Primary care providers and medical students often receive limited dermatologic education, leading to delayed diagnosis and treatment for patients with cutaneous conditions. Additionally, dermatology education has historically focused on light skin, neglecting skin of color, which exacerbates diagnostic delays and treatment disparities. The University of Utah's Eccles Health Sciences Library and Department of Dermatology, along with Oregon Health & Science University, developed Utah Dermatology Education Resources & Modules (UtahDERM) to address these educational gaps. UtahDERM features a custom-built slide-viewer platform with clinical dermatology images, diagnoses, clinical characteristics, and textbook references, along with a quick reference tool for core dermatology diagnoses.

Introduction: Patients often present to clinicians who may not know how to accurately identify and diagnose dermatologic conditions. To address this educational gap, the University of Utah Department of Dermatology and Spencer S. Eccles Health Sciences Library digitized 15,000 photographs of both pediatric and adult dermatologic cases donated by Dr. Leonard Swinyer. This report summarizes the development and challenges of the UtahDERM (Dermatology Education Resources & Modules) project, an open-access and searchable database for displaying a vast repository of clinical images.

A 45-year-old man from Tonga was noted to have thick, scaly skin on both feet. He reported a 20-year history of painful calluses and fissures on the soles, as well as nail thickening and intermittent white patches in the oral cavity. On physical examination, there was thick, yellow-colored hyperkeratotic scale projecting from the plantar aspects of both feet (Fig 1), hypertrophic nail dystrophy, and wedge-shaped subungual hyperkeratosis (Fig 2).Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) Question 1: Which of the following investigations would be most useful in establishing the correct diagnosis?A.Skin scraping for potassium hydroxideB.Skin biopsyC.Nail clipping for histology and cultureD.Genetic testing Answers:A.Skin scraping for potassium hydroxide – Incorrect. Nail dystrophy and subungual hyperkeratosis can be seen in dermatophyte infection though the chronicity, severity, and associated keratoderma make this unlikely as the primary diagnosis.B.Skin biopsy – Incorrect. Biopsy of hyperkeratotic regions will demonstrate histopathologic findings suggestive of pachyonychia congenita (PC), such as atypical keratinocytes with pale cytoplasm and eosinophilic inclusions; however, genetic testing remains the gold standard for diagnosis.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google ScholarC.Nail clipping for histology and culture – Incorrect. Onychomycosis can mimic the nail changes seen in PC and dermatophyte infection can complicate PC secondarily, but nail fungus alone does not explain the chronic, severe presentation described previously.D.Genetic testing – Correct. PC is an autosomal dominant genodermatosis caused by mutations in keratins 6A, 6B, 6C, 16, and 17.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Although generally suspected based on clinical findings alone, molecular genetic testing should be performed to confirm the diagnosis and identify the causative keratin mutation.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar In our patient, genetic testing was performed and revealed a mutation in the keratin gene KRT16. Question 2: Which of the following is not commonly associated with the diagnosis pictured here?A.Oral leukokeratosisB.AlopeciaC.Pilosebaceous cystsD.Follicular keratoses Answers:A.Oral leukokeratosis – Incorrect. Oral leukokeratosis is a classic finding in PC and presents as white-gray, hyperkeratotic plaques, most commonly on the buccal mucosa but can also involve the tongue, palate, mucosal lips, larynx, and upper airway.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Involvement of the airway can cause acute airway obstruction in young children.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google ScholarB.Alopecia – Correct. Alopecia is not a typical finding in patients with PC but can be associated with a variety of other genodermatoses, including Clouston syndrome. Clouston syndrome, or hidrotic ectodermal dysplasia, classically presents with micronychia or anonychia, cone-shaped nails, palmoplantar hyperkeratosis, and sparse, fragile hair that progresses to alopecia by adulthood.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google ScholarC.Pilosebaceous cysts – Incorrect. Patients with PC frequently develop multiple cutaneous cysts.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Pilosebaceous cysts – including steatocystomas and vellus hair cysts – and epidermal inclusion cysts develop during adolescence and continue into adulthood.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google ScholarD.Follicular keratoses – Incorrect. Follicular keratoses at sites of friction, most commonly on the elbows and knees, are another finding commonly observed in pachyonychia congenita.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Question 3: Which abnormal gene product is implicated in the most likely diagnosis?A.Keratins 6, 16, and/or 17B.Connexin 30C.Transient receptor potential cation channelD.Keratins 5 and 14E.Various proteins involved in telomere maintenance Answers:A.Keratins 6, 16, and/or 17 – Correct. PC is inherited in an autosomal dominant fashion and results from mutations in 1 of 5 genes encoding epidermal keratins – KRT6A, KRT6B, KRT6C, KRT16, and KRT17.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar,2Eliason M.J. Leachman S.A. Feng B.J. Schwartz M.E. Hansen C.D. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita.J Am Acad Dermatol. 2012; 67: 680Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Spontaneous mutations in epidermal keratins occur in about one-third of patients with PC.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google ScholarB.Connexin 30 – Incorrect. Clouston syndrome is an autosomal dominant disorder resulting in mutations in GJB6 gene which encodes connexin 30.3Lamartine J. Munhoz Essenfelder G. Kibar Z. et al.Mutations in GJB6 cause hidrotic ectodermal dysplasia.Nat Genet. 2000; 26: 142-144Crossref PubMed Scopus (224) Google Scholar Both palmoplantar hyperkeratosis and nail dystrophy of Clouston syndrome can mimic PC but the partial or total alopecia is lacking in patients with PC.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google ScholarC.Transient receptor potential cation channel – Incorrect. Olmsted syndrome is a very rare keratinizing disorder that presents with palmoplantar keratoderma and periorificial keratotic plaques.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar The autosomal dominant form of Olmsted syndrome is caused by a gain of function mutation in the TRPV3 gene which encodes transient receptor potential cation channel, subfamily V, member 3.4Lin Z. Chen Q. Lee M. et al.Exome sequencing reveals mutations in TRPV3 as a cause of Olmsted syndrome.Am J Hum Genet. 2012; 90: 558-564Abstract Full Text Full Text PDF PubMed Scopus (252) Google ScholarD.Keratins 5 and 14 – Incorrect. Abnormal keratins 5 and 14 are implicated in epidermolysis bullosa simplex.5Fuchs E. Coulombe P. Cheng J. et al.Genetic bases of epidermolysis bullosa simplex and epidermolytic hyperkeratosis.J Invest Dermatol. 1994; 103: 25S-30SAbstract Full Text PDF PubMed Scopus (73) Google Scholar Epidermolysis bullosa simplex manifests as blisters and hyperkeratosis of the palms and soles but lacks the classic wedge-shaped nail dystrophy of PC.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar Additionally, palmoplantar blisters are not typical in PC, which can be another differentiating factor between the 2 entities.E.Various proteins involved in telomere maintenance – Incorrect. Dyskeratosis congenita (DC) is a genetically heterogenous disorder with multiple potential mutations all resulting in impaired telomere maintenance.6Ballew B. Savage S. Updates on the biology and management of dyskeratosis congenita and related telomere biology disorders.Expert Rev Hematol. 2013; 6: 327-337Crossref PubMed Scopus (107) Google Scholar This condition presents clinically as a triad of nail dystrophy, leukoplakia, and reticulated hyperpigmentation or poikiloderma.1Bolognia J.L. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsiever, 2018Google Scholar While both pachyonychia congenita and DC can have associated nail dystrophy and white patches/plaques of the oral mucosa, several key differences separate the conditions including distinctive nail dystrophies (omega nail in pachyonychia congenita vs longitudinal striation and/or brittleness in DC), the absence of palmoplantar hyperkeratosis in DC, and reticulated hyperpigmentation, which is present in DC but not PC. None disclosed.

BACKGROUND:Amelanotic melanoma (AM) is a rare form of melanoma lacking pigment. Data on AM risk factors and factors predicting survival are limited.OBJECTIVES:We sought to identify predictors of AM, survival differences in AM and melanotic melanoma, and AM-specific survival rates.METHODS:Using 2004 through 2015 National Cancer Database data, we compared 358,543 melanoma cases to 1,384 AM cases. Multivariable logistic regression identified AM risk factors, and AM survival was explored using Kaplan-Meier and multivariable Cox regression.RESULTS:Increased age; tumor location on the face, scalp, and neck; increased Breslow thickness; metastatic disease; ulceration; and higher mitotic rate were associated with AM. Five- and ten-year survival rates were higher for patients with MM (melanotic melanoma) than AM tumors (75.4% vs. 58.8% and 62.4% vs 45.1%; log-rank P<0.0001). No survival difference was seen after adjusting for staging factors. Among patients with AM, more recent diagnosis was associated with improved survival. Increased age, T4 tumor size, higher N-stage, metastasis, and ulceration predicted poorer survival. No survival advantage was seen for chemotherapy, immunotherapy, or radiation therapy, likely due to confounding.CONCLUSION:AM is more common in older patients on sun-exposed skin and is diagnosed at later stages. Advanced staging at diagnosis explains the survival differences. In patients with AM, regional and metastatic disease were the primary contributors of poorer outcomes. In at-risk patients, the threshold to biopsy should be lower for suspicious nonpigmented lesions.

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: Noninvasive techniques for facilitating melanoma detection include total body photography (TBP), serial digital dermoscopic imaging (SDDI), and reflectance confocal microscopy (RCM). Recommendations for implementing these technologies in clinical practice are lacking; therefore, a committee of dermato-oncologists performed an online Delphi process to obtain consensus opinion regarding appropriate use of these techniques. The principal investigators (R.A.W. and J.G.K.) selected 13 committee members based on their dermato-oncology experience. The principle investigators developed 24 clinical scenarios that were sent to committee members who evaluated each scenario using a 5-point Likert scale that ranged from strongly agree to strongly disagree. Committee members were asked to provide rationale for their position on each recommendation. At the end of the first round, all committee members were asked to propose scenarios for evaluation during the next round. Recommendations were considered to represent consensus of the committee if 75% or more of the committee members reported that they agreed/strongly agreed or disagreed/strongly disagreed with the statement (Table I). At the end of the second round, 11 consensus statements were generated (Table II).Table IList of all discussed scenariosTotal body photography—Round 1 Total body photography is recommended for evaluation of patients with a personal history of malignant melanoma Total body photography is recommended for evaluation of patients with either greater than 5 clinically atypical nevi or a personal history of biopsy proven dysplastic nevus Total body photography is recommended for evaluation of patients with a first-degree relative (eg, parent, sibling, child) with a history of malignant melanoma Total body photography is recommended for evaluation of patients with either known genetic mutations that confer risk of malignant melanoma or a syndrome that confers risk of malignant melanoma Total body photography is recommended for evaluation of adults with greater than 100 nevi who are otherwise at average risk for malignant melanoma Total body photography is recommended for evaluation of children with greater than 100 nevi who are otherwise at average risk for malignant melanoma Total body photography is recommended for evaluation of children with clinically atypical nevi AND a first-degree relative (e.g. parent, sibling, child) with a history of malignant melanoma Total body photography is recommended for evaluation of children with a history of a Spitz nevus In the above scenarios, total body photography is preferable to serial digital photography when available. Serial digital photography is recommended in the above scenarios when total body photography is not available When utilizing total body photography new images should be obtained at every total body skin examination When utilizing total body photography new images should be obtained once a year When utilizing total body photography new images should be obtained if the patient has had many skin biopsies or is developing new melanocytic lesions When available, total body photography should be performed in conjunction with serial digital dermoscopy imaging for evaluation of clinically atypical neviTotal body photography—Round 2 Total body photography is recommended for patients with familial atypical multiple mole melanoma syndrome (FAMMM Syndrome, aka dysplastic nevus syndrome) Total body photography is recommended in adults with more than 50 nevi that have 1 or more of the following: a personal history of multiple malignant melanomas, a personal history of an amelanotic melanoma, multiple pink nevi, multiple clinically atypical nevi, a genetic syndrome that predisposes to the development of malignant melanoma. Total body photography is NOT recommended for all patients with >50 nevi in the absence of atypical nevi, changing nevi, pink nevi, or significant risk factors for melanoma Total body photography is NOT recommended for all patients with a history of a solitary melanoma in the absence of >50 nevi, multiple clinically atypical nevi, pink nevi, or multiple changing nevi. Total body photography is generally NOT recommended in children given the volatility of their nevi and their low risk of developing a malignant melanoma. When utilizing total body photography it is recommended that new images should be obtained once previous images are not easily comparable to the patients current appearance When performing total body photography, the use of serial digital dermoscopy imaging and/or serial digital photography is also recommended for evaluation of clinically atypical neviSerial digital dermoscopic imaging—Round 1 Serial digital dermoscopic imaging is recommended in patients with less than 5 clinically atypical nevi who are otherwise at average risk for development of MM Initial repeat digital dermoscopic imaging is recommended 3 months after initial images are obtained. Serial digital dermoscopic imaging is recommended in patients with a medium to giant size congenital melanocytic nevus Serial digital dermoscopic imaging is recommended in patients with a large or growing lentigo-like lesion In the above scenarios, serial digital dermoscopic imaging is preferable to serial digital photography when available. Serial digital photography is recommended in the above scenarios when serial digital dermoscopic imaging is not available Serial digital dermoscopic imaging is not recommended for evaluation of lesions that are highly concerning for malignant melanoma Initial repeat digital dermoscopic follow-up images are recommended 6 months after the initial images are obtained. In patients with a personal history of for malignant melanoma, a first-degree relative with for malignant melanoma, greater than 5 clinically atypical nevi, or greater than 100 nevi serial digital dermoscopic imaging is not recommended for use as a solo modality for digitally evaluating nevi; however, in these scenarios it is recommended as an adjunct to total body photographySerial digital dermoscopic imaging—Round 2 Serial digital dermoscopy is recommended for monitoring “ugly duckling” nevi with equivocal dermoscopic features Except when evaluating lentigo-like lesions, lesions undergoing digital dermoscopic imaging should be re-evaluated at a 3-month interval Serial digital dermoscopy imaging is recommended in patients with a large or growing lentigo-like lesion that lack diagnostic dermoscopic features with a plan to re-evaluate at a 6-month intervalReflectance confocal microscopy—Round 1 Reflectance confocal microscopy is recommended for evaluation of dermoscopically equivocal pigmented lesions in cosmetically sensitive areas or in areas prone to poor wound healing Reflectance confocal microscopy is recommended for evaluation of dermoscopically equivocal pigmented lesions with dermoscopic signs of regression Reflectance confocal microscopy is recommended for evaluation of dermoscopically equivocal amelanotic lesions Reflective confocal microscopy is recommended for evaluation of dermoscopically equivocal pigmented lesions on children or patients that are reluctant to undergo biopsy Reflectance confocal microscopy is recommended for evaluation of suspected lentigo maligna Reflectance confocal microscopy is recommended for patients with clinically atypical nevi with reassuring dermoscopic features that are the cause of significant psychosocial distress Reflectance confocal microscopy is recommended for all pigmented lesions Reflectance confocal microscopy is recommended for changing melanocytic lesions that are not definitely malignant Reflectance confocal microscopy is recommended to help distinguish an actinic keratosis from a squamous cell carcinoma Reflectance confocal microscopy is recommended to help rule out a desmoplastic melanoma Reflectance confocal microscopy is recommended to determine margins of a neoplasmReflectance confocal microscopy—Round 2 When available, reflectance confocal microscopy is recommended for monitoring response of lentigo maligna undergoing treatment with imiquimod Reflectance confocal microscopy is recommended for evaluation of dermoscopically equivocal pink and/or amelanotic lesions with a plan for re-evaluation in 3 months for lesions with negative reflectance confocal microscopy Reflectance confocal microscopy is not recommended as a tool for providing reassurance to patients with nevi with dermoscopically reassuring features that are the cause of significant psychosocial distress. Open table in a new tab Table IIConsensus recommendationsConsensus recommendationsResultTotal body photography Recommendation #1: Total body photography is recommended for patients with familial atypical multiple mole melanoma syndrome (FAMMM Syndrome, aka dysplastic nevus syndrome)Strongly agree: 91%Agree: 0%Neither agree nor disagree: 9%Disagree: 0%Strongly disagree: 0% Recommendation #2: Total body photography is recommended in adults with more than 50 nevi that have 1 or more of the following: (1) a personal history of multiple cutaneous melanomas; (2) a personal history of an amelanotic melanoma; multiple pink nevi, multiple clinically atypical nevi, and/or; (3) a genetic syndrome that predisposes to the development of cutaneous melanoma.Strongly agree: 64%Agree: 36%Neither agree nor disagree: 0%Disagree: 0%Strongly disagree: 0% Recommendation #3: Total body photography is generally NOT recommended in children given the volatility of their nevi and their low risk of developing a malignant melanoma.Strongly agree: 64%Agree: 36%Neither agree nor disagree: 0%Disagree: 0%Strongly disagree: 0% Recommendation #4: When utilizing total body photography, it is recommended that new images should be obtained once previous images are not easily comparable to the patient's current appearanceStrongly agree: 55%Agree: 36%Neither agree nor disagree: 9%Disagree: 0%Strongly disagree: 0% Recommendation #5: When performing total body photography, the use of serial digital dermoscopy imaging and/or serial digital photography is also recommended for evaluation of clinically atypical neviStrongly agree: 45%Agree: 36%Neither agree nor disagree: 18%Disagree: 0%Strongly disagree: 0%Serial digital dermoscopic imaging Recommendation #1: Serial digital dermoscopic imaging is recommended for monitoring “ugly duckling” nevi with equivocal dermoscopic featuresStrongly agree: 55%Agree: 27%Neither agree nor disagree: 0%Disagree: 0%Strongly disagree: 18% Recommendation #2: Serial digital dermoscopic imaging is recommended in patients with a large or growing lentigo-like lesion that lack diagnostic dermoscopic features with a plan to re-evaluate at a 3- to 6-month intervalStrongly agree: 27%Agree: 55%Neither agree nor disagree: 18%Disagree: 9%Strongly disagree: 0%Reflectance confocal microscopy Recommendation #1: When available, reflectance confocal microscopy is recommended for evaluation of dermoscopically equivocal pigmented lesions in cosmetically sensitive areas or in areas prone to poor wound healingStrongly agree: 80%Agree: 10%Neither agree nor disagree: 0%Disagree: 10%Strongly disagree: 0% Recommendation #2: When available, reflective confocal microscopy is recommended for evaluation of dermoscopically equivocal pigmented lesions on children or patients that are reluctant to undergo biopsyStrongly agree: 70%Agree: 10%Neither agree nor disagree: 10%Disagree: 0%Strongly disagree: 10% Recommendation #3: When available, reflectance confocal microscopy is recommended for evaluation of suspected lentigo maligna with a consideration for reimaging in 6 months should initial imaging be negative for malignancyStrongly agree: 70%Agree: 10%Neither agree nor disagree: 10%Disagree: 0%Strongly Disagree: 10% Recommendation #4: When available, reflectance confocal microscopy is recommended for evaluation of dermoscopically equivocal pink and/or amelanotic macular lesions with a plan for reevaluation in 3 months for lesions with negative reflectance confocal microscopy (this may not be suitable for palpable lesions)Strongly agree: 18%Agree: 64%Neither agree nor disagree: 9%Disagree: 9%Strongly disagree: 0% Open table in a new tab Patient need for TBP is based on a combination of mole phenotype and baseline risk for developing melanoma.1Salerni G. Carrera C. Lovatto L. et al.Benefits of total body photography and digital dermatoscopy (“two-step method of digital follow-up”) in the early diagnosis of melanoma in patients at high risk for melanoma.J Am Acad Dermatol. 2012; 67: e17-e27Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Other considerations that support using TBP include presence of significant photodamage, patient history of many biopsies, and patient anxiety. Although children do not typically require TBP given the volatility of their nevi and generally low risk of developing melanoma, patients with genetic syndromes or large congenital nevi may benefit from TBP. Once baseline images are obtained, new images do not need to be retaken until the patients' skin lesions have significantly evolved, resulting in difficulty comparing their dermatologic examination to their photographs. Pigmented lesions with obviously malignant dermoscopic features should be biopsied in toto. SDDI is used for lesions with equivocal dermoscopic features and can be used alone or in conjunction with TBP for monitoring new or changing lesions.1Salerni G. Carrera C. Lovatto L. et al.Benefits of total body photography and digital dermatoscopy (“two-step method of digital follow-up”) in the early diagnosis of melanoma in patients at high risk for melanoma.J Am Acad Dermatol. 2012; 67: e17-e27Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar The interval that lesions undergoing monitoring with SDDI should be reassessed is based on prospective and retrospective studies and is dependent on the lesion phenotype (eg, macule/patch vs papule/plaque).2Menzies S.W. Evidence-based dermoscopy.Dermatol Clin. 2013; 31: 521-524.viiAbstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar,3Altamura D. Avramidis M. Menzies S.W. Assessment of the optimal interval for and sensitivity of short-term sequential digital dermoscopy monitoring for the diagnosis of melanoma.Arch Dermatol. 2008; 144: 502-506Crossref PubMed Scopus (103) Google Scholar Some members dissented from recommendation #1, preferring biopsy or RCM for “ugly duckling” pigmented lesions with equivocal dermoscopic features.4Gaudy-Marqueste C. Wazaefi Y. Bruneu Y. et al.Ugly duckling sign as a major factor of efficiency in melanoma detection.JAMA Dermatol. 2017; 153: 279-284Crossref PubMed Scopus (32) Google Scholar RCM is recommended when biopsy is indicated but patient factors (eg, cosmetically sensitive areas, sites with delayed healing, or patient hesitation about a biopsy) make noninvasive testing preferable, because prospective data support that RCM can detect melanoma while also sparing patients unnecessary biopsies.5Dinnes J. Deeks J.J. Saleh D. et al.Reflectance confocal microscopy for diagnosing cutaneous melanoma in adults.Cochrane Database Syst Rev. 2018; 12: CD013190PubMed Google Scholar For melanoma in situ, RCM allows patients to undergo only 1 definitive therapeutic procedure; whereas, for invasive melanoma, biopsy is still necessary to determine Breslow depth. Repeat RCM is not typically performed after negative imaging but can be considered for borderline or changing lesions. These techniques can help facilitate earlier diagnosis of melanoma and can spare patients unnecessary biopsies. These consensus recommendations aim to help clinicians appropriately implement these techniques into practice. These recommendations do not exhaust all possible indications for these techniques and are not meant to replace physician judgment.

Gel nails are a common artificial nail option. Ultraviolet (UV) nail lamps are commonly used to cure gel nails. Ultraviolet A radiation is a known mutagen that penetrates into the nail bed. Although previously reported, the role of UV nail lamps in the carcinogenesis of both keratinocyte carcinoma and melanoma remains controversial. Herein, we report a patient taking the photosensitizing agent hydrochlorothiazide who developed numerous squamous cell carcinomas on the dorsal hands and feet with a 10-year history of UV nail light exposure every 2-3 weeks.

Importance Use of prognostic gene expression profile (GEP) testing in cutaneous melanoma (CM) is rising despite a lack of endorsement as standard of care. Objective To develop guidelines within the national Melanoma Prevention Working Group (MPWG) on integration of GEP testing into the management of patients with CM, including (1) review of published data using GEP tests, (2) definition of acceptable performance criteria, (3) current recommendations for use of GEP testing in clinical practice, and (4) considerations for future studies. Evidence Review The MPWG members and other international melanoma specialists participated in 2 online surveys and then convened a summit meeting. Published data and meeting abstracts from 2015 to 2019 were reviewed. Findings The MPWG members are optimistic about the future use of prognostic GEP testing to improve risk stratification and enhance clinical decision-making but acknowledge that current utility is limited by test performance in patients with stage I disease. Published studies of GEP testing have not evaluated results in the context of all relevant clinicopathologic factors or as predictors of regional nodal metastasis to replace sentinel lymph node biopsy (SLNB). The performance of GEP tests has generally been reported for small groups of patients representing particular tumor stages or in aggregate form, such that stage-specific performance cannot be ascertained, and without survival outcomes compared with data from the American Joint Committee on Cancer 8th edition melanoma staging system international database. There are significant challenges to performing clinical trials incorporating GEP testing with SLNB and adjuvant therapy. The MPWG members favor conducting retrospective studies that evaluate multiple GEP testing platforms on fully annotated archived samples before embarking on costly prospective studies and recommend avoiding routine use of GEP testing to direct patient management until prospective studies support their clinical utility. Conclusions and Relevance More evidence is needed to support using GEP testing to inform recommendations regarding SLNB, intensity of follow-up or imaging surveillance, and postoperative adjuvant therapy. The MPWG recommends further research to assess the validity and clinical applicability of existing and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results should only be made in the context of discussion of testing limitations with the patient or within a multidisciplinary group.

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.

ImportanceUse of prognostic gene expression profile (GEP) testing in cutaneous melanoma (CM) is rising despite a lack of endorsement as standard of care.ObjectiveTo develop guidelines within the national Melanoma Prevention Working Group (MPWG) on integration of GEP testing into the management of patients with CM, including (1) review of published data using GEP tests, (2) definition of acceptable performance criteria, (3) current recommendations for use of GEP testing in clinical practice, and (4) considerations for future studies.Evidence ReviewThe MPWG members and other international melanoma specialists participated in 2 online surveys and then convened a summit meeting. Published data and meeting abstracts from 2015 to 2019 were reviewed.FindingsThe MPWG members are optimistic about the future use of prognostic GEP testing to improve risk stratification and enhance clinical decision-making but acknowledge that current utility is limited by test performance in patients with stage I disease. Published studies of GEP testing have not evaluated results in the context of all relevant clinicopathologic factors or as predictors of regional nodal metastasis to replace sentinel lymph node biopsy (SLNB). The performance of GEP tests has generally been reported for small groups of patients representing particular tumor stages or in aggregate form, such that stage-specific performance cannot be ascertained, and without survival outcomes compared with data from the American Joint Committee on Cancer 8th edition melanoma staging system international database. There are significant challenges to performing clinical trials incorporating GEP testing with SLNB and adjuvant therapy. The MPWG members favor conducting retrospective studies that evaluate multiple GEP testing platforms on fully annotated archived samples before embarking on costly prospective studies and recommend avoiding routine use of GEP testing to direct patient management until prospective studies support their clinical utility.Conclusions and RelevanceMore evidence is needed to support using GEP testing to inform recommendations regarding SLNB, intensity of follow-up or imaging surveillance, and postoperative adjuvant therapy. The MPWG recommends further research to assess the validity and clinical applicability of existing and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results should only be made in the context of discussion of testing limitations with the patient or within a multidisciplinary group.

To the Editor: As the use of cosmetic fillers has increased, so have adverse reactions to these substances. The diagnosis of adverse reaction patterns can be difficult for several reasons. Reactions may be delayed for months to years and substances may have migrated from the original injection site. Patients may not be aware of substances used in fillers, or they may be reluctant to share this information. Additionally, unfamiliar histopathological patterns emerge as new substances appear in the market. Although granulomatous response is by far the most commonly reported reaction pattern, hypertrophic scarring, ulceration, infection, sterile abscess, and filler embolism have been recognized.1 Recently, the development of xanthelasma palpebrarum of the bilateral lower eyelids after hyaluronic acid injections was reported in 2 patients.2 Here, we report a case of xanthelasma palpebrarum after polymethylmethacrylate collagen injections. A 58-year-old woman without a history of hyperlipidemia presented for evaluation of yellow plaques overlying the bilateral tear trough area (Fig. 1). The patient had Artecoll (Suneva Medical Inc, San Diego, CA), a polymethylmethacrylate collagen filler, placed 6 months previously. She noted bruising and swelling immediately after placement followed by the appearance of yellow plaques 1 month later. A punch biopsy of the right infraorbital plaque was performed that revealed collections of foam cells with small rounded nuclei in the papillary and upper reticular dermis. Deeper in the dermis and subcutaneous fat were small, uniform clear spaces surrounded by foreign body multinucleated giant cells. On higher magnification and lowering of the condenser, small, regular, nonbirefringent beads were easily visualized in the vacuoles (Fig. 2). Her fasting lipid panel was normal.FIGURE 1.: Clinical appearance of yellow plaques in bilateral tear troughs at site of Artecoll (polymethylmethacrylate collagen) injections.FIGURE 2.: Punch biopsy of tear trough, ×20 (A). Superficial foamy histiocytes resemble xanthelasma, ×200 (B). Deep dermis and subcutaneous fat demonstrate foreign body giant cells surrounding small, uniform clear spaces, ×400 (C). Nonbirefringent beads are easily visualized within the vacuoles on lowering of the condenser of the microscope, ×400 (D).Artecoll is a biphasic filler composed of 30- to 50-μm polymethylmethacrylate smooth permanent microspheres suspended 1:3 in 3.5% degradable bovine collagen suspension with 0.3% lidocaine.3 It has been used in Europe under the name Artecoll since 1994 and as Artefill since 2006 in the United States for the correction of deep facial wrinkles.4 It is now available as Bellafill and is Food and Drug Administration-approved for use in the nasolabial folds and atrophic acne scars on the cheeks for patients aged over 21 years.5 The filler must be placed in the deep reticular dermis just above the subcutaneous fat for the proper effect.4 The microspheres stimulate fibroblasts to replace atelocollagen by the body's own connective tissue after 3 months.4 Previous reported adverse effects to Artecoll include allergic reactions, telangiectasias, hypertrophic scarring, as well as foreign body granuloma formation.4,6,7 Histologically, foreign body granulomas are nodular or diffuse and may involve the dermis, subcutaneous fat, or even skeletal muscle. Within these, foreign body granulomas are uniform, clear vacuoles that contain the polymethylmethacrylate beads. Rudolph et al7 note that polymethylmethacrylate microspheres are transparent and nonpolarizable but can be seen under phase-contrast microscopic conditions within vacuoles those appear empty with traditional light microscopy. These authors visualized the polymethylmethacrylate beads by lowering the condenser of the microscope, a simple, yet underutilized, way to use phase-contrast microscopy in daily practice. Silicone granulomas show similar microscopic features to polymethylmethacrylate microsphere granulomas but can be distinguished because the vacuoles in silicone granulomas are devoid of foreign material by polariscopic or phase-contrast methods. The occurrence of xanthelasma palpebrarum after Artecoll (polymethylmethacrylate collagen) implantation has not been previously reported; however, D'Acunto et al2 described 2 patients who developed xanthelasma palpebrarum after hyaluronic acid injections. As a possible mechanism, the authors note that in animal models, hyaluronic acid is known to bind extravasated low-density lipoproteins, and this complex is internalized by macrophages that can subsequently transform into foam cells.2,8 Other reports have implicated the role of trauma in the development of xanthelasma, specifically related to contact with boiling oil.9 Our patient reported bruising and swelling shortly after the Artecoll injections that transitioned directly to the clinical appearance of xanthelasma, which suggests a causal relationship, although the mechanism is unclear. We suspect the development of xanthelasma may be a response to the trauma, edema, and inflammation of injection into an anatomically predisposed site (periorbital) or possibly the binding of Artecoll filler material to extravasated lipids, as previously proposed for hyaluronic acid-induced xanthelasma. Our patient was pleased with the removal of most of the xanthelasma by this technique and elected to undergo a therapeutic punch excision on her left infraorbital xanthelasma. Xanthelasma palpebrarum should be recognized as a potential adverse event following tear trough injection of the dermal fillers: Artecoll (polymethylmethacrylate collagen) and hyaluronic acid.

To the Editor: Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) represent a spectrum of life-threatening mucocutaneous diseases and are associated with significant morbidity and mortality. Treatment of SJS and TEN depends on early recognition, immediate withdrawal of the causative agents, and intensive intravenous and topical supportive care. Specific treatments consist of intravenous immunoglobulin (IVIG), high-dose corticosteroids, or other immunosuppressants, including cyclosporine and thalidomide. There is currently a lack of consensus regarding the most effective systemic and topical therapies.1Kardaun S.H. Jonkman M.F. Dexamethasone pulse therapy for Stevens-Johnson syndrome/toxic epidermal necrolysis.Acta Derm Venereol. 2007; 87: 144-148Crossref PubMed Scopus (180) Google Scholar, 2Schwartz R.A. McDonough P.H. Lee B.W. Toxic epidermal necrolysis: Part II. Prognosis, sequelae, diagnosis, differential diagnosis, prevention, and treatment.J Am Acad Dermatol. 2013; 69 (quiz 203-204): 187.e1-187.e16Abstract Full Text Full Text PDF Scopus (209) Google Scholar, 3Viard I. Wehrli P. Bullani R. et al.Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin.Science. 1998; 282: 490-493Crossref PubMed Scopus (987) Google Scholar, 4Bachot N. Revuz J. Roujeau J.C. Intravenous immunoglobulin treatment for Stevens-Johnson syndrome and toxic epidermal necrolysis: a prospective noncomparative study showing no benefit on mortality or progression.Arch Dermatol. 2003; 139: 33-36Crossref PubMed Scopus (313) Google Scholar Furthermore, retrospective analyses have not shown a statistically significant benefit for any treatments.5Prins C. Kerdel F.A. Padilla R.S. et al.Treatment of toxic epidermal necrolysis with high-dose intravenous immunoglobulins: multicenter retrospective analysis of 48 consecutive cases.Arch Dermatol. 2003; 139: 26-32Crossref PubMed Scopus (297) Google Scholar We sought to evaluate health care providers' preferred treatments for SJS and TEN across the United States. We conducted a non-funded, institutional review board–approved Internet survey of providers using e-mail lists from the Medical Dermatology Society and dermatology residency programs, as well as emailing directly burn center fellowship programs from April through November 2014. The provider specialty was not identified within the survey questions. The survey was a short questionnaire with closed- and open-ended questions regarding treatment of SJS, SJS/TEN overlap, and TEN with options of systemic corticosteroids, IVIG, and “other” as a free-text response. We asked additional questions about epidermal debridement and preferred wound care therapies with options of petrolatum-impregnated gauze, nonadherent dressings with nanocrystalline silver, biosynthetic skin substitutes (Biobrane, Aquacel AG), cadaver skin, or “other.” A total of 290 providers responded to our survey link out of an estimated total of 1927, with 131 respondents completing the questionnaire and having treated a patient with SJS or TEN in the last 10 years. We classified the responses between provider subsets who had seen 10 or fewer patients and those who had seen more than 10 patients in the last 5 years. The survey results show that the majority of providers in both subsets do not use systemic steroids for patients in any classification of SJS or TEN. Both provider subsets prefer IVIG in SJS/TEN overlap and TEN (statistically significant); however, providers in the subset who cared for fewer than 10 patients overwhelmingly did not use IVIG in SJS cases (Table I). Cyclosporine was the most frequently used alternative therapy for all classifications. Additionally, both provider subsets do not debride the skin (Table II) and most preferred petrolatum-impregnated gauze and nonadherent dressings with nanocrystalline silver. Biosynthetic skin substitutes, cadaver skin, and xenografts were less frequently used.Table IProviders' Preferred Treatment of SJS, SJS overlap, and TENTreatment≤10 patients>10 patientsTotalP value < .05SJS steroids YES30 (43%)26 (43%)56 (43%) NO40 (57%)35 (57%)75 (57%) Total70611310.98SJS IVIG YES20 (29%)25 (41%)45 (34%) NO50 (71%)36 (59%)86 (66%) Total70611310.14SJS overlap steroids YES20 (29%)19 (31%)39 (30%) NO50 (71%)42 (69%)92 (70%) Total70611310.75SJS overlap IVIG YES38 (54%)39 (64%)77 (59%) NO32 (46%)22 (36%)54 (41%) Total70611310.26TEN steroids YES14 (20%)12 (20%)26 (20%) NO56 (80%)49 (80%)105 (80%) Total70611310.96TEN IVIG YES44 (63%)48 (79%)92 (70%) NO26 (37%)13 (21%)39 (30%) Total70611310.048 Open table in a new tab Table IIProviders' debridement preferencesTherapy≤10 patients>10 patientsTotalP value < .05Debride = YES20 [0.39]23 [0.44]43 (33%)Debride = NO50 [0.19]38 [0.22]88 (67%)Total70 (53%)61 (47%)1310.27 Open table in a new tab With every case of SJS or TEN, there is much discussion regarding effective treatments that lessen the morbidity and mortality of the patient and there are very few randomized controlled trials to aid in these decisions. We believe that prospective multicentered randomized controlled trials are needed to elucidate effective treatment options and explore other pharmacologic agents based on newly identified pathophysiologic mechanisms. Our survey findings highlight a lack of consensus for the care of these complicated and often life-threatening spectrum of skin diseases.

To the Editor: The letter by Curtis et al,1Curtis J. Tanner P. Judd C. Childs B. Hull C. Leachman S. Acrylic nail curing UV lamps: high-intensity exposure warrants further research of skin cancer risk.J Am Acad Dermatol. 2013; 69: 1069-1070Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar “Acrylic nail curing UV lamps: High intensity exposure warrants further research of skin cancer risk,” is based upon inappropriate measurements and improper analysis of results. Our contemporaneous stringent photobiological safety analysis2Dowdy J.C. Sayre R.M. Photobiological safety evaluation of UV nail lamps.Photochem Photobiol. 2013; 89: 961-967Crossref PubMed Scopus (14) Google Scholar of 6 nail lamps, 2 of which we both appear to have examined, strongly contradicts Curtis et al's conclusions. We followed IESNA/ANSI Photobiological Safety Standard RP-27 using the required UV-Visible double grating scanning spectroradiometer, with integrating sphere, calibrated to a National Institute of Standards and Technology traceable standard lamp. We specifically addressed Markova and Weinstock's3Markova A. Weinstock M.A. Risk of skin cancer associated with the use of UV nail lamp.J Invest Dermatol. 2013; 133: 1097-1099Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar use of an inappropriate spectrometer as unfortunately Curtis et al have likewise used. Single fixed-grating diode array spectrometers are inappropriate for photobiological UV risk evaluation, lacking single measurement dynamic range with poor straylight rejection inherent in the design—critically required as explicitly noted in accepted international testing standards.4International Illumination Commission (CIE), Technical Committee 6-471st ed. Joint International Standard, CEI/IEC 62471-CIE S 009/E: Photobiological Safety of Lamps and Lamp Systems. Vol. CEI/IEC 62471. International Electrotechnical Commission (IEC) Central Office, Geneva2006: 89Google Scholar Physicians, rarely expert UV-metrologists, must be less culpable for these errors than those falsely claiming such instrument capabilities. Nonetheless statements alleging “High-Intensity exposure” warrant further elucidation. We found, consistent with Diffey's concurrent analysis,5Diffey B.L. The risk of squamous cell carcinoma in women from exposure to UVA lamps used in cosmetic nail treatment.Br J Dermatol. 2012; 167: 1175-1178Crossref PubMed Scopus (23) Google Scholar at most only moderate UV risks from these sources with approximately 30 to 130 minutes of permissible daily occupational exposure. This is greatly mitigated by much less frequent nail lamp use, as Curtis et al correctly recognized. Our analysis of nonmelanoma skin cancer (NMSC) risks, computed using International Illumination Commission (CIE) NMSC spectral weighting,6International Illumination Commission (CIE) Technical Committee 6-32CIE Standard S 019/E:2006, Photocarcinogenesis Action Spectrum (Non-Melanoma Skin Cancers). Commission Internationale de l'Eclairage (CIE) Central Bureau, Vienna, Austria2006: 12Google Scholar found NMSC risk from nail lamps was 11 to 46 times less than overhead sunlight and 3 to 12 times less than mid-angle sunlight for equivalent exposure duration. This is further mitigated by known relative UV acclimatization of the dorsum of the hand.7Olson R.L. Sayre R.M. Everett M.A. Effect of anatomic location and time on ultraviolet erythema.Arch Dermatol. 1966; 93: 211-215Crossref PubMed Scopus (64) Google Scholar We offer a comparison of 3 sources (Fig 1), OPI fluorescent nail lamp from our earlier study,2Dowdy J.C. Sayre R.M. Photobiological safety evaluation of UV nail lamps.Photochem Photobiol. 2013; 89: 961-967Crossref PubMed Scopus (14) Google Scholar a Daavlin PUVA unit, and the CIE standard 1 atmosphere, AM-1, solar spectrum. The nail lamp was measured at close use distance and the PUVA unit at 8 inches. Calculations showed the nail lamp, despite the closer position, only emits approximately 10% of the UV risk for erythema or NMSC resultant from exposures to the PUVA lamp or overhead sunlight. In our opinion this type of device is not a significant threat to the user. Even at 4 times 370 nm solar intensity, the relatively biologically ineffective fluorescent emission has an order of magnitude less erythema or NMSC risk. Curtis et al's results seem to contradict their own conclusions. Their accumulated estimate of habitual nail lamp exposure amounting to only 1.1 to 1.5 MED/year is trivial and despite media attention hardly cause for public alarm. Acrylic nail curing UV lamps: High-intensity exposure warrants further research of skin cancer riskJournal of the American Academy of DermatologyVol. 69Issue 6PreviewTo the Editor: Recent media headlines have highlighted safety concerns regarding skin cancer risk and ultraviolet (UV) lamps used to cure artificial nail acrylics.1,2 We also read with great interest a recently published article by Markova and Weinstock refuting this risk.3 Full-Text PDF Reply to: “Nail curing UV lamps: Trivial exposure not cause for public alarm”Journal of the American Academy of DermatologyVol. 73Issue 5PreviewTo the Editor: Thank you for the opportunity to comment on the response by Drs Sayre and Dowdy. We appreciate their concerns regarding our measurements and analysis of the results. We acknowledge that the authors are well-known experts in photobiology and ultraviolet (UV) light devices, who hold patents on such devices,1,2 and we do not dispute their previous analysis of nail lamps. Full-Text PDF

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Objective To better understand postoperative opioid use after dermatologic surgery. Design Prospective observational study. Setting Academic dermatology department. Patients The study included 212 adults (1) who were undergoing a single skin excision (including Mohs micrographic surgery), (2) who consented to participate, and (3) who were able to be reached by telephone on postoperative day 3 or 4. Patients who did not meet these criteria and those referred to another physician for further surgical treatment or repair were excluded. Main Outcome Measures The study examined (1) the incidence of opioid prescription after dermatologic surgery, (2) the percentage of prescribed opioid pain medications used in the postoperative period, and (3) patient and surgical characteristics associated with opioid pain medication prescription and use. Results Opioids were prescribed to 72 of the 212 patients (34%). Twenty-five of the 72 patients (35%) who were prescribed opioids did not use them. Forty-nine of 57 patients (86%) who filled an opioid prescription had leftover pills, and 26 of the 49 patients (53%) planned to keep them. Only maximum pain score was significantly associated with opioid use. Conclusions Opioids were overprescribed after dermatologic surgery. Patients who had leftover opioids did not dispose of them properly, which could lead to potential misuse and abuse.