Joseph C. English

Diagnostic Inaccuracy of Smartphone Applications for Melanoma Detection

OBJECTIVE To measure the performance of smartphone applications that evaluate photographs of skin lesions and provide the user with feedback about the likelihood of malignancy. DESIGN Case-control diagnostic accuracy study. SETTING Academic dermatology department. PARTICIPANTS AND MATERIALS: Digital clinical images of pigmented cutaneous lesions (60 melanoma and 128 benign control lesions) with a histologic diagnosis rendered by a board-certified dermatopathologist, obtained before biopsy from patients undergoing lesion removal as a part of routine care. MAIN OUTCOME MEASURES Sensitivity, specificity, and positive and negative predictive values of 4 smartphone applications designed to aid nonclinician users in determining whether their skin lesion is benign or malignant. RESULTS Sensitivity of the 4 tested applications ranged from 6.8% to 98.1%; specificity, 30.4% to 93.7%; positive predictive value, 33.3% to 42.1%; and negative predictive value, 65.4% to 97.0%. The highest sensitivity for melanoma diagnosis was observed for an application that sends the image directly to a board-certified dermatologist for analysis; the lowest, for applications that use automated algorithms to analyze images. CONCLUSIONS The performance of smartphone applications in assessing melanoma risk is highly variable, and 3 of 4 smartphone applications incorrectly classified 30% or more of melanomas as unconcerning. Reliance on these applications, which are not subject to regulatory oversight, in lieu of medical consultation can delay the diagnosis of melanoma and harm users.

Calciphylaxis and metastatic calcification associated with nephrogenic fibrosing dermopathy

Background:  Calciphylaxis and metastatic calcification are known complications of chronic renal failure. Recently, a sclerosing condition of the skin termed nephrogenic fibrosing dermopathy (NFD) has been described in patients with renal disease, many of whom have undergone hemodialysis and/or renal transplantation. To our knowledge, the simultaneous occurrence of both conditions in the same patient, in the same lesion, has not been previously reported.

Non-Infectious Granulomatous Diseases of the Skin and their Associated Systemic Diseases

Non-infectious granulomatous diseases of the skin are a broad group of distinct reactive inflammatory conditions that share important similarities. As a group, they are relatively difficult to diagnose and distinguish both clinically as well as histologically. Many of these disorders have significant associations with systemic diseases that impact the patient’s overall prognosis. In this update, we offer a discussion of emerging concepts and controversies in this field, as presented through evidence-based answers to seven important clinical questions regarding palisading and epithelioid granulomata. These questions offer an opportunity to review ten non-infectious granulomatous conditions that have implications for systemic disease: granuloma annulare, annular elastolytic giant cell granuloma, necrobiosis lipoidica, methotrexate-induced accelerated rheumatoid nodulosis, necrobiotic xanthogranuloma, interstitial granulomatous dermatitis, interstitial granulomatous drug reaction, palisaded neutrophilic granulomatous dermatitis, sarcoidosis, and metastatic Crohn disease. Recent clinical, epidemiologic, and laboratory studies have shed some light on these diseases, the association of these conditions with systemic disorders, and their overall prognoses.

Acquired Palmoplantar Keratoderma

Palmoplantar keratodermas (PPKs) are a diverse entity of disorders that are characterized by abnormal thickening of the skin on the palms and soles. Traditionally they have been classified as either hereditary or acquired and are distinguished from each other on the basis of mode of inheritance, presence of transgrediens (defined as contiguous extension of hyperkeratosis beyond the palmar and/or plantar skin), co-morbidities with other symptoms, and extent of epidermal involvement, namely diffuse, focal, and punctate. As the terms hyperkeratosis and keratoderma have been used interchangeably throughout the literature, we define acquired keratoderma as a non-hereditary, non-frictional hyperkeratosis of the palms and/or soles that involves ≥50% of the surface of involved acral areas and that may or may not be associated with clinical and histologic inflammation.Given the numerous possible underlying causes for acquired PPKs, evaluation of patients presenting with acquired PPK can be a perplexing task. To facilitate such evaluations, this review categorizes the acquired PPKs as: keratoderma climactericum, drug related, malnutrition associated, chemically induced, systemic disease related, malignancy associated, dermatoses related, infectious, and idiopathic. In order to avoid the possibility of overlooking an underlying etiology and to eliminate excessive testing, we present an algorithm for assessing patients presenting with acquired PPK. The first step should include a comprehensive history and a physical examination, including a complete skin examination. If findings are consistent with a hereditary keratoderma, then a genetics consultation should be considered. Any findings suggestive of underlying conditions should be aggressively evaluated and treated. If no pertinent findings are identified after a history and a physical examination, laboratory and radiology studies should be undertaken in a systematic, logical fashion.In terms of treatment, the most successful results occur when the underlying etiology is diagnosed and treated. If no such etiology is evident, then conservative treatment options include topical keratolytics (urea, salicylic acid, lactic acid), repeated physical debridement, topical retinoids, topical psoralen plus UVA, and topical corticosteroids. Etretinate and acitretin have also shown some success as alternative treatments in recalcitrant cases.

Adolescent Female Acne: Etiology and Management

Acne vulgaris, a multifactorial condition often conferring significant psychosocial morbidity, affects an estimated 40 million people in the United States. The majority of these individuals are adolescents and young adults. The pathophysiology of the condition is still not fully known, but it is believed to be related in part to excess sebum production, follicular hyperkeratinization, microbial colonization by P acnes, and inflammation. Prior to initiating treatment in a female patient, a hyperandrogenic state must be considered and ruled out through history, physical exam, and laboratory evaluation if necessary. Treatment options are vast and include hormonal therapy among others. Hormonal therapies have long been noted to reduce acne lesions and offer a valuable adjuvant to standard therapy. Hormonal agents are thought to improve acne by blocking the androgen receptor and/or decreasing circulating androgens which leads to decreased sebum production. Hormonal treatment options include spironolactone, other antiandrogens, and oral contraceptives. The use of these agents to effectively treat acne has been demonstrated in several randomized, placebo-controlled clinical trials. Optimal results are often achieved with combination therapy with the goal of targeting multiple pathogenic pathways in acne development.

Intertriginous epidermal dysmaturation from pegylated liposomal doxorubicin

Background:  A new formulation of doxorubicin (pegylated liposomal doxorubicin) has been developed to attenuate the systemic side effects produced by this agent. Although pegylated liposomal doxorubicin has a much lower risk for cardiotoxicity, it has been associated with cutaneous side effects that differ from, and may also be more frequent than, those produced by the free form of the drug.

The skin and hypercoagulable states

Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patients HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.

Tattoo-Associated Complications

Tattoo rates in the United States have been rising in recent years, with an expected concomitant rise in tattoo-associated complications. Tattoo complications range from cutaneous localized and generalized inflammatory eruptions, to local bacterial or viral infections, and finally to infectious endocarditis and hepatitis. Many complications may be avoided with proper counseling prior to tattoo placement, especially in high risk individuals. It is important for physicians to be able to recognize and diagnose complications from tattoos to avoid morbidity and possible mortality.

The purple digit: an algorithmic approach to diagnosis.

The acute onset of purple digits is a concerning manifestation and may represent underlying, potentially life-threatening disease. Correctly identifying the etiology of purple digits is essential to proper management, and can aid in the diagnosis of systemic disease. Multiple causes of purple digits and significant overlap in clinical presentation can make diagnosis difficult. Despite the various causes of acute purple digits in the published literature, an algorithmic approach to the evaluation and management of the most common and alarming etiologies has yet to be established.The initial step in evaluating a patient with purple digits is to determine if the cause is associated with hypoxemia or trauma. If the patient is in a stable condition, the dermatologist needs to determine if the process could be related to cold exposure such as Raynaud phenomenon, acrocyanosis, pernio, cryoglobulinemia or frostbite. If the disease occurs independent of temperature, physical examination and histological evaluation of the skin is recommended. The lack of peripheral pulses are concerning for acute arterial thrombosis from peripheral vascular disease or arterial embolism. Non-blanching skin changes on the digit that lack inflammation and microthrombosis most likely represent a bleeding or platelet abnormality; however, if microthrombi are identified a more life-threatening processes such as purpura fulminans or embolic phenomenon may be occurring. Evidence of blood vessel inflammation suggests a leukocytoclastic vasculitis. The patient with a purple blanching digit and normal pulses requires an extensive historical review to help determine the cause. This review presents an algorithmic approach to assist in the evaluation and management of the purple digit.

Hydroxyethyl starch–induced pruritus relieved by a combination of menthol and camphor

Hydroxyethyl starch is a key component of many colloid volume expanders used in hypovolemic shock and otologic disease. Pruritus is a common side effect. Histopathology reveals multiple cytoplasmic vacuoles in dermal macrophages, endothelial cells, and perineural cells with electron-dense foreign material within the said vacuoles. Although classically refractory to treatment with corticosteroids and antihistamines, some benefit has been achieved with capsaicin, ultraviolet light therapy, and oral naltrexone. We present a case responsive to menthol and camphor and discuss the possible therapeutic mechanism.