public education about sun protection over the last 10 years has impacted the use of hats at Major League Baseball (MLB) games. Photographs of seating sections during a 3-game series in New York, New York, were obtained and analyzed to evaluate the percentage of spectators wearing hats. Different seating sections were evaluated (sunny, shaded, bleachers) and assessed as well as compared to similar data reported 10 years prior. Given the limited change in hat use over the last decade, a knowledge and behavioral gap exists that may be exploitable to achieve better skin cancer prevention.

BACKGROUND: Early detection and subsequent management of melanoma are critical for patient survival. New technologies have been developed to augment clinician analysis of suspicious pigmented skin lesions. OBJECTIVE: To determine how information provided by a multispectral digital skin lesion analysis device affects the biopsy decisions of international dermatologists following clinical and dermoscopic pigmented skin lesion evaluation. METHODS: Participants at a dermoscopy conference in Vienna, Austria, were shown 12 clinical and dermoscopic images of pigmented skin lesions (2 melanomas in situ, 3 invasive melanomas, and 7 low-grade dysplastic nevi) previously analyzed by multispectral digital skin lesion analysis. Participants were asked if they would biopsy the lesion based on clinical images, again after observing high-resolution dermoscopy images, and again when subsequently shown multispectral digital skin lesion analysis information. RESULTS: Data were analyzed from a total of 70 international dermatologists. Overall, sensitivity was 58 percent after clinical evaluation (C) and 59 percent post-dermoscopy (D), but 74 percent after multispectral digital skin lesion analysis. Participant specificity was 56 percent (C) decreasing to 51 percent (D), but increasing to 61 percent with multispectral digital skin lesion analysis. Diagnostic accuracy was 57 percent (C) decreasing to 54 percent (D), but increasing to 67 percent for dermatologists after integrating the multispectral digital skin lesion analysis data into the biopsy decision. The overall number of lesions biopsied increased from 50 percent (C) to 53 percent (D), rising to 54 percent after multispectral digital skin lesion analysis. CONCLUSION: Decisions to biopsy melanocytic lesions were more sensitive and specific when multispectral digital skin lesion analysis information was provided with no significant increase in the number of biopsies recommended. Providing multispectral digital skin lesion analysis data may lead to additional improvement in biopsy accuracy with a concomitant decrease in the number of nonessential biopsies for pigmented skin lesions even after dermoscopic evaluation.

Background: The American Academy of Dermatology and FDA recommend reapplying sunscreen at two hour intervals. Additionally, the sun protection factor (SPF) of sunscreens is tested using a thickness of 2 mg/cm². However, studies show that sunscreen under real-life conditions is neither applied sufficiently and often not reapplied. Recently developed sunscreen products claim to offer improved water resistance and photostability. This study investigated the durability of two current sunscreens with different SPF protection over an eight hour period. Methods: Participants (n = 50) were randomized into two study groups utilizing either 2 mg/cm² (FDA testing concentration) or 1 mg/cm² (real-life application levels) amounts of sunscreen. Two current SPF 15 and 70 sunscreens were applied to test spots on each participant's back. In vivo SPF values were obtained at baseline, 3.5, and 8 hours post initial application during which subjects completed 30 minutes of moderate exercise followed by 80 minutes of water exposure. All participants and evaluators were blinded of their study group or product used. Results: Participants in both dose study groups revealed only a 15-20% overall decrease in their SPF protection 8 hours after application. The study group that received half the FDA test concentration of sunscreen also achieved approximately half or less the labeled SPF. At 8 hours, the test sites that received SPF 70 maintained an average SPF greater than 60 (2 mg/cm² application) and 20 (1 mg/cm² application). Similarly, the SPF 15 product test sites revealed an in vivo protection of 12 (2 mg/cm²) and 6 (1 mg/cm²). Conclusions: This study demonstrates that current sunscreens may be durable on skin even following significant exercise and water exposure suggesting that reapplication intervals may be longer than currently recommended. In addition, the higher SPF sunscreen maintained a skin-cancer protective level of SPF following extended use. High SPF sunscreen may provide an additional margin of safety especially for people who do not reapply frequently. Advances in sunscreen technology should continue to involve higher SPF products that can offer durable real-use protection

OBJECTIVE:To correlate Multi-spectral Digital Skin Lesion Analysis classifier scores with histopathological severity of pigmented lesions and clinical features of melanoma. DESIGN/METHODS:Classifier scores were computed for 1,632 skin lesions. Dermatologists evaluated the same lesions for Asymmetry, Border Irregularity, Color variegation, Diameter >6mm, Evolution, Patient's Concern, Regression, and/or "Ugly Duckling" sign. Classifier scores were correlated to the number of clinical risk features and for six histopathological severity levels of pigmented lesions. MEASUREMENTS/METHODS:Average classifier score, Welch's t-test, and chi-square analysis. RESULTS:Melanomas had higher mean classifier scores (3.5) than high-grade dysplastic nevi (2.7, p=0.002), low-grade dysplastic nevi (1.7, p<0.0001), non-dysplastic nevi (1.6, p<0.0001), and benign non-melanocytic lesions (2.0, p<0.0001). Classifier score and the number of clinical risk characteristics directly correlated (Pearson coefficient 0.32, p<0.0001). CONCLUSION/CONCLUSIONS:Correlation of classifier scores to clinical and histological melanoma features supports the effectiveness of Multi-spectral Digital Skin Lesion Analysis in assessing the risk of pigmented lesions requiring biopsy. Optimizing outcomes of dermatologist decisions to biopsy suspicious pigmented lesions may be enhanced utilizing Multi-spectral Digital Skin Lesion Analysis.