BACKGROUND Although dermatologists perform more cutaneous reconstructions than any other specialists for the Medicare population, the perception of dermatologists as surgeons may not be as fully recognized. Mohs surgeons are trained in complex reconstructions of cosmetically and functionally sensitive (CFS) sites, although the proportion they account for is unknown. OBJECTIVE To quantify the proportion of cutaneous reconstructions in CFS sites performed by Mohs surgeons compared with other specialists, and to identify trends from 2013 to 2019. METHODSA cross-sectional analysis was performed using the Medicare Public Use Files for 2013 to 2019. Data were stratified by physician specialty, with dermatologists further subdivided into Mohs surgeons and non-Mohs dermatologists. RESULTS Mohs surgeons performed 75.3% of all reconstructions in 2019, a significant increase from 2013 (p < .0001). Mohs surgeons dominated nearly every type of CFS cutaneous reconstruction, with significant increases in proportion (p < .0001) from 2013 to 2019 for every category except interpolation flaps. Complex repairs were the most commonly performed cutaneous reconstruction type. CONCLUSION Mohs surgeons perform far more cutaneous reconstructive surgeries in CFS sites than any other specialty for the Medicare population, with significant increases in their lead over the study period.

Dental dams are a barrier method of protection, which may help prevent the spread of sexually transmitted infections during oral-vaginal or oral-anal sex. Despite their relative simplicity of use, data on dental dams are limited and patients infrequently utilize this method of barrier protection because of the lack of awareness, perceived barriers to procurement and accessibility, and unfamiliarity on the part of health educators. Nevertheless, increased knowledge of dental dams may be beneficial especially in high-risk populations, where sexually transmitted infections are more common and remain a significant cause for morbidity. This article aims to increase awareness and knowledge of dental dams, as well as provide an informational guide on their procurement and use that may be helpful to dermatologists when counseling patients.

Background: MoleMap NZ is a novel New Zealande-based store-and-forward telemedicine service to detect melanoma. It uses expert review of total body photography and close-up and dermoscopic images of skin lesions that are suspicious for malignancy. Objective: The purpose of this study was to assess the effectiveness of MoleMap NZ as a melanoma early detection program. Methods: We conducted a review of 2108 melanocytic lesions recommended for biopsy/excision by MoleMap NZ dermoscopists between January 2015 and December 2016. Results: Pathologic diagnoses were available for 1571 lesions. Of these, 1303 (83%) lesions were benign and 260 (17%) lesions were diagnosed as melanoma, for a melanoma-specific benign:malignant ratio of 5.0:1. The number needed to biopsy to obtain 1 melanoma was 6. Among melanomas with available tumor thickness data (n = 137), 92% were\0.8 mm (range in situ to 3.1 mm), with in situ melanomas comprising 74%. Limitations: Only lesions recommended for excision were analyzed. Pathology results were available for 75% of these cases. Tumor thickness data were available for 53% of melanomas diagnosed. Conclusions: This real-world study of MoleMap NZ, a community-based teledermoscopy program, suggests that it has the potential to increase patients' access to specialist expertise via telemedicine. Additional studies are needed to more accurately define its efficacy.

Importance Dermoscopy education in US dermatology residency programs varies widely, and there is currently no existing expert consensus identifying what is most important for resident physicians to know. Objectives To identify consensus-based learning constructs representing an appropriate foundational proficiency in dermoscopic image interpretation for dermatology resident physicians, including dermoscopic diagnoses, associated features, and representative teaching images. Defining these foundational proficiency learning constructs will facilitate further skill development in dermoscopic image interpretation to help residents achieve clinical proficiency. Design, Setting, and Participants A 2-phase modified Delphi surveying technique was used to identify resident learning constructs in 3 sequential sets of surveys—diagnoses, features, and images. Expert panelists were recruited through an email distributed to the 32 members of the Pigmented Lesion Subcommittee of the Melanoma Prevention Working Group. Twenty-six (81%) opted to participate. Surveys were distributed using RedCAP software. Main Outcomes and Measures Consensus on diagnoses, associated dermoscopic features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for US dermatology resident physicians. Results Twenty-six pigmented lesion and dermoscopy specialists completed 8 rounds of surveys, with 100% (26/26) response rate in all rounds. A final list of 32 diagnoses and 116 associated dermoscopic features was generated. Three hundred seventy-eight representative teaching images reached consensus with panelists. Conclusions and Relevance Consensus achieved in this modified Delphi process identified common dermoscopic diagnoses, associated features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for dermatology residency training. This list of validated objectives provides a consensus-based foundation of key learning points in dermoscopy to help resident physicians achieve clinical proficiency in dermoscopic image interpretation.

To the Editor: Patients with clinically atypical and increased numbers of nevi may pose a diagnostic and management challenge to dermatologists. Sequential digital dermoscopic imaging and total body photography facilitate the identification of early-stage melanomas and minimize biopsies of benign lesions.1 We recently reported the performance of a proprietary, New Zealand-based telemedicine platform (MoleMap NZ) that integrates total body photography and dermoscopy to help address the country's high incidence of melanoma.

The growth of molecular technologies analyzing skin cells and inherited genetic variations has the potential to address current gaps in both diagnostic accuracy and prognostication in patients with melanoma or in individuals who are at risk for developing melanoma. In the second article in this continuing medical education series, novel molecular technologies are reviewed. These have been developed as adjunct tools for melanoma management and include the Pigmented Lesion Assay, myPath Melanoma, and DecisionDx-Melanoma tests, and genetic testing in patients with a strong familial melanoma history. These tests are commercially available and marketed as ancillary tools for clinical decision-making, diagnosis, and prognosis. We review fundamental principles behind each test, discuss peer-reviewed literature assessing their performance, and highlight the utility and limitations of each assay. The goal of this article is to provide a comprehensive, evidence-based foundation for clinicians regarding the management of patients with difficult pigmented lesions.

Tan, Andrea BS; Martinez Luna, Orlando BS; Glass, Donald A. II MD, PhD Author Information

Managing the balance between accurately identifying early stage melanomas while avoiding obtaining biopsy specimens of benign lesions (ie, overbiopsy) is the major challenge of melanoma detection. Decision making can be especially difficult in patients with extensive atypical nevi. Recognizing that the primary screening modality for melanoma is subjective examination, studies have shown a tendency toward overbiopsy. Even low-risk routine surgical procedures are associated with morbidity, mounting health care costs, and patient anxiety. Recent advancements in noninvasive diagnostic modalities have helped improve diagnostic accuracy, especially when managing melanocytic lesions of uncertain diagnosis. Breakthroughs in artificial intelligence have also shown exciting potential in changing the landscape of melanoma detection. In the first article in this continuing medical education series, we review novel diagnostic technologies, such as automated 2- and 3-dimensional total body imaging with sequential digital dermoscopic imaging, reflectance confocal microscopy, and electrical impedance spectroscopy, and we explore the logistics and implications of potentially integrating artificial intelligence into existing melanoma management paradigms.

To the Editor: The halo nevus is thought to be of little concern in children. In adults, however, a new-onset halo nevus has been suggested to be a harbinger of melanoma either within the halo nevus or at distant cutaneous or noncutaneous sites, according to case reports and small case series.1Epstein W.L. Sagebeil R. Spitler L. Wybran J. Reed W.B. Blois M.S. Halo nevi and melanoma.JAMA. 1973; 225: 373-377Crossref PubMed Scopus (62) Google Scholar,2Pellegrini J.R. Wagner Jr., R.F. Nathanson L. Halo nevi and melanoma.Am Fam Physician. 1984; 30: 157-159PubMed Google Scholar Multiple widely used dermatologic reference texts3Bolognia J. Schaffer J.V. Cerroni L. Dermatology: 2-Volume Set. Elsevier, Philadelphia, PA2017Google Scholar,4James W.D. Berger T.G. Elston D.M. Andrews' Diseases of the Skin. Saunders/Elsevier, London, England2011Google Scholar and online references (eg, UpToDate.com, DermNetNZ.org) advocate extensive melanoma screening in adults with new-onset halo nevus, including full cutaneous, oral, ophthalmic, and vaginal examinations, despite limited evidence supporting an association between halo nevus and melanoma. We aimed to further investigate the association between new-onset halo nevus and melanoma in adults by evaluating the incidence of melanoma in the year after a new halo nevus diagnosis. A multicenter retrospective chart review of clinical and histopathologic records at 8 university hospitals identified 879 patients in whom 888 halo nevi were diagnosed at aged 18 years or older (Brigham and Women's Hospital [n = 80], Massachusetts General Hospital [n = 166], New York University [n = 7], Northwestern University [n = 36], Oregon Health & Science University [n = 103], University of Pennsylvania [n = 27], Huntsman Cancer Institute and the University of Utah [n = 364], and Yale University [n = 96]). Ethical approval was obtained from each university's institutional review board. Patients being treated with immunotherapy for melanoma were excluded. Mean age at halo nevus diagnosis was 36.3 years (standard deviation 13.2 years) (Table I). Clinical records review identified 95 occurrences of melanoma in these 879 patients. Only 9 halo nevi were diagnosed within 1 year before melanoma diagnosis, representing a melanoma incidence rate of 0.01 (95% confidence interval 0.004-0.017) per person per year. All 9 of these melanomas represented primary cutaneous melanoma; there were no occurrences of primary noncutaneous melanoma, metastatic melanoma, or melanoma within the incident halo nevus. None of these 9 patients presented with multiple halo nevi. The remaining 86 melanoma diagnoses occurred either before the halo nevus diagnosis (n = 78) or greater than 1 year after (n = 8) (mean 5.75 years [standard deviation 4.30 years]). Personal history of vitiligo was not significantly associated with odds of melanoma development within the year after an incident halo nevus (odds ratio 3.97; 95% confidence interval 0.65-24.2; P = .13).Table IPatient demographicsCharacteristicAll patients with HN, n = 879Patients with melanoma diagnosed in the year after a new HN, n = 9Patients without melanoma diagnoses, n = 784Mean age at HN diagnosis ± SD, y36.3 ± 13.239.1 ± 11.935.3 ± 12.7 18–39580 (66)5 (55.6)540 (68.9) 40–59212 (24.1)4 (44.4)174 (22.2) 60–7968 (7.7)051 (6.5) ≥801 (0.1)01 (0.1) Unknown18 (2.0)018 (2.3)Mean age at melanoma diagnosis ± SD, y39.4 ± 14.740.4 ± 11.8NASex Men348 (39.6)5 (55.6)307 (39.3) Women529 (60.2)4 (44.4)475 (60.6) Unknown2 (0.2)02 (0.3)Race White799 (90.9)9 (100)711 (90.7) Nonwhite18 (2.0)017 (2.2) Unknown62 (7.1)056 (7.2)Halo nevus biopsied Yes396 (45.1)6 (66.7)345 (44.0) No474 (53.9)3 (33.3)431 (55.0) Unknown9 (1.0)08 (1.0)Vitiligo Yes78 (8.9)2 (22.2)70 (8.9) No450 (51.2)3 (33.3)391 (49.9) Unknown351 (39.9)4 (44.4)323 (41.2)Values are provided as No. (%) unless otherwise indicated.HN, Halo nevus; NA, not applicable; SD, standard deviation. Open table in a new tab Values are provided as No. (%) unless otherwise indicated. HN, Halo nevus; NA, not applicable; SD, standard deviation. Limitations of the study include the retrospective design and heterogeneity by which each site identified halo nevus cases. Halo nevus and melanoma were identified by documentation and coding that may not accurately reflect the true date of onset or incidence. In conclusion, this study found that adult-onset halo nevi were associated with a 1% risk of primary cutaneous melanoma development in the year after halo nevus diagnosis, with no cases of primary noncutaneous or metastatic melanoma. This melanoma risk is comparable to that of individuals with a history of atypical nevi or personal or family history of melanoma.5Varedi A. Bishop M.D. Boucher K.M. Kim C.C. Grossman D. Powering a prospective melanoma chemoprevention trial in high-risk cohorts.Int J Dermatol. 2019; 58: e232-e234Crossref PubMed Scopus (3) Google Scholar Given these findings, we recommend annual total body skin examinations in adults with a new diagnosis of halo nevus and without additional risk factors, and we do not advocate reflexive screening for primary noncutaneous or metastatic melanoma.

A 30-year-old man presented with a 6-month history of an exophytic mass growing on the lower mid-back (Figure 1). It was initially suspected to be verruca vulgaris, and he had been referred to a specialty clinic for sexually transmitted infections to confi rm it. The lesion was occasionally tender to palpation and bled spontaneously. Physical examination revealed a 1.5-cm ulcerated, violaceous-to-erythematous polypoid nodule with overlying serous crust on the lower back. No pigmentation was noted within the mass or adjacent to the base of the lesion. Histopathologic examination of a shave biopsy specimen revealed: • An exophytic polypoid lesion with broad ulceration, composed of markedly atypical melanocytes in a sheet-like pattern throughout the dermis (Figure 2A) • Focal epidermal contiguity with atypical melanocytes arranged in single cells and nests in the epidermis (Figure 2B) • A mitotic rate of greater than 30 mitoses/ mm2 (Figure 2C) • Lymphovascular invasion (Figure 2D) • Melanocytes highlighted by S-100 protein on immunohistochemical staining. These fi ndings were diagnostic of melanoma, specifi cally the polypoid variant, with a tumor thickness of 5 mm. The patient was referred for wide local excision with sentinel lymph node biopsy, which demonstrated inguinal node involvement and BRAF mutation on immunostaining. Positronemission tomography–computed tomography, magnetic resonance imaging, and computed tomography of the head, chest, abdomen, and pelvis were unrevealing. The formal diagnosis was stage IIIC disease (T4bN1M0). The patient began immunotherapy with nivolumab. He was treated with this drug for 1 year and now is on active surveillance.

The increasing presence of social media in dermatology has led to fundamental changes in how patients interact with the health care system. We present a case of a health-related pitfall associated with this technological shift.

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.

Vulvar malignancies represent a serious gynecologic health concern, especially given the increasing incidence over the past several decades. Squamous cell carcinoma and melanoma are common subtypes, although other neoplasms, such as basal cell carcinoma and Paget disease of the vulva, might be seen. Many vulvar cancers are initially misdiagnosed as inflammatory conditions, delaying diagnosis and worsening prognosis. It is essential that dermatologists are familiar with characteristic findings for each malignancy to ensure appropriate diagnosis and management. Herein, we review the unique epidemiologic and clinical characteristics of each major vulvar malignancy, as well as discuss their respective prognoses and current management recommendations.

Proton pump inhibitors (PPIs) are potent inhibitors of gastric acid secretion by parietal cells in gastric mucosa. Cutaneous pigmentation mimicking ashy dermatosis (AD)/erythema dyschromicum perstans (EDP) has been described with both omeprazole and esomeprazole. This report describes the presentation, histopathologic findings, and treatment of EDP-like pigmentation in the setting of lansoprazole and esomeprazole use.

To the Editor: Vitiligo may significantly impair quality of life, particularly in social functioning and interpersonal interactions.1Ongenae K. Van Geel N. De Schepper S. Naeyaert J.M. Effect of vitiligo on self-reported health-related quality of life.Br J Dermatol. 2005; 152: 1165-1172Crossref PubMed Scopus (150) Google Scholar Psychosocial interventions remain scarce, however. Social Interaction Skills Training (SIST) has been shown to significantly reduce social anxiety and avoidance and improve confidence in patients with visible differences.2Robinson E. Rumsey N. Partridge J. An evaluation of the impact of social interaction skills training for facially disfigured people.Br J Plast Surg. 1996; 49: 281-289Abstract Full Text PDF PubMed Scopus (184) Google Scholar SIST incorporates cognitive behavioral therapy principles, using coping mechanisms to retrain maladaptive thinking patterns and communication techniques to reframe interactions. Common techniques include social dynamic exploration, behavioral modeling, role playing, feedback, and coaching. We developed a SIST workshop for vitiligo patients (Supplemental Table I, available at https://doi.org/10.17632/rcw37kjcrp.1), based on principles emphasized by Robinson et al and the British charity Changing Faces.2Robinson E. Rumsey N. Partridge J. An evaluation of the impact of social interaction skills training for facially disfigured people.Br J Plast Surg. 1996; 49: 281-289Abstract Full Text PDF PubMed Scopus (184) Google Scholar Primary end points included the Social Avoidance and Distress (SAD) Scale.3Watson D. Friend R. Measurement of social-evaluative anxiety.J Consult Clin Psychol. 1969; 33: 448-457Crossref PubMed Scopus (2114) Google Scholar Secondary end points included the Brief Fear of Negative Evaluation-II (BFNE-II) Scale,3Watson D. Friend R. Measurement of social-evaluative anxiety.J Consult Clin Psychol. 1969; 33: 448-457Crossref PubMed Scopus (2114) Google Scholar,4Carleton R.N. Collimore K.C. Asmundson G.J. Social anxiety and fear of negative evaluation: construct validity of the BFNE-II.J Anxiety Disord. 2007; 21: 131-141Crossref PubMed Scopus (117) Google Scholar 2 visual analog scales5Salman A. Kurt E. Topcuoglu V. Demircay Z. Social anxiety and quality of life in vitiligo and acne patients with facial involvement: a cross-sectional controlled study.Am J Clin Dermatol. 2016; 17: 305-311Crossref PubMed Scopus (32) Google Scholar assessing comfort levels in social situations, and open-ended workshop-specific questionnaires. The SAD, BFNE-II, and visual analog scales are standardized instruments validated in measuring social avoidance and anxiety. This prospective pilot study, which was approved by the University of Texas Southwestern Medical Center Institutional Review Board, recruited 17 patients with vitiligo from the University of Texas Southwestern Medical Center Pigmentary Disorders Clinic (Table I). All were 18 years or older, fluent in English, had no significant neuropsychiatric history, and attended one of two 6-hour SIST workshops facilitated by clinical psychologists. Participants completed the outcome measures at 4 separate times: immediately before and after the workshop and again 3 and 8 weeks afterwards.Table IParticipant demographicsDemographic factorsParticipants (n = 17)NumberPercentageSex Male16 Female1694Age, y 15-29318 30-44847 45-59318 ≥60318Race/ethnicity African American424 White318 Hispanic741 South Asian318Body surface area involvement, % 0-10847 10-25741 25-5016 50-7516 75-10000 Open table in a new tab A repeated-measures analyses of variance was performed to assess quantitative scores (Table II), using imputation with the last-observation-carried-forward method to address any missing data. An inductive thematic analysis was conducted to interpret qualitative data and generate overarching themes/subthemes.Table IISummary of mean scoresAssessment scalePreworkshopPostworkshopWeek 0Week 3Week 8SAD11.767.53∗Significantly lower than preworkshop level (P < .01).8.47∗Significantly lower than preworkshop level (P < .01).7.65∗Significantly lower than preworkshop level (P < .01).BFNE-II36.9430.18∗Significantly lower than preworkshop level (P < .01).33.4132.29Visual analog scale Company of strangers52.7671.94†Significantly higher than preworkshop level (P < .01).63.65†Significantly higher than preworkshop level (P < .01).63.35†Significantly higher than preworkshop level (P < .01). Meeting new people54.8874.24†Significantly higher than preworkshop level (P < .01).67.76†Significantly higher than preworkshop level (P < .01).67.35†Significantly higher than preworkshop level (P < .01).BFNE-II, Brief Fear of Negative Evaluation-II; SAD, Social Avoidance and Distress.∗ Significantly lower than preworkshop level (P < .01).† Significantly higher than preworkshop level (P < .01). Open table in a new tab BFNE-II, Brief Fear of Negative Evaluation-II; SAD, Social Avoidance and Distress. SAD scores showed a significant decrease immediately after the workshop compared with preworkshop baselines at α = 0.05, which was also observed at the 3- and 8-week follow-up assessments. BFNE-II scores showed a significant decrease immediately after the workshop. Although scores were still decreased at 3 and 8 weeks compared with baseline, statistical significance was not reached at these time points. Scores on the visual analog scales showed significant increases for both items immediately after the workshop and at the 3- and 8-week follow-up assessments. Themes commonly reported before the workshop included low self-esteem and body acceptance, self-consciousness, social stigmatization, and a lack of adaptive coping strategies. Themes reported after the workshop included empowerment from new coping techniques, sense of community, and increased social confidence. These preliminary results suggest that although patients might still fear anticipated negative evaluations, the strategies and coping mechanisms learned from SIST may help reframe social interactions. Measurable improvements from this pilot study correlated to decreases in clinically significant social anxiety and avoidance, which Robinson et al2Robinson E. Rumsey N. Partridge J. An evaluation of the impact of social interaction skills training for facially disfigured people.Br J Plast Surg. 1996; 49: 281-289Abstract Full Text PDF PubMed Scopus (184) Google Scholar also observed. Study limitations include uneven sex distribution (possibly related to sex differences in perceived societal expectations), small sample size, and lack of controls. Future larger randomized controlled trials are needed to confirm findings. Vitiligo can be detrimental to the quality of life, psychological well-being, and social functioning of affected individuals. SIST may be useful for patients with vitiligo and warrants further exploration as a therapeutic intervention. More detailed information on how to conduct a SIST workshop can be obtained by contacting the corresponding author. We thank Changing Faces and the North Texas Burn Rehabilitation Model System (funded by National Institute on Disability, Independent Living, and Rehabilitation Research ) for providing the study concept and resources to develop our workshop, as well as Brandon Oscarson, at Children's Medical Center Dallas, for statistical assistance.