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In 2005, the ARCHIVES converted from paper-based submission and review of manuscripts to electronic methods. The international dermatology community of authors appreciates the shorter turn-around time that is possible with reviews performed electronically. We wish to recognize the superb efforts of our reviewers, who made it possible to review manuscripts by e-mail. Like the letter carriers, who get the mail through in blizzards, these peer reviewers get the reviews through the spam blockers, viruses, and worms that beset our e-mail systems in 2005. We offer our profound thanks to these reviewers for their critical analyses and dedication to advancing the field of dermatology. We look forward to processing manuscripts for the Archives of Dermatology with a Web-based system in 2006.

Objective To compare identification of the border of lentigo maligna (LM) with digital epiluminescence microscopy (DELM) with clinical and Wood light assessment. Design The borders of lesions identified clinically with the Wood light, with DELM, and after excision by Mohs micrographic surgery were traced onto plastic sheets. The borders defined on the tracings were compared for congruence and mean surface area. Setting Cardinal Bernardin Cancer Center for Skin Cancer, Loyola University Health System, Maywood, Ill. Patients Twenty-six consecutive patients with LM of the head and neck. Main Outcome Measures Results of the comparison of the outlines of the borders and the mean surface area identified by the 4 methods. Results The border determined by clinical examination was smaller than that determined with the Wood lamp or by DELM. Most lesions underwent an additional excision 5 mm beyond the DELM-defined border. The DELM pattern of LM with asymmetric follicular openings and dark brown rhomboidal structures changed at the periphery and became a pigmented thin mesh that was associated with the histopathological features of melanoma in situ. More homogeneous pigmented areas extending from the LM were associated with the pathologic features of melanocytic hyperplasia. Conclusions Visualization of LM by DELM (dermoscopy) helps to guide resection. Because LM arises in sun-damaged skin with melanocytic hyperplasia, determining the tumor-free margin requires the judgment of an experienced physician.

Objective To examine the outcome of digital epiluminescence microscopic (DELM) surveillance of atypical nevi in a high-risk population for 4 years. Design Atypical, flat melanocytic lesions in 100 patients at high risk of developing melanoma were followed annually with DELM. Pigmentary changes or an increase in DELM diameter of 1 mm or greater was an indication to perform an excisional biopsy. Setting Cardinal Bernardin Cancer Center Melanoma Program, Loyola University Health System, Maywood. Patients A consecutive sample of 3482 lesions from 100 patients (aged 18-65 years) with at least 2 images of the same lesion. Main Outcome Measures The DELM change was confirmed by histopathologic examination. Patient confidence in and comfort with dermatologic surveillance and skin self-examination performance were assessed. Results During annual surveillance with DELM, 5.5% of the lesions changed. Among the 193 excisional biopsy specimens there were 4 melanomas in situ, 169 dysplastic nevi, and 20 common nevi. Confidence in and comfort with surveillance and skin self-examination improved after DELM. Conclusions The criteria applied to detect substantial DELM changes were an increase in DELM diameter of 1 mm or greater and pigmentary changes, including radial streaming, focal enlargement, peripheral black dots, and "clumping" within the irregular pigment network. Use of DELM enhanced confidence in and comfort with care, which extended to performing more extensive skin self-examination.

Background. Aesthetic facial reconstruction requires understanding regional anatomy and tissue movement and the ability to use innovatively the tissue adjacent to the defect to create a reconstruction that preserves the function of the area and the cosmetic facial units. Objective. Facial reconstruction after Mohs micrographic resection of nonmelanoma skin cancer confined to one cosmetic unit was compared with reconstruction of two or more units using techniques to place scars at the junction of cosmetic units with combinations of local flaps and grafts. Acute complications, function, and final appearance of the reconstruction were evaluated. Methods. During a 10-year period, 500 cases acquired prospectively had facial surgical defects repaired. Tissue was removed to place the closure line at the junction of cosmetic units and was mobilized from within one cosmetic unit with primary closure or local advancement, rotation, or transposition flaps. When the defect bridged cosmetic units, segmental repair was performed with combinations of flaps and grafts placing scars at the junction of cosmetic units. Segmental repair often combined advancement flaps to restore contours with full-thickness skin grafts to prevent distortion in areas with minimal loss of contour. Scars were more often unfavorably placed with single flap repair within a cosmetic unit. There was more flap loss with single flap repair of a single unit than with segmental facial repair using a combination of flaps and/or grafts. Conclusion. Segmenting the wound into smaller units reflecting the underlying cosmetic units of the face was useful to develop a reconstruction plan to replace tissue with similar tissue and to provide consistently satisfying aesthetic results. Facial contours were restored without distorting surrounding structures.

Summary Background Detection of CDw60 in skin is representative of ganglioside D3 expression. This ganglioside is expressed primarily by melanocytes, and is of interest as a membrane antigen targeted by immunotherapy for melanoma patients. Expression of CDw60 by keratinocytes is defined by the presence of T-helper cell (Th)1 vs. Th2 cytokines, and can serve as a sentinel molecule to characterize an ongoing skin immune response. Objectives These immunobiological characteristics have provided the incentive to study the expression of CDw60 in the context of progressive vitiligo. Methods Frozen sections were obtained from control skin and from vitiligo lesions and immunostained to show CDw60. Cells were cultured, their CDw60 expression studied and ribonuclease protection assays run to detect cytokine mRNA. Results Resistance to cytokine-mediated regulation of CDw60 expression was demonstrated in vitro by melanocytes, which appeared capable of generating autocrine and paracrine regulatory molecules supporting CDw60 expression. Induction of CDw60 expression was inhibited by antibodies to interleukin (IL)-4, suggesting that this cytokine was responsible, at least in part, for melanocyte-induced CDw60 expression. Marginal skin from patients with progressive generalized vitiligo consistently showed a reduction in epidermal CDw60 expression alongside elevated human leucocyte associated antigen (HLA)-DR expression at the margin. It thus appears that inflammatory infiltrates present in marginal skin generate type 1 rather than type 2 cytokines, supportive of a cell-mediated autoimmune response. Conclusions These results support an active role of melanocytes within the skin immune system, and associate their loss in generalized vitiligo with a cell-mediated immune response mediated by type 1 cytokines.

ABSTRUCT: The incidence and mortality rates of melanoma increased dramatically from 1973 to 1994, rising 120.5 and 38.9%, respectively (1). From 1990 to 1994, men had higher incidence (17.3/100,000) and mortality rates (3.5/100,000) than women (incidence: 11.6/100,000; mortality: 1.7/100,000) and had more melanomas on the trunk or the head and neck; women had more on the lower limbs, but the largest increases for an anatomic site were for the trunk. Incidence rates for birth cohorts born after 1945 seem to be stabilizing. Mortality rates of melanoma are declining for women born in the 1930s or later and men born since the 1950s.

Background The incidence of metastatic basal cell carcinoma ranges from 0.003% to 0.55%. The 230 reported cases most often occurred in long-standing recurrent lesions and appeared in regional nodes or the lungs. Observations The stromal dependence of the tumor provides an explanation for the nonmetastasizing nature of basal cell carcinoma. The dense fibrous stroma of the lymph node in the case of metastatic basal cell carcinoma reported in the present study is similar to other reported cases with metastases to lymph nodes, bone, bone marrow, glands, and subcutaneous tissue. Conclusions This metastatic basal cell carcinoma demonstrated lymphatic and hematogenous dissemination to the lungs and lymph nodes. A dense accumulation of microvessels was present at the boundary of the tumor nests and dermal stroma and in the stroma surrounding the tumor in the lymph node.

Objective To establish a safe and efficacious dosing regimen for the treatment of primary nodular basal cell carcinoma (BCC) using 5% imiquimod cream. Design Two phase 2 studies were conducted: a 6-week, randomized, open-label, dose-response study evaluating 4 dosing regimens and a 12-week, randomized, vehicle-controlled, double-blind, dose-response study evaluating 4 dosing regimens. Setting Twenty-four public and private dermatology clinics in Australia and New Zealand (6-week study) and the United States (12-week study) participated. Patients The study populations comprised 99 patients enrolled in the 6-week study and 92 patients in the 12-week study. Patients were at least 18 years old and had a biopsy-confirmed diagnosis of nodular BCC. Interventions In the 6-week study, imiquimod was applied once daily for 3 or 7 days per week or twice daily for 3 or 7 days per week. In the 12-week study, imiquimod or placebo cream (vehicle) was applied once daily for 3, 5, or 7 days per week, or twice daily for 7 days per week. The entire tumor area was excised 6 weeks after treatment and examined histologically for evidence of remaining BCC. Main Outcome Measure The proportion of patients having no histologic evidence of BCC in the posttreatment excision specimen. Results Dosing once daily for 7 days per week resulted in the highest clearance rate, with 25 (71%) of 35 and 16 (76%) of 21 patients showing clearance of their tumor in the 6- and 12-week studies, respectively. Conclusions Topical 5% imiquimod cream is well tolerated and most effective in treating nodular BCC when applied once daily for 7 days per week for either 12 or 6 weeks.

BACKGROUND Skin self-examination (SSE) may reduce the death rate from melanoma by as much as 63%. Enhancing SSE performance may reduce mortality and morbidity. This study determined predictors of SSE performance in a population of individuals who were at risk of developing melanoma or nonmelanoma skin carcinoma (NMSC). METHODS Patients (n = 200) were asked about their knowledge of the warning signs, their sense of the importance of SSE to them, their attitude about and confidence in their ability to perform SSE, and their impression of their partner's comfort and ability with assisting in the skin examination. The interval since last skin examination, the number of physician visits (nondermatologist and dermatologist), the number and type of skin malignancies, the time since initial diagnosis, the number of skin biopsies, and health insurance status were determined from the medical records for the prior 3 years. RESULTS Seventy percent of participants performed SSE. The three strongest predictors of SSE performance were attitude, having dermatology visits with skin biopsies and at least one skin carcinoma in the previous 3 years, and confidence in performance (P = 0.0001). Other predictors of SSE performance were perceived risk (P = 0.0001), knowledge (P = 0.004), and younger age (P = 0.045). CONCLUSIONS Annual skin examination by physicians and monthly SSE by patients reinforce one another in promoting early detection. In this high-risk population, the dermatologist reinforced SSE performance by biopsy of skin lesions that were skin malignancies. People have intimate knowledge of their own skin and bear the consequences for failure to detect and treat skin carcinoma early; thus, monthly SSE becomes relevant as a personal health-promotion habit. Cancer 2002;95:135–46. © 2002 American Cancer Society. DOI 10.1002/cncr.10637

priority. What can be done to address the rising health care costs of diagnosing and treating melanoma and reduce the loss of productivity of patients? Melanoma screening by a physician is associated with detection of thinner melanomas, which results in decreased mortality. 2 A higher proportion of melanoma diagnosed at an earlier stage can be expected to lower costs for both years of productive life lost as well as disease treatment. Currently, 59.6% of primary care physicians (PCPs) routinely perform skin examinations, compared with 81.3% of dermatologists. Lack of reimbursement was cited by 43.3% of PCPs and 25.1% of dermatologists as one barrier to performing complete skin examination to screen patients for melanoma. Other barriers for PCPs are lack of time, lack of training, and their low confidence in their skills pertaining to pigmented lesion examinations. 3 In a 1-year pilot skin cancer-screening program in

Background. Recently Mohs micrographic surgery, which is widely used for the removal of nonmelanoma skin cancers, has been used to remove lentigo maligna with both rush permanent sections and frozen sections. Several investigators have incorporated the use of immunohistochemical techniques to aid in the interpretation of the specimens. Objective. To determine the current practices of Mohs surgery laboratories, including the use of immunostains and automation of laboratory processes. Methods. A total of 108 laboratories responded to a written questionnaire with 13 items about the types of tumors resected, routine stains performed, average number of slides processed per day, and use of automation and immunostains. Results. Forty-nine percent of the laboratories are completely manual and 51% are automated. The Linistainer automated system, which is the predominant one used, decreased processing time by about 30% and provided an estimated 21–30% improved quality. Automation was associated with the number of slides processed. Immunostaining is performed by a limited number of laboratories which use the technique for basal and squamous cell carcinoma, lentigo maligna, and dermatofibrosarcoma protuberans. Conclusion. Automation of routine slide preparation with a Linistainer decreased staining variability by providing a consistent environment, and decreased processing time. Most laboratories do not perform immunostaining. The relatively high cost of reagents, lack of a reliable automated process, the additional time to process specimens, and the additional technician and physician time makes the procedure impractical for many laboratories.

As we enter a new millennium, the use of evidence-based medicine, which uses the best current evidence to make decisions regarding patient care, to validate medical concepts has become increasingly important. 1 We applaud the ARCHIVES for instituting a regular section dedicated to this approach.

Background Because the probability of basal cell carcinoma (BCC) recurrence was thought to be 30% to 50%, surgical tradition became not to perform additional resection when the margin was positive. Objective To determine whether there is an association among age or sex of the patient, anatomic location, histologic type, or reconstructive procedures and the signs and symptoms of the recurrence, interval between incomplete resection and Mohs micrographic surgery (MMS), or extent of MMS resection. Design During 20 years, all patients with incompletely excised BCC of the head referred for MMS were sequentially prospectively accrued into the cohort. Setting An outpatient MMS practice. Patients Nine hundred ninety-four patients. Main Outcome Measures Interval to tumor recurrence, interval to MMS, and extent of MMS as determined by mean surface area resected, depth of resection, and number of tumor nests. Results The interval to signs or symptoms of recurrence and to MMS from incomplete resection was greater for men, patients older than 65 years, those having a tumor on the nose or cheek, those with aggressive or fibrosing BCC, and those who underwent flap reconstruction ( P = .001). The extent of MMS resection was greater for those with flap and split-thickness skin graft repairs. The number of tumor nests identified by MMS was significantly greater in those treated with split-thickness skin graft and flap ( P = .001). Conclusion Because it is more difficult to control recurrent BCC, treating tumor remaining at the margin of resection in the immediate postoperative period could result in less extensive surgery.

Background: Because an estimated 50% to 80% of the skin's lifetime sun damage is thought to occur in childhood and adolescence, it is during these critical periods that intense, intermittent sun exposure causing burning increases melanoma risk. Methods: A 1997 telephone survey of 503 households evaluated parental attitudes about their child having a tan, and ease of practicing sun protection, sun protection methods used, and sunburning on 5 successive summer weekends. Results: In a random sample of 1 child from each household, 13% of children sunburned during the past week or weekend, and 9% of their parents experienced a sunburn during the past weekend. Children's sunburn was significantly associated with sunburn in the adult respondent, increasing age of the child, having fair skin, being white, and using sunscreens. Duration and peak hours of sun exposure were associated for children and parents. Sunscreen with a sun protection factor of at least 15 was the predominant form of sun protection used. Sunscreen use in children was significantly associated with longer duration of sun exposure, sunny weather conditions, younger age, fair skin, a history of sunburns before this study, a family history of skin cancer, and a higher family income. Feeling that a tan appeared healthy was associated with male gender of the adult and increasing age of the child. Complimenting the child on the appearance of a tan was associated with male gender of the adult, older children, children with skin type reported as olive or dark, and lower educational levels. Conclusion: Although there has been a promising initial effort to alert parents to the need to protect their children from sunburns, many view a tan as healthy and do not effectively implement sun protection behaviors for their children, which results in sunburns. Sun protection that prevents sunburning could be achieved by more children seeking shade, wearing protective clothing, limiting exposure during peak hours, and effectively using sunscreen. (J Am Acad Dermatol 2000;42:746-53.)

Skin cancer prevention and detection public education programs were established by dermatologists in 1983.1 Since 1985 the American Academy of Dermatology’s (AAD) national program of Melanoma/Skin Cancer Detection and Prevention has occurred annually in May2 and has produced extensive print, radio, and television coverage about the dangers of sun exposure and benefits of sun protection. This program was developed in response to the rising incidence of invasive melanoma and the nonmelanoma skin cancers, basal cell and squamous cell carcinoma. Statistics have indicated that the incidence of melanoma in 1980 was 1 in 250 (up from 1 in 1500 in 1930)3 and now is projected to reach 1 in 75 by the year 2000.4 In 1994, an estimated 1,000,000 Americans developed a skin cancer of some type.5 The long-term strategic goal of the AAD’s skin cancer control program has been to reduce the incidence and mortality of skin cancer. The interim tactical objectives were to increase the awareness and knowledge of skin cancer with eventual change in the attitudes, beliefs, and behaviors that affect individual skin cancer risk. Initially, the goal was to educate the public about melanoma and nonmelanoma skin cancer and the potentially harmful aspects of ultraviolet light (UVL) exposure. Later the emphasis was placed on societal attitudes about having a tan obtained by the deliberate use of either indoor or outdoor UVL. Media advocacy and consumer interest from this program brought the matter to the attention of the United States Food and Drug Administration, which issued guidelines about tanning facilities in 1986.6 Since then, dermatologists have carried the legislative regulatory and safety programs for tanning facilities to the state level. Although the majority of states have not legislated tanning facility guidelines or policies, several states have adopted various programs to help monitor and assure safety. Since 1985, the annual AAD May program of free skin cancer screening and counseling about sun protection provided a focus for the development of media materials for print, television, and radio, which were covered by the national media each summer from 1985 to 1998.7–9 In 1994, many local television news programs and newspapers began to report the daily “Ultraviolet Index” (UV Index) in conjunction with the United States National Weather Service ozone and ultraviolet radiation monitoring program. Media coverage of the UV Index promoted awareness of the ease of sunburning and provided guidelines for sun avoidance and the use of sun protection.10 Because an estimated 80% of an individual’s lifetime sun exposure occurs by age 18, it is particularly important to protect children from damage by the sun.11 This compelling need for sun safety messages for children and their parents was recognized by other nonprofit organizations, and a great wealth of educational materials and programs were created over the years by many different organizations, including national organizations such as the American Cancer Society and the Skin Cancer Foundation and local community organizations such as hospital or health department-based cancer prevention programs. National education groups began to develop age-appropriate school health materials on sun protection for preschool to grade 12 (this is discussed more fully in the chapter on public education projects). In April 1995, the variety of materials and messages available was discussed at the National Conference to Develop a National Skin Cancer Agenda in Washington, DC, sponsored by the AAD and the Centers for Disease Control and Prevention. Those attending felt that teaching photoprotective habits should reduce the incidence of adverse health effects from both short-term UV exposure (e.g., sunburn) and long-term exposure (e.g., cutaneous photodamage, skin cancer, and cataracts). The basic safe sun recommendations developed for the agenda were as follows.12

During the last decade, results of surveys of adults showed an increase in sun protection knowledge, a slight decline in the attitude that having a tan was healthy, widespread sunscreen use as the principal method of solar protection, and an increase in sunburning.During the summer of 1996, observers recorded the sun protection activities of 352 family groups as they arrived at the beach and did concurrent interviews.Ninety-eight percent of families using sunscreen applied it after arrival at the beach and it was the dominant form of sun protection used. Usually, the adult woman provided the sunscreen and applied it to a child before applying it to herself. The median delay in application from arrival at the beach to application to the last family member was 51 minutes. Wearing either a hat, shirt, or sunscreen by 1 adult was associated with wearing the same item by at least 1 child in the family group (hat, P.001; shirt, P.001; sunscreen, P.001). Children's sunscreen use was associated with having fair skin and a parent who used it.Because those with fair skin type are more likely to use sunscreen and to burn after short periods of exposure, delay in sunscreen application may cause sunburns. While solar protection has become part of routine beach behaviors for most families, there is room for improvement with better application of sunscreen; more use of clothing, especially hats; and seeking shade.

The American Academy of Dermatology's national program of Melanoma/Skin Cancer Detection and Prevention, developed in response to the rising incidence of invasive melanoma in the United States, has annually produced extensive print, radio, and television coverage about performing skin self-examination (SSE). This study was conducted to determine factors that motivate people to perform SSE. A 1996 telephone survey evaluated performance of SSE for skin cancer and used questions to identify self-perceived. The performance of SSE was directly correlated with the self-perceived risk of the development of melanoma or skin cancer and discussions with physicians or nurses. People were motivated to perform SSE based on their perceived risk and discussions with doctors. Because patients most easily have access to primary care physicians, these physicians must be educated to identify those who are at risk for the development of melanoma. Primary care physicians and nurses should be encouraged to counsel patients about risk levels, the utility of SSE in limiting their risk, and how to perform SSE. To facilitate this process, risk levels for the development of melanoma (defined on the basis of simple and readily ascertained characteristics that help to educate physicians, nurses, and patients) are provided.

Background Pediatric visits during summer months may be especially opportune times for sun protection counseling for children and their parents. Few data exist on the extent of such counseling. Objective To begin to assess this, we surveyed practicing Massachusetts pediatricians to examine current attitudes and practices of sun protection counseling. Design and Setting Surveys mailed to Massachusetts pediatricians. Results We received surveys from 756 (60%) of 1263 eligible Massachusetts pediatricians. Almost 70% indicated that they recommended safe sun practices to more than 50% of their patients and their parents during the summer months. Counseling regarding seat belt use, bicycle helmet use, and smoking prevention were ranked higher in priority than sun protection counseling by pediatricians; nutritional guidelines were noted by pediatricians to be a parent's most frequent concern. Four variables were independently associated with a practitioner's providing safe sun recommendations to more than 50% of parents and children: (1) private setting and health maintenance organization practitioners as opposed to academic physicians, (2) high ranking of patients' safe sun knowledge, (3) high priorities of both parents and physicians for sun protection counseling and parental knowledge of safe sun practices relative to other recommendations, and (4) pediatrician interest in receiving instructional materials. Conclusions For the most part, summer sun protection counseling among Massachusetts pediatricians seems well integrated into standard practice. Most pediatricians rated their confidence level as high for discussing sun protection and only a few cited inadequate training or poor reimbursement as barriers toward improved counseling. Small steps, such as providing more instructional materials to patients and using office-based reminder systems, may improve the quality of sun protection counseling practices. Incorporating sunburn prevention into the list of routinely recommended injury prevention guidelines for pediatricians should be considered.

Background: The American Academy of Dermatology's national program Melanoma/Skin Cancer Detection and Prevention, developed in response to the rising incidence of invasive melanoma in the United States, has annually during the past decade produced extensive print, radio, and television coverage about the dangers of sun exposure and benefits of sun protection. Objective: We measured the progress achieved in increasing the awareness and knowledge of skin cancer and changing the attitudes, beliefs, and behaviors that affect skin cancer risk. We also describe current sun-related behavior including sunburning, assess the likelihood of practicing sun protection strategies, and provide a baseline against which future changes in sun protection behavior may be evaluated. Methods: A 1996 telephone survey repeated questions used in 1986 to evaluate change and used classifying questions to better define attitudes and behaviors. Results: From 1986 to 1996, the knowledge of the perceived harmful effects of the sun significantly broadened, but the UV exposure behavior as measured by sunburning (30% to 39%) and regular use of a tanning booth (2% to 6%) also increased. There was a decline in the attitude that having a tan was healthy; however, in 1996 having a tan was still considered to enhance appearance, particularly by men. Sunscreen use increased (35% to 53%). Women, younger persons, persons residing in areas with fewer sunny days, and whites were more likely to tan intentionally, but men who lived in the South were more likely to sunburn. Conclusion: During the past decade, the early process of change involving cognitive and emotional activities began. With this study, high-risk population subsets performing specific adverse behavior were identified. In the future, they can be targeted with messages that promote attitudinal and behavioral change. (J Am Acad Dermatol 1997;37:179-86.)

With this issue we launch the new format of JAMA Dermatology. This is the first major redesign in more than 2 decades. Every article type, including research, opinion, news, humanities, clinical reviews, and letters, was redesigned across all 10 journals that comprise the JAMA Network. The font, tables, graphs, and figure styles have been reviewed and revised. The redesign will be most evident in the print issue, but it will also improve the readability of our content on the web. The goals of the redesign were to create a more modern look with improved navigation across the JAMA Network, reinforce the scholarly importance of our research and evidence-based review sections, and ensure that our viewpoints and editorials are more welcoming.

As the oldest English-language dermatology journal in continuous publication, it is appropriate for JAMA Dermatology to acknowledge the English-language publication of a landmark text of dermatologic medical history: Pantheon of Dermatology: Outstanding Historical Figures by Christoph Loser, Gerd Plewig, and Walter Burgdorf, published by Springer in 2013. The text and over 2200 illustrations provide insight into the lives of 209 outstanding dermatologists who developed dermatology over 6 centuries. Since the founding of JAMA Dermatology in 1882 as the Journal of Cutaneous and Venereal Disease, the journal has published definitive manuscripts by the leaders in our field. It is a privilege to be able to give a glimpse into the lives of some of these leaders with Notable Notes derived from the Pantheon of Dermatology.

Importance Lack of training hampers melanoma recognition by physicians. Objective To evaluate a melanoma simulation model to teach visual assessment and counseling skills. Design and Setting Simulation model study in an academic research setting. Participants A convenience sample of third-year medical students was randomly assigned to receive the intervention before or after a standardized patient. Intervention During the primary care clerkship, medical students participated in melanoma skills training using 2 simulation models replicating melanomas and abnormal or benign nevi. Scoring threshold rules for visual assessment and management of pigmented lesions and videos of patient counseling were provided. Main Outcome Measures Identifying a melanoma moulage and counseling the standardized patient. Secondary measures were preintervention and 2-week postintervention knowledge, attitudes about and confidence in their ability to perform opportunistic surveillance and counseling, as well as identification on the model of clinically suspicious pigmented lesions, lesions needing a biopsy, and lesions to be monitored for change. Results Among 74 students, confidence in their ability to perform opportunistic surveillance improved significantly after skills training (P 2 test). Monitoring clinically suspicious lesions for change decreased from 16% (12 of 74) to 3% (2 of 74) and performing a biopsy increased from 80% (59 of 74) to 96% (71 of 74), monitoring benign lesions for change decreased from 43% (32 of 74) to 3% (2 of 74), and biopsying melanoma in situ increased from 10% (7 of 74) to 26% (20 of 74) (P 2 test). Detection of the melanoma moulage on the standardized patient occurred more often by trained students (P 2 test). Conclusion and Relevance A 1-hour melanoma simulation education and skills training experience improved performance of opportunistic surveillance, management, and patient counseling by third-year medical students. Trial Registration clinicaltrials.gov Identifier: NCT01191294

Physician counseling about sun protection and routine screening for skin cancer in high-risk individuals have been widely recommended. The purpose of this study was to assess the skin cancer control practices and knowledge among physicians in a university-based general medicine practice. Fifty-two physicians completed a survey on attitudes toward, behaviors in, and knowledge of skin cancer control. In addition, the ability of general medicine residents and attending physicians to correctly identify and make biopsy recommendations for ten photographed skin lesions was compared with that of third-year medical students and dermatology residents and attendings. The results of the survey illustrate a need for improving primary care physicians’ knowledge and identification of skin cancer risk factors, and increasing the frequency and consistency with which they perform skin cancer prevention counseling and complete skin examination in high-risk patient groups.

Background. Knowledge-based skin cancer risk and prevention educational interventions by physicians and nurses were directed to subjects who had a nonmelanoma skin cancer. These high-risk patients asked relatives or friends to assist with postoperative care rendered after surgical removal of the skin cancer. The patient′s experience with the nonmelanoma skin cancer was expected to raise the awareness of the helper. The study examined whether the patient became a source of information, risk assessment, and skills training for his or her helper. Methods. Sequential patients between 30 and 60 years of age and their designated helpers completed a self-report questionnaire prior to the intervention and 1 year after the intervention. The questionnaire examined: (a) knowledge of skin cancer and sun protection; (b) individual susceptibility as determined by ease of sunburning or tanning; (c) attitudes about self-esteem, sun exposure, and health locus of control; (d) intentions to use sun protection; and (e) behaviors of sun protection used. Results. Over the course of 1 year, 200 pairs were entered into the study. Both patients and helpers demonstrated an increase in knowledge after the educational intervention with the patients. There was a change in the self-reported intention to use sun protection and the behaviors of sun protection used in both patients and helpers after the intervention; however, there was no attitudinal change demonstrated in pre- and post-tests for either patients or helpers. Among both patients and helpers, gender-specific differences in attitudes, intentions, and behaviors existed. Women expressed a greater likelihood of taking precautions, including the use of sunblock; however, men reported the protective strategy of wearing a hat more than women did. Men valued a tan more than women and had greater outdoor exposure, which they restricted after the intervention. Women helpers ceased using indoor tanning devices after the intervention. Behavioral change in use of sun protection measures, including protective clothing or sunblock use and decrease in hours of outdoor sun exposure or use of indoor tanning devices, was dependent upon the patient or helper′s own reported susceptibility as determined by his or her history of poor tanning and ease of sunburning. Conclusion. Patients transferred knowledge to their helpers. intention to change behavior and behavioral change were strongly correlated with the individual′s reported susceptibility to easy sunburning and poor tanning. Despite a lack of change in attitudes, changes in both intention to change behavior and behavior itself occurred in those who perceived themselves to be at risk. While the attitudes of participants in this study reflected popular beliefs, targeted education of high-risk adults with a nonmelanoma skin cancer caused changes in sun protection behaviors in both the patients and their helpers.

To develop easily disseminated educational materials that enable early detection of skin cancer, and to examine the effectiveness of the materials to promote skin self-examination (SSE) among kidney transplant recipients (KTRs).Randomized controlled trial of an educational intervention in comparison with a group that received only the assessment, education, and treatment as part of usual care with a nephrologist.Academic ambulatory nephrology practice.Seventy-five KTRs returning for routine care to their nephrologists 1 to 1.2 years or 3 to 7 years after transplantation.Educational workbook.Skin self-examination performance and new appointments with a dermatologist if a concerning skin lesion was found.Twenty-two percent of those in the control group checked their skin after the visit compared with 89% of the treatment condition; thus, KTRs receiving the intervention were significantly more likely to have checked their skin (χ(2); P.001). Among the 8 control KTRs who checked their skin, none found areas of concern. Of the 34 intervention KTRs who checked their skin, 12 participants (35%) found areas of concern. All 12 of these individuals made appointments with a dermatologist for follow-up.The KTRs were receptive to performing SSE and acted on the recommendation made in the workbook to make an appointment with a dermatologist when a concerning lesion was discovered. Printed educational materials can be initiated in the tertiary care center 1 year after transplantation and used across a continuum of time during which KTRs may be transferred from the tertiary care center to community nephrologists.clinicaltrials.gov Identifier: NCT01127737.