Early detection of melanoma, which is known to improve survival rates, remains a challenge for dermatologists. Suspicious pigmented lesions typically are evaluated via clinical examination and dermoscopy; however, new technologies are being developed to provide additional objective information for clinicians to incorporate into their biopsy decisions.

Multispectral digital skin lesion analysis (MSDSLA) uses 10 bands of visible and near-infrared light (430–950 nm) to image and analyze pigmented skin lesions (PSLs) down to 2.5 mm below the skin surface and measures the distribution of melanin using 75 unique algorithms to determine the degree of the morphologic disorder. Using a logical regression model previously validated on a set of 1632 PSLs, the probability of melanoma and probability of being a melanoma/PSL of high-risk malignant potential are then provided to the clinician.¹

In this study, we analyzed aggregate data from 7 prior studies^2-8 to better determine how MSDSLA impacts the biopsy decisions of dermatologists and nondermatologists following clinical examination and dermoscopic evaluation of PSLs.

Methods

A total of 855 practitioners (657 dermatologists, 126 dermatology residents, 72 nondermatologists [ie, primary care physicians, physician assistants, nurse practitioners]) in 7 prior reader studies (Table)^2-8 were shown a total of 62 clinical (distant and close-up) and dermoscopic images of PSLs (13 invasive melanomas, 10 melanomas in situ, 7 high-grade dysplastic nevi, 32 benign skin lesions including low-grade dysplastic nevi) previously analyzed by MSDSLA.^2-8 For each lesion evaluated, the practitioners were first asked if they would biopsy based on their review of the clinical and dermoscopic images and were asked again when given the associated MSDSLA information. Data were aggregated across all participants for the individual lesions presented in each reader study. Biopsy decisions were compared overall after evaluation of clinical and dermoscopic findings and then after evaluation of MSDSLA findings. Statistical analyses were performed using t-test and χ² analysis for proportions where appropriate.

Results

Overall sensitivity for the detection of melanoma or other high-grade PSLs improved from 70% on clinical and dermoscopic evaluation to 88% after MSDSLA information was provided (P<.0001), and specificity increased from 52% to 58% (P<.001). Diagnostic accuracy also improved from 59% on clinical evaluation to 69% after review of MSDSLA findings (P<.0001). The positive predictive value of biopsy decisions was 47% following clinical evaluation, which improved to 56% after evaluation of MSDSLA findings (P<.001), and the negative predictive value increased from 74% to 89% (P<.0001). The overall percentage of lesions selected for biopsy did not significantly change following MSDSLA data integration (57% vs 60%)(Figure). Given that similar numbers of lesions were biopsied with improved sensitivity and specificity, the integration of MSDSLA data into the biopsy decision led to an improved biopsy ratio (ratio of melanomas biopsied to total biopsies) and fewer unnecessary biopsies.

Comment

Our broad analysis further supported the findings of prior studies that decisions to biopsy clinically suspicious PSLs are more sensitive, specific, and accurate when practitioners are provided MSDSLA information following clinical examination.^2-8With no significant increase in the number of biopsies performed, the fact that all 5 of the standard diagnostic evaluation metrics (sensitivity, specificity, diagnostic accuracy, positive predictive value, negative predictive value) were improved after MSDSLA information was provided additionally supported this conclusion.

Given the evolution in health care economics, it is clear that greater emphasis will continue to be placed on superior, evidence-based, effective care. The reported diagnostic sensitivities and specificities of clinical evaluation and dermoscopy for melanoma detection vary widely throughout the literature, with sensitivities ranging from 58% to over 90% and specificities ranging from 77% to 99%.^9-11Diagnostic performance generally has been found to be higher among dermatologists than nondermatologists and is highest in specialized pigmented lesion clinics.¹²

Our study had several limitations. For this analysis to be more representative of lesion biopsy selection in the clinical setting, biopsy sensitivity (correctly identifying lesions appropriate for biopsy) vs melanoma sensitivity (identifying a lesion as melanoma) was used.¹³ The overall sensitivity found was within the range of prior studies,^2-8 but this approach may have potentially led to a lower specificity due to an increased number of lesions biopsied. Additionally, the melanomas selected for these studies were early (malignant melanoma in situ or mean thickness of invasive malignant melanoma of 0.3 mm), and the nonmelanomas (including low-grade dysplastic nevi) were not necessarily diagnostically straightforward. This may have led to the clinical and dermoscopic sensitivity and specificity noted being lower than in some prior studies.^9-11

The risk of missing a melanoma with MSDSLA devices has led manufacturers to strive for a high sensitivity for their devices, leading to lower specificity as a consequence. For this reason and other ambiguous practical considerations (eg, device and patient costs, difficulty with insurance reimbursement), the adoption of this technology into routine clinical practice has remained relatively static; however, using enhanced diagnostic technologies such as MSDSLA may help with more accurate identification of high-risk PSLs, thereby leading to earlier detection and overall less expensive, more cost-effective treatment of melanoma.

Early detection of melanoma, which is known to improve survival rates, remains a challenge for dermatologists. Suspicious pigmented lesions typically are evaluated via clinical examination and dermoscopy; however, new technologies are being developed to provide additional objective information for clinicians to incorporate into their biopsy decisions.

Multispectral digital skin lesion analysis (MSDSLA) uses 10 bands of visible and near-infrared light (430–950 nm) to image and analyze pigmented skin lesions (PSLs) down to 2.5 mm below the skin surface and measures the distribution of melanin using 75 unique algorithms to determine the degree of the morphologic disorder. Using a logical regression model previously validated on a set of 1632 PSLs, the probability of melanoma and probability of being a melanoma/PSL of high-risk malignant potential are then provided to the clinician.¹

In this study, we analyzed aggregate data from 7 prior studies^2-8 to better determine how MSDSLA impacts the biopsy decisions of dermatologists and nondermatologists following clinical examination and dermoscopic evaluation of PSLs.

Methods

A total of 855 practitioners (657 dermatologists, 126 dermatology residents, 72 nondermatologists [ie, primary care physicians, physician assistants, nurse practitioners]) in 7 prior reader studies (Table)^2-8 were shown a total of 62 clinical (distant and close-up) and dermoscopic images of PSLs (13 invasive melanomas, 10 melanomas in situ, 7 high-grade dysplastic nevi, 32 benign skin lesions including low-grade dysplastic nevi) previously analyzed by MSDSLA.^2-8 For each lesion evaluated, the practitioners were first asked if they would biopsy based on their review of the clinical and dermoscopic images and were asked again when given the associated MSDSLA information. Data were aggregated across all participants for the individual lesions presented in each reader study. Biopsy decisions were compared overall after evaluation of clinical and dermoscopic findings and then after evaluation of MSDSLA findings. Statistical analyses were performed using t-test and χ² analysis for proportions where appropriate.

Results

Overall sensitivity for the detection of melanoma or other high-grade PSLs improved from 70% on clinical and dermoscopic evaluation to 88% after MSDSLA information was provided (P<.0001), and specificity increased from 52% to 58% (P<.001). Diagnostic accuracy also improved from 59% on clinical evaluation to 69% after review of MSDSLA findings (P<.0001). The positive predictive value of biopsy decisions was 47% following clinical evaluation, which improved to 56% after evaluation of MSDSLA findings (P<.001), and the negative predictive value increased from 74% to 89% (P<.0001). The overall percentage of lesions selected for biopsy did not significantly change following MSDSLA data integration (57% vs 60%)(Figure). Given that similar numbers of lesions were biopsied with improved sensitivity and specificity, the integration of MSDSLA data into the biopsy decision led to an improved biopsy ratio (ratio of melanomas biopsied to total biopsies) and fewer unnecessary biopsies.

Comment

Our broad analysis further supported the findings of prior studies that decisions to biopsy clinically suspicious PSLs are more sensitive, specific, and accurate when practitioners are provided MSDSLA information following clinical examination.^2-8With no significant increase in the number of biopsies performed, the fact that all 5 of the standard diagnostic evaluation metrics (sensitivity, specificity, diagnostic accuracy, positive predictive value, negative predictive value) were improved after MSDSLA information was provided additionally supported this conclusion.

Given the evolution in health care economics, it is clear that greater emphasis will continue to be placed on superior, evidence-based, effective care. The reported diagnostic sensitivities and specificities of clinical evaluation and dermoscopy for melanoma detection vary widely throughout the literature, with sensitivities ranging from 58% to over 90% and specificities ranging from 77% to 99%.^9-11Diagnostic performance generally has been found to be higher among dermatologists than nondermatologists and is highest in specialized pigmented lesion clinics.¹²

Our study had several limitations. For this analysis to be more representative of lesion biopsy selection in the clinical setting, biopsy sensitivity (correctly identifying lesions appropriate for biopsy) vs melanoma sensitivity (identifying a lesion as melanoma) was used.¹³ The overall sensitivity found was within the range of prior studies,^2-8 but this approach may have potentially led to a lower specificity due to an increased number of lesions biopsied. Additionally, the melanomas selected for these studies were early (malignant melanoma in situ or mean thickness of invasive malignant melanoma of 0.3 mm), and the nonmelanomas (including low-grade dysplastic nevi) were not necessarily diagnostically straightforward. This may have led to the clinical and dermoscopic sensitivity and specificity noted being lower than in some prior studies.^9-11

The risk of missing a melanoma with MSDSLA devices has led manufacturers to strive for a high sensitivity for their devices, leading to lower specificity as a consequence. For this reason and other ambiguous practical considerations (eg, device and patient costs, difficulty with insurance reimbursement), the adoption of this technology into routine clinical practice has remained relatively static; however, using enhanced diagnostic technologies such as MSDSLA may help with more accurate identification of high-risk PSLs, thereby leading to earlier detection and overall less expensive, more cost-effective treatment of melanoma.

Early detection of melanoma, which is known to improve survival rates, remains a challenge for dermatologists. Suspicious pigmented lesions typically are evaluated via clinical examination and dermoscopy; however, new technologies are being developed to provide additional objective information for clinicians to incorporate into their biopsy decisions.

Multispectral digital skin lesion analysis (MSDSLA) uses 10 bands of visible and near-infrared light (430–950 nm) to image and analyze pigmented skin lesions (PSLs) down to 2.5 mm below the skin surface and measures the distribution of melanin using 75 unique algorithms to determine the degree of the morphologic disorder. Using a logical regression model previously validated on a set of 1632 PSLs, the probability of melanoma and probability of being a melanoma/PSL of high-risk malignant potential are then provided to the clinician.¹

In this study, we analyzed aggregate data from 7 prior studies^2-8 to better determine how MSDSLA impacts the biopsy decisions of dermatologists and nondermatologists following clinical examination and dermoscopic evaluation of PSLs.

Methods

A total of 855 practitioners (657 dermatologists, 126 dermatology residents, 72 nondermatologists [ie, primary care physicians, physician assistants, nurse practitioners]) in 7 prior reader studies (Table)^2-8 were shown a total of 62 clinical (distant and close-up) and dermoscopic images of PSLs (13 invasive melanomas, 10 melanomas in situ, 7 high-grade dysplastic nevi, 32 benign skin lesions including low-grade dysplastic nevi) previously analyzed by MSDSLA.^2-8 For each lesion evaluated, the practitioners were first asked if they would biopsy based on their review of the clinical and dermoscopic images and were asked again when given the associated MSDSLA information. Data were aggregated across all participants for the individual lesions presented in each reader study. Biopsy decisions were compared overall after evaluation of clinical and dermoscopic findings and then after evaluation of MSDSLA findings. Statistical analyses were performed using t-test and χ² analysis for proportions where appropriate.

Results

Overall sensitivity for the detection of melanoma or other high-grade PSLs improved from 70% on clinical and dermoscopic evaluation to 88% after MSDSLA information was provided (P<.0001), and specificity increased from 52% to 58% (P<.001). Diagnostic accuracy also improved from 59% on clinical evaluation to 69% after review of MSDSLA findings (P<.0001). The positive predictive value of biopsy decisions was 47% following clinical evaluation, which improved to 56% after evaluation of MSDSLA findings (P<.001), and the negative predictive value increased from 74% to 89% (P<.0001). The overall percentage of lesions selected for biopsy did not significantly change following MSDSLA data integration (57% vs 60%)(Figure). Given that similar numbers of lesions were biopsied with improved sensitivity and specificity, the integration of MSDSLA data into the biopsy decision led to an improved biopsy ratio (ratio of melanomas biopsied to total biopsies) and fewer unnecessary biopsies.

Comment

Our broad analysis further supported the findings of prior studies that decisions to biopsy clinically suspicious PSLs are more sensitive, specific, and accurate when practitioners are provided MSDSLA information following clinical examination.^2-8With no significant increase in the number of biopsies performed, the fact that all 5 of the standard diagnostic evaluation metrics (sensitivity, specificity, diagnostic accuracy, positive predictive value, negative predictive value) were improved after MSDSLA information was provided additionally supported this conclusion.

Given the evolution in health care economics, it is clear that greater emphasis will continue to be placed on superior, evidence-based, effective care. The reported diagnostic sensitivities and specificities of clinical evaluation and dermoscopy for melanoma detection vary widely throughout the literature, with sensitivities ranging from 58% to over 90% and specificities ranging from 77% to 99%.^9-11Diagnostic performance generally has been found to be higher among dermatologists than nondermatologists and is highest in specialized pigmented lesion clinics.¹²

Our study had several limitations. For this analysis to be more representative of lesion biopsy selection in the clinical setting, biopsy sensitivity (correctly identifying lesions appropriate for biopsy) vs melanoma sensitivity (identifying a lesion as melanoma) was used.¹³ The overall sensitivity found was within the range of prior studies,^2-8 but this approach may have potentially led to a lower specificity due to an increased number of lesions biopsied. Additionally, the melanomas selected for these studies were early (malignant melanoma in situ or mean thickness of invasive malignant melanoma of 0.3 mm), and the nonmelanomas (including low-grade dysplastic nevi) were not necessarily diagnostically straightforward. This may have led to the clinical and dermoscopic sensitivity and specificity noted being lower than in some prior studies.^9-11

The risk of missing a melanoma with MSDSLA devices has led manufacturers to strive for a high sensitivity for their devices, leading to lower specificity as a consequence. For this reason and other ambiguous practical considerations (eg, device and patient costs, difficulty with insurance reimbursement), the adoption of this technology into routine clinical practice has remained relatively static; however, using enhanced diagnostic technologies such as MSDSLA may help with more accurate identification of high-risk PSLs, thereby leading to earlier detection and overall less expensive, more cost-effective treatment of melanoma.

Telemedicine arose from the need to provide critical and timely advice directly to health care providers and patients in remote or resource-scarce settings. Whether by radio, telephone, or other means of telecommunication technology, the US military has long utilized telemedicine. What started as a way to expedite the delivery of emergency consultations and medical expertise to remote populations in need has since evolved into a billion-dollar innovation industry that is poised to improve health care efficiency and access to specialist care as well as to lower health care costs for all patients.

Teledermatology in the Military

A primary mission of military medicine is to keep service members anywhere in the world in good health on the job during training, combat, and humanitarian operations.¹ Telemedicine greatly supports this mission by bringing the expertise of medical specialists to service members in the field without the cost or risks of travel for physicians. Telemedicine also is effective in promoting timely triage of patients and administration of the most appropriate levels of care. With the advent and globalization of high-speed wireless networks, advancements in telemedicine continue to develop and are becoming increasingly useful in military medicine.

As a specialty, dermatology is heavily reliant on visual information and therefore is particularly amenable to telemedicine applications. The rising popularity of such services has led to the development of the term teledermatology. While early teledermatology services were provided using radio, telephone, fax, and videoconferencing,² three distinct visual methods typically are used today, including (1) store-and-forward (S&F), (2) live-interactive, and (3) a hybrid of the two.³ Military dermatology predominantly utilizes an S&F system, as still photographs of lesions generally are preferred over video for more focused visualization.

In 2004, the US Army Medical Department established a centralized telemedicine program using Army Knowledge Online,¹ an S&F system that allows providers in remote locations to store and forward information about a patient’s clinical history along with digital photographs of the patient’s condition to a military dermatologist to review and make a diagnosis or suggest a treatment from a different location at a later time. Using this platform to provide asynchronous teledermatology services avoids the logistics required to schedule appointments and promotes convenience and more efficient use of physicians’ time and resources.

Given the ease of use of S&F systems among military practitioners, dermatology became one of the most heavily utilized teleconsultation specialties within the Army Knowledge Online system, accounting for 40% of the 10,817 consultations initiated from April 2004 to December 2012.⁵ It also is important to note that skin conditions historically account for 15% to 75% of outpatient visits during wartime; therefore, there is a need for dermatologic consultations, as primary care providers typically are responsible for providing dermatologic care to these patients.⁶ Because of the high demand for and low volume of US military dermatologists, the use of teledermatology (ie, Amy Knowledge Online) in the US military became a helpful educational tool and specialist extender for many primary care providers in the military.

Teledermatology in the military has evolved to not only provide timely and efficient care but also to reduce health care costs. In a retrospective evaluation of the US Department of Defense’s teledermatology consultation program from April 2004 to December 2012, as many as 98% of teledermatology consultations were answered within 24 hours of submission, 46 medical evacuations were avoided, and 41 medical evacuations were facilitated.⁴ In a study of teledermatology services used by deployed clinicians in Iraq from January 2005 to January 2009, it was estimated that teledermatology services would help save the military approximately $30.4 million among 2157 dermatology patients.⁷

Advances in Teledermatology

While the military continues to use S&F teleconsultations—a model in which a deployed referring clinician sends information to a military dermatologist for diagnosis and/or management recommendations—a number of teledermatology programs have been developed for civilians that provide additional advantages over standard face-to-face dermatology care. The advantages of S&F teledermatology applications are many, including faster communication with dermatology providers, diagnostic concordance comparable to face-to-face appointments, cost-effective care for patients, the ability to educate providers remotely,⁸ and similar outcomes to in-person care.⁹ However, as to be expected, in-person care remains the gold standard, especially when diagnostic accuracy depends on biopsy findings. A recent systematic review of teledermatology applications in the diagnosis and management of skin cancer showed that the diagnostic accuracy of in-person dermatology consultations remained higher than the accuracy provided by teledermatology consultations; however, as a result of additional technological advances in the quality of digital photography, some investigators have reported high accuracy when macroscopic and dermoscopic images were used in tandem.¹⁰

The development of the smartphone along with advances in digital photography and consumer-friendly mobile applications has allowed for the emergence of direct-to-consumer (DTC) teledermatology applications. Regardless of the user’s ability, the quality of photographs taken with smartphones has improved, as standard features such as high-resolution cameras with image stabilization, automatic focus, and lighting have become commonplace. The popularity of smartphone technology also has increased, with nearly 75% of all adults and more than 90% of adults younger than 35 years of age owning a smartphone according to a 2016 survey.¹¹

In 2015, there were at least 29 DTC teledermatology applications available on various mobile platforms,¹² accounting for an estimated 1.25 million teleconsultations with providers.¹³ Teledermatology platforms such as DermatologistOnCall and Spruce Health have made accessing dermatologic care convenient, timely, and affordable for patients via patient-friendly mobile applications. Direct-to-consumer telemedicine allows patients to communicate directly with a specialist without the need for a referral from a primary care provider–gatekeeper.¹⁴

Regular access to dermatologic care is especially important for patients who have chronic skin conditions. Several unique practice models have emerged as innovative solutions to providing more convenient and timely care. For example, Curology (https://curology.com) is an online teledermatology practice specializing in acne treatment. The cost to the patient includes unlimited dermatology consultations via a web application and custom-made prescription topical medication sent by mail. Clarify Medical (www.clarifymed.com) makes phototherapy easy for patients and health care providers. Although narrowband UVB treatment traditionally is administered in a dermatologist’s office 3 times weekly for several months until a skin condition has cleared, this smartphone application facilitates convenient, at-home phototherapy. An app-enabled light source allows patients to treat themselves in their own homes within the parameters of a physician’s prescription.

Although DTC teledermatology practices are convenient for many patients and providers, some have been criticized for providing poor quality of care¹² or facilitating fragmented care by not integrating with established electronic health record (EHR) systems.¹⁵ As a result, recommended practice guidelines for DTC teledermatology have been developed by the American Academy of Dermatology and some state medical boards.¹⁶ Moreover, several EHR systems, such as Epic (www.epic.com) and Modernizing Medicine’s EMA (www.modmed.com), have developed fully integrated S&F teledermatology platforms to be incorporated with established brick-and-mortar care.¹⁷

The Future of Teledermatology in the Military

The Army Knowledge Online telemedicine platform used by the US military has continued to be useful, particularly when treating patients in remote locations, and shows promise for improving routine domestic dermatology care. It has reduced the number of medical evacuations and improved care for those who do not have access to a dermatologist.⁴ Furthermore, one study noted that most consultations submitted via teledermatology applications from a combat zone received a diagnosis and treatment recommendation from a military dermatologist faster than they would have stateside, where the wait often is 4 to 8 weeks. On average, a teledermatology consultation from Afghanistan was answered in less than 6 hours.⁴ Although this response time might not be realistic for all dermatology practices, there clearly is potential in certain situations and utilizing certain models of care to diagnose and treat more patients more efficiently utilizing teledermatology applications than in an in-person office visit. A review of 658 teledermatology consultations in the US military from January 2011 to December 2012 revealed that the leading diagnoses were eczematous dermatitis (14%), contact dermatitis (9%), nonmelanoma skin cancer (5%), psoriasis (4%), and urticaria (4%).⁴ Increased use of teledermatology evaluation of these conditions in routine US-based military practice could help expedite care, decrease patient travel time, and utilize in-clinic dermatologist time more efficiently. Teledermatology visits for postoperative concerns also have demonstrated utility and convenience for triage and management of patients in the civilian setting and may be an additional novel use of teledermatology in the military setting.¹⁸ With the use of an integrated S&F teledermatology platform within an existing EHR system that is paired with a secure patient mobile application that allows easy upload of photos, medical history, and messaging, it can be argued that quality of life could greatly be enhanced for both military patients and providers.

Limitations of Teledermatology

Certainly, there are and will always be limitations to teledermatology. Even as digital photography improves, the quality and context of clinical images are user dependent, and key associated skin findings in other locations of the body can be missed. The ability to palpate the skin also is lacking in virtual encounters. Therefore, teledermatology might be considered most appropriate for specific diseases and conditions (eg, acne, psoriasis, eczema). Embracing teledermatology does not mean replacing in-person care; rather, it should be seen as an adjunct used to manage the high demand for dermatology expertise in military and civilian practice. For the US military, the promise and potential to embrace innovation in providing dermatologic care is there, as long as there are leaders to continue to champion it. In the current state of health care, many of the perceived barriers of teledermatology applications have already been overcome, including lack of training, lack of reimbursement, and perceived medicolegal risks.¹⁹

The US Federal Government is a large entity, and it will undoubtedly take time and effort to implement new and innovative programs such as the ones described here in the military. The first step in implementation is awareness that the possibilities exist; then, with the cooperation of dermatologists and support from the chain of command, it will be possible to incorporate advances in teledermatology and cultivate new ones.

Final Thoughts

The S&F teledermatology method used in the military setting has become commonplace in both military and civilian settings alike. Newer innovations in telemedicine, particularly in teledermatology, will continue to shape the future of military and civilian medicine for years to come.

Telemedicine arose from the need to provide critical and timely advice directly to health care providers and patients in remote or resource-scarce settings. Whether by radio, telephone, or other means of telecommunication technology, the US military has long utilized telemedicine. What started as a way to expedite the delivery of emergency consultations and medical expertise to remote populations in need has since evolved into a billion-dollar innovation industry that is poised to improve health care efficiency and access to specialist care as well as to lower health care costs for all patients.

Teledermatology in the Military

A primary mission of military medicine is to keep service members anywhere in the world in good health on the job during training, combat, and humanitarian operations.¹ Telemedicine greatly supports this mission by bringing the expertise of medical specialists to service members in the field without the cost or risks of travel for physicians. Telemedicine also is effective in promoting timely triage of patients and administration of the most appropriate levels of care. With the advent and globalization of high-speed wireless networks, advancements in telemedicine continue to develop and are becoming increasingly useful in military medicine.

As a specialty, dermatology is heavily reliant on visual information and therefore is particularly amenable to telemedicine applications. The rising popularity of such services has led to the development of the term teledermatology. While early teledermatology services were provided using radio, telephone, fax, and videoconferencing,² three distinct visual methods typically are used today, including (1) store-and-forward (S&F), (2) live-interactive, and (3) a hybrid of the two.³ Military dermatology predominantly utilizes an S&F system, as still photographs of lesions generally are preferred over video for more focused visualization.

In 2004, the US Army Medical Department established a centralized telemedicine program using Army Knowledge Online,¹ an S&F system that allows providers in remote locations to store and forward information about a patient’s clinical history along with digital photographs of the patient’s condition to a military dermatologist to review and make a diagnosis or suggest a treatment from a different location at a later time. Using this platform to provide asynchronous teledermatology services avoids the logistics required to schedule appointments and promotes convenience and more efficient use of physicians’ time and resources.

Given the ease of use of S&F systems among military practitioners, dermatology became one of the most heavily utilized teleconsultation specialties within the Army Knowledge Online system, accounting for 40% of the 10,817 consultations initiated from April 2004 to December 2012.⁵ It also is important to note that skin conditions historically account for 15% to 75% of outpatient visits during wartime; therefore, there is a need for dermatologic consultations, as primary care providers typically are responsible for providing dermatologic care to these patients.⁶ Because of the high demand for and low volume of US military dermatologists, the use of teledermatology (ie, Amy Knowledge Online) in the US military became a helpful educational tool and specialist extender for many primary care providers in the military.

Teledermatology in the military has evolved to not only provide timely and efficient care but also to reduce health care costs. In a retrospective evaluation of the US Department of Defense’s teledermatology consultation program from April 2004 to December 2012, as many as 98% of teledermatology consultations were answered within 24 hours of submission, 46 medical evacuations were avoided, and 41 medical evacuations were facilitated.⁴ In a study of teledermatology services used by deployed clinicians in Iraq from January 2005 to January 2009, it was estimated that teledermatology services would help save the military approximately $30.4 million among 2157 dermatology patients.⁷

Advances in Teledermatology

While the military continues to use S&F teleconsultations—a model in which a deployed referring clinician sends information to a military dermatologist for diagnosis and/or management recommendations—a number of teledermatology programs have been developed for civilians that provide additional advantages over standard face-to-face dermatology care. The advantages of S&F teledermatology applications are many, including faster communication with dermatology providers, diagnostic concordance comparable to face-to-face appointments, cost-effective care for patients, the ability to educate providers remotely,⁸ and similar outcomes to in-person care.⁹ However, as to be expected, in-person care remains the gold standard, especially when diagnostic accuracy depends on biopsy findings. A recent systematic review of teledermatology applications in the diagnosis and management of skin cancer showed that the diagnostic accuracy of in-person dermatology consultations remained higher than the accuracy provided by teledermatology consultations; however, as a result of additional technological advances in the quality of digital photography, some investigators have reported high accuracy when macroscopic and dermoscopic images were used in tandem.¹⁰

The development of the smartphone along with advances in digital photography and consumer-friendly mobile applications has allowed for the emergence of direct-to-consumer (DTC) teledermatology applications. Regardless of the user’s ability, the quality of photographs taken with smartphones has improved, as standard features such as high-resolution cameras with image stabilization, automatic focus, and lighting have become commonplace. The popularity of smartphone technology also has increased, with nearly 75% of all adults and more than 90% of adults younger than 35 years of age owning a smartphone according to a 2016 survey.¹¹

In 2015, there were at least 29 DTC teledermatology applications available on various mobile platforms,¹² accounting for an estimated 1.25 million teleconsultations with providers.¹³ Teledermatology platforms such as DermatologistOnCall and Spruce Health have made accessing dermatologic care convenient, timely, and affordable for patients via patient-friendly mobile applications. Direct-to-consumer telemedicine allows patients to communicate directly with a specialist without the need for a referral from a primary care provider–gatekeeper.¹⁴

Regular access to dermatologic care is especially important for patients who have chronic skin conditions. Several unique practice models have emerged as innovative solutions to providing more convenient and timely care. For example, Curology (https://curology.com) is an online teledermatology practice specializing in acne treatment. The cost to the patient includes unlimited dermatology consultations via a web application and custom-made prescription topical medication sent by mail. Clarify Medical (www.clarifymed.com) makes phototherapy easy for patients and health care providers. Although narrowband UVB treatment traditionally is administered in a dermatologist’s office 3 times weekly for several months until a skin condition has cleared, this smartphone application facilitates convenient, at-home phototherapy. An app-enabled light source allows patients to treat themselves in their own homes within the parameters of a physician’s prescription.

Although DTC teledermatology practices are convenient for many patients and providers, some have been criticized for providing poor quality of care¹² or facilitating fragmented care by not integrating with established electronic health record (EHR) systems.¹⁵ As a result, recommended practice guidelines for DTC teledermatology have been developed by the American Academy of Dermatology and some state medical boards.¹⁶ Moreover, several EHR systems, such as Epic (www.epic.com) and Modernizing Medicine’s EMA (www.modmed.com), have developed fully integrated S&F teledermatology platforms to be incorporated with established brick-and-mortar care.¹⁷

The Future of Teledermatology in the Military

The Army Knowledge Online telemedicine platform used by the US military has continued to be useful, particularly when treating patients in remote locations, and shows promise for improving routine domestic dermatology care. It has reduced the number of medical evacuations and improved care for those who do not have access to a dermatologist.⁴ Furthermore, one study noted that most consultations submitted via teledermatology applications from a combat zone received a diagnosis and treatment recommendation from a military dermatologist faster than they would have stateside, where the wait often is 4 to 8 weeks. On average, a teledermatology consultation from Afghanistan was answered in less than 6 hours.⁴ Although this response time might not be realistic for all dermatology practices, there clearly is potential in certain situations and utilizing certain models of care to diagnose and treat more patients more efficiently utilizing teledermatology applications than in an in-person office visit. A review of 658 teledermatology consultations in the US military from January 2011 to December 2012 revealed that the leading diagnoses were eczematous dermatitis (14%), contact dermatitis (9%), nonmelanoma skin cancer (5%), psoriasis (4%), and urticaria (4%).⁴ Increased use of teledermatology evaluation of these conditions in routine US-based military practice could help expedite care, decrease patient travel time, and utilize in-clinic dermatologist time more efficiently. Teledermatology visits for postoperative concerns also have demonstrated utility and convenience for triage and management of patients in the civilian setting and may be an additional novel use of teledermatology in the military setting.¹⁸ With the use of an integrated S&F teledermatology platform within an existing EHR system that is paired with a secure patient mobile application that allows easy upload of photos, medical history, and messaging, it can be argued that quality of life could greatly be enhanced for both military patients and providers.

Limitations of Teledermatology

Certainly, there are and will always be limitations to teledermatology. Even as digital photography improves, the quality and context of clinical images are user dependent, and key associated skin findings in other locations of the body can be missed. The ability to palpate the skin also is lacking in virtual encounters. Therefore, teledermatology might be considered most appropriate for specific diseases and conditions (eg, acne, psoriasis, eczema). Embracing teledermatology does not mean replacing in-person care; rather, it should be seen as an adjunct used to manage the high demand for dermatology expertise in military and civilian practice. For the US military, the promise and potential to embrace innovation in providing dermatologic care is there, as long as there are leaders to continue to champion it. In the current state of health care, many of the perceived barriers of teledermatology applications have already been overcome, including lack of training, lack of reimbursement, and perceived medicolegal risks.¹⁹

The US Federal Government is a large entity, and it will undoubtedly take time and effort to implement new and innovative programs such as the ones described here in the military. The first step in implementation is awareness that the possibilities exist; then, with the cooperation of dermatologists and support from the chain of command, it will be possible to incorporate advances in teledermatology and cultivate new ones.

Final Thoughts

The S&F teledermatology method used in the military setting has become commonplace in both military and civilian settings alike. Newer innovations in telemedicine, particularly in teledermatology, will continue to shape the future of military and civilian medicine for years to come.

Telemedicine arose from the need to provide critical and timely advice directly to health care providers and patients in remote or resource-scarce settings. Whether by radio, telephone, or other means of telecommunication technology, the US military has long utilized telemedicine. What started as a way to expedite the delivery of emergency consultations and medical expertise to remote populations in need has since evolved into a billion-dollar innovation industry that is poised to improve health care efficiency and access to specialist care as well as to lower health care costs for all patients.

Teledermatology in the Military

A primary mission of military medicine is to keep service members anywhere in the world in good health on the job during training, combat, and humanitarian operations.¹ Telemedicine greatly supports this mission by bringing the expertise of medical specialists to service members in the field without the cost or risks of travel for physicians. Telemedicine also is effective in promoting timely triage of patients and administration of the most appropriate levels of care. With the advent and globalization of high-speed wireless networks, advancements in telemedicine continue to develop and are becoming increasingly useful in military medicine.

As a specialty, dermatology is heavily reliant on visual information and therefore is particularly amenable to telemedicine applications. The rising popularity of such services has led to the development of the term teledermatology. While early teledermatology services were provided using radio, telephone, fax, and videoconferencing,² three distinct visual methods typically are used today, including (1) store-and-forward (S&F), (2) live-interactive, and (3) a hybrid of the two.³ Military dermatology predominantly utilizes an S&F system, as still photographs of lesions generally are preferred over video for more focused visualization.

In 2004, the US Army Medical Department established a centralized telemedicine program using Army Knowledge Online,¹ an S&F system that allows providers in remote locations to store and forward information about a patient’s clinical history along with digital photographs of the patient’s condition to a military dermatologist to review and make a diagnosis or suggest a treatment from a different location at a later time. Using this platform to provide asynchronous teledermatology services avoids the logistics required to schedule appointments and promotes convenience and more efficient use of physicians’ time and resources.

Given the ease of use of S&F systems among military practitioners, dermatology became one of the most heavily utilized teleconsultation specialties within the Army Knowledge Online system, accounting for 40% of the 10,817 consultations initiated from April 2004 to December 2012.⁵ It also is important to note that skin conditions historically account for 15% to 75% of outpatient visits during wartime; therefore, there is a need for dermatologic consultations, as primary care providers typically are responsible for providing dermatologic care to these patients.⁶ Because of the high demand for and low volume of US military dermatologists, the use of teledermatology (ie, Amy Knowledge Online) in the US military became a helpful educational tool and specialist extender for many primary care providers in the military.

Teledermatology in the military has evolved to not only provide timely and efficient care but also to reduce health care costs. In a retrospective evaluation of the US Department of Defense’s teledermatology consultation program from April 2004 to December 2012, as many as 98% of teledermatology consultations were answered within 24 hours of submission, 46 medical evacuations were avoided, and 41 medical evacuations were facilitated.⁴ In a study of teledermatology services used by deployed clinicians in Iraq from January 2005 to January 2009, it was estimated that teledermatology services would help save the military approximately $30.4 million among 2157 dermatology patients.⁷

Advances in Teledermatology

While the military continues to use S&F teleconsultations—a model in which a deployed referring clinician sends information to a military dermatologist for diagnosis and/or management recommendations—a number of teledermatology programs have been developed for civilians that provide additional advantages over standard face-to-face dermatology care. The advantages of S&F teledermatology applications are many, including faster communication with dermatology providers, diagnostic concordance comparable to face-to-face appointments, cost-effective care for patients, the ability to educate providers remotely,⁸ and similar outcomes to in-person care.⁹ However, as to be expected, in-person care remains the gold standard, especially when diagnostic accuracy depends on biopsy findings. A recent systematic review of teledermatology applications in the diagnosis and management of skin cancer showed that the diagnostic accuracy of in-person dermatology consultations remained higher than the accuracy provided by teledermatology consultations; however, as a result of additional technological advances in the quality of digital photography, some investigators have reported high accuracy when macroscopic and dermoscopic images were used in tandem.¹⁰

The development of the smartphone along with advances in digital photography and consumer-friendly mobile applications has allowed for the emergence of direct-to-consumer (DTC) teledermatology applications. Regardless of the user’s ability, the quality of photographs taken with smartphones has improved, as standard features such as high-resolution cameras with image stabilization, automatic focus, and lighting have become commonplace. The popularity of smartphone technology also has increased, with nearly 75% of all adults and more than 90% of adults younger than 35 years of age owning a smartphone according to a 2016 survey.¹¹

In 2015, there were at least 29 DTC teledermatology applications available on various mobile platforms,¹² accounting for an estimated 1.25 million teleconsultations with providers.¹³ Teledermatology platforms such as DermatologistOnCall and Spruce Health have made accessing dermatologic care convenient, timely, and affordable for patients via patient-friendly mobile applications. Direct-to-consumer telemedicine allows patients to communicate directly with a specialist without the need for a referral from a primary care provider–gatekeeper.¹⁴

Regular access to dermatologic care is especially important for patients who have chronic skin conditions. Several unique practice models have emerged as innovative solutions to providing more convenient and timely care. For example, Curology (https://curology.com) is an online teledermatology practice specializing in acne treatment. The cost to the patient includes unlimited dermatology consultations via a web application and custom-made prescription topical medication sent by mail. Clarify Medical (www.clarifymed.com) makes phototherapy easy for patients and health care providers. Although narrowband UVB treatment traditionally is administered in a dermatologist’s office 3 times weekly for several months until a skin condition has cleared, this smartphone application facilitates convenient, at-home phototherapy. An app-enabled light source allows patients to treat themselves in their own homes within the parameters of a physician’s prescription.

Although DTC teledermatology practices are convenient for many patients and providers, some have been criticized for providing poor quality of care¹² or facilitating fragmented care by not integrating with established electronic health record (EHR) systems.¹⁵ As a result, recommended practice guidelines for DTC teledermatology have been developed by the American Academy of Dermatology and some state medical boards.¹⁶ Moreover, several EHR systems, such as Epic (www.epic.com) and Modernizing Medicine’s EMA (www.modmed.com), have developed fully integrated S&F teledermatology platforms to be incorporated with established brick-and-mortar care.¹⁷

The Future of Teledermatology in the Military

The Army Knowledge Online telemedicine platform used by the US military has continued to be useful, particularly when treating patients in remote locations, and shows promise for improving routine domestic dermatology care. It has reduced the number of medical evacuations and improved care for those who do not have access to a dermatologist.⁴ Furthermore, one study noted that most consultations submitted via teledermatology applications from a combat zone received a diagnosis and treatment recommendation from a military dermatologist faster than they would have stateside, where the wait often is 4 to 8 weeks. On average, a teledermatology consultation from Afghanistan was answered in less than 6 hours.⁴ Although this response time might not be realistic for all dermatology practices, there clearly is potential in certain situations and utilizing certain models of care to diagnose and treat more patients more efficiently utilizing teledermatology applications than in an in-person office visit. A review of 658 teledermatology consultations in the US military from January 2011 to December 2012 revealed that the leading diagnoses were eczematous dermatitis (14%), contact dermatitis (9%), nonmelanoma skin cancer (5%), psoriasis (4%), and urticaria (4%).⁴ Increased use of teledermatology evaluation of these conditions in routine US-based military practice could help expedite care, decrease patient travel time, and utilize in-clinic dermatologist time more efficiently. Teledermatology visits for postoperative concerns also have demonstrated utility and convenience for triage and management of patients in the civilian setting and may be an additional novel use of teledermatology in the military setting.¹⁸ With the use of an integrated S&F teledermatology platform within an existing EHR system that is paired with a secure patient mobile application that allows easy upload of photos, medical history, and messaging, it can be argued that quality of life could greatly be enhanced for both military patients and providers.

Limitations of Teledermatology

Certainly, there are and will always be limitations to teledermatology. Even as digital photography improves, the quality and context of clinical images are user dependent, and key associated skin findings in other locations of the body can be missed. The ability to palpate the skin also is lacking in virtual encounters. Therefore, teledermatology might be considered most appropriate for specific diseases and conditions (eg, acne, psoriasis, eczema). Embracing teledermatology does not mean replacing in-person care; rather, it should be seen as an adjunct used to manage the high demand for dermatology expertise in military and civilian practice. For the US military, the promise and potential to embrace innovation in providing dermatologic care is there, as long as there are leaders to continue to champion it. In the current state of health care, many of the perceived barriers of teledermatology applications have already been overcome, including lack of training, lack of reimbursement, and perceived medicolegal risks.¹⁹

The US Federal Government is a large entity, and it will undoubtedly take time and effort to implement new and innovative programs such as the ones described here in the military. The first step in implementation is awareness that the possibilities exist; then, with the cooperation of dermatologists and support from the chain of command, it will be possible to incorporate advances in teledermatology and cultivate new ones.

Final Thoughts

The S&F teledermatology method used in the military setting has become commonplace in both military and civilian settings alike. Newer innovations in telemedicine, particularly in teledermatology, will continue to shape the future of military and civilian medicine for years to come.

CHICAGO – A combination of an immunostimulatory IL-15-based agent, ALT-803, with a therapeutic monoclonal antibody (mAb) against CD20, was well tolerated and had clinical activity in patients with indolent non-Hodgkin lymphoma (iNHL), according to preliminary findings from a phase 1 study.

“The cancer immunotherapy breakthrough that happened several years ago continues year after year, with a plethora of different modalities of immunotherapy at our disposal,” Todd A. Fehniger, MD, PhD, said at the annual meeting of the American Association for Cancer Research.

Immunotherapy with anti-CD20 mAbs, alone or in combination with chemotherapy, is a standard therapy for iNHL patients. Since iNHL cells express CD20, targeting it with mAbs triggers antitumor responses via cell surface receptors resulting in a potent antibody-dependent cellular toxicity. However, response in patients is highly heterogeneous, with relapse within a few months in a subset of patients. In addition, chemotherapeutic combinations can be toxic and result in serious and long-term complications.

“Relapsed or refractory iNHL is not curable and treatment strategies without long-term complications are needed,” said Dr. Fehniger, associate professor of medicine at Washington University, St. Louis.

In an attempt to address this, Dr. Fehniger and his colleagues combined rituximab, an anti-CD20 antibody, with a relatively new IL-15 agonist immunostimulatory agent called ALT-803.

In the phase 1 trial, the researchers enrolled patients with indolent non-Hodgkin lymphoma who had relapsed after at least 1 prior to CD20 antibody containing therapy. The study was a standard 3+3 dose escalation design with rituximab administered by intravenous infusion, 375 mg/m² in four weekly doses, followed by a rest and four consolidation doses every 8 weeks for four cycles.

ALT-803 was administered concurrently at dose levels of 1 mcg/kg, 3 mcg/kg, and 6 mcg/kg IV followed by 6 mcg/kg, 10 mcg/kg, 15 mcg/kg, and 20 mcg/kg subcutaneously.

SOURCE: Fehniger TA et al. AACR Annual Meeting, Abstract CT146.

CHICAGO – A combination of an immunostimulatory IL-15-based agent, ALT-803, with a therapeutic monoclonal antibody (mAb) against CD20, was well tolerated and had clinical activity in patients with indolent non-Hodgkin lymphoma (iNHL), according to preliminary findings from a phase 1 study.

“The cancer immunotherapy breakthrough that happened several years ago continues year after year, with a plethora of different modalities of immunotherapy at our disposal,” Todd A. Fehniger, MD, PhD, said at the annual meeting of the American Association for Cancer Research.

Immunotherapy with anti-CD20 mAbs, alone or in combination with chemotherapy, is a standard therapy for iNHL patients. Since iNHL cells express CD20, targeting it with mAbs triggers antitumor responses via cell surface receptors resulting in a potent antibody-dependent cellular toxicity. However, response in patients is highly heterogeneous, with relapse within a few months in a subset of patients. In addition, chemotherapeutic combinations can be toxic and result in serious and long-term complications.

“Relapsed or refractory iNHL is not curable and treatment strategies without long-term complications are needed,” said Dr. Fehniger, associate professor of medicine at Washington University, St. Louis.

In an attempt to address this, Dr. Fehniger and his colleagues combined rituximab, an anti-CD20 antibody, with a relatively new IL-15 agonist immunostimulatory agent called ALT-803.

In the phase 1 trial, the researchers enrolled patients with indolent non-Hodgkin lymphoma who had relapsed after at least 1 prior to CD20 antibody containing therapy. The study was a standard 3+3 dose escalation design with rituximab administered by intravenous infusion, 375 mg/m² in four weekly doses, followed by a rest and four consolidation doses every 8 weeks for four cycles.

ALT-803 was administered concurrently at dose levels of 1 mcg/kg, 3 mcg/kg, and 6 mcg/kg IV followed by 6 mcg/kg, 10 mcg/kg, 15 mcg/kg, and 20 mcg/kg subcutaneously.

SOURCE: Fehniger TA et al. AACR Annual Meeting, Abstract CT146.

CHICAGO – A combination of an immunostimulatory IL-15-based agent, ALT-803, with a therapeutic monoclonal antibody (mAb) against CD20, was well tolerated and had clinical activity in patients with indolent non-Hodgkin lymphoma (iNHL), according to preliminary findings from a phase 1 study.

“The cancer immunotherapy breakthrough that happened several years ago continues year after year, with a plethora of different modalities of immunotherapy at our disposal,” Todd A. Fehniger, MD, PhD, said at the annual meeting of the American Association for Cancer Research.

Immunotherapy with anti-CD20 mAbs, alone or in combination with chemotherapy, is a standard therapy for iNHL patients. Since iNHL cells express CD20, targeting it with mAbs triggers antitumor responses via cell surface receptors resulting in a potent antibody-dependent cellular toxicity. However, response in patients is highly heterogeneous, with relapse within a few months in a subset of patients. In addition, chemotherapeutic combinations can be toxic and result in serious and long-term complications.

“Relapsed or refractory iNHL is not curable and treatment strategies without long-term complications are needed,” said Dr. Fehniger, associate professor of medicine at Washington University, St. Louis.

In an attempt to address this, Dr. Fehniger and his colleagues combined rituximab, an anti-CD20 antibody, with a relatively new IL-15 agonist immunostimulatory agent called ALT-803.

In the phase 1 trial, the researchers enrolled patients with indolent non-Hodgkin lymphoma who had relapsed after at least 1 prior to CD20 antibody containing therapy. The study was a standard 3+3 dose escalation design with rituximab administered by intravenous infusion, 375 mg/m² in four weekly doses, followed by a rest and four consolidation doses every 8 weeks for four cycles.

ALT-803 was administered concurrently at dose levels of 1 mcg/kg, 3 mcg/kg, and 6 mcg/kg IV followed by 6 mcg/kg, 10 mcg/kg, 15 mcg/kg, and 20 mcg/kg subcutaneously.

SOURCE: Fehniger TA et al. AACR Annual Meeting, Abstract CT146.

Mohs micrographic surgery (MMS) is a specialized surgical technique for the treatment of melanoma and nonmelanoma skin cancers (NMSCs).^1-3 The procedure involves surgical excision, histopathologic examination, precise mapping of malignant tissue, and wound management. Indications for MMS in skin cancer patients include recurring lesions, lesions in high-risk anatomic locations, aggressive histologic subtypes (ie, morpheaform, micronodular, infiltrative, high-grade, poorly differentiated), perineural invasion, large lesion size (>2 cm in diameter), poorly defined lateral or vertical clinical borders, rapid growth of the lesion, immunocompromised status, and sites of positive margins on prior excision. The therapeutic advantages of MMS include tissue conservation and optimal margin control in cosmetically or functionally sensitive areas, such as acral sites (eg, hands, feet, digits).^1,3

The intricacies of the nail apparatus complicate diagnostic biopsy and precise delineation of peripheral margins in digital skin cancers; thus, early diagnosis and intraoperative histologic examination of the margins are essential. Traditionally, the surgical approach to subungual cutaneous tumors such as melanoma has included digital amputation⁴; however, a study of the treatment of subungual melanoma revealed no difference in survival based on the level of amputation, therefore advocating for less radical treatment.⁴

Interestingly, MMS for cutaneous tumors localized to the digits is not frequently reviewed in the dermatologic literature. We present a retrospective case series evaluating the clinical outcomes of digital melanoma and NMSCs treated with MMS.

Methods

A retrospective chart review was performed at a private dermatology practice to identify patients who underwent MMS for melanoma or NMSC localized to the digits from January 2009 to December 2014. All patients were treated in the office by 1 Mohs surgeon (A.H.) and were evaluated before and after MMS. Data were collected from the electronic medical record of the practice, including patient demographics, histopathologic diagnosis, tumor status (primary or recurrent lesion), anatomic site of the tumor, preoperative and postoperative size of the lesion, number of MMS stages, surgical repair technique, postoperative complications, and follow-up period.

Results

Twenty-seven patients (13 male, 14 female) with a total of 28 lesions (malignant melanoma or NMSC) localized to the digits were identified (Table). The mean age at the time of MMS was 64.07 years. Twelve (42.86%) patients were 70 years of age or older, 11 (39.29%) were between 50 and 69 years, and 5 (17.85%) were younger than 50 years. Fifteen (53.57%) of the lesions were localized to the fingers, and 13 (46.43%) were localized to the toes; 18 (64.3%) of the lesions were distal and 10 (35.7%) were proximal to the distal interphalangeal joint. The most common pathologic diagnosis was squamous cell carcinoma (SCC) in situ (12/28 [42.86%]), followed by melanoma in situ (6/28 [21.42%]), severely dysplastic nevus (4/28 [14.29%]), SCC (4/28 [14.29%]), acrospiroma (1/28 [3.57%]), and melanoma (1/28 [3.57%]).

Surgical techniques used for repair following MMS included xenograft (10/28 [35.71%]); split-thickness skin graft (7/28 [25.0%]); secondary intention (4/28 [14.29%]); flap (4/28 [14.29%]); full-thickness skin graft (2/28 [7.14%]); and complex closure (1/28 [3.57%]). Clinical preoperative, operative, and postoperative photos from Patient 21 in this series are shown here (Figure). Two patients required bony phalanx resection due to invasion of the tumor into the periosteum: 1 had a malignant melanoma (Breslow depth, 2.52 mm); the other had an SCC. In addition, following removal of a severely dysplastic nevus, debulked tissue revealed melanoma in 1 patient.

Postoperative complications were noted in 4 (14.29%) of 28 MMS procedures, including bacterial wound infection (3.57%), excess granulation tissue that required wound debridement (7.14%), and delay in wound healing (3.57%). Follow-up data were available for 25 of the 28 MMS procedures (mean follow-up, 35.4 months), during which no recurrences were observed.

Comment

Mohs micrographic surgery is a specialized technique used in the treatment of cutaneous tumors, including basal cell carcinoma, SCC, melanoma in situ, atypical fibroxanthoma, dermatofibrosarcoma protuberans, sebaceous carcinoma, microcystic adnexal carcinoma, and Merkel cell carcinoma, among other cutaneous tumors.^1-3 Mohs micrographic surgery provides the advantage of tissue conservation as well as optimal margin control in cosmetically or functionally sensitive areas while providing a higher cure rate than surgical excision. During the procedure, the surgical margin is examined histologically, thus ensuring definitive removal of the tumor but minimal loss of surrounding normal tissue.^1-3 Mohs micrographic surgery is particularly useful for treating lesions on acral sites (eg, hands, feet, and digits).^3-5

The treatment of digital skin cancers has evolved over the past 50 years with advancements resulting in more precise, tissue-sparing methods, in contrast to previous treatments such as amputation and wide local excision.⁶ More specifically, traditional digital amputation for the treatment of subungual melanoma has been reevaluated in multiple studies, which did not demonstrate a statistically significant difference in survival based on the level of amputation, thereby favoring less radical treatment.^4,6 Moehrle et al⁷ found no statistical difference in recurrence rate when comparing patients with digital melanomas treated with partial amputation and those treated with digit-sparing surgery with limited excision and histologic evaluation of margins. Additionally, in a study conducted by Lazar et al,⁸ no recurrence of 13 subungual malignancies treated with MMS that utilized a full-thickness graft was reported at 4-year follow-up. In a large retrospective series of digital melanomas treated with MMS, Terushkin et al⁵ reported that 96.5% (55/57) of patients with primary melanomas that were treated with MMS avoided amputation, and the 5- and 10-year melanoma-specific survival rates for all patients treated with MMS were 95.0% and 82.6%, respectively. Based on a review of PubMed articles indexed for MEDLINE using the search terms surgical treatment of digital melanoma and nonmelanoma skin cancers, Mohs micrographic surgery for melanoma and nonmelanoma skin cancer, and surgical treatment of subungual skin cancer, conservative functional surgical approaches have been found to be cosmetically favorable, whereas local recurrence and survival rates have been shown to be unaffected by the level and degree of amputation.^4,5

In our study, cutaneous malignancies were located most often on the fingers, and the most common skin cancer identified was SCC in situ. The literature has shown that SCC in situ and SCC are the most common cutaneous neoplasms of the digits and nail unit.⁹ The most common specific anatomic site of cutaneous malignancy in our study was the great toe, followed by the fourth finger. A study conducted by Tan et al⁹ revealed that the great toe was the most common location of melanoma of the nail bed and subungual region, followed by the thumb. In contrast, primary subungual SCCs occur most frequently on the finger, with rare cases involving the toes.¹⁰

The etiology of digital SCC may involve extensive sun exposure, chronic trauma and wounds, and viral infection.^9,11 More specifically, the dermatologic literature provides evidence of human papillomavirus (HPV) type 16 involvement in the pathogenesis of digital and periungual SCC. A genital-digital mechanism of spread has been implicated.^11,12 An increased recurrence rate of HPV-associated digital SCCs has been reported following MMS, likely secondary to residual postsurgical HPV infection.^11,12

Maintaining function and cosmesis of the hands, feet, and digits following MMS can be challenging, sometimes requiring skin grafts and flaps to close the defect. In the 28 MMS procedures evaluated in our study, 19 (67.9%) surgical defects were repaired with a graft (ie, split-thickness skin graft, full-thickness skin graft, xenograft), 4 (14.3%) with a flap (advancement and rotation), 4 (14.3%) by secondary intention, and 1 (3.6%) with primary complex closure.

Surgical grafts can be categorized based on the origin of the graft.^2,13 Autografts, derived from the patient’s skin, are the most frequently used dermatologic graft and can be further categorized as full-thickness skin grafts, which include the epidermis and the entire dermis, thus preserving adnexal structures, and split-thickness skin grafts, which include the epidermis and partial dermis.^2,13Xenografts (eg, porcine grafts) can be used to repair defects involving the mucosa and those with a large wound depth, exposed cartilage, and/or bony defects, as well as wounds with indeterminate tumor margins and in patients with medical comorbidities that might prevent or delay plans for immediate wound reconstruction (eg, diabetes, cardiovascular disease, autoimmune connective tissue disease).^13,14

A cross-sectional survey of fellowship-trained Mohs surgeons revealed that more than two-thirds of repairs for cutaneous acral cancers were performed using a primary closure technique, and one-fourth of closures were performed using secondary intention.¹⁵ Of the less frequently utilized skin-graft repairs, more were for acral lesions on the legs than on the arms.¹⁴ The type of procedure and graft used is dependent on multiple variables, including the anatomic location of the lesion and final size of the defect following MMS.² Similarly, the use of specific types of sutures depends on the anatomic location of the lesion, relative thickness of the skin, degree of tension, and desired cosmetic result.¹⁵ The expertise of a hand surgeon may be required, particularly in cases in which the extensor tendon of the distal interphalangeal joint is compromised, manifested by a droopy fingertip when the hand is held horizontally. Additionally, special attention should be paid to removing the entire nail matrix before skin grafting for subungual tumors to avoid nail growth under the skin graft.

Evaluation of debulked tissue from digital skin cancers proved to be important in our study. In Patient 21, debulked tissue revealed melanoma following removal of a severely dysplastic nevus. This finding emphasizes the importance of complete excision of such lesions, as remaining underlying portions of the lesion can reveal residual tumor of the same or different histopathology.

In a prospective study, MMS was shown to have a low rate (0.91%; 95% confidence interval, 0.38%-1.45%) of surgical site infection in the absence of prophylactic antibiotics.¹⁶ The highest rates of surgical site infection were closely associated with flap closure. In our study, most patients had an uncomplicated and successful postoperative recovery. Only 1 (3.57%) of the 28 MMS procedures (Patient 22) was complicated by a bacterial wound infection postoperatively. The lesion removed in this case was a severely dysplastic melanocytic nevus on the toe. Infection resolved after a course of oral antibiotics, but the underlying cause of the wound infection in the patient was unclear. Other postoperative complications in our study included delayed wound healing and excess granulation tissue requiring wound debridement.

There are limited data in the dermatologic literature regarding outcomes following MMS for the treatment of cutaneous malignancies localized to the digits. In our study, patients treated with MMS were evaluated for recurrence of the primary lesion during postoperative follow-up appointments at the office or with the patient’s referring dermatologist. Follow-up data evaluating tumor recurrence were obtained for 25 of the patients, demonstrating no recurrence (mean follow-up, 35.4 months). Longer follow-up data would be more informative, but our findings nonetheless demonstrate that MMS is an effective treatment option for cutaneous malignancies of the digits.

Additional limitations of this case review include its single-center and retrospective design, the small sample size, and 1 Mohs surgeon having performed all surgeries.

Conclusion

This study provides further evidence of the benefit of MMS for the treatment of malignant melanoma and NMSCs of the digits. This procedure provides margin-controlled excision of these malignant neoplasms while preserving maximal normal tissue, thereby providing patients with improved postoperative function and cosmesis. Long-term follow-up data demonstrating a lack of tumor recurrence underscores the assertion that MMS is safe and effective for the treatment of skin cancer of the digits.

Mohs micrographic surgery (MMS) is a specialized surgical technique for the treatment of melanoma and nonmelanoma skin cancers (NMSCs).^1-3 The procedure involves surgical excision, histopathologic examination, precise mapping of malignant tissue, and wound management. Indications for MMS in skin cancer patients include recurring lesions, lesions in high-risk anatomic locations, aggressive histologic subtypes (ie, morpheaform, micronodular, infiltrative, high-grade, poorly differentiated), perineural invasion, large lesion size (>2 cm in diameter), poorly defined lateral or vertical clinical borders, rapid growth of the lesion, immunocompromised status, and sites of positive margins on prior excision. The therapeutic advantages of MMS include tissue conservation and optimal margin control in cosmetically or functionally sensitive areas, such as acral sites (eg, hands, feet, digits).^1,3

The intricacies of the nail apparatus complicate diagnostic biopsy and precise delineation of peripheral margins in digital skin cancers; thus, early diagnosis and intraoperative histologic examination of the margins are essential. Traditionally, the surgical approach to subungual cutaneous tumors such as melanoma has included digital amputation⁴; however, a study of the treatment of subungual melanoma revealed no difference in survival based on the level of amputation, therefore advocating for less radical treatment.⁴

Interestingly, MMS for cutaneous tumors localized to the digits is not frequently reviewed in the dermatologic literature. We present a retrospective case series evaluating the clinical outcomes of digital melanoma and NMSCs treated with MMS.

Methods

A retrospective chart review was performed at a private dermatology practice to identify patients who underwent MMS for melanoma or NMSC localized to the digits from January 2009 to December 2014. All patients were treated in the office by 1 Mohs surgeon (A.H.) and were evaluated before and after MMS. Data were collected from the electronic medical record of the practice, including patient demographics, histopathologic diagnosis, tumor status (primary or recurrent lesion), anatomic site of the tumor, preoperative and postoperative size of the lesion, number of MMS stages, surgical repair technique, postoperative complications, and follow-up period.

Results

Twenty-seven patients (13 male, 14 female) with a total of 28 lesions (malignant melanoma or NMSC) localized to the digits were identified (Table). The mean age at the time of MMS was 64.07 years. Twelve (42.86%) patients were 70 years of age or older, 11 (39.29%) were between 50 and 69 years, and 5 (17.85%) were younger than 50 years. Fifteen (53.57%) of the lesions were localized to the fingers, and 13 (46.43%) were localized to the toes; 18 (64.3%) of the lesions were distal and 10 (35.7%) were proximal to the distal interphalangeal joint. The most common pathologic diagnosis was squamous cell carcinoma (SCC) in situ (12/28 [42.86%]), followed by melanoma in situ (6/28 [21.42%]), severely dysplastic nevus (4/28 [14.29%]), SCC (4/28 [14.29%]), acrospiroma (1/28 [3.57%]), and melanoma (1/28 [3.57%]).

Surgical techniques used for repair following MMS included xenograft (10/28 [35.71%]); split-thickness skin graft (7/28 [25.0%]); secondary intention (4/28 [14.29%]); flap (4/28 [14.29%]); full-thickness skin graft (2/28 [7.14%]); and complex closure (1/28 [3.57%]). Clinical preoperative, operative, and postoperative photos from Patient 21 in this series are shown here (Figure). Two patients required bony phalanx resection due to invasion of the tumor into the periosteum: 1 had a malignant melanoma (Breslow depth, 2.52 mm); the other had an SCC. In addition, following removal of a severely dysplastic nevus, debulked tissue revealed melanoma in 1 patient.

Postoperative complications were noted in 4 (14.29%) of 28 MMS procedures, including bacterial wound infection (3.57%), excess granulation tissue that required wound debridement (7.14%), and delay in wound healing (3.57%). Follow-up data were available for 25 of the 28 MMS procedures (mean follow-up, 35.4 months), during which no recurrences were observed.

Comment

Mohs micrographic surgery is a specialized technique used in the treatment of cutaneous tumors, including basal cell carcinoma, SCC, melanoma in situ, atypical fibroxanthoma, dermatofibrosarcoma protuberans, sebaceous carcinoma, microcystic adnexal carcinoma, and Merkel cell carcinoma, among other cutaneous tumors.^1-3 Mohs micrographic surgery provides the advantage of tissue conservation as well as optimal margin control in cosmetically or functionally sensitive areas while providing a higher cure rate than surgical excision. During the procedure, the surgical margin is examined histologically, thus ensuring definitive removal of the tumor but minimal loss of surrounding normal tissue.^1-3 Mohs micrographic surgery is particularly useful for treating lesions on acral sites (eg, hands, feet, and digits).^3-5

The treatment of digital skin cancers has evolved over the past 50 years with advancements resulting in more precise, tissue-sparing methods, in contrast to previous treatments such as amputation and wide local excision.⁶ More specifically, traditional digital amputation for the treatment of subungual melanoma has been reevaluated in multiple studies, which did not demonstrate a statistically significant difference in survival based on the level of amputation, thereby favoring less radical treatment.^4,6 Moehrle et al⁷ found no statistical difference in recurrence rate when comparing patients with digital melanomas treated with partial amputation and those treated with digit-sparing surgery with limited excision and histologic evaluation of margins. Additionally, in a study conducted by Lazar et al,⁸ no recurrence of 13 subungual malignancies treated with MMS that utilized a full-thickness graft was reported at 4-year follow-up. In a large retrospective series of digital melanomas treated with MMS, Terushkin et al⁵ reported that 96.5% (55/57) of patients with primary melanomas that were treated with MMS avoided amputation, and the 5- and 10-year melanoma-specific survival rates for all patients treated with MMS were 95.0% and 82.6%, respectively. Based on a review of PubMed articles indexed for MEDLINE using the search terms surgical treatment of digital melanoma and nonmelanoma skin cancers, Mohs micrographic surgery for melanoma and nonmelanoma skin cancer, and surgical treatment of subungual skin cancer, conservative functional surgical approaches have been found to be cosmetically favorable, whereas local recurrence and survival rates have been shown to be unaffected by the level and degree of amputation.^4,5

In our study, cutaneous malignancies were located most often on the fingers, and the most common skin cancer identified was SCC in situ. The literature has shown that SCC in situ and SCC are the most common cutaneous neoplasms of the digits and nail unit.⁹ The most common specific anatomic site of cutaneous malignancy in our study was the great toe, followed by the fourth finger. A study conducted by Tan et al⁹ revealed that the great toe was the most common location of melanoma of the nail bed and subungual region, followed by the thumb. In contrast, primary subungual SCCs occur most frequently on the finger, with rare cases involving the toes.¹⁰

The etiology of digital SCC may involve extensive sun exposure, chronic trauma and wounds, and viral infection.^9,11 More specifically, the dermatologic literature provides evidence of human papillomavirus (HPV) type 16 involvement in the pathogenesis of digital and periungual SCC. A genital-digital mechanism of spread has been implicated.^11,12 An increased recurrence rate of HPV-associated digital SCCs has been reported following MMS, likely secondary to residual postsurgical HPV infection.^11,12

Maintaining function and cosmesis of the hands, feet, and digits following MMS can be challenging, sometimes requiring skin grafts and flaps to close the defect. In the 28 MMS procedures evaluated in our study, 19 (67.9%) surgical defects were repaired with a graft (ie, split-thickness skin graft, full-thickness skin graft, xenograft), 4 (14.3%) with a flap (advancement and rotation), 4 (14.3%) by secondary intention, and 1 (3.6%) with primary complex closure.

Surgical grafts can be categorized based on the origin of the graft.^2,13 Autografts, derived from the patient’s skin, are the most frequently used dermatologic graft and can be further categorized as full-thickness skin grafts, which include the epidermis and the entire dermis, thus preserving adnexal structures, and split-thickness skin grafts, which include the epidermis and partial dermis.^2,13Xenografts (eg, porcine grafts) can be used to repair defects involving the mucosa and those with a large wound depth, exposed cartilage, and/or bony defects, as well as wounds with indeterminate tumor margins and in patients with medical comorbidities that might prevent or delay plans for immediate wound reconstruction (eg, diabetes, cardiovascular disease, autoimmune connective tissue disease).^13,14

A cross-sectional survey of fellowship-trained Mohs surgeons revealed that more than two-thirds of repairs for cutaneous acral cancers were performed using a primary closure technique, and one-fourth of closures were performed using secondary intention.¹⁵ Of the less frequently utilized skin-graft repairs, more were for acral lesions on the legs than on the arms.¹⁴ The type of procedure and graft used is dependent on multiple variables, including the anatomic location of the lesion and final size of the defect following MMS.² Similarly, the use of specific types of sutures depends on the anatomic location of the lesion, relative thickness of the skin, degree of tension, and desired cosmetic result.¹⁵ The expertise of a hand surgeon may be required, particularly in cases in which the extensor tendon of the distal interphalangeal joint is compromised, manifested by a droopy fingertip when the hand is held horizontally. Additionally, special attention should be paid to removing the entire nail matrix before skin grafting for subungual tumors to avoid nail growth under the skin graft.

Evaluation of debulked tissue from digital skin cancers proved to be important in our study. In Patient 21, debulked tissue revealed melanoma following removal of a severely dysplastic nevus. This finding emphasizes the importance of complete excision of such lesions, as remaining underlying portions of the lesion can reveal residual tumor of the same or different histopathology.

In a prospective study, MMS was shown to have a low rate (0.91%; 95% confidence interval, 0.38%-1.45%) of surgical site infection in the absence of prophylactic antibiotics.¹⁶ The highest rates of surgical site infection were closely associated with flap closure. In our study, most patients had an uncomplicated and successful postoperative recovery. Only 1 (3.57%) of the 28 MMS procedures (Patient 22) was complicated by a bacterial wound infection postoperatively. The lesion removed in this case was a severely dysplastic melanocytic nevus on the toe. Infection resolved after a course of oral antibiotics, but the underlying cause of the wound infection in the patient was unclear. Other postoperative complications in our study included delayed wound healing and excess granulation tissue requiring wound debridement.

There are limited data in the dermatologic literature regarding outcomes following MMS for the treatment of cutaneous malignancies localized to the digits. In our study, patients treated with MMS were evaluated for recurrence of the primary lesion during postoperative follow-up appointments at the office or with the patient’s referring dermatologist. Follow-up data evaluating tumor recurrence were obtained for 25 of the patients, demonstrating no recurrence (mean follow-up, 35.4 months). Longer follow-up data would be more informative, but our findings nonetheless demonstrate that MMS is an effective treatment option for cutaneous malignancies of the digits.

Additional limitations of this case review include its single-center and retrospective design, the small sample size, and 1 Mohs surgeon having performed all surgeries.

Conclusion

This study provides further evidence of the benefit of MMS for the treatment of malignant melanoma and NMSCs of the digits. This procedure provides margin-controlled excision of these malignant neoplasms while preserving maximal normal tissue, thereby providing patients with improved postoperative function and cosmesis. Long-term follow-up data demonstrating a lack of tumor recurrence underscores the assertion that MMS is safe and effective for the treatment of skin cancer of the digits.

Mohs micrographic surgery (MMS) is a specialized surgical technique for the treatment of melanoma and nonmelanoma skin cancers (NMSCs).^1-3 The procedure involves surgical excision, histopathologic examination, precise mapping of malignant tissue, and wound management. Indications for MMS in skin cancer patients include recurring lesions, lesions in high-risk anatomic locations, aggressive histologic subtypes (ie, morpheaform, micronodular, infiltrative, high-grade, poorly differentiated), perineural invasion, large lesion size (>2 cm in diameter), poorly defined lateral or vertical clinical borders, rapid growth of the lesion, immunocompromised status, and sites of positive margins on prior excision. The therapeutic advantages of MMS include tissue conservation and optimal margin control in cosmetically or functionally sensitive areas, such as acral sites (eg, hands, feet, digits).^1,3

The intricacies of the nail apparatus complicate diagnostic biopsy and precise delineation of peripheral margins in digital skin cancers; thus, early diagnosis and intraoperative histologic examination of the margins are essential. Traditionally, the surgical approach to subungual cutaneous tumors such as melanoma has included digital amputation⁴; however, a study of the treatment of subungual melanoma revealed no difference in survival based on the level of amputation, therefore advocating for less radical treatment.⁴

Interestingly, MMS for cutaneous tumors localized to the digits is not frequently reviewed in the dermatologic literature. We present a retrospective case series evaluating the clinical outcomes of digital melanoma and NMSCs treated with MMS.

Methods

A retrospective chart review was performed at a private dermatology practice to identify patients who underwent MMS for melanoma or NMSC localized to the digits from January 2009 to December 2014. All patients were treated in the office by 1 Mohs surgeon (A.H.) and were evaluated before and after MMS. Data were collected from the electronic medical record of the practice, including patient demographics, histopathologic diagnosis, tumor status (primary or recurrent lesion), anatomic site of the tumor, preoperative and postoperative size of the lesion, number of MMS stages, surgical repair technique, postoperative complications, and follow-up period.

Results

Twenty-seven patients (13 male, 14 female) with a total of 28 lesions (malignant melanoma or NMSC) localized to the digits were identified (Table). The mean age at the time of MMS was 64.07 years. Twelve (42.86%) patients were 70 years of age or older, 11 (39.29%) were between 50 and 69 years, and 5 (17.85%) were younger than 50 years. Fifteen (53.57%) of the lesions were localized to the fingers, and 13 (46.43%) were localized to the toes; 18 (64.3%) of the lesions were distal and 10 (35.7%) were proximal to the distal interphalangeal joint. The most common pathologic diagnosis was squamous cell carcinoma (SCC) in situ (12/28 [42.86%]), followed by melanoma in situ (6/28 [21.42%]), severely dysplastic nevus (4/28 [14.29%]), SCC (4/28 [14.29%]), acrospiroma (1/28 [3.57%]), and melanoma (1/28 [3.57%]).

Surgical techniques used for repair following MMS included xenograft (10/28 [35.71%]); split-thickness skin graft (7/28 [25.0%]); secondary intention (4/28 [14.29%]); flap (4/28 [14.29%]); full-thickness skin graft (2/28 [7.14%]); and complex closure (1/28 [3.57%]). Clinical preoperative, operative, and postoperative photos from Patient 21 in this series are shown here (Figure). Two patients required bony phalanx resection due to invasion of the tumor into the periosteum: 1 had a malignant melanoma (Breslow depth, 2.52 mm); the other had an SCC. In addition, following removal of a severely dysplastic nevus, debulked tissue revealed melanoma in 1 patient.

Postoperative complications were noted in 4 (14.29%) of 28 MMS procedures, including bacterial wound infection (3.57%), excess granulation tissue that required wound debridement (7.14%), and delay in wound healing (3.57%). Follow-up data were available for 25 of the 28 MMS procedures (mean follow-up, 35.4 months), during which no recurrences were observed.

Comment

Mohs micrographic surgery is a specialized technique used in the treatment of cutaneous tumors, including basal cell carcinoma, SCC, melanoma in situ, atypical fibroxanthoma, dermatofibrosarcoma protuberans, sebaceous carcinoma, microcystic adnexal carcinoma, and Merkel cell carcinoma, among other cutaneous tumors.^1-3 Mohs micrographic surgery provides the advantage of tissue conservation as well as optimal margin control in cosmetically or functionally sensitive areas while providing a higher cure rate than surgical excision. During the procedure, the surgical margin is examined histologically, thus ensuring definitive removal of the tumor but minimal loss of surrounding normal tissue.^1-3 Mohs micrographic surgery is particularly useful for treating lesions on acral sites (eg, hands, feet, and digits).^3-5

The treatment of digital skin cancers has evolved over the past 50 years with advancements resulting in more precise, tissue-sparing methods, in contrast to previous treatments such as amputation and wide local excision.⁶ More specifically, traditional digital amputation for the treatment of subungual melanoma has been reevaluated in multiple studies, which did not demonstrate a statistically significant difference in survival based on the level of amputation, thereby favoring less radical treatment.^4,6 Moehrle et al⁷ found no statistical difference in recurrence rate when comparing patients with digital melanomas treated with partial amputation and those treated with digit-sparing surgery with limited excision and histologic evaluation of margins. Additionally, in a study conducted by Lazar et al,⁸ no recurrence of 13 subungual malignancies treated with MMS that utilized a full-thickness graft was reported at 4-year follow-up. In a large retrospective series of digital melanomas treated with MMS, Terushkin et al⁵ reported that 96.5% (55/57) of patients with primary melanomas that were treated with MMS avoided amputation, and the 5- and 10-year melanoma-specific survival rates for all patients treated with MMS were 95.0% and 82.6%, respectively. Based on a review of PubMed articles indexed for MEDLINE using the search terms surgical treatment of digital melanoma and nonmelanoma skin cancers, Mohs micrographic surgery for melanoma and nonmelanoma skin cancer, and surgical treatment of subungual skin cancer, conservative functional surgical approaches have been found to be cosmetically favorable, whereas local recurrence and survival rates have been shown to be unaffected by the level and degree of amputation.^4,5

In our study, cutaneous malignancies were located most often on the fingers, and the most common skin cancer identified was SCC in situ. The literature has shown that SCC in situ and SCC are the most common cutaneous neoplasms of the digits and nail unit.⁹ The most common specific anatomic site of cutaneous malignancy in our study was the great toe, followed by the fourth finger. A study conducted by Tan et al⁹ revealed that the great toe was the most common location of melanoma of the nail bed and subungual region, followed by the thumb. In contrast, primary subungual SCCs occur most frequently on the finger, with rare cases involving the toes.¹⁰

The etiology of digital SCC may involve extensive sun exposure, chronic trauma and wounds, and viral infection.^9,11 More specifically, the dermatologic literature provides evidence of human papillomavirus (HPV) type 16 involvement in the pathogenesis of digital and periungual SCC. A genital-digital mechanism of spread has been implicated.^11,12 An increased recurrence rate of HPV-associated digital SCCs has been reported following MMS, likely secondary to residual postsurgical HPV infection.^11,12

Maintaining function and cosmesis of the hands, feet, and digits following MMS can be challenging, sometimes requiring skin grafts and flaps to close the defect. In the 28 MMS procedures evaluated in our study, 19 (67.9%) surgical defects were repaired with a graft (ie, split-thickness skin graft, full-thickness skin graft, xenograft), 4 (14.3%) with a flap (advancement and rotation), 4 (14.3%) by secondary intention, and 1 (3.6%) with primary complex closure.

Surgical grafts can be categorized based on the origin of the graft.^2,13 Autografts, derived from the patient’s skin, are the most frequently used dermatologic graft and can be further categorized as full-thickness skin grafts, which include the epidermis and the entire dermis, thus preserving adnexal structures, and split-thickness skin grafts, which include the epidermis and partial dermis.^2,13Xenografts (eg, porcine grafts) can be used to repair defects involving the mucosa and those with a large wound depth, exposed cartilage, and/or bony defects, as well as wounds with indeterminate tumor margins and in patients with medical comorbidities that might prevent or delay plans for immediate wound reconstruction (eg, diabetes, cardiovascular disease, autoimmune connective tissue disease).^13,14

A cross-sectional survey of fellowship-trained Mohs surgeons revealed that more than two-thirds of repairs for cutaneous acral cancers were performed using a primary closure technique, and one-fourth of closures were performed using secondary intention.¹⁵ Of the less frequently utilized skin-graft repairs, more were for acral lesions on the legs than on the arms.¹⁴ The type of procedure and graft used is dependent on multiple variables, including the anatomic location of the lesion and final size of the defect following MMS.² Similarly, the use of specific types of sutures depends on the anatomic location of the lesion, relative thickness of the skin, degree of tension, and desired cosmetic result.¹⁵ The expertise of a hand surgeon may be required, particularly in cases in which the extensor tendon of the distal interphalangeal joint is compromised, manifested by a droopy fingertip when the hand is held horizontally. Additionally, special attention should be paid to removing the entire nail matrix before skin grafting for subungual tumors to avoid nail growth under the skin graft.

Evaluation of debulked tissue from digital skin cancers proved to be important in our study. In Patient 21, debulked tissue revealed melanoma following removal of a severely dysplastic nevus. This finding emphasizes the importance of complete excision of such lesions, as remaining underlying portions of the lesion can reveal residual tumor of the same or different histopathology.

In a prospective study, MMS was shown to have a low rate (0.91%; 95% confidence interval, 0.38%-1.45%) of surgical site infection in the absence of prophylactic antibiotics.¹⁶ The highest rates of surgical site infection were closely associated with flap closure. In our study, most patients had an uncomplicated and successful postoperative recovery. Only 1 (3.57%) of the 28 MMS procedures (Patient 22) was complicated by a bacterial wound infection postoperatively. The lesion removed in this case was a severely dysplastic melanocytic nevus on the toe. Infection resolved after a course of oral antibiotics, but the underlying cause of the wound infection in the patient was unclear. Other postoperative complications in our study included delayed wound healing and excess granulation tissue requiring wound debridement.

There are limited data in the dermatologic literature regarding outcomes following MMS for the treatment of cutaneous malignancies localized to the digits. In our study, patients treated with MMS were evaluated for recurrence of the primary lesion during postoperative follow-up appointments at the office or with the patient’s referring dermatologist. Follow-up data evaluating tumor recurrence were obtained for 25 of the patients, demonstrating no recurrence (mean follow-up, 35.4 months). Longer follow-up data would be more informative, but our findings nonetheless demonstrate that MMS is an effective treatment option for cutaneous malignancies of the digits.

Additional limitations of this case review include its single-center and retrospective design, the small sample size, and 1 Mohs surgeon having performed all surgeries.

Conclusion

This study provides further evidence of the benefit of MMS for the treatment of malignant melanoma and NMSCs of the digits. This procedure provides margin-controlled excision of these malignant neoplasms while preserving maximal normal tissue, thereby providing patients with improved postoperative function and cosmesis. Long-term follow-up data demonstrating a lack of tumor recurrence underscores the assertion that MMS is safe and effective for the treatment of skin cancer of the digits.

In critically ill patients, treating blood glucose with a low target of 80-110 mg/dL was associated with a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.

With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST^®.

monkeybusinessimages/Thinkstock

Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.

Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).

These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.

Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.

“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.

Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.

SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.

In critically ill patients, treating blood glucose with a low target of 80-110 mg/dL was associated with a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.

With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST^®.

monkeybusinessimages/Thinkstock

Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.

Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).

These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.

Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.

“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.

Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.

SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.

In critically ill patients, treating blood glucose with a low target of 80-110 mg/dL was associated with a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL, according to results of a retrospective cohort analysis.

With the computerized intravenous insulin protocol used in the study, the strict target could be achieved with a low rate of hypoglycemia, the authors wrote. The analysis was published in the journal CHEST^®.

monkeybusinessimages/Thinkstock

Unadjusted 30-day mortality was significantly lower in the 80-110–mg/dL group compared with the 90-140–mg/dL group (4.3% vs. 9.2%, respectively; P less than .001), according to the investigators.

Furthermore, logistic regression analysis showed that patients treated with a target of 80-110 mg/dL had a lower risk of 30-day mortality compared with patients with a target of 90-140 mg/dL (odds ratio 0.65; 95% confidence interval, 0.43-0.98; P = .04).

These results advance the debate over appropriate blood glucose targets in critically ill patients, as they suggest that the effects of targeting blood glucose and the effects of severe hypoglycemia “can be separated,” the investigators wrote.

Current guidelines on intensive insulin therapy are based in part on findings of the NICE-SUGAR trial, which found that among adults treated in the ICU, intensive glucose control increased mortality. However, a post hoc analysis suggested the mortality increase in NICE-SUGAR was “largely driven by a significant incidence of moderate hypoglycemia, and to a greater degree severe hypoglycemia,” Dr. Hersh and his coauthors noted in their report.

“Given improvements in insulin delivery and glucose monitoring, a reassessment of potential benefits of [intensive insulin therapy] should once again be evaluated in a prospective randomized trial,” they wrote.

Dr. Hersh and his coauthors declared no financial or nonfinancial disclosures related to the study.

SOURCE: Hersh AM et al. CHEST 2018. doi: 10.1016/j.chest.2018.04.025.

DALLAS – An investigational device that couples laser spectroscopy with a machine-learning algorithm demonstrated a high sensitivity and specificity for discriminating skin cancers from benign lesions in real time, results from a single-center study showed.

“More than 5.4 million cases of nonmelanoma skin cancer were treated in 2012, but the accuracy of skin cancer screening prior to biopsy is pretty low, about 70%, and is individual dependent,” lead study author Sung Hyun Pyun, PhD, said at the annual conference of the American Society for Laser Medicine and Surgery. “There have been several in vivo skin cancer screening devices based on noninvasive techniques such as multispectral imaging, Raman spectroscopy, and electrical impedance spectroscopy, but their diagnostic accuracies were not sufficient for clinical use and could not be applied in real time.”

[email protected]

DALLAS – An investigational device that couples laser spectroscopy with a machine-learning algorithm demonstrated a high sensitivity and specificity for discriminating skin cancers from benign lesions in real time, results from a single-center study showed.

“More than 5.4 million cases of nonmelanoma skin cancer were treated in 2012, but the accuracy of skin cancer screening prior to biopsy is pretty low, about 70%, and is individual dependent,” lead study author Sung Hyun Pyun, PhD, said at the annual conference of the American Society for Laser Medicine and Surgery. “There have been several in vivo skin cancer screening devices based on noninvasive techniques such as multispectral imaging, Raman spectroscopy, and electrical impedance spectroscopy, but their diagnostic accuracies were not sufficient for clinical use and could not be applied in real time.”

[email protected]

DALLAS – An investigational device that couples laser spectroscopy with a machine-learning algorithm demonstrated a high sensitivity and specificity for discriminating skin cancers from benign lesions in real time, results from a single-center study showed.

“More than 5.4 million cases of nonmelanoma skin cancer were treated in 2012, but the accuracy of skin cancer screening prior to biopsy is pretty low, about 70%, and is individual dependent,” lead study author Sung Hyun Pyun, PhD, said at the annual conference of the American Society for Laser Medicine and Surgery. “There have been several in vivo skin cancer screening devices based on noninvasive techniques such as multispectral imaging, Raman spectroscopy, and electrical impedance spectroscopy, but their diagnostic accuracies were not sufficient for clinical use and could not be applied in real time.”

[email protected]

A group of oncologists is urging the Food and Drug Administration to review a new, flat-pricing strategy for all doses of ibrutinib (Imbruvica), calling the shift potentially dangerous for patients.

Pharmacyclics, an AbbVie company based in Sunnyvale, Calif., recently introduced a new, single-tablet formulation of ibrutinib in varying strengths (140 mg, 280 mg, 420 mg, and 560 mg) and set a flat price across all doses. At the same time, they removed the drug’s original 140-mg capsules – which cost about a third of the new, flat-rate price – from the market. The drug company says the new, single-tablet formulations give patients a convenient, once-a-day dosing regimen that could improve therapy adherence.

Ibrutinib is approved to treat a number of hematologic cancers, including mantle cell lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma, Waldenstrom macroglobulinemia, and marginal zone lymphoma.

But in an April letter published in the Cancer Letter, nine physicians from cancer centers across the country expressed concern that the new dosage and pricing scheme could compromise patient safety and limit doctors’ dosage decisions.

“While the prescribing information is complex, prescribers and patients have had the flexibility of taking anywhere from one to four 140-mg capsules, readily permitting dose reduction to all but the lowest labeled dose [70 mg],” the authors wrote. “However, the new formulation and its associated marketing scheme [YOU&i] greatly impact the ability of the prescriber and patient to follow the prescribing information, resulting in the potential for a greatly enhanced risk of toxicities relative to that observed in the clinical trials which utilized multiples of the 140-mg capsules.”

The problems stem from a cancer drug that often requires dosage adjustments, the authors noted. The specific dosage for an ibrutinib patient depends on the indication, prior toxicities, concomitant medications, occurrence of ibrutinib intolerance, and current hepatic function. Because of such diverse criteria, dosage modifications are made frequently.

The new pricing system makes it harder for physicians to adjust the dose without running afoul of insurers and potentially affecting access for patients.

A group of oncologists is urging the Food and Drug Administration to review a new, flat-pricing strategy for all doses of ibrutinib (Imbruvica), calling the shift potentially dangerous for patients.

Pharmacyclics, an AbbVie company based in Sunnyvale, Calif., recently introduced a new, single-tablet formulation of ibrutinib in varying strengths (140 mg, 280 mg, 420 mg, and 560 mg) and set a flat price across all doses. At the same time, they removed the drug’s original 140-mg capsules – which cost about a third of the new, flat-rate price – from the market. The drug company says the new, single-tablet formulations give patients a convenient, once-a-day dosing regimen that could improve therapy adherence.

Ibrutinib is approved to treat a number of hematologic cancers, including mantle cell lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma, Waldenstrom macroglobulinemia, and marginal zone lymphoma.

But in an April letter published in the Cancer Letter, nine physicians from cancer centers across the country expressed concern that the new dosage and pricing scheme could compromise patient safety and limit doctors’ dosage decisions.

“While the prescribing information is complex, prescribers and patients have had the flexibility of taking anywhere from one to four 140-mg capsules, readily permitting dose reduction to all but the lowest labeled dose [70 mg],” the authors wrote. “However, the new formulation and its associated marketing scheme [YOU&i] greatly impact the ability of the prescriber and patient to follow the prescribing information, resulting in the potential for a greatly enhanced risk of toxicities relative to that observed in the clinical trials which utilized multiples of the 140-mg capsules.”

The problems stem from a cancer drug that often requires dosage adjustments, the authors noted. The specific dosage for an ibrutinib patient depends on the indication, prior toxicities, concomitant medications, occurrence of ibrutinib intolerance, and current hepatic function. Because of such diverse criteria, dosage modifications are made frequently.

The new pricing system makes it harder for physicians to adjust the dose without running afoul of insurers and potentially affecting access for patients.

A group of oncologists is urging the Food and Drug Administration to review a new, flat-pricing strategy for all doses of ibrutinib (Imbruvica), calling the shift potentially dangerous for patients.

Pharmacyclics, an AbbVie company based in Sunnyvale, Calif., recently introduced a new, single-tablet formulation of ibrutinib in varying strengths (140 mg, 280 mg, 420 mg, and 560 mg) and set a flat price across all doses. At the same time, they removed the drug’s original 140-mg capsules – which cost about a third of the new, flat-rate price – from the market. The drug company says the new, single-tablet formulations give patients a convenient, once-a-day dosing regimen that could improve therapy adherence.

Ibrutinib is approved to treat a number of hematologic cancers, including mantle cell lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma, Waldenstrom macroglobulinemia, and marginal zone lymphoma.

But in an April letter published in the Cancer Letter, nine physicians from cancer centers across the country expressed concern that the new dosage and pricing scheme could compromise patient safety and limit doctors’ dosage decisions.

“While the prescribing information is complex, prescribers and patients have had the flexibility of taking anywhere from one to four 140-mg capsules, readily permitting dose reduction to all but the lowest labeled dose [70 mg],” the authors wrote. “However, the new formulation and its associated marketing scheme [YOU&i] greatly impact the ability of the prescriber and patient to follow the prescribing information, resulting in the potential for a greatly enhanced risk of toxicities relative to that observed in the clinical trials which utilized multiples of the 140-mg capsules.”

The problems stem from a cancer drug that often requires dosage adjustments, the authors noted. The specific dosage for an ibrutinib patient depends on the indication, prior toxicities, concomitant medications, occurrence of ibrutinib intolerance, and current hepatic function. Because of such diverse criteria, dosage modifications are made frequently.

The new pricing system makes it harder for physicians to adjust the dose without running afoul of insurers and potentially affecting access for patients.

WASHINGTON – A U.S. grant program that was started in 2004 to fund youth suicide prevention efforts throughout the country was linked with nearly 900 youth suicide deaths prevented by 2015, according to a matched, case-control analysis.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

[email protected] .

WASHINGTON – A U.S. grant program that was started in 2004 to fund youth suicide prevention efforts throughout the country was linked with nearly 900 youth suicide deaths prevented by 2015, according to a matched, case-control analysis.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

[email protected] .

WASHINGTON – A U.S. grant program that was started in 2004 to fund youth suicide prevention efforts throughout the country was linked with nearly 900 youth suicide deaths prevented by 2015, according to a matched, case-control analysis.

Mitchel L. Zoler/MDedge News

Mitchel L. Zoler/MDedge News

[email protected] .

Novartis’s tisagenlecleucel (Kymriah) is now approved for adults with relapsed or refractory large B-cell lymphoma after failure of two or more lines of systemic therapy.

The Food and Drug Administration approved the expanded indication on May 1. The chimeric antigen receptor (CAR) T-cell therapy was initially approved in Aug. 2017 for refractory or relapsed B-cell precursor acute lymphoblastic leukemia (ALL) in patients up to 25 years old. The new approval brings tisagenlecleucel into direct competition with Gilead Science’s CAR T-cell therapy axicabtagene ciloleucel (Yescarta), which was approved in Oct. 2017 for B-cell lymphoma.

Courtesy Novartis

[email protected]

Novartis’s tisagenlecleucel (Kymriah) is now approved for adults with relapsed or refractory large B-cell lymphoma after failure of two or more lines of systemic therapy.

The Food and Drug Administration approved the expanded indication on May 1. The chimeric antigen receptor (CAR) T-cell therapy was initially approved in Aug. 2017 for refractory or relapsed B-cell precursor acute lymphoblastic leukemia (ALL) in patients up to 25 years old. The new approval brings tisagenlecleucel into direct competition with Gilead Science’s CAR T-cell therapy axicabtagene ciloleucel (Yescarta), which was approved in Oct. 2017 for B-cell lymphoma.

Courtesy Novartis

[email protected]

Novartis’s tisagenlecleucel (Kymriah) is now approved for adults with relapsed or refractory large B-cell lymphoma after failure of two or more lines of systemic therapy.

The Food and Drug Administration approved the expanded indication on May 1. The chimeric antigen receptor (CAR) T-cell therapy was initially approved in Aug. 2017 for refractory or relapsed B-cell precursor acute lymphoblastic leukemia (ALL) in patients up to 25 years old. The new approval brings tisagenlecleucel into direct competition with Gilead Science’s CAR T-cell therapy axicabtagene ciloleucel (Yescarta), which was approved in Oct. 2017 for B-cell lymphoma.

Courtesy Novartis

[email protected]

Deep gray matter volume loss drives disability accumulation in multiple sclerosis (MS), according to a multicenter, longitudinal study published in the February issue of Annals of Neurology.

The results “suggest that the development of deep gray matter atrophy may drive disability accumulation irrespective of clinical phenotypes, thereby becoming a useful outcome measure in neuroprotective clinical trials,” said Arman Eshaghi, MD, of the Queen Square MS Centre at the University College London Institute of Neurology, and colleagues.

—Jake Remaly

Suggested Reading

Eshaghi A, Prados F, Brownlee WJ, et al. Deep gray matter volume loss drives disability worsening in multiple sclerosis. Ann Neurol. 2018;83(2):210-222.

Deep gray matter volume loss drives disability accumulation in multiple sclerosis (MS), according to a multicenter, longitudinal study published in the February issue of Annals of Neurology.

The results “suggest that the development of deep gray matter atrophy may drive disability accumulation irrespective of clinical phenotypes, thereby becoming a useful outcome measure in neuroprotective clinical trials,” said Arman Eshaghi, MD, of the Queen Square MS Centre at the University College London Institute of Neurology, and colleagues.

—Jake Remaly

Suggested Reading

Eshaghi A, Prados F, Brownlee WJ, et al. Deep gray matter volume loss drives disability worsening in multiple sclerosis. Ann Neurol. 2018;83(2):210-222.

Deep gray matter volume loss drives disability accumulation in multiple sclerosis (MS), according to a multicenter, longitudinal study published in the February issue of Annals of Neurology.

The results “suggest that the development of deep gray matter atrophy may drive disability accumulation irrespective of clinical phenotypes, thereby becoming a useful outcome measure in neuroprotective clinical trials,” said Arman Eshaghi, MD, of the Queen Square MS Centre at the University College London Institute of Neurology, and colleagues.

—Jake Remaly

Suggested Reading

Eshaghi A, Prados F, Brownlee WJ, et al. Deep gray matter volume loss drives disability worsening in multiple sclerosis. Ann Neurol. 2018;83(2):210-222.