Timothy Patton

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.

Novel therapies for pemphigus vulgaris: an overview.

Pemphigus comprises a group of autoimmune, mucocutaneous blistering disorders. Its principal cause may be a group of antibodies directed against proteins present on the surface of keratinocytes that provide mechanical structure to the epidermis. In the case of pemphigus vulgaris, the characteristic blistering noted just above the basal layer may be triggered by auto-antibodies directed against desmoglein 3 (Dsg3). The process by which the binding of these antibodies leads to acantholysis, apoptosis and eventual loss of epidermal function is not completely understood. Current therapies are primarily directed against the formation of these antibodies by suppression of the immune system, and are associated with significant adverse events. As our understanding of the pathophysiology of pemphigus increases, newer therapies have been proposed and evaluated. These novel therapies include intravenous immunoglobulin, plasmapheresis, immunoadsorption, extra-corporeal photochemotherapy, biological agents, as well as experimental therapies such as cholinergic receptor agonists, Dsg3 peptides and a p38 mitogen-activated protein kinase inhibitor. Current limitations to the widespread use of these therapies include cost, a lack of consistent data regarding their benefit, limited availability, and the experimental nature of some of the treatments. This review highlights the latest case reports and studies that employ established as well as new therapeutics in a novel way to treat this rare, but serious, disorder.

The predominance of IgG4 in prodromal bullous pemphigoid

Background  Prodromal bullous pemphigoid (PBP) and bullous pemphigoid (BP) demonstrate immunoglobulin G (IgG) and/or C3 deposition at the basement membrane zone (BMZ) on direct immunofluorescence. BP‐180‐specific IgG1, IgG4, and IgE antibodies have been detected in BP. However, the distribution of IgG subclasses is unknown in PBP.

Role of Methotrexate in the Treatment of Bullous Pemphigoid in the Elderly

Bullous pemphigoid (BP) is an autoimmune blistering disease that commonly occurs in the elderly. Immunosuppressive medications are effective at controlling the disease in the majority of cases. Mortality can occur as a consequence of severe disease or as a result of the therapies that are frequently employed as treatment. Commonly employed therapies include systemic corticosteroids, azathioprine and mycophenolate mofetil. In a small subset of patients, these first- and second-line therapies do not control disease or are not tolerated by the patients. Optional therapies include nicotinamide (niacinamide), tetracycline, intravenous immunoglobulin, cyclophosphamide, dapsone and methotrexate. The majority of BP patients are elderly, and several considerations need to be taken into account before a specific therapy is chosen. Methotrexate provides several advantages in the elderly population in terms of practicality, cost and tolerability. Several retrospective and prospective studies have evaluated its effectiveness in the treatment of BP in the elderly population. The results of these studies indicate that methotrexate is an effective therapy for BP and is a reasonable option for treatment in the elderly population, although maybe not as a first- or second-line therapy.

Dysplastic nevi with severe atypia: Long-term outcomes in patients with and without re-excision

Background: Dysplastic nevi with severe atypia (severely dysplastic nevi [SDN]) are frequently re‐excised because of the concern that these lesions may in fact represent early melanoma. Data on long‐term follow‐up of these patients are limited. Objective: We sought to determine the rate of subsequent melanoma development in patients with SDN who underwent re‐excision versus those who did not and to determine factors associated with decision to re‐excise. Methods: A retrospective single institutional study was conducted with 451 adult patients (mean age 41.3 years) with SDN biopsied between November 1994 and November 2004, with clinical follow‐up of at least 5 years. Results: In 451 patients with SDN, re‐excision was performed on 36.6%. Two melanomas were diagnosed in the re‐excision specimens. Subsequent metastatic melanoma developed in 7 patients, all of whom had a history of melanoma. Margin comments influenced decision to re‐excise. Limitations: This was a retrospective study at a single institution. Conclusion: Re‐excision of all SDN may not be necessary.

Treatment of recalcitrant Darier's disease with electron beam therapy

Dariers disease (DD) is difficult to treat and has no cure. Although many modalities have been investigated, treatment options to date are largely unsatisfactory. Side‐effect profiles have limited the use of many of these therapies, as has their ability to target only limited areas of disease. Furthermore, the effectiveness of most available treatments seems to be highly individualized, varying with disease severity and offering little alteration in the natural course of the disease. The present study reports a case of severe DD that was poorly responsive to known therapeutic modalities but responded to electron beam radiotherapy, and recommends this therapeutic modality for localized areas of severe, recalcitrant symptomatic disease.

Oral systemic agents for immunobullous disorders

The immunobullous diseases comprise a number of clinically heterogeneous disorders caused by the production of antibodies directed against different proteins present in the skin and/or mucous membranes. Multiple therapies, both topical and systemic, make up the armamentarium for these varied conditions. In terms of the systemic therapies that are available, the appropriate medication in each individual patient must take into account the specific diagnosis, severity of the disease, comorbidities of the patient, potential interactions with other medications, and short and long-term goals of therapy. In this chapter, we review the oral systemic agents that can be used for the different immunobullous diseases and review their efficacy, side effects, and recommendations for patient monitoring for long-term therapy.

A cross-sectional study of indoor tanning use among patients seeking skin cancer screening

Cancer and Population Studies Group and Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, Australia; and Institute of Cardiovascular and Cell Sciences (Dermatology Unit), St George’s University of London, and CRUK (Cancer Research United Kingdom) Manchester Institute and Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Center, United Kingdom.

Tattoo Artists’ Approach to Melanocytic Nevi

Author Contributions: Dr Cordel and Mr Tressières had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Cordel. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Cordel, Chosidow. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Tressières. Administrative, technical, or material support: Cordel, Herrmann Storck. Study supervision: Cordel.

Autoimmune Blistering Diseases of the Skin and Mucous Membranes

Autoimmune blistering diseases of the skin and mucous membranes are characterized by the presence of tissue bound and circulating antibodies that are directed against specific proteins present in the skin. The different diseases that compose this category of conditions vary in their clinical presentation, prognosis, and response to therapy.