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BACKGROUND Effective and aesthetically appealing management options are needed for basal cell carcinoma (BCC), the most common skin cancer. The Nd:YAG laser shows promise, but most studies use biopsy to demonstrate tumor clearance. Optical coherence tomography (OCT) could allow good tumor margin control while enabling recurrence monitoring. OBJECTIVE Determine the efficacy of the Nd:YAG laser to treat BCCs while controlling for tumor margin with OCT. METHODS A 1064-nm Nd:YAG laser was applied to treat 119 BCCs in 102 patients, where tumor margins were approximated using OCT. Lesions were treated every 2 months until no residual tumor remained; patients were monitored for 1 year after treatment completion for clinical and subclinical recurrences. Outcomes were analyzed retrospectively. RESULTS Most BCCs cleared after one treatment (85/119, 70.4%). Several factors were significantly associated with a suboptimal response, that is, those with recurrence or requiring ≥2 treatments: lesion size >5 mm (p = 0.03), focal sclerosing subtype (p = 0.018), and immunosuppression (p = 0.039). Midface location, patient compliance, and diagnosis method were codependent variables (r2 = 0.2011, p = 0.0008). All BCCs (119/119) demonstrated complete clinical and subclinical tumor clearance 2 months after final laser treatment. By 1 year, overall clinical recurrence rate (RR) was 1.7% (2/119) and cumulative subclinical RR was 4.2% (5/119). Upon excluding immunosuppressed patients, clinical RR and combined subclinical RR for primary BCC were 1% (1/98) and 2% (2/98), respectively, and 0% (0/17) and 11.8% (2/17), respectively, for recurrent BCC. CONCLUSIONS The Nd:YAG nonablative laser can offer an effective treatment for BCCs when used with noninvasive diagnostic tools such as OCT.

Few reported cases discuss distinguishing between melanoma and melanoacanthoma, a seborrheic keratosis (SK) variant, using noninvasive imaging devices. We present a case of a 38-year-old man with Fitzpatrick skin type IV with an asymmetric black papule showing clinical and dermoscopic features of both melanoma and SK. Reflectance confocal microscopy (RCM) and dynamic optical coherence tomography (d-OCT) were used for further evaluation. RCM revealed acanthotic epidermis with a mixed honeycomb and cobblestone pattern, polycyclic bulbous rete ridges, and bright plump cells within entrapped, edged, dermal papillae, compatible with pigmented SK. Also noted were a population of fairly uniform bright dendritic cells scattered quite evenly at all levels of the epidermis and the notable absence of concomitant features of a melanocytic neoplasm (roundish Pagetoid cells, sheets of roundish or dendritic cells at the dermal-epidermal junction, junctional thickenings, and melanocytic nests), suggesting melanoacanthoma. d-OCT showed well-circumscribed, regular, epidermal acanthosis, superficial rounded hypodense structures, normal vascular flow, and notable absence of wiry or contoured vessels, features typically seen in SKs and benign lesions, respectively. Similarly, histologic examination revealed characteristics of pigmented SK containing a population of evenly dispersed dendritic melanocytes (decorated using Melan-A stain) confirming a diagnosis of melanoacanthoma. This case highlights the advantages of incorporating both RCM and d-OCT into clinical practice to noninvasively differentiate melanoma from its clinical mimickers.

During the past decade, noninvasive imaging has emerged as a valuable tool in clinical dermatology and dermatologic research. Optical coherence tomography (OCT) is one such type of noninvasive imaging. OCT uses the principle of interferometry to produce real-time images. A low-power diode laser shines infrared light onto tissues, which reflects back to an optical fiber interferometer. Using time delay and the backscattered light intensity, a two-dimensional image akin to an ultrasound is rendered. We review the history, types, and modalities of OCT, plus the many applications of frequency domain, high definition, and dynamic OCT in practice, including its utility in diagnosis, monitoring, and grading disease severity in a variety of cutaneous conditions.

Advanced cutaneous squamous cell carcinoma (cSCC), though rare, is fatal with an 89% 5-year mortality rate. The diagnostic criteria for advanced basal cell carcinoma were recently redefined with the introduction of hedgehog inhibitors such as vismodegib. Similarly, the authors suggest redefining the diagnostic criteria of advanced cSCC given the introduction of immune checkpoint inhibitors in order to broaden the patient population that can benefit from both new and old treatment options as potential neoadjuvants. Cemiplimab is a programmed death-1 (PD-1) inhibitor recently FDA-approved in 2018 for advanced cSCC with improved response rates (47–50%) compared to prior treatments. Given the lack of standardization, we suggest the diagnostic criteria of advanced cSCC to consider the patient condition, age, comorbidities, immunosuppression, and cosmetic outcome when determining a treatment regimen. Patients with diffuse cSCC due to immunosuppression may benefit from acitretin, while lesions on the lip may have a poor cosmetic outcome with surgery and may benefit from neoadjuvant therapy. Advanced cSCC does not have standardized diagnostic criteria likely due to the lack of treatment options until now. Additional treatment options may be beneficial to a broader patient population when redefining advanced cSCC to include factors such as immunosuppression and cosmetic outcome from the perspective of the patient.

Mobile applications (apps) have been a growing part of medicine for the last decade. Our cross-sectional online survey studied the role of apps in dermatology resident training. The demographic results and response rate suggest that our study sample is representative of the target population of dermatology residents in America. Our survey highlights the increasing role of apps in dermatology resident training, differences in priorities among different years of residency, and differences in information utilization between sexes. This knowledge should help guide standardization, quality assurance, and formal integration of medical mobile apps into traditional dermatology teaching.

Although the complexity of health-related applications (apps) has evolved, they have not been adequately regulated or monitored for quality. We review the primary literature behind and regulation of apps that impact dermatologists, with a focus on the 3 most prevalent dermatology-related apps used by dermatology residents in the United States: VisualDx, UpToDate, and Mohs Surgery Appropriate Use Criteria. These apps are widely utilized but have not undergone approval by the 3 main government agencies responsible for regulating mobile medical apps: the US Food and Drug Administration (FDA), Federal Trade Commission, and Office for Civil Rights. Health-related apps that target providers can be a valuable tool, but given their potential impact on human lives, they should be well regulated and evidence based. It is important that apps designed to assist in health care delivery are appropriately monitored and that physicians are aware of the rigor of review of the apps that they choose to use in clinical practice.

Nonmelanoma skin cancer (NMSC) is the most common malignancy worldwide, and the incidence continues to increase. Originally, treatment options for NMSCs largely relied on destructive and surgical methods. Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) commonly are treated with cryosurgery, electrodesiccation and curettage, or more definitive surgical options. Over time, topical agents such as 5-fluorouracil, imiquimod, ingenol mebutate, and various forms of aminolevulinic acid (ALA) for photodynamic therapy (PDT) were included for superficial lesions as well as field treatment. The development of oral hedgehog (Hh) inhibitors such as vismodegib offered a promising alternative to patients with advanced disease. Each treatment has its own specific indications and side effects, thus there is always room for novel therapeutic approaches. We review new and potential treatments for NMSCs since 2018 including topical sonidegib, cemiplimab, taladegib, posaconazole, radiation therapy (RT), combination RT with vismodegib, PDT, and laser therapies.

Optical coherence tomography (OCT) is a noninvasive imaging modality that enables acquisition of 2-dimensional cross-sectional in vivo images of the skin.1 The images are created by the backscatter of light and provide the reader with a real-time view of the anatomic microstructure of the skin.2, 3 Although it lacks cell-level resolution, OCT permits visualization of the architecture of the stratum corneum, epidermis, and papillary dermis, as well as the skin's vasculature. This, in turn, has provided a convenient in vivo means to evaluate both inflammatory cutaneous conditions and neoplasms of the skin.4 Basal cell carcinoma (BCC) is particularly amenable to OCT visualization, and OCT is, in fact, being used to assist in the diagnosis and management of this skin cancer.5, 6 At the time of publication, histology and more recently reflectance confocal microscopy (RCM) are considered gold standard for BCC diagnosis, and both have Current Procedural Terminology Category 1 code options. OCT currently has a category 3 code, which is used to track the utilization of emerging technology, and the device has demonstrated a sensitivity of 87% and a specificity of 80% for diagnosing BCC.7 In addition, OCT can assist in determining the extent and depth of BCC tumors.

The focus of this review is to present some of the new noninvasive diagnostic imaging tools and their use in conjunction with nonsurgical modalities that have been demonstrated to be effective for the treatment and prevention of nonmelanoma skin cancer (NMSC). Given the vast prevalence of NMSC and substantial associated morbidity, clinicians are working toward effective nonsurgical therapeutic options, including topical treatments, laser and photodynamic therapy, radiation as well as newer systemic treatment modalities. With this shift toward increasingly nonsurgical therapies comes the need to find new noninvasive ways to assess treatment efficacy, monitor treatment response, and detect subclinical residual disease. Recent developments in imaging modalities, including dermoscopy, optical coherence tomography, and reflectance confocal microscopy, are emerging as useful tools for diagnosis and treatment management of NMSC.

Skin cancer is the most commonly diagnosed cancer in the USA. Mohs micrographic surgery is a microscopically controlled surgical technique that excises lateral and deep surgical margins while also sparing function and achieving a good cosmetic outcome. Given the increasing incidence in skin cancer worldwide and its associated treatment costs, techniques are being developed to improve the time and cost efficacy of this procedure. The use of noninvasive imaging, both in vivo and ex vivo, has the potential to increase efficiency of diagnosis and surgical management of skin cancers. These devices are useful in delineating lateral and deep tumor margins prior to surgery in vivo as well as to detect residual tumor ex vivo virtually in real time.

Optical coherence tomography (OCT) has emerged as a novel noninvasive imaging device that allows for the real-time, in vivo, cross-sectional imaging of skin morphology. OCT has increased imaging depth and field of view compared with reflectance confocal microscopy, at the cost of decreased cellular resolution. Frequency domain OCT, dynamic OCT (D-OCT), and high-definition OCT (HD-OCT) are useful in the diagnosis, treatment planning, and treatment monitoring of nonmelanoma skin cancers. Research is currently underway to assess the utilization of these devices in distinguishing between malignant and benign melanocytic lesions based on vascular patterns on D-OCT and cellular information on HD-OCT.

The use of computers or machines in medicine dates back to the 1960s. Deep learning software programming is a subset of artificial intelligence (AI) based on the ability of a machine to learn from data and adaptively change. Deep learning is creating the next industrial revolution across the economy by replacing repetitive low-skilled tasks with learning algorithms. In medicine, image-based fields such as radiology, dermatology, and pathology have seen an increase in the number of studies using deep learning. However, given the current lack of standardized data sets to train these machines, it is difficult to predict if the present results eventually will be translated to real-life clinical settings.

The increasing incidence of nonmelanoma skin cancer (NMSC) poses a serious public health concern. Standard care for basal cell carcinoma (BCC) requires patients to attend multiple visits for diagnosis and treatment. This pilot study describes a model of care that aims to alleviate some of the demand placed both on the specialty and on patients by utilizing a novel same-day approach to BCC management with noninvasive diagnosis, same-day treatment, and noninvasive imaging follow-up. This study evaluates the efficacy of the 1064-nm Nd:YAG laser for treating BCC while leveraging noninvasive imaging technology for diagnosis and confirmation of clearance.

Although Mohs micrographic surgery (MMS) is the gold standard for treatment of nonmelanoma skin cancers (NMSCs), laser management has been an emerging treatment option that continues to be studied. Nonablative laser therapy is a noninvasive alternative. This study used a combined pulsed dye laser (PDL) and fractional laser approach to treat basal cell carcinomas (BCCs) in conjunction with noninvasive imaging such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) to enhance efficacy rates.

With the implementation of the new Medicare Physician Fee Schedule on January 1, 2019, it can be beneficial for all practitioners to grasp an understanding of how reimbursement is determined. With the new Physician Fee Schedule also came new relative value units (RVUs) and new billing codes. Biopsy codes, in particular, were changed to reflect the complexity of the sampling technique (ie, tangential, punch, incisional). In this article, we explain RVUs and how they determine reimbursement. This article also highlights changes and additions to billing codes, specifically for biopsies and telemedicine services.

Dermoscopy is a non-invasive diagnostic technique that facilitates the visualization of surface and subsurface structures of the skin. It has been proven to be an essential tool in the diagnosis of both malignant and benign cutaneous lesions. In this article, we review some of the most recent and noteworthy advances in dermoscopy. In addition, we discuss Reflectance Confocal Microscopy (RCM) and Optical Coherence Topography (OCT), two non-invasive imaging devices that may be used alongside dermoscopy to improve diagnostic accuracy.

Optical coherence tomography (OCT), an emerging noninvasive imaging modality, recently received category III Current Procedural Terminology (CPT) codes from the American Medical Association, enabling tracking of its use in the medical community. In this article, we review OCT imaging and its variant systems, discussing its applications and limitations for clinical use. Future directions of OCT technology and goals for obtaining category I CPT codes and reimbursement also are discussed.

OBJECTIVE: To determine whether actinic keratosis and photodamaged perilesional areas (field cancerization) treated successfully with topical ingenol mebutate gel 0.015% remained clear one year later, and to treat actinic keratosis and perilesional skin not treated one year earlier. DESIGN: Single-center, single-arm, open-label extension of an original clinical study completed one year earlier. SETTING: An outpatient clinic. PARTICIPANTS: Fifteen of the original 28 study patients enrolled in and who completed the extension phase. MEASUREMENTS: All treated and untreated lesions in the original study were evaluated clinically, dermoscopically, and with optical coherence tomography at Day 0 of the extension study. Previously untreated lesions were then treated with ingenol mebutate gel 0.015% for three days and reevaluated at Day 60. RESULTS: There was no significant increase in actinic keratoses over one year. The majority of actinic keratoses not treated in the original study were still present at the beginning of the extension study. Following treatment, 69 percent of these lesions cleared by Day 60 of the extension study, which was not significantly different from the 79 percent clearance observed in the original study. CONCLUSION: Ingenol mebutate 0.015% maintained clearance of lesions treated one year earlier. Optical coherence therapy demonstrated its reliability as a noninvasive mode of diagnosis for actinic keratosis as well as actinic damage in the surrounding areas of field cancerization. Optical coherence therapy also showed that previously untreated lesions exhibited similar clearance rates once treated with the medication.

Early diagnosis and treatment of melanoma improve survival. New technologies are emerging that may augment the diagnosis, assessment, and management of melanoma but penetrance into everyday practice is low. In the current health care climate, greater emphasis will be placed on the incorporation of technology for clinically suspicious pigmented lesions to facilitate better, more cost-effective management.

Reflectance confocal microscopy (RCM) has recently received Category I Current Procedural Terminology (CPT) codes by the Centers for MedicareMedicaid Services for reimbursement comparable to a skin biopsy. In this article, we present a review of RCM imaging and its benefits and limitations in diagnosis and treatment planning. We also comment on guidelines for receiving reimbursement for acquiring, reading, and interpreting RCM images.

Actinic keratoses (AKs) are common premalignant lesions that have the potential to evolve into squamous cell carcinoma (SCC) if left untreated. There are many modalities available to treat AKs, including localized and field therapies; however, each modality presents unique treatment challenges. Topical ingenol mebutate gel, derived from the sap of the plant Euphorbia peplus, has been recently FDA-approved as a field therapy for treatment of AKs. Ingenol mebutate has a dual mechanism of action, combining rapid direct cell death with a neutrophil-mediated immune response to target the atypical keratinocytes of AKs. Its efficacy, safety, and tolerability have been demonstrated in its clinically relevant sustained clearance and long-term lesion reduction. Additionally, its short treatment schedule of either 2 or 3 consecutive days increases compliance. We present the most recent and significant clinical studies investigating the use of topical ingenol mebutate for the treatment of AKs.

Immunosuppressed transplant recipients have increased risk for the development of basal cell carcinoma skin cancers. While oral vismodegib therapy has been successful in treating locally advanced basal cell tumors, few studies document its use and efficacy in organ transplant patients. In this immunocompromised population, topical imiquimod 5% cream has been shown to be an effective and well-tolerated option for superficial and nodular basal cell carcinomas. To the authors’ knowledge, no data documents the use of optical coherence tomography, a noninvasive imaging technique, to monitor progress of such combined therapies on in vivo skin. The authors report the successful treatment of an extensive basal cell carcinoma on the nose of an immunosuppressed 54-year-old Caucasian man with a history of kidney and pancreas transplantations. By combining continuous noninvasive lesion monitoring with vismodegib 150mg/d therapy and adjuvant imiquimod 5% topical cream, the patient showed complete disease clearance on clinical, optical coherence tomography, and histological evaluation. This report supports the feasibility and efficacy of nonsurgical treatment of basal cell lesions in complicated transplant patients and the need for individualized treatment plans. A noninvasive follow-up tool, especially during nonsurgical therapy, is of critical value to ensure the best possible treatment outcome for the patient.

Objective: The objective of this study was to assess the ability of optical coherence tomography to detect clinical and subclinical actinic keratoses confirmed by histopathology. The efficacy of ingenol mebutate treatment of actinic keratosis was also evaluated using optical coherence tomography, and correlation of treatment efficacy with severity of local skin reactions was determined. Design: Single-arm, open-label, split-face study. Setting: Hospital outpatient clinic. Participants: Male subjects (N=30) with seven actinic keratoses. Measurements: A suspected actinic keratosis and the normal-appearing, perilesional skin were imaged, biopsied for histopathologic analysis, and the results compared with the clinical and a blinded optical coherence tomography diagnosis. Treatment with ingenol mebutate gel 0.015% was randomly administered to three clinically suspected actinic keratoses and the perilesional skin; three additional, suspected actinic keratoses lesions and perilesional areas were left untreated. Clinical and optical coherence tomography images were obtained for all lesions. Severity of local skin reactions was recorded to evaluate the relationship between local skin reaction and treatment effect. Results: Optical coherence tomography analysis had a 100-percent (28/28) correlation with the clinical diagnosis of actinic keratosis and detected 16 of 22 (73%) histopathologically confirmed subclinical lesions from perilesional skin sites. By optical coherence tomography assessment, the clearance rate for clinically observed lesions was 76 percent for ingenol mebutate-treated areas versus 11 percent for untreated areas; the clearance rate for treated subclinical lesions was 88 percent versus 43 percent for untreated areas. Clearance rates did not vary with the severity of the local response. Conclusion: Optical coherence tomography is effective at detecting clinical and subclinical actinic keratoses and monitoring their response to treatment.

Optical coherence tomography (OCT) is a technique that enables real-time in-vivo examination of tissue. This technology provides the clinician with the potential to use a non-invasive tool in the identification and diagnosis of many skin lesions. However, the diagnostic features of basal cell carcinoma have not yet been described with comparison to their histopathology.br /To identify and describe key features of basal cell carcinoma (BCC) and its subtypes as they present in multi-beam Swept Source - OCT (MSS-OCT), and to correlate those against conventional histopathology.br/A total of 40 lesions were assessed by MSS-OCT prior to biopsy. 60-slice OCT images of the lesions were obtained and correlated with histology sections taken in the same plane. OCT scans were assessed retrospectively by a panel to determine the OCT criteria for BCC and its subtypes.br/The following diagnostic criteria were identified: hyporeflective ovoid structures (40/40), dark halo boundaries (38/40), epidermal thinning (28/40), and collagen compression (14/40). Lesional tissue also showed a destruction of layers when compared to the surrounding normal tissue. In addition to the shared criteria, other subtypes showed distinct diagnostic criteria.br/With its higher sensitivity, using MSS-OCT allowed for non-invasive, accurate identification of the key diagnostic features of BCC and its subtypes with high correlation to the histopathologic features found with biopsy.br /br /emJ Drugs Dermatol./em2016;15(5):545-550.

Joanna Emilio,1 Michelle Schwartz,2–4 Eleanor Feldman,2–4 Amy Kalowitz Bieber,2–4 Amanda Bienenfeld,2–4 Min-Kyung Jung,1 Daniel M Siegel,2,3 Orit Markowitz2–4 1Department of Dermatology, NYIT College of Osteopathic Medicine, Old Westbury, 2Department of Dermatology, SUNY Downstate Medical Center, 3Department of Dermatology, NY Harbor Healthcare System, Brooklyn, 4Department of Dermatology, Mount Sinai Medical Center, New York, NY, USA Abstract: Actinic keratoses (AKs), especially on areas of the face, have a negative impact on a patient's quality of life (QoL). These lesions manifest on sun-damaged skin and have the potential to progress to squamous cell carcinoma. Field-directed therapy alone and in combination with lesion-directed treatment is effective in clearing both visible and nonvisible AK lesions. Topical treatments of AKs thus have the potential to improve a patient's well-being. However, evidence demonstrating improvements in patient QoL is limited, and is mostly based on observational or retrospective studies. Some prospective studies have reported unchanged or even worsening QoL despite excellent treatment outcomes. Our prospective, pilot study demonstrated a significant increase in QoL in 28 subjects with AKs of the face treated with ingenol mebutate gel 0.015%. QoL was assessed at days 0 and 60 using the Skindex-16 survey. Mean overall scores improved from 24.5% at baseline to 15.5% at day 60 (P=0.031). Improvements in QoL were consistent with an 80% reduction in AK lesion number at day 60. These improved QoL findings are in line with those from a recent retrospective study using ingenol mebutate 0.015% gel. This study therefore further demonstrates the potential for field therapy to improve both treatment outcomes and patient satisfaction. Keywords: actinic keratosis, squamous cell carcinoma, ingenol mebutate gel, local skin reaction, quality of life, Skindex-16

Background Psoriatic arthritis is a chronic and debilitating condition. The biologic therapies are targeted therapeutic options that have shown promise; notably, there are substantial data supporting the use of the anti–tumor necrosis factor (TNF) agents in the treatment of psoriatic arthritis and in the prevention of radiographic progression of joint destruction. We report three cases that demonstrate the selective benefits of ustekinumab and of TNF blockers, depending on the relative severities of joint and cutaneous symptoms. Observations We describe three cases of psoriatic arthritis and psoriasis in patients being treated with anti-TNF agents who, after switching to ustekinumab from TNF blockers, complained of worsening joint pain, although their cutaneous findings improved. Two of these patients opted to discontinue their therapy with ustekinumab and restart anti-TNF therapy; they prioritized control of their joint pain over the skin clearing they had while taking ustekinumab. Conclusions Ustekinumab may not be as efficacious as agents that block TNF for the treatment of psoriatic arthritis. Further study is needed to assess its efficacy in psoriatic arthritis.

Making accurate diagnoses when certain lesions are in a relatively young stage can prove challenging, as their “textbook descriptions” are often not fully apparent, and may in fact be markedly different. The authors present three interesting cases of early lesions that were clinically difficult to differentiate from one another: a cystic variation of a keratoacanthoma squamous cell carcinoma, a basal cell carcinoma, and an excoriated facial acne vulgaris. The subtle clinical nuances found in each of these cases demonstrated the importance of a careful clinical evaluation; however, this was not sufficient for adequate assessment of whether or not to biopsy. With early lesions such as these, the use of the noninvasive imaging modalities of dermoscopy and optical coherence tomography becomes critical in order to avoid unnecessary biopsy. The discussion of the clinically and dermoscopically challenging features is both instructive and enlightening. Oftentimes, “textbook descriptions” of lesions focus on the description of an already mature stage of growth, despite the fact that we continue to strive toward earlier detection of potential malignancies. With this in mind, the features found with optical coherence tomography proved essential to the elucidation of these difficult lesions. These three interesting cases illustrated the challenges encountered when dealing with early lesions specifically. The authors bring to light features in each of these cases that are often not thought of as being the “typical” presentation in each lesion category and demonstrate the clinical utility of noninvasive devices in difficult-to-diagnose cases such as these.

Patients with moderate to severe rosacea often seek treatment to reduce erythema and vascular markings. Few studies have looked at the effectiveness of the novel treatment, brimonidine topical gel 0.33%, trademark name Mirvaso®, in the treatment of rosacea. We report the use of optical coherence tomography (OCT) scanning to monitor the effectiveness of Mirvaso® on in vivo skin. OCT is a non-invasive optical imaging technique that can provide high-resolution imaging of vessel and cellular morphology. OCT may be useful as a pre-treatment assessment tool for identifying possible morphologic features in the skin that may serve as outcome predictors. OCT may also serve as a monitoring tool in the treatment of rosacea.To examine and describe how OCT skin morphology changes when exposed to brimonidine topical gel 0.33% in the treatment of erythematotelangiectatic rosacea.Normal in vivo telangiectasias and erythematous patches and papules were examined prior to treatment clinically, dermatoscopically, and through OCT scans. Brimonidine topical gel 0.33% was applied to the face and OCT images were acquired at defined time intervals: baseline; immediately (5 minutes) after application; 4 hours after application; and after 2 weeks' once daily application. OCT morphology was then described.OCT imaging showed an increase in the mean gray value (MGV), a measure of dermal reflectivity, corresponding to a decrease in dermal edema. MGV measurements for the nasal telangiectasia were: baseline, MGV 10,471 (standard deviation [SD] 6,847); immediate, MGV 15,634 (SD 8,983); after 4 hours, MGV 16,357 (SD 7,647); and after 2 weeks, MGV 15,505 (SD 6,870). MGV measurements for the chin erythema were: baseline, MGV 8,850 (SD 4,969); immediate, MGV 10,799 (SD 5,266); after 4 hours, MGV 12,419 (SD 6,714); and after 2 weeks, MGV 13,395 (SD 6,170). No significant change in vessel lumen diameter was appreciated. Vessel lumen diameter for the facial papule ranged from 0.13 mm at baseline, 0.09 mm immediately after treatment, 0.09 mm after 4 hours, and 0.11 mm after 2 weeks.OCT scanning showed a decrease in the dermal hyporeflectivity of the dermis consistent with a decrease in dermal edema. The OCT scans obtained did not show any significant change in vessel lumen diameter. These results may reflect an increase in vascular tone, which can be attributable to the clinical improvement and decreased erythema noted in the patient. This technology could potentially be used for the non-invasive in vivo monitoring of other topical treatments.

Background Melanoma tumor thickness remains the most important determinant of patient survival. Several large population-based studies have shown that full-body skin examinations (FBSE) improve melanoma mortality and others that FBSEs may detect melanomas at a thinner, more curable stage. Purpose To relate the detection method to lesion thickness at the time of diagnosis. Methods A retrospective chart review of all cases of biopsy-proven primary cutaneous melanomas diagnosed from 2000 to 2012 at the Veterans Affairs Hospital in Brooklyn NY was conducted. Data were collected in 2012–2013 and analyzed in 2013. Main outcome measures include lesion thickness stratified by method of detection and probabilities of detecting thin lesions per method (using cut-offs of in situ and 0.75 mm). Secondary outcomes include interaction between method and body site or lesion diameter. Results Sixty-three percent of melanomas were detected by FBSE and 59% of all melanomas were in situ. There was no statistically significant difference in thickness among the detection groups when a cut-off of in situ (Fisher's exact test, p =0.6148) or 0.75 mm was used ( p =0.8910). A majority of lesions on the back were found by FBSE (68%). Conclusions FBSE was not shown to detect melanomas at a thinner stage. Prospective studies are needed to analyze the utility and efficacy of FBSEs in clinical practice.

Background Optical coherence tomography (OCT) is a noninvasive imaging technique that uses a low-power infrared laser to image up to 2 mm beneath the skin's surface. Objective To test the feasibility and diagnostic value of using in vivo OCT to define excision margins before Mohs micrographic surgery (MMS) of basal cell carcinoma (BCC). Methods Patients with biopsy confirmed BCC undergoing MMS were recruited (n = 52). Excision margins defined by experienced dermatologists were compared with those of OCT-assessed borders and validated with histologic assessments. Results Forty-one (79%) lesions were clear after one MMS procedure; 11 (21%) lesions required a second MMS stage after excision of the clinician-predicted boundary. Generally, the OCT instrument indicated that the estimated clinical margin was 0.4-mm larger than the OCT margin. For lesions requiring a single MMS stage, OCT indicated that lesions were 1.4 ± 1.3 mm smaller than the Mohs excision. Before excision of lesions requiring more than one MMS stage, OCT always indicated that the lesion boundary would extend outside the planned MMS defect boundary. Conclusions The present study shows the prospective utility of using OCT to refine clinically estimated borders for MMS. OCT assessment has the potential to reduce the excised area without compromising the integrity of tumor-free borders.

Abuse takes many forms, including physical abuse, sexual abuse, emotional abuse, and neglect. The definition of child abuse, by the Center for Prevention and Treatment of Child Abuse (USA), is stated as the mental and physical injury, sexual abuse, neglect, or mistreatment of individuals under 18 years of age, perpetrated by a caregiver, which indicates that the health of the child is threatened [1]. Physicians must always be alert for signs indicating any manifestation of abuse, looking for symptoms beyond skin lesions. The authors consider any form of abuse a medical emergency, recognizing that most children, or elderly, are unable to articulate their condition or alert authorities of any wrongdoing and rely nearly exclusively on the awareness of astute professionals. Many cases of abuse are left unrecognized by professionals, the findings being exceedingly subtle, often written off as innocuous lesions. Early recognition is crucial, not only to prevent subsequent injury which occurs in 30–70 % of children, but reports have indicated that abuse tends to increase in severity with time [2], and early intervention may avert these avoidable events.

For melanoma treatment, the primary goal is complete removal with histologically negative margins. Mohs micrographic surgery (MMS) has been extensively used and studied for the treatment of nonmelanoma skin cancer, particularly at sites where tissue conservation is vital. The use of MMS for melanoma treatment has yet to become widely accepted owing to difficulties in histologic interpretation, among other factors. MMS may offer lower recurrence rates and improved survival when compared with historical controls for standard excision. Continued advances in MMS technique and immunohistochemical staining have allowed the technique to gain further support.

Patch testing is an important diagnostic tool commonly used to identify allergens responsible for allergic contact dermatitis, especially in cases where the diagnosis is not clearly apparent. The authors report the patch test results from 2004-2008 and compare the results with the North American Contact Dermatitis Group and Mayo Clinic. Four hundred thirty-four patients with suspected allergic contact dermatitis underwent standardized patch testing with a tray consisting of 50 allergens at Mount Sinai Medical Center. Two hundred ninety patients (66.8%) had positive reactions to at least one allergen. The most frequent contact allergens included nickel sulfate (13%), fragrance mix (9.6%), propylene glycol (7.8%), neomycin sulfate (6.6%), thimerosal (6.4%), bacitracin (6.2%), and sodium gold thiosulfate (5.8%).

Evaluate cryosurgery followed by 3.75% imiquimod cream to treat actinic keratoses (AK).Adults withor =10 AKs on the face underwent cryosurgery of five to 14 lesions. Subjects withor =5 lesions remaining were randomized to 3.75% imiquimod or placebo cream applied to the entire face daily for two two-week cycles. Efficacy was assessed through week 26.For the cryosurgery/3.75% imiquimod (n=126) and cryosurgery/placebo (n=121) groups, respectively, median total AK reductions were 86.5 and 50 percent, and proportions of subjects with complete clearance were 30.2 and 3.3 percent (P0.0001, both). Analyzing cryosurgery-treated lesions only, median reductions were 100 and 80 percent (P = 0.0008), and subject complete clearance rates were 59.5% and 29.8% (P0.001), respectively. Only one subject discontinued for a treatment-related adverse event (cryosurgery/3.75% imiquimod group).Cryosurgery was performed per usual study center practice and not standardized.A short, cyclical treatment course of field-directed daily 3.75% imiquimod cream following lesion-directed cryosurgery was well tolerated and provided additional therapeutic benefits to cryosurgery alone.

The treatment of menopause relies mainly upon the use of estrogens to alleviate climacteric symptoms, increase bone mass, and consequently, potentially improve quality of life. Although a great deal of experimental data supports the beneficial effects of estrogen treatments on (arterial) cardiovascular prevention and brain function, it was recently discovered that some of the doses used, as well as certain routes of administration or different combinations with varying forms and doses of progestins, could increase the risk of cardiovas-cular events, breast cancer, and even dementia. The current literature clearly demonstrates the major controversy of administering hormone replacement therapy to women with increased risk of breast cancer and arterial cardiovascular complications because of their age notwithstanding the further risk due to some comorbid risk factors such as diabetes, high blood pressure, hyperlipidemia, etc. At this stage in our knowledge, a profound gap still exists between our hope, experimental information, and evidence-based medicine. Until this gap is closed or corrected, physicians must be very critical in their use of Hormone Replacement (HR), and use minimal doses in selected volunteer women that demand such a treatment to alleviate symptoms.