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Background and Objective: The Simplified Psoriasis Index (SPI) is a recently validated tool in Spanish that measures psoriasis severity by integrating 3 different spheres: clinical severity (SPI-s), psychosocial impact (SPI-p), and natural history (SPI-i). Our objective was to study the validity and equivalence of this new scale compared to routinely used scales such as the Psoriasis Area and Severity Index, PASI, and the Dermatology Life Quality Index (DLQI)., Materials and Methods: This was a cross-sectional and observational study that included 45 patients aged 18-74 years. Demographic data and information associated with psoriasis severity and the patients' quality of life were collected, using PASI, DLQI, and SPI simultaneously. The correlation of reference scales (PASI and DLQI) with SPI was examined. The degree of agreement between the 2 versions of SPI completed by the physician (proSPI-s) and self-administered by the patient (saSPI-s) was also studied., Results: The mean age of the study population was 51 years, with a mean psoriasis history of 14.05 years. A strong correlation was found between PASI and proSPI-s (r=0.89), as well as between DLQI and SPI-p (r=0.89), with a moderate correlation being reported between PASI and saSPI-s (r=0.52). The degree of agreement between proSPI-s and saSPI-s was moderate., Conclusions: These findings represent the initial results of real clinical practice using the validated Spanish version of SPI, making its use truly promising in the routine clinical practice., (Copyright © 2024 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Abstract: We report a rare case of cellular schwannoma (CS) manifesting as an ulcerated nodular lesion, mimicking spindle cell melanoma on the sole of the foot. CS, a benign variant of schwannoma, typically occurs in deep soft tissues but can rarely present cutaneously. The diagnosis of CS heavily relies on histopathological examination and immunohistochemical staining for specific markers such as SOX10 and S100. In this case, initial clinical suspicion of nodular melanoma was confirmed on biopsy, which revealed a spindle cell neoplasm positive for SOX10 and negative for melanocytic markers. Misdiagnosis of nodular melanoma was averted through complete excision. CS diagnosis demands careful consideration due to its resemblance to other spindle cell neoplasms, especially melanoma. Meticulous histopathological evaluation and immunostaining are important to differentiate CS from similar lesions, ensuring accurate diagnosis and appropriate management. This report contributes valuable insights into the diagnostic challenges and management of CS, particularly in unusual cutaneous presentations., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objective: The Simplified Psoriasis Index (SPI) is a recently validated tool in Spanish that measures psoriasis severity by integrating 3 different spheres: clinical severity (SPI-s), psychosocial impact (SPI-p), and natural history (SPI-i). Our objective was to study the validity and equivalence of this new scale compared to routinely used scales such as the Psoriasis Area and Severity Index, PASI, and the Dermatology Life Quality Index (DLQI)., Materials and Methods: This was a cross-sectional and observational study that included 45 patients aged 18 to 74 years. Demographic data and information associated with psoriasis severity and the patients' quality of life were collected, using PASI, DLQI, and SPI simultaneously. The correlation of reference scales (PASI and DLQI) with SPI was examined. The degree of agreement between the 2 versions of SPI completed by the physician (proSPI-s) and self-administered by the patient (saSPI-s), was also studied., Results: The mean age of the study population was 51 years, with a mean psoriasis history of 14.05 years. A strong correlation was found between PASI and proSPI-s (r=0.89), as well as between DLQI and SPI-p (r=0.89), with a moderate correlation being reported between PASI and saSPI-s (r=0.52). The degree of agreement between proSPI-s and saSPI-s was moderate., Conclusions: These findings represent the initial results of real clinical practice using the validated Spanish version of SPI, making its use truly promising in the routine clinical practice., (Copyright © 2024 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Systemic treatment with immunotherapy or targeted therapy can significantly improve survival in patients with advanced (metastatic or high-risk) melanoma. Fifty percent of patients with melanoma have a BRAF mutation. Decisions on optimal sequencing of systemic treatments should take into account drug- and tumor-related factors and patient characteristics. Although the combination of ipilimumab and nivolumab is associated with the best survival outcomes, it is associated with significant toxicity. Targeted therapy may be a more favorable option in certain clinical situations. We review the literature on immunotherapy and targeted therapy in melanoma and present an algorithm for guiding decision-making on their use as first-line systemic treatments for advanced BRAF-mutated melanoma., (Copyright © 2023 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

BRCA1-associated protein 1 (BAP1)-inactivated melanomas can occur sporadically or in germline contexts, particularly in recently recognized BAP1-tumor predisposition syndrome. Diagnosis represents a clinical and histopathological challenge, requiring comprehensive analysis of morphology and sometimes molecular analysis in addition to immunohistochemistry. We report a BAP1-inactivated cutaneous melanoma initially diagnosed as an atypical Spitz tumor on the auricle in a patient with BAP1-tumor predisposition syndrome. Immunohistochemistry, fluorescence in situ hybridization, and comparative genomic hybridization allowed diagnosis. Cutaneous BAP1-inactivated melanocytic tumors, previously classified as atypical Spitz Nevi, may have a dermal mitotic activity that can resemble melanoma and on the other hand, atypical Spitz tumors are sometimes difficult to differentiate from BAP1-inactivated melanoma. Specific criteria, requiring molecular diagnosis have been proposed in order to support melanoma diagnosis., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Psoriasis is a chronic immune-mediated inflammatory systemic disease with skin manifestations characterized by erythematous, scaly, itchy and/or painful plaques resulting from hyperproliferation of keratinocytes. Certolizumab pegol [CZP], a PEGylated antigen binding fragment of a humanized monoclonal antibody against TNF-alpha, is approved for the treatment of moderate-to-severe plaque psoriasis. Patients with psoriasis present clinical and molecular variability, affecting response to treatment. Herein, we utilized an in silico approach to model the effects of CZP in a virtual population (vPop) with moderate-to-severe psoriasis. Our proof-of-concept study aims to assess the performance of our model in generating a vPop and defining CZP response variability based on patient profiles., Methods: We built a quantitative systems pharmacology (QSP) model of a clinical trial-like vPop with moderate-to-severe psoriasis treated with two dosing schemes of CZP (200 mg and 400 mg, both every two weeks for 16 weeks, starting with a loading dose of CZP 400 mg at weeks 0, 2, and 4). We applied different modelling approaches: (i) an algorithm to generate vPop according to reference population values and comorbidity frequencies in real-world populations; (ii) physiologically based pharmacokinetic (PBPK) models of CZP dosing schemes in each virtual patient; and (iii) systems biology-based models of the mechanism of action (MoA) of the drug., Results: The combination of our different modelling approaches yielded a vPop distribution and a PBPK model that aligned with existing literature. Our systems biology and QSP models reproduced known biological and clinical activity, presenting outcomes correlating with clinical efficacy measures. We identified distinct clusters of virtual patients based on their psoriasis-related protein predicted activity when treated with CZP, which could help unravel differences in drug efficacy in diverse subpopulations. Moreover, our models revealed clusters of MoA solutions irrespective of the dosing regimen employed., Conclusion: Our study provided patient specific QSP models that reproduced clinical and molecular efficacy features, supporting the use of computational methods as modelling strategy to explore drug response variability. This might shed light on the differences in drug efficacy in diverse subpopulations, especially useful in complex diseases such as psoriasis, through the generation of mechanistically based hypotheses., Competing Interests: Authors CS-V, GJ, VJ, FG and JM are full-time employees at Anaxomics Biotech. Authors CC and OS-M are full-time employees at UCB Pharma. Author SA was a former employee at UCB Pharma. The authors declare that this study received funding from Anaxomics Biotech. The funder had the following involvement in the study: data analysis., (Copyright © 2023 Coto-Segura, Segú-Vergés, Martorell, Moreno-Ramírez, Jorba, Junet, Guerri, Daura, Oliva, Cara, Suárez-Magdalena, Abraham and Mas.)

Basal cell carcinoma (BCC), the most common type of skin cancer, is characterized by aberrant activation of the hedgehog molecular pathway. Systemic therapy is indicated when local approaches, such as surgery and radiation, are inappropriate. In this article, a group of clinical experts recommends the long-term management strategy for advanced BCC patients treated with systemic therapy. The hedgehog inhibitors sonidegib and vismodegib are first-line treatments for advanced BCC with a long-lasting response, but long-term treatment with hedgehog inhibitors is often challenged by tolerability issues. However, several strategies for adverse effect management are available, such as dose interruptions, on-label alternate-day dosing and supportive medications. In conclusion, although BCC shows a high tumor mutational burden that favors a response to immunotherapy, experts recommend keeping patients on hedgehog inhibitors limiting immunotherapy to those who developed resistance during hedgehog inhibitor therapy or in case of persisting toxicity despite long-term management of adverse events., Competing Interests: Declaration of Competing Interest The authors declare the following conflicts of interest. Pietro Quaglino: advisory boards and speaker fees from Sanofi, SUNPharma, Roche. Ralf Gutzmer: research support to Pfizer, Johnson&Johnson, Novartis, Amgen, Sanofi, Merck-Serono, Kyowa-Kirin, Almirall; honoraria for lectures from Roche Pharma, Bristol-MyersSquibb, Novartis, MSD, Almirall-Hermal, Amgen, Merck-Serono, Bayer, SUN, Pierre-Fabre, Sanofi; honoraria for advice from Roche Pharma, Bristol-MyersSquibb, Novartis, MSD, Almirall-Hermal, Amgen, Pierre-Fabre, Merck-Serono, 4SC, SUN, Sanofi, Immunocore; support for participation in meetings from Roche Pharma, Bristol-MyersSquibb, Pierre-Fabre, Merck-Serono, SUN, Merck-Serono. Brigitte Dreno: personal fees for board meetings from Roche, Regeneron and Sun Pharma. Paolo Ascierto: consultant/advisory role for Bristol Myers Squibb, Roche-Genentech, Merck Sharp & Dohme, Novartis, Merck Serono, Pierre-Fabre, AstraZeneca, Sun Pharma, Sanofi, Idera, Sandoz, Immunocore, 4SC, Italfarmaco, Nektar, Boehringer-Ingelheim, Eisai, Regeneron, Daiichi Sankyo, Pfizer, Oncosec, Nouscom, Lunaphore, Seagen, iTeos, Medicenna, Bio-Al Health, ValoTX. He also received research funding from Bristol Myers Squibb, Roche-Genentech, Pfizer, Sanofi. Roland Kaufmann: institutional grants outside the submitted talk and entirely linked to clinical trials from Novartis and Roche, and grants from AbbVie, Amgen, Astra Zeneca, Biontech, BMS, Celgene, Galderma, Incyte, Janssen, Leo, Lilly., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

On March 11, 2020, the World Health Organization officially declared SARS-CoV-2 a pandemic, and governments and health institutions enacted various public health measures to decrease its transmission rate. The COVID-19 pandemic made occupational health disparities for small businesses more visible and created an unprecedented financial burden, particularly for those located in communities of color. In part, communities of color experienced disproportionate mortality and morbidity rates from COVID-19 due to their increased exposure. The COVID-19 pandemic has prompted the public to reflect on risks daily. Risk perception is a critical factor influencing how risk gets communicated and perceived by individuals, groups, and communities. This study explores competing risk perceptions regarding COVID-19, economic impacts, vaccination, and disinfectant exposures of workers at beauty salons and auto shops in Tucson, Arizona, using a perceived risk score measured on a scale of 1-10, with higher scores indicating more perceived risk. The primary differences between respondents at beauty salons and auto shops regarding their perceived risks of COVID-19 vaccination were between the vaccinated and unvaccinated. For every group except the unvaccinated, the perceived risk score of getting the COVID-19 vaccine was low, and the score of not getting the COVID-19 vaccine was high. Study participants in different demographic groups ranked economic risk the highest compared to the other five categories: getting the COVID-19 vaccine, not getting the COVID-19 vaccine, COVID-19, disinfection, and general. A meaningful increase of four points in the perceived risk score of not getting the COVID-19 vaccine was associated with a 227% (95% CI: 27%, 740%) increase in the odds of being vaccinated. Analyzing these data collected during the coronavirus pandemic may provide insight into how to promote the health-protective behavior of high-risk workers and employers in the service sector during times of new novel threats (such as a future pandemic or crisis) and how they process competing risks., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Moreno Ramírez, Gutenkunst, Honan, Ingram, Quijada, Chaires, Sneed, Sandoval, Spitz, Carvajal, Billheimer, Wolf and Beamer.)

Background and Objective: No recent data on health care resources and medical and surgical activity in Spanish dermatology departments are available in the literature. The aim of this study was to compile this information for 2019., Material and Methods: Cross-sectional study based on an online survey sent to the heads of dermatology departments at public hospitals in Spain., Results: Of the 162 department heads contacted, 59 answered the survey (participation rate, 36.4%). General findings included a shortage of staff, especially dermatologists, in hospitals of low and medium complexity. The main reason given for the shortage of dermatologists was a lack of interested applicants. Large hospital complexes had more infrastructure and equipment. Over 50% of the departments surveyed used a combination of in-person and virtual visits. Psoriasis units were the most common specialized care units. Approximately 75% of the hospitals had operating rooms with an anesthetist. More complex procedures such as sentinel lymph node biopsy and Mohs micrographic surgery were performed more often in large hospital complexes. Hospitalization and the presence of dermatology residents working call shifts were also more common in these hospitals. Teaching and research activity differed according to hospital complexity., Conclusions: We have mapped health care resource availability and medical and surgical activity in Spanish dermatology departments prior to the COVID-19 pandemic. Our findings could be useful for improving clinical management and defining future actions and areas for improvement., (Copyright © 2021 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Numerous cells with very large and irregular nuclei ("monster" cells) have not hitherto been reported in desmoplastic melanoma (DM). Their prognostic significance in melanomas is a matter of debate, although some authors have associated them with more aggressive tumor behavior. We report a mixed DM on the scalp of an 88-year-old woman imitating an atypical fibroxanthoma. Tumor cells stained positive for SOX10, S100, and cyclin D1; BRAF mutation status was negative, and fluorescence in situ hybridization analysis showed copy number gains in 11q13 (cyclin D1) and 6p25 (RREB1), and loss in 6q23 (MYB). Cyclin D1 amplification is associated with poor prognosis in melanoma.

Antibiotics remain one of the main treatment alternatives in mild-to-moderate hidradenitis suppurativa. The use of topical 15% resorcinol reduces antibiotic pressure and the generation of resistance. However, knowledge on its efficacy and safety is limited. This single-center, prospective, follow-up cohort study evaluated topical 15% resorcinol every 12-h response at 16 weeks. Those individuals with mild-to-moderate hidradenitis suppurativa (Hurley I-II) who started treatment with topical resorcinol monotherapy between April 2019 and May 2020 were eligible for follow-up. The primary endpoint for effectiveness was the proportion of patients who achieved an overall clinical response (complete or partial response) at week 16, evaluated as intention-to-treat. Responses were measured according to the Hidradenitis Suppurativa Clinical Response index. Target lesion size was measured clinically and by ultrasonography. Quality of life was assessed through the Dermatology Life Quality Index (DLQI) questionnaire. Safety was measured by recording the adverse events reported during the follow-up period. A total of 32 patients were enrolled (mean age, 40.1 years [95% confidence interval, 35.7-44.4]; women, 20 [62.5%]; Hurley I, 17 [53.1%]). Under the intention-to-treat analysis, 68.8% (n = 22) of the patients achieved a clinical response. A ≥50% reduction in the size of the main lesion was observed in 56.3% of the patients (n = 18). Some 65.6% (n = 21) of the patients had a ≥50% reduction (improvement) in their baseline DLQI score. Fifty percent of patients who completed the follow-up period experienced adverse events, all of which were local, mild, and transient and did not lead to discontinuation of resorcinol. To conclude, in this cohort study, topical 15% resorcinol was shown to be effective for mild-to-moderate hidradenitis suppurativa and to have a positive impact on quality of life with an acceptable safety profile., (© 2022 Japanese Dermatological Association.)

Background and Objective: Accurate information on the incidence of melanoma by stage and a better understanding of transition between stages are important for determining the burden of disease and assessing the impact of new adjuvant therapies on recurrence and survival. The aim of this study was to estimate the incidence rates of the various stages of melanoma in Spain and to estimate the number of patients with stage III disease who are eligible for adjuvant systemic therapies., Materials and Method: We built an epidemiological model using prospectively collected data from patients diagnosed with de novo or recurrent melanoma between 2012 and 2016 in the melanoma units of 4 public hospitals., Results: The estimated crude incidence rates for stage I and II melanoma were 7 and 2.9 cases per 100,000 person-years, respectively. The corresponding rates for stage III and IV melanoma were 1.9 and 1.3 cases per 100,000 person-years; 25.8% of patients with stage III melanoma were stage IIIA, 47% were stage IIIB, and 27.3% were stage IIIC. The respective estimated incidence rates for recurrent stage III and IV melanoma were 1.1 and 0.9 cases per 100,000 person-years. Overall, 54% of patients with recurrent stage III melanoma had progressed from stage I or II; the other cases corresponded to changes in substage. Of the patients with stage III melanoma, 85% of those with a de novo diagnosis and 80% of those who had relapsed had resectable disease, meaning they were eligible for adjuvant therapy; 47% of these patients had a BRAF mutation., Conclusions: The above estimates could have a major impact on health care resource planning. Assessing the number of patients with melanoma who are eligible for adjuvant therapies in melanoma could help decision-makers and clinicians anticipate future needs for the management of this disease., (Copyright © 2021 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

The therapeutic value of sentinel lymph node biopsy (SLNB) in thin melanoma remains controversial. The aim of this study is to determine the role of SLNB in the survival of thin melanomas (≤1 mm). A multicenter retrospective observational study was designed. A propensity score matching was performed to compare patients who underwent SLNB vs. observation. A multivariate Cox regression was used. A total of 1438 patients were matched by propensity score. There were no significant differences in melanoma-specific survival (MSS) between the SLNB and observation groups. Predictors of MSS in the multivariate model were age, tumor thickness, ulceration, and interferon treatment. Results were similar for disease-free survival and overall survival. The 5- and 10-year MSS rates for SLN-negative and -positive patients were 98.5% vs. 77.3% ( p < 0.001) and 97.3% vs. 68.7% ( p < 0.001), respectively. SLNB does not improve MSS in patients with thin melanoma. It also had no impact on DSF or OS. However, a considerable difference in MSS, DFS, and OS between SLN-positive and -negative patients exists, confirming its value as a prognostic procedure and therefore we recommend discussing the option of SLNB with patients.

Atopic dermatitis (AD) is the most frequent chronic inflammatory skin disease, and its incidence has been rapidly increasing in developed countries in the last years. AD presents a high degree of heterogeneity due to biases and confounding factors such as age range, sex, or ethnicity. For those reasons, the search for new biomarkers is crucial. At the same time, obesity, which is a global health problem, has also increased over the years. It has been associated with many pathophysiological states, including skin diseases such as AD, mostly in childhood. Obesity promotes a low grade inflammation driven by many different cytokines and adipokines, including leptin, which has a key role in many other diseases due to its pleiotropic effects. Leptin also has a role in both skin and allergic diseases very related to AD. Thus, this adipokine could have an important role in the pathogenesis of AD, especially in its chronicity. Despite the limited literature available, there is some evidence that leads us to consider leptin as an important adipokine in this skin disease. For this reason, here we have reviewed the role of leptin in the pathophysiology of AD.

Background: Isolated limb perfusion (ILP) is a locoregional procedure indicated by the unresectable melanoma of the limbs. Its complexity and highly demanding multidisciplinary approach means that it is a technique only implemented in a few referral centers around the globe. This report aims to examine its potential role in the era of targeted therapies and immunotherapy by conducting a systematic review of the literature on ILP., Methods: PubMed, Embase and Cochrane Library were searched. The eligibility criteria included publications from 2000-2020 providing valid data o effectiveness, survival or toxicity. Studies in which the perfusion methodology was not clearly described, letters to the editor, non-systematic reviews and studies that applied outdated clinical guidelines were excluded. To rule out studies of a low methodological quality and assess the risk of bias, the following aspects were also required: a detailed description of the applied ILP regimen, the clinical context, follow-up periods, analyzed clinical endpoints, and the number of analyzed ILPs. The disagreements were resolved by consensus. The results are presented in tables and figures., Results: Twenty-seven studies including 2637 ILPs were selected. The median overall response rate was 85%, with a median complete response rate of 58.5%. The median overall survival was 38 months, with a 5-year overall survival of 35%. The toxicity was generally mild according to Wieberdink toxicity criteria., Discussion: ILP still offer a high efficacy in selected patients. The main limitation of our review is the heterogeneity and age of most of the articles, as well as the absence of clinical trials comparing ILP with other procedures, making it difficult to transfer its results to the current era., Conclusions: ILP is still an effective and safe procedure for selected patients with unresectable melanoma of the limbs. In the era of targeted therapies and immunotherapy, ILP remains an acceptable and reasonable palliative treatment alternative, especially to avoid limb amputations. The ongoing clinical trials combining systemic therapies and ILP will provide more valuable information in the future to clarify the potential synergism of both strategies.

Surgery remains the first-line therapeutic option for most patients with cutaneous squamous cell carcinoma (cSCC). However, in the current therapeutic landscape, surgery must attempt to the complete tumor resection (R0 resection) with the lowest risk of surgical complications. This double aim is usually accomplished through standard excision with clinical margins in patients with low-risk tumors or by some of the micrographically controlled surgery procedures for patients with tumors at high-risk of local recurrence and metastasis. Surgery is also a first-line treatment for nodal metastases of cSCC as well as an option to consider in patients who develop recurrences while receiving immunotherapy, or as a palliation procedure in patients with advanced tumors. Neoadjuvant immunotherapy, that is the use of a medical treatment before surgery, is under investigation in patients with cSCC. The decision-making process and guidelines recommendations regarding cSCC surgery are reviewed in this manuscript., Competing Interests: Competing interests: None., (©2021 Moreno-Ramírez et al.)

The aim of this study was to compare tumour burden in patients who underwent surgery for melanoma and cutaneous squamous cell carcinoma during nationwide lockdown in Spain due to COVID-19 (for the period 14 March to 13 June 2020) and during the same dates in 2019 before the COVID-19 pandemic. In addition, associations between median tumour burden (Breslow thickness for melanoma and maximum clinical diameter for cutaneous squamous cell carcinoma) and demographic, clinical, and medical factors were analysed, building a multivariate linear regression model. During the 3 months of lockdown, there was a significant decrease in skin tumours operated on (41% decrease for melanoma (n = 352 vs n = 207) and 44% decrease for cutaneous squamous cell carcinoma (n = 770 vs n = 429)) compared with the previous year. The proportion of large skin tumours operated on increased. Fear of SARS-CoV-2 infection, with respect to family member/close contact, and detection of the lesion by the patient or doctor, were related to thicker melanomas; and fear of being diagnosed with cancer, and detection of the lesion by the patient or relatives, were related to larger size cutaneous squamous cell carcinoma. In conclusion, lockdown due to COVID-19 has resulted in a reduction in treatment of skin cancer.

Background: In developed countries, health care delivery in dermatology is hampered by the low availability of dermatologists., Objective: To analyze the feasibility of a teledermatology-based action plan to provide initial dermatologic care in areas with low availability of dermatologists., Methods: A cross-sectional study describing the feasibility and cost of a 12-month action plan based on a store-and-forward teledermatology (TD) connecting primary care centers and a TD center. Teleconsultations from patients complaining of any cutaneous condition were included. The primary outcome measure was the percentage of patients not referred to the local dermatologist., Results: Among the total of 15,523 teleconsultations attended in the TD-based action plan, 3360 (21.65%) required a face-to-face visit with a local dermatologist. In 32.32% (n = 5017) of the cases, a therapeutic and follow-up plan report was issued. The most common conditions managed were melanocytic nevi (15.63%, n = 2426), followed by seborrheic keratosis (14.89%, n = 2312), and actinic keratosis (8.65%, n = 1342). The average response time was 14.52 days (95% CI 14.35-15.23). The additional total investment in this action plan was $142,681.01, with a unit cost of 9.20$/patient., Limitations: Noncontrolled study., Conclusions: Experienced dermatologists working with store-and-forward TD can deliver a fast and effective response in health care areas with access limitations., Competing Interests: None disclosed., (© 2021 by the American Academy of Dermatology, Inc. Published by Elsevier Inc.)

The use and acceptance of teledermatology increased more in the last 2 months of the recent lockdown owing to coronavirus disease 2019 than in the preceding 20 years. This sudden popularity -even among the greatest skeptics- was driven by the need to offer solutions to patients in both public and private settings who suddenly found themselves unable to access in-person dermatological care. Even departments already offering an asynchronous, store-and-forward teledermatology service were obliged to create new systems to support direct interaction between specialists and patients (the direct-to-consumer model). This article suggests some practical ways to implement TD safely and to expedite and optimize teleconsultations; these ideas are not just applicable to a pandemic situation., (Copyright © 2020 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Specialist approaches to the diagnosis and treatment of melanoma have undergone many changes. This guideline aims to provide Spanish dermatologists with evidence-based information for resolving the most common doubts that arise in clinical practice. Members of the Spanish Oncologic Dermatology and Surgery Group (GEDOC) with experience treating melanoma were invited to participate in drafting the guideline. The group developed a new guideline on the basis of existing ones, using the ADAPTE collaboration process, first summarizing the care process and posing relevant clinical questions, then selecting guidelines with the best scores according to the AGREE II (Appraisal of Guidelines for Research and Evaluation) tool. Finally, the group searched the selected guidelines for answers to the clinical questions, drafted recommendations, and sent them for external review. The guideline is structured around 21 clinical questions chosen for their relevance to issues that make clinical decisions about the management of melanoma difficult. Evidence from existing guidelines was used to answer the questions. A limitation of this guide derives from the scarce evidence available for answering some questions. Moreover, some areas are changing rapidly, so recommendations must be updated often. The present guideline offers answers to clinical questions about the routine management of melanoma in clinical practice and provides dermatologists with a reference to guide decisions, taking into consideration the resources available and patient preferences., (Copyright © 2020 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background and Objectives: Spain is in a situation of indefinite lockdown due to the ongoing coronavirus disease 2019 (COVID-19) pandemic. One of the consequences of this lockdown is delays in medical and surgical procedures for common diseases. The aim of this study was to model the impact on survival of tumor growth caused by such delays in patients with squamous cell carcinoma (SCC) and melanoma., Material and Methods: Multicenter, retrospective, observational cohort study. We constructed an exponential growth model for both SCC and melanoma to estimate tumor growth between patient-reported onset and surgical excision at different time points., Results: Data from 200 patients with SCC of the head and neck and 1000 patients with cutaneous melanoma were included. An exponential growth curve was calculated for each tumor type and we estimated tumor size after 1, 2, and 3 months of potential surgical delay. The proportion of patients with T3 SCC (diameter >4cm or thickness >6 mm) increased from 41.5% (83 patients) in the initial study group to an estimated 58.5%, 70.5%, and 72% after 1, 2, and 3 months of delay. Disease-specific survival at 2, 5, and 10 years in patients whose surgery was delayed by 3 months decreased by 6.2%, 8.2%, and 5.2%, respectively. The proportion of patients with ultrathick melanoma (>6 mm) increased from 6.9% in the initial study group to 21.9%, 30.2%, and 30.2% at 1, 2, and 3 months. Five- and 10-year disease-specific survival both decreased by 14.4% in patients treated after a potential delay of 3 months., Conclusions: In the absence of adequate diagnosis and treatment of SCC and melanoma in the current lockdown situation in Spain, we can expect to see to a considerable increase in large and thick SCCs and melanomas. Efforts must be taken to encourage self-examination and facilitate access to dermatologists in order to prevent further delays., (© 2020 Published by Elsevier España, S.L.U. on behalf of AEDV.)

The ex vivo confocal microscope is an imaging system designed to analyze freshly excised tissue using two diode lasers with different wavelengths. The technique can dramatically reduce margin analysis times and offers a sensitivity of 88% and a specificity of 89% relative to histopathology. A new technology has recently been developed that produces images more quickly and with a higher resolution than before. By means of a fusion mode that combines simultaneously scanned fluorescence and reflectance images, it produces digitally stained images that simulate the effect of hematoxylin-eosin staining. Application of this new technology has opened the door to real-time tissue diagnostics., (Copyright © 2019 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Ex vivo confocal microscopy (CM) works under two modes, fluorescence and reflectance, allowing the visualization of different structures. Fluorescence CM (FCM) requires a contrast agent and has been used for the analysis of basal cell carcinomas (BCCs) during Mohs surgery. Conversely, reflectance CM (RCM) is mostly used for in vivo diagnosis of equivocal skin tumours. Recently, a new, faster ex vivo confocal microscope has been developed which simultaneously uses both lasers (fusion mode)., Objectives: To describe the BCC features identified on reflectance, fluorescence and fusion modes using this novel device. To determine the best mode to identify characteristic BCC features. To develop a new staining protocol to improve the visualization of BCC under the different modes., Methods: From September 2016 to June 2017, we prospectively included consecutive BCCs which were excised using Mohs surgery in our department. The lesions were evaluated using ex vivo CM after routine Mohs surgery. The specimens were first stained with acridine orange and then stained using both acetic acid and acridine orange., Results: We included 78 BCCs (35 infiltrative, 25 nodular, 12 micronodular, 6 superficial). Most features were better visualized with the fusion mode using the double staining. We also identified new CM ex vivo features, dendritic and plump cells, which have not been reported previously., Conclusions: Our results suggest that nuclei characteristics are better visualized in FCM but cytoplasm and surrounding stroma are better visualized in RCM. Thus, the simultaneous evaluation of reflectance and fluorescence seems to be beneficial due to its complementary effect. What's already known about this topic? Ex vivo fluorescent confocal microscopy (FCM) is an imaging technique that allows histopathological analysis of fresh tissue. FCM is faster - at least one-third of the time - than conventional methods. FCM has a sensitivity of 88% and a specificity of 99% in detecting basal cell carcinomas (BCCs). What does this study add? Reflectance and fluorescence modes can be used simultaneously in a new ex vivo CM device. Each mode complements the other, resulting in an increase in the detection of BCC features in fusion mode. A combined staining using acetic acid and acridine orange enhances the visualization of tumour and stroma without damaging the tissue for further histopathological analysis., (© 2019 British Association of Dermatologists.)

Introduction: Sentinel lymph node (SLN) biopsy is useful for the prognostic stratification of patients with thick melanoma. Identifying which variables are associated with SLN involvement and establishing risk in different subgroups of patients could be useful for guiding the indication of SLN biopsy. The value of complete lymph node dissection (CLND) in patients with a positive SLN biopsy is currently under debate., Materials and Methods: To identify factors associated with SLN involvement in thick melanoma we performed a multicentric retrospective cohort study involving 660 patients with thick melanoma who had undergone SLN biopsy. To analyze the role of CLND in thick melanoma patients with a positive SLN biopsy, we built a multivariate Cox proportional hazards model for melanoma-specific survival (MSS) and disease-free survival (DFS) and compared 217 patients who had undergone CLND with 44 who had not., Results: The logistic regression analysis showed that age, histologic subtype, ulceration, microscopic satellitosis, and lymphovascular invasion were associated with nodal disease. The CHAID (Chi-squared Automatic Interaction Detection) decision tree showed ulceration to be the most important predictor of lymphatic involvement. For nonulcerated melanomas, the histologic subtype lentigo maligna melanoma was associated with a low rate of SLN involvement (4.3%). No significant differences were observed for DFS and MSS between the CLND performed and not-performed groups. Nodal status on CLND was associated with differences in DFS and MSS rates., Conclusion: We identified subgroups of thick melanoma patients with a low likelihood of SLN involvement. CLND does not offer survival benefit, but provides prognostic information., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: There is no consensus on the imaging tests that should be performed at the initial staging of melanoma patients., Objective: To evaluate the diagnostic accuracy of 4 imaging studies for the initial staging of melanoma patients., Methods: Cross-sectional study with prospectively collected data, from January 2011 to April 2017, including patients with clinical stage T2b to T4b according to 2009 American Joint Committee on Cancer, without evidence of metastasis., Results: Initial staging of 308 patients detected 16.6% of metastases and 5.8% false-positive results, overall. Regional lymph node ultrasonography showed a metastasis detection rate (MDR) of 12.8%, false-positive rate of 0.8%, and accuracy of 96.0%. Computed tomography (CT) and positron emission tomography-CT had the highest detection rates at stage T4b: MDR, 13.3%; false-positive rate, 8.9%; accuracy, 91.1%; and MDR, 6.9%; false-positive rate, 0%; and accuracy, 93.1%, respectively. Brain magnetic resonance imaging showed a MDR of 2.0% in T4b., Limitations: Single-center study., Conclusion: Performing ultrasound scans for assessing lymph node metastasis in patients with American Joint Committee on Cancer T2b stage and above is advisable. In patients with stage T4b, CT or positron emission tomography-CT are suitable for the detection of metastasis. Brain magnetic resonance imaging at T4b deserves further discussion, considering the ultimate clinical benefit in management and therapeutic options for asymptomatic patients., (Copyright © 2019. Published by Elsevier Inc.)

Mitotic rate is no longer considered a staging criterion for thin melanoma in the 8th edition of the American Joint Committee on Cancer Staging Manual. The aim of this observational study was to identify prognostic factors for thin melanoma and predictors and prognostic significance of sentinel lymph node (SLN) involvement in a large multicenter cohort of patients with melanoma from nine tertiary care hospitals. A total of 4249 consecutive patients with thin melanoma diagnosed from January 1, 1998 to December 31, 2016 were included. The main outcomes were disease-free interval and melanoma-specific survival for the overall population and predictors of SLN metastasis (n = 1083). Associations between survival and SLN status and different clinical and pathologic variables (sex, age, tumor location, mitosis, ulceration, regression, lymphovascular invasion, histologic subtype, Clark level, and Breslow thickness) were analyzed by Cox proportional hazards regression and logistic regression. SLN status was the most important prognostic factor for melanoma-specific survival (hazard ratio, 13.8; 95% CI, 6.1-31.2; P < 0.001), followed by sex, ulceration, and Clark level for patients who underwent SLNB. A mitotic rate of >2 mitoses/mm 2 was the only factor associated with a positive SLN biopsy (odds ratio, 2.9; 95% CI, 1.22-7; P = 0.01. SLN status is the most important prognostic factor in thin melanoma. A high mitotic rate is associated with metastatic SLN involvement. SLN biopsy should be discussed and recommended in patients with thin melanoma and a high mitotic rate., (© 2019 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Many follow-up guidelines for patients with high-risk melanoma include expensive imaging studies, serum biomarkers and regular visits to the dermatologist, with little attention to cost-effectiveness., Objectives: To establish the cost-effectiveness of chest-abdomen-pelvis computed tomography (CT) and brain magnetic resonance imaging (MRI) in a follow-up protocol for patients at high risk of relapse., Methods: This was a prospective single-centre cohort study of 290 patients with clinicopathological American Joint Committee on Cancer (AJCC) stage IIB, IIC and III melanoma. Patients had a body CT scan and brain MRI every 6 months and were withdrawn from the study after completing a 5-year follow-up or when metastases were detected. A cost-effectiveness analysis for each follow-up radiological procedure was performed., Results: Patients underwent 1805 body CT scans and 1683 brain MRIs. Seventy-six metastases (26·2%) were identified by CT or MRI. CT scan was cost-effective in the first 4 years (cost-effectiveness ratio €4710·70-€14 437·10/patient with metastasis); brain MRI was cost-effective during the first year (cost-effectiveness ratio €14 090·60/patient with metastasis). Limitations included lack of survival analysis and comparisons with willingness-to-pay thresholds., Conclusions: Six-monthly CT scan of the chest, abdomen and pelvis is a cost-effective technique for the early detection of metastases in the first 4 years of follow-up in patients with AJCC stage IIC and III melanoma, and in the first 3 years in patients with AJCC stage IIB melanoma. In addition, brain MRI has been shown to be cost-effective only in the first year of follow-up in patients with AJCC stage IIC and III melanoma., (© 2018 British Association of Dermatologists.)

Background: Teledermatology (TD) provides efficient care for skin cancer patients., Objective: To compare the clinical effectiveness of imiquimod 5% for the treatment of AK with in-person care and through TD., Methods: Longitudinal prospective controlled study including patients with single AK diagnosed and treated at face-to-face visits (FTF group) or through teledermatology (TD group) with imiquimod 5% cream. The main outcome measures assessed were the complete and global response percentage (CR and GR) under per-protocol (PP) and intention-to-treat (ITT) analysis., Results: A total of 157 patients were enrolled (FTF = 75, TD = 82). PP analysis showed CR in 66.7% of FTF patients and 65.6% in TD patients (P > 0.05). The ITT yielded CR in 64.0% and 51.2% in FTF visits and TD, respectively (P = 0.073). The analysis showed an advantage of FTF care against TD in achieving GR (84.0% vs. 70.7%; P = 0.036). Facial location and local adverse reactions were the only explanatory factors of complete response in the ITT approach. Treatment completion was found in 90.7% and 72.0% in the FTF and TD groups, respectively (P = 0.004)., Conclusions: Improvements in patient counselling at the primary care centre are needed before the implementation of TD as a routine methodology for the management of AK., (© 2018 European Academy of Dermatology and Venereology.)

Introduction and Objectives: A series of quality indicators for melanoma and nonmelanoma skin cancer were recently approved within a project promoted by the Healthy Skin Foundation of the Spanish AEDV. The aim of this study was to evaluate adherence to these indicators., Material and Methods: In November 2016, an anonymous questionnaire consisting of 32 items was sent to the heads of Spanish dermatology and venereology departments listed in the AEDV's database. The questions referred to the above-mentioned quality of care indicators., Results: The questionnaire was completed by 104 of the 150 people contacted (response rate, 69.3%). The lowest response rate for any given question was 56% (84 respondents). Over 85% of respondents answered 29 questions or more (91%). The most widely used indicators were those related to the use of computed tomography or magnetic resonance imaging for squamous cell carcinoma (98%), followed by the availability of a standardized melanoma pathology report (90%). The least widely used indicators were related to availability of electrochemotherapy (25%) and other invasive therapies for locoregionally advanced melanoma (20%)., Conclusions: Adherence to quality of cancer care criteria at the different hospitals evaluated varied. Our findings could be useful for identifying areas for improvement at different hospitals. Future studies should focus on measuring both process and outcome indicators., (Copyright © 2018 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Teledermatology is the most advanced clinical specialty in telemedicine. The development of teledermatology in specific countries has not been studied in depth., Methods: Our objective was to analyze teledermatology models in clinical practice in Spain. We paid special attention to organization, technical aspects, training, and the advantages/disadvantages as seen by teledermatologists. Two surveys were carried out (2009 and 2014)., Results: Teledermatology was used at 25 centers in 2009 and at 70 in 2014. The extended survey was completed by 21 centers in 2009 and 41 in 2014. Store-and-forward teledermatology was the main technique (83%) in 2014. Only 12% of centers used the real-time method, and 5% used a hybrid modality. Patients lived less than 25km away in 75% of cases (urban teledermatology). Most centers used mid-range bridge cameras; only 12% used mobile phones. Teledermoscopy and tertiary teledermatology were each used in 15% of centers. Teledermatology was restricted to skin cancer in 25% of cases, and 66% of centers used it to train primary care physicians. The main advantages, assessed on a scale of 1 to 10, were prioritization in cancer screening (8.3), rapid emergency care (7.8), training of and communication with primary care physicians (7.6), screening for trivial conditions (7.6), and reduction in the number of face-to-face visits (7.6). The main disadvantages were poor image quality (6.3), fear of error (5.7), difficulty in coordinating with primary care physicians (3.8), and time commitment (3.3). Between 2009 and 2014, the number of centers using teledermatology and the number of teledermatologists increased, as did use of the store-and-forward and urban models. The technology used also improved., Conclusion: Teledermatology is an emerging technology that is becoming well established in Spain. More than 25% of dermatology centers in Spain have implemented a teledermatology model. Store-and-forward in an urban setting is the most widely used modality. Teledermatologists see this technology as an effective option with more advantages than disadvantages. General satisfaction is high, although there is room for significant improvement in some areas., (Copyright © 2018 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Recent publication of the results of clinical trials in which lymph node dissection was not associated with any survival benefit in patients with sentinel node metastasis makes it necessary to reconsider the treatment of patients with melanoma. This article provides an update on the available evidence on the diverse factors (routes of metastatic spread, predictors, adjuvant therapy, etc.) that must be considered when treating patients with sentinel node-positive melanoma. The authors propose a decision-making algorithm for use in this clinical setting. The current evidence no longer supports lymph node dissection in patients with low-risk sentinel node metastasis (sentinel node tumor load ≤1mm)., (Copyright © 2018 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

The clinical value of sentinel lymph node (SLN) biopsy in thick melanoma patients (Breslow >4 mm) has not been sufficiently studied. The aim of the study is to evaluate whether SLN biopsy increases survival in patients with thick cutaneous melanoma, and, as a secondary objective, to investigate correlations between survival and lymph node status. We included 1,211 consecutive patients with thick melanomas (>4 mm) registered in the participating hospitals' melanoma databases between 1997 and 2015. Median follow-up was 40 months. Of these patients, 752 were matched into pairs by propensity scores based on sex, age, tumor location, histologic features of melanoma, year of diagnosis, hospital and adjuvant interferon therapy. The SLN biopsy vs. observation was associated with better DFS [adjusted hazard ratio (AHR), 0.74; 95% confidence interval (CI) 0.61-0.90); p = 0.002] and OS (AHR, 0.75; 95% CI, 0.60-0.94; p = 0.013) but not MSS (AHR, 0.84; 95% CI, 0.65-1.08; p = 0.165). SLN-negative patients had better 5- and 10-year MSS compared with SLN-positive patients (65.4 vs. 51.9% and 48.3 vs. 38.8%; p = 0.01, respectively). As a conclusion, SLN biopsy was associated with better DFS but not MSS in thick melanoma patients after adjustment for classic prognostic factors. SLN biopsy is useful for stratifying these patients into different prognostic groups., (© 2017 UICC.)

Background and Objectives: Locoregional lymph node ultrasound is not typically included in guidelines as part of the staging process prior to sentinel lymph node biopsy (SLNB). The objective of the present study was to make a clinical and economic analysis of lymph node ultrasound prior to SLNB., Materials and Methods: We performed a retrospective study of 384 patients with clinical stage I-II primary melanoma who underwent locorregional lymph node ultrasound (with or without ultrasound-guided biopsy) prior to SLNB between 2004 and 2015. We evaluated the reliability and cost-effectiveness of the strategy., Results: Use of locorregional lymph node ultrasound avoided SLNB in 23 patients (6%). Ultrasound had a sensitivity of 46% and specificity of 76% for the detection of metastatic lymph nodes that were not clinically palpable. False negatives were significantly more common in patients aged over 60 years and in tumors with a thickness of less than 2mm. The staging process using SLNB and ultrasound with ultrasound-guided biopsy produced an increase of €16.30 in the unit price. Our cost-effectiveness analysis identified the staging protocol with ultrasound and SLNB as the dominant strategy, with a lower cost-effectiveness ratio than the alternative, consisting of SLNB alone (8,095.24 vs. €28,605.00)., Conclusions: Ultrasound with ultrasound-guided biopsy for the diagnostic staging of melanoma prior to SLNB is a useful and cost-effective tool. This procedure does not substitute SLNB, though it does allow to avoid SLNB in a not insignificant proportion of patients., (Copyright © 2017 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: The Psoriasis Area Severity Index (PASI) is the most widely used scale for assessing the severity of psoriasis and for therapeutic decision making. On the basis of the PASI score, patients have been stratified into 2 groups: mild disease and moderate-to-severe disease., Objective: To draft a proposal for the definition and characterization of moderate psoriasis based on PASI and Dermatology Life Quality Index (DLQI) scores., Material and Methods: A group of 6 dermatologists with experience in the treatment of psoriasis undertook a critical review of the literature and a discussion of cases to draft a proposal., Results: In order of priority, PASI, DLQI, and body surface area (BSA) are the parameters to be used in daily practice to classify psoriasis as mild, moderate, or severe. Severity should be assessed on the basis of a combined evaluation and interpretation of the PASI and DLQI. And 3, PASI and DLQI should carry equal weight in the determination of disease severity. On this basis, psoriasis severity was defined using the following criteria: mild, PASI<7 and DLQI<7; moderate, PASI=7-15 and DLQI=5-15 (classified as severe when difficult-to-treat sites are affected or when there is a significant psychosocial impact); severe, PASI >15, independently of the DLQI score., Conclusions: A more precise classification of psoriasis according to disease severity will improve the risk-benefit assessment essential to therapeutic decision making in these patients., (Copyright © 2017 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To compare the cost consequence of biologic drugs for moderate-to-severe psoriasis from the perspective of the Spanish National Health System., Methods: We built a decision tree with a two-year time horizon. Efficacy data for biologics (etanercept, infliximab, adalimumab, ustekinumab and secukinumab) were drawn from published meta-analyses: PASI75 for the induction phase and PASI90 for the rest of follow-up. Patients with PASI < 75 at week 10-16 were switched to another biologic agent. Efficacy at week 24 was considered the highest possible efficacy for each drug and assumed to remain constant throughout the two-year period. Only drug treatment costs were used. The number needed to treat (NNT), annual cost per patient, annual cost per patient with PASI90 (cost per responder) and cost of primary failure (PASI < 75 at first efficacy evaluation) were calculated., Results: Secukinumab monotherapy was associated with the lowest cost per responder, followed by infliximab and ustekinumab. Treatment sequences starting with secukinumab were the most efficient, having the lowest NNT and cost per responder. Although the annual cost per treatment is similar for all drugs, there are huge differences in the cost per responder., Conclusions: Secukinumab as first-line biologic treatment is the most efficient treatment for moderate-to-severe plaque psoriasis in the short-to-medium term.

Background: Screening of skin cancer by teledermatology (TD) has improved the early detection of skin cancer by enhancing access to skin cancer clinics., Objective: We sought to analyze how TD-based skin cancer screening has changed the frequency of consultations for benign lesions., Patients and Methods: A cross-sectional study including teleconsultations received during a 7-year period was conducted to analyze and compare the trendlines of each lesion type over the study period. Trendlines were analyzed using a linear regression model with the R-squared (R 2 ) test for goodness of fit., Results: A total of 34,553 teleconsultations were included in the study. Seborrheic keratoses, followed by benign melanocytic lesions, were the most frequent lesions diagnosed. The pick-up rate for malignant lesions was 1:8.6 teleconsultations. Seborrheic keratoses and precancerous lesions showed a positive trendline with good fit to the linear model (R 2  = 0.8 and R 2  = 0.8, respectively). Tis-T1 malignant melanoma (in situ melanoma or melanoma with a Breslow thickness <1 mm) showed an increasing trendline with moderate-to-low fit to the model (R 2  = 0.4)., Conclusions: TD-based screening of skin cancer is associated with an increasing rate of consultations involving seborrheic keratoses, which can be considered a consequence of improved access to dermatologists resulting from TD implementation.