Search

Background: Vancomycin requires therapeutic drug monitoring (TDM) based on its pharmacokinetic properties, and guidelines have shifted to analyzing area under the curve over 24 hours (AUC24) rather than trough concentrations due to nephrotoxicity concerns and correlation to efficacy. Obesity is an established risk factor for vancomycin-induced nephrotoxicity due to increased drug exposure based on dosing calculations and volume of distribution estimation. The aim of this study is to assess the relationship between AUC-based versus trough-based dosing and nephrotoxicity among obese patients receiving vancomycin. Methods: This research project was conducted as a retrospective, observational, single-centered study which included obese adults who received at least 48 hours of vancomycin. The electronic medical record provided data for patients with vancomycin pharmacokinetic consults either evaluated with trough-only or AUC-based dosing. The primary objective was to compare the development of nephrotoxicity after vancomycin initiation, while secondary objectives included vancomycin loading dose exposure, total daily dose of vancomycin, and whether target TDM was attained. Nominal data were evaluated utilizing the chi-square test and continuous data using the independent samples t-test or Mann-Whitney test. The a priori level of significance was .05. Data analysis was performed using Microsoft Excel and SAS statistical software. Results: Two hundred fifty-four patients were included in the primary analysis. Four patients in the AUC cohort (6.3%) developed nephrotoxicity compared to 32 (17.4%) in the trough cohort ( P = .035). Both cohorts received a median of 4 days of therapy; however, the median loading dose per actual body weight in the AUC cohort was 20 mg/kg as compared to 16 mg/kg in the trough cohort. Of the 130 patients with available TDM in the trough cohort, 97 (74.6%) did not meet target attainment as compared to 15 of the 57 in the AUC cohort (26.3%) ( P

Actinic keratoses (AKs) are a consequence of chronic exposure to ultraviolet radiation. Treatment of chronically photo-damaged skin and AKs is driven by risk of progression to squamous cell carcinoma, as well as for symptomatic relief. Conventional photodynamic therapy (c-PDT) is indicated when AKs are multiple or confluent and if patients respond poorly or are unable to tolerate other therapies. c-PDT is limited by the field size that can be treated in single sessions and can cause significant discomfort.Recent studies investigated daylight illumination to activate protoporphyrin IX and daylight-PDT (d-PDT) is now licensed in the UK for face and scalp AKs. A group of experts met to discuss application of d-PDT with methyl aminolevulinate (MAL) and develop a UK consensus statement, specific to UK weather conditions.The UK consensus recommendations were reached among eight experts, who reviewed recent studies on d-PDT, assessed UK meteorological data and discussed personal experiences of d-PDT for AKs.Recommendations from these discussions provide guidance on d-PDT use, specifically regarding patient selection, therapeutic indications, when to treat, skin preparation, MAL application and daylight exposure for patients with AKs.This UK expert consensus provides practical guidance for UK application of d-PDT.

Background: Deep learning convolutional neural networks (CNN) may facilitate melanoma detection, but data comparing a CNN's diagnostic performance to larger groups of dermatologists are lacking.Methods: Google's Inception v4 CNN architecture was trained and validated using dermoscopic images and corresponding diagnoses. In a comparative cross-sectional reader study a 100-image test-set was used (level-I: dermoscopy only; level-II: dermoscopy plus clinical information and images). Main outcome measures were sensitivity, specificity and area under the curve (AUC) of receiver operating characteristics (ROC) for diagnostic classification (dichotomous) of lesions by the CNN versus an international group of 58 dermatologists during level-I or -II of the reader study. Secondary end points included the dermatologists' diagnostic performance in their management decisions and differences in the diagnostic performance of dermatologists during level-I and -II of the reader study. Additionally, the CNN's performance was compared with the top-five algorithms of the 2016 International Symposium on Biomedical Imaging (ISBI) challenge.Results: In level-I dermatologists achieved a mean (±standard deviation) sensitivity and specificity for lesion classification of 86.6% (±9.3%) and 71.3% (±11.2%), respectively. More clinical information (level-II) improved the sensitivity to 88.9% (±9.6%, P = 0.19) and specificity to 75.7% (±11.7%, P < 0.05). The CNN ROC curve revealed a higher specificity of 82.5% when compared with dermatologists in level-I (71.3%, P < 0.01) and level-II (75.7%, P < 0.01) at their sensitivities of 86.6% and 88.9%, respectively. The CNN ROC AUC was greater than the mean ROC area of dermatologists (0.86 versus 0.79, P < 0.01). The CNN scored results close to the top three algorithms of the ISBI 2016 challenge.Conclusions: For the first time we compared a CNN's diagnostic performance with a large international group of 58 dermatologists, including 30 experts. Most dermatologists were outperformed by the CNN. Irrespective of any physicians' experience, they may benefit from assistance by a CNN's image classification.Clinical trial number: This study was registered at the German Clinical Trial Register (DRKS-Study-ID: DRKS00013570; https://www.drks.de/drks_web/). (Less)

Background: Dermoscopy is a useful tool to aid diagnosis of pigmented and non-pigmented skin lesions, as well as many other dermatological conditions. Use of dermoscopy is increasing worldwide, but to date, there are no reported data on attitudes of dermatologists in the United Kingdom (UK) towards dermoscopy. Objective: To determine current attitudes of UK dermatologists towards dermoscopy and assess how these attitudes have changed over the last decade. Methods: In October 2012, an online survey was sent to members of British Association of Dermatologists over a 12-week period. Data were subsequently compared with data from a similar UK nationwide paper questionnaire distributed to members in 2003. Results: The 2003 survey collected 292 responses (uptake 42%), and in 2012 there were 209 responses (22%), predominantly from consultants and registrars. In 2012, 86% respondents reported increased use of dermoscopy over the previous decade with 98.5% of respondents reporting regular clinical use of dermoscopy, compared with 54% in 2003. Overall, 81% respondents in 2012 had received dermoscopy training, mainly from UK-based courses (62% of respondents) but increasingly via Internet-based resources (30% vs. 7% in 2003). However, 39% respondents lacked confidence when making a diagnosis based on their interpretation of dermoscopy findings. Conclusions: Over the last decade, use of dermoscopy has increased amongst UK dermatologists and the majority of respondents now employ dermoscopy in daily clinical practice. However, the use of dermoscopy in the dermatology community overall is not known and for those individuals there is a continued need for education.

Melanoma incidence is increasing globally, but consistently accurate skin-lesion classification methods remain elusive. We developed a simple software system to classify potentially all types of skin lesions. In the current study, we evaluated the system's ability to identify melanomas with a diameter of 10 mm or larger.The skin-lesion classification system is composed of a proprietary database of nearly 12,000 diagnosed skin-lesion images and a computer algorithm based on the principles of content-based image retrieval. The algorithm compares characteristics of new skin-lesion images with images in the database to identify the nearest-match diagnosis.Nearly all classification accuracy measures for this new system exceeded 90%, with results for sensitivity of 90.4% (95% confidence interval, 85.6-93.7%), specificity of 91.5% (85.4-95.2%), positive predictive value of 94.5% (90.4-96.9%), negative predictive value of 85.5% (78.7-90.4%), and overall classification accuracy of 90.8% (87.2-93.4%).The image-matching algorithm performed with high accuracy for the classification of larger melanomas. Furthermore, the system does not require a dermoscope or any other specialized hardware; any close-focusing camera will do. This system has the potential to be an inexpensive and accurate tool for the evaluation of skin lesions in ethnically and geographically diverse populations.

N/A

WOS: 000320857700008, PubMed ID: 23553375, Importance: Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical. Objective: To determine the dermoscopy features of NM. Design: Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/hypomelanotic or pigmented to assess outcomes. Setting: Predominantly hospital-based clinics from 5 continents. Main Outcome Measures: Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma. Results: Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular non-melanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, blue-white veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (>98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/ hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM. Conclusions and Relevance: When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.

ejd.2013.1919 Auteur(s) : Rubeta N Matin rnhmatin@doctors.org.uk, Ben A Esdaile, Jonathan C Bowling Oxford University Hospitals NHS Trust, Dermatology Department, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LJ. United Kingdom Dermoscopy is an extension of clinical examination of the skin for dermatologists. This new section will provide a better understanding of the concept of dermoscopy during the evolution of cutaneous disease. Dermoscopy of a vascular lesion Case: A 45 year-old female [...]

Tungiasis, caused by the impregnated female sand flea Tunga penetrans, is increasingly common in returned travellers from endemic areas. Clinical suspicion is raised by the clinicodermoscopic correlation, leading to rapid treatment which involves extraction of the intact flea. Ex vivo dermoscopy demonstrates the parasite's head and distended abdomen full of eggs, confirming the diagnosis.

Injectable synthetic melanotropic peptides (often called melanotan) to enhance tanning are available over the Internet despite being unlicensed compounds with an unproven safety record. There have been reports of dysplastic naevi and melanoma associated with the use of melanotropic peptides. We report a case of melanotan-associated melanoma in situ.

Dermoscopy of pigmented lesions on the palms and soles often display a parallel pigment pattern due to the unique anatomy of acral skin.The anatomy of the acral skinThe eccrine ducts open at the top of the ridges (crista superficialis) (figure 1). Benign naevi tend to localise to the crista limitans and transfer their pigment to keratinocytes associated with the furrow, giving the classical benign parallel furrow pattern seen on dermoscopy (figure 2A).The parallel ridge patternThe parallel ridge [...]

Malignant melanoma is a life threatening skin tumour which may arise on the foot. The prognosis for the condition is good when lesions are diagnosed and treated early. However, lesions arising on the soles and within the nail unit can be difficult to recognise leading to delays in diagnosis. These guidelines have been drafted to alert health care practitioners to the early signs of the disease so an early diagnosis can be sought.

W E DESCRIBE 3 PATIENTS WITH CONfirmed mutations in the folliculin gene to illustrate the dermoscopic features of Birt-Hogg-Dube (BHD) syndrome. Physical examination revealed that all 3 patients had multiple, firm, pale facial papules on examination (Figure 1 [case 1, 50-year-old woman], Figures 2 and 3 [case 2, 55-year-old woman], and Figure 4 [case 3, 37-year-old man]). Each lesion showed well-demarcated areas of pallor with central follicular opening on dermoscopy (Figures 5 [case 1], 6 [case 2], and 7 [case 3]). Histologic examination showed trabeculae of squamous cells, with horn cysts and clear cells, intervening loose spindle cell stroma, and surrounding fibrosis, in keeping with fibrofolliculoma (Figure 8). InitiallydescribedbyBirt et al, fibrofolliculomasare the hallmarkofBHDsyndrome.Togetherwith trichodiscomas and acrochordons, they form the triad of cutaneous lesions seen in this condition, which is also associated with an increased risk of pulmonary cysts, spontaneous pneumothorax, and renal carcinoma. Onset, typically in adulthood, is characterized by asymptomatic papules that primarily involve the head, neck, chest, back, and arms and often have a central hair. In conclusion, fibrofolliculomas have reproducible dermoscopic features which, if multiple, should prompt consideration of a diagnosis of BHD syndrome as well as monitoring for associated complications.

W E DESCRIBE 2 PATIENTS WITH KNOWN mutations in the CYLD-1 gene (OMIM 123850) who were seen in the skin cancer genetics clinic to illustratethedermoscopicappearance ofcylindromasinBrooke-Spieglersyndrome.Case1involved a42-year-oldwomanwithmultiple firm,rubbery,pinknodules with areas of hyperpigmentation and telangiectasia (Figure1).Case2involveda45-year-oldwomanwithmultiple fleshy dermal nodules, some of which were erythematous with surface telangiectasia (Figure2). Dermoscopy showedareasofbackgroundpinkcolorationwithill-defined arborizing vessels and ill-defined blue structures (case 1, Figure 3; case 2, Figure 4). Histologic analysis revealed features that were intermediate between a cylindroma and a spiradenoma in case 1 and consistent with cylindromas in case 2. Brooke-Spiegler syndrome is characterized by a predispositiontocutaneousadnexaltumors,mostfrequently cylindromas, trichoepitheliomas,and,occasionally, spiradenomas. Although the disease is usually benign, malignant transformation of cylindromas has been reported; therefore, suchcasesshouldbemonitored forsignsofulceration, rapidgrowth,bleeding, andblue-pinknodules. Inconclusion,cylindromashaveareproducibledermoscopicappearanceandshouldbeaddedtothedifferentialdiagnosisofpapuleswith telangiectasiaandbluestructuresondermoscopy, particularly if multiple lesions are present and the arborizing vessels are not sharply in focus.

Malignant melanoma is the most common primary malignant tumour arising on the foot. Where improvements in the prognosis have been observed for patients with melanoma elsewhere on the skin, pedal lesions are still frequently delayed in presentation through neglect or misdiagnosis. Detection of foot melanoma relies on the health care practitioner's skills and observations in recognising early changes. Recent publications have documented the use a dermoscopy as a tool to improve recognition of such suspicious lesions. This paper reviews current literature with a special emphasis of its potential applications on plantar and nail unit melanoma. Data from these studies suggest that the technique is a useful and significant adjunct to clinical examination, which ultimately may lead to earlier recognition of this aggressive tumour.

TRICHOSTASIS SPINULOSA (TS) is a relatively common but underdiagnosed disorder of hair follicles that retain successive telogen hairs. It has been described within skin lesions (secondary TS) or as an isolated finding (primary TS). Dermoscopy may help identify the characteristic hair tuft. We report 2 cases of TS. The first case involved a 23-year-old woman who presented with a long-standing history of a light-brown papule on the lower part of her back. There was a black punctum in the upper central area of the lesion (Figure 1). Dermoscopy showed a sparse pigment network, multiple commalike blood vessels that are typical of intradermal melanocytic nevi, a few peripheral vellous hairs, and a small hair tuft emerging from the central punctum (Figure 2). Histologic examination confirmed the presence of an intradermal melanocytic nevus along with dilated folliculosebaceous bunits containing several cross-sectioned hair shafts (Figure 3). The second case involved a 30-yearold man who presented with a micropapular eruption on both flanks. Dermoscopy showed multiple vellous hairs erupting through the follicles (Figure 4). Hair tufts are the result of folliculosebaceous hamartomas with multiple units around a central pore (trichofolliculomas) or retained hair shafts within follicles with infundibular keratosis (TS). Trichostasis spinulosa may appear as an isolated finding or in association with expansile nondestructive lesions that narrow hair infundibulae, such as melanocytic nevi, seborrheic keratoses, syringomas, or nodular basal cell carcinomas. Dermoscopy is helpful in diagnosing TS.

The dermoscopy era is developing momentum. Our greater understanding of the morphological features seen with dermoscopy has corresponded with an exponential rise in dermoscopy publications. Publications have in- cluded conditions as diverse as inf lammatory and in- fective dermatoses, alongside reports of tumours and pigmented and non-pigmented skin lesions. The ter- minology used for describing structures seen under dermoscopy have been standardized by consensus and previously published [1] . The 2-step algorithm for differ- entiating melanocytic from non-melanocytic tumours has become the foundation on which dermoscopic diag- nosis depends. Furthermore, several algorithms are cur- rently in use to help differentiate between benign and malignant melanocytic neoplasms [1] .

Juvenile xanthogranuloma (JXG) is the commonest form of non-Langerhans cell histiocytosis and manifests as asymptomatic yellow-red papulonodules that usually occur in childhood and spontaneously regress within a year of formation. The diagnosis may be made by clinical examination alone and confirmed by histology in cases of diagnostic doubt. Here we report the use of dermoscopy in evaluating skin lesions suggestive of JXG. Three patients diagnosed as having JXG in our dermatology department over the last year showed a characteristic orange-yellow ‘setting sun’ appearance on dermoscopy. We therefore feel that the use of dermoscopy can be extended to include the examination of non-pigmented skin lesions, particularly in paediatric patients.

background. Surgical simulators are an established part of surgical training and are regularly used as part of the objective structured assessment of technical skills. Specific artificial skin models representing cutaneous pathology are available, although they are expensive when compared with pigskin. The limitations of artificial skin models include their difficulty in representing lifelike cutaneous pathology. objective. Our aim was to devise an inexpensive, reproducible surgical simulator that provides the most lifelike representation of the sebaceous cyst. materials and methods. Pigskin, either pig's feet/trotters or pork belly, was incised, and a paintball was inserted subcutaneously and fixed with cyanoacrylic glue. results. This model has regularly been used in cutaneous surgical courses that we have organized. Either adding more cyanoacrylic glue or allowing more time for the paint ball to absorb fluid from surrounding tissue can also adjust the degree of difficulty. conclusions. The degree of correlation with lifelike cutaneous pathology is such that we recommend that all courses involved in basic skin surgery should consider using the porcine sebaceous cyst model when teaching excision of sebaceous cysts.

The use of dermoscopy in the diagnosis of infestations is termed entodermoscopy. With increasing international travel, physicians should be aware of the use of dermoscopy in the diagnosis of some travel-associated dermatoses. This section will discuss the clinical and dermoscopic appearance of two such infestations.TungiasisThis infestationresults from the burrowing flea Tunga penetrans. The flea is now indigenous to many parts of the world, from Central America/Caribbean to Africa and the Indian [...]

A 50-year-old woman presented with black necrotic lesions over her left medial canthus and mastoid process. She had recently been diagnosed as having Hodgkin lymphoma and had received her first course of chemotherapy. Over the next 2 weeks, she became pancytopenic and developed sepsis. A subsequent bacterial culture of a venous access line tip yielded Staphylococcus aureus. Despite antistaphylococcal treatment with intravenous benzylpenicillin and floxacillin, the patient’s condition deteriorated, and she was transferred to the intensive care unit at our hospital, where she received ventilatory and cardiovascular support and underwent hemofiltration. She was dependent on noradrenaline and adrenaline for inotropic support. Within 24 hours, she developed several large, black, necrotic ulcerations over the mastoid process and left medial canthus (Figure 1). Other necrotic lesions were also evident on the sole of her right foot (Figure 2). An echocardiogram was obtained to look for an underlying thrombotic source. Although a possible thrombus was observed in her left ventricle, anticoagulation was considered to be inappropriate because disseminated intravascular coagulation had developed. A skin biopsy specimen was obtained from the patient’s neck (Figure 3). Multiple necrotic lesions developed rapidly to involve her torso, including her vulva, and she died 3 days later. What is your diagnosis?

Injectable synthetic melanotropic peptides (often called melanotan) to enhance tanning are available over the Internet despite being unlicensed compounds with an unproven safety record. There have been reports of dysplastic naevi and melanoma associated with the use of melanotropic peptides. We report a case of melanotan-associated melanoma in situ.

A woman fitted with a Mirena® intrauterine system (IUS) for menorrhagia presented with a short history of fever and progressive skin lesions. Histological examination of a skin biopsy was compatible with the clinical diagnosis of Sweet9s syndrome. Treatment was with topical and oral steroids, however the condition relapsed on reduction of the steroid dose. Symptoms finally resolved on removal of the IUS and the patient remained symptom free at 9-month follow-up. There have been previous reports of Sweet9s syndrome in association with hormonal contraceptives, however this is believed to be the first reported case in association with a Mirena IUS.

(2003). Severe pruritus in a patient with urticaria pigmentosa treated with topical 5% urea and 3% polidocanol cream. Journal of Dermatological Treatment: Vol. 14, No. 3, pp. 190-191.