Kimberly A. Bohjanen

Accuracy of teledermatology for pigmented neoplasms

BACKGROUND Accurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma. OBJECTIVE We sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology. METHODS We conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed. RESULTS We enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within +/-10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology. LIMITATIONS Nondiverse study population and relatively small number of melanomas were limitations. CONCLUSIONS In general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

Original articleAccuracy of teledermatology for nonpigmented neoplasms

BACKGROUND Studies of teledermatology utilizing the standard reference of histopathology are lacking. OBJECTIVE To compare accuracy of store-and-forward teledermatology for non-pigmented neoplasms with in-person dermatology. METHODS This study was a repeated-measures equivalence trial involving veterans with non-pigmented skin neoplasms. Each lesion was evaluated by an in-person dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and management plan. The primary outcome was aggregated diagnostic accuracy (percent correct matches of any chosen diagnosis with histopathology). Secondary outcomes included management plan accuracy (percent correct matches with expert panel management plan). Additional analyses included evaluation of the incremental effect of using polarized light dermatoscopy in addition to standard macro images, and evaluating benign and malignant lesion subgroups separately. RESULTS Most of the 728 participants were male (97.8%) and Caucasian (98.9%). The aggregated diagnostic accuracy (primary outcome) of teledermatology (macro images) was not equivalent (95% confidence interval [CI] for difference within +/-10%) and was inferior (95% CI lower bound <10%) to in-person dermatology for all lesions and the subgroups of benign and malignant lesions. However, management plan accuracy was equivalent. Teledermatology aggregated diagnostic accuracy using polarized light dermatoscopy was significantly better than for macro images alone (P = .0017). The addition of polarized light dermatoscopy showed the same pattern for malignant lesions, but not for benign lesions. Most interestingly, for malignant lesions, the addition of polarized light dermatoscopy yielded equivalent aggregated diagnostic accuracy rates. LIMITATIONS Non-diverse study population. CONCLUSIONS Using macro images, the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but accuracy of management plans was equivalent. The addition of polarized light dermatoscopy yielded significantly better aggregated diagnostic accuracy, but management plan accuracy was not significantly improved. For the important subgroup of malignant lesions, the addition of polarized light dermatoscopy yielded equivalent diagnostic accuracy between teledermatologists and clinic dermatologists.

Multicenter Photopheresis Intervention Trial in Early-Stage Mycosis Fungoides

PURPOSE To demonstrate the efficacy of the UVAR XTS Photopheresis System and evaluate health-related quality of life in patients with early-stage mycosis fungoides (MF). PATIENTS AND METHODS Extracorporeal photopheresis was administered 2 days every 4 weeks for 6 months. Patients with partial responses by skin weighted assessment continued for 6 months; nonresponders added oral bexarotene and/or interferon α. Health-related quality of life was assessed at baseline and every 3 months with 3 validated tools. RESULTS Nineteen patients with early-stage MF (7 men, 12 women; 16 white, 3 African Americans) with median age of 63.5 years (range, 46-85 years) participated. Their stages were IA (n = 3), IB (n = 14), and IIA (n = 2). The overall response rate for extracorporeal photopheresis (ECP) alone, was 42% (8/19; including 7 partial response, 1 complete response), with a median of 12 ECP sessions (range, 3-32) given over a median of 12 months (3-32 months) and with an overall duration of response of 6.5 months (range, 1-48 months). Seven patients with stable disease at 3 months received additional bexarotene (3/5; 1 complete response) or bexarotene plus interferon α (1/2), and 4 (57%) of 7 responded. Treatment-related adverse effects were limited to those expected with interferon (fatigue, nausea, vomiting, and diarrhea), or with hypertriglyceridemia and bexarotene. Trends in health-related quality of life indicated an improvement in emotional scores over time. CONCLUSIONS ECP is effective for patients with early-stage MF alone or in combination with biologic response modifiers with low toxicity and improved quality of life.

Psoriasis and physical activity: a review.

Psoriasis is a common, chronic inflammatory skin disease that can cause significant discomfort and impairment to quality of life. Recent research indicates that individuals with moderate‐to‐severe psoriasis are likely at greater risk for chronic cardiometabolic co‐morbidities such as cardiovascular disease, type 2 diabetes, obesity and metabolic syndrome. Physical activity can be an effective primary and adjunctive treatment for these maladies in other populations. Unfortunately, only a limited number of studies have examined physical activity in psoriasis, which are limited by poor design and lack of validated physical activity assessment methodologies. A variety of data suggest shared physiologic pathways between physical activity, psoriasis, and psoriasis cardiometabolic co‐morbidities. Increased adiposity, inflammation, oxidative stress, adhesion molecules and lipids are physiologically linked to psoriasis, the risk of psoriasis cardiometabolic co‐morbidities, and low levels of physical activity. In addition, epigenetic pathways are involved in psoriasis and could be influenced by physical activity. The physical and psychosocial impairments common in psoriasis may make it difficult to participate in regular physical activity, and future studies should aim to determine if physical activity interventions improve functioning and reduce co‐morbidities in psoriasis.

Psoriasis and physical activity

Psoriasis is a common, chronic inflammatory skin disease that can cause significant discomfort and impairment to quality of life. Recent research indicates that individuals with moderate‐to‐severe psoriasis are likely at greater risk for chronic cardiometabolic co‐morbidities such as cardiovascular disease, type 2 diabetes, obesity and metabolic syndrome. Physical activity can be an effective primary and adjunctive treatment for these maladies in other populations. Unfortunately, only a limited number of studies have examined physical activity in psoriasis, which are limited by poor design and lack of validated physical activity assessment methodologies. A variety of data suggest shared physiologic pathways between physical activity, psoriasis, and psoriasis cardiometabolic co‐morbidities. Increased adiposity, inflammation, oxidative stress, adhesion molecules and lipids are physiologically linked to psoriasis, the risk of psoriasis cardiometabolic co‐morbidities, and low levels of physical activity. In addition, epigenetic pathways are involved in psoriasis and could be influenced by physical activity. The physical and psychosocial impairments common in psoriasis may make it difficult to participate in regular physical activity, and future studies should aim to determine if physical activity interventions improve functioning and reduce co‐morbidities in psoriasis.

Interobserver accuracy of store and forward teledermatology for skin neoplasms

adjacent nonirradiated (ie, shielded) site. These specimens were bisected for CD determination and hematoxylin-eosin staining. A histologic examination showed mild superficial perivascular inflammatory lymphocytic infiltrates in the majority of the control group’s irradiated sites. Baseline CD could not be quantified in two subjects in the nonP leucotomosetreated group; they were excluded from the subsequent analysis. At two times the MED, average CD values in the non-P leucotomosetreated group increased by 217% over baseline, while values in the P leucotomosetreated decreased by 84% (P 1⁄4 .06). At three times the MED, those values increased 760% and 61%, respectively (P 1⁄4 .07). No interaction significance was found (P 1⁄4 .08). Pretreatment with P leucotomos showed a strong trend but failed to achieve statistical significance in preventing the increase of CD levels 24 hours after UVA irradiation. Although chronic UVA exposure has been associated with CD elevation, our findings showed increments in CD expression after acute UVA exposure. According to our interaction analysis, P leucotomos’ effect exhibited a trend towards preventing the increase of CD levels as the UVA dose increased. Except for the expected erythema after UVA irradiation, no treatment-related adverse events were recorded in any of the subjects. Although pretreatment with P leucotomos did not prevent the development of mild superficial perivascular inflammatory lymphocytic infiltrate in subjects irradiated with UVA, more biopsies in the control group (those not receiving P leucotomos; n 1⁄4 6) reported the development of the infiltrate after UVA irradiation compared with biopsy reports in the PL group (n1⁄4 5) after irradiation with UVA. In addition, all biopsies from adjacent nonirradiated (ie, shielded) sites reported normal skin (ie, no infiltrates). Although larger studies are needed to characterize P leucotomos’ role in photoaging, this pilot study’s findings suggest that P leucotomos may prevent UVAinduced skin photodamage possibly by preventing UVA-dependent mitochondrial DNA damage.

Human papillomavirus vaccine acceptance among young men in Bangalore, India.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the world. It can lead to anogenital, cervical, and head and neck cancer, with higher risk of malignant disease in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) patients. In India, 73,000 of the 130,000 women diagnosed with cervical cancer die annually. Gardasil®, a vaccine available against HPV types 6, 11, 16, and 18, is approved for use in women in India but not men. A backlash to post‐licensure trials has created a negative public opinion of the vaccine for women. Vaccinating boys and men is an alternate approach to prevent cervical cancer in women. This study gauges facilitators and barriers to vaccination acceptance among men in Bangalore, India.

Black-spot poison ivy.

In black-spot poison ivy dermatitis, a black lacquerlike substance forms on the skin when poison ivy resin is exposed to air. Although the Toxicodendron group of plants is estimated to be the most common cause of allergic contact dermatitis in the United States, black-spot poison ivy dermatitis is relatively rare.

Toxic epidermal necrolysis secondary to emergency contraceptive pills.

This case letter discusses a woman who developed dysuria conjunctivitis and erythematous papules on 20% of her body from ingesting four contraceptive pills as a single dose five days before her visit to the emergency room. It shows the significance of the implication that the emergency contraceptive pills (ECPs) may have caused her to develop toxic epidermal necrolysis (TEN).

Mortality in intravascular large B-cell lymphoma: A SEER analysis

We identified 30,355 patients with HS; their characteristics are described in Table I. Among those patients who did not receive IS, the crude incidences of HZ were 0.42% (85 of 20,105) and 0.38% (81,500 of 21,542,350) among patients with HS and without HS, respectively (P\.0020). In this group, patients with HS had increased odds of developing HZ compared with patients without HS in unadjusted (odds ratio [OR], 1.12; 95% confidence interval [CI], 0.90-1.38) and adjusted (OR, 1.40; 95% CI, 1.13-1.73) analyses. A prescription for IS was given to 33.8% of patients with HS (10,250 of 30,355) and 14.9% of patients without HS (3,776,450 of 25,318,800). Among the patients receiving IS, the crude incidences of HZ were 1.27% (130 of 10,250) and 1.03% (38,870 of 3,776,450) among patients with HS and without HS, respectively (P \ .0001). Compared to patients without HS, patients with HS who were receiving IS had an increased risk of developing HZ in unadjusted (OR, 1.24; 95%, CI 1.04-1.47) and adjusted (OR, 1.49; 95% CI, 1.25-1.77) analyses (Table II). Patients with HS who were not receiving IS had a very low incidence of HZ. Exposure to IS was associated with a tripling of the crude incidence of HZ, although the incidence was still less than 2%. The likelihood of development of HZ among patients with HS, compared to patients without HS, was similar regardless of exposure to IS, suggesting that IS use does not modify the relationship between HS and HZ. The incidence of HZ among patients with HS appears to approximate the rates observed in the general US population. In a claims-based analysis, the overall incidence rate of HZ among adults was observed to be 4.47 per 1000 person-years. We could not account for HZ vaccination in this analysis. Because of the low number of events in each group, we could not stratify risk of HZ by type of IS. We conclude that risk of development of HZ infection among patients with HS is only slightly higher than among patients without HS. The risk however is still low, even with exposure to IS. Although the need for vaccination should be assessed for patients individually, those with HS generally may not require HZ vaccination, even with immunomodulation, before the age of 50 years.