Integration of a deep learning basal cell carcinoma detection and tumor mapping algorithm into the Mohs micrographic surgery workflow and effects on clinical staffing: A simulated, retrospective study

Background

Artificial intelligence (AI) enabled tools have been proposed as 1 solution to improve health care delivery. However, research on downstream effects of AI integration into the clinical workflow is lacking.

Objective

We aim to analyze how integration of an automated basal cell carcinoma detection and tumor mapping algorithm in a Mohs micrographic surgery unit impacts the work efficiency of clinical and laboratory staff.

Methods

Slide, staff, and histotechnician waiting times were analyzed over a 20-day period in a Mohs micrographic surgery unit. A simulated AI workflow was created and the time differences between the real and simulated workflows were compared.

Results

Simulated nonautonomous algorithm integration led to savings of 35.6% of slide waiting time, 18.4% of staff waiting time, and 18.6% of histotechnician waiting time per day. Algorithm integration on days with increased reconstruction complexity resulted in the greatest time savings.

Limitations

One Mohs micrographic surgery unit was analyzed and simulated AI integration was performed retrospectively.

Conclusions

AI integration results in reduced staff waiting times, enabling increased productivity and a streamlined clinical workflow. Schedules containing surgical cases with either increased repair complexity or numerous tumor removal stages stand to benefit most. However, significant logistical challenges must be addressed before broad adoption into clinical practice is realistic.

Inpatient Management of Epidermolysis Bullosa: Consensus-Based Hands-On Instructions for Neonates and Post-Neonates

BACKGROUND

Epidermolysis bullosa (EB), characterized by skin fragility and blistering, often requires hospitalization. Training for inpatient management of EB is limited, with no unified recommendations available in North America.

OBJECTIVE

To develop consensus-derived best practices for hands-on inpatient management of EB in both the neonatal and post-neonatal period.

METHODS

A modified Delphi method (expert-based input via two surveys and a final review) was implemented. Available guidelines from EB Clinical Research Consortium (EBCRC) centers were analyzed to determine areas of focus and formulate statements to be voted on by EBCRC members, experienced EB nurses, and select family members. Study participants evaluated statements using a Likert scale: statements with at least 70% agreement were accepted; statements with 30% or more disagreement were rejected.

RESULTS

Ten areas of focus were identified. Delphi participants included 15 dermatologists, 8 nurses, and 6 non-healthcare caregivers. Consensus was established on 103/119 neonatal statements and 105/122 post-neonatal statements; no statements were rejected. Most recommendations applied to both age groups.

LIMITATIONS

Recommendations may require adjustment based on individual patient's clinical context.

CONCLUSION

Using the Delphi method, a consensus-derived resource for hospital-based healthcare professionals who manage patients with EB has been developed to improve the quality of inpatient care.

Microbiome modulators for atopic eczema: a systematic review of experimental and investigational therapeutics

INTRODUCTION

Atopic dermatitis (AD) is a common inflammatory cutaneous disease that arises due to dysregulation of the Th2 immune response, impaired skin barrier integrity, and dysbiosis of the skin and gut microbiota. An abundance of Staphylococcus aureus biofilms in AD lesions increases the Th2 immune response, and gut bacteria release breakdown products such as Short Chain Fatty Acids that regulate the systemic immune response.

AREAS COVERED

We aim to evaluate therapies that modulate the microbiome in humans and discuss the clinical implications of these treatments. We performed a review of the literature in which 2,673 records were screened, and describe the findings of 108 studies that were included after full-text review. All included studies discussed the effects of therapies on the human microbiome and AD severity. Oral probiotics, topical probiotics, biologics, and investigational therapies were included in our analysis.

EXPERT OPINION

Oral probiotics demonstrate mixed efficacy at relieving AD symptoms. Topical probiotics reduce S. aureus abundance in AD lesional skin, yet for moderate-severe disease, these therapies may not reduce AD severity scores to the standard of biologics. Dupilumab and tralokinumab target key inflammatory pathways in AD and modulate the skin microbiome, further improving disease severity.

The epidemiology of acne vulgaris in a multiethnic adolescent population from Rotterdam, the Netherlands: A cross-sectional study

BACKGROUND

Although acne is a prevalent multifactorial inflammatory skin condition, few studies were performed in multiethnic populations.

OBJECTIVES

To study the prevalence and determinants of acne in a multiethnic study at the start of puberty.

METHODS

This cross-sectional study is embedded in Generation R, a population-based prospective study from Rotterdam, the Netherlands. Three-dimensional facial photos at the center visit in 2016-2019 (of ∼13-year-olds) were used to grade acne severity using the Global Evaluation of the Acne Severity (GEA). Analyses were stratified by biological sex and explored through chi-square tests and multivariable ordinal logistic regression.

RESULTS

A total of 4561 children (51% girls) with a median age of 13.5 (IQR 13.3-13.6) were included. The visible acne prevalence (GEA 2-5) for girls vs boys was 62% vs 45% and moderate-to-severe acne (GEA 3-5) 14% vs 9%. Higher puberty stages (adjusted odds ratios: 1.38 [1.20-1.59] and 2.16 [1.86-2.51] for girls and boys, respectively) and darker skin colors V and VI (adjusted odds ratios: 1.90 [1.17-3.08] and 2.43 [1.67-3.56]) were associated with more severe acne in both sexes, and being overweight in boys (adjusted odds ratio: 1.58 [1.15-2.17]).

LIMITATIONS

Cross-sectional design.

CONCLUSIONS

Acne prevalence was high at the age of 13 years and was associated with advanced puberty, darker skin color, and weight status.

The Origins and Development of Pre-emptive Dermatologic Anesthesia: A Systematic Review

This study delves into the historical trajectory of dermatological anesthesia, tracing its roots from ancient civilizations to modern times. It emphasizes the relentless pursuit of pain relief in dermatologic procedures and the transformative impact of anesthesia on surgical practices. A comprehensive analysis was conducted through an extensive literature review, employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review model on the PubMed and Embase databases. A total of 1304 articles were initially identified, with six publications from these databases and 10 additional sources from the World Wide Web included in the study. This systematic approach allowed for a thorough examination of the historical journey of dermatological anesthesia. The historical trajectory outlined in this study highlights the progress in dermatological anesthesia, showcasing its impact on contemporary procedures with a continual emphasis on patient comfort and safety. As medical knowledge expands, the ongoing quest for enhanced pain control in dermatology remains a central focus.

Sunscreen Safety and Efficacy for the Prevention of Cutaneous Neoplasm

Sunscreen is widely used for ultraviolet radiation protection. Studies validate sun protection factors (SPFs) to prevent ultraviolet (UV)-induced skin changes such as melanoma and squamous cell carcinoma (SCC). Few studies examine sunscreen's impact on endocrine and immune system dysregulation, the production of radical oxygen species, and whether the ingredients deteriorate under prolonged exposure. We present an investigation of sunscreen labels and how ingredients impact sun safety and human health. A review of the literature was conducted using Embase and PubMed to examine sunscreen safety, efficacy, and use to prevent UV-induced skin damage. Increasing sunscreen reapplication, wearing protective clothing, and limiting exposure can reduce the incidence of skin cancer. Inorganic sunscreens form barriers to block UV light, but without titanium dioxide (TiO2), they may not be advantageous due to their low UVA protection. Organic sunscreens absorb into the skin and provide a better feeling after application. Octocrylene and avobenzone are stable and provide UVA and UVB protection with minimal adverse effects. Oxybenzone is harmful to the neuroendocrine system and should be avoided. Titanium dioxide works for broad-spectrum UV protection and offers minimal adverse effects. Octocrylene and avobenzone are organic sunscreen ingredients that also provide a better feeling on the skin after application, which enables higher rates of use. Oxybenzone should be avoided.

To Debride or Not to Debride: A Review of Wound Management for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are immune-mediated skin reactions with high mortality as a result of severely compromised skin barrier function. Currently, there is no consensus on the topical management of these conditions. Some advocate for surgical debridement of affected skin as a means of preventing infection and facilitating reepithelialization with synthetic and biological wound coverage. Others prefer a conservative approach that relies on leaving the blistered skin in situ. A consensus is lacking, primarily due to the rarity of the disease and the lack of high-quality evidence supporting one particular form of management. The goal of this review is to explore and compare the two treatment approaches for SJS and TEN, namely conservative management and surgical debridement.

The First Report of Multiple, Bilateral Axillary Epidermal Inclusion Cysts

Epidermal inclusion cysts (EICs) are benign masses that often develop on the face, scalp, neck, and back. Typically, EICs occur secondary to acne or obstructed hair follicles. However, the development of multiple EICs is associated with various syndromes and invasive procedures. Despite their relatively benign nature, a small percentage of EICs have been found to undergo malignant transformation. The complete excision of EICs is essential for their definitive treatment because of their ability to rupture, causing pain and infection. We present the first reported case of a patient without a history of acne, axillary surgery, or genetic syndromes who presented with multiple, painless, bilateral axillary EICs.

Best practices in the treatment of melasma with a focus on patients with skin of color

BACKGROUND

Melasma is a chronic hypermelanosis of the skin that affects approximately 1% of the global population, predominantly affects women, and is more prevalent in skin of color. Melasma is a common driver for patients with skin of color to seek out a dermatologist for treatment, and ensuring the right approach for these patients is important because some treatments may be associated with adverse side effects. Because of the chronicity of the disease and established psychosocial and emotional impacts, there is a large need to ensure care follows the best available evidence on the treatment of patients with melasma.

OBJECTIVE

Here, we summarized current available topical treatments for melasma with considerations dermatologists should have for their patients with skin of color.

METHODS

Steering committee consensus on clinical best practices.

RESULTS

We describe a flexible and focused treatment algorithm that reflects both treatment and maintenance periods that is a consensus of our extensive clinical experience.

LIMITATIONS

Use of real-world evidence and potential for individual practice bias.

CONCLUSION

Melasma can be challenging to treat, particularly in patients with skin of color, and our recommendations for best practices for patients in the United States are an important step toward standardizing care.

Estimating remaining life expectancy in veterans with basal cell carcinoma using an automated electronic health record scoring system: A retrospective cohort study

BACKGROUND

Active surveillance may be considered for low-risk basal cell carcinomas (BCCs) in patients with limited life expectancy; however, estimates of life expectancy are not readily available. Veterans Health Administration's Care Assessment Need (CAN) score may address this problem.

OBJECTIVE

We examined the CAN score's performance in predicting 1-, 3-, and 5-year mortality in US veterans with BCC.

METHODS

This retrospective cohort study used national Veterans Health Administration's electronic medical record data. The CAN score's performance in the prediction of mortality in veterans with BCC was evaluated based on tests of goodness-of-fit, discrimination, and calibration.

RESULTS

For 54,744 veterans with BCC treatment encounters between 2013 and 2018, the CAN score performed well in the prediction of mortality based on multiple tests. A threshold CAN score of 90 had a positive predictive value of 55% for 3-year mortality, clinically useful in identifying patients with intermediate-term survival.

LIMITATIONS

The study relied upon the combination of diagnosis codes and procedure codes to identify BCC cases.

CONCLUSION

The CAN score has the potential to improve the quality of cancer care for veterans by providing clinicians with an estimate of life expectancy and facilitating conversations in cases where active surveillance can be considered.

Surgical excision versus topical 5% 5-fluorouracil and photodynamic therapy in treatment of Bowen's disease: A multicenter randomized controlled trial

BACKGROUND

Randomized controlled trials comparing the effectiveness of 5-fluorouracil cream, methylaminolevulinate photodynamic therapy (MAL-PDT) and surgical excision in patients with Bowen's disease are lacking.

METHODS

In this multicenter noninferiority trial, patients with a histologically proven Bowen's disease of 4-40 mm were randomly assigned to excision with 5 mm margin, 5% 5-fluorouracil cream twice daily for 4 weeks, or 2 sessions of MAL-PDT with 1 week interval. The primary outcome was the proportion of patients with sustained clearance at 12 months after treatment. A noninferiority margin of 22% was used.

RESULTS

Between May 2019 and January 2021, 250 patients were randomized. The proportion of patients with sustained clearance was 97.4% (75/77) after excision, 85.7% (66/77) after 5-fluorouracil, and 82.1% (64/78) after MAL-PDT. Absolute differences were -11.7% (95% CI -18.9 to -4.5; P = .0049) for 5-fluorouracil versus excision and -15.4% (95% CI -23.1 to -7.6; P = .00078) for MAL-PDT versus excision. Both noninvasive treatments significantly more often led to good or excellent cosmetic outcome.

CONCLUSIONS

Based on our predefined noninferiority margin of 22%, 5-fluorourcail is noninferior to excision and associated with better cosmetic outcome. For MAL-PDT noninferiority to excision cannot be concluded. Therefore, 5-fluorouracil should be preferred over excision and MAL-PDT in treatment of Bowen's disease.

A deep learning algorithm to detect cutaneous squamous cell carcinoma on frozen sections in Mohs micrographic surgery: A retrospective assessment

Intraoperative margin analysis is crucial for the successful removal of cutaneous squamous cell carcinomas (cSCC). Artificial intelligence technologies (AI) have previously demonstrated potential for facilitating rapid and complete tumour removal using intraoperative margin assessment for basal cell carcinoma. However, the varied morphologies of cSCC present challenges for AI margin assessment. The aim of this study was to develop and evaluate the accuracy of an AI algorithm for real-time histologic margin analysis of cSCC. To do this, a retrospective cohort study was conducted using frozen cSCC section slides. These slides were scanned and annotated, delineating benign tissue structures, inflammation and tumour to develop an AI algorithm for real-time margin analysis. A convolutional neural network workflow was used to extract histomorphological features predictive of cSCC. This algorithm demonstrated proof of concept for identifying cSCC with high accuracy, highlighting the potential for integration of AI into the surgical workflow. Incorporation of AI algorithms may improve efficiency and completeness of real-time margin assessment for cSCC removal, particularly in cases of moderately and poorly differentiated tumours/neoplasms. Further algorithmic improvement incorporating surrounding tissue context is necessary to remain sensitive to the unique epidermal landscape of well-differentiated tumours, and to map tumours to their original anatomical position/orientation.

Pancreatic Cancer Presenting to the Dermatology Clinic

In patients with skin of color, jaundice may present more discretely, which can lead to a delay in diagnosing underlying disease and widening racial disparity gaps. It is important for clinicians to recognize the subtleties of jaundice to achieve the most optimal outcomes for patients. Careful examination of the sclera and palms, sites where yellowing is most obvious, as well as asking patients if they have noticed any skin color changes can be beneficial. We present a case of a patient who presented to the dermatology clinic with jaundice and pruritus refractory to standard treatment, ultimately leading to a diagnosis of pancreatic cancer.

A Deep Dive Into Instagram's Top Skinfluencers

We characterized skinfluencers from various training backgrounds and compared their posts on Instagram featuring skin care products.

DMT310, a novel once-weekly topical treatment for patients with moderate-to-severe acne vulgaris: Results of a phase 2b randomized, double-blind, placebo-controlled trial

BACKGROUND

Poor patient adherence with antiacne medications is a common clinical challenge. DMT310, a natural, topical product with a once-weekly application schedule, may alleviate this obstacle.

OBJECTIVE

Evaluate the safety, tolerability, and efficacy of DMT310 in treating moderate-to-severe acne.

METHODS

This 12-week, randomized, double-blind, placebo-controlled, multicenter clinical trial enrolled participants 12 years and older with moderate-to-severe acne.

RESULTS

The intent-to-treat population included a total of 181 participants (DMT310, N = 91; placebo, N = 90). Participants who received DMT310 vs participants treated with placebo demonstrated a statistically significant greater reduction in the number of inflammatory and noninflammatory lesions at all time points: inflammatory lesion counts at week 12 (-15.64 vs -10.84, P < .001); noninflammatory lesion counts at week 12 (-18.26 vs -12.41, P < .001). DMT310-treated participants also had higher rates of Investigator's Global Assessment treatment success than participants in the placebo group at all time points: Investigator's Global Assessment at week 12 (44.40% vs 17.78%; P < .001). No serious treatment related adverse events occurred.

CONCLUSIONS

DMT310 once-weekly topical treatment significantly reduced both inflammatory and noninflammatory lesions and yielded a greater proportion of Investigator's Global Assessment treatment success at all time points in participants with moderate-to-severe acne.

Optimisation of skin phototype classification

Understanding individuals' skin pigmentation and photosensitivity is important in judging risk of skin cancer and response to certain treatment modalities. However, individuals with darkly pigmented skin are poorly represented in the widely used Fitzpatrick skin phototype (FST) system. Moreover, the FST system is prone to misuse, as it relies on subjective patient and clinician assessment of skin type, and does not clearly differentiate pigmentation from photosensitivity. By evaluating the key literature surrounding the FST system, its criticisms and proposed alternatives, this review serves to understand how skin phototype classification can be optimised.

Ulcerative Colitis Flare Post Isotretinoin Use: A Case Report

Ulcerative colitis (UC) is an inflammatory bowel disease characterized by chronic intestinal inflammation. We present a case of UC flare induced by isotretinoin, a medication commonly used for the treatment of severe acne. A 36-year-old male with a history of UC in remission presented with moderate-severe cystic acne and was started on isotretinoin. After four months of treatment, he developed symptoms of UC flare, including bloody diarrhea. A colonoscopy revealed ulcerative pancolitis, and isotretinoin was discontinued. The patient was subsequently treated with adalimumab and azathioprine, achieving good disease control. This case highlights the potential link between isotretinoin and UC exacerbation, suggesting the need for further research to understand the underlying mechanisms and assess the risk associated with isotretinoin use in patients with UC.

Androgenetic alopecia in transgender and gender diverse populations: A review of therapeutics

Androgenetic alopecia (AGA) management is a significant clinical and therapeutic challenge for transgender and gender-diverse (TGD) patients. Although gender-affirming hormone therapies affect hair growth, there is little research about AGA in TGD populations. After reviewing the literature on approved treatments, off-label medication usages, and procedures for treating AGA, we present treatment options for AGA in TGD patients. The first-line treatments for any TGD patient include topical minoxidil 5% applied to the scalp once or twice daily, finasteride 1 mg oral daily, and/or low-level laser light therapy. Spironolactone 200 mg daily is also first-line for transfeminine patients. Second-line options include daily oral minoxidil dosed at 1.25 or 2.5 mg for transfeminine and transmasculine patients, respectively. Topical finasteride 0.25% monotherapy or in combination with minoxidil 2% solution are second-line options for transmasculine and transfeminine patients, respectively. Other second-line treatments for any TGD patient include oral dutasteride 0.5 mg daily, platelet-rich plasma, or hair restoration procedures. After 6-12 months of treatment, AGA severity and treatment progress should be assessed via scales not based on sex; eg, the Basic and Specific Classification or the Bouhanna scales. Dermatologists should coordinate care with the patient's primary gender-affirming clinician(s) so that shared knowledge of all medications exists across the care team.

Host and primary tumor factors for the development of multiple cutaneous squamous cell carcinomas among a retrospective cohort in Rhode Island

INTRODUCTION

Risk factors for a primary cutaneous squamous cell carcinoma (CSCC) are well-established; however, the host and primary tumor risk factors for subsequent CSCC have not been fully explored.

METHODS

We performed a retrospective chart review of patients diagnosed with CSCC in an academic dermatology clinic in Rhode Island from 2016-2019. Logistic regression was used to evaluate the associations between host factors and multiple CSCC and between primary tumor characteristics and the risk of subsequent CSCC. Adjusted odds ratios (aORs) and 95% CIs were calculated.

RESULTS

A total of 1312 patients with CSCC diagnoses were included. Host risk factors significantly associated with multiple CSCCs included: aged >80 years (aOR, 2.18; 95% CI, 1.46-3.31); history of: solid organ transplant (aOR, 2.41; 95% CI, 1.20-4.80); skin cancer (aOR, 1.96; 95% CI, 1.52-2.54); other cancer (aOR, 1.49; 95% CI, 1.11-2.00); family history of skin cancer (aOR, 1.36; 95% CI, 1.03-1.78); and actinic keratosis (aOR, 1.52; 95% CI, 1.18-1.95). Tumor location, diameter, histologic differentiation, and treatment were not significant predictors of subsequent CSCCs.

LIMITATIONS

Study patients were predominantly White and from a single institution, limiting the generalizability of results.

CONCLUSIONS

Certain host characteristics were associated with the development of subsequent CSCC, which may inform clinical guidelines for follow-up.