Faculty Bibliography

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.

BACKGROUND: The incidence of melanoma has been rising over the past century. With 37% of patients presenting to their primary care physician with at least 1 skin problem, primary care physicians and other nondermatologist practitioners have substantial opportunity to make an impact at the forefront of the disease process. New diagnostic aids have been developed to augment physician analysis of suspicious pigmented skin lesions (PSLs). OBJECTIVE: To determine the effects of computer-aided multispectral digital skin lesion analysis (MSDSLA) on dermatologists' and nondermatologist clinicians' decisions to biopsy suspicious PSLs after clinical and dermatoscopic evaluation. METHODS: Participants were shown 6 images of PSLs. For each PSL, participants were asked 3 times if they would biopsy the lesion: first after reviewing a clinical image of the PSL, again after reviewing a high-resolution dermatoscopic image, and again after reviewing MSDSLA probability findings. An answer was right if a melanoma or high-risk lesion was selected for biopsy or a low-risk lesion was not selected for biopsy. An answer was wrong if a melanoma or high-risk lesion was not selected for biopsy or a low-risk lesion was selected for biopsy. Clinicians' decisions to biopsy were evaluated using chi(2) analysis for proportions. RESULTS: Data were analyzed from a total of 212 participants, 177 of whom were dermatologists. Overall, sensitivity of clinical image review was 63%; dermatoscopic image review, 5%; and MSDSLA, 83%. Specificity of clinical image review was 59%; dermatoscopic image review, 40%; and MSDSLA, 76%. Biopsy decision accuracy was 61% after review of clinical images, 52% after review of dermatoscopic images, and 80% after review of MSDSLA findings. The number of lesions participants indicated that they would biopsy increased significantly, from 52% after reviewing clinical images to 63% after reviewing dermatoscopic images (P<.001). However, the overall number of specimens that participants indicated they would biopsy did not change significantly after they reviewed MSDSLA findings (53%). CONCLUSION: Sensitivity, specificity, and biopsy decision accuracy increased after clinicians reviewed MSDSLA findings. The use of objective, computer-based diagnostic aids such as MSDSLA during clinical evaluations of ambiguous PSLs could aid clinicians' decisions to biopsy such lesions.

OBJECTIVE: To determine the impact of multispectral digital skin lesion analysis on German dermatologist biopsy decisions of atypical pigmented skin lesions. DESIGN: Participants were shown high-resolution clinical images of 12 atypical pigmented skin lesions previously analyzed by multispectral digital skin lesion analysis. Participants were asked if they would biopsy the lesion based on clinical images and high-resolution dermoscopy images and again when subsequently shown multispectral digital skin lesion analysis probability information. SETTING/PARTICIPANTS: Forty-one dermatologists at a skin cancer conference in Germany in September 2014. MEASUREMENTS: Sensitivity, specificity, diagnostic accuracy, percent biopsying all melanomas, and overall biopsy rates. RESULTS: Sensitivity for the detection of melanoma following clinical evaluation was 64 percent. After receipt of multispectral digital skin lesion analysis probability information, sensitivity decreased nonsignificantly to 62 percent. Specificity with clinical evaluation was 57 percent and increased to 73 percent using multispectral digital skin lesion analysis. Overall biopsy accuracy increased from 60 percent with clinical evaluation to 68 percent with multispectral digital skin lesion analysis. The percentage of low-grade dysplastic nevi chosen for biopsy decreased from 43 percent after clinical evaluation to 27 percent with multispectral digital skin lesion analysis. Finally, the overall percentage of lesions biopsied decreased from 52 percent with clinical evaluation to 42 percent after multispectral digital skin lesion analysis. CONCLUSION: Multispectral digital skin lesion analysis can be used reliably to detect melanoma as well as clinical evaluation. Dermatologists can confidently use multispectral digital skin lesion analysis to significantly improve specificity and reduce their overall number of biopsies while increasing overall diagnostic accuracy.