Skin Disease Education Foundation (SDEF) 2016: Hawaii Dermatology Seminar

WAIKOLOA, HAWAII – Nodular melanoma is one of a handful of morphologic subtypes of melanoma that are difficult to diagnose in a timely way because they lack the conventional features associated with melanoma. But certain clinical and dermoscopic clues are helpful in avoiding misdiagnosis, Dr. Ashfaq A. Marghoob said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He provided tips on how to recognize nodular melanoma and other difficult-to-diagnose morphologic subtypes, including desmoplastic, amelanotic, nevoid, and epidermotropic metastatic melanoma.

Bruce Jancin/Frontline Medical News

These diagnostically challenging melanoma subtypes have several things in common: clinically, they don’t look like melanomas, and dermoscopically, they display specific tell-tale features that speak of malignancy, including atypical polymorphous blood vessels and crystalline structures. Dermoscopy can be a big help in deciding whether to biopsy a clinically unremarkable-looking lesion, observed Dr. Marghoob of Memorial Sloan Kettering Cancer Center in New York.

Here’s the rundown on how to avoid delayed diagnosis of these melanomas:

Nodular melanoma: The big challenge posed by nodular melanoma is that it grows at a very high rate, a median of 0.5 mm per month, “so it’s really not a subtype of melanoma that’s amenable to screening,” the dermatologist said.

“Think about this: A patient comes in for screening today and you see nothing on their skin. Then a month from today they start a nodular melanoma. Their next appointment with you is a year from now. By the time they come back, that nodular melanoma is going to be a life-threatening cancer,” he explained. “It requires patient engagement in self-examination to bring these lesions to our attention, and we have to be perceptive enough to see these patients in a timely manner when they call. Otherwise these are melanomas that are really the killer tumors.”

Nodular melanomas often lack the “ABCD” features associated with most melanomas: asymmetry, border irregularity, color, and diameter greater than one-quarter of an inch. Instead, the lesions may exhibit the modified ABCDs described in pediatric melanoma: amelanotic, bump showing symmetry, color homogeneity in a shade of either pink or blue-black, and de novo, meaning the lesion didn’t arise in association with a nevus, Dr. Marghoob continued.

Roughly 60% of nodular melanomas are pigmented, the other 40% amelanotic. Dermoscopically, pigmented nodular melanomas are characterized by a greater degree of symmetry than that seen with other melanomas. Atypical vessels that exhibit tortuosity, a cork screw pattern, or an irregular hairpin shape are prominently visible. The lesions are multicolored, often blue-black, and may exhibit a blue-white veil. Notably absent are regression structures, streaks, and networks.

An amelanotic nodular melanoma also features prominent atypical vessels, symmetry, and sometimes crystalline structures, which appear as shiny white lines. Comma vessels and arborizing vessels are absent.

A more detailed description of the dermoscopic findings in nodular melanoma is available in a study coauthored by Dr. Marghoob (JAMA Dermatol. 2013;149[6]:699-709).

Desmoplastic melanoma: Seventy percent of desmoplastic melanomas are amelanotic. They often present as an unremarkable firm subcutaneous papule or nodule. Indeed, desmoplastic melanomas often have such a banal clinical appearance that in one-third of cases, melanoma is not even in the differential diagnosis.

“You’re thinking cyst, lipoma, dermatofibroma ... something other than a malignancy,” Dr. Marghoob said.

Suspicion is raised by a benign-looking lesion that’s symptomatic and/or exhibiting growth on chronically sun-damaged skin in an older patient. A scar with no history of trauma that’s located on chronically sun-damaged skin is another tipoff. Also, desmoplastic melanoma can arise in association with a lentigo maligna component.

“It is this knowledge of the association between lentigo maligna and desmoplastic melanoma that for the first time has enabled us to diagnose desmoplastic melanomas that are thin – not 5 or 10 mm, but more like 0.6 mm in thickness,” Dr. Marghoob said.

The main dermoscopic clue is the presence of atypical vascular structures.

For a fuller account of the dermoscopic characteristics of desmoplastic melanomas, Dr. Marghoob recommended a study he coauthored (JAMA Dermatol. 2013;149[4]:413-21).

Amelanotic melanoma: An indication of how difficult these cancers are to diagnose was provided by the international Genes, Environment, and Melanoma Study of nearly 3,500 invasive melanomas, 8% of which were amelanotic. They were at a more advanced tumor stage at diagnosis. As a result, the mortality risk during a median 7.6 years of follow-up was an adjusted twofold greater for patients with amelanotic as compared with pigmented melanomas (JAMA Dermatol. 2014;150[12]:1306-314).

Dr. Marghoob coauthored a retrospective review of 20 consecutively diagnosed amelanotic melanomas. The lesions lacked any of the classic ABCD features. Most were symmetric, oval to round in shape, had regular borders, and were pink in color. Dermoscopically, a consistent finding was a polymorphous vascular pattern (J Eur Acad Dermatol Venereol. 2012;26[5]:591-6).

In an earlier five-continent study comparing dermoscopic features of 222 amelanotic melanomas, 105 pigmented melanomas, and 170 benign melanocytic lesions, investigators came up with a simple model that distinguished melanomas from nonmelanomas with 70% sensitivity and 56% specificity. The take-home message: Amelanotic melanomas often feature more than one shade of pink upon dermoscopic examination, along with dotted and linear irregular vessels and predominant central vessels (Arch Dermatol. 2008;144[9]:1120-7).

Nevoid melanoma: Clinically they often resemble an intradermal nevus, and they’re often amelanotic. Dermoscopically, however, an intradermal nevus displays a mammillated surface, with each individual mammillated area being associated with an isolated comma or hairpin vessel. In contrast, the surface of a nevoid melanoma is more undulating in appearance and lacks the classic vascular pattern seen in intradermal nevi. If there’s pigmentation present in a nevoid melanoma it will be distributed heterogeneously. The dermoscopic finding of irregular blood vessels and/or crystalline structures tips the balance in favor of biopsy.

Dr. Marghoob referred dermatologists interested in the dermoscopic features of nevoid melanoma to a recent study by members of the International Dermoscopy Society; he was one of the authors (Br J Dermatol. 2015;172[4]:961-7).

Epidermotropic metastatic melanoma: These lesions lack the ABCDs, are often amelanotic, and look like nondescript papules. If such a lesion is new, especially in a patient with a history of melanoma, think epidermotropic metastatic melanoma.

Spanish dermatologists have described five different dermoscopic patterns of melanoma metastases in an informative retrospective study: blue nevus-like, angioma-like, nevus-like, vascular, and unspecific. The vascular type is the most common form, characterized by amelanotic papules 2-3 mm in diameter and tortuous corkscrew vessels within the lesions (Br J Dermatol. 2013;169[1]:91-9).

Dr. Marghoob reported having no financial conflicts of interest regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Nodular melanoma is one of a handful of morphologic subtypes of melanoma that are difficult to diagnose in a timely way because they lack the conventional features associated with melanoma. But certain clinical and dermoscopic clues are helpful in avoiding misdiagnosis, Dr. Ashfaq A. Marghoob said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He provided tips on how to recognize nodular melanoma and other difficult-to-diagnose morphologic subtypes, including desmoplastic, amelanotic, nevoid, and epidermotropic metastatic melanoma.

Bruce Jancin/Frontline Medical News

These diagnostically challenging melanoma subtypes have several things in common: clinically, they don’t look like melanomas, and dermoscopically, they display specific tell-tale features that speak of malignancy, including atypical polymorphous blood vessels and crystalline structures. Dermoscopy can be a big help in deciding whether to biopsy a clinically unremarkable-looking lesion, observed Dr. Marghoob of Memorial Sloan Kettering Cancer Center in New York.

Here’s the rundown on how to avoid delayed diagnosis of these melanomas:

Nodular melanoma: The big challenge posed by nodular melanoma is that it grows at a very high rate, a median of 0.5 mm per month, “so it’s really not a subtype of melanoma that’s amenable to screening,” the dermatologist said.

“Think about this: A patient comes in for screening today and you see nothing on their skin. Then a month from today they start a nodular melanoma. Their next appointment with you is a year from now. By the time they come back, that nodular melanoma is going to be a life-threatening cancer,” he explained. “It requires patient engagement in self-examination to bring these lesions to our attention, and we have to be perceptive enough to see these patients in a timely manner when they call. Otherwise these are melanomas that are really the killer tumors.”

Nodular melanomas often lack the “ABCD” features associated with most melanomas: asymmetry, border irregularity, color, and diameter greater than one-quarter of an inch. Instead, the lesions may exhibit the modified ABCDs described in pediatric melanoma: amelanotic, bump showing symmetry, color homogeneity in a shade of either pink or blue-black, and de novo, meaning the lesion didn’t arise in association with a nevus, Dr. Marghoob continued.

Roughly 60% of nodular melanomas are pigmented, the other 40% amelanotic. Dermoscopically, pigmented nodular melanomas are characterized by a greater degree of symmetry than that seen with other melanomas. Atypical vessels that exhibit tortuosity, a cork screw pattern, or an irregular hairpin shape are prominently visible. The lesions are multicolored, often blue-black, and may exhibit a blue-white veil. Notably absent are regression structures, streaks, and networks.

An amelanotic nodular melanoma also features prominent atypical vessels, symmetry, and sometimes crystalline structures, which appear as shiny white lines. Comma vessels and arborizing vessels are absent.

A more detailed description of the dermoscopic findings in nodular melanoma is available in a study coauthored by Dr. Marghoob (JAMA Dermatol. 2013;149[6]:699-709).

Desmoplastic melanoma: Seventy percent of desmoplastic melanomas are amelanotic. They often present as an unremarkable firm subcutaneous papule or nodule. Indeed, desmoplastic melanomas often have such a banal clinical appearance that in one-third of cases, melanoma is not even in the differential diagnosis.

“You’re thinking cyst, lipoma, dermatofibroma ... something other than a malignancy,” Dr. Marghoob said.

Suspicion is raised by a benign-looking lesion that’s symptomatic and/or exhibiting growth on chronically sun-damaged skin in an older patient. A scar with no history of trauma that’s located on chronically sun-damaged skin is another tipoff. Also, desmoplastic melanoma can arise in association with a lentigo maligna component.

“It is this knowledge of the association between lentigo maligna and desmoplastic melanoma that for the first time has enabled us to diagnose desmoplastic melanomas that are thin – not 5 or 10 mm, but more like 0.6 mm in thickness,” Dr. Marghoob said.

The main dermoscopic clue is the presence of atypical vascular structures.

For a fuller account of the dermoscopic characteristics of desmoplastic melanomas, Dr. Marghoob recommended a study he coauthored (JAMA Dermatol. 2013;149[4]:413-21).

Amelanotic melanoma: An indication of how difficult these cancers are to diagnose was provided by the international Genes, Environment, and Melanoma Study of nearly 3,500 invasive melanomas, 8% of which were amelanotic. They were at a more advanced tumor stage at diagnosis. As a result, the mortality risk during a median 7.6 years of follow-up was an adjusted twofold greater for patients with amelanotic as compared with pigmented melanomas (JAMA Dermatol. 2014;150[12]:1306-314).

Dr. Marghoob coauthored a retrospective review of 20 consecutively diagnosed amelanotic melanomas. The lesions lacked any of the classic ABCD features. Most were symmetric, oval to round in shape, had regular borders, and were pink in color. Dermoscopically, a consistent finding was a polymorphous vascular pattern (J Eur Acad Dermatol Venereol. 2012;26[5]:591-6).

In an earlier five-continent study comparing dermoscopic features of 222 amelanotic melanomas, 105 pigmented melanomas, and 170 benign melanocytic lesions, investigators came up with a simple model that distinguished melanomas from nonmelanomas with 70% sensitivity and 56% specificity. The take-home message: Amelanotic melanomas often feature more than one shade of pink upon dermoscopic examination, along with dotted and linear irregular vessels and predominant central vessels (Arch Dermatol. 2008;144[9]:1120-7).

Nevoid melanoma: Clinically they often resemble an intradermal nevus, and they’re often amelanotic. Dermoscopically, however, an intradermal nevus displays a mammillated surface, with each individual mammillated area being associated with an isolated comma or hairpin vessel. In contrast, the surface of a nevoid melanoma is more undulating in appearance and lacks the classic vascular pattern seen in intradermal nevi. If there’s pigmentation present in a nevoid melanoma it will be distributed heterogeneously. The dermoscopic finding of irregular blood vessels and/or crystalline structures tips the balance in favor of biopsy.

Dr. Marghoob referred dermatologists interested in the dermoscopic features of nevoid melanoma to a recent study by members of the International Dermoscopy Society; he was one of the authors (Br J Dermatol. 2015;172[4]:961-7).

Epidermotropic metastatic melanoma: These lesions lack the ABCDs, are often amelanotic, and look like nondescript papules. If such a lesion is new, especially in a patient with a history of melanoma, think epidermotropic metastatic melanoma.

Spanish dermatologists have described five different dermoscopic patterns of melanoma metastases in an informative retrospective study: blue nevus-like, angioma-like, nevus-like, vascular, and unspecific. The vascular type is the most common form, characterized by amelanotic papules 2-3 mm in diameter and tortuous corkscrew vessels within the lesions (Br J Dermatol. 2013;169[1]:91-9).

Dr. Marghoob reported having no financial conflicts of interest regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Nodular melanoma is one of a handful of morphologic subtypes of melanoma that are difficult to diagnose in a timely way because they lack the conventional features associated with melanoma. But certain clinical and dermoscopic clues are helpful in avoiding misdiagnosis, Dr. Ashfaq A. Marghoob said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He provided tips on how to recognize nodular melanoma and other difficult-to-diagnose morphologic subtypes, including desmoplastic, amelanotic, nevoid, and epidermotropic metastatic melanoma.

Bruce Jancin/Frontline Medical News

These diagnostically challenging melanoma subtypes have several things in common: clinically, they don’t look like melanomas, and dermoscopically, they display specific tell-tale features that speak of malignancy, including atypical polymorphous blood vessels and crystalline structures. Dermoscopy can be a big help in deciding whether to biopsy a clinically unremarkable-looking lesion, observed Dr. Marghoob of Memorial Sloan Kettering Cancer Center in New York.

Here’s the rundown on how to avoid delayed diagnosis of these melanomas:

Nodular melanoma: The big challenge posed by nodular melanoma is that it grows at a very high rate, a median of 0.5 mm per month, “so it’s really not a subtype of melanoma that’s amenable to screening,” the dermatologist said.

“Think about this: A patient comes in for screening today and you see nothing on their skin. Then a month from today they start a nodular melanoma. Their next appointment with you is a year from now. By the time they come back, that nodular melanoma is going to be a life-threatening cancer,” he explained. “It requires patient engagement in self-examination to bring these lesions to our attention, and we have to be perceptive enough to see these patients in a timely manner when they call. Otherwise these are melanomas that are really the killer tumors.”

Nodular melanomas often lack the “ABCD” features associated with most melanomas: asymmetry, border irregularity, color, and diameter greater than one-quarter of an inch. Instead, the lesions may exhibit the modified ABCDs described in pediatric melanoma: amelanotic, bump showing symmetry, color homogeneity in a shade of either pink or blue-black, and de novo, meaning the lesion didn’t arise in association with a nevus, Dr. Marghoob continued.

Roughly 60% of nodular melanomas are pigmented, the other 40% amelanotic. Dermoscopically, pigmented nodular melanomas are characterized by a greater degree of symmetry than that seen with other melanomas. Atypical vessels that exhibit tortuosity, a cork screw pattern, or an irregular hairpin shape are prominently visible. The lesions are multicolored, often blue-black, and may exhibit a blue-white veil. Notably absent are regression structures, streaks, and networks.

An amelanotic nodular melanoma also features prominent atypical vessels, symmetry, and sometimes crystalline structures, which appear as shiny white lines. Comma vessels and arborizing vessels are absent.

A more detailed description of the dermoscopic findings in nodular melanoma is available in a study coauthored by Dr. Marghoob (JAMA Dermatol. 2013;149[6]:699-709).

Desmoplastic melanoma: Seventy percent of desmoplastic melanomas are amelanotic. They often present as an unremarkable firm subcutaneous papule or nodule. Indeed, desmoplastic melanomas often have such a banal clinical appearance that in one-third of cases, melanoma is not even in the differential diagnosis.

“You’re thinking cyst, lipoma, dermatofibroma ... something other than a malignancy,” Dr. Marghoob said.

Suspicion is raised by a benign-looking lesion that’s symptomatic and/or exhibiting growth on chronically sun-damaged skin in an older patient. A scar with no history of trauma that’s located on chronically sun-damaged skin is another tipoff. Also, desmoplastic melanoma can arise in association with a lentigo maligna component.

“It is this knowledge of the association between lentigo maligna and desmoplastic melanoma that for the first time has enabled us to diagnose desmoplastic melanomas that are thin – not 5 or 10 mm, but more like 0.6 mm in thickness,” Dr. Marghoob said.

The main dermoscopic clue is the presence of atypical vascular structures.

For a fuller account of the dermoscopic characteristics of desmoplastic melanomas, Dr. Marghoob recommended a study he coauthored (JAMA Dermatol. 2013;149[4]:413-21).

Amelanotic melanoma: An indication of how difficult these cancers are to diagnose was provided by the international Genes, Environment, and Melanoma Study of nearly 3,500 invasive melanomas, 8% of which were amelanotic. They were at a more advanced tumor stage at diagnosis. As a result, the mortality risk during a median 7.6 years of follow-up was an adjusted twofold greater for patients with amelanotic as compared with pigmented melanomas (JAMA Dermatol. 2014;150[12]:1306-314).

Dr. Marghoob coauthored a retrospective review of 20 consecutively diagnosed amelanotic melanomas. The lesions lacked any of the classic ABCD features. Most were symmetric, oval to round in shape, had regular borders, and were pink in color. Dermoscopically, a consistent finding was a polymorphous vascular pattern (J Eur Acad Dermatol Venereol. 2012;26[5]:591-6).

In an earlier five-continent study comparing dermoscopic features of 222 amelanotic melanomas, 105 pigmented melanomas, and 170 benign melanocytic lesions, investigators came up with a simple model that distinguished melanomas from nonmelanomas with 70% sensitivity and 56% specificity. The take-home message: Amelanotic melanomas often feature more than one shade of pink upon dermoscopic examination, along with dotted and linear irregular vessels and predominant central vessels (Arch Dermatol. 2008;144[9]:1120-7).

Nevoid melanoma: Clinically they often resemble an intradermal nevus, and they’re often amelanotic. Dermoscopically, however, an intradermal nevus displays a mammillated surface, with each individual mammillated area being associated with an isolated comma or hairpin vessel. In contrast, the surface of a nevoid melanoma is more undulating in appearance and lacks the classic vascular pattern seen in intradermal nevi. If there’s pigmentation present in a nevoid melanoma it will be distributed heterogeneously. The dermoscopic finding of irregular blood vessels and/or crystalline structures tips the balance in favor of biopsy.

Dr. Marghoob referred dermatologists interested in the dermoscopic features of nevoid melanoma to a recent study by members of the International Dermoscopy Society; he was one of the authors (Br J Dermatol. 2015;172[4]:961-7).

Epidermotropic metastatic melanoma: These lesions lack the ABCDs, are often amelanotic, and look like nondescript papules. If such a lesion is new, especially in a patient with a history of melanoma, think epidermotropic metastatic melanoma.

Spanish dermatologists have described five different dermoscopic patterns of melanoma metastases in an informative retrospective study: blue nevus-like, angioma-like, nevus-like, vascular, and unspecific. The vascular type is the most common form, characterized by amelanotic papules 2-3 mm in diameter and tortuous corkscrew vessels within the lesions (Br J Dermatol. 2013;169[1]:91-9).

Dr. Marghoob reported having no financial conflicts of interest regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Some melanomas can be diagnosed from the examination room doorway. Others are evident only upon close visual inspection. But the most challenging cases require integration of information regarding the lesion’s dermoscopic pattern in the context of the clues provided by key patient-specific characteristics, according to Dr. Michael A. Marchetti.

“Consider a melanoma diagnosis when a lesion is wrong for the patient’s age, the anatomic location, or skin type, or if it deviates from the patient’s expected signature pattern of nevi,” noted Dr. Marchetti, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

Bruce Jancin/Frontline Medical News

A landmark study that provides guidance in this area was conducted several years ago at dermatology centers in four European countries and at Memorial Sloan-Kettering. The investigators enrolled 480 consecutive children and adults with a total of 5,481 melanocytic nevi. The study showcased significant age- and anatomic site–related differences in the distribution of nevi categorized according to dermoscopic subgroups (Arch Dermatol. 2011;147[6]:663-70).

For example, nevi characterized dermoscopically by a peripheral rim of globules were found to be vastly more common during the first 3 decades of life than later. Based upon this study and other data, Dr. Marchetti’s suggested management strategy for peripheral globular nevus with no other concerning features in patients up to age 30 is reassurance that the lesion is not going to be a problem and doesn’t require careful monitoring or biopsy. In a patient beyond age 30, however, frequent monitoring or biopsy is appropriate – and the older the patient with a peripheral globular nevus, the lower the threshold for biopsy.

A peripheral globular nevus is typically a nevus in its radial growth phase, which can continue for years before the nevus enters senescence. The same is true of a nevus that exhibits a Spitzoid starbust pattern on dermoscopy. It is growing radially, and the pretest probability that it’s malignant is highly age dependent.

“In a child, it’s very likely to be a Spitz nevus. In an adult, it’s very likely to be a melanoma. Based upon morphology alone, you really can’t make a distinction between these lesions,” Dr. Marchetti said.

The importance of age in differentiating these starburst lesions was underscored in a recent Italian study involving 384 symmetric, dermoscopically Spitzoid-looking lesions in patients aged 12 or older. Histopathologically, 13.3% of the lesions were diagnosed as melanoma. The probability increased with advancing age, reaching 50% or more after age 50 years. The investigators concluded that the only safe strategy to avoid missing a melanoma is to excise all Spitzoid-looking lesions in patients aged 12 years or older (J Am Acad Dermatol. 2015;72[1]:47-53).

“That concurs with our practice at Memorial Sloan-Kettering. We tend to biopsy all lesions with this particular morphology because you just can’t tell,” Dr. Marchetti said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Nevi with a globular dermoscopic pattern occur mostly in children and mainly on the upper back. A globular lesion that develops in an adult or on an extremity is “wrong,” and therefore biopsy should be seriously considered.

In contrast, nevi classified dermoscopically as reticular occur on the trunk and extremities with similar frequency, he continued.

Age and anatomic location are also important considerations in deciding whether a lesion might be a case of nested melanoma of the elderly. This is a form of melanoma first described only a few years ago. It takes the form of a large flat pigmented lesion showing a dermoscopic pattern of irregular globules throughout in a patient over aged 60 years. Notably, three-quarters of cases of nested melanoma of the elderly occur on the extremities (JAMA Dermatol. 2013;149[8]:941-5).

Skin type can raise or diminish the concern that a pigmented lesion is a melanoma. Patients with a lighter skin type tend to have light brown nevi with a patchy reticular network and central hypopigmentation; dark nevi are relatively uncommon in lighter-skinned patients and thus stand out as suspicious outliers. The flip side is also true: Patients with darker skin types tend to have dark nevi with central hyperpigmentation.

A nevus that deviates from a patient’s signature pattern is often referred to as the ugly duckling sign of melanoma.

“It’s the context provided by the background nevi which informs you if there’s an outlier. This can be helpful not only in detecting melanoma, but also in reducing unnecessary biopsies. If a lesion you’re wondering about looks dermoscopically like the patient’s other nevi, that’s reassuring,” Dr. Marchetti said.

He reported having no financial conflicts regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Some melanomas can be diagnosed from the examination room doorway. Others are evident only upon close visual inspection. But the most challenging cases require integration of information regarding the lesion’s dermoscopic pattern in the context of the clues provided by key patient-specific characteristics, according to Dr. Michael A. Marchetti.

“Consider a melanoma diagnosis when a lesion is wrong for the patient’s age, the anatomic location, or skin type, or if it deviates from the patient’s expected signature pattern of nevi,” noted Dr. Marchetti, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

Bruce Jancin/Frontline Medical News

A landmark study that provides guidance in this area was conducted several years ago at dermatology centers in four European countries and at Memorial Sloan-Kettering. The investigators enrolled 480 consecutive children and adults with a total of 5,481 melanocytic nevi. The study showcased significant age- and anatomic site–related differences in the distribution of nevi categorized according to dermoscopic subgroups (Arch Dermatol. 2011;147[6]:663-70).

For example, nevi characterized dermoscopically by a peripheral rim of globules were found to be vastly more common during the first 3 decades of life than later. Based upon this study and other data, Dr. Marchetti’s suggested management strategy for peripheral globular nevus with no other concerning features in patients up to age 30 is reassurance that the lesion is not going to be a problem and doesn’t require careful monitoring or biopsy. In a patient beyond age 30, however, frequent monitoring or biopsy is appropriate – and the older the patient with a peripheral globular nevus, the lower the threshold for biopsy.

A peripheral globular nevus is typically a nevus in its radial growth phase, which can continue for years before the nevus enters senescence. The same is true of a nevus that exhibits a Spitzoid starbust pattern on dermoscopy. It is growing radially, and the pretest probability that it’s malignant is highly age dependent.

“In a child, it’s very likely to be a Spitz nevus. In an adult, it’s very likely to be a melanoma. Based upon morphology alone, you really can’t make a distinction between these lesions,” Dr. Marchetti said.

The importance of age in differentiating these starburst lesions was underscored in a recent Italian study involving 384 symmetric, dermoscopically Spitzoid-looking lesions in patients aged 12 or older. Histopathologically, 13.3% of the lesions were diagnosed as melanoma. The probability increased with advancing age, reaching 50% or more after age 50 years. The investigators concluded that the only safe strategy to avoid missing a melanoma is to excise all Spitzoid-looking lesions in patients aged 12 years or older (J Am Acad Dermatol. 2015;72[1]:47-53).

“That concurs with our practice at Memorial Sloan-Kettering. We tend to biopsy all lesions with this particular morphology because you just can’t tell,” Dr. Marchetti said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Nevi with a globular dermoscopic pattern occur mostly in children and mainly on the upper back. A globular lesion that develops in an adult or on an extremity is “wrong,” and therefore biopsy should be seriously considered.

In contrast, nevi classified dermoscopically as reticular occur on the trunk and extremities with similar frequency, he continued.

Age and anatomic location are also important considerations in deciding whether a lesion might be a case of nested melanoma of the elderly. This is a form of melanoma first described only a few years ago. It takes the form of a large flat pigmented lesion showing a dermoscopic pattern of irregular globules throughout in a patient over aged 60 years. Notably, three-quarters of cases of nested melanoma of the elderly occur on the extremities (JAMA Dermatol. 2013;149[8]:941-5).

Skin type can raise or diminish the concern that a pigmented lesion is a melanoma. Patients with a lighter skin type tend to have light brown nevi with a patchy reticular network and central hypopigmentation; dark nevi are relatively uncommon in lighter-skinned patients and thus stand out as suspicious outliers. The flip side is also true: Patients with darker skin types tend to have dark nevi with central hyperpigmentation.

A nevus that deviates from a patient’s signature pattern is often referred to as the ugly duckling sign of melanoma.

“It’s the context provided by the background nevi which informs you if there’s an outlier. This can be helpful not only in detecting melanoma, but also in reducing unnecessary biopsies. If a lesion you’re wondering about looks dermoscopically like the patient’s other nevi, that’s reassuring,” Dr. Marchetti said.

He reported having no financial conflicts regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Some melanomas can be diagnosed from the examination room doorway. Others are evident only upon close visual inspection. But the most challenging cases require integration of information regarding the lesion’s dermoscopic pattern in the context of the clues provided by key patient-specific characteristics, according to Dr. Michael A. Marchetti.

“Consider a melanoma diagnosis when a lesion is wrong for the patient’s age, the anatomic location, or skin type, or if it deviates from the patient’s expected signature pattern of nevi,” noted Dr. Marchetti, a dermatologist at Memorial Sloan-Kettering Cancer Center in New York.

Bruce Jancin/Frontline Medical News

A landmark study that provides guidance in this area was conducted several years ago at dermatology centers in four European countries and at Memorial Sloan-Kettering. The investigators enrolled 480 consecutive children and adults with a total of 5,481 melanocytic nevi. The study showcased significant age- and anatomic site–related differences in the distribution of nevi categorized according to dermoscopic subgroups (Arch Dermatol. 2011;147[6]:663-70).

For example, nevi characterized dermoscopically by a peripheral rim of globules were found to be vastly more common during the first 3 decades of life than later. Based upon this study and other data, Dr. Marchetti’s suggested management strategy for peripheral globular nevus with no other concerning features in patients up to age 30 is reassurance that the lesion is not going to be a problem and doesn’t require careful monitoring or biopsy. In a patient beyond age 30, however, frequent monitoring or biopsy is appropriate – and the older the patient with a peripheral globular nevus, the lower the threshold for biopsy.

A peripheral globular nevus is typically a nevus in its radial growth phase, which can continue for years before the nevus enters senescence. The same is true of a nevus that exhibits a Spitzoid starbust pattern on dermoscopy. It is growing radially, and the pretest probability that it’s malignant is highly age dependent.

“In a child, it’s very likely to be a Spitz nevus. In an adult, it’s very likely to be a melanoma. Based upon morphology alone, you really can’t make a distinction between these lesions,” Dr. Marchetti said.

The importance of age in differentiating these starburst lesions was underscored in a recent Italian study involving 384 symmetric, dermoscopically Spitzoid-looking lesions in patients aged 12 or older. Histopathologically, 13.3% of the lesions were diagnosed as melanoma. The probability increased with advancing age, reaching 50% or more after age 50 years. The investigators concluded that the only safe strategy to avoid missing a melanoma is to excise all Spitzoid-looking lesions in patients aged 12 years or older (J Am Acad Dermatol. 2015;72[1]:47-53).

“That concurs with our practice at Memorial Sloan-Kettering. We tend to biopsy all lesions with this particular morphology because you just can’t tell,” Dr. Marchetti said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

Nevi with a globular dermoscopic pattern occur mostly in children and mainly on the upper back. A globular lesion that develops in an adult or on an extremity is “wrong,” and therefore biopsy should be seriously considered.

In contrast, nevi classified dermoscopically as reticular occur on the trunk and extremities with similar frequency, he continued.

Age and anatomic location are also important considerations in deciding whether a lesion might be a case of nested melanoma of the elderly. This is a form of melanoma first described only a few years ago. It takes the form of a large flat pigmented lesion showing a dermoscopic pattern of irregular globules throughout in a patient over aged 60 years. Notably, three-quarters of cases of nested melanoma of the elderly occur on the extremities (JAMA Dermatol. 2013;149[8]:941-5).

Skin type can raise or diminish the concern that a pigmented lesion is a melanoma. Patients with a lighter skin type tend to have light brown nevi with a patchy reticular network and central hypopigmentation; dark nevi are relatively uncommon in lighter-skinned patients and thus stand out as suspicious outliers. The flip side is also true: Patients with darker skin types tend to have dark nevi with central hyperpigmentation.

A nevus that deviates from a patient’s signature pattern is often referred to as the ugly duckling sign of melanoma.

“It’s the context provided by the background nevi which informs you if there’s an outlier. This can be helpful not only in detecting melanoma, but also in reducing unnecessary biopsies. If a lesion you’re wondering about looks dermoscopically like the patient’s other nevi, that’s reassuring,” Dr. Marchetti said.

He reported having no financial conflicts regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – The incidence of infantile hemangiomas has climbed steadily in recent decades in concert with rising rates of prematurity and low birth weight, Dr. Sheila Fallon Friedlander said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“We spend a lot of time talking about port wine stains, but guess what? They’re much less frequent than are infantile hemangiomas, which most studies agree have an incidence of about 5%, as compared to 0.1%-0.3% for port wine stains,” observed Dr. Friedlander, professor of dermatology and pediatrics at the University of California, San Diego.

Bruce Jancin/Frontline Medical News

Most of these lesions resolve over time, but some are disfiguring or even life threatening. With the availability of safe and effective therapies in the form of propranolol, nadolol, timolol, and lasers, it’s incumbent on physicians to make the diagnosis early and intervene in a timely manner when appropriate to avoid complications, the pediatric dermatologist emphasized.

She highlighted a recent population-based study of infants born in Olmsted County, Minn., during 1976-2010. The Mayo Clinic investigators found that the incidence of infantile hemangiomas climbed from 0.97 to 1.97 per 100 person-years over that time span. Meanwhile, the average gestational age at birth among babies with infantile hemangiomas in the county fell from 39.2 weeks to 38.3 weeks, and their average birth weight dropped from 3,383 g to 3,185 g (J Am Acad Dermatol. 2016;74[1]:120-6).

Dr. Friedlander was senior investigator for a unique study, the first prospective U.S. study to track the incidence of infantile hemangiomas from birth through 9 months of age. The study included 578 mothers enrolled in pregnancy and their 594 offspring. All of the neonates were examined by a pediatric dermatologist within 48 hours after delivery, allowing for precise differentiation between infantile hemangiomas and other neonatal vascular lesions.

The incidence of infantile hemangiomas was 4.5%. The majority of the lesions occurred on the trunk or extremities. Of note, only one infantile hemangioma required intervention. Twenty percent of the infantile hemangiomas were small focal lesions with abortive or telangiectatic morphology that stopped growing by 3 months of age.

As in the Mayo Clinic study, Dr. Friedlander noted, the risk of infantile hemangioma in this San Diego–area study population increased with decreasing gestational age and weight. The incidence was 3.9% in term infants, 7.4% in premature infants, and 14.3% in those who were very premature. Similarly, infantile hemangiomas occurred in 4% of normal-birth-weight babies but in 16.6% of those who were very low birth weight (Br J Dermatol. 2014;170[4]:907-13).

Abnormalities of placental perfusion occurred in nearly 35% of pregnancies that produced babies with infantile hemangiomas, a rate twice that seen in pregnancies not associated with a subsequent infantile hemangioma. This and other evidence points to hypoxia as a key factor in precipitating the development of infantile hemangiomas.

“We believe that these lesions are related to embolization of tissue, perhaps placental, or hypoxia in utero,” Dr. Friedlander said. “Extreme prematurity, low birth weight, Caucasian race, placental anomalies, increased maternal age, use of fertility drugs – these are all things that will up your ante for having a child with an infantile hemangioma.”

She reported receiving grant/research support from Merz and Valeant Pharmaceuticals, and serving as a consultant for Sandoz.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – The incidence of infantile hemangiomas has climbed steadily in recent decades in concert with rising rates of prematurity and low birth weight, Dr. Sheila Fallon Friedlander said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“We spend a lot of time talking about port wine stains, but guess what? They’re much less frequent than are infantile hemangiomas, which most studies agree have an incidence of about 5%, as compared to 0.1%-0.3% for port wine stains,” observed Dr. Friedlander, professor of dermatology and pediatrics at the University of California, San Diego.

Bruce Jancin/Frontline Medical News

Most of these lesions resolve over time, but some are disfiguring or even life threatening. With the availability of safe and effective therapies in the form of propranolol, nadolol, timolol, and lasers, it’s incumbent on physicians to make the diagnosis early and intervene in a timely manner when appropriate to avoid complications, the pediatric dermatologist emphasized.

She highlighted a recent population-based study of infants born in Olmsted County, Minn., during 1976-2010. The Mayo Clinic investigators found that the incidence of infantile hemangiomas climbed from 0.97 to 1.97 per 100 person-years over that time span. Meanwhile, the average gestational age at birth among babies with infantile hemangiomas in the county fell from 39.2 weeks to 38.3 weeks, and their average birth weight dropped from 3,383 g to 3,185 g (J Am Acad Dermatol. 2016;74[1]:120-6).

Dr. Friedlander was senior investigator for a unique study, the first prospective U.S. study to track the incidence of infantile hemangiomas from birth through 9 months of age. The study included 578 mothers enrolled in pregnancy and their 594 offspring. All of the neonates were examined by a pediatric dermatologist within 48 hours after delivery, allowing for precise differentiation between infantile hemangiomas and other neonatal vascular lesions.

The incidence of infantile hemangiomas was 4.5%. The majority of the lesions occurred on the trunk or extremities. Of note, only one infantile hemangioma required intervention. Twenty percent of the infantile hemangiomas were small focal lesions with abortive or telangiectatic morphology that stopped growing by 3 months of age.

As in the Mayo Clinic study, Dr. Friedlander noted, the risk of infantile hemangioma in this San Diego–area study population increased with decreasing gestational age and weight. The incidence was 3.9% in term infants, 7.4% in premature infants, and 14.3% in those who were very premature. Similarly, infantile hemangiomas occurred in 4% of normal-birth-weight babies but in 16.6% of those who were very low birth weight (Br J Dermatol. 2014;170[4]:907-13).

Abnormalities of placental perfusion occurred in nearly 35% of pregnancies that produced babies with infantile hemangiomas, a rate twice that seen in pregnancies not associated with a subsequent infantile hemangioma. This and other evidence points to hypoxia as a key factor in precipitating the development of infantile hemangiomas.

“We believe that these lesions are related to embolization of tissue, perhaps placental, or hypoxia in utero,” Dr. Friedlander said. “Extreme prematurity, low birth weight, Caucasian race, placental anomalies, increased maternal age, use of fertility drugs – these are all things that will up your ante for having a child with an infantile hemangioma.”

She reported receiving grant/research support from Merz and Valeant Pharmaceuticals, and serving as a consultant for Sandoz.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – The incidence of infantile hemangiomas has climbed steadily in recent decades in concert with rising rates of prematurity and low birth weight, Dr. Sheila Fallon Friedlander said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“We spend a lot of time talking about port wine stains, but guess what? They’re much less frequent than are infantile hemangiomas, which most studies agree have an incidence of about 5%, as compared to 0.1%-0.3% for port wine stains,” observed Dr. Friedlander, professor of dermatology and pediatrics at the University of California, San Diego.

Bruce Jancin/Frontline Medical News

Most of these lesions resolve over time, but some are disfiguring or even life threatening. With the availability of safe and effective therapies in the form of propranolol, nadolol, timolol, and lasers, it’s incumbent on physicians to make the diagnosis early and intervene in a timely manner when appropriate to avoid complications, the pediatric dermatologist emphasized.

She highlighted a recent population-based study of infants born in Olmsted County, Minn., during 1976-2010. The Mayo Clinic investigators found that the incidence of infantile hemangiomas climbed from 0.97 to 1.97 per 100 person-years over that time span. Meanwhile, the average gestational age at birth among babies with infantile hemangiomas in the county fell from 39.2 weeks to 38.3 weeks, and their average birth weight dropped from 3,383 g to 3,185 g (J Am Acad Dermatol. 2016;74[1]:120-6).

Dr. Friedlander was senior investigator for a unique study, the first prospective U.S. study to track the incidence of infantile hemangiomas from birth through 9 months of age. The study included 578 mothers enrolled in pregnancy and their 594 offspring. All of the neonates were examined by a pediatric dermatologist within 48 hours after delivery, allowing for precise differentiation between infantile hemangiomas and other neonatal vascular lesions.

The incidence of infantile hemangiomas was 4.5%. The majority of the lesions occurred on the trunk or extremities. Of note, only one infantile hemangioma required intervention. Twenty percent of the infantile hemangiomas were small focal lesions with abortive or telangiectatic morphology that stopped growing by 3 months of age.

As in the Mayo Clinic study, Dr. Friedlander noted, the risk of infantile hemangioma in this San Diego–area study population increased with decreasing gestational age and weight. The incidence was 3.9% in term infants, 7.4% in premature infants, and 14.3% in those who were very premature. Similarly, infantile hemangiomas occurred in 4% of normal-birth-weight babies but in 16.6% of those who were very low birth weight (Br J Dermatol. 2014;170[4]:907-13).

Abnormalities of placental perfusion occurred in nearly 35% of pregnancies that produced babies with infantile hemangiomas, a rate twice that seen in pregnancies not associated with a subsequent infantile hemangioma. This and other evidence points to hypoxia as a key factor in precipitating the development of infantile hemangiomas.

“We believe that these lesions are related to embolization of tissue, perhaps placental, or hypoxia in utero,” Dr. Friedlander said. “Extreme prematurity, low birth weight, Caucasian race, placental anomalies, increased maternal age, use of fertility drugs – these are all things that will up your ante for having a child with an infantile hemangioma.”

She reported receiving grant/research support from Merz and Valeant Pharmaceuticals, and serving as a consultant for Sandoz.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – The incidence of infantile hemangiomas has climbed steadily in recent decades in concert with rising rates of prematurity and low birth weight, Dr. Sheila Fallon Friedlander said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“We spend a lot of time talking about port wine stains, but guess what? They’re much less frequent than are infantile hemangiomas, which most studies agree have an incidence of about 5%, as compared to 0.1%-0.3% for port wine stains,” observed Dr. Friedlander, professor of dermatology and pediatrics at the University of California, San Diego.

Bruce Jancin/Frontline Medical News

Most of these lesions resolve over time, but some are disfiguring or even life threatening. With the availability of safe and effective therapies in the form of propranolol, nadolol, timolol, and lasers, it’s incumbent on physicians to make the diagnosis early and intervene in a timely manner when appropriate to avoid complications, the pediatric dermatologist emphasized.

She highlighted a recent population-based study of infants born in Olmsted County, Minn., during 1976-2010. The Mayo Clinic investigators found that the incidence of infantile hemangiomas climbed from 0.97 to 1.97 per 100 person-years over that time span. Meanwhile, the average gestational age at birth among babies with infantile hemangiomas in the county fell from 39.2 weeks to 38.3 weeks, and their average birth weight dropped from 3,383 g to 3,185 g (J Am Acad Dermatol. 2016;74[1]:120-6).

Dr. Friedlander was senior investigator for a unique study, the first prospective U.S. study to track the incidence of infantile hemangiomas from birth through 9 months of age. The study included 578 mothers enrolled in pregnancy and their 594 offspring. All of the neonates were examined by a pediatric dermatologist within 48 hours after delivery, allowing for precise differentiation between infantile hemangiomas and other neonatal vascular lesions.

The incidence of infantile hemangiomas was 4.5%. The majority of the lesions occurred on the trunk or extremities. Of note, only one infantile hemangioma required intervention. Twenty percent of the infantile hemangiomas were small focal lesions with abortive or telangiectatic morphology that stopped growing by 3 months of age.

As in the Mayo Clinic study, Dr. Friedlander noted, the risk of infantile hemangioma in this San Diego–area study population increased with decreasing gestational age and weight. The incidence was 3.9% in term infants, 7.4% in premature infants, and 14.3% in those who were very premature. Similarly, infantile hemangiomas occurred in 4% of normal-birth-weight babies but in 16.6% of those who were very low birth weight (Br J Dermatol. 2014;170[4]:907-13).

Abnormalities of placental perfusion occurred in nearly 35% of pregnancies that produced babies with infantile hemangiomas, a rate twice that seen in pregnancies not associated with a subsequent infantile hemangioma. This and other evidence points to hypoxia as a key factor in precipitating the development of infantile hemangiomas.

“We believe that these lesions are related to embolization of tissue, perhaps placental, or hypoxia in utero,” Dr. Friedlander said. “Extreme prematurity, low birth weight, Caucasian race, placental anomalies, increased maternal age, use of fertility drugs – these are all things that will up your ante for having a child with an infantile hemangioma.”

She reported receiving grant/research support from Merz and Valeant Pharmaceuticals, and serving as a consultant for Sandoz.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – The incidence of infantile hemangiomas has climbed steadily in recent decades in concert with rising rates of prematurity and low birth weight, Dr. Sheila Fallon Friedlander said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“We spend a lot of time talking about port wine stains, but guess what? They’re much less frequent than are infantile hemangiomas, which most studies agree have an incidence of about 5%, as compared to 0.1%-0.3% for port wine stains,” observed Dr. Friedlander, professor of dermatology and pediatrics at the University of California, San Diego.

Bruce Jancin/Frontline Medical News

Most of these lesions resolve over time, but some are disfiguring or even life threatening. With the availability of safe and effective therapies in the form of propranolol, nadolol, timolol, and lasers, it’s incumbent on physicians to make the diagnosis early and intervene in a timely manner when appropriate to avoid complications, the pediatric dermatologist emphasized.

She highlighted a recent population-based study of infants born in Olmsted County, Minn., during 1976-2010. The Mayo Clinic investigators found that the incidence of infantile hemangiomas climbed from 0.97 to 1.97 per 100 person-years over that time span. Meanwhile, the average gestational age at birth among babies with infantile hemangiomas in the county fell from 39.2 weeks to 38.3 weeks, and their average birth weight dropped from 3,383 g to 3,185 g (J Am Acad Dermatol. 2016;74[1]:120-6).

Dr. Friedlander was senior investigator for a unique study, the first prospective U.S. study to track the incidence of infantile hemangiomas from birth through 9 months of age. The study included 578 mothers enrolled in pregnancy and their 594 offspring. All of the neonates were examined by a pediatric dermatologist within 48 hours after delivery, allowing for precise differentiation between infantile hemangiomas and other neonatal vascular lesions.

The incidence of infantile hemangiomas was 4.5%. The majority of the lesions occurred on the trunk or extremities. Of note, only one infantile hemangioma required intervention. Twenty percent of the infantile hemangiomas were small focal lesions with abortive or telangiectatic morphology that stopped growing by 3 months of age.

As in the Mayo Clinic study, Dr. Friedlander noted, the risk of infantile hemangioma in this San Diego–area study population increased with decreasing gestational age and weight. The incidence was 3.9% in term infants, 7.4% in premature infants, and 14.3% in those who were very premature. Similarly, infantile hemangiomas occurred in 4% of normal-birth-weight babies but in 16.6% of those who were very low birth weight (Br J Dermatol. 2014;170[4]:907-13).

Abnormalities of placental perfusion occurred in nearly 35% of pregnancies that produced babies with infantile hemangiomas, a rate twice that seen in pregnancies not associated with a subsequent infantile hemangioma. This and other evidence points to hypoxia as a key factor in precipitating the development of infantile hemangiomas.

“We believe that these lesions are related to embolization of tissue, perhaps placental, or hypoxia in utero,” Dr. Friedlander said. “Extreme prematurity, low birth weight, Caucasian race, placental anomalies, increased maternal age, use of fertility drugs – these are all things that will up your ante for having a child with an infantile hemangioma.”

She reported receiving grant/research support from Merz and Valeant Pharmaceuticals, and serving as a consultant for Sandoz.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – The incidence of infantile hemangiomas has climbed steadily in recent decades in concert with rising rates of prematurity and low birth weight, Dr. Sheila Fallon Friedlander said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

“We spend a lot of time talking about port wine stains, but guess what? They’re much less frequent than are infantile hemangiomas, which most studies agree have an incidence of about 5%, as compared to 0.1%-0.3% for port wine stains,” observed Dr. Friedlander, professor of dermatology and pediatrics at the University of California, San Diego.

Bruce Jancin/Frontline Medical News

Most of these lesions resolve over time, but some are disfiguring or even life threatening. With the availability of safe and effective therapies in the form of propranolol, nadolol, timolol, and lasers, it’s incumbent on physicians to make the diagnosis early and intervene in a timely manner when appropriate to avoid complications, the pediatric dermatologist emphasized.

She highlighted a recent population-based study of infants born in Olmsted County, Minn., during 1976-2010. The Mayo Clinic investigators found that the incidence of infantile hemangiomas climbed from 0.97 to 1.97 per 100 person-years over that time span. Meanwhile, the average gestational age at birth among babies with infantile hemangiomas in the county fell from 39.2 weeks to 38.3 weeks, and their average birth weight dropped from 3,383 g to 3,185 g (J Am Acad Dermatol. 2016;74[1]:120-6).

Dr. Friedlander was senior investigator for a unique study, the first prospective U.S. study to track the incidence of infantile hemangiomas from birth through 9 months of age. The study included 578 mothers enrolled in pregnancy and their 594 offspring. All of the neonates were examined by a pediatric dermatologist within 48 hours after delivery, allowing for precise differentiation between infantile hemangiomas and other neonatal vascular lesions.

The incidence of infantile hemangiomas was 4.5%. The majority of the lesions occurred on the trunk or extremities. Of note, only one infantile hemangioma required intervention. Twenty percent of the infantile hemangiomas were small focal lesions with abortive or telangiectatic morphology that stopped growing by 3 months of age.

As in the Mayo Clinic study, Dr. Friedlander noted, the risk of infantile hemangioma in this San Diego–area study population increased with decreasing gestational age and weight. The incidence was 3.9% in term infants, 7.4% in premature infants, and 14.3% in those who were very premature. Similarly, infantile hemangiomas occurred in 4% of normal-birth-weight babies but in 16.6% of those who were very low birth weight (Br J Dermatol. 2014;170[4]:907-13).

Abnormalities of placental perfusion occurred in nearly 35% of pregnancies that produced babies with infantile hemangiomas, a rate twice that seen in pregnancies not associated with a subsequent infantile hemangioma. This and other evidence points to hypoxia as a key factor in precipitating the development of infantile hemangiomas.

“We believe that these lesions are related to embolization of tissue, perhaps placental, or hypoxia in utero,” Dr. Friedlander said. “Extreme prematurity, low birth weight, Caucasian race, placental anomalies, increased maternal age, use of fertility drugs – these are all things that will up your ante for having a child with an infantile hemangioma.”

She reported receiving grant/research support from Merz and Valeant Pharmaceuticals, and serving as a consultant for Sandoz.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – The topical vasoconstrictor brimonidine 0.33% gel brings impressive improvement in the facial redness component of rosacea, but it does nothing to address the inflammatory lesions of the disease, Dr. Joseph F. Fowler, Jr., said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Rebound flushing wasn’t seen in the 52-week, large, open-label safety study of brimonidine gel, but has been anecdotally reported since its approval. Flushing occurs 12-24 hours after application, and usually lasts a day or two, according to Dr. Fowler, who was the first author of several multicenter randomized trials of the therapy.

“The rebound phenomenon is not something that frightens me or others I know who use the medication routinely, because it’s not something that’s going to cause a long-term problem,” he declared. Indeed, once brimonidine gel (Mirvaso) has quelled the erythema, the inflammatory lesions will stand out even more prominently, noted Dr. Fowler, the conference co-director and a dermatologist at the University of Louisville. “You’ve got to do something about the inflammatory component.”

Two topical therapies that address the inflammatory component include ivermectin 1% cream (Soolantra), shown to reduce counts of papules and pustules in two 40-week extension studies of phase III trials (J Drugs Dermatol. 2014 Nov;13[11]:1380-6), and azelaic acid 15% foam (Finacea), which also achieved an impressive reduction in inflammatory lesion counts in a phase III trial (Cutis. 2015 Jul;96[1]:54-61).

Both agents were well tolerated in those studies. That’s a major treatment consideration because rosacea patients have elevated facial skin sensitivity and often can’t tolerate older off-label topical therapies because of stinging and burning, according to Dr. Fowler.

Some rosacea patients are so intolerant of topicals that they prefer oral therapy. For those patients, subantimicrobial-dose doxycycline is a good option, Dr. Fowler said.

In addition to its anti-inflammatory effects, topical ivermectin kills Demodex. While rosacea is an inflammatory disorder, not an infection, drugs like ivermectin and crotamiton 10% cream (Eurax) that kill Demodex also improve rosacea, he observed.

The initial irritation event rate with azelaic acid 15% foam in the phase III trial was in the 2%-5% range, and those events were short lived. Irritation is a much bigger problem with the older azelaic acid 15% gel, with event rates in the 15%-25% range.

Dr. Fowler has also had good results using topical calcineurin inhibitors off-label for rosacea. Pimecrolimus cream (Elidel) is in ongoing studies for treatment of seborrheic dermatitis, which often coexists with rosacea, he noted.

He reported serving as a consultant to half a dozen pharmaceutical companies, including Galderma, which markets ivermectin cream and brimonidine gel, and Bayer, which markets azelaic acid foam.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – The topical vasoconstrictor brimonidine 0.33% gel brings impressive improvement in the facial redness component of rosacea, but it does nothing to address the inflammatory lesions of the disease, Dr. Joseph F. Fowler, Jr., said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Rebound flushing wasn’t seen in the 52-week, large, open-label safety study of brimonidine gel, but has been anecdotally reported since its approval. Flushing occurs 12-24 hours after application, and usually lasts a day or two, according to Dr. Fowler, who was the first author of several multicenter randomized trials of the therapy.

“The rebound phenomenon is not something that frightens me or others I know who use the medication routinely, because it’s not something that’s going to cause a long-term problem,” he declared. Indeed, once brimonidine gel (Mirvaso) has quelled the erythema, the inflammatory lesions will stand out even more prominently, noted Dr. Fowler, the conference co-director and a dermatologist at the University of Louisville. “You’ve got to do something about the inflammatory component.”

Two topical therapies that address the inflammatory component include ivermectin 1% cream (Soolantra), shown to reduce counts of papules and pustules in two 40-week extension studies of phase III trials (J Drugs Dermatol. 2014 Nov;13[11]:1380-6), and azelaic acid 15% foam (Finacea), which also achieved an impressive reduction in inflammatory lesion counts in a phase III trial (Cutis. 2015 Jul;96[1]:54-61).

Both agents were well tolerated in those studies. That’s a major treatment consideration because rosacea patients have elevated facial skin sensitivity and often can’t tolerate older off-label topical therapies because of stinging and burning, according to Dr. Fowler.

Some rosacea patients are so intolerant of topicals that they prefer oral therapy. For those patients, subantimicrobial-dose doxycycline is a good option, Dr. Fowler said.

In addition to its anti-inflammatory effects, topical ivermectin kills Demodex. While rosacea is an inflammatory disorder, not an infection, drugs like ivermectin and crotamiton 10% cream (Eurax) that kill Demodex also improve rosacea, he observed.

The initial irritation event rate with azelaic acid 15% foam in the phase III trial was in the 2%-5% range, and those events were short lived. Irritation is a much bigger problem with the older azelaic acid 15% gel, with event rates in the 15%-25% range.

Dr. Fowler has also had good results using topical calcineurin inhibitors off-label for rosacea. Pimecrolimus cream (Elidel) is in ongoing studies for treatment of seborrheic dermatitis, which often coexists with rosacea, he noted.

He reported serving as a consultant to half a dozen pharmaceutical companies, including Galderma, which markets ivermectin cream and brimonidine gel, and Bayer, which markets azelaic acid foam.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – The topical vasoconstrictor brimonidine 0.33% gel brings impressive improvement in the facial redness component of rosacea, but it does nothing to address the inflammatory lesions of the disease, Dr. Joseph F. Fowler, Jr., said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Rebound flushing wasn’t seen in the 52-week, large, open-label safety study of brimonidine gel, but has been anecdotally reported since its approval. Flushing occurs 12-24 hours after application, and usually lasts a day or two, according to Dr. Fowler, who was the first author of several multicenter randomized trials of the therapy.

“The rebound phenomenon is not something that frightens me or others I know who use the medication routinely, because it’s not something that’s going to cause a long-term problem,” he declared. Indeed, once brimonidine gel (Mirvaso) has quelled the erythema, the inflammatory lesions will stand out even more prominently, noted Dr. Fowler, the conference co-director and a dermatologist at the University of Louisville. “You’ve got to do something about the inflammatory component.”

Two topical therapies that address the inflammatory component include ivermectin 1% cream (Soolantra), shown to reduce counts of papules and pustules in two 40-week extension studies of phase III trials (J Drugs Dermatol. 2014 Nov;13[11]:1380-6), and azelaic acid 15% foam (Finacea), which also achieved an impressive reduction in inflammatory lesion counts in a phase III trial (Cutis. 2015 Jul;96[1]:54-61).

Both agents were well tolerated in those studies. That’s a major treatment consideration because rosacea patients have elevated facial skin sensitivity and often can’t tolerate older off-label topical therapies because of stinging and burning, according to Dr. Fowler.

Some rosacea patients are so intolerant of topicals that they prefer oral therapy. For those patients, subantimicrobial-dose doxycycline is a good option, Dr. Fowler said.

In addition to its anti-inflammatory effects, topical ivermectin kills Demodex. While rosacea is an inflammatory disorder, not an infection, drugs like ivermectin and crotamiton 10% cream (Eurax) that kill Demodex also improve rosacea, he observed.

The initial irritation event rate with azelaic acid 15% foam in the phase III trial was in the 2%-5% range, and those events were short lived. Irritation is a much bigger problem with the older azelaic acid 15% gel, with event rates in the 15%-25% range.

Dr. Fowler has also had good results using topical calcineurin inhibitors off-label for rosacea. Pimecrolimus cream (Elidel) is in ongoing studies for treatment of seborrheic dermatitis, which often coexists with rosacea, he noted.

He reported serving as a consultant to half a dozen pharmaceutical companies, including Galderma, which markets ivermectin cream and brimonidine gel, and Bayer, which markets azelaic acid foam.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – Curettage alone for the treatment of basal cell carcinomas offers several distinct advantages over the widely accepted technique of curettage followed by electrodesiccation, Dr. David L. Swanson said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

When he asked for an audience show of hands as to who treats BCCs using curettage without electrodesiccation, the packed auditorium full of dermatologists remained hands-down. But there is good evidence that curettage alone provides cure rates similar to published rates for curettage and electrodesiccation, along with improved cosmesis, faster healing, and fewer problems with scarring and hypopigmentation, according to Dr. Swanson, a dermatologist at Mayo Clinic Arizona, Scottsdale.

He cited a persuasive study by other dermatologists at Mayo Clinic Arizona (J Am Acad Dermatol. 2006 Jun;54[6]:1039-45).

“This article was transformative for my practice,” said Dr. Swanson, who wasn’t involved in the study.

The investigators reviewed the records of 302 biopsy-proven BCCs in 136 patients. All were amenable to curettage and electrodesiccation but were instead treated by curettage alone during 1993-1998. The BCCs lacked histopathologic high-risk features; most were superficial or nodular lesions. Nearly one-quarter of the BCCs, however, were located on high-risk anatomic sites.

The 5-year cure rate was 96%. The authors’ review of 10 published series of BCCs treated using curettage and electrodesiccation showed recurrence rates mostly in the 3%-7% range.

Among the advantages cited by the investigators of going with curettage alone were its simplicity, reduced equipment requirement, cost effectiveness, lack of electrical interference with implantable cardiac devices, the avoidance of potentially hazardous viral smoke plumes, and reduced rates of hypopigmentation and scarring.

This was a retrospective study. Its other significant limitation was that all 302 BCCs were treated by the same dermatologist: Dr. Mark J. Zalla, who Dr. Swanson considers to be a dermatologic surgeon of exceptional talent.

“I’m not Mark Zalla. Nobody else in this room is Mark Zalla, so we can’t necessarily extrapolate from this study what your outcomes are going to be. That said, I’ve adopted this technique, and most of my colleagues do not do electrodesiccation anymore. I take off several basal cell carcinomas per day with curettage, and it’s my sense that I don’t have higher recurrence rates and that it does heal better with less scarring,” Dr. Swanson said.

He reported having no financial conflicts of interest regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Curettage alone for the treatment of basal cell carcinomas offers several distinct advantages over the widely accepted technique of curettage followed by electrodesiccation, Dr. David L. Swanson said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

When he asked for an audience show of hands as to who treats BCCs using curettage without electrodesiccation, the packed auditorium full of dermatologists remained hands-down. But there is good evidence that curettage alone provides cure rates similar to published rates for curettage and electrodesiccation, along with improved cosmesis, faster healing, and fewer problems with scarring and hypopigmentation, according to Dr. Swanson, a dermatologist at Mayo Clinic Arizona, Scottsdale.

He cited a persuasive study by other dermatologists at Mayo Clinic Arizona (J Am Acad Dermatol. 2006 Jun;54[6]:1039-45).

“This article was transformative for my practice,” said Dr. Swanson, who wasn’t involved in the study.

The investigators reviewed the records of 302 biopsy-proven BCCs in 136 patients. All were amenable to curettage and electrodesiccation but were instead treated by curettage alone during 1993-1998. The BCCs lacked histopathologic high-risk features; most were superficial or nodular lesions. Nearly one-quarter of the BCCs, however, were located on high-risk anatomic sites.

The 5-year cure rate was 96%. The authors’ review of 10 published series of BCCs treated using curettage and electrodesiccation showed recurrence rates mostly in the 3%-7% range.

Among the advantages cited by the investigators of going with curettage alone were its simplicity, reduced equipment requirement, cost effectiveness, lack of electrical interference with implantable cardiac devices, the avoidance of potentially hazardous viral smoke plumes, and reduced rates of hypopigmentation and scarring.

This was a retrospective study. Its other significant limitation was that all 302 BCCs were treated by the same dermatologist: Dr. Mark J. Zalla, who Dr. Swanson considers to be a dermatologic surgeon of exceptional talent.

“I’m not Mark Zalla. Nobody else in this room is Mark Zalla, so we can’t necessarily extrapolate from this study what your outcomes are going to be. That said, I’ve adopted this technique, and most of my colleagues do not do electrodesiccation anymore. I take off several basal cell carcinomas per day with curettage, and it’s my sense that I don’t have higher recurrence rates and that it does heal better with less scarring,” Dr. Swanson said.

He reported having no financial conflicts of interest regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Curettage alone for the treatment of basal cell carcinomas offers several distinct advantages over the widely accepted technique of curettage followed by electrodesiccation, Dr. David L. Swanson said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

When he asked for an audience show of hands as to who treats BCCs using curettage without electrodesiccation, the packed auditorium full of dermatologists remained hands-down. But there is good evidence that curettage alone provides cure rates similar to published rates for curettage and electrodesiccation, along with improved cosmesis, faster healing, and fewer problems with scarring and hypopigmentation, according to Dr. Swanson, a dermatologist at Mayo Clinic Arizona, Scottsdale.

He cited a persuasive study by other dermatologists at Mayo Clinic Arizona (J Am Acad Dermatol. 2006 Jun;54[6]:1039-45).

“This article was transformative for my practice,” said Dr. Swanson, who wasn’t involved in the study.

The investigators reviewed the records of 302 biopsy-proven BCCs in 136 patients. All were amenable to curettage and electrodesiccation but were instead treated by curettage alone during 1993-1998. The BCCs lacked histopathologic high-risk features; most were superficial or nodular lesions. Nearly one-quarter of the BCCs, however, were located on high-risk anatomic sites.

The 5-year cure rate was 96%. The authors’ review of 10 published series of BCCs treated using curettage and electrodesiccation showed recurrence rates mostly in the 3%-7% range.

Among the advantages cited by the investigators of going with curettage alone were its simplicity, reduced equipment requirement, cost effectiveness, lack of electrical interference with implantable cardiac devices, the avoidance of potentially hazardous viral smoke plumes, and reduced rates of hypopigmentation and scarring.

This was a retrospective study. Its other significant limitation was that all 302 BCCs were treated by the same dermatologist: Dr. Mark J. Zalla, who Dr. Swanson considers to be a dermatologic surgeon of exceptional talent.

“I’m not Mark Zalla. Nobody else in this room is Mark Zalla, so we can’t necessarily extrapolate from this study what your outcomes are going to be. That said, I’ve adopted this technique, and most of my colleagues do not do electrodesiccation anymore. I take off several basal cell carcinomas per day with curettage, and it’s my sense that I don’t have higher recurrence rates and that it does heal better with less scarring,” Dr. Swanson said.

He reported having no financial conflicts of interest regarding his presentation. SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Emailing patients must be done with care in order to avoid potentially treacherous medicolegal problems under the Health Insurance Portability and Accountability Act, Dr. Whitney A. High said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

And as for exchanging conventional texts with patients, colleagues, or staff, forget about it. Texting is a flat out terrible idea if the message includes anything defined under HIPAA as protected health information – and HIPAA’s definition is surprisingly inclusive, according to Dr. High, director of dermatopathology at the University of Colorado and a nonpracticing attorney who follows medicolegal issues closely. HIPAA is no longer the toothless paper tiger it was in the early years after the legislation’s passage. The HITECH Act of 2009 and the HIPAA Final Omnibus Rule of 2013 beefed up the financial penalties for HIPAA violations and allowed state attorneys general to enforce the law, not just federal officials. The revisions also reversed the burden of proof for breaches of HIPAA such that when protected health information gets mishandled, it’s automatically assumed that harm resulted. It’s up to the physician or health plan to prove otherwise.

Bruce Jancin/Frontline Medical News

For example, when an employee at a New England dermatology practice lost a flash drive containing before-and-after images from several thousand Mohs micrographic surgery procedures, the practice was fined $250,000 under HIPAA, even though there was no indication that the missing information had ever been published or misused in any way, Dr. High noted.

Under HIPAA, health information is protected if it’s identifiable. And the patient’s name needn’t be mentioned for that to be the case. A birth date, Social Security number, email address, medical record number, account number, website address, vehicle identifier, full-face photo, image of an unusual tattoo or birthmark – that’s all potentially identifiable and therefore protected information.

Dr. High recalled that while in law school, he had a professor who used to say that if you want your pants to stay up, the surest way is to use both a belt and suspenders.

“I’m a belt and suspenders guy. I practice dermatology that way,” he said by way of explaining his own cautious, multisafeguard approach to medicolegal self-protection in the Internet age.

“Unencrypted email is a morass,” he cautioned. It’s vulnerable to compromise at multiple points during a message’s transmission, receipt, and storage on a server. For that reason, a physician who emails patients should use email that’s encrypted “at rest”, meaning the server is encrypted and a Business Associate Agreement exists with the email provider. Even so, if the patient’s email is not encrypted there is the possibility of unauthorized access by a third party, so it’s advisable to obtain a written acceptance of this risk from the patient before responding to any medical questions the patient might pose electronically.

Dr. High and other providers in the University of Colorado system utilize a “patient portal” built into the group’s website. They can send encrypted emails to patients there. An alert about the message is sent to the patient’s unencrypted email, so the patient can go to the portal and read the secure email after creating an account and logging on.

Other secure options for email include RelayHealth (www.relayhealth.com), Pretty Good Privacy (www.pgp.com), Neocertified (www.neocertified.com), and Zixmail (www.zixcorp.com), although Dr. High noted he has no personal experience with any of those companies.

Sending out appointment reminder emails to patients without their permission in an effort to cut down on no-shows is a HIPAA violation. The correct, HIPAA-approved way to do this is to proactively get the patients’ written permission to receive such reminders, along with the email address where they’d like them to be sent and their acknowledgment that the reminder message could be intercepted if their email isn’t encrypted. That’s the belt-and-suspenders approach, Dr. High noted.

Most text messaging systems do not provide encryption. Thus, it’s not possible to safely send protected health information by text message. The only way to do so is to purchase the use of a pseudo–text messaging service such as Tiger Text (www.tigertext.com), QliqSOFT (www.qliqsoft.com), or Spok (www.spok.com), the dermatologist continued.

It’s important to understand that patients aren’t covered by HIPAA. They can email their physician with photos of a skin lesion, information about a change in their symptoms, or anything else without consequences under HIPAA. But if the photos or other data provided electronically by the patient are used in medical decision making, then that email must get incorporated into the electronic health record. Like the rest of the EHR, that email needs to be kept for 10 years and must be available on demand. In the event of a malpractice allegation, a physician will be on shaky ground if he says he based his medical decision on information provided in a patient’s email which no longer exists, Dr. High said.

He reported having no financial conflicts of interest regarding his presentation.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Emailing patients must be done with care in order to avoid potentially treacherous medicolegal problems under the Health Insurance Portability and Accountability Act, Dr. Whitney A. High said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

And as for exchanging conventional texts with patients, colleagues, or staff, forget about it. Texting is a flat out terrible idea if the message includes anything defined under HIPAA as protected health information – and HIPAA’s definition is surprisingly inclusive, according to Dr. High, director of dermatopathology at the University of Colorado and a nonpracticing attorney who follows medicolegal issues closely. HIPAA is no longer the toothless paper tiger it was in the early years after the legislation’s passage. The HITECH Act of 2009 and the HIPAA Final Omnibus Rule of 2013 beefed up the financial penalties for HIPAA violations and allowed state attorneys general to enforce the law, not just federal officials. The revisions also reversed the burden of proof for breaches of HIPAA such that when protected health information gets mishandled, it’s automatically assumed that harm resulted. It’s up to the physician or health plan to prove otherwise.

Bruce Jancin/Frontline Medical News

For example, when an employee at a New England dermatology practice lost a flash drive containing before-and-after images from several thousand Mohs micrographic surgery procedures, the practice was fined $250,000 under HIPAA, even though there was no indication that the missing information had ever been published or misused in any way, Dr. High noted.

Under HIPAA, health information is protected if it’s identifiable. And the patient’s name needn’t be mentioned for that to be the case. A birth date, Social Security number, email address, medical record number, account number, website address, vehicle identifier, full-face photo, image of an unusual tattoo or birthmark – that’s all potentially identifiable and therefore protected information.

Dr. High recalled that while in law school, he had a professor who used to say that if you want your pants to stay up, the surest way is to use both a belt and suspenders.

“I’m a belt and suspenders guy. I practice dermatology that way,” he said by way of explaining his own cautious, multisafeguard approach to medicolegal self-protection in the Internet age.

“Unencrypted email is a morass,” he cautioned. It’s vulnerable to compromise at multiple points during a message’s transmission, receipt, and storage on a server. For that reason, a physician who emails patients should use email that’s encrypted “at rest”, meaning the server is encrypted and a Business Associate Agreement exists with the email provider. Even so, if the patient’s email is not encrypted there is the possibility of unauthorized access by a third party, so it’s advisable to obtain a written acceptance of this risk from the patient before responding to any medical questions the patient might pose electronically.

Dr. High and other providers in the University of Colorado system utilize a “patient portal” built into the group’s website. They can send encrypted emails to patients there. An alert about the message is sent to the patient’s unencrypted email, so the patient can go to the portal and read the secure email after creating an account and logging on.

Other secure options for email include RelayHealth (www.relayhealth.com), Pretty Good Privacy (www.pgp.com), Neocertified (www.neocertified.com), and Zixmail (www.zixcorp.com), although Dr. High noted he has no personal experience with any of those companies.

Sending out appointment reminder emails to patients without their permission in an effort to cut down on no-shows is a HIPAA violation. The correct, HIPAA-approved way to do this is to proactively get the patients’ written permission to receive such reminders, along with the email address where they’d like them to be sent and their acknowledgment that the reminder message could be intercepted if their email isn’t encrypted. That’s the belt-and-suspenders approach, Dr. High noted.

Most text messaging systems do not provide encryption. Thus, it’s not possible to safely send protected health information by text message. The only way to do so is to purchase the use of a pseudo–text messaging service such as Tiger Text (www.tigertext.com), QliqSOFT (www.qliqsoft.com), or Spok (www.spok.com), the dermatologist continued.

It’s important to understand that patients aren’t covered by HIPAA. They can email their physician with photos of a skin lesion, information about a change in their symptoms, or anything else without consequences under HIPAA. But if the photos or other data provided electronically by the patient are used in medical decision making, then that email must get incorporated into the electronic health record. Like the rest of the EHR, that email needs to be kept for 10 years and must be available on demand. In the event of a malpractice allegation, a physician will be on shaky ground if he says he based his medical decision on information provided in a patient’s email which no longer exists, Dr. High said.

He reported having no financial conflicts of interest regarding his presentation.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Emailing patients must be done with care in order to avoid potentially treacherous medicolegal problems under the Health Insurance Portability and Accountability Act, Dr. Whitney A. High said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

And as for exchanging conventional texts with patients, colleagues, or staff, forget about it. Texting is a flat out terrible idea if the message includes anything defined under HIPAA as protected health information – and HIPAA’s definition is surprisingly inclusive, according to Dr. High, director of dermatopathology at the University of Colorado and a nonpracticing attorney who follows medicolegal issues closely. HIPAA is no longer the toothless paper tiger it was in the early years after the legislation’s passage. The HITECH Act of 2009 and the HIPAA Final Omnibus Rule of 2013 beefed up the financial penalties for HIPAA violations and allowed state attorneys general to enforce the law, not just federal officials. The revisions also reversed the burden of proof for breaches of HIPAA such that when protected health information gets mishandled, it’s automatically assumed that harm resulted. It’s up to the physician or health plan to prove otherwise.

Bruce Jancin/Frontline Medical News

For example, when an employee at a New England dermatology practice lost a flash drive containing before-and-after images from several thousand Mohs micrographic surgery procedures, the practice was fined $250,000 under HIPAA, even though there was no indication that the missing information had ever been published or misused in any way, Dr. High noted.

Under HIPAA, health information is protected if it’s identifiable. And the patient’s name needn’t be mentioned for that to be the case. A birth date, Social Security number, email address, medical record number, account number, website address, vehicle identifier, full-face photo, image of an unusual tattoo or birthmark – that’s all potentially identifiable and therefore protected information.

Dr. High recalled that while in law school, he had a professor who used to say that if you want your pants to stay up, the surest way is to use both a belt and suspenders.

“I’m a belt and suspenders guy. I practice dermatology that way,” he said by way of explaining his own cautious, multisafeguard approach to medicolegal self-protection in the Internet age.

“Unencrypted email is a morass,” he cautioned. It’s vulnerable to compromise at multiple points during a message’s transmission, receipt, and storage on a server. For that reason, a physician who emails patients should use email that’s encrypted “at rest”, meaning the server is encrypted and a Business Associate Agreement exists with the email provider. Even so, if the patient’s email is not encrypted there is the possibility of unauthorized access by a third party, so it’s advisable to obtain a written acceptance of this risk from the patient before responding to any medical questions the patient might pose electronically.

Dr. High and other providers in the University of Colorado system utilize a “patient portal” built into the group’s website. They can send encrypted emails to patients there. An alert about the message is sent to the patient’s unencrypted email, so the patient can go to the portal and read the secure email after creating an account and logging on.

Other secure options for email include RelayHealth (www.relayhealth.com), Pretty Good Privacy (www.pgp.com), Neocertified (www.neocertified.com), and Zixmail (www.zixcorp.com), although Dr. High noted he has no personal experience with any of those companies.

Sending out appointment reminder emails to patients without their permission in an effort to cut down on no-shows is a HIPAA violation. The correct, HIPAA-approved way to do this is to proactively get the patients’ written permission to receive such reminders, along with the email address where they’d like them to be sent and their acknowledgment that the reminder message could be intercepted if their email isn’t encrypted. That’s the belt-and-suspenders approach, Dr. High noted.

Most text messaging systems do not provide encryption. Thus, it’s not possible to safely send protected health information by text message. The only way to do so is to purchase the use of a pseudo–text messaging service such as Tiger Text (www.tigertext.com), QliqSOFT (www.qliqsoft.com), or Spok (www.spok.com), the dermatologist continued.

It’s important to understand that patients aren’t covered by HIPAA. They can email their physician with photos of a skin lesion, information about a change in their symptoms, or anything else without consequences under HIPAA. But if the photos or other data provided electronically by the patient are used in medical decision making, then that email must get incorporated into the electronic health record. Like the rest of the EHR, that email needs to be kept for 10 years and must be available on demand. In the event of a malpractice allegation, a physician will be on shaky ground if he says he based his medical decision on information provided in a patient’s email which no longer exists, Dr. High said.

He reported having no financial conflicts of interest regarding his presentation.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – The list of nonatopic comorbid conditions associated with atopic dermatitis is rapidly expanding.

Just in the past year, published studies have linked pediatric atopic dermatitis to increased risks of obesity, high blood pressure, headaches, anemia, and speech disorders. Meanwhile, adult atopic dermatitis was reported to be associated with increased rates of fracture and cardiovascular disease. And in the dermatologic arena, a link between atopic dermatitis, vitiligo, and alopecia areata was identified, Dr. Lawrence F. Eichenfield noted at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Actually, these reported associations published in 2015-2016 might best be termed “emerging comorbidities,” as they are first reports and thus need confirmation, said Dr. Eichenfield, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital San Diego.

Much of this work on emerging comorbidities has been done by dermatologist Dr. Jonathan I. Silverberg of Northwestern University, Chicago, and various coinvestigators. They have been prolific.

For example, in a multivariate logistic regression analysis of 207,007 children and adolescents included in the cross-sectional 1997-2013 U.S. National Health Interview Survey, Dr. Silverberg and coinvestigators found that eczema was independently associated with a 1.83-fold increased odds of anemia. They bolstered this observation with an analysis of more than 30,000 children and adolescents in the 1992-2012 National Health and Nutrition Examination Survey (NHANES) in which they found that current eczema was associated with a 1.93-fold increased odds of anemia, particularly microcytic anemia. The underlying mechanism is unknown; however, the investigators noted that chronic inflammation and systemic immunosuppressant drugs have been shown to be associated with anemia (JAMA Pediatr. 2016;170[1]:29-34).

Dr. Silverberg also found in a multivariate logistic regression analysis of data on more than 400,000 pediatric participants in the National Survey of Children’s Health and the National Health Interview Survey that mild and severe eczema were independently associated with 1.79-fold and 2.72-fold, respectively, increased odds of headaches (J Allergy Clin Immunol. 2016 Feb;137[2]:492-9).

Using these same two data sources, with multivariate analysis adjusted for potential confounders, the investigators found that eczema was associated with a 1.81-fold increased risk of speech disorder (J Pediatr. 2016 Jan;168:185-92).

In a case-control study involving 132 children and adolescents with current moderate to severe atopic dermatitis and 143 healthy controls, Dr. Silverberg and coinvestigators found in a logistic regression analysis that atopic dermatitis was independently associated with a doubled risk of having a systolic blood pressure in the 90th percentile or higher – as well as 3.92-fold increased odds of central obesity, as defined by a waist circumference in the 85th percentile or higher (JAMA Dermatol. 2015 Feb;151[2]:144-52).

In a systematic review and meta-analysis of 16 published vitiligo studies and 17 published studies of alopecia areata, Dr. Silverberg and medical student Girish C. Mohan found that patients with vitiligo or alopecia areata were respectively 7.8 and 2.6 times more likely to have atopic dermatitis than controls without those disorders (JAMA Dermatol. 2015 May;151[5]:522-8).

In a logistic regression analysis of data on 34,500 adults with a history of eczema within the prior year who participated in the 2012 National Health Interview Survey, Drs. Nitin Garg and Dr. Silverberg concluded that the results suggested that adult atopic dermatitis is a previously unrecognized risk factor for fracture and other bone or joint injuries causing limitation. Adults with atopic dermatitis were at a 1.67-fold increased risk for such injuries in an analysis controlling for sociodemographics, other forms of atopic disease, and psychiatric and behavioral disorders (JAMA Dermatol. 2015 Jan;151[1]:33-41).

In another large cross-sectional study, Dr. Silverberg found that adults with atopic dermatitis had significantly higher odds of a history of acute MI, coronary artery disease, heart failure, and stroke (Allergy. 2015 Oct;70[10]:1300-8).

Dr. Eichenfield said that while he would like to see these hot-off-the-presses 2015-2016 findings on nonatopic comorbidities backed up by confirmatory studies in other populations, the evidence is stronger for an association between pediatric atopic dermatitis and several mental health disorders. The initial reports came mainly from Europe, but were then supported by a large study by Dr. Eric L. Simpson and coinvestigators at Oregon Health and Science University, Portland.

In their analysis of data on nearly 93,000 noninstitutionalized children and adolescents included in the 2007 National Survey of Children’s Health, the investigators found after controlling for potential confounders that atopic dermatitis was associated with a 1.87-fold increased risk of having attention-deficit/hyperactivity disorder, a 3-fold increased risk of diagnosed autism, an adjusted 1.81-fold increase in depression, and 1.87-fold increased odds of conduct disorder. The Oregon group found a clear dose-dependent relationship between the reported severity of the skin disease and the likelihood of those mental health disorders (J Allergy Clin Immunol. 2013 Feb;131[2]:428-33).

The hope is that emerging strategies to prevent atopic dermatitis or aggressively treat it early on will reduce the risk of many of these comorbid conditions, Dr. Eichenfield said.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – The list of nonatopic comorbid conditions associated with atopic dermatitis is rapidly expanding.

Just in the past year, published studies have linked pediatric atopic dermatitis to increased risks of obesity, high blood pressure, headaches, anemia, and speech disorders. Meanwhile, adult atopic dermatitis was reported to be associated with increased rates of fracture and cardiovascular disease. And in the dermatologic arena, a link between atopic dermatitis, vitiligo, and alopecia areata was identified, Dr. Lawrence F. Eichenfield noted at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Actually, these reported associations published in 2015-2016 might best be termed “emerging comorbidities,” as they are first reports and thus need confirmation, said Dr. Eichenfield, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital San Diego.

Much of this work on emerging comorbidities has been done by dermatologist Dr. Jonathan I. Silverberg of Northwestern University, Chicago, and various coinvestigators. They have been prolific.

For example, in a multivariate logistic regression analysis of 207,007 children and adolescents included in the cross-sectional 1997-2013 U.S. National Health Interview Survey, Dr. Silverberg and coinvestigators found that eczema was independently associated with a 1.83-fold increased odds of anemia. They bolstered this observation with an analysis of more than 30,000 children and adolescents in the 1992-2012 National Health and Nutrition Examination Survey (NHANES) in which they found that current eczema was associated with a 1.93-fold increased odds of anemia, particularly microcytic anemia. The underlying mechanism is unknown; however, the investigators noted that chronic inflammation and systemic immunosuppressant drugs have been shown to be associated with anemia (JAMA Pediatr. 2016;170[1]:29-34).

Dr. Silverberg also found in a multivariate logistic regression analysis of data on more than 400,000 pediatric participants in the National Survey of Children’s Health and the National Health Interview Survey that mild and severe eczema were independently associated with 1.79-fold and 2.72-fold, respectively, increased odds of headaches (J Allergy Clin Immunol. 2016 Feb;137[2]:492-9).

Using these same two data sources, with multivariate analysis adjusted for potential confounders, the investigators found that eczema was associated with a 1.81-fold increased risk of speech disorder (J Pediatr. 2016 Jan;168:185-92).

In a case-control study involving 132 children and adolescents with current moderate to severe atopic dermatitis and 143 healthy controls, Dr. Silverberg and coinvestigators found in a logistic regression analysis that atopic dermatitis was independently associated with a doubled risk of having a systolic blood pressure in the 90th percentile or higher – as well as 3.92-fold increased odds of central obesity, as defined by a waist circumference in the 85th percentile or higher (JAMA Dermatol. 2015 Feb;151[2]:144-52).

In a systematic review and meta-analysis of 16 published vitiligo studies and 17 published studies of alopecia areata, Dr. Silverberg and medical student Girish C. Mohan found that patients with vitiligo or alopecia areata were respectively 7.8 and 2.6 times more likely to have atopic dermatitis than controls without those disorders (JAMA Dermatol. 2015 May;151[5]:522-8).

In a logistic regression analysis of data on 34,500 adults with a history of eczema within the prior year who participated in the 2012 National Health Interview Survey, Drs. Nitin Garg and Dr. Silverberg concluded that the results suggested that adult atopic dermatitis is a previously unrecognized risk factor for fracture and other bone or joint injuries causing limitation. Adults with atopic dermatitis were at a 1.67-fold increased risk for such injuries in an analysis controlling for sociodemographics, other forms of atopic disease, and psychiatric and behavioral disorders (JAMA Dermatol. 2015 Jan;151[1]:33-41).

In another large cross-sectional study, Dr. Silverberg found that adults with atopic dermatitis had significantly higher odds of a history of acute MI, coronary artery disease, heart failure, and stroke (Allergy. 2015 Oct;70[10]:1300-8).

Dr. Eichenfield said that while he would like to see these hot-off-the-presses 2015-2016 findings on nonatopic comorbidities backed up by confirmatory studies in other populations, the evidence is stronger for an association between pediatric atopic dermatitis and several mental health disorders. The initial reports came mainly from Europe, but were then supported by a large study by Dr. Eric L. Simpson and coinvestigators at Oregon Health and Science University, Portland.

In their analysis of data on nearly 93,000 noninstitutionalized children and adolescents included in the 2007 National Survey of Children’s Health, the investigators found after controlling for potential confounders that atopic dermatitis was associated with a 1.87-fold increased risk of having attention-deficit/hyperactivity disorder, a 3-fold increased risk of diagnosed autism, an adjusted 1.81-fold increase in depression, and 1.87-fold increased odds of conduct disorder. The Oregon group found a clear dose-dependent relationship between the reported severity of the skin disease and the likelihood of those mental health disorders (J Allergy Clin Immunol. 2013 Feb;131[2]:428-33).

The hope is that emerging strategies to prevent atopic dermatitis or aggressively treat it early on will reduce the risk of many of these comorbid conditions, Dr. Eichenfield said.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – The list of nonatopic comorbid conditions associated with atopic dermatitis is rapidly expanding.

Just in the past year, published studies have linked pediatric atopic dermatitis to increased risks of obesity, high blood pressure, headaches, anemia, and speech disorders. Meanwhile, adult atopic dermatitis was reported to be associated with increased rates of fracture and cardiovascular disease. And in the dermatologic arena, a link between atopic dermatitis, vitiligo, and alopecia areata was identified, Dr. Lawrence F. Eichenfield noted at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Actually, these reported associations published in 2015-2016 might best be termed “emerging comorbidities,” as they are first reports and thus need confirmation, said Dr. Eichenfield, professor of dermatology and pediatrics at the University of California, San Diego, and chief of pediatric and adolescent dermatology at Rady Children’s Hospital San Diego.

Much of this work on emerging comorbidities has been done by dermatologist Dr. Jonathan I. Silverberg of Northwestern University, Chicago, and various coinvestigators. They have been prolific.

For example, in a multivariate logistic regression analysis of 207,007 children and adolescents included in the cross-sectional 1997-2013 U.S. National Health Interview Survey, Dr. Silverberg and coinvestigators found that eczema was independently associated with a 1.83-fold increased odds of anemia. They bolstered this observation with an analysis of more than 30,000 children and adolescents in the 1992-2012 National Health and Nutrition Examination Survey (NHANES) in which they found that current eczema was associated with a 1.93-fold increased odds of anemia, particularly microcytic anemia. The underlying mechanism is unknown; however, the investigators noted that chronic inflammation and systemic immunosuppressant drugs have been shown to be associated with anemia (JAMA Pediatr. 2016;170[1]:29-34).

Dr. Silverberg also found in a multivariate logistic regression analysis of data on more than 400,000 pediatric participants in the National Survey of Children’s Health and the National Health Interview Survey that mild and severe eczema were independently associated with 1.79-fold and 2.72-fold, respectively, increased odds of headaches (J Allergy Clin Immunol. 2016 Feb;137[2]:492-9).

Using these same two data sources, with multivariate analysis adjusted for potential confounders, the investigators found that eczema was associated with a 1.81-fold increased risk of speech disorder (J Pediatr. 2016 Jan;168:185-92).

In a case-control study involving 132 children and adolescents with current moderate to severe atopic dermatitis and 143 healthy controls, Dr. Silverberg and coinvestigators found in a logistic regression analysis that atopic dermatitis was independently associated with a doubled risk of having a systolic blood pressure in the 90th percentile or higher – as well as 3.92-fold increased odds of central obesity, as defined by a waist circumference in the 85th percentile or higher (JAMA Dermatol. 2015 Feb;151[2]:144-52).

In a systematic review and meta-analysis of 16 published vitiligo studies and 17 published studies of alopecia areata, Dr. Silverberg and medical student Girish C. Mohan found that patients with vitiligo or alopecia areata were respectively 7.8 and 2.6 times more likely to have atopic dermatitis than controls without those disorders (JAMA Dermatol. 2015 May;151[5]:522-8).

In a logistic regression analysis of data on 34,500 adults with a history of eczema within the prior year who participated in the 2012 National Health Interview Survey, Drs. Nitin Garg and Dr. Silverberg concluded that the results suggested that adult atopic dermatitis is a previously unrecognized risk factor for fracture and other bone or joint injuries causing limitation. Adults with atopic dermatitis were at a 1.67-fold increased risk for such injuries in an analysis controlling for sociodemographics, other forms of atopic disease, and psychiatric and behavioral disorders (JAMA Dermatol. 2015 Jan;151[1]:33-41).

In another large cross-sectional study, Dr. Silverberg found that adults with atopic dermatitis had significantly higher odds of a history of acute MI, coronary artery disease, heart failure, and stroke (Allergy. 2015 Oct;70[10]:1300-8).

Dr. Eichenfield said that while he would like to see these hot-off-the-presses 2015-2016 findings on nonatopic comorbidities backed up by confirmatory studies in other populations, the evidence is stronger for an association between pediatric atopic dermatitis and several mental health disorders. The initial reports came mainly from Europe, but were then supported by a large study by Dr. Eric L. Simpson and coinvestigators at Oregon Health and Science University, Portland.

In their analysis of data on nearly 93,000 noninstitutionalized children and adolescents included in the 2007 National Survey of Children’s Health, the investigators found after controlling for potential confounders that atopic dermatitis was associated with a 1.87-fold increased risk of having attention-deficit/hyperactivity disorder, a 3-fold increased risk of diagnosed autism, an adjusted 1.81-fold increase in depression, and 1.87-fold increased odds of conduct disorder. The Oregon group found a clear dose-dependent relationship between the reported severity of the skin disease and the likelihood of those mental health disorders (J Allergy Clin Immunol. 2013 Feb;131[2]:428-33).

The hope is that emerging strategies to prevent atopic dermatitis or aggressively treat it early on will reduce the risk of many of these comorbid conditions, Dr. Eichenfield said.

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