Swanson, David C.

Introduction: Limited research explores dermoscopy use among physician associates (PAs), outside of one prior study examining dermoscopy in PA student education. This study sought to investigate dermoscopy use among practicing PAs and its impact on their overall diagnostic confidence, including in darker skin tones, when differentiating between benign and malignant skin lesions. Methods: An anonymous survey was developed in 2023 with input from experts in dermoscopy and survey creation to assess PA confidence in skin lesion evaluation as well as PA dermoscopy knowledge and use, perceptions, barriers to use, and prior education. The dermoscopy survey was included as an optional module in the 2024 American Academy of Physician Associates (AAPA) Salary Survey. Results: Of 3,174 invited PAs, 995 (31.4%) responded. Most had never used dermoscopy in practice (81%) but knew or recognized the term (71%). A majority (53%) believed PAs should be trained in dermoscopy during PA school, and 26% reported no interest in future dermoscopy use. Dermatology PAs reported more frequent dermoscopy use and generally greater confidence in evaluating skin lesions, both overall and in darker skin tones, than PAs in other specialties. PAs in surgical (OR=0.2, 95% CI 0.1-0.6) and medical (OR=0.3, 95% CI 0.2-0.5) subspecialties were less likely to use dermoscopy at least annually compared with PAs in primary care. PAs in rural areas were more likely to feel confident in differentiating skin lesions than those in urban areas (OR 2.9, 95% CI 1.7-5.0). Conclusion: Dermoscopy use is associated with higher overall skin lesion assessment confidence. Wider adoption, especially outside dermatology, requires training, increased advocacy, and expanded education.

Abstract Lentigo maligna (LM) is a subtype of cutaneous melanoma in situ that develops on chronically sun‐damaged skin in elderly individuals. Its diagnosis and management remain challenging due to its slow progression, frequent occurrence on cosmetically sensitive areas in frail individuals, and tendency for subclinical peripheral extension. Despite its potential for invasive transformation, the natural history of LM remains incompletely understood and evidence‐based management strategies for this specific entity remain limited. This work aims to bridge the gap between scarce high‐quality evidence and the clinicians' need for practical guidance on LM management by formulating evidence‐based and expert consensus‐driven recommendations for diagnosis, treatment and follow‐up. Under the coordination of the International Dermoscopy Society, a global, multidisciplinary consortium of 53 experts—including dermatologists, dermato‐oncologists, dermatologic surgeons, radiologists, radiotherapists, pathologists and epidemiologists—formulated recommendations through structured consensus, informed by a comprehensive review of current scientific evidence and clinical practice standards. Optimal management of LM requires accurate diagnosis and individualized treatment planning. Non‐invasive skin imaging techniques, especially dermoscopy and reflectance confocal microscopy, aid in diagnosis, biopsy orientation, lesion delineation and post‐treatment monitoring. Multiple partial biopsies help confirm diagnosis and rule out invasion. Complete surgical excision remains the first treatment option. No definitive safety margins can be recommended for standard surgery; margin‐controlled techniques are preferable for large or ill‐defined lesions. Topical imiquimod and radiotherapy are effective alternatives where surgery is unsuitable. Topical imiquimod is useful as primary, adjuvant or neoadjuvant therapy. Blind destructive methods should be avoided. Close clinical and imaging follow‐up is needed. Patient‐centred care, shared decision‐making, and a multidisciplinary approach are critical for optimal outcomes. These international consensus recommendations summarize current best practices for LM management, offering practical, evidence‐informed guidance to clinicians while acknowledging the potential of future research in refining these conclusions.

Introduction: Porokeratosis is a group of keratinization disorders characterized by the histopathological presence of the cornoid lamella, a hallmark feature across all subtypes. The clinical diagnosis of porokeratosis can be challenging due to its similarity to other dermatological conditions. While polarized light dermatoscopy (PLD) enhances diagnostic accuracy, certain features remain difficult to identify. Ultraviolet-induced fluorescence dermatoscopy (UVFD) is a novel imaging technique that may improve the visualization of porokeratosis features, particularly the peripheral keratin rim. Objectives: This study aimed to assess the diagnostic utility of UVFD compared with PLD in identifying the dermatoscopic features of porokeratosis. Methods: In this retrospective study, dermatologists from five institutions in Chile, Brazil, Poland, and the United States contributed with dermatoscopic images of porokeratosis cases. Both PLD and UVFD images were obtained for each lesion. Two independent investigators evaluated each lesion in PLD and UVFD for the presence of peripheral keratin rim, rim continuity, central scaling, follicular plugs, vascular structures, and photodamaged surrounding skin. A third investigator reviewed discrepancies. Frequencies and means were calculated. McNemar’s chi-square was used for comparison. Results: A total of 136 lesions from 35 patients with biopsy-proven porokeratosis were analyzed. UVFD significantly improved the visualization of the peripheral keratin rim (95.6% vs. 66.2% in PLD; P<0.001) and increased identification rates for central scaling, follicular plugs, and interrupted rims. PLD remained superior for detecting vascular structures(P<0.001). Conclusions: UVFD enhances the visualization of key dermatoscopic features of porokeratosis, particularly the peripheral keratin rim and other keratin-related structures.

Importance: Dermoscopy is increasingly recognized by skin cancer experts and professional leaders as an essential skill for physicians in dermatology and primary care. A substantial number of patients in both settings also receive care from physician assistants (PAs), who provide additional opportunities to evaluate patients with concerning skin lesions. Earning dermatology-specific credentials from the National Commission on Certification for PAs requires passing a written exam with dermoscopic content, and 77% of practicing PAs (all specialties) believe dermoscopy should be a standard element of their formal education. No published studies have identified precise learning objectives that would represent appropriate foundational proficiency in dermoscopy for PAs. Objective: We sought to identify common diagnoses with distinct dermoscopic features and delineate which of these represent appropriate proficiency expectations for early-career PAs in primary care and dermatology. Design, setting, and participants: A panel of 14 dermoscopists was assembled (8 dermatologists; 6 PAs), reflecting contributors to existing consensus statements on physician dermoscopy proficiency benchmarks, dermatologist-recommended competencies for PAs, and/or standardized test content for dermatology PAs. Panelists completed a modified Delphi consensus process involving electronic surveys and roundtable discussions. Main outcomes and measures: Consensus on which specific dermoscopic diagnoses reflect appropriate foundational proficiency expectations for PAs in both primary care and dermatology. Results: Twelve of 14 panelists (86%) reported using dermoscopy for over 12 years (mean: 15.5 y). All panelists completed 2 iterations of an electronic survey regarding 54 diagnoses, with 39 (72%) reaching a final consensus for inclusion in PA curricula and 15 (28%) being identified as non-priority items for early-career PAs. Panelists recommended 14 conditions for primary care PAs and 25 conditions for dermatology PAs. Conclusions and Relevance: Consensus achieved in this modified Delphi process identified diagnoses that represent pragmatic learning objectives to achieve foundational proficiency in dermoscopy for PAs in both primary care and dermatology. This list of validated objectives provides a consensus-based guide to help educators, supervising physicians, and professional leaders to cultivate specialty-appropriate dermoscopic proficiency among early-career PAs.

Background: Proper diagnosis in primary care is crucial due to the large number of skin cancer diagnoses each year and its associated growing economic burden. Understanding how primary care providers can be best trained in dermoscopy is instrumental in helping primary care providers differentiate benign and malignant cutaneous lesions so that appropriate action can be taken (eg, biopsy/referral to dermatology or reassurance). Objective: To assess the success of concise dermoscopy training among primary care providers. Design: A cohort study was conducted in primary care at Mayo Clinic, Rochester, including primary care physicians, nurse practitioners, and physician assistants in internal medicine and family medicine. Diagnostic accuracy was measured on standardized testing through image-based recognition and in clinical practice through observation of referral and biopsy patterns both before and after dermoscopy education, focused on the TADA plus method. Results: Forty-three primary care providers completed the image-based recognition tests, with significant improvement in mean score measured after dermoscopy training workshop (20%). Among the thirteen primary care providers who continued to use dermoscopy in clinical practice, a significant improvement (31%) in mean clinical diagnostic accuracy was observed comparing 1 year of practice data before versus after dermoscopy training. Conclusion: Improvement in diagnostic accuracy with utilization of the TADA plus method translates into clinical practice. Therefore, training primary care providers in dermoscopy may improve the dermatologic care patients receive in primary care, especially in rural or medically underserved areas where access to dermatology is limited.

Background: Patients with skin lesions suspicious for skin cancer or atypical melanocytic nevi of uncertain malignant potential often present to dermatologists, who may have variable dermoscopy triage clinical experience. Objective: To evaluate the clinical utility of a digital dermoscopy image-based artificial intelligence algorithm (DDI-AI device) on the diagnosis and management of skin cancers by dermatologists. Methods: Thirty-six United States board-certified dermatologists evaluated 50 clinical images and 50 digital dermoscopy images of the same skin lesions (25 malignant and 25 benign), first without and then with knowledge of the DDI-AI device output. Participants indicated whether they thought the lesion was likely benign (unremarkable) or malignant (suspicious). Results: The management sensitivity of dermatologists using the DDI-AI device was 91.1%, compared to 84.3% with DDI, and 70.0% with clinical images. The management specificity was 71.0%, compared to 68.4% and 64.9%, respectively. The diagnostic sensitivity of dermatologists using the DDI-AI device was 86.1%, compared to 78.8% with DDI, and 63.4% with clinical images. Diagnostic specificity using the DDI-AI device increased to 80.7%, compared to 75.9% and 73.6%, respectively. Conclusion: The use of the DDI-AI device may quickly, safely, and effectively improve dermoscopy performance, skin cancer diagnosis, and management when used by dermatologists, independent of training and experience.

AbstractBackgroundImmunotherapies have changed the landscape of late‐stage melanoma; however, data evaluating timely access to immunotherapy are lacking.MethodsA retrospective cohort study utilizing the National Cancer Database was conducted. Stage III and IV melanoma cases diagnosed between 2011 and 2018 that received systemic treatment with either immunotherapy or chemotherapy were included. Chemotherapy included BRAF/MEK inhibitors. Multivariable logistic regression models were utilized to evaluate factors associated with the likelihood of receiving immunotherapy as primary systemic treatment relative to chemotherapy; additionally, Cox proportional hazards models were utilized to incorporate time from diagnosis to primary systemic therapy into the analysis.ResultsThe study population was comprised of 14,446 cases. The cohort included 12,053 (83.4%) immunotherapy and 2393 (16.6%) chemotherapy cases. In multivariable logistic regression analysis, factors significantly associated with immunotherapy receipt included population density, circle distance, year of diagnosis, Breslow thickness, and cancer stage. Immunotherapy timing was evaluated using multivariable Cox regression analysis. Minorities were less likely to receive timely immunotherapy than non‐Hispanic Whites (HR 0.83, CI 0.74–0.93, p = 0.001). Patients at circle distances of 10–49 miles (HR 0.94, CI 0.89–0.99, p = 0.02) and ≥50 miles (HR 0.83, CI 0.77–0.90, p < 0.001) were less likely to receive timely immunotherapy.ConclusionPatients traveling ≥10 miles and minorities have a decreased likelihood of receiving timely immunotherapy administration for primary systemic treatment. Future research is needed to identify what barriers and approaches can be leveraged to address these inequities.

Abstract Background Hidradenitis suppurativa (HS) is associated with substantial morbidity. Few studies have addressed the natural history and mortality rates associated with HS. A higher risk of cardiovascular death in patients with HS has been reported. We investigated whether patients with HS have an increased overall risk of death compared with age‐ and gender‐matched referents. Methods We performed a retrospective cohort study of residents of Olmsted County, Minnesota, with incident HS between January 1, 1980, and December 31, 2008, and age‐ and gender‐matched referents. The main outcomes and measures were the overall and cause‐specific risks of death. Results We identified 226 incident cases of HS and 678 age‐ and gender‐matched referents among Olmsted County residents during the study period. Compared to referents, patients with HS had a significantly higher risk of all‐cause death (hazard ratio [HR, 2.48; 95% CI, 1.53–4.03, P < 0.001) and cardiovascular‐ or cerebrovascular‐related death (HR, 2.85; 95% CI, 1.10–7.40, P = 0.03). However, these risks were attenuated by adjusting for smoking history: all‐cause HR, 1.65 (95% CI, 0.97–2.82, P = 0.07) and cardiovascular‐ or cerebrovascular‐related HR, 2.03 (95% CI, 0.71–5.81, P = 0.18). The 71% of patients were former or current smokers at the time of HS diagnosis. Conclusions Hidradenitis suppurativa patients have a substantially increased risk of death from any cause, including cardiovascular or cerebrovascular causes; the risk is especially dependent on smoking history.

AbstractBackgroundThe International Dermoscopy Society (IDS) recently released a set of five basic dermoscopic parameters (vessels, scales, follicular findings, “other structures,” and specific clues) encompassing a total of 31 subitems to standardize the use of dermoscopy in non‐neoplastic dermatoses, yet they have been developed taking into account Caucasian/Asian skin, with consequent possible limitations if used in dark skin.ObjectivesTo validate the abovementioned criteria for the use in dark‐skinned patients (phototypes IV–VI) through an expert consensus.MethodsThe two‐round Delphi method was adopted, with an iterative process consisting of two rounds of email questionnaires. Potential panelists were recruited via e‐mail from all over the world based on their expertise on dermoscopy of non‐neoplastic dermatoses in skin of color.ResultsTwenty‐two panelists took part in the validation process. All of the five originally proposed parameters and subitems reached agreement during the first round, aside from “follicular red dots.” Additionally, during round 1, five new subitems were proposed (perifollicular scales distribution, follicular openings obliteration, broken hairs, eccrine pigmentation, and eccrine ostia obliteration), along with the possibility to change the denomination of parameter 3 (from “follicular findings” to “follicular/eccrine findings”) and split it into two subparameters (“follicular findings” and “eccrine findings”). All such proposals reached agreement during the second round and therefore were included in the final list, for a total of 37 items.ConclusionsAlthough nearly all the dermoscopic criteria originally proposed by the IDS are applicable even to darker phototypes, several additional variables need to be assessed.