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Background: Several smartphone applications (app) with an automated risk assessment claim to be able to detect skin cancer at an early stage. Various studies that have evaluated these apps showed mainly poor performance. However, all studies were done in patients and lesions were mainly selected by a specialist. Objectives: To investigate the performance of the automated risk assessment of an app by comparing its assessment to that of a dermatologist in lesions selected by the participants. Methods: Participants of a National Skin Cancer Day were enrolled in a multicentre study. Skin lesions indicated by the participants were analysed by the automated risk assessment of the app prior to blinded rating by the dermatologist. The ratings of the automated risk assessment were compared to the assessment and diagnosis of the dermatologist. Due to the setting of the Skin Cancer Day, lesions were not verified by histopathology. Results: We included 125 participants (199 lesions). The app was not able to analyse 90 cases (45%) of which nine BCC, four atypical naevi and one lentigo maligna. Thirty lesions (67%) with a high and 21 with a medium risk (70%) rating by the app were diagnosed as benign naevi or seborrhoeic keratoses. The interobserver agreement between the ratings of the automated risk assessment and the dermatologist was poor (weighted kappa = 0.02; 95% CI −0.08‐0.12; P = 0.74). Conclusions: The rating of the automated risk assessment was poor. Further investigations about the diagnostic accuracy in real‐life situations are needed to provide consumers with reliable information about this healthcare application. [ABSTRACT FROM AUTHOR]

Dear Editor, Patients with superficial basal cell carcinoma (sBCC) may be offered several treatment options including surgery, imiquimod, 5-fluorouracil (5-FU) or photodynamic therapy (PDT).1,2 Patient decision aids (PDAs) are tools to assist patients and physicians in shared decision making; a recent study showed that patients with BCC would like to participate in decision making.3 Stacey I et al i . provided evidence showing that PDAs helped patients improve knowledge of their disease and possible treatments, and perform risk assessment.4 Junn I et al i . recently described the development of a paper-based PDA for patients with sBCC with limited life expectancy that weighs the benefits and risks of treatments vs. watchful waiting.5 We describe the development of a digital PDA for all patients with sBCC. Information on cryotherapy and electrodesiccation and curettage was not included, because these treatments are reserved for patients who desire quick treatment. From the dermatology department of a university hospital (MUMC+), 21 patients (minimum 18 years old) with a history of sBCC were invited for the focus group; eight patients were included (three men and five women). [Extracted from the article]

Background In order to evaluate and improve aesthetic outcome for patients undergoing dermatological surgery, a reliable evaluation tool must be used. The 4-point scale and the Patient and Observer Scar Assessment Scale ( POSAS) were both developed for this purpose. Objective To compare the reliability of the POSAS scale with the 4-point scale for facial linear surgical scars and to assess the influence of different scar characteristics on the overall impression. Methods Patients visiting the outpatient clinics of the Maastricht University Medical Centre with linear facial scars were included. The 4-point scale and the Observer Scar Assessment Scale ( OSAS) were completed by three independent observers. The Patient Scar Assessment Scale ( PSAS) was completed by the patient on the day of the visit and 2 weeks later. The intra-class correlation coefficient ( ICC) with corresponding 95% confidence intervals ( CI) were calculated to assess the reliability of the scales. Linear multivariate regression analyses were performed to evaluate how the score on each aspect affected the overall opinion. Results Fifty scars in 50 patients were included. The ICC of the 4-point scale was 0.819 (95% CI: 0.708-0.892) for multiple observers and 0.602 (95% CI: 0.447-0.734) for single observer. These were superior to the ICCs of total OSAS scores (0.783 95% CI: 0.547-0.888 for multiple observers and 0.546 95% CI: 0.287-0.726 for single observer). ICCs of individual sub-items on the OSAS scored even lower. The sub-items contributed differently to the overall opinion among the different observers or patient. Conclusion In terms of reliability, the overall opinion and the 4-point scale were superior to the total POSAS score or the sub-items. Observers do not weight individual scar characteristics equally to arrive at an overall opinion, which challenges the assumption that calculating a total POSAS score by summing of the scores on the individual items is a valid approach. [ABSTRACT FROM AUTHOR]

Background The success of Mohs micrographic surgery ( MMS) depends partly on the correct diagnosis of slides. Objectives To determine reliability of diagnosis from Mohs slides. Methods This was a prospective study evaluating the reliability of diagnosis from Mohs slides of basal cell carcinoma ( BCC) presence, BCC location on the slide and BCC subtype among six raters who independently assessed 50 Mohs slides twice with a 2-month interval. Slides were randomly selected whereby difficult-to-diagnose slides were oversampled. For each slide, a reference diagnosis was established by an expert panel. Cohen's kappa (κ) was calculated to determine levels of agreement interpersonally (rater vs. reference diagnosis) and intrapersonally (rater at T1 vs. T2). Multivariable logistic regression was used to determine independent risk factors for slides with interpersonal discordant diagnosis. The variables studied were BCC presence, whether a slide was scored as easy or difficult to diagnose, review duration of the 50 slides, profession and years of experience in diagnosis from Mohs slides. Results Interpersonal and intrapersonal agreement were substantial on BCC presence (κ = 0·66 and 0·68) and moderate on BCC subtype (κ = 0·45 and 0·55). Slides that were scored as difficult to diagnose were an independent risk factor for interpersonal discordant diagnosis on BCC presence (odds ratio 3·54, 95% confidence interval 1·81-6·84). Conclusions Reliability of diagnosis from Mohs slides was substantial on BCC presence and moderate on BCC subtype. For slides that are scored difficult to diagnose, a second opinion is recommended to prevent misinterpretation and thereby recurrence of skin cancer. [ABSTRACT FROM AUTHOR]

Background A recent noninferiority randomized controlled trial ( RCT) indicated that imiquimod can be considered as superior to methylaminolevulinate photodynamic therapy ( MAL- PDT) in the treatment of superficial basal cell carcinoma (s BCC). Knowledge of treatment effectiveness in subgroups of patients is of great value in clinical practice to select the most effective treatment for an individual patient with s BCC. Objectives To explore whether the relative treatment effect of MAL- PDT and imiquimod is consistent across subgroups defined by patient and tumour characteristics. Methods Data were derived from a single-blinded, noninferiority, multicentre RCT comparing MAL- PDT, topical imiquimod and fluorouracil ( ISRCTN79701845). Treatment success was defined as free of tumour recurrence at 12-month follow-up. Subgroup analyses were performed for subgroups defined by sex, age, tumour location and tumour size. Results Two hundred and two patients received MAL- PDT and 198 received imiquimod. The superiority of imiquimod vs. MAL- PDT was observed in subgroups of females, s BCC on the trunk and large tumours with risk differences in favour of imiquimod of 18·4% [95% confidence interval ( CI) 7·8-29·0%], 21·0% (95% CI 10·9-31·1%) and 18·9% (95% CI 7·1-30·7%), respectively. Higher probability of treatment success for imiquimod vs. MAL- PDT was consistently found in all other subgroups with the exception of s BCC localized on the lower extremities in older patients. In the latter subgroup, the risk difference at the expense of imiquimod was −57·3% (95% CI −81·7% to −32·9%). Conclusions Imiquimod remains the first-choice treatment for s BCC in terms of effectiveness. In older patients with s BCC on the lower extremities MAL- PDT might be preferred. Results should be interpreted carefully as subgroup analyses were exploratory and not driven by prior hypotheses. [ABSTRACT FROM AUTHOR]

Background Diagnosis of clinically suspected basal cell carcinoma (BCC) by histological confirmation with punch biopsy has been recommended before treatment. Even shave biopsy has been proposed as useful to predict the correct subtype in primary BCC in 76-81%, whereas the agreement between histological BCC subtype on punch biopsy and subsequent excision specimens in recurrent BCC is 67.1%. However, no large studies on the agreement between histological BCC subtype seen on punch biopsy and the following surgical excision are performed in primary BCC. Objective The aims of this study were (i) to establish the agreement between histological BCC subtype on punch biopsy and the subsequent surgical excision of primary BCC and; (ii) to investigate the proportion of primary BCCs in which punch biopsy enables identification of the most aggressive growth pattern. Methods Retrospective analyses of 243 primary BCCs with both punch biopsy and subsequent surgical excision. Analyses were based on the most aggressive histological subtype of the tumour. Results The agreement between BCC subtype on punch biopsy and the subsequent surgical excision of primary BCCs was 60.9%. A punch biopsy can predict the most aggressive growth pattern of primary BCCs in 84.4%. Seventy-four percentage of all primary BCCs consisted of more than one histological subtype. Conclusion Dermatologists and other physicians have to be aware of the limited diagnostic value of a punch biopsy to determine the histological BCC subtype of the whole lesion. Misdiagnosis of the subtype will lead to undertreatment in one of six primary BCCs. [ABSTRACT FROM AUTHOR]

Background Cosmetic results following non-invasive treatments are difficult to compare. Although qualified objective scar assessment scales are available, they are not used in dermatological studies. Usually a 4-point scale is used in dermatological scars. The reproducibility of this method has never been evaluated. Moreover, significant specific scar characteristics are lacking. The patient and observer scar assessment scale (POSAS) is a scale qualified for the assessments of surgical scars. It has proven to be as reliable as the widely used Vancouver Scar Scale, but has the advantage that it includes the patient's opinion and specifies different scar characteristics. Objective Both methods were used to evaluate cosmetic results following non-invasive treatments of superficial basal cell carcinoma (BCC). Methods A total of 54 lesions following non-invasive treatment for BCC in 54 patients were evaluated with the traditional 4-point scale and the POSAS. Results The 4-point scale showed the best reproducibility and had an intra-class correlation coefficient (ICC) of 0.66 (95% CI: 0.52-0.77) for a single observer and 0.85 (95% CI: 0.77-0.91) for multiple observers. The ICC of the POSAS was 0.41 (95% CI: 0.21-0.58) for a single observer and 0.67 (95% CI: 0.45-0.81) for three observers. The scar characteristics, vascularity and pigmentation were most decisive for the overall opinion. Conclusion The use of the 4-point scale is a valid method to compare scars of non-invasive dermatological treatments. Supplementary registering vascularity and pigmentation can be useful in future studies. [ABSTRACT FROM AUTHOR]