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Background: Differentiating melanoma (MM) from seborrheic keratosis (SK) containing a blue-white veil (BWV) remains challenging., Objective: Identify dermoscopic features that can improve upon the differentiation between MMs and SKs exhibiting BWV., Methods: Images from 110 MMs and 121 SKs containing BWV were aggregated, and 91 MMs and 62 SKs from this dataset had complete agreement on the presence of BWV according to 3 expert dermoscopists. Independent readers recorded the presence or absence of dermoscopic structures using a web-based data collection instrument. Odds ratios were used to evaluate the association between features and diagnosis, and Fisher's exact test was used to determine significance of associations., Results: The combination of milia-like cysts and/or comedo-like openings (MCCO) within the BWV and BWV encompassing the entire lesion occurred in 56% of SKs and 0% of MM. All MMs had at least one MM-specific structure other than BWV or lacked MCCO., Limitations: Agreement on dermoscopic feature prevalence was variable. The subset of lesions with complete agreement on the presence of BWV may not be representative of lesions encountered in an individual clinician's practice., Conclusion: Lesions exhibiting BWV with MCCO and no additional MM-specific features suggests a benign diagnosis, as was not seen in any cases of MM., (Copyright © 2024. Published by Elsevier Inc.)

Lentigo Maligna (LM) arises on chronically-sun damaged skin and can have extensive subclinical spread, often in functionally and cosmetically challenging areas. This two-part continuing medical education (CME) series reviews LM. Part I reviews epidemiology, risk factors, clinical presentation, diagnostic tools, biopsy technique, and histopathology of LM. Part II reviews both surgical and non-surgical treatment options. Surgical approaches - including conventional excision, Mohs micrographic surgery, and staged excision - remain first-line therapy to achieve cure. Some patients may be poor surgical candidates or elect for alternative treatments. Non-surgical modalities, such as topical and radiation therapy, are also reviewed. Finally, surveillance recommendations are discussed., (Copyright © 2024 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Lentigo maligna (LM) is an increasingly common subtype of melanoma, presenting as a slow-growing tan-brown macule or patch with irregular borders arising on chronically solar-damaged skin. This two-part continuing medical education (CME) series provides an overview of LM. Part I reviews LM's epidemiology, risk factors, and clinical presentation. Clinical tools to aid in diagnosis - such as dermoscopy and reflectance confocal microscopy - are discussed, as well as optimal biopsy strategies. Histopathology and current understanding of molecular underpinnings are also reviewed. Management of LM presents unique challenges given a predilection for subclinical spread on functionally and cosmetically sensitive areas such as the face. Part II reviews the two pillars of management including both surgical and non-surgical treatment options and surveillance., (Copyright © 2024. Published by Elsevier Inc.)

The presence of congenital melanocytic nevi (CMN) is determined in utero. The location, size, and number of CMN may be of cosmetic concern with significant psychosocial implications. They may also be associated with symptoms such as pruritus, eczema/xerosis, and skin fragilit; however, the most medically concerning issue is the association of CMN with the risk of developing cutaneous melanoma, extracutaneous melanoma, and neurocutaneous melanocytosis (NCM). Patients with CMN are currently risk-stratified based on the projected adult maximum diameter of the largest CMN and the number of CMN (satellites) present. In small and medium CMN the absolute risk of developing cutaneous melanoma is estimated to be approximately 0.3% with a relative risk of 9.5. While patients with large CMN are at increased risk for developing primary cutaneous melanoma within the CMN, they are also at increased risk for developing primary melanoma within the central nervous system (CNS) in association with CNS melanocytic deposits, an entity known as NCM. The absolute risk for developing melanoma in patients with large CMN is estimated to be between 1.25-10% with a relative risk between 52-1046. Regarding the risk for the presence of NCM, the risk correlates with the number of CMN, with the lowest risk in those with a single CMN and with risk escalation as the number of CMN increase. We have provided an overview of the existing evidence about the risk of melanoma and NCM in patients with CMN. The role of the clinical examination, dermatoscopy, MRI scanning of the CNS, and the role of surgery in the management of CMN of varying sizes is discussed., Competing Interests: Declaration of competing interest I have no conflicts of interest for the article., (Copyright © 2024. Published by Elsevier Inc.)

Competing Interests: Conflicts of interest None disclosed.

Incorporation of dermoscopy and artificial intelligence (AI) is improving healthcare professionals' ability to diagnose melanoma earlier, but these algorithms often suffer from a "black box" issue, where decision-making processes are not transparent, limiting their utility for training healthcare providers. To address this, an automated approach for generating melanoma imaging biomarker cues (IBCs), which mimics the screening cues used by expert dermoscopists, was developed. This study created a one-minute learning environment where dermatologists adopted a sensory cue integration algorithm to combine a single IBC with a risk score built on many IBCs, then immediately tested their performance in differentiating melanoma from benign nevi. Ten participants evaluated 78 dermoscopic images, comprised of 39 melanomas and 39 nevi, first without IBCs and then with IBCs. Participants classified each image as melanoma or nevus in both experimental conditions, enabling direct comparative analysis through paired data. With IBCs, average sensitivity improved significantly from 73.69% to 81.57% ( p = 0.0051), and the average specificity improved from 60.50% to 67.25% ( p = 0.059) for the diagnosis of melanoma. The index of discriminability ( d ') increased significantly by 0.47 ( p = 0.002). Therefore, the incorporation of IBCs can significantly improve physicians' sensitivity in melanoma diagnosis. While more research is needed to validate this approach across other healthcare providers, its use may positively impact melanoma screening practices.

Competing Interests: Conflicts of interest None disclosed.

Importance: Somatic variants in the RAS/MAPK pathway genes are commonly associated with melanocytic nevi and melanoma, whereas germline variants in these genes are associated with RASopathies, syndromes involving multiple organs, including the skin. Nevi counts may be higher in some RASopathies, but studies on features observed through dermoscopy are limited., Objective: To determine the distinguishing dermoscopic features of melanocytic nevi and how the RAS pathway influences them by comparing nevi in patients with cardiofaciocutaneous syndrome (CFC) and Costello syndrome (CS)., Design, Setting, and Participants: In this prospective cohort study, patients with CFC and CS, 2 RASopathies caused by variants in the downstream and upstream components of the RAS/MAPK pathway, were recruited from the international CFC and CS family conferences. Some patients with CFC also elected to participate in a longitudinal follow-up study., Main Outcomes and Measures: The main outcomes were dermoscopic features and, in the longitudinal follow-up study, nevi counts, which were recorded over time., Results: A total of 39 patients, 16 with CFC and 23 with CS, were enrolled (overall cohort: 26 [66.7%] female; median [IQR] age, 13.0 [7.6-22.0] years). The 112 nevi overall frequently displayed an organized dermoscopic pattern (CFC, 61 [84.7%]; CS, 34 [85.0%]) rather than a disorganized pattern (CFC, 6 [8.3%]; CS, 1 [2.5%]). Of the organized nevi, homogenous brown was the most common pattern (CFC, 41 [67.2%]; CS, 22 [64.7%]), followed by reticular (CFC, 11 [18.0%]; CS, 7 [20.6%]) and globular (CFC, 9 [14.8%]; CS, 5 [14.7%]). Pigmented networks occurred in 12 nevi in CFC (16.7%) and 6 nevi in CS (15%; P > .99). Of these, 6 CFC-associated nevi (50%) and no CS-associated nevi had atypical networks (P = .05). Six patients with CFC in the follow-up study developed significantly more nevi within 5 years (median [IQR] increase, 24.5 [10-120] nevi; P = .04)., Conclusions and Relevance: In this cohort study, the findings suggest that nevi in patients with CFC and CS commonly display organized homogenous brown dermoscopic patterns, and the number of nevi may significantly increase over time in those with CFC. A disorganized pattern and atypical networks may be more frequent in patients with CFC. Future studies are needed to determine the risk of melanoma in individuals with CFC or CS.

Background: A common terminology for diagnosis is critically important for clinical communication, education, research and artificial intelligence. Prevailing lexicons are limited in fully representing skin neoplasms., Objectives: To achieve expert consensus on diagnostic terms for skin neoplasms and their hierarchical mapping., Methods: Diagnostic terms were extracted from textbooks, publications and extant diagnostic codes. Terms were hierarchically mapped to super-categories (e.g. 'benign') and cellular/tissue-differentiation categories (e.g. 'melanocytic'), and appended with pertinent-modifiers and synonyms. These terms were evaluated using a modified-Delphi consensus approach. Experts from the International-Skin-Imaging-Collaboration (ISIC) were surveyed on agreement with terms and their hierarchical mapping; they could suggest modifying, deleting or adding terms. Consensus threshold was >75% for the initial rounds and >50% for the final round., Results: Eighteen experts completed all Delphi rounds. Of 379 terms, 356 (94%) reached consensus in round one. Eleven of 226 (5%) benign-category terms, 6/140 (4%) malignant-category terms and 6/13 (46%) indeterminate-category terms did not reach initial agreement. Following three rounds, final consensus consisted of 362 terms mapped to 3 super-categories and 41 cellular/tissue-differentiation categories., Conclusions: We have created, agreed upon, and made public a taxonomy for skin neoplasms and their hierarchical mapping. Further study will be needed to evaluate the utility and completeness of the lexicon., (© 2024 European Academy of Dermatology and Venereology.)

Background: Full-body skin examination (FSE) is a vital practice in the diagnosis of cutaneous malignancy. Precisely how FSE should be conducted with respect to concealed site inclusion remains poorly elucidated., Objective: To establish the approach of Australian dermatologists to concealed site examination (CSE)., Methods: A cross-sectional study was performed consisting of an online self-administered 11-question survey delivered to fellows of the Australasian College of Dermatologists., Results: There were 237 respondents. Anogenitalia was the least often examined concealed site (4.6%), and 59.9, 32.9, and 14.3% reported always examining the scalp, breasts, and oral mucosa, respectively. Patient concern was the most frequently cited factor prompting examination, while many cited low incidence of pathology and limited chaperone availability as the main barriers to routine examination of these sites., Conclusion: Most Australian dermatologists do not routinely examine breasts, oral mucosal, or anogenital sites as part of an FSE. Emphasis should be made on identifying individual patient risk factors and education regarding self-examination of sensitive sites. A consensus approach to the conduct of the FSE, including concealed sites, is needed to better delineate clinician responsibilities and address medicolegal implications., (© 2023 The Authors. International Journal of Dermatology published by Wiley Periodicals LLC on behalf of the International Society of Dermatology.)

Background: Pediatric melanoma presents with distinct clinical features compared to adult disease., Objective: Characterize risk factors and negative outcomes in pediatric melanoma., Methods: Multicenter retrospective study of patients under 20 years diagnosed with melanoma between January 1, 1995 and June 30, 2015 from 11 academic medical centers., Results: Melanoma was diagnosed in 317 patients, 73% of whom were diagnosed in adolescence (age ≥11). Spitzoid (31%) and superficial spreading (26%) subtypes were most common and 11% of cases arose from congenital nevi. Sentinel lymph node biopsy was performed in 68% of cases and positive in 46%. Fatality was observed in 7% of cases. Adolescent patients with melanoma were more likely to have family history of melanoma (P = .046) compared to controls., Limitations: Retrospective nature, cohort size, control selection, and potential referral bias., Conclusion: Pediatric melanoma has diverse clinical presentations. Better understanding of these cases and outcomes may facilitate improved risk stratification of pediatric melanoma., Competing Interests: Conflicts of interest SH reports honorarium from Elsevier and past consulting for Novan Pharmaceuticals., (Copyright © 2024. Published by Elsevier Inc.)

Competing Interests: Conflicts of interest The authors declare no conflicts of interest.

Dermoscopy aids in melanoma detection; however, agreement on dermoscopic features, including those of high clinical relevance, remains poor. In this study, we attempted to evaluate agreement among experts on exemplar images not only for the presence of melanocytic-specific features but also for spatial localization. This was a cross-sectional, multicenter, observational study. Dermoscopy images exhibiting at least 1 of 31 melanocytic-specific features were submitted by 25 world experts as exemplars. Using a web-based platform that allows for image markup of specific contrast-defined regions (superpixels), 20 expert readers annotated 248 dermoscopic images in collections of 62 images. Each collection was reviewed by five independent readers. A total of 4,507 feature observations were performed. Good-to-excellent agreement was found for 14 of 31 features (45.2%), with eight achieving excellent agreement (Gwet's AC >0.75) and seven of them being melanoma-specific features. These features were peppering/granularity (0.91), shiny white streaks (0.89), typical pigment network (0.83), blotch irregular (0.82), negative network (0.81), irregular globules (0.78), dotted vessels (0.77), and blue-whitish veil (0.76). By utilizing an exemplar dataset, a good-to-excellent agreement was found for 14 features that have previously been shown useful in discriminating nevi from melanoma. All images are public (www.isic-archive.com) and can be used for education, scientific communication, and machine learning experiments., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Dermatoscopy is a non-invasive and cost-efficient imaging technique augmenting clinical examination in neoplastic and non-neoplastic dermatoses. Recently, novel dermatoscopic techniques based on principles of reflectance/absorption and excited fluorescence have been developed. However, comprehensive data on their applications are sparse, and terminology is inconsistent. In this systematic review, we addressed the principles of ultraviolet (UV) imaging and proposed categorization based on spectral characteristics and signal acquisition, as well as discussed documented and potential clinical applications, safety measures during examination, and limitations associated with reflectance and fluorescence dermatoscopy. A literature search was conducted in the PubMed medical database until 2 December 2023 according to PRISMA guidelines, and 28 papers fit the scope of this review, whereas additional relevant articles were included to provide broader context regarding the chosen terminology, chromophores described, safety of sub-UV/UV, and regulations for light-emitting devices. UV and sub-UV dermatoscopy, categorized into different methods on the basis of the emitted wavelength and signal acquisition process (reflectance versus fluorescence), augment conventional dermatoscopy by optimizing safety margins in melanoma, facilitating early detection of tumor recurrence, and enhancing visualization in non-neoplastic conditions, including pigmentation disorders, intertrigo, papulo-desquamative dermatoses, and beyond. The review highlights the limitations of these techniques, including difficulty in differentiating melanin from hemoglobin, challenges in evaluating uneven surfaces, and artifacts. Although UV dermatoscopy complements conventional dermatoscopy, clinicians should be aware of their peculiarities, artifacts, limitations, and safety concerns to optimize their diagnostic accuracy and ensure patient's safety., (© 2024. The Author(s).)

Background: Lentigo maligna (LM) can mimic benign, flat, pigmented lesions and can be challenging to diagnose., Objective: To describe a new dermatoscopic feature termed "perifollicular linear projections (PLP)" as a diagnostic criterion for LM on the face., Methods: Retrospective study on reflectance confocal microscopy and dermatoscopy images of flat facial pigmented lesions originating from 2 databases. PLP were defined as short, linear, pigmented projections emanating from hair follicles. Dermatoscopy readers were blinded to the final histopathologic diagnosis., Results: From 83 consecutive LMs, 21/83 (25.3%) displayed "bulging of hair follicles" on reflectance confocal microscopy and 18 of these 21 (85.7%), displayed PLP on dermatoscopy. From a database of 2873 consecutively imaged and biopsied lesions, 252 flat-pigmented facial lesions were included. PLP was seen in 47/76 melanomas (61.8%), compared with 7/176 lesions (3.9%) with other diagnosis (P < .001). The sensitivity was 61.8% (95% CI, 49.9%-72.7%), specificity 96.0% (95% CI, 92.9%-98.4%). PLP was independently associated with LM diagnosis on multivariate analysis (OR 26.1 [95% CI, 9.6%-71.0])., Limitations: Retrospective study., Conclusion: PLP is a newly described dermatoscopic criterion that may add specificity and sensitivity to the early diagnosis of LM located on the face. We postulate that PLP constitutes an intermediary step in the LM progression model., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2023 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest Collin Costello, MD, has grant support from the Melanoma Research Alliance to support melanoma educational programs and research support from DeepX Health for melanoma imaging technology. Both were paid to the institution. Allan Halpern, MD, is an advisor to Canfield Scientific Inc and Scibase Inc.

Competing Interests: Conflicts of interest None disclosed.

Introduction: Epinephrine is commonly used in combination with local anesthetic (lidocaine/epinephrine) due to its beneficial vasoconstrictive properties. Typically, pallor is appreciated after injection as a sign of effect; however, we observed that some cutaneous malignancies paradoxically revealed increased redness and vascularity after injection of lidocaine/epinephrine. In this study, we investigate this phenomenon among a series of biopsied lesions to identify characteristics of lesions associated with increased redness and/or vascularity., Objectives: To determine characteristics of lesions which become redder or more vascular after injection with lidocaine/epinephrine prior to biopsy., Methods: This cross-sectional study consisted of a convenience sample of lesions scheduled for biopsy. Lesions were photographed prior to and 7 min after injection of lidocaine/epinephrine as a part of standard care. Two readers blinded to study objectives and histopathological diagnosis assessed lesions for changes in redness and vascular features., Results: Fifty-four lesions from 47 patients-61.7% male, mean age 64.8 years, age-range 24-91 were included. Thirty-six lesions were biopsy confirmed malignant, with 5 in situ and 31 invasive malignancies; the remaining 18 lesions were benign. In comparison with non-malignant lesions, malignant lesions were associated with an increase in clinically appreciable vascular features after injection of lidocaine/epinephrine, X 2 (1) = 21.600, p < 0.001. Further stratification into benign, in situ, and invasive lesions strengthened the association, X 2 (1) = 23.272, p < 0.001., Conclusions: Combination lidocaine/epinephrine has been shown to paradoxically increase the visibility of vessels seen in cutaneous malignancies. This is consistent with prior literature suggesting aberrant adrenergic signaling in neoangiogenic vessels., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The use of artificial intelligence (AI) has the potential to improve the assessment of lesions suspicious of melanoma, but few clinical studies have been conducted. We validated the accuracy of an open-source, non-commercial AI algorithm for melanoma diagnosis and assessed its potential impact on dermatologist decision-making. We conducted a prospective, observational clinical study to assess the diagnostic accuracy of the AI algorithm (ADAE) in predicting melanoma from dermoscopy skin lesion images. The primary aim was to assess the reliability of ADAE's sensitivity at a predefined threshold of 95%. Patients who had consented for a skin biopsy to exclude melanoma were eligible. Dermatologists also estimated the probability of melanoma and indicated management choices before and after real-time exposure to ADAE scores. All lesions underwent biopsy. Four hundred thirty-five participants were enrolled and contributed 603 lesions (95 melanomas). Participants had a mean age of 59 years, 54% were female, and 96% were White individuals. At the predetermined 95% sensitivity threshold, ADAE had a sensitivity of 96.8% (95% CI: 91.1-98.9%) and specificity of 37.4% (95% CI: 33.3-41.7%). The dermatologists' ability to assess melanoma risk significantly improved after ADAE exposure (AUC 0.7798 vs. 0.8161, p = 0.042). Post-ADAE dermatologist decisions also had equivalent or higher net benefit compared to biopsying all lesions. We validated the accuracy of an open-source melanoma AI algorithm and showed its theoretical potential for improving dermatology experts' ability to evaluate lesions suspicious of melanoma. Larger randomized trials are needed to fully evaluate the potential of adopting this AI algorithm into clinical workflows., (© 2023. The Author(s).)

Introduction: Melanoma of the lentigo maligna (LM) type is challenging. There is lack of consensus on the optimal diagnosis, treatment, and follow-up., Objectives: To obtain general consensus on the diagnosis, treatment, and follow-up for LM., Methods: A modified Delphi method was used. The invited participants were either members of the International Dermoscopy Society, academic experts, or authors of published articles relating to skin cancer and melanoma. Participants were required to respond across three rounds using a 4-point Likert scale). Consensus was defined as >75% of participants agreeing/strongly agreeing or disagreeing/strongly disagreeing., Results: Of the 31 experts invited to participate in this Delphi study, 29 participants completed Round 1 (89.9% response rate), 25/31 completed Round 2 (77.5% response rate), and 25/31 completed Round 3 (77.5% response rate). Experts agreed that LM diagnosis should be based on a clinical and dermatoscopic approach (92%) followed by a biopsy. The most appropriate primary treatment of LM was deemed to be margin-controlled surgery (83.3%), although non-surgical modalities, especially imiquimod, were commonly used either as alternative off-label primary treatment in selected patients or as adjuvant therapy following surgery; 62% participants responded life-long clinical follow-up was needed for LM., Conclusions: Clinical and histological diagnosis of LM is challenging and should be based on macroscopic, dermatoscopic, and RCM examination followed by a biopsy. Different treatment modalities and follow-up should be carefully discussed with the patient.

Background: Existing artificial intelligence for melanoma detection has relied on analysing images of lesions of clinical interest, which may lead to missed melanomas. Tools analysing the entire skin surface are lacking., Objectives: To determine if melanoma can be distinguished from other skin lesions using data from automated analysis of 3D-images., Methods: Single-centre, retrospective, observational convenience sample of patients diagnosed with melanoma at a tertiary care cancer hospital. Eligible participants were those with a whole-body 3D-image captured within 90 days prior to the diagnostic skin biopsy. 3D-images were obtained as standard of care using VECTRA WB360 Whole Body 3-dimensional Imaging System (Canfield Scientific). Automated data from image processing (i.e. lesion size, colour, border) for all eligible participants were exported from VECTRA DermaGraphix research software for analysis. The main outcome was the area under the receiver operating characteristic curve (AUC)., Results: A total of 35 patients contributed 23,538 automatically identified skin lesions >2 mm in largest diameter (102-3021 lesions per participant). All were White patients and 23 (66%) were males. The median (range) age was 64 years (26-89). There were 49 lesions of melanoma and 22,489 lesions that were not melanoma. The AUC for the prediction model was 0.94 (95% CI: 0.92-0.96). Considering all lesions in a patient-level analysis, 14 (28%) melanoma lesions had the highest predicted score or were in the 99th percentile among all lesions for an individual patient., Conclusions: In this proof-of-concept pilot study, we demonstrated that automated analysis of whole-body 3D-images using simple image processing techniques can discriminate melanoma from other skin lesions with high accuracy. Further studies with larger, higher quality, and more representative 3D-imaging datasets would be needed to improve and validate these results., (© 2023 European Academy of Dermatology and Venereology.)

Competing Interests: Dr Jain is a consultant on Enspectra Health Inc. Drs Abdalla, Harris, Reiter, Payulert, Lezcano, and Marghoob and author Posner have no conflicts of interest to declare.

Although the use of dermoscopy has markedly improved both the sensitivity and specificity for skin cancer detection, there is still opportunity for improvement. Ancillary techniques provide additional ways to assess a lesion with the aim of improving our diagnostic ability with little extra cost. Usage of these techniques can strengthen diagnosis and help reduce unnecessary biopsies of benign lesions., Competing Interests: Conflict of interest: The authors declare that they have no conflict of interest., (© The Author(s) 2022. Published by Oxford University Press on behalf of British Association of Dermatologists. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy., Methods: A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither., Results: Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features., Conclusions: This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection., Competing Interests: Conflict of interest: None., (© Copyright by the American Board of Family Medicine.)

Background: Dermoscopy is commonly used for the evaluation of pigmented lesions, but agreement between experts for identification of dermoscopic structures is known to be relatively poor. Expert labeling of medical data is a bottleneck in the development of machine learning (ML) tools, and crowdsourcing has been demonstrated as a cost- and time-efficient method for the annotation of medical images., Objective: The aim of this study is to demonstrate that crowdsourcing can be used to label basic dermoscopic structures from images of pigmented lesions with similar reliability to a group of experts., Methods: First, we obtained labels of 248 images of melanocytic lesions with 31 dermoscopic "subfeatures" labeled by 20 dermoscopy experts. These were then collapsed into 6 dermoscopic "superfeatures" based on structural similarity, due to low interrater reliability (IRR): dots, globules, lines, network structures, regression structures, and vessels. These images were then used as the gold standard for the crowd study. The commercial platform DiagnosUs was used to obtain annotations from a nonexpert crowd for the presence or absence of the 6 superfeatures in each of the 248 images. We replicated this methodology with a group of 7 dermatologists to allow direct comparison with the nonexpert crowd. The Cohen κ value was used to measure agreement across raters., Results: In total, we obtained 139,731 ratings of the 6 dermoscopic superfeatures from the crowd. There was relatively lower agreement for the identification of dots and globules (the median κ values were 0.526 and 0.395, respectively), whereas network structures and vessels showed the highest agreement (the median κ values were 0.581 and 0.798, respectively). This pattern was also seen among the expert raters, who had median κ values of 0.483 and 0.517 for dots and globules, respectively, and 0.758 and 0.790 for network structures and vessels. The median κ values between nonexperts and thresholded average-expert readers were 0.709 for dots, 0.719 for globules, 0.714 for lines, 0.838 for network structures, 0.818 for regression structures, and 0.728 for vessels., Conclusions: This study confirmed that IRR for different dermoscopic features varied among a group of experts; a similar pattern was observed in a nonexpert crowd. There was good or excellent agreement for each of the 6 superfeatures between the crowd and the experts, highlighting the similar reliability of the crowd for labeling dermoscopic images. This confirms the feasibility and dependability of using crowdsourcing as a scalable solution to annotate large sets of dermoscopic images, with several potential clinical and educational applications, including the development of novel, explainable ML tools., (©Jonathan Kentley, Jochen Weber, Konstantinos Liopyris, Ralph P Braun, Ashfaq A Marghoob, Elizabeth A Quigley, Kelly Nelson, Kira Prentice, Erik Duhaime, Allan C Halpern, Veronica Rotemberg. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 18.01.2023.)

Background: There is little understanding regarding the long-term natural history of melanocytic nevi among adults., Objective: The objective of the study was to describe the long-term natural history of individual nevi located on the torso of high-risk patients., Methods: All patients attending Memorial Sloan Kettering Cancer Center (MSKCC) who underwent two total body photography (TBP) sessions 15+ years apart were included ('retrospective' group). To account for a potential selection bias, we also included consecutive patients who had TBP 15+ years ago and consented to undergo follow-up TBP ('prospective' group). We compared baseline and follow-up torso images on the TBPs and evaluated the number of total, new and disappearing nevi; number of seborrheic keratoses and actinic keratoses; each nevus' diameter at both time points; each nevus' colour change; the presence of clinical atypia; and when dermoscopy was available, the dermoscopic features at each time point., Results: One hundred six patients were included in the study. Although the average age of the patients was 40 at baseline TBP, most patients developed new nevi between imaging sessions (median 16.4 years) with an average of 2.6 (SD = 4.8) nevi per participant. The average number of disappearing nevi was 0.3 (SD = 0.6). In addition, 62/106 (58%) patients had an absolute increase, and 9/106 (8%) patients had an absolute decrease in their total nevus count. Roughly half (49%: 1416/2890) of the nevi that could be evaluated at both time points increased in diameter by at least 25%. Only 6% (159/2890) of nevi shrunk in diameter by at least 25%. Patients with a history of melanoma had a higher rate of disappearing nevi, and their nevi were more likely to grow. Most nevi demonstrated no significant dermoscopic changes., Conclusions: High-risk patients acquire new nevi throughout life with very few nevi disappearing over time. Contrary to prior reports, most nevi in adults increase in diameter, while few nevi shrink., (© 2022 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology.)

On the basis of the clinical impression and current knowledge, acquired melanocytic nevi and melanomas may not occur in random localizations. The goal of this study was to identify whether their distribution on the back is random and whether the location of melanoma correlates with its adjacent lesions. Therefore, patient-level and lesion-level spatial analyses were performed using the Clark‒Evans test for complete spatial randomness. A total of 311 patients with three-dimensional total body photography (average age of 40.08 [30‒49] years; male/female ratio: 128/183) with 5,108 eligible lesions in total were included in the study (mean sum of eligible lesions per patient of 16.42 [3‒199]). The patient-level analysis revealed that the distributions of acquired melanocytic neoplasms were more likely to deviate toward clustering than dispersion (average z-score of ‒0.55 [95% confidence interval = ‒0.69 to ‒0.41; P < 0.001]). The lesion-level analysis indicated a higher portion of melanomas (n = 57 of 72, 79.2% [95% confidence interval = 69.4‒88.9%]) appearing in proximity to neighboring melanocytic neoplasms than to nevi (n = 2,281 of 5,036, 45.3% [95% confidence interval = 43.9‒46.7%]). In conclusion, the nevi and melanomas' distribution on the back tends toward clustering as opposed to dispersion. Furthermore, melanomas are more likely to appear proximally to their neighboring neoplasms than to nevi. These findings may justify various oncogenic theories and improve diagnostic methodology., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Competing Interests: Conflicts of interest None disclosed.

Introduction: Among the various widely recognized basal cell carcinoma (BCC) clinical patterns, linear basal cell carcinoma (LBCC) is an uncommon morphologic variant of BCC., Objectives: Describe the clinical and dermoscopic characteristics of LBCC., Methods: Retrospective study including LBCC cases from 5 dermatology centers in North and South America. Biopsy-proven primary BCCs, that presented with at least 3:1 length:width ratio on physical examination, irrespective of tumor subtype or location, were included. Clinical and dermoscopic analysis were performed by 2 experts in dermoscopy., Results: Eighteen cases of LBCC met our inclusion criteria and were included in the study. Median age at diagnosis was 86.0 years, 10 patients (58.8%) were males. Regarding anatomic location, 11/18 (61.1%) were located on the head and neck, 5/18 (27.7%) cases were found on the trunk, and 2 on lower extremities (11.1%). Under dermoscopy, 15/18 (83.3%) of LBCC were pigmented. All tumors displayed at least one of the BCC-specific dermoscopic criteria the most common being blue-grey globules (72.2%)., Conclusions: Dermoscopy might be useful in the differentiation of LBCC from other diagnoses presenting as linear lesions such as scars, scratches/erosions, and tattoos, among others. Some of these lesions might be confused by naked eye examination alone., Competing Interests: Competing interests: None., (©2022 Navarrete-Dechent et al.)

Introduction: In image interpretation education, many educators have shifted away from traditional methods that involve passive instruction and fragmented learning to interactive ones that promote active engagement and integrated knowledge. By training pattern recognition skills in an effective manner, these interactive approaches provide a promising direction for dermoscopy education., Objectives: A narrative review of the literature was performed to probe emerging directions in medical image interpretation education that may support dermoscopy education. This article represents the second of a two-part review series., Methods: To promote innovation in dermoscopy education, the International Skin Imaging Collaborative (ISIC) assembled an Education Working Group that comprises international dermoscopy experts and educational scientists. Based on a preliminary literature review and their experiences as educators, the group developed and refined a list of innovative approaches through multiple rounds of discussion and feedback. For each approach, literature searches were performed for relevant articles., Results: Through a consensus-based approach, the group identified a number of theory-based approaches, as discussed in the first part of this series. The group also acknowledged the role of motivation, metacognition, and early failures in optimizing the learning process. Other promising teaching tools included gamification, social media, and perceptual and adaptive learning modules (PALMs)., Conclusions: Over the years, many dermoscopy educators may have intuitively adopted these instructional strategies in response to learner feedback, personal observations, and changes in the learning environment. For dermoscopy training, PALMs may be especially valuable in that they provide immediate feedback and adapt the training schedule to the individual's performance., Competing Interests: Competing interests: None., (©2022 Tran et al.)

Introduction: Efficient interpretation of dermoscopic images relies on pattern recognition, and the development of expert-level proficiency typically requires extensive training and years of practice. While traditional methods of transferring knowledge have proven effective, technological advances may significantly improve upon these strategies and better equip dermoscopy learners with the pattern recognition skills required for real-world practice., Objectives: A narrative review of the literature was performed to explore emerging directions in medical image interpretation education that may enhance dermoscopy education. This article represents the first of a two-part review series on this topic., Methods: To promote innovation in dermoscopy education, the International Skin Imaging Collaborative (ISIC) assembled a 12-member Education Working Group that comprises international dermoscopy experts and educational scientists. Based on a preliminary literature review and their experiences as educators, the group developed and refined a list of innovative approaches through multiple rounds of discussion and feedback. For each approach, literature searches were performed for relevant articles., Results: Through a consensus-based approach, the group identified a number of emerging directions in image interpretation education. The following theory-based approaches will be discussed in this first part: whole-task learning, microlearning, perceptual learning, and adaptive learning., Conclusions: Compared to traditional methods, these theory-based approaches may enhance dermoscopy education by making learning more engaging and interactive and reducing the amount of time required to develop expert-level pattern recognition skills. Further exploration is needed to determine how these approaches can be seamlessly and successfully integrated to optimize dermoscopy education., Competing Interests: Competing Interests: None., (©2022 Tran et al.)

Background: The morphology and biology of nevi with peripheral globules are well known, whereas those of melanomas with peripheral globules remain unclear., Objective: Comparing the dermatoscopic characteristics of nevi and melanomas with peripheral globules., Methods: A total of 401 melanocytic lesions with peripheral globules were included in this retrospective study. Dermatoscopic patterns and structures, including those of peripheral globules, were evaluated. A generalized estimating equation model with a binomial distribution dependent variable and logit link function was fitted to the dataset to identify features with the highest odds of differentiating melanoma from nevi., Results: Of the 401 lesions, 179 (44.64%) were excised, 41 (10.22%) of which were melanomas. Melanomas were most common in the lower extremities (P < .01), with a disorganized pattern, whereas melanocytic nevi were most common on the trunk, with an organized pattern. In addition, the presence of blotches, atypical dots and globules, or atypical vessels was associated with melanomas (P < .01)., Limitations: The retrospective design of the study may have caused an inclusion bias., Conclusion: Melanocytic lesions displaying peripheral globules are at the greatest risk of melanoma if located on the lower extremity and if lesions reveal any of the following structures: blotch, atypical dots and globules, or atypical vessels., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions., Objective: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials., Methods: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group., Results: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome., Limitations: English-speaking patients and professionals rated outcomes extracted from English language studies., Conclusion: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians., Competing Interests: Conflicts of interest Dr Kirkham is involved with the COMET and CS-COUSIN Methods groups. Drs Schmitt and Alam are involved with the CS-COUSIN Methods group. Dr Armstrong has served as a research investigator and/or scientific advisor to AbbVie, Almirall, Arcutis, ASLAN, Beiersdorf, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Nimbus, Novartis, Ortho Dermatologics, Sun, Dermavant, Dermira, Sanofi, Regeneron, Pfizer, and Modmed. The remaining authors have no relevant conflicts to disclose., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Competing Interests: None disclosed.

Background: Congenital nail matrix nevi (NMN) are difficult to diagnose because they feature clinical characteristics suggestive of adult subungual melanoma. Nail matrix biopsy is difficult to perform, especially in children., Objective: To describe the initial clinical and dermatoscopic features of NMN appearing at birth (congenital) or after birth but before the age of 5 years (congenital-type)., Methods: We conducted a prospective, international, and consecutive data collection in 102 hospitals or private medical offices across 30 countries from 2009 to 2019., Results: There were 69 congenital and 161 congenital-type NMNs. Congenital and congenital-type NMN predominantly displayed an irregular pattern of longitudinal microlines (n = 146, 64%), reminiscent of subungual melanoma in adults. The distal fibrillar ("brush-like") pattern, present in 63 patients (27.8%), was more frequently encountered in congenital NMN than in congenital-type NMN (P = .012). Moreover, congenital NMN more frequently displayed a periungual pigmentation (P = .029) and Hutchinson's sign (P = .027) than did congenital-type NMN., Limitations: Lack of systematic biopsy-proven diagnosis and heterogeneity of clinical and dermatoscopic photographs., Conclusion: Congenital and congenital-type NMN showed worrisome clinical and dermatoscopic features similar to those observed in adulthood subungual melanoma. The distal fibrillar ("brush-like") pattern is a suggestive feature of congenital and congenital-type NMN., Competing Interests: Conflicts of interest None disclosed., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Competing Interests: None disclosed.

The primary cause of the increase in melanoma incidence in the United States has been suggested to be overdiagnosis. We used Surveillance, Epidemiology, and End Result Program data from 1975 to 2017 to examine epidemiologic trends of melanoma incidence and mortality and better characterize overdiagnosis in white Americans. Over the 43-year period, incidence and mortality showed discordant temporal changes across population subgroups; trends most suggestive of overdiagnosis alone were present in females aged 55-74. Other groups showed mixed changes suggestive of overdiagnosis plus changes in underlying disease risk (decreasing risk in younger individuals and increasing risk in older males). Cohort effects were identified for male and female mortality and male incidence but were not as apparent for female incidence, suggesting that period effects have had a greater influence on changes in incidence over time in females. Encouraging trends included long-term declines in mortality in younger individuals and recent stabilization of invasive incidence in individuals aged 15-44 years and males aged 45-54 years. Melanoma in situ incidence, however, has continued to increase throughout the population. Overdiagnosis appears to be relatively greater in American females and for melanoma in situ., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Testicular germ-cell tumours (TGCT) are the most common cancer among young adult men. Previous studies suggested TGCT survivors have an increased risk for skin cancer. The goal of this study was to systematically review the literature and evidence regarding skin cancer risk among TGCT survivors compared with the general population. PubMed, EMBASE, Web of Science, Cochrane Databases and reference lists were included in the search. A systematic review of all comparative studies with more than 10 TGCT survivors reporting on skin cancer incidence was performed. A meta-analysis of the Standardized Incidence Rate (SIR) was calculated by pooling study-specific log-transformed estimates using the random-effects model. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. Nineteen studies that reported on 147 935 TGCT survivors were included. Pooled SIR for skin cancer and for melanoma incidence among TGCT survivors were 1.93 (95% CI 1.62-2.29, P < 0.0001) and 1.81 (95% CI 1.57-2.08, P < 0.0001), respectively. In conclusion, compared to the general population, TGCT survivors have an increased risk for developing skin cancer and melanoma. Additional long-term studies that include TGCT survivors, additional risk factors and all subtypes of skin cancer are required., (© 2022 European Academy of Dermatology and Venereology.)

Introduction: Minimal knowledge exists regarding skin cancers in Black individuals, which may adversely affect patient care., Objectives: To describe clinical features and risk factors of skin cancers in Black individuals., Methods: Retrospective study of Black individuals diagnosed with skin cancer between January 2000 and January 2020 at our institution., Results: 38,589 patients were diagnosed with skin cancer, of which 165 were Black individuals. One-hundred-thirteen of these Black individuals were diagnosed with melanoma, 35 with squamous cell carcinoma (SCC), and 17 with basal cell carcinoma (BCC). Most melanomas (80.0%, n = 90) were of the acral subtype; 75% (6 of 8 cases with dermoscopic images) displayed a parallel ridge pattern (PRP). The surrounding uninvolved background skin was visible in 7 cases, all demonstrating a PRP. This disappeared adjacent to most of the melanoma lesions (n = 4, 57.1%). creating a peripheral hypopigmented "halo". The nonmelanoma skin cancers were pigmented and had similar dermoscopic features as reported in predominantly White populations. Most SCCs (n = 5, 71.4%) had a hypopigmented "halo" and most BCCs (n = 10, 55.6%) had an accentuated reticular network adjacent to the lesions., Conclusions: Skin cancers are pigmented in Black individuals. In both acral melanomas and SCCs, we noted a peripheral rim of hypopigmentation between the lesions and the surrounding uninvolved background skin, while BCCs had accentuation of the background pigmentation adjacent to the lesions. Most acral melanomas displayed a PRP, which was also seen in surrounding uninvolved background skin., Competing Interests: Competing interests: None., (©2022 Manci et al.)

Background: Melanoma screening includes the assessment of changes in melanocytic lesions using images. However, previous studies of normal nevus temporal changes showed variable results and the optimal method for evaluating these changes remains unclear. Our aim was to evaluate the reproducibility of (a) nevus count done at a single time point (method I) versus two time points (method II); and (b) manual and automated nevus diameter measurements., Materials and Methods: In a first experiment, participants used either a single time point or a two time point annotation method to evaluate the total number and size of nevi on the back of an atypical mole syndrome patient. A Monte Carlo simulation was used to calculate the variance observed. In a second experiment, manual measurements of nevi on 2D images were compared to an automated measurement on 3D images. Percent difference in the paired manual and automated measurements was calculated., Results: Mean nevus count was 137 in method I and 115.5 in method II. The standard deviation was greater in method I (38.80) than in method II (4.65) (p = 0.0025). Manual diameter measurements had intraclass correlation coefficient of 0.88. The observed mean percent difference between manual and automated diameter measurements was 1.5%. Lightly pigmented and laterally located nevi had a higher percent difference., Conclusions: Comparison of nevi from two different time points is more consistent than nevus count performed separately at each time point. In addition, except for selected cases, automated measurements of nevus diameter on 3D images can be used as a time-saving reproducible substitute for manual measurement on 2D images., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Fibroepithelioma of Pinkus (FEP) is a subtype of basal cell carcinoma (BCC) that can clinically resemble intradermal nevi (IDN) and fibromas. We performed a retrospective review of consecutively biopsied lesions confirmed to be FEP on histopathology diagnosed from January 1, 2008 to April 8, 2019. Clinical (n = 48), contact non-polarized dermoscopy (NPD) (n = 44), and contact polarized dermoscopy (PD) (n = 22) images from 36 patients were reviewed. Mean age was 64.5 years (SD 15.1 years, range 24-86 years) at diagnosis of first FEP lesion. Most lesions were located on the torso (n = 28, 58.3%), followed by the lower extremity (n = 9, 18.8%). The most common differential diagnoses at the time of biopsy included BCC (n = 40) and nevus (other than IDN, n = 5). Clinically, FEP were pink (95.8%), scaly (66.7%) papules (77.1%) displaying disrupted skin markings (62.5%) and absence of hair follicles (87.5%). NPD revealed serpentine (97.7%), dotted (81.8%), or polymorphous vessels (86.4%), and hypopigmented to pink lines intersecting at acute angles (HPLA) (52.3%). PD demonstrated serpentine (95.5%), dotted (86.4%), or polymorphous vessels (81.8%), shiny white lines (50.0%), and HPLA (59.1%). Classic features of BCC such as arborizing vessels (n = 2), ulceration (n = 1), shiny white blotches and strands (n = 1), blue-gray ovoid nest (n = 1), and leaf-like areas (n = 1) were uncommon. FEP often presents as scaly, erythematous papules with disrupted skin markings and absence of hair follicles. Dermoscopy reveals polymorphous vessels with shiny white lines and HPLA., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Dermoscopy and reflectance confocal microscopy (RCM) are two noninvasive, optical imaging tools used to facilitate clinical diagnosis. A biopsy technique that produces exact correlation with optical imaging features is not previously reported. To evaluate the applications of a novel feature-focused 'precision biopsy' technique that correlates clinical-dermoscopy-RCM findings with histopathology. This was a prospective case-series performed during August 2017 and June 2019 at a tertiary care cancer. We included consecutive patients requiring a precise dermoscopy-RCM-histopathologic correlation. We performed prebiopsy dermoscopy and both wide probe and handheld RCM of suspicious lesions. Features of interest were isolated with the aid of paper rings and a 2 mm punch biopsy was performed in the dermoscopy- or RCM-highlighted area. Tissue was processed either en face or with vertical sections. One-to-one correlation with histopathology was obtained. Twenty-three patients with 24 lesions were included in the study. The mean age was 64.6 years (range 22-91 years); there were 16 (69.6%) males, 14 (58.3%) lesions biopsied were on head and neck region. We achieved tissue-conservation diagnosis in 100% (24/24), 13 (54.2%) were clinically equivocal lesions, six (25%) were selected for 'feature correlation' of structures on dermoscopy or RCM, and five (20.8%) for 'correlation of new/unknown' RCM features seen on follow-up. The precision biopsy technique described herein is a novel method that facilitates direct histopathological correlation of dermoscopy and RCM features. With the aids of optical imaging devices, accurate diagnosis may be achieved by minimally invasive tissue extraction., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)