Confocal scanning laser reflectance microscopy: why bother?
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Diagnosis, Differential↗
Biomedical subjects
Allan C Halpern
Publications and source records attributed to Allan C Halpern.
Variation in the diagnosis, treatment, and management of melanoma in situ: a survey of US dermatologists.
OBJECTIVE: To assess current practices of US dermatologists regarding the diagnosis, treatment, and management of melanoma in situ (MIS). DESIGN: Survey. PARTICIPANTS: A total of 1200 dermatologists randomly selected from the American Board of Medical Specialists Directory of Board Certified Medical Specialists. MAIN OUTCOME MEASURES: Results based on 597 questionnaires returned. RESULTS: The overall response rate was 63% (597 of 945 eligible participants). To aid in clinical assessment, respondents reported using a magnifying lens (57.4%) and dermoscopy (17.4%). Most dermatologists preferred excisional and saucerization biopsies as the method of choice for sampling. A large percentage of physicians (78.9%) preferentially used dermatopathologists for the evaluation of the majority of pigmented lesions. Although most respondents would not unquestioningly accept a benign pathology diagnosis when there was a clinical suspicion of MIS, 16.1% would accept a pathologist's diagnosis without further action. There was no consensus on the appropriate surgical margins or depth of excision for MIS. Of the respondents who characterized MIS as premalignant and malignant, 63.2% and 46.4%, respectively, did not know what percentage of MISs would progress to metastatic disease if left untreated. CONCLUSIONS: Considerable variability exists in the clinical concept and management of MIS. Dermoscopy is underutilized. The true nature of the evolution of MIS is unknown. Surgical margins and depth of excision need to be standardized to help dermatologists manage disease. Further research in the specific area of MIS is warranted to develop clear guidelines in the management and prevention of further disease.
Biopsy, Needle↗
Agminated acquired melanocytic nevi of the common and dysplastic type.
We previously reported a single case of agminated acquired melanocytic nevi, consisting of a localized clustering of banal and atypical moles. We now report 4 more cases, confirming that the initial case was not an isolated finding. We examined the lesions clinically, with a dermoscope, with a Wood's light, and in 3 cases with UV photography so as to exclude nevus spilus from the differential diagnosis. The presence of an underlying dysplastic nevus syndrome phenotype in 4 of the 5 cases raises the possibility that agminated nevi arise as a consequence of postzygotic loss of heterozygosity and, thus, may represent a type 2 segmental manifestation of the atypical mole syndrome phenotype. Further studies of similar cases using microdissection techniques for analysis of loss of heterozygosity pattern are warranted.
Adult↗
Student-parent agreement in self-reported sun behaviors.
OBJECTIVE: We sought to describe agreement between parent proxy and student self-reported sun behaviors and sun protective practices in adolescents aged 10 to 14 years. METHODS: We conducted a cross-sectional pilot study of students (n = 52) from two classrooms, grades 6 and 7, at a school system in Framingham, Mass. Data were collected using self-administered questionnaires. Students were asked to report their sun behaviors and sun protective practices. Proxy measures were obtained by asking parents to report sun behaviors and practices of their children. Agreement was measured using weighted kappa analysis for ordinal data. Mean differences (95% confidence intervals) were calculated. RESULTS: The response rate for student/proxy pairs was 96% (n = 50). Agreement between student and proxy was good for skin color, sunscreen use, number of sunburns in the past summer, and application of sunscreen while in other outdoor places (range kappa = 0.52-0.73). Lowest agreement was found for questions relating to wearing a shirt, wearing a hat, sitting in the shade, and frequency of parental sunscreen application to the students' backs (range kappa = 0.08-0.28). Mean differences in responses between student and proxy respondents were relatively small ranging from -0.39 to +0.25. CONCLUSIONS: The lack of a gold standard in the assessment of sun exposure and related sun protective practices limits the ability to validate these exposure measures in skin cancer studies. The assessment of sun exposure behaviors is especially problematic when relying on a child's ability to accurately recall these exposures. Parent proxy measures are often used as surrogate measures and for validation purposes. We found low to moderate student/proxy agreement in this pilot study suggesting that adolescents can effectively recall their recent sun behaviors and protective practices when compared with parent proxy measures.
Adolescent↗
The association between large congenital melanocytic naevi and cutaneous melanoma: preliminary findings from an Internet-based registry of 379 patients.
There is ample evidence in the literature to support the fact that there is an increased risk of the development of melanoma in individuals with a large congenital melanocytic naevus (LCMN). The published melanoma risk estimates, by and large, do not distinguish between cutaneous and extracutaneous melanomas. It is currently not known to what extent each contributes to the overall cited melanoma risk estimates. In order to obtain a better understanding of the association between LCMN and cutaneous melanoma arising within an LCMN, we report the preliminary findings of a cross-sectional study of 379 patients, with a median age of 3 years, from the first self-referred, Internet-based registry of patients with LCMN. To date, no cutaneous melanoma has been reported; possible reasons for this finding are discussed. Further research is required to clarify the risk of the development of cutaneous melanoma separate from non-cutaneous melanoma and to identify subgroups of patients with LCMN at highest risk for the development of melanoma. This information will help to formulate appropriate decisions concerning the management of patients with LCMN.
Adolescent↗
Bringing histology to the bedside.
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Histological Techniques↗
Dual mode reflectance and fluorescence confocal laser scanning microscopy for in vivo imaging melanoma progression in murine skin.
A system was designed and developed for simultaneous fluorescence and reflectance contrast in vivo confocal imaging of murine skin using 488 nm (fluorescence mode) and 830 nm (reflectance mode) laser light sources. B16 melanoma cells and B16-enhanced green fluorescent protein (EGFP) cells were inoculated intradermally into transgenic C57BL/6-TgN (ACTbEGFP) 10sb and non-transgenic C57BL/6 mice, respectively. The inoculation sites were imaged sequentially over a 20 d period. The in vivo confocal images were correlated with ex vivo conventional microscopy. The combined modality system provided single-cell resolution and adequate image registration. In fluorescence mode, B16 melanoma cells appeared as dark objects in the bright background of the GFP expressing murine cells of the C57BL/6 transgenic mouse, and the B16-EGFP melanoma cells had a bright signal within a dark background in C57BL/6 mice. In the C57BL/6 transgenic mouse, a population of fluorescent dendritic cells was observed in the vicinity of the tumor cells. The reflectance images provide a useful reference for those areas in the dermal tissues lacking a fluorescent signal. Combined reflectance/fluorescence in vivo confocal laser scanning microscopy holds significant promise for studies of tumor progression in murine skin.
Animals↗
Awareness, knowledge and attitudes to non-melanoma skin cancer and actinic keratosis among the general public.
BACKGROUND: The incidence of nonmelanoma skin cancer (NMSC) has dramatically increased worldwide. In areas of high incidence this will place a significant burden on the health system. Objectives To establish the awareness, knowledge and attitudes of the general public to NMSC and provide an overview on their level of understanding and knowledge of preventative measures. METHODS: Two thousand and one hundred Caucasian and Hispanic individuals, aged 40-75 years, from the UK, Italy, Germany, Spain, France, the USA and Australia were randomly selected to participate in this market research survey. In a structured telephone interview lasting approximately 10 min, respondents answered questions on NMSC, specifically actinic keratosis (AK) and basal cell carcinoma (BCC). RESULTS: Overall, 6% of respondents had been diagnosed with NMSC, of which the incidence was highest in Australia and the USA. The frequency of skin cancer detection examinations was also greater within these populations. Countries with a high incidence of NSMC had greater awareness of the condition, with more awareness of BCC than AK. The majority of respondents believed there was a correlation between skin cancer and sun exposure, however, a minority of respondents associated skin cancer with 'moderate' tanning. Overall, 86% of respondents claimed that they always took precautions against ultraviolet exposure when in the sun, but only 26% applied sunscreen most or all of the time when they were exposed to the sun for more than 1 h. In most of the countries, outside workers reported lower sunscreen use than other respondents. CONCLUSION: Nonmelanoma skin cancer awareness and prevention behaviors varied significantly among the countries studied. Improved population-specific documentation of skin cancer knowledge and prevention behaviors will facilitate the development and assessment of public health campaigns.
Adult↗
Patient experiences with photo books in monthly skin self-examinations.
Patients with multiple nevi are at greater risk for developing melanoma but may be unable to assess their skin accurately without an effective tool. At Memorial Sloan-Kettering Cancer Center, the standard of practice has been to use a patient educational brochure teaching high-risk patients mole mapping, a procedure of recording moles by drawing them. The photo print book offers patients an improved way of peforming skin self-examination (SSE) in comparison to drawing. The purpose of this study was to determine patient experiences through patient interview and to learn ways to increase patient compliance and understanding of monthly SSE performance using a photo book.
Humans↗
Diagnostic accuracy of patients in performing skin self-examination and the impact of photography.
OBJECTIVE: To determine the sensitivity and specificity of skin self-examination (SSE) to detect new and changing moles with and without the aid of baseline digital photographs in patients with dysplastic nevi. DESIGN AND INTERVENTION: Patients had baseline digital photography and mole counts of their back, chest, and abdomen and were instructed to perform a baseline SSE. Print copies of the images were provided to the patient. Following the baseline examination, the appearance of existing moles was altered and new moles were created using cosmetic eyeliner. The number of moles altered and/or created totaled approximately 10% of each patients' absolute mole count. SETTING AND PATIENTS: Fifty patients with 5 or more dysplastic nevi from the outpatient clinic at Memorial Sloan-Kettering Cancer Center, New York, NY. MAIN OUTCOME MEASURE: Skin self-examinations with and without access to the baseline photographs to identify the number of new and altered moles. RESULTS: The sensitivity and specificity of SSE for detection of both altered and new moles without photography were 60.2% and 96.2%, respectively. Skin self-examination with photography yielded a sensitivity and specificity of 72.4% and 98.4%, respectively. The findings were similar when stratified by site (back vs chest or abdomen). The sensitivity and specificity for new moles were higher compared with altered moles. CONCLUSIONS: Access to baseline photography improved the diagnostic accuracy of SSE on the back and chest or abdomen and improved detection of changing and new moles. Our results suggest that baseline digital photography in tandem with SSE may be effective in improving the diagnostic accuracy of patients performing SSE.
Adult↗
Number of satellite nevi as a correlate for neurocutaneous melanocytosis in patients with large congenital melanocytic nevi.
BACKGROUND: Patients with large congenital melanocytic nevi (LCMN) are at risk for neurocutaneous melanocytosis (NCM). Patients with LCMN on the posterior axis or in conjunction with many satellite melanocytic nevi seem to represent subgroups at greatest risk. OBJECTIVE: To determine the relationship between LCMN location, number of satellite nevi, and risk of NCM. DESIGN: Descriptive survey study. SETTING: An Internet Web-based registry of patients with LCMN, maintained by a nevus support group (Nevus Outreach Inc). PARTICIPANTS: Individuals with LCMN or their guardians visiting the Nevus Outreach Web site were provided the opportunity to complete the questionnaire. OUTCOME MEASURES: Location of LCMN, number of satellite nevi, and NCM as assessed by patient self-report. RESULTS: A total of 379 patients with LCMN were evaluated, 26 of whom had NCM. A significantly higher percentage of patients with NCM had their LCMN on the posterior axis compared with patients without NCM (96% and 70%, respectively). Patients with NCM had significantly more satellite melanocytic nevi compared with non-NCM patients (median, 68.5 and 18, respectively). Furthermore, patients with LCMN and more than 20 satellites had a 5.1-fold (95% confidence interval, 1.9-14.0) increased risk for NCM compared with LCMN patients with 20 or fewer satellites. Logistic regression analysis, controlling for age, sex, number of satellite nevi, and LCMN location, identified number of satellite nevi as the only significant risk factor for NCM. CONCLUSIONS: The presence of large numbers of satellite nevi is the most important risk factor for NCM in patients with LCMN. Although location of the LCMN on the posterior axis was a moderate risk factor for NCM in univariate analysis, the strength of the relationship was attenuated in the multivariate analysis.
Child↗
The Framingham school nevus study: a pilot study.
OBJECTIVES: To (1). describe nevus patterns using digital photography and dermoscopy; (2). evaluate the relationship between host and environmental factors and prevalence of nevi in schoolchildren; and (3). demonstrate the feasibility of conducting a longitudinal study. DESIGN: Cross-sectional survey and 1-year prospective follow-up study. PARTICIPANTS: Students from 2 classrooms, grades 6 and 7, in the Framingham, Mass, school system (N = 52). MAIN OUTCOME MEASURES: A survey was completed by students and 1 of their parents that included questions on demographic and phenotypic characteristics, family history of skin cancer, and sun exposure and protection practices. An examination of nevi on the back was performed that included digital photography and digital dermoscopy. Follow-up child and parent surveys and examinations were conducted at 1-year follow-up. RESULTS: At baseline, the median number of back nevi was 15 (mean [SD], 21.9 [15.3]). Older age, male sex, fair skin, belief that a tan is healthier, tendency to burn, and sporadic use of sunscreen were positively associated with mole count, although age was the only statistically significant factor. Predominant dermoscopic patterns for the index nevus were as follows: 38% globular, 14% reticulated, 38% structureless, and 10% combinations of the above patterns with no predominant characteristic. The overall participation rate from baseline to follow-up was 81% (42/52) for the skin examination process. At the 1-year follow-up examination, new nevi were identified in 36% of students (n = 15), while 9.6% of baseline index nevi had changes in the dermoscopic pattern. Dominant dermoscopic pattern was related to nevus size: smaller nevi tended to be structureless, while larger nevi were of mixed pattern. CONCLUSION: This study supports the feasibility and utility of digital photography and dermoscopy for the longitudinal study of nevus evolution in early adolescence.
Adolescent↗
Patient adherence to skin self-examination. effect of nurse intervention with photographs.
BACKGROUND: Results from a single case-control study suggest that skin self-examination (SSE) has the potential to reduce mortality from melanoma by 63%. Despite these encouraging results, SSE rates are low. Few prospective studies of interventions to increase SSE in high-risk cohorts have been performed. The purpose of this study was to assess the impact of a brief nurse-delivered intervention using digital photographs on patients' adherence to performing SSE. DESIGN SETTING/PARTICIPANTS: Patients at high risk for melanoma skin cancer (five or more dysplastic nevi) (N=100) were recruited from the outpatient Pigmented Lesion Clinic at Memorial Sloan-Kettering Cancer Center. All participants had baseline whole-body digital photography as part of their clinical evaluation. INTERVENTION: Patients were randomized: Group A (n =49) received a teaching intervention (physician and nurse education module) with a photo book (personal whole-body photographs compiled in the form of a booklet, with nurse instruction on how to use the photographs); and Group B (n =51) received the teaching intervention only without a photo book. MAIN OUTCOMES/MEASURES: Self-administered questionnaires were provided at three intervals: baseline, post-teaching intervention, and at the 4-month post-baseline visit. To assess adherence with SSE, patients were asked, "How many times in the past 4 months did you (or someone else) usually, thoroughly examine your skin?" RESULTS: In Group A (teaching intervention with photo book), 10.2% of the patients at baseline reported skin examination three or more times during the past 4 months, while 61.2% reported skin examination three or more times at the 4-month follow-up (p =0.039 for paired comparison). In Group B (teaching intervention only), nearly 20% of the patients at baseline reported skin examination three or more times during the past 4 months, while 37% reported skin examination three or more times at the 4-month follow-up (p =0.63). The increase in reported skin examination was compared between the two groups (>51% v >17.6%, p =0.001). CONCLUSIONS: The results suggest that a brief nurse-delivered intervention is effective at increasing patient adherence with SSE. Utilizing digital photographs as an adjunct to screening appeared to increase patient adherence to performing SSE.
Adolescent↗
Sunless tanning.
BACKGROUND: Americans continue to desire and pursue the tan. Recent data indicate continued high incidence of sunburn and ultraviolet tanning despite public health skin cancer prevention messages. The rising popularity of recently available sunless tanning booths prompted this review. OBJECTIVE: To present an overview of the history of sunless tanning and the sunless tanning booth industry, and to describe the current availability and safety practices of sunless tanning booth providers. METHODS: The current literature and internet resources were reviewed. Phone surveys of 300 businesses were conducted in July, 2003. RESULTS: Sunless tanning services were offered by 43% (39/90) of businesses with tanning services of any type. Sunless tanning booths were the most commonly offered sunless tanning application modality. The safety precautions most commonly offered to sunless tanning customers were recommendations to close their eyes (100%, 17/17), hold their breath (77%, 13/17), and utilize post-sunless tanning sun protection (82%, 14/17). CONCLUSION: Uniform guidelines should be developed to address safety issues associated with sunless tanning booth use. Future investigations are warranted to assess both the medical and behavioral implications of perpetuating the aesthetic appeal of the tan.
Beauty Culture↗
Clearing of psoriasis in a nephrectomized patient by monotherapy with TNF-alpha antagonist, infliximab, with follow-up of 1 year.
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Journal Article↗
Awareness of, knowledge of and attitudes to nonmelanoma skin cancer (NMSC) and actinic keratosis (AK) among physicians.
BACKGROUND: Nonmelanoma skin cancer (NMSC) is the most common type of cancer that affects the Caucasian population. Approximately 80% of NMSCs are basal cell carcinoma (BCC) and 20% are squamous cell carcinoma (SCC). Actinic keratosis (AK) is a precancerous lesion that may develop into SCC. METHODS: A market research survey was conducted in which dermatologists and primary care physicians (PCPs) were randomly selected from seven countries (USA, Australia, UK, Italy, France, Germany and Spain). Their knowledge of nonmelanoma skin cancer and their current clinical practice were assessed. RESULTS: In total, 2100 physicians took part in the survey. They had practised medicine for between 1 and 30 years and saw at least 30 patients in a typical week. The majority of dermatologists (97%) were familiar with BCC and AK, and treated each condition with a minimum of referrals. PCPs were more familiar with BCC (90%) than with AK (74%). Of the PCPs that were aware of BCC, only 31% treated the condition, and of those aware of AK, 40% treated the condition. Surgery was the most common choice of treatment for BCC. The most popular treatment choice for AK lesions was cryotherapy. Eighty to 100% of physicians reported that they discussed skin cancer prevention with their patients. A much lower number of physicians (ranging from 5 to 37%) provided educational material to patients. Overall, PCPs in the two countries that have a high incidence of NMSC (USA and Australia) were more familiar with BCC and AK and more likely to treat each condition than PCPs in Europe. All physicians rated BCC as a more serious condition than AK. Facial lesions were considered more serious than lesions on the head or trunk for both conditions. CONCLUSIONS: As the burden of disease and the number of patients seeking treatment for NMSC increase, dermatologists are well placed to lead educational initiatives for PCPs and provide educational material for patients. This would increase awareness of AK and BCC and could improve early diagnosis.
Australia↗
Skin cancer prevention and detection by nurses: attitudes, perceptions, and barriers.
BACKGROUND: To examine attitudes and perceptions of nurses with respect to skin cancer prevention and detection; to identify barriers to skin cancer prevention and detection by nurses. METHODS: Descriptive survey of 457 nurses from the Texas State Board of Nurse Examiners in 1997. RESULTS: Eighty-nine percent of the nurses reported that skin cancer was a serious problem, and 97% believed that many people were at risk. More than 89% stated that skin cancer prevention/detection would benefit patients, and 94% believed that such skills would benefit nurses. Eighty-four percent reported that it was in their scope of practice to teach skin cancer prevention to patients, and 61% stated that it was in their scope of practice to detect skin cancer in patients. Barriers to skin cancer prevention and detection included lack of national guidelines (69%), low priority among doctors (63%), and the belief that patients should take full responsibility for prevention (50%). Barriers to continuing education for skin cancer screening included lack of money (43%), not knowing how to obtain education (41%), time away from work (36%), and time away from home (26%). CONCLUSIONS: These findings may suggest that nurses can play a role in skin cancer prevention and detection.
Adult↗
Adoption of new technologies for early detection of melanoma in dermatologic practice.
The identification and diagnosis of early melanoma will reduce unnecessary operations and may be important in reducing mortality from melanoma and impacting cost savings to the health system. New technologies are being developed and used at some specialized centers to facilitate the detection and diagnosis of early melanoma for patients at high risk. These technologies include but are not limited to digital photography, dermoscopy, computerized image analysis systems, and confocal scanning laser microscopy. To most effectively implement these novel approaches, it is important to identify the key factors that influence the adoption or diffusion of new medical technologies. We propose patient-, physician-, and health care system-related factors that influence the diffusion of new technologies for the early detection of skin cancer. Studies involving physicians and patients in a variety of clinical settings need to be conducted to achieve a greater understanding of the barriers to the adoption of these new technologic tools that are intended to aid in skin cancer screening.
Dermatology↗