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Reflectance confocal microscopy (RCM) is an emerging and noninvasive imaging tool in dermatological practice. Benefits of this modality include differentiation between benign and malignant skin lesions, prevention of unnecessary biopsies, and cost effectiveness. However, RCM findings for benign lesions are rarely reported in the literature. We describe a case of reflectance confocal microscopy findings of a hidrocystoma and review potential applications of this imaging technique in everyday clinical practice.

IMPORTANCE: Use of prognostic gene expression profile (GEP) testing in cutaneous melanoma (CM) is rising despite a lack of endorsement as standard of care. OBJECTIVE: To develop guidelines within the national Melanoma Prevention Working Group (MPWG) on integration of GEP testing into the management of patients with CM, including (1) review of published data using GEP tests, (2) definition of acceptable performance criteria, (3) current recommendations for use of GEP testing in clinical practice, and (4) considerations for future studies. EVIDENCE REVIEW: The MPWG members and other international melanoma specialists participated in 2 online surveys and then convened a summit meeting. Published data and meeting abstracts from 2015 to 2019 were reviewed. FINDINGS: The MPWG members are optimistic about the future use of prognostic GEP testing to improve risk stratification and enhance clinical decision-making but acknowledge that current utility is limited by test performance in patients with stage I disease. Published studies of GEP testing have not evaluated results in the context of all relevant clinicopathologic factors or as predictors of regional nodal metastasis to replace sentinel lymph node biopsy (SLNB). The performance of GEP tests has generally been reported for small groups of patients representing particular tumor stages or in aggregate form, such that stage-specific performance cannot be ascertained, and without survival outcomes compared with data from the American Joint Committee on Cancer 8th edition melanoma staging system international database. There are significant challenges to performing clinical trials incorporating GEP testing with SLNB and adjuvant therapy. The MPWG members favor conducting retrospective studies that evaluate multiple GEP testing platforms on fully annotated archived samples before embarking on costly prospective studies and recommend avoiding routine use of GEP testing to direct patient management until prospective studies support their clinical utility. CONCLUSIONS AND RELEVANCE: More evidence is needed to support using GEP testing to inform recommendations regarding SLNB, intensity of follow-up or imaging surveillance, and postoperative adjuvant therapy. The MPWG recommends further research to assess the validity and clinical applicability of existing and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results should only be made in the context of discussion of testing limitations with the patient or within a multidisciplinary group.

Importance Dermoscopy education in US dermatology residency programs varies widely, and there is currently no existing expert consensus identifying what is most important for resident physicians to know. Objectives To identify consensus-based learning constructs representing an appropriate foundational proficiency in dermoscopic image interpretation for dermatology resident physicians, including dermoscopic diagnoses, associated features, and representative teaching images. Defining these foundational proficiency learning constructs will facilitate further skill development in dermoscopic image interpretation to help residents achieve clinical proficiency. Design, Setting, and Participants A 2-phase modified Delphi surveying technique was used to identify resident learning constructs in 3 sequential sets of surveys—diagnoses, features, and images. Expert panelists were recruited through an email distributed to the 32 members of the Pigmented Lesion Subcommittee of the Melanoma Prevention Working Group. Twenty-six (81%) opted to participate. Surveys were distributed using RedCAP software. Main Outcomes and Measures Consensus on diagnoses, associated dermoscopic features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for US dermatology resident physicians. Results Twenty-six pigmented lesion and dermoscopy specialists completed 8 rounds of surveys, with 100% (26/26) response rate in all rounds. A final list of 32 diagnoses and 116 associated dermoscopic features was generated. Three hundred seventy-eight representative teaching images reached consensus with panelists. Conclusions and Relevance Consensus achieved in this modified Delphi process identified common dermoscopic diagnoses, associated features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for dermatology residency training. This list of validated objectives provides a consensus-based foundation of key learning points in dermoscopy to help resident physicians achieve clinical proficiency in dermoscopic image interpretation.

Immunoglobulin A (IgA) dermatoses represent a distinct but diverse category of immunologic skin diseases, including linear IgA bullous dermatosis, dermatitis herpetiformis, IgA subcorneal pemphigus, IgA intraepidermal pemphigus and IgA vasculitis (Henoch-Schonlein purpura).

Objective To better understand postoperative opioid use after dermatologic surgery. Design Prospective observational study. Setting Academic dermatology department. Patients The study included 212 adults (1) who were undergoing a single skin excision (including Mohs micrographic surgery), (2) who consented to participate, and (3) who were able to be reached by telephone on postoperative day 3 or 4. Patients who did not meet these criteria and those referred to another physician for further surgical treatment or repair were excluded. Main Outcome Measures The study examined (1) the incidence of opioid prescription after dermatologic surgery, (2) the percentage of prescribed opioid pain medications used in the postoperative period, and (3) patient and surgical characteristics associated with opioid pain medication prescription and use. Results Opioids were prescribed to 72 of the 212 patients (34%). Twenty-five of the 72 patients (35%) who were prescribed opioids did not use them. Forty-nine of 57 patients (86%) who filled an opioid prescription had leftover pills, and 26 of the 49 patients (53%) planned to keep them. Only maximum pain score was significantly associated with opioid use. Conclusions Opioids were overprescribed after dermatologic surgery. Patients who had leftover opioids did not dispose of them properly, which could lead to potential misuse and abuse.