Pigmented Lesion Clinic Research Articles

Piloting the Use of Smartphones, Reminders, and Accountability Partners to Promote Skin Self-Examinations in Patients with Total Body Photography: A Randomized Controlled Trial.

The aim of this study was to evaluate the use of a mobile application (app) in patients already using total body photography (TBP) to increase skin self-examination (SSE) rates and pilot the effectiveness of examination reminders and accountability partners. Randomized controlled trial with computer generated randomization table to allocate interventions. University of Pennsylvania pigmented lesion clinic. 69 patients aged 18years or older with an iPhone/iPad, who were already in possession of TBP photographs. A mobile app loaded with digital TBP photos for all participants, and either (1) the mobile app only, (2) skin examination reminders, (3) an accountability partner, or (4) reminders and an accountability partner. Change in SSE rates as assessed by enrollment and end-of-study surveys 6months later. Eighty one patients completed informed consent, however 12 patients did not complete trial enrollment procedures due to device incompatibility, leaving 69 patients who were randomized and analyzed [mean age 54.3years, standard deviation 13.9). SSE rates increased significantly from 58% at baseline to 83% at 6months (odds ratio 2.64, 95% confidence interval 1.20-4.09), with no difference among the intervention groups. The group with examination reminders alone had the highest (94%) overall satisfaction, and the group with accountability partners alone accounted for the lowest (71%). A mobile app alone, or with reminders and/or accountability partners, was found to be an effective tool that can help to increase SSE rates. Skin examination reminders may help provide a better overall experience for a subset of patients. ClinicalTrials.gov Identifier: NCT02520622.

Acuidade Diagnóstica da Dermatoscopia em Lesões Melanocíticas: Estudo Retrospetivo com Correlação Histológica.

Introdução: A dermatoscopia é uma técnica in vivo não-invasiva, amplamente usada como ferramenta complementar no estudo de lesões pigmentadas da pele, permitindo um diagnóstico mais precoce do melanoma cutâneo. O objetivo deste estudo é avaliar a acuidade diagnóstica da dermatoscopia em lesões melanocíticas e alargar as correlações dermatoscopia-histopatologia já estabelecidas.Material e Métodos: Estudo retrospetivo utilizando a base de dados da Consulta de Dermatoscopia e Lesões Pigmentadas e a base de dados da Histologia de um Serviço de Dermatologia. Cada lesão melanocítica foi avaliada segundo parâmetros dermatoscópicos e histológicos. Determinou-se a concordância entre os diagnósticos e entre os parâmetros avaliados.Resultados: Verificou-se um ratio maligno/benigno de 1:9,2. Obteve-se uma concordância razoável entre os diagnósticos dermatoscópicos e histológicos. Para os melanomas obteve-se uma concordância excelente, tendo a dermatoscopia revelado uma sensibilidade de 92,9% e especificidade de 96,9%. Observou-se concordância entre padrão reticular e a presença de fusão de cristas e atipia citológica; padrão globular e presença de tecas; rede atípica e a presença de fibrose e atipia citológica; blotches e paraqueratose pigmentada; véu azul esbranquiçado e a presença de fibrose.Conclusão: Apesar de algumas limitações e achados não esperados, muitos dos resultados do presente estudo vêm na continuidade do que tem vindo a ser descrito na literatura, mostrando uma elevada sensibilidade e especificidade da dermatoscopia no diagnóstico de melanoma, o que se reflete numa otimização do diagnóstico precoce sem necessidade de aumento do número total de excisões de lesões pigmentadas.

Association of clinicopathological features of melanoma with total naevus count and a history of dysplastic naevi: a cross-sectional retrospective study within an academic centre.

High naevus count (HNC) (≥ 50 naevi) and presence of dysplastic naevi (DN) are risk factors for malignant melanoma (MM); however, MMs also occur in patients with low naevus count (LNC) (< 50 naevi) and in patients without DN. Little is known about differences between MMs in these groups. To characterize the clinicopathological differences between MMs in patients with HNC and those in patients with LNC, with or without biopsy-proven DN. This was a cross-sectional retrospective chart review of 281 patients with MM seen between April 2013 and March 2014 at an academic pigmented lesion clinic (Boston, MA, USA). Patients with LNC MMs were diagnosed at an older age (51 vs. 41 years, P < 0.001, OR = 0.95, 95% CI 0.93-0.97), with more aggressive MM features, including greater Breslow thickness (1.1 vs. 0.8 mm, P = 0.01), more mitoses (2 vs. 1 mitoses/mm2 , P < 0.001), lower rate of superficial spreading subtype (58 vs. 78%, P < 0.01, OR = 2.57, 95% CI 1.31-5.03) and higher MM stage (P < 0.001), compared to patients with HNC. Patients with DN had similar trends as those in patients with HNC described above, and in addition, were more likely to have a truncal MM (55 vs. 39%, P < 0.01, OR = 1.97, 95% CI 1.22-3.18) with less ulceration (13 vs. 29%, P < 0.01, OR = 0.36, 95% CI 0.19-0.71). Patients without DN were more likely to have a history of a non-MM skin cancer (32 vs. 19%, P = 0.01, OR = 0.49, 95% CI 0.28-0.85) and an amelanotic MM (33 vs 21%, P = 0.03, OR = 0.55, 95% CI 0.31-0.96). Patients with LNC may develop MMs with more aggressive features at an older age than patients with HNC. A history of biopsy-proven DN reveals distinct MM differences compared to patients without DN.

Management strategies of academic pigmented lesion clinic directors in the United States

Management strategies of academic pigmented lesion clinic directors in the United States

Unscheduled Visits of Patients with Familial Melanoma to a Pigmented Lesion Clinic: Evaluation of Patients' Characteristics and Suspicious Lesions.

Approximately 10% of all melanomas occur in subjects with a family history of melanoma. This retrospective follow-up study investigated the characteristics of patients with familial melanoma who made unscheduled visits to our pigmented lesions clinic, and the diagnosis of excised lesions. A total of 110 (9%) out of 1,267 patients made at least one unscheduled visit between May 2011 and February 2016. Histopathology was taken from 59 patients. Thirty-four naevi, 7 melanomas and 3 basal cell carcinomas were detected. All patients with melanoma were CDKN2A carriers and all melanomas were discovered at a very early stage. In this patient population it appears to be safe to limit visits to once or twice yearly, provided patients are easily able to make an unscheduled extra visit if they have a worrisome lesion. We recommend supporting patients' self-reliance by stimulating them to carry out self-examination of their skin.

Collision skin lesions-results of a multicenter study of the International Dermoscopy Society (IDS).

BackgroundCollision lesions as two independent and unrelated skin tumors often manifest an atypical morphology.ObjectiveTo determine the combinations of collision skin lesions (CSLs).MethodsTwenty-one pigmented lesion clinics in nine countries included 77 histopathologically proven CSLs in this retrospective observational study.ResultsSeventy-seven CSLs from 75 patients (median age 59.8 years) were analyzed; 24.7% of CSLs were located on the head and neck area, 5.2% on the upper extremities, 48.1% on the trunk, and 11.7% on the lower extremities; 40.3% revealed a melanocytic component (median age 54.7 years), followed by 45.5% with a basal cell carcinoma (BCC) (median age 62.4 years) and 11.7% with a seborrheic keratosis (median age 64.7 years). CSLs with a BCC component were more often found on the head and neck area compared to tumors with a melanocytic component (34.3% versus 16.1%). Lesions with a melanocytic component were more often detected on the trunk compared to lesions with a BCC (64.5% versus 37.1%). Patients with CSLs with epidermal-epidermal cell combination were older than patients with epidermal-dermal cell combination (63 versus 55.2 years), were more often male than female (63% versus 43.3%), more often had the lesion on the head and neck area (32.6% versus 13.3%), and less often on the upper (2.2 % versus 10%) or lower extremities (8.7% versus 16.6%).ConclusionsCSLs consist of a heterogeneous group of lesions of varying cell types. They are associated with advancing age and cumulative UV-exposure. CSLs manifest a complex morphology making it challenging to diagnose correctly.

Melanoma diagnosis and management after the introduction of a pigmented lesion clinic in the Mid-West of Ireland

A pigmented lesion clinic (PLC) was introduced and Consultant Dermatology posts were increased in the Mid-West of Ireland with the aim of improving early detection of melanoma. We analysed retrospectively the invasive melanomas excised in the Mid-West of Ireland over a 2-year period prior to (2010-2011) and after (2013-2014) the advent of the PLC. The number of melanomas excised almost doubled from 54 (2010-2011) to 107 (2013-2014). There was a significant rise in the rate of excision biopsies performed by Dermatologists compared to non-dermatology clinicians from 19 to 56% (p<0.0001). There was a significant difference in the diagnostic accuracy of excised melanomas by Dermatologists compared to non-dermatology clinicians during both time periods (2010-2011: p=0.001; 2013-2014: p<0.0001). There was a non-significant decrease in the median Breslow thickness of melanomas from 1.3mm (0.6-2.6) (2010-2011) to 1.0mm (0.5-2.3) (2013-2014) (n=145, p=0.48). The PLC has led to an increase in the number of melanomas excised by Dermatologists in the Mid-West of Ireland which has led to higher diagnostic accuracy.

Compliance with serial dermoscopic monitoring: An academic perspective

For even seasoned practitioners, early melanomas can be difficult to distinguish from melanocytic nevi. Although serial digital dermoscopy is considered by many to be the gold standard for monitoring patients at high risk, poor compliance can seriously alter efficacy. In 2014, a concerning compliance rate of 25% was reported from a single, private clinic. Information is currently limited regarding the determinants of compliance and whether patients at high risk return at an acceptable rate. We sought to determine the compliance rate within the pigmented lesions clinic at our academic institution and identify demographic variables that may influence adherence. A retrospective review was conducted using 120 patient charts. An overall compliance rate of 87.5% was observed with 63.3% of patients returning within 1month of the recommended interval. The most notable risk factor for noncompliance was patient age between 20 and 29years. Factors promoting adherence include a personal history of melanoma, greater than 5 serially monitored nevi, and a personal history of atypical nevi. The external validity is limited and the sample size is small. These findings contradict concerns that adherence to serial monitoring is unacceptably poor and demonstrate that compliance is highest for patients with the greatest inherent risk.

Reexamining the Threshold for Reexcision of Histologically Transected Dysplastic Nevi

Controversy persists regarding the appropriate management of incompletely excised, biopsy-proven, mild and moderate dysplastic nevi (DN). To determine long-term risk of associated melanoma in biopsied mild or moderate DN with positive histologic margins that were clinically observed vs reexcised with negative margins. Retrospective cohort study of mixed referral and community patients from an academic pigmented lesion clinic and dermatology clinics of the affiliated Veteran Affairs medical center with biopsy-confirmed DN with positive histologic margins diagnosed from May 15, 1991, to July 8, 2015, and followed up through May 30, 2016. A consecutive sample of 1473 histologically confirmed DN was identified using surgical pathology databases at the study sites; 590 cases in 498 patients met eligibility criteria. The primary outcome was the proportion of biopsied DN that progressed to histologically confirmed invasive or in situ melanoma. Secondary outcomes included local nevus recurrence and development of primary melanoma at other anatomic sites. The 498 patients had a mean (range) age of 57.6 (14-93) years and 90% were male. Among 590 positive-margin DN, 191 were reexcised and 399 clinically observed without further surgery; 170 reexcised and 304 observed DN had available follow-up data, with mean (SD) follow-up of 5.5 (4.6) years. Cases in the observation group were more likely to demonstrate nevus recurrence than those that were reexcised (3.3% vs 0%; P = .02). Six of 304 (2.0%) observed DN subsequently developed melanoma at the same site, compared with 1 of 170 (0.06%) that were reexcised (P = .43). Five of 6 observed patients who developed melanoma initially underwent partial biopsy with grossly positive margins; 1 melanoma in situ evolved from an excisionally biopsied moderately dysplastic nevus 5 years later. Only 1 case of thin invasive melanoma (≤1 mm) was observed, and no deaths from melanoma arising from biopsy-proven DN occurred through the latest dermatology follow-up. New primary melanoma developed at other sites in 9.9% of excised and 9.4% of resected DN. In cases of mild and moderate DN with microscopically positive margins and no concerning clinical residual lesion, observation, rather than reexcision, was a reasonable management option. Partial biopsies of pigmented lesions suspicious for melanoma may lead to delayed melanoma diagnosis and should be discouraged.

Reduction in nevus biopsies in patients monitored by total body photography

Total body photography (TBP) can facilitate identification of new and changing lesions. By confirming that particular nevi are stable, TBP may reduce nevus biopsies. We sought to determine the number and rate of nevus biopsies before and after TBP, and the factors associated with increased biopsy rate during monitoring by TBP. We reviewed records of all patients in 2 pigmented lesion clinics (PLCs) who received TBP and had 2 or more follow-up visits over a period of 2years or longer. Before PLCs and TBP, the mean number of nevus biopsies per patient was 5.92 (589 patients) at a mean rate of 1.62 per year (160 patients). After TBP in PLCs, the same patients averaged 1.56 biopsies at a mean rate of 0.34 per year (P<2×10(-16)). The entire cohort (926 patients) averaged similarly low post-TBP biopsy rates of less than 0.2 per year and per visit. Biopsy rates after TBP were positively correlated with decreased age, male gender, and family history of melanoma, but not nevus number. Some information was not available for some patients. Patients at risk for melanoma experienced a 3.8-fold reduction in nevus biopsies after TBP. Younger male patients with family history of melanoma had higher biopsy rates after TBP.

Precise Longitudinal Tracking of Microscopic Structures in Melanocytic Nevi Using Reflectance Confocal Microscopy: A Feasibility Study.

Reflectance confocal microscopy (RCM), a cellular-level, in vivo imaging technique, may be potentially used for monitoring melanocytic neoplasms for microscopic stability vs changes over time. To test feasibility of using RCM to track specific microscopic structures within nevi over 1 year. This was an observational study, a review of prospectively acquired RCM images, performed at a tertiary academic medical center. Seventeen patients were enrolled from adult patients presenting to pigmented lesion clinic; from each participant, 3 confirmed benign nevi were randomly selected from the upper and lower back and from the lower extremity. Nevi underwent standardized RCM imaging at baseline and after 1 year. We tested interobserver reproducibility in recognition of tissue anchors, RCM structures that can be identified at 2 time points. We used 2 tests to measure concordance between independent readers: (1) In the multiple choice matching test (n = 43 nevi), readers were shown a tissue anchor in a baseline RCM image (≤ 1 × 1-mm field-of-view) and asked to identify the same structure in 1 of 4 equally sized RCM images obtained from the same nevus at follow-up. (2) In the annotation test (n = 29 nevi), readers were shown a tissue anchor in a follow-up RCM image (≤ 1 × 1-mm field-of-view) and asked to annotate the corresponding location of this structure in the baseline RCM mosaic image (≤ 5 × 5-mm field-of-view) from the same nevus; good agreement was defined as annotations deviant by less than 10% of the mosaic's width. In total, 17 patients (mean age, 45 years [range, 28-70 years]; 10 [59%] were women) contributed a total of 51 nevi, of which 44 nevi (86%) were used for the study. Images from 7 nevi (14%) were suboptimal in quality. Tissue anchors were identified at both time points in all 44 nevi. Selected tissue anchors were located at a mean depth of 54.3 µm; the most commonly selected anchors (37 of 44 images [84.1%]) were dermal papillae. In the multiple choice matching test, compared with a reference reader, 2 readers correctly matched baseline to follow-up tissue anchors in 40 of 43 nevi (93%; P < .01) and 42 of 43 nevi (98%; P < .01), respectively. In the annotation test, there was good agreement between 2 readers in all 29 cases (100%); the mean deviation was 2% (range, 0%-7.5%). Precise longitudinal tracking of microscopic structures in melanocytic nevi using RCM is feasible.

Unusual Dermoscopic Patterns of Seborrheic Keratosis

Background: Seborrheic keratoses (SKs) may sometimes mimic benign and malignant skin tumors, and a biopsy can be necessary in order to rule out malignancy. Methods: From the database of our pigmented lesion clinic, we evaluated the dermoscopic features of difficult-to-diagnose SKs that were biopsied between January 2010 and December 2014. Results: SKs represented 3.8% of all excised lesions (161/ 4,182). Specifically, 91 (56.5%) were excised to rule out melanoma, 63 (39.1%) to rule out squamous cell carcinoma and 7 (4.4%) to rule out basal cell carcinoma. The following 10 global dermoscopic patterns were identified: multicomponent (32; 19.9%); reticular (24; 14.9%), characterized by an irregular pigment network; bowenoid (21; 13.0%); hairpin (19; 11.8%); keratoacanthoma-like (16; 9.9%); blue-nevus-like (15; 9.3%); lichenoid (6; 3.7%); hyperkeratotic (6; 3.7%); clonal (5; 3.1%); spitzoid (5; 3.1%). Furthermore, 12 SKs (7.5%) were not included in any of such patterns (not classified). Conclusion: Our results are in line with previous studies highlighting the dermoscopic variability of SKs. Although excised SKs may be classified into 1 of 10 repetitive dermoscopic patterns, a biopsy remains mandatory for those that cannot be clearly differentiated from common skin malignancies.

Depth of melanoma diagnosed using digital dermatoscopy and full body photography in a pigmented lesion clinic versus dermatoscopy in a general dermatology clinic

Depth of melanoma diagnosed using digital dermatoscopy and full body photography in a pigmented lesion clinic versus dermatoscopy in a general dermatology clinic

Effects of total-body digital photography on cancer worry in patients with atypical mole syndrome.

Cancer worry about developing melanoma in at-risk patients may affect one's quality of life and adherence to screening. Little is known about melanoma-related worry in patients with atypical mole syndrome (AMS). To quantify levels and elucidate predictors of worry related to developing melanoma in patients with AMS and to determine whether total-body digital photography (TBDP) in pigmented lesion clinics (PLCs) reduces worry. In this pretest-posttest study, patients with AMS from PLCs at 2 academic medical centers were recruited from June 1, 2005, through October 31, 2008, to answer questions about cancer worry before and after undergoing TBDP. Questionnaires used included the new melanoma and recurrent melanoma Revised Impact of Event Scale (RIES), the Melanoma Worry Scale (MWS), the Hospital Anxiety and Depression Scale, and the Life Orientation Test. All patients underwent TBDP. Changes in the MWS and new melanoma RIES scores. A total of 138 patients completed baseline questionnaires; 108 patients (78.3%) completed questionnaires after TBDP. Baseline levels of worry were low and reduced further after TBDP. In patients with a personal history of melanoma, worry was reduced on all scales. In patients without a personal history of melanoma, only the new melanoma RIES score was significantly decreased. Predictors of baseline MWS scores include female sex, personal history of melanoma, and higher Hospital Anxiety and Depression Scale scores, adjusted for demographics, family history of melanoma, and Life Orientation Test scores. Adjusted predictors of the baseline new melanoma RIES score were similar but also included lower educational level and did not include sex. Patients with AMS have low levels of melanoma-related worry, which is similar to data from other populations at high risk of cancers. We found that TBDP is a clinically useful tool that can be used in PLCs to help decrease worry about developing melanoma in at-risk patients.

Supply-and-demand discrepancy in academic pigmented lesion clinics: a case for a new health care delivery model.

There is an increasing demand for a limited number of pigmented lesion clinic (PLC) visits at dermatology centers. To determine the proportion of visits to PLCs that are more frequent ("additional screening") than the recommended ("standard") follow-up schedule and to determine if certain patient characteristics correlate with the demand for these visits. A retrospective medical chart review of all PLC visits at an academic dermatology center from October 2010 to January 2012. A total of 609 patients associated with 1756 visits were identified. Of these, 25 patients associated with 26 visits were excluded owing to lack of melanoma diagnosis or risk factors, leaving 584 patients and 1730 visits. Diagnoses of these patients included in situ and invasive melanoma, dysplastic nevi, Spitz nevi, atypical nevus syndrome, family history of melanoma only, and other risk factors. The mean (SD) age was 48 (16) years, and 235 (40.2%) of the patients were male. The proportion of additional screening visits compared with standard visits. Standard visits were defined as occurring at the following frequencies: annually for mildly dysplastic nevi, Spitz nevi, or solely family history of melanoma; biannually for the first year, then annually thereafter for moderately dysplastic nevi or atypical nevus syndrome; biannually for up to 3 years, then annually thereafter for severely dysplastic nevi or melanomas in situ; every 3 months for 2 years, biannually for the following 2 years, then annually thereafter for invasive melanoma. A total of 1400 visits (80.9%) were standard, 257 (14.9%) were for additional screening, and 73 (4.2%) were "problem focused." Thirty percent of patients had at least 1 additional screening visit. The distribution of diagnoses among standard vs additional screening visits differed significantly, with "family history only" and "other risk factors" taking up a larger percentage of standard visits (15.1%) than the percentage of additional screening visits (8.9%), and all other diagnoses being better represented among additional screening visits (P = .04). No particular patient characteristic described those who sought additional screening visits. A substantial proportion of additional screening PLC visits exist and are desired by all patients with pigmented lesions. We propose alternative clinic models, such as diagnosis-specific, adjunctive fee-for-additional-service, and teledermatology clinics to meet patient needs while creating resources to expand PLC visits.

Palmar and plantar melanomas differ for sex prevalence and tumor thickness but not for dermoscopic patterns

The specific anatomy of the glabrous skin, characterized by marked orthokeratosis and the presence of furrows and ridges, results in peculiar dermoscopic patterns of acral melanocytic lesions. Most frequently, acral nevi are typified by a parallel furrow pattern and acral melanoma (AM) by a parallel ridge pattern (PRP). Although the dermoscopic patterns of AM have been extensively investigated, little attention has been paid to site-related differences between palmar and plantar AM. The current study aimed to compare patients' characteristics, melanoma thickness, and the morphologic variability of AM depending on the localization on palms or soles. Patients demographics and dermoscopic images of 118 AM, including 99 (83.9%) plantar and 19 (16.1%) palmar lesions (mean thickness, 2.1 mm), were extracted from the databases of seven pigmented skin lesion clinics and were evaluated for the presence of predefined criteria. Palmar melanomas were remarkably more frequent in women (male-to-female ratio, 1/3.8) and thinner than plantar melanomas (1.3 vs. 2.2 mm). Dermoscopically, no significant differences were found between plantar and palmar melanomas, with PRP scored in 64.6 and 68.4% of plantar and palmar lesions, respectively. Non-site-specific melanoma criteria were detected in 83.9% of lesions and, among melanomas not exhibiting a PRP, 95.1% showed at least one non-site-specific melanoma criterion. In conclusion, plantar and palmar AMs show sex-related and thickness-related differences, but do not differ with respect to their dermoscopic features. For cases lacking the PRP, non-site-specific melanoma criteria may be considered as helpful additional clues for the correct diagnosis.

Recurrent Melanocytic Nevi and Melanomas in Dermoscopy

IMPORTANCE Differentiating recurrent nevi from recurrent melanoma is challenging. OBJECTIVE To determine dermoscopic features to differentiate recurrent nevi from melanomas. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study of 15 pigmented lesion clinics from 12 countries; 98 recurrent nevi (61.3%) and 62 recurrent melanomas (38.8%) were collected from January to December 2011. MAIN OUTCOMES AND MEASURES Scoring the dermoscopic features, patterns, and colors in correlation with the histopathologic findings. RESULTS In univariate analysis, radial lines, symmetry, and centrifugal growth pattern were significantly more common dermoscopically in recurrent nevi; in contrast, circles, especially if on the head and neck area, eccentric hyperpigmentation at the periphery, a chaotic and noncontinuous growth pattern, and pigmentation beyond the scar's edge were significantly more common in recurrent melanomas. Patients with recurrent melanomas were significantly older than patients with recurrent nevi (mean [SD] age, 63.1 [17.5] years vs 30.2 [12.4] years) (P<.001), and there was a significantly longer time interval between the first procedure and the second treatment (median time interval, 25 vs 8 months) (P<.001). In a multivariate analysis, pigmentation beyond the scar's edge (P=.002), age (P<.001), and anatomic site (P=.002) were significantly and independently associated with the diagnosis of recurrent melanoma in dermoscopy. CONCLUSIONS AND RELEVANCE Dermoscopically, pigmentation beyond the scar's edge is the strongest clue for melanoma. Dermoscopy is helpful in evaluating recurrent lesions, but final interpretation requires taking into account the patient age, anatomic site, time to recurrence, growth pattern, and, if available, the histopathologic findings of the first excision.

Efficacy of a multimodality curriculum in a pigmented lesion clinic to teach dermatoscopy to dermatology residents

Efficacy of a multimodality curriculum in a pigmented lesion clinic to teach dermatoscopy to dermatology residents

Availability of digital dermoscopy in daily practice dramatically reduces the number of excised melanocytic lesions: results from an observational study

Digital dermoscopy has been shown to permit an earlier detection of melanoma. However, few studies have investigated its added value in reducing unnecessary excisions in everyday clinical practice. To compare, in daily practice, the efficiency of three dermoscopy methods: dermoscopy alone with little training, dermoscopy alone with adequate training and dermoscopy with adequate training and access to digital dermoscopy, and to confirm the safety of this latter approach. Thirty-six dermatologists working without digital dermoscopy were divided into two groups according to their training in dermoscopy. The third group constituted of two dermatologists working in a pigmented lesion clinic with access to the digital dermoscopy technique and eight additional dermatologists working in the same dermatology department. These 46 dermatologists included all presumed melanocytic lesions excised over a period of 1 year. The primary endpoint was the melanoma/nonmelanoma ratio (M/NM-R); secondary endpoints were the ratio of 'problem' naevi to common naevi (PN/CN-R), specificity and sensitivity for the diagnosis of melanoma, in situ/invasive melanoma ratio, and the mean Breslow thickness. In total, 1865 excised lesions, including 231 melanomas, were included. In the digital dermoscopy availability group (DD-G) the M/NM-R was significantly better (1/2.43), as was the PN/CN-R (1/1.48) (P < 0.001 in both cases). The specificity was significantly higher in the DD-G and significantly higher for trained examiners as compared with examiners with little training. More that one-third of all melanomas discovered by digital dermoscopy were in situ, and the mean Breslow thickness was 0.32 mm for the invasive ones. The reduction of unnecessary excisions when using digital dermoscopy compared with dermoscopy alone in our study suggests that access to digital dermoscopy offers a better management of pigmented lesions in daily practice. The high number of early lesions diagnosed by this technique confirms that its use is safe.

Changes observed in slow-growing melanomas during long-term dermoscopic monitoring

Melanomas vary in growth rate from rapidly developing nodular melanomas to slow-growing melanomas (SGM) that hardly change over years. To evaluate longitudinal changes in dermoscopic findings of SGM. We retrospectively analysed a dermoscopic image dataset from 15 pigmented lesion clinics, of SGM that were followed sequentially by digital dermoscopy for at least 1 year. We evaluated baseline and follow-up images for changes in global pattern, organization, colours, structure and size. Our series consisted of 92 SGM. On follow-up, these melanomas developed the following dermoscopic findings: more homogeneous and less reticular global dermoscopic pattern; more frequent disorganization of pattern (baseline, 67% vs. follow-up, 79%); decreased prominence of light brown colour, increased prominence of dark brown colour, and increased frequency of the colours red, white, grey, blue and black (baseline: 29%, 3%, 18%, 6% and 33% vs. follow-up: 41%, 10%, 31%, 13% and 45%, respectively); decrease in prominence of dermoscopic structure of pigmented network, with a concomitant increase in prominence of structureless areas; and increased prominence or new appearance of melanoma-specific dermoscopic structures, including negative network, blue-white structures and blotches. The majority of lesions (75%) remained the same size or grew by < 2 mm in diameter. An increase in lesion size was associated with change in the total number of colours and structures (χ(2) = 14·3, P = 0·027) at follow-up. While their diameter changed minimally over time, most SGM became more disorganized, revealed loss of network in favour of structureless areas, and developed new colours.