Vitaly Terushkin

Estimated equivalency of vitamin D production from natural sun exposure versus oral vitamin D supplementation across seasons at two US latitudes

BACKGROUND The relationship between oral vitamin D supplementation and cutaneous photosynthesis is not well understood. OBJECTIVE We sought to provide estimates of the equivalency of vitamin D production from natural sun exposure versus oral supplementation. METHODS Using the FastRT simulation tool, we determined sun exposure times needed to achieve serum vitamin D(3) concentrations equivalent to 400 or 1000 IU vitamin D for individuals of various Fitzpatrick skin types living in Miami, FL, and Boston, MA, during the months of January, April, July, and October. RESULTS Peak ultraviolet B irradiation for vitamin D synthesis occurs around 12 pm Eastern Standard Time (EST). In Boston, MA, from April to October at 12 pm EST an individual with type III skin, with 25.5% of the body surface area exposed, would need to spend 3 to 8 minutes in the sun to synthesize 400 IU of vitamin D. It is difficult to synthesize vitamin D during the winter in Boston, MA. For all study months in Miami, FL, an individual with type III skin would need to spend 3 to 6 minutes at 12 pm EST to synthesize 400 IU. Vitamin D synthesis occurs faster in individuals with lighter Fitzpatrick skin types. The duration to attain 1000 IU of vitamin D is longer in all scenarios. LIMITATIONS Results of the computer model are only approximations. In addition, calculations were made based on the assumption that (1/4) of 1 minimal erythema dose directed at (1/4) body surface area is equal to 1000 IU of oral vitamin D. CONCLUSIONS Although it may be tempting to recommend intentional sun exposure based on our findings, it is difficult, if not impossible to titrate ones exposure. There are well-known detrimental side effects of ultraviolet irradiation. Therefore, oral supplementation remains the safest way for increasing vitamin D status.

Melanoma Early Detection

Recognizing early forms of melanoma may have significant impact on decreasing mortality from this malignancy. As a result, multiple efforts have focused on developing new and improving current early detection strategies. These include educating patients about the importance of performing skin self-examination, increasing rates of complete skin examinations by physicians in the context of routine care, initiating mass screening campaigns, creating specialized skin cancer clinics, and developing better diagnostic tools through advances in technology. In this article, the current state of these efforts is reviewed.

Use of and beliefs about total body photography and dermatoscopy among US dermatology training programs: An update

BACKGROUND Total body photography (TBP) and dermatoscopy are imaging techniques used to treat patients with pigmented lesions. OBJECTIVE We sought to describe use, training, logistics, and beliefs about these tools among residency programs and to assess changes during a 10-year period. METHODS Surveys were sent to all directors (n = 111) and chief residents (n = 109) of US dermatology training programs. RESULTS A total of 83 (74.8%) attendings answered the questionnaire. In all, 59 (71.1%) reported using TBP, an 11.9% increase (P = .2484) over the past decade. Reasons for using TBP included: reduces patient anxiety (81.4%), helps detect early melanoma (78.0%), and leads to fewer biopsies (66.1%). Logistical (79.2%) and financial (45.8%) constraints were reasons for not using TBP. Seventy respondents (84.3%) reported using dermatoscopy, a 40.0% increase (P = .0001) over the 10-year period. Reasons for dermatoscopy use were consistent over time: helps find melanoma in curable stage (75.7%), reduces patient anxiety (61.4%), and leads to fewer biopsies (57.1%). The most common reason for not using dermatoscopy remained lack of training (38.5%). A total of 92 (84.4%) residents completed their survey, of which 41 (44.6%) and 81 (88.0%) reported using TBP and dermatoscopy, respectively. In all, 62 (67.4%) and 79 (85.9%) respondents would prefer additional training in TBP and dermatoscopy, respectively. LIMITATIONS Results may not be applicable to the general dermatology community. CONCLUSIONS Use of dermatoscopy among residency programs has increased significantly during the last decade. A more modest increase in the use of TBP was observed. Barriers to diffusion of these technologies into practice persist, including insufficient logistics and training.

Pathways to Involution of Nevi Insights From Dermoscopic Follow-up

T HE LIFE OF A MELANOCYTIC NEVUS CAN BE conceptually divided into 3 stages: inception to growth, senescence, and involution. Dermoscopy has provided insights into understanding the first 2 stages of nevogenesis. Herein, we show longitudinal changes in dermoscopic features of nevi that highlight distinct pathways to nevus involution. The first nevus demonstrates disappearance via a halo phenomenon. During dermoscopic follow-up (Figure 1 [A, at baseline in a 33-year-old patient; B, after 12 months; and C, after 21⁄2 additional years]), the pigmented central portion, which has a globular-homogeneous dermoscopic pattern, became progressively smaller and was replaced by the centripetally growing depigmented halo. The remaining hypopigmented macule usually repigments and becomes inconspicuous. An immunemediated process primarily involving T-cell lymphocytes has been implicated in this phenomenon. The second nevus displays a regression pattern. The pigment globules and network are gradually replaced with dermoscopic regression structures, including peppering (granularity) and white scarlike areas (Figure 2 [A, at baseline in a 3-year-old patient; B, after 6 months; and

Analysis of the benign to malignant ratio of lesions biopsied by a general dermatologist before and after the adoption of dermoscopy.

A lthough the benefits of using dermoscopy as a diagnostic aid are well described, dermoscopy currently remains underutilized in the United States. According to a recent survey of US academic dermatologists, reasons cited for lack of utilization included lack of training, logistical constraints, and the belief that the procedure was not helpful. Also, some clinicians may be apprehensive about introducing dermoscopy into their practices because many of the studies that highlight the benefits of dermoscopy have been conducted by pigmented lesion specialists (PLSs). The purpose of our pilot study was to assess changes in the management of pigmented lesions by a general dermatologist after the introduction of dermoscopy. As our end point, we calculated the benign to malignant ratio (BMR) for biopsied pigmented lesions having a clinical differentialdiagnosisofdysplasticnevusand/ormelanoma.Togauge theperformanceof thegeneraldermatologist,wecompared his results to thoseofanexperienceddermoscopyuserwho primarily sees patients with pigmented skin lesions.

Mohs Surgery for Basal Cell Carcinoma Assisted by Dermoscopy: Report of Two Cases

The incidence of nonmelanoma skin cancer in the United States is estimated at more than 1 million, with basal cell carcinoma (BCC) contributing 80% of the cases. Treatment options include curettage, cryosurgery, Mohs micrographic surgery (MMS), radiotherapy, topical therapy, and surgical excision. For BCCs located on the face, hands, and genital region, MMS is a commonly chosen technique because it provides histologic margin control and maximal conservation of normal tissue. The 5-year recurrence rate is less than 1%.

Ablative Fractional Resurfacing for Involuted Hemangioma Residuum

BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

Dermatologists, General Practitioners, and the Best Method to Biopsy Suspect Melanocytic Neoplasms

T HE ARTICLE PUBLISHED BY NG ET AL 1 IN THIS issue of the Archives compares the rates of melanoma misdiagnosis between partial and excisional biopsies. The authors report an increased rate of misdiagnosis, as well as microstaging inaccuracy, associated with partial biopsy compared with complete excision. Partial biopsy with a punch, specifically, increased the odds of melanoma misdiagnosis with adverse outcomes such as progression of the primary melanoma or development of metastasis. In addition, the authors reported that lesions initially managed by general practitioners (GPs) were also associated with increased odds of misdiagnosis with adverse outcomes compared with lesions initially managed by dermatologists.

Effect of General Anesthesia on Neurodevelopmental Abnormalities in Children Undergoing Treatment of Vascular Anomalies With Laser Surgery: A Retrospective Review

BACKGROUND Multiple exposures to general anesthesia may be neurotoxic to the developing brain. This relationship has not been evaluated in children undergoing laser surgery for vascular anomalies. OBJECTIVE To evaluate the prevalence of neurodevelopmental abnormalities in children who received multiple laser procedures under general anesthesia before the age of 4 years for the treatment of vascular anomalies. METHODS AND MATERIALS Retrospective chart review of patients with contact of parents for telephone interview. RESULTS Thirty-three patients were eligible. Average age at the time of survey was 7.8 years. Twenty-three (84.8%) patients were female, with average age at the time of first treatment at 1.9 years. Average number of treatments received before the age of 4 years was 6.7. Anesthetics included inhalational nitrous oxide and isoflurane and intravenous propofol. Seven patients carried one or more of the following diagnoses: attention-deficit hyperactivity disorder (3.0%), anxiety (6.1%), behavioral disorder (3.0%), language disorder (3.0%), speech disorder (3.0%), and motor disorder (6.1%). These prevalence rates are similar to those found in the US population. CONCLUSION This is the first report on the prevalence of neurodevelopmental disorders in children undergoing multiple laser treatments under general anesthesia. Although the study sample is small, no increased risks when comparing with prevalence rates reported in the literature were noted.

Disappearance of Melanocytic Nevi

Nevus involution is a common phenomenon, but the mechanisms responsible for this process are currently not well characterized. With the development of noninvasive imaging technologies, such as dermoscopy and reflectance confocal microscopy, we have begun to appreciate distinct morphological features that develop, or in some case, disappear during nevus involution. In this chapter, we describe several dermoscopic patterns of disappearing nevi and attempt to illustrate their potential mechanisms using evidence from the literature and personal experience.