Melanoma

EDINBURGH – How would you like a smartphone app that offers a personalized sun protection strategy based on location and skin type?

At the 15th World Congress on Cancers of the Skin, Nina Goad, head of communications for the British Association of Dermatologists, discussed an app that does just that: the World UV App. The app, developed by the British Association of Dermatologists, provides daily UV forecasts based on an individual’s location via a smartphone or tablet. In addition, the app fine-tunes UV risk according to skin type.

In a video interview at the meeting, Ms. Goad discussed the app’s development and how patients can use it to improve their approach to sun protection.

[email protected]

EDINBURGH – How would you like a smartphone app that offers a personalized sun protection strategy based on location and skin type?

At the 15th World Congress on Cancers of the Skin, Nina Goad, head of communications for the British Association of Dermatologists, discussed an app that does just that: the World UV App. The app, developed by the British Association of Dermatologists, provides daily UV forecasts based on an individual’s location via a smartphone or tablet. In addition, the app fine-tunes UV risk according to skin type.

In a video interview at the meeting, Ms. Goad discussed the app’s development and how patients can use it to improve their approach to sun protection.

[email protected]

EDINBURGH – How would you like a smartphone app that offers a personalized sun protection strategy based on location and skin type?

At the 15th World Congress on Cancers of the Skin, Nina Goad, head of communications for the British Association of Dermatologists, discussed an app that does just that: the World UV App. The app, developed by the British Association of Dermatologists, provides daily UV forecasts based on an individual’s location via a smartphone or tablet. In addition, the app fine-tunes UV risk according to skin type.

In a video interview at the meeting, Ms. Goad discussed the app’s development and how patients can use it to improve their approach to sun protection.

[email protected]

A recently published prospective cohort study reported that sildenafil use may increase the risk for melanoma (JAMA Intern Med. 2014;174:964-970). BRAF activation, which is pathogenic in some melanoma variants, downregulates phosphodiesterase 5A and sildenafil downregulates phosphodiesterase 5A, surmising that either one may enhance melanoma invasion. The Health Professionals’ Follow-up Study cohort was utilized, which has prospectively evaluated male health professionals’ nutrition and incidences of serious illnesses since 1986. In 2000, more than 25,000 men were interviewed about sildenafil use for erectile dysfunction, and the incidence of skin cancer was obtained by questionnaire every 2 years for 10 years. The questionnaire showed that 142 melanomas were diagnosed, and recent or prior sildenafil use (with no breakdown of frequency of dosing) was significantly associated with increased risk for melanoma (hazard ratio, 1.84 for recent use; 1.92 for ever use) adjusted for age, erectile dysfunction without sildenafil, and several skin-related and genetic melanoma risk factors. No other types of skin cancer exhibited this risk trend.

What’s the issue?

Vascular tone and manipulation of such is a contender as a hot topic in melanoma given that even aspirin has been implicated as a risk factor. Unfortunately, similar to the aspirin data, without a true continuum providing any sildenafil dosage or frequency relationship to the development of melanoma, especially for this very short half-life medication, we likely cannot consider sildenafil as a hazard in patients at high risk for melanoma as we do for smokers and oral contraceptives, or alcoholics and terbinafine. Because UV radiation is the only behavioral risk factor linked to melanoma and considering that so many of our male patients take this class of drug, in your opinion what percentage of your patients in this risk category follow strict sun protection? Should we mention this potential association to them?

We want to know your views! Tell us what you think.

A recently published prospective cohort study reported that sildenafil use may increase the risk for melanoma (JAMA Intern Med. 2014;174:964-970). BRAF activation, which is pathogenic in some melanoma variants, downregulates phosphodiesterase 5A and sildenafil downregulates phosphodiesterase 5A, surmising that either one may enhance melanoma invasion. The Health Professionals’ Follow-up Study cohort was utilized, which has prospectively evaluated male health professionals’ nutrition and incidences of serious illnesses since 1986. In 2000, more than 25,000 men were interviewed about sildenafil use for erectile dysfunction, and the incidence of skin cancer was obtained by questionnaire every 2 years for 10 years. The questionnaire showed that 142 melanomas were diagnosed, and recent or prior sildenafil use (with no breakdown of frequency of dosing) was significantly associated with increased risk for melanoma (hazard ratio, 1.84 for recent use; 1.92 for ever use) adjusted for age, erectile dysfunction without sildenafil, and several skin-related and genetic melanoma risk factors. No other types of skin cancer exhibited this risk trend.

What’s the issue?

Vascular tone and manipulation of such is a contender as a hot topic in melanoma given that even aspirin has been implicated as a risk factor. Unfortunately, similar to the aspirin data, without a true continuum providing any sildenafil dosage or frequency relationship to the development of melanoma, especially for this very short half-life medication, we likely cannot consider sildenafil as a hazard in patients at high risk for melanoma as we do for smokers and oral contraceptives, or alcoholics and terbinafine. Because UV radiation is the only behavioral risk factor linked to melanoma and considering that so many of our male patients take this class of drug, in your opinion what percentage of your patients in this risk category follow strict sun protection? Should we mention this potential association to them?

We want to know your views! Tell us what you think.

A recently published prospective cohort study reported that sildenafil use may increase the risk for melanoma (JAMA Intern Med. 2014;174:964-970). BRAF activation, which is pathogenic in some melanoma variants, downregulates phosphodiesterase 5A and sildenafil downregulates phosphodiesterase 5A, surmising that either one may enhance melanoma invasion. The Health Professionals’ Follow-up Study cohort was utilized, which has prospectively evaluated male health professionals’ nutrition and incidences of serious illnesses since 1986. In 2000, more than 25,000 men were interviewed about sildenafil use for erectile dysfunction, and the incidence of skin cancer was obtained by questionnaire every 2 years for 10 years. The questionnaire showed that 142 melanomas were diagnosed, and recent or prior sildenafil use (with no breakdown of frequency of dosing) was significantly associated with increased risk for melanoma (hazard ratio, 1.84 for recent use; 1.92 for ever use) adjusted for age, erectile dysfunction without sildenafil, and several skin-related and genetic melanoma risk factors. No other types of skin cancer exhibited this risk trend.

What’s the issue?

Vascular tone and manipulation of such is a contender as a hot topic in melanoma given that even aspirin has been implicated as a risk factor. Unfortunately, similar to the aspirin data, without a true continuum providing any sildenafil dosage or frequency relationship to the development of melanoma, especially for this very short half-life medication, we likely cannot consider sildenafil as a hazard in patients at high risk for melanoma as we do for smokers and oral contraceptives, or alcoholics and terbinafine. Because UV radiation is the only behavioral risk factor linked to melanoma and considering that so many of our male patients take this class of drug, in your opinion what percentage of your patients in this risk category follow strict sun protection? Should we mention this potential association to them?

We want to know your views! Tell us what you think.

Thin actinic keratoses on the face or scalp were 14% more likely to clear completely in patients treated with photodynamic therapy, compared with cryotherapy, in a meta-analysis of four studies including 641 patients.

Complete clearance 3 months after treatment was significantly more likely in the 2,170 actinic keratoses treated by photodynamic therapy (PDT), compared with 2,174 actinic keratoses treated by cryotherapy, Dr. Gayatri Patel and her associates reported.

© Dr-Strangelove / ThinkStockPhotos.com

The data came from randomized trials with 10 or more participants in which the PDT used topical aminolevulinic acid hydrochloride or methyl aminolevulinate hydrochloride, the most widely available PDT stabilizers in North America and Europe. Methyl aminolevulinate recently was withdrawn from the U.S. market but remains common in Europe, noted Dr. Patel of the University of California, Davis, and her associates.

The study results were published online in JAMA Dermatology (2014 Aug. 27 [doi:10.1001/jamadermatol.2014.1253]).

The results suggested that PDT works better on thinner actinic keratoses. Grade 1 (thin) actinic keratoses on the face or scalp were 86% more likely to clear by 12 weeks after PDT, compared with cryotherapy, the investigators reported.

Only one of the fours studies found higher efficacy rates for cryotherapy, compared with PDT, and more than 60% of lesions in that study were grade 2 (moderately thick, easily felt) or grade 3 (very thick and/or obvious) actinic keratoses. The other three studies in the meta-analysis excluded thicker lesions or favored thinner ones, the researchers noted.

They excluded from the meta-analysis two other studies that compared PDT with cryotherapy for actinic keratoses because of incompatible follow-up times. They reviewed 13 studies in all, including studies involving treatment of actinic keratosis with imiquimod, fluorouracil, or carbon dioxide laser, but could not meta-analyze data on these other treatments because of different outcome measures and follow-up times or lack of a comparator.

Photosensitivity, pain, erythema, and pruritus were common after PDT. Cryotherapy induced pain and pruritus, but at lower rates than did PDT. Hypopigmentation occurred in 33% of patients after cryotherapy and in 9% after PDT in one study.

Satisfaction ratings by patients and unblinded investigators tended to favor PDT over cryotherapy, perhaps because PDT may produce ancillary cosmetic improvements when treating actinic keratosis, Dr. Patel and her associates speculated.

The findings were limited by the poor quality of the studies, which were lacking double-blind design and description of randomization methods, but no sources of bias were evident, and the large number of patients and relatively similar treatment locations were strengths of the analysis, they said.

Dr. Patel reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Thin actinic keratoses on the face or scalp were 14% more likely to clear completely in patients treated with photodynamic therapy, compared with cryotherapy, in a meta-analysis of four studies including 641 patients.

Complete clearance 3 months after treatment was significantly more likely in the 2,170 actinic keratoses treated by photodynamic therapy (PDT), compared with 2,174 actinic keratoses treated by cryotherapy, Dr. Gayatri Patel and her associates reported.

© Dr-Strangelove / ThinkStockPhotos.com

The data came from randomized trials with 10 or more participants in which the PDT used topical aminolevulinic acid hydrochloride or methyl aminolevulinate hydrochloride, the most widely available PDT stabilizers in North America and Europe. Methyl aminolevulinate recently was withdrawn from the U.S. market but remains common in Europe, noted Dr. Patel of the University of California, Davis, and her associates.

The study results were published online in JAMA Dermatology (2014 Aug. 27 [doi:10.1001/jamadermatol.2014.1253]).

The results suggested that PDT works better on thinner actinic keratoses. Grade 1 (thin) actinic keratoses on the face or scalp were 86% more likely to clear by 12 weeks after PDT, compared with cryotherapy, the investigators reported.

Only one of the fours studies found higher efficacy rates for cryotherapy, compared with PDT, and more than 60% of lesions in that study were grade 2 (moderately thick, easily felt) or grade 3 (very thick and/or obvious) actinic keratoses. The other three studies in the meta-analysis excluded thicker lesions or favored thinner ones, the researchers noted.

They excluded from the meta-analysis two other studies that compared PDT with cryotherapy for actinic keratoses because of incompatible follow-up times. They reviewed 13 studies in all, including studies involving treatment of actinic keratosis with imiquimod, fluorouracil, or carbon dioxide laser, but could not meta-analyze data on these other treatments because of different outcome measures and follow-up times or lack of a comparator.

Photosensitivity, pain, erythema, and pruritus were common after PDT. Cryotherapy induced pain and pruritus, but at lower rates than did PDT. Hypopigmentation occurred in 33% of patients after cryotherapy and in 9% after PDT in one study.

Satisfaction ratings by patients and unblinded investigators tended to favor PDT over cryotherapy, perhaps because PDT may produce ancillary cosmetic improvements when treating actinic keratosis, Dr. Patel and her associates speculated.

The findings were limited by the poor quality of the studies, which were lacking double-blind design and description of randomization methods, but no sources of bias were evident, and the large number of patients and relatively similar treatment locations were strengths of the analysis, they said.

Dr. Patel reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

Thin actinic keratoses on the face or scalp were 14% more likely to clear completely in patients treated with photodynamic therapy, compared with cryotherapy, in a meta-analysis of four studies including 641 patients.

Complete clearance 3 months after treatment was significantly more likely in the 2,170 actinic keratoses treated by photodynamic therapy (PDT), compared with 2,174 actinic keratoses treated by cryotherapy, Dr. Gayatri Patel and her associates reported.

© Dr-Strangelove / ThinkStockPhotos.com

The data came from randomized trials with 10 or more participants in which the PDT used topical aminolevulinic acid hydrochloride or methyl aminolevulinate hydrochloride, the most widely available PDT stabilizers in North America and Europe. Methyl aminolevulinate recently was withdrawn from the U.S. market but remains common in Europe, noted Dr. Patel of the University of California, Davis, and her associates.

The study results were published online in JAMA Dermatology (2014 Aug. 27 [doi:10.1001/jamadermatol.2014.1253]).

The results suggested that PDT works better on thinner actinic keratoses. Grade 1 (thin) actinic keratoses on the face or scalp were 86% more likely to clear by 12 weeks after PDT, compared with cryotherapy, the investigators reported.

Only one of the fours studies found higher efficacy rates for cryotherapy, compared with PDT, and more than 60% of lesions in that study were grade 2 (moderately thick, easily felt) or grade 3 (very thick and/or obvious) actinic keratoses. The other three studies in the meta-analysis excluded thicker lesions or favored thinner ones, the researchers noted.

They excluded from the meta-analysis two other studies that compared PDT with cryotherapy for actinic keratoses because of incompatible follow-up times. They reviewed 13 studies in all, including studies involving treatment of actinic keratosis with imiquimod, fluorouracil, or carbon dioxide laser, but could not meta-analyze data on these other treatments because of different outcome measures and follow-up times or lack of a comparator.

Photosensitivity, pain, erythema, and pruritus were common after PDT. Cryotherapy induced pain and pruritus, but at lower rates than did PDT. Hypopigmentation occurred in 33% of patients after cryotherapy and in 9% after PDT in one study.

Satisfaction ratings by patients and unblinded investigators tended to favor PDT over cryotherapy, perhaps because PDT may produce ancillary cosmetic improvements when treating actinic keratosis, Dr. Patel and her associates speculated.

The findings were limited by the poor quality of the studies, which were lacking double-blind design and description of randomization methods, but no sources of bias were evident, and the large number of patients and relatively similar treatment locations were strengths of the analysis, they said.

Dr. Patel reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

VANCOUVER, B.C. – In the clinical opinion of Dr. Mariusz Sapijaszko, treating actinic keratosis without field therapy creates a disadvantage "because this is not an individual lesion disease," he maintained at the annual meeting of the Pacific Dermatologic Association.

Actinic keratosis "is a field concept disease. I tell patients ‘the sun has not been shining only on your left temple. It’s been shining all over your face and scalp, neck, and arms. ... It’s time to start looking after your skin with sun protection and lesion-directed field therapies.’"

An estimated 11% of all dermatologic visits in the United States are for actinic keratosis (AK) and "we worry about it because the natural course of AK lesions is unpredictable," said Dr. Sapijaszko of the Western Canada Dermatology Institute, Edmonton, Alta. It’s not easy to predict which lesions will progress to in situ or invasive squamous cell carcinomas (SCCs).

An estimated 40%-80% of cutaneous SCCs arise from, or near, an AK lesion, which supports the concept of field UV damage. AK lesions may persist, regress, or progress, depending on the patient’s immune status. Some lesions that regress will recur, from 32% within 1 year to 92% within 5 years. Progression can lead to hypertrophic AKs, in situ SCC, or invasive SCC. It can be difficult to distinguish AKs and early forms of SCC or even other nonmelanoma skin cancers, "so it’s important to treat all AKs," Dr. Sapijaszko said. Lesions that can progress to SCC include those that are hyperkeratotic, painful, have atypical features such as broader or deeper presentations, as well as those difficult to clear with standard therapies and those that occur in immunocompromised patients.

Locally destructive, mechanical ways to treat AKs include liquid nitrogen cryosurgery, electrodessication and curettage, and excision. "All of these treatments are highly operator dependent, because clearly if you use liquid nitrogen cryotherapy enough you will destroy that lesion but you will not destroy the surrounding DNA damage that has been present," he said.

Field-directed therapies, however, provide an opportunity for a more complete treatment effect. Options include 5-FU (5-fluorouracil), imiquimod, ingenol mebutate, and photodynamic therapy as well as chemical peels and laser resurfacing. Chemical peels and laser resurfacing "have less robust data, but they’re operator dependent, because you can do laser resurfacing with 100 microns or 300 microns," Dr. Sapijaszko said.

"That can depend on the technique you use, and the laser you use, and the patient in front of you." Some of the field treatment options are easier to apply than others. For example, 5-FU is applied twice daily, while imiquimod is applied twice weekly; yet all boast complete clearance rates in the 40%-50% range. "Side effects are also similar between these agents," he said. "Pain is not a big issue except with 5-FU; some patients experience a significant burning sensation."

The newest approved field therapy option, ingenol mebutate, has a dual mechanism of action: it causes cell death within 24 hours and it has been shown to reduce the number of UV-induced mutated p53 patches in mice. "This is important because we’re not just treating the lesions that we see, we want to treat the molecular changes that lead to the actual problem," Dr. Sapijaszko said. "Having decreased mutations is a huge advantage. Direct cell death leads to secondary inflammation. The immune response is characterized by cytokine release and activation of endothelial cells, leading to infiltration of lymphocytes and neutrophils, which contributes to clearance of tumor cells."

Before ingenol mebutate came on the market, investigators randomized patients with AKs to one of three treatment groups: imiquimod 5% cream, 5-FU 5% ointment, or cryotherapy (Br. J. Dermatol. 2007; 157 [suppl. 2]:34-40). Compared with their counterparts, patients in the imiquimod group fared significantly better in terms of sustained clearance of cleared lesions (73% vs. 54% in the 5-FU group, vs. 28% in the cryosurgery group (P less than .01).

"I wish we had comparative data to ingenol mebutate, but to me, of these three modalities, imiquimod stands out as the favorite," Dr. Sapijaszko said.

He went on to note that combining the available mechanical and field treatments for AK simultaneously or sequentially can lead to optimal outcomes. "Combination therapy, in particular cryotherapy, has been successfully used with a variety of topicals and has been shown to be highly advantageous, compared with placebo or to some of these agents alone," he said. "In addition, cryotherapy can be used with PDT, chemical peels, and laser resurfacing. Almost nobody in my practice gets one treatment, unless it’s a single individual lesion. Everybody gets recommendations on appropriate sun protection – just being sun smart."

Dr. Sapijaszko disclosed that he has received honoraria from and is an advisor to Galderma, Leo Pharma, and Valeant.

[email protected]

On Twitter @dougbrunk

VANCOUVER, B.C. – In the clinical opinion of Dr. Mariusz Sapijaszko, treating actinic keratosis without field therapy creates a disadvantage "because this is not an individual lesion disease," he maintained at the annual meeting of the Pacific Dermatologic Association.

Actinic keratosis "is a field concept disease. I tell patients ‘the sun has not been shining only on your left temple. It’s been shining all over your face and scalp, neck, and arms. ... It’s time to start looking after your skin with sun protection and lesion-directed field therapies.’"

An estimated 11% of all dermatologic visits in the United States are for actinic keratosis (AK) and "we worry about it because the natural course of AK lesions is unpredictable," said Dr. Sapijaszko of the Western Canada Dermatology Institute, Edmonton, Alta. It’s not easy to predict which lesions will progress to in situ or invasive squamous cell carcinomas (SCCs).

An estimated 40%-80% of cutaneous SCCs arise from, or near, an AK lesion, which supports the concept of field UV damage. AK lesions may persist, regress, or progress, depending on the patient’s immune status. Some lesions that regress will recur, from 32% within 1 year to 92% within 5 years. Progression can lead to hypertrophic AKs, in situ SCC, or invasive SCC. It can be difficult to distinguish AKs and early forms of SCC or even other nonmelanoma skin cancers, "so it’s important to treat all AKs," Dr. Sapijaszko said. Lesions that can progress to SCC include those that are hyperkeratotic, painful, have atypical features such as broader or deeper presentations, as well as those difficult to clear with standard therapies and those that occur in immunocompromised patients.

Locally destructive, mechanical ways to treat AKs include liquid nitrogen cryosurgery, electrodessication and curettage, and excision. "All of these treatments are highly operator dependent, because clearly if you use liquid nitrogen cryotherapy enough you will destroy that lesion but you will not destroy the surrounding DNA damage that has been present," he said.

Field-directed therapies, however, provide an opportunity for a more complete treatment effect. Options include 5-FU (5-fluorouracil), imiquimod, ingenol mebutate, and photodynamic therapy as well as chemical peels and laser resurfacing. Chemical peels and laser resurfacing "have less robust data, but they’re operator dependent, because you can do laser resurfacing with 100 microns or 300 microns," Dr. Sapijaszko said.

"That can depend on the technique you use, and the laser you use, and the patient in front of you." Some of the field treatment options are easier to apply than others. For example, 5-FU is applied twice daily, while imiquimod is applied twice weekly; yet all boast complete clearance rates in the 40%-50% range. "Side effects are also similar between these agents," he said. "Pain is not a big issue except with 5-FU; some patients experience a significant burning sensation."

The newest approved field therapy option, ingenol mebutate, has a dual mechanism of action: it causes cell death within 24 hours and it has been shown to reduce the number of UV-induced mutated p53 patches in mice. "This is important because we’re not just treating the lesions that we see, we want to treat the molecular changes that lead to the actual problem," Dr. Sapijaszko said. "Having decreased mutations is a huge advantage. Direct cell death leads to secondary inflammation. The immune response is characterized by cytokine release and activation of endothelial cells, leading to infiltration of lymphocytes and neutrophils, which contributes to clearance of tumor cells."

Before ingenol mebutate came on the market, investigators randomized patients with AKs to one of three treatment groups: imiquimod 5% cream, 5-FU 5% ointment, or cryotherapy (Br. J. Dermatol. 2007; 157 [suppl. 2]:34-40). Compared with their counterparts, patients in the imiquimod group fared significantly better in terms of sustained clearance of cleared lesions (73% vs. 54% in the 5-FU group, vs. 28% in the cryosurgery group (P less than .01).

"I wish we had comparative data to ingenol mebutate, but to me, of these three modalities, imiquimod stands out as the favorite," Dr. Sapijaszko said.

He went on to note that combining the available mechanical and field treatments for AK simultaneously or sequentially can lead to optimal outcomes. "Combination therapy, in particular cryotherapy, has been successfully used with a variety of topicals and has been shown to be highly advantageous, compared with placebo or to some of these agents alone," he said. "In addition, cryotherapy can be used with PDT, chemical peels, and laser resurfacing. Almost nobody in my practice gets one treatment, unless it’s a single individual lesion. Everybody gets recommendations on appropriate sun protection – just being sun smart."

Dr. Sapijaszko disclosed that he has received honoraria from and is an advisor to Galderma, Leo Pharma, and Valeant.

[email protected]

On Twitter @dougbrunk

VANCOUVER, B.C. – In the clinical opinion of Dr. Mariusz Sapijaszko, treating actinic keratosis without field therapy creates a disadvantage "because this is not an individual lesion disease," he maintained at the annual meeting of the Pacific Dermatologic Association.

Actinic keratosis "is a field concept disease. I tell patients ‘the sun has not been shining only on your left temple. It’s been shining all over your face and scalp, neck, and arms. ... It’s time to start looking after your skin with sun protection and lesion-directed field therapies.’"

An estimated 11% of all dermatologic visits in the United States are for actinic keratosis (AK) and "we worry about it because the natural course of AK lesions is unpredictable," said Dr. Sapijaszko of the Western Canada Dermatology Institute, Edmonton, Alta. It’s not easy to predict which lesions will progress to in situ or invasive squamous cell carcinomas (SCCs).

An estimated 40%-80% of cutaneous SCCs arise from, or near, an AK lesion, which supports the concept of field UV damage. AK lesions may persist, regress, or progress, depending on the patient’s immune status. Some lesions that regress will recur, from 32% within 1 year to 92% within 5 years. Progression can lead to hypertrophic AKs, in situ SCC, or invasive SCC. It can be difficult to distinguish AKs and early forms of SCC or even other nonmelanoma skin cancers, "so it’s important to treat all AKs," Dr. Sapijaszko said. Lesions that can progress to SCC include those that are hyperkeratotic, painful, have atypical features such as broader or deeper presentations, as well as those difficult to clear with standard therapies and those that occur in immunocompromised patients.

Locally destructive, mechanical ways to treat AKs include liquid nitrogen cryosurgery, electrodessication and curettage, and excision. "All of these treatments are highly operator dependent, because clearly if you use liquid nitrogen cryotherapy enough you will destroy that lesion but you will not destroy the surrounding DNA damage that has been present," he said.

Field-directed therapies, however, provide an opportunity for a more complete treatment effect. Options include 5-FU (5-fluorouracil), imiquimod, ingenol mebutate, and photodynamic therapy as well as chemical peels and laser resurfacing. Chemical peels and laser resurfacing "have less robust data, but they’re operator dependent, because you can do laser resurfacing with 100 microns or 300 microns," Dr. Sapijaszko said.

"That can depend on the technique you use, and the laser you use, and the patient in front of you." Some of the field treatment options are easier to apply than others. For example, 5-FU is applied twice daily, while imiquimod is applied twice weekly; yet all boast complete clearance rates in the 40%-50% range. "Side effects are also similar between these agents," he said. "Pain is not a big issue except with 5-FU; some patients experience a significant burning sensation."

The newest approved field therapy option, ingenol mebutate, has a dual mechanism of action: it causes cell death within 24 hours and it has been shown to reduce the number of UV-induced mutated p53 patches in mice. "This is important because we’re not just treating the lesions that we see, we want to treat the molecular changes that lead to the actual problem," Dr. Sapijaszko said. "Having decreased mutations is a huge advantage. Direct cell death leads to secondary inflammation. The immune response is characterized by cytokine release and activation of endothelial cells, leading to infiltration of lymphocytes and neutrophils, which contributes to clearance of tumor cells."

Before ingenol mebutate came on the market, investigators randomized patients with AKs to one of three treatment groups: imiquimod 5% cream, 5-FU 5% ointment, or cryotherapy (Br. J. Dermatol. 2007; 157 [suppl. 2]:34-40). Compared with their counterparts, patients in the imiquimod group fared significantly better in terms of sustained clearance of cleared lesions (73% vs. 54% in the 5-FU group, vs. 28% in the cryosurgery group (P less than .01).

"I wish we had comparative data to ingenol mebutate, but to me, of these three modalities, imiquimod stands out as the favorite," Dr. Sapijaszko said.

He went on to note that combining the available mechanical and field treatments for AK simultaneously or sequentially can lead to optimal outcomes. "Combination therapy, in particular cryotherapy, has been successfully used with a variety of topicals and has been shown to be highly advantageous, compared with placebo or to some of these agents alone," he said. "In addition, cryotherapy can be used with PDT, chemical peels, and laser resurfacing. Almost nobody in my practice gets one treatment, unless it’s a single individual lesion. Everybody gets recommendations on appropriate sun protection – just being sun smart."

Dr. Sapijaszko disclosed that he has received honoraria from and is an advisor to Galderma, Leo Pharma, and Valeant.

[email protected]

On Twitter @dougbrunk

CHICAGO – Malignancy rates in patients with psoriasis outstrip those in the general population, based on data from a retrospective analysis of commercial claims.

Rates for all cancers were similar among patients undergoing different psoriasis treatments, with the exception of nonmelanoma skin cancer and lymphoma.

Rates for these two cancers were more variable across treatment groups, but were still above those in the general public, Dr. Alexa B. Kimball reported at the American Academy of Dermatology summer meeting.

The increased cancer risk may be associated with chronic inflammation, a hallmark of psoriasis, and exposure to some psoriasis therapies such as phototherapy with psoralen plus ultraviolet, cyclosporine, and methotrexate, she noted in the study’s background information.

Previous studies also have suggested that patients with psoriasis may be at increased risk for some cancers such as respiratory tract, urinary tract, and liver cancers, non-Hodgkin’s lymphoma, and skin cancers.

To evaluate the incidence of malignancy, the investigators obtained data from the MarketScan Commercial and Medicare Supplemental claims databases for patients with a diagnosis of psoriasis on or before Dec. 31, 2006, and at least one prescription claim for etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), ustekinumab (Stelara), nonbiologic therapies, or phototherapy.

The general population cohort included patients at least 18 years old as of 2005 or at enrollment in the health care plan. Both cohorts had 12 months’ continuous enrollment in the health care plan from Jan. 1, 2005, through Dec. 31, 2006.

Follow-up for a patient ended at the first cancer event, disenrollment from the health care plan, or after 5 years from the index date.

Patients with psoriasis had a 5-year malignancy rate of 115.5 cases/10,000 person-years, compared with 96/10,000 person-years for the general population, reported Dr. Kimball of Massachusetts General Hospital, Boston.

Excluding nonmelanoma skin cancer and lymphoma, incidence rates were similar across treatment groups: etanercept (100.2/10,000), adalimumab (94.6/10,000), infliximab (138.1/10,000), ustekinumab (100.6/10,000), nonbiologics (116.8/10,000), and phototherapy (117.3/10,000).

"These large database queries continue to be reassuring that most systemic therapies are not changing the risk for common cancers, excluding lymphoma and skin cancer, which we continue to examine separately," Dr. Kimball said in an interview.

Nonmelanoma skin cancer was far and away the most common malignancy in psoriasis patients, occurring at a rate of 147.2/10,000 person-years vs. 94.2/10,000 person-years among the general public. Rates were highest in patients treated with adalimumab (234.2/10,000 person-years) and ustekinumab (233.3/10,000) and lowest in those treated with etanercept (155.9/10,000).

"Even with the large size of the database, the number of skin cancers remains small, so making conclusions about specific therapies may be premature," she said.

Incidence rates of lymphoma were considerably lower, but again higher in psoriasis patients than the general public (11.1/10,000 vs. 6.6/10,000). Rates of this hematologic cancer were highest with ustekinumab (25.1/10,000) and, once again, lowest with etanercept (6.9/10,000), according to the poster.

In all, 5,857 patients received nonbiologic therapies, 6,856 received etanercept, 3,314 adalimumab, 1,044 infliximab, 526 ustekinumab, and 5,156 were treated with phototherapy.

Dr. Kimball is a consultant for several pharmaceutical companies including Amgen, the study sponsor.

[email protected]

CHICAGO – Malignancy rates in patients with psoriasis outstrip those in the general population, based on data from a retrospective analysis of commercial claims.

Rates for all cancers were similar among patients undergoing different psoriasis treatments, with the exception of nonmelanoma skin cancer and lymphoma.

Rates for these two cancers were more variable across treatment groups, but were still above those in the general public, Dr. Alexa B. Kimball reported at the American Academy of Dermatology summer meeting.

The increased cancer risk may be associated with chronic inflammation, a hallmark of psoriasis, and exposure to some psoriasis therapies such as phototherapy with psoralen plus ultraviolet, cyclosporine, and methotrexate, she noted in the study’s background information.

Previous studies also have suggested that patients with psoriasis may be at increased risk for some cancers such as respiratory tract, urinary tract, and liver cancers, non-Hodgkin’s lymphoma, and skin cancers.

To evaluate the incidence of malignancy, the investigators obtained data from the MarketScan Commercial and Medicare Supplemental claims databases for patients with a diagnosis of psoriasis on or before Dec. 31, 2006, and at least one prescription claim for etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), ustekinumab (Stelara), nonbiologic therapies, or phototherapy.

The general population cohort included patients at least 18 years old as of 2005 or at enrollment in the health care plan. Both cohorts had 12 months’ continuous enrollment in the health care plan from Jan. 1, 2005, through Dec. 31, 2006.

Follow-up for a patient ended at the first cancer event, disenrollment from the health care plan, or after 5 years from the index date.

Patients with psoriasis had a 5-year malignancy rate of 115.5 cases/10,000 person-years, compared with 96/10,000 person-years for the general population, reported Dr. Kimball of Massachusetts General Hospital, Boston.

Excluding nonmelanoma skin cancer and lymphoma, incidence rates were similar across treatment groups: etanercept (100.2/10,000), adalimumab (94.6/10,000), infliximab (138.1/10,000), ustekinumab (100.6/10,000), nonbiologics (116.8/10,000), and phototherapy (117.3/10,000).

"These large database queries continue to be reassuring that most systemic therapies are not changing the risk for common cancers, excluding lymphoma and skin cancer, which we continue to examine separately," Dr. Kimball said in an interview.

Nonmelanoma skin cancer was far and away the most common malignancy in psoriasis patients, occurring at a rate of 147.2/10,000 person-years vs. 94.2/10,000 person-years among the general public. Rates were highest in patients treated with adalimumab (234.2/10,000 person-years) and ustekinumab (233.3/10,000) and lowest in those treated with etanercept (155.9/10,000).

"Even with the large size of the database, the number of skin cancers remains small, so making conclusions about specific therapies may be premature," she said.

Incidence rates of lymphoma were considerably lower, but again higher in psoriasis patients than the general public (11.1/10,000 vs. 6.6/10,000). Rates of this hematologic cancer were highest with ustekinumab (25.1/10,000) and, once again, lowest with etanercept (6.9/10,000), according to the poster.

In all, 5,857 patients received nonbiologic therapies, 6,856 received etanercept, 3,314 adalimumab, 1,044 infliximab, 526 ustekinumab, and 5,156 were treated with phototherapy.

Dr. Kimball is a consultant for several pharmaceutical companies including Amgen, the study sponsor.

[email protected]

CHICAGO – Malignancy rates in patients with psoriasis outstrip those in the general population, based on data from a retrospective analysis of commercial claims.

Rates for all cancers were similar among patients undergoing different psoriasis treatments, with the exception of nonmelanoma skin cancer and lymphoma.

Rates for these two cancers were more variable across treatment groups, but were still above those in the general public, Dr. Alexa B. Kimball reported at the American Academy of Dermatology summer meeting.

The increased cancer risk may be associated with chronic inflammation, a hallmark of psoriasis, and exposure to some psoriasis therapies such as phototherapy with psoralen plus ultraviolet, cyclosporine, and methotrexate, she noted in the study’s background information.

Previous studies also have suggested that patients with psoriasis may be at increased risk for some cancers such as respiratory tract, urinary tract, and liver cancers, non-Hodgkin’s lymphoma, and skin cancers.

To evaluate the incidence of malignancy, the investigators obtained data from the MarketScan Commercial and Medicare Supplemental claims databases for patients with a diagnosis of psoriasis on or before Dec. 31, 2006, and at least one prescription claim for etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), ustekinumab (Stelara), nonbiologic therapies, or phototherapy.

The general population cohort included patients at least 18 years old as of 2005 or at enrollment in the health care plan. Both cohorts had 12 months’ continuous enrollment in the health care plan from Jan. 1, 2005, through Dec. 31, 2006.

Follow-up for a patient ended at the first cancer event, disenrollment from the health care plan, or after 5 years from the index date.

Patients with psoriasis had a 5-year malignancy rate of 115.5 cases/10,000 person-years, compared with 96/10,000 person-years for the general population, reported Dr. Kimball of Massachusetts General Hospital, Boston.

Excluding nonmelanoma skin cancer and lymphoma, incidence rates were similar across treatment groups: etanercept (100.2/10,000), adalimumab (94.6/10,000), infliximab (138.1/10,000), ustekinumab (100.6/10,000), nonbiologics (116.8/10,000), and phototherapy (117.3/10,000).

"These large database queries continue to be reassuring that most systemic therapies are not changing the risk for common cancers, excluding lymphoma and skin cancer, which we continue to examine separately," Dr. Kimball said in an interview.

Nonmelanoma skin cancer was far and away the most common malignancy in psoriasis patients, occurring at a rate of 147.2/10,000 person-years vs. 94.2/10,000 person-years among the general public. Rates were highest in patients treated with adalimumab (234.2/10,000 person-years) and ustekinumab (233.3/10,000) and lowest in those treated with etanercept (155.9/10,000).

"Even with the large size of the database, the number of skin cancers remains small, so making conclusions about specific therapies may be premature," she said.

Incidence rates of lymphoma were considerably lower, but again higher in psoriasis patients than the general public (11.1/10,000 vs. 6.6/10,000). Rates of this hematologic cancer were highest with ustekinumab (25.1/10,000) and, once again, lowest with etanercept (6.9/10,000), according to the poster.

In all, 5,857 patients received nonbiologic therapies, 6,856 received etanercept, 3,314 adalimumab, 1,044 infliximab, 526 ustekinumab, and 5,156 were treated with phototherapy.

Dr. Kimball is a consultant for several pharmaceutical companies including Amgen, the study sponsor.

[email protected]

CHICAGO – The anus and genitalia are often overlooked during total body skin examinations, leaving mucosal diseases to go unchecked, especially in women, according to Dr. Bethanee Schlosser.

She acknowledged that there is no literature to quantify the issue but said that her experience suggests mucocutaneous exams may be getting short shrift.

When Dr. Schlosser queried some 300 dermatologists assembled earlier this year, almost all said that they examine the oral cavity during total body skin exams; three-fourths responded that they routinely examine male patients’ genitalia. When asked whether they do the same for their female patients, less than 20 hands went up in the crowd.

"I think there are a couple of reasons for it," Dr. Schlosser of Northwestern University, Chicago, said at the American Academy of Dermatology summer meeting.

First, dermatologists don’t often look at the genitalia, so they may not know what the normal variations are.

Second, many patients don’t expect a dermatologist to examine genitalia. "Patients may be like, ‘You want to look where? I just have a mole on my chest.’ So it’s a matter of patient education," she said.

Third is the added time involved, and finally, some dermatologists are hesitant because they may not be comfortable managing mucosal disease should they find it.

Most dermatologists assume that gynecologists are evaluating their patients’ vulvar skin, but some gynecologists view the vulva more as "the doorway to the cervix. They may simply walk through it, not looking at what is around them, and to that effect, I don’t think it’s necessarily their fault, but their training," Dr. Schlosser said. "While vulvar disease is on the ob.gyn. board exam, the senior ob.gyn. residents rotate through our clinic with me and they routinely say they don’t get that education anywhere else."

Dr. Schlosser offered pearls for managing a number of mucosal diseases, including vulvar lichen sclerosis (VLS).

VLS affects about 1 in 600 women and can carry significant morbidity, including complete obliteration of the clitoral hood and labia minora, narrowing of the vaginal introitus, sexual dysfunction, and potential urinary obstruction, she said.

The risk of developing squamous cell carcinoma (SCC) in patients with VLS is 300-fold higher than in the general patient population. The specific risk factors for vulvar SCC are not fully elucidated in VLS, but include localized hyperkeratosis and age over 75 years.

"It’s important to realize that these older patients ... often don’t see their gynecologists because they’re told the pelvic examination is not indicated anymore," Dr. Schlosser said. "It really behooves us as dermatologists to be doing a genital exam as part of our total body skin exam."

Researchers think, but don’t have the evidence to suggest, that treating VLS changes the risk of SCC, "which is one of the hardest things to discuss with our patients," she added.

Suspicion of SCC should be raised if the patient has hyperkeratotic lesions; ulceration, even pinpoint in size, that doesn’t improve with standard therapy; erythematous, indurated plaques; or if the patient reports a change in symptom quality – previously itchy and now painful, for example – or a change in symptom distribution, such as previously all over and now localized to one spot.

"That can really herald that something bad has occurred," Dr. Schlosser cautioned.

Superpotent topical corticosteroids such as clobetasol propionate are first-line therapy for VLS, with no rationale to support the old-school treatment of topical testosterone. Maintenance therapy is common, as up to 85% of women will relapse.

Dr. Schlosser also advised physicians to educate women on how much medication to use, to send them home with a diagram of the affected area, and to use a hand mirror during the exam.

"Patients don’t want to look, but I tell them you’re not going to get better if you don’t know where to put your medication," she said.

Dr. Schlosser reported no relevant conflicts of interest.

[email protected]

CHICAGO – The anus and genitalia are often overlooked during total body skin examinations, leaving mucosal diseases to go unchecked, especially in women, according to Dr. Bethanee Schlosser.

She acknowledged that there is no literature to quantify the issue but said that her experience suggests mucocutaneous exams may be getting short shrift.

When Dr. Schlosser queried some 300 dermatologists assembled earlier this year, almost all said that they examine the oral cavity during total body skin exams; three-fourths responded that they routinely examine male patients’ genitalia. When asked whether they do the same for their female patients, less than 20 hands went up in the crowd.

"I think there are a couple of reasons for it," Dr. Schlosser of Northwestern University, Chicago, said at the American Academy of Dermatology summer meeting.

First, dermatologists don’t often look at the genitalia, so they may not know what the normal variations are.

Second, many patients don’t expect a dermatologist to examine genitalia. "Patients may be like, ‘You want to look where? I just have a mole on my chest.’ So it’s a matter of patient education," she said.

Third is the added time involved, and finally, some dermatologists are hesitant because they may not be comfortable managing mucosal disease should they find it.

Most dermatologists assume that gynecologists are evaluating their patients’ vulvar skin, but some gynecologists view the vulva more as "the doorway to the cervix. They may simply walk through it, not looking at what is around them, and to that effect, I don’t think it’s necessarily their fault, but their training," Dr. Schlosser said. "While vulvar disease is on the ob.gyn. board exam, the senior ob.gyn. residents rotate through our clinic with me and they routinely say they don’t get that education anywhere else."

Dr. Schlosser offered pearls for managing a number of mucosal diseases, including vulvar lichen sclerosis (VLS).

VLS affects about 1 in 600 women and can carry significant morbidity, including complete obliteration of the clitoral hood and labia minora, narrowing of the vaginal introitus, sexual dysfunction, and potential urinary obstruction, she said.

The risk of developing squamous cell carcinoma (SCC) in patients with VLS is 300-fold higher than in the general patient population. The specific risk factors for vulvar SCC are not fully elucidated in VLS, but include localized hyperkeratosis and age over 75 years.

"It’s important to realize that these older patients ... often don’t see their gynecologists because they’re told the pelvic examination is not indicated anymore," Dr. Schlosser said. "It really behooves us as dermatologists to be doing a genital exam as part of our total body skin exam."

Researchers think, but don’t have the evidence to suggest, that treating VLS changes the risk of SCC, "which is one of the hardest things to discuss with our patients," she added.

Suspicion of SCC should be raised if the patient has hyperkeratotic lesions; ulceration, even pinpoint in size, that doesn’t improve with standard therapy; erythematous, indurated plaques; or if the patient reports a change in symptom quality – previously itchy and now painful, for example – or a change in symptom distribution, such as previously all over and now localized to one spot.

"That can really herald that something bad has occurred," Dr. Schlosser cautioned.

Superpotent topical corticosteroids such as clobetasol propionate are first-line therapy for VLS, with no rationale to support the old-school treatment of topical testosterone. Maintenance therapy is common, as up to 85% of women will relapse.

Dr. Schlosser also advised physicians to educate women on how much medication to use, to send them home with a diagram of the affected area, and to use a hand mirror during the exam.

"Patients don’t want to look, but I tell them you’re not going to get better if you don’t know where to put your medication," she said.

Dr. Schlosser reported no relevant conflicts of interest.

[email protected]

CHICAGO – The anus and genitalia are often overlooked during total body skin examinations, leaving mucosal diseases to go unchecked, especially in women, according to Dr. Bethanee Schlosser.

She acknowledged that there is no literature to quantify the issue but said that her experience suggests mucocutaneous exams may be getting short shrift.

When Dr. Schlosser queried some 300 dermatologists assembled earlier this year, almost all said that they examine the oral cavity during total body skin exams; three-fourths responded that they routinely examine male patients’ genitalia. When asked whether they do the same for their female patients, less than 20 hands went up in the crowd.

"I think there are a couple of reasons for it," Dr. Schlosser of Northwestern University, Chicago, said at the American Academy of Dermatology summer meeting.

First, dermatologists don’t often look at the genitalia, so they may not know what the normal variations are.

Second, many patients don’t expect a dermatologist to examine genitalia. "Patients may be like, ‘You want to look where? I just have a mole on my chest.’ So it’s a matter of patient education," she said.

Third is the added time involved, and finally, some dermatologists are hesitant because they may not be comfortable managing mucosal disease should they find it.

Most dermatologists assume that gynecologists are evaluating their patients’ vulvar skin, but some gynecologists view the vulva more as "the doorway to the cervix. They may simply walk through it, not looking at what is around them, and to that effect, I don’t think it’s necessarily their fault, but their training," Dr. Schlosser said. "While vulvar disease is on the ob.gyn. board exam, the senior ob.gyn. residents rotate through our clinic with me and they routinely say they don’t get that education anywhere else."

Dr. Schlosser offered pearls for managing a number of mucosal diseases, including vulvar lichen sclerosis (VLS).

VLS affects about 1 in 600 women and can carry significant morbidity, including complete obliteration of the clitoral hood and labia minora, narrowing of the vaginal introitus, sexual dysfunction, and potential urinary obstruction, she said.

The risk of developing squamous cell carcinoma (SCC) in patients with VLS is 300-fold higher than in the general patient population. The specific risk factors for vulvar SCC are not fully elucidated in VLS, but include localized hyperkeratosis and age over 75 years.

"It’s important to realize that these older patients ... often don’t see their gynecologists because they’re told the pelvic examination is not indicated anymore," Dr. Schlosser said. "It really behooves us as dermatologists to be doing a genital exam as part of our total body skin exam."

Researchers think, but don’t have the evidence to suggest, that treating VLS changes the risk of SCC, "which is one of the hardest things to discuss with our patients," she added.

Suspicion of SCC should be raised if the patient has hyperkeratotic lesions; ulceration, even pinpoint in size, that doesn’t improve with standard therapy; erythematous, indurated plaques; or if the patient reports a change in symptom quality – previously itchy and now painful, for example – or a change in symptom distribution, such as previously all over and now localized to one spot.

"That can really herald that something bad has occurred," Dr. Schlosser cautioned.

Superpotent topical corticosteroids such as clobetasol propionate are first-line therapy for VLS, with no rationale to support the old-school treatment of topical testosterone. Maintenance therapy is common, as up to 85% of women will relapse.

Dr. Schlosser also advised physicians to educate women on how much medication to use, to send them home with a diagram of the affected area, and to use a hand mirror during the exam.

"Patients don’t want to look, but I tell them you’re not going to get better if you don’t know where to put your medication," she said.

Dr. Schlosser reported no relevant conflicts of interest.

[email protected]

An important topic at the 2014 Summer AAD Meeting in Chicago, Illinois, was the nonsurgical treatment of skin cancers, including adjuvant therapy, topical creams, photodynamic therapy, and radiation for melanoma and nonmelanoma skin cancers. Dr. Anthony M. Rossi discusses the benefits of some of these nonsurgical treatment options for skin cancers and describes how he uses them in his practice. He also discusses how to determine which treatment option is best for each patient and emphasizes the importance of patient compliance and close follow-up.

An important topic at the 2014 Summer AAD Meeting in Chicago, Illinois, was the nonsurgical treatment of skin cancers, including adjuvant therapy, topical creams, photodynamic therapy, and radiation for melanoma and nonmelanoma skin cancers. Dr. Anthony M. Rossi discusses the benefits of some of these nonsurgical treatment options for skin cancers and describes how he uses them in his practice. He also discusses how to determine which treatment option is best for each patient and emphasizes the importance of patient compliance and close follow-up.

An important topic at the 2014 Summer AAD Meeting in Chicago, Illinois, was the nonsurgical treatment of skin cancers, including adjuvant therapy, topical creams, photodynamic therapy, and radiation for melanoma and nonmelanoma skin cancers. Dr. Anthony M. Rossi discusses the benefits of some of these nonsurgical treatment options for skin cancers and describes how he uses them in his practice. He also discusses how to determine which treatment option is best for each patient and emphasizes the importance of patient compliance and close follow-up.

CHICAGO – The number of skin lesions biopsied to rule out melanoma remains exceedingly high among U.S. dermatologists, compared with the MelaFind digital skin analysis device.

Dermatologists performed approximately 22 biopsies of histologically benign lesions for every one melanoma or severely dysplastic nevus removed, according to a dermatopathology review of 1,100 lesions from patients in approximately 500 practices nationwide.

Courtesy Dr. Clay J. Cockerell

This compares with a biopsy ratio of 7.6:1 reported in a pivotal prospective study of the MelaFind device (Arch. Dermatol. 2011;147:188-94), Dr. Clay J. Cockerell reported at the American Academy of Dermatology summer meeting.

The noninvasive MelaFind device was designed to aid dermatologists in diagnosing melanoma and uses multispectral light to characterize the morphologic disorganization of clinically atypical pigmented lesions.

It is approved in the European Union and gained U.S. approval in November 2011, with a long list of indications and caveats regarding how the device should be used and by whom.

The 22:1 biopsy rate among dermatologists is "pretty high" and likely reflects several factors, according to past AAD president Dr. Cockerell, who is director of the division of dermatopathology at the University of Texas Southwestern Medical Center and in group practice in Dallas.

Overall, clinicians are conservative regarding pigmented lesions, particularly in litigious areas of the country, and the device may have made some clinicians "more of a student of pigmented lesions, pushing them to look more carefully, and heightening awareness," he said in an interview.

Biopsies also may have been conducted by physician assistants and nurse practitioners, who may have a lower threshold for biopsy than dermatologists.

Lesion data were collected at Dr. Cockerell’s facility over a 3-week period for 1,400 lesions, but information was not available on how many practices had a MelaFind device, who performed the biopsy, the level of that clinician’s expertise in pigmented lesion management, or the proportion of high-risk patients, a group for whom biopsy ratios can reach 33:1 to 53:1, he said.

A total of 300 lesions were excluded from analysis because they were ineligible for use with the MelaFind device based on its indications.

Still, the MelaFind biopsy ratio is better than that observed in the real-world and was seen in lesions that were more clinically difficult, Dr. Cockerell reported in a poster.

The proportion of lesions that were melanoma or high-grade dysplastic nevi was higher in the pivotal study than in the real world data (11% vs. 4%), as was the proportion of nevi that were low-grade dysplastic nevi (79.3% vs. 41%).

Invasive melanomas, however, were thicker in the real life review (1.1 vs. 0.36 mm), raising a red flag that patients are still not fully educated on the need for early evaluation of suspicious lesions, he said.

"Biopsies, at least in our part of the country and I think in other parts as well, are performed in a seasonal fashion," Dr. Cockerell said. "There are people who don’t go to the dermatologist and don’t get a skin biopsy done for the first 5-6 months of the year because they’re waiting to get their deductible met. If they had a melanoma and put off a biopsy until June, it’s had 6 months of growth time. The doubling time can be very rapid."

Although the MelaFind-computed scores are subjective and do not state whether a biopsy is warranted, the data would be useful if sent along with a specimen to aid dermatopathologists in rendering a more definitive diagnosis, he said. Optimally, the device is "handcrafted" for practices and clinics that follow patients with hundreds of dysplastic nevi where repeated biopsies are not practical, an avenue Dr. Cockerell said he hopes to pursue in the future.

Mela Sciences sponsored the study. Dr. Cockerell and his coauthors disclosed no conflicting financial interests.

[email protected]

CHICAGO – The number of skin lesions biopsied to rule out melanoma remains exceedingly high among U.S. dermatologists, compared with the MelaFind digital skin analysis device.

Dermatologists performed approximately 22 biopsies of histologically benign lesions for every one melanoma or severely dysplastic nevus removed, according to a dermatopathology review of 1,100 lesions from patients in approximately 500 practices nationwide.

Courtesy Dr. Clay J. Cockerell

This compares with a biopsy ratio of 7.6:1 reported in a pivotal prospective study of the MelaFind device (Arch. Dermatol. 2011;147:188-94), Dr. Clay J. Cockerell reported at the American Academy of Dermatology summer meeting.

The noninvasive MelaFind device was designed to aid dermatologists in diagnosing melanoma and uses multispectral light to characterize the morphologic disorganization of clinically atypical pigmented lesions.

It is approved in the European Union and gained U.S. approval in November 2011, with a long list of indications and caveats regarding how the device should be used and by whom.

The 22:1 biopsy rate among dermatologists is "pretty high" and likely reflects several factors, according to past AAD president Dr. Cockerell, who is director of the division of dermatopathology at the University of Texas Southwestern Medical Center and in group practice in Dallas.

Overall, clinicians are conservative regarding pigmented lesions, particularly in litigious areas of the country, and the device may have made some clinicians "more of a student of pigmented lesions, pushing them to look more carefully, and heightening awareness," he said in an interview.

Biopsies also may have been conducted by physician assistants and nurse practitioners, who may have a lower threshold for biopsy than dermatologists.

Lesion data were collected at Dr. Cockerell’s facility over a 3-week period for 1,400 lesions, but information was not available on how many practices had a MelaFind device, who performed the biopsy, the level of that clinician’s expertise in pigmented lesion management, or the proportion of high-risk patients, a group for whom biopsy ratios can reach 33:1 to 53:1, he said.

A total of 300 lesions were excluded from analysis because they were ineligible for use with the MelaFind device based on its indications.

Still, the MelaFind biopsy ratio is better than that observed in the real-world and was seen in lesions that were more clinically difficult, Dr. Cockerell reported in a poster.

The proportion of lesions that were melanoma or high-grade dysplastic nevi was higher in the pivotal study than in the real world data (11% vs. 4%), as was the proportion of nevi that were low-grade dysplastic nevi (79.3% vs. 41%).

Invasive melanomas, however, were thicker in the real life review (1.1 vs. 0.36 mm), raising a red flag that patients are still not fully educated on the need for early evaluation of suspicious lesions, he said.

"Biopsies, at least in our part of the country and I think in other parts as well, are performed in a seasonal fashion," Dr. Cockerell said. "There are people who don’t go to the dermatologist and don’t get a skin biopsy done for the first 5-6 months of the year because they’re waiting to get their deductible met. If they had a melanoma and put off a biopsy until June, it’s had 6 months of growth time. The doubling time can be very rapid."

Although the MelaFind-computed scores are subjective and do not state whether a biopsy is warranted, the data would be useful if sent along with a specimen to aid dermatopathologists in rendering a more definitive diagnosis, he said. Optimally, the device is "handcrafted" for practices and clinics that follow patients with hundreds of dysplastic nevi where repeated biopsies are not practical, an avenue Dr. Cockerell said he hopes to pursue in the future.

Mela Sciences sponsored the study. Dr. Cockerell and his coauthors disclosed no conflicting financial interests.

[email protected]

CHICAGO – The number of skin lesions biopsied to rule out melanoma remains exceedingly high among U.S. dermatologists, compared with the MelaFind digital skin analysis device.

Dermatologists performed approximately 22 biopsies of histologically benign lesions for every one melanoma or severely dysplastic nevus removed, according to a dermatopathology review of 1,100 lesions from patients in approximately 500 practices nationwide.

Courtesy Dr. Clay J. Cockerell

This compares with a biopsy ratio of 7.6:1 reported in a pivotal prospective study of the MelaFind device (Arch. Dermatol. 2011;147:188-94), Dr. Clay J. Cockerell reported at the American Academy of Dermatology summer meeting.

The noninvasive MelaFind device was designed to aid dermatologists in diagnosing melanoma and uses multispectral light to characterize the morphologic disorganization of clinically atypical pigmented lesions.

It is approved in the European Union and gained U.S. approval in November 2011, with a long list of indications and caveats regarding how the device should be used and by whom.

The 22:1 biopsy rate among dermatologists is "pretty high" and likely reflects several factors, according to past AAD president Dr. Cockerell, who is director of the division of dermatopathology at the University of Texas Southwestern Medical Center and in group practice in Dallas.

Overall, clinicians are conservative regarding pigmented lesions, particularly in litigious areas of the country, and the device may have made some clinicians "more of a student of pigmented lesions, pushing them to look more carefully, and heightening awareness," he said in an interview.

Biopsies also may have been conducted by physician assistants and nurse practitioners, who may have a lower threshold for biopsy than dermatologists.

Lesion data were collected at Dr. Cockerell’s facility over a 3-week period for 1,400 lesions, but information was not available on how many practices had a MelaFind device, who performed the biopsy, the level of that clinician’s expertise in pigmented lesion management, or the proportion of high-risk patients, a group for whom biopsy ratios can reach 33:1 to 53:1, he said.

A total of 300 lesions were excluded from analysis because they were ineligible for use with the MelaFind device based on its indications.

Still, the MelaFind biopsy ratio is better than that observed in the real-world and was seen in lesions that were more clinically difficult, Dr. Cockerell reported in a poster.

The proportion of lesions that were melanoma or high-grade dysplastic nevi was higher in the pivotal study than in the real world data (11% vs. 4%), as was the proportion of nevi that were low-grade dysplastic nevi (79.3% vs. 41%).

Invasive melanomas, however, were thicker in the real life review (1.1 vs. 0.36 mm), raising a red flag that patients are still not fully educated on the need for early evaluation of suspicious lesions, he said.

"Biopsies, at least in our part of the country and I think in other parts as well, are performed in a seasonal fashion," Dr. Cockerell said. "There are people who don’t go to the dermatologist and don’t get a skin biopsy done for the first 5-6 months of the year because they’re waiting to get their deductible met. If they had a melanoma and put off a biopsy until June, it’s had 6 months of growth time. The doubling time can be very rapid."

Although the MelaFind-computed scores are subjective and do not state whether a biopsy is warranted, the data would be useful if sent along with a specimen to aid dermatopathologists in rendering a more definitive diagnosis, he said. Optimally, the device is "handcrafted" for practices and clinics that follow patients with hundreds of dysplastic nevi where repeated biopsies are not practical, an avenue Dr. Cockerell said he hopes to pursue in the future.

Mela Sciences sponsored the study. Dr. Cockerell and his coauthors disclosed no conflicting financial interests.

[email protected]

CHICAGO – Doctors who don’t abide by accepted norms can sometimes achieve better outcomes when treating patients who have unusual and tenacious tumors. This was the theme of a session covering cases of confounding tumors at the American Academy of Dermatology summer meeting.

In an interview after the session, panel moderator and case presenter Dr. John A. Carucci, chief of Mohs and dermatologic surgery at New York (N.Y.) University, shared his thoughts on when certain kinds of imaging are more appropriate than others, even if it’s not the "usual way."

Dr. Carucci also addressed the use of postsurgical negative pressure wound therapy, radiation therapy in conjunction with Mohs surgery, and potentially controversial topics such as the use of a protein kinase inhibitor as a neoadjuvant therapy.

And what new information on staging squamous cell carcinomas has Dr. Carucci and his colleagues excited? Listen and find out. Dr. Carucci said that he had no financial conflicts to disclose.

[email protected]

On Twitter @whitneymcknight

CHICAGO – Doctors who don’t abide by accepted norms can sometimes achieve better outcomes when treating patients who have unusual and tenacious tumors. This was the theme of a session covering cases of confounding tumors at the American Academy of Dermatology summer meeting.

In an interview after the session, panel moderator and case presenter Dr. John A. Carucci, chief of Mohs and dermatologic surgery at New York (N.Y.) University, shared his thoughts on when certain kinds of imaging are more appropriate than others, even if it’s not the "usual way."

Dr. Carucci also addressed the use of postsurgical negative pressure wound therapy, radiation therapy in conjunction with Mohs surgery, and potentially controversial topics such as the use of a protein kinase inhibitor as a neoadjuvant therapy.

And what new information on staging squamous cell carcinomas has Dr. Carucci and his colleagues excited? Listen and find out. Dr. Carucci said that he had no financial conflicts to disclose.

[email protected]

On Twitter @whitneymcknight

CHICAGO – Doctors who don’t abide by accepted norms can sometimes achieve better outcomes when treating patients who have unusual and tenacious tumors. This was the theme of a session covering cases of confounding tumors at the American Academy of Dermatology summer meeting.

In an interview after the session, panel moderator and case presenter Dr. John A. Carucci, chief of Mohs and dermatologic surgery at New York (N.Y.) University, shared his thoughts on when certain kinds of imaging are more appropriate than others, even if it’s not the "usual way."

Dr. Carucci also addressed the use of postsurgical negative pressure wound therapy, radiation therapy in conjunction with Mohs surgery, and potentially controversial topics such as the use of a protein kinase inhibitor as a neoadjuvant therapy.

And what new information on staging squamous cell carcinomas has Dr. Carucci and his colleagues excited? Listen and find out. Dr. Carucci said that he had no financial conflicts to disclose.

[email protected]

On Twitter @whitneymcknight