Curricular factors associated with medical students\u27 practice of the skin cancer examination: an educational enhancement initiative by the integrated skin exam consortium

IMPORTANCE: As medical school curricula become progressively integrated, a need exists to optimize education related to the skin cancer examination (SCE) for melanoma, a relevant competency gap that influences secondary prevention efforts. OBJECTIVES: To identify curricular factors associated with medical students\u27 confidence, intent, and performance regarding the SCE. DESIGN, SETTING, AND PARTICIPANTS: Survey-based cross-sectional study from the Integrated Skin Exam Consortium at accredited US medical schools among a volunteer sample of second-year students representing 8 geographically varied public and private institutions. Students were administered a questionnaire to assess characteristics, curricular exposures, and educational and practical experiences related to skin cancer, as well as knowledge of melanoma risk and a detection method. MAIN OUTCOMES AND MEASURES: Primary outcomes were confidence in performing the SCE, intent to perform an integrated skin examination, and actual performance of the SCE. RESULTS: Physical diagnosis session and clinical encounter were most predictive of confidence in performance of the SCE (odds ratios [ORs], 15.35 and 11.48, respectively). Other curricular factors associated with confidence included instruction time of at least 60 minutes on skin cancer (OR, 6.35), lecture on the SCE (OR, 7.54), knowledge of melanoma risk (OR, 3.71), and at least 1 opportunity to observe the SCE (OR, 2.70). Physical diagnosis session and at least 4 opportunities to observe the SCE were most predictive of intent to perform an integrated skin examination (ORs, 4.84 and 4.72, respectively). Other curricular factors associated with intent included knowledge of melanoma risk (OR, 1.83), clinical encounter (OR, 2.39), and at least 1 opportunity to observe the SCE (OR, 1.95). Clinical encounter, physical diagnosis session, and at least 1 opportunity to observe the SCE were most predictive of performance of the SCE (ORs, 21.67, 15.48, and 9.92, respectively). Other curricular factors associated with performance included instruction time of at least 60 minutes on skin cancer (OR, 2.42) and lecture on the SCE (OR, 5.04). CONCLUSIONS AND RELEVANCE: To augment the practice of the SCE among medical students, course directors may design an integrated curriculum that includes at least 60 minutes of instruction related to melanoma and the SCE, a description of the integrated skin examination as part of the physical diagnosis course, and education on high-risk demographic groups and anatomic sites specific to men and women and on the ABCDEs of melanoma, and at least 1 opportunity to observe the SCE

The Utility of Complete Skin Examinations

Background: Complete skin examinations (CSE’s), also known as full body skin examinations (FBSE’s), are routinely performed on new patients presenting to dermatology clinics with the goal of detecting pre-malignant and malignant cutaneous lesions, resulting in decreased morbidity and mortality. Current literature is limited, focusing solely on neoplasm detection. One recent retrospective study demonstrated the utility of FBSE’s in the early detection of melanoma in a private practice setting.(1) Data combining the discovery of incidental cutaneous neoplasms and premalignancies on CSE by a dermatologist is not readily available. Currently, groups such as the United States Preventive Forces Task Force do not make recommendations for CSE’s. The prognosis of cutaneous neoplasms is based on the depth of penetration, which can be curtailed if lesions are discovered early. Melanomas are most worrisome and the 5-year survival rate for those diagnosed with melanoma at a thickness of \u3c 0.76 mm is 98%. (2) Other malignancies include basal cell (BCC) and squamous cell carcinomas (SCC). Pre-malignancies include actinic keratoses (AK) and dysplastic nevi (DN). Although most dermatologists perform CSE’s on all new patients, many primary care physicians (PCP’s) do not regularly do so. Dermatologists are both more likely to perform CSE’s on patients perceived to be at high risk for cutaneous malignancy (3) and more likely than PCP’s to identify lesions. (4) Careful CSE’s result in cost and morbidity reduction. (4) Barriers to performing CSE’s include time limits and lack of emphasis on CSE’s during training. (3) While it seems appropriate for dermatologists and PCP’s to perform CSE’s in daily practice, PCP’s have a vital role in recognizing, diagnosing, and appropriately referring patients with concerning lesions. Objectives: Our pilot-study sought to provide data demonstrating the benefits of CSE’s for detecting both pre-malignant and malignant cutaneous lesions. By performing CSE’s on all new patients, we hoped to demonstrate that lesions that would otherwise go undiagnosed, are discovered earlier, decreasing morbidity. We hypothesized new patients presenting to the dermatology clinic for one skin lesion would actually have others discovered incidentally. Methods: Study subjects were identified as new patients presenting to the dermatology clinic at the University of Massachusetts Medical Center from September 2009 through March 2010, of varying ages, ethnicities, and sex. Each patient was asked to indicate “birthmarks, moles, or spots” they wanted examined; these lesions were considered the primary reason for the CSE. A CSE was performed on each subject with the patient’s complaints in mind. These were noted, and depending on the clinical diagnosis, the patient was biopsied, reassured, scheduled for follow-up, or treated. Other lesions detected by a dermatologist were noted, clinically diagnosed, and appropriately biopsied or treated, if necessary. Data analysis was done utilizing Microsoft excel. Data included the percentage of patients with physician-detected lesions and breakdown according to malignant potential and lack of it. Relationships between gender and incidental discovery of lesions were examined. Results: A total of 53 patients were recruited, 50 adults (94.3%) and 3 children (5.7%) from October 2009 through March 2010. There were 35 females (66.0%) and 18 males (34.0%). Of the 53 patients, a total of 10 (18.9%) had dermatologist-detected lesions and 5 (9.4%) had consequential (premalignant or malignant) lesions. There were not any lesions detected in children. A total of 14 lesions were detected and 8 (57.1%) of these lesions were considered consequential. Six (42.9%) of the 14 lesions were premalignant and 2 (14.3%) were malignant. Both malignancies were BCC’s and did not include more malignant neoplasms. Fifty percent of the premalignancies were diagnosed pathologically via a shave biopsy and 50 % were diagnosed clinically. All of the malignant lesions were diagnosed pathologically. Of the 35 females, 5 (14.3%) had lesions detected by a dermatologist. Of the 18 males, 5 (27.8%) had lesions detected similarly. There were no statistically significant differences in the patients having lesions discovered on exam with respect to gender (Fisher exact test p = 0.279); test of proportions revealed statistically insignificant results (p = 0.117, z score -1.188). An equal amount (50%) of premalignant lesions was discovered in both genders. Six (42.9%) of the 14 lesions were benign, including a blue nevus, nevus sebaceus, acne, dermatofibroma, and perioral dermatitis. Discussion: To our knowledge, our pilot-study is the first attempting to determine the utility of CSE’s in detecting lesions other than just cutaneous neoplasms. We also focused on premalignancies such as AK’s and DN. Because of our study, one female patient was worked up for neurofibromatosis type 1 (NF1) because she had multiple café-au-lait macules and inguinal freckling, suspicious for NF1. Our study’s limitations included the small patient population surveyed. The surveys were also not consistently used in all clinics. Although unintentional, this may have led to selection bias by not including new patients at all clinics attended by the dermatologists involved in the study. Our study also included twice as many females as males. Women may be more likely to seek dermatologic evaluation. Although no statistical significance was found with dermatologist detection of lesions comparing patient gender, this may have resulted from the small number of study subjects. Therefore, gender differences should be examined with a larger population. Racial and ethnic differences, as well as the cost-benefit ratio of discovering consequential lesions early on, should also be studied in the future. Conclusion: According to our pilot-study, we were able to demonstrate that a CSE does detect consequential lesions in 9.4% of patients. Although this is clinically significant, there does not appear to be any statistical significance since our population size was small. This pilot-study has been used as a basis for a larger scale study in the future with a larger patient population including children and adults of all ethnicities. Although further data collection is needed, this study demonstrates that lesions may be detected by a dermatologist even though a patient may not recognize them, helping decrease morbidity. References: 1. Kantor J, Kantor DE. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol 2009;145(8):873-876. 2. Aitken, Joanne F, Youl, Philippa H, Janda, Monika, Lowe, John B, Ring, Ian T, Elwood, Mark. Increase in skin cancer screening during a community-based randomized intervention trial. Int J Cancer 2006;118:1010-1016. 3. Federman, Daniel G, Kravetz, Jeffrey D, Kirsner, Robert S. Skin cancer screening by dermatologists: prevalence and barriers. J Am Acad Dermatol 2002;46:710-4. 4. Hubert, Jason N, Callen, Jeffrey P, Kasteler, Scott J. Prevalence of Cutaneous Findings in Hospitalized Pediatric Patients. Pediatr Dermatol 1997;14(6):426-429. Presented as part of the Senior Scholars Program at the University of Massachusetts Medical School, May 3, 2010

A comparison of psoriasis severity in pediatric patients treated with methotrexate vs biologic agents

This cohort study compares the use of methotrexate vs biologic agents in children with moderate to severe psoriasis. Question What is the association between use of methotrexate vs biologics and psoriasis severity and drug survival (rate and duration of adherence to a specific drug regimen) in pediatric patients with moderate to severe psoriasis? Findings In this cohort study including 234 pediatric patients with moderate to severe psoriasis, those receiving biologics were more likely than those treated with methotrexate to achieve a Physician Global Assessment status of clear/almost clear and 75% or more improvement of the Psoriasis Area and Severity Index rating at 6 months. In addition, biologics were associated with better drug survival rates at 1, 3, and 5 years, with comparable discontinuation rates owing to lack of response. Meaning In pediatric patients with psoriasis, treatment with biologics may be associated with a significantly greater reduction in psoriasis severity than methotrexate; nevertheless, with 35.6% of the patients achieving clear/almost clear and 40.0% reaching 75% or more improvement on the Psoriasis Area and Severity Index, methotrexate remains an effective treatment for pediatric psoriasis. Importance Few studies have compared the use of methotrexate and biologics, the most commonly used systemic medications for treatment of moderate to severe psoriasis in children. Objective To assess the real-world, 6-month reduction in psoriasis severity and long-term drug survival (rate and duration of adherence to a specific drug) of methotrexate vs biologics in plaque psoriasis in children. Design, Setting, and Participants A retrospective medical records review was conducted at 20 European and North American centers. Treatment response was based on site-reported Psoriasis Area and Severity Index (PASI) and/or Physician Global Assessment (PGA) scores at baseline and within the first 6 months of treatment. Participants included all 234 consecutively seen children with moderate to severe psoriasis who received at least 3 months of methotrexate or biologics from December 1, 1990, to September 16, 2014, with sufficient data for analysis. Data analysis was performed from December 14, 2015, to September 1, 2016. Main Outcomes and Measures PASI, with a range from 0 to 72 (highest score indicating severe psoriasis), and/or PGA, with a scale of 0 (clear), 1 (minimal), 2 (mild), 3 (moderate), 4 (severe), and 5 (very severe). Results Of 234 pediatric patients (103 boys [44.0%]; 131 girls [56.0%]) treated with methotrexate and/or biologics, 163 patients (69.7%) exclusively received methotrexate, 47 patients (20.1%) exclusively received biologics, and 24 children (10.2%) received methotrexate and biologics sequentially. Of the latter cohort, 23 children were treated initially with methotrexate. Mean (SD) age at initiation was 11.6 (3.7) years for methotrexate and 13.3 (2.9) years for biologics (73.2% for etanercept) (P = .002). Among patients evaluated by a scoring method at 6-month follow-up, 75% or greater improvement in PASI (PASI75) was achieved in 12 of 30 patients (40.0%) receiving methotrexate and 20 of 28 patients (71.4%) receiving biologics, and PGA was clear/almost clear (PGA 0/1) in 41 of 115 patients (35.6%) receiving methotrexate and 18 of 37 patients (48.6%) receiving biologics. Achieving PASI75 and/or PGA 0/1 between baseline and 6 months was more likely with biologics than methotrexate (PASI75: odds ratio [OR], 4.56; 95% CI, 2.02-10.27; P < .001; and PGA 0/1: OR, 2.00; 95% CI, 0.98-4.00; P = .06). Decreased mean PASI and PGA scores were associated with biologics more than with methotrexate (PASI effect, -3.13; 95% CI, -4.33 to -1.94; P < .001; and PGA effect, -0.31; 95% CI, -0.56 to -0.06; P = .02). After 1, 3, and 5 years of use, overall drug survival rates for methotrexate were 77.5%, 50.3%, and 35.9%, and for biologics, the rates were 83.4%, 64.3%, and 57.1%, respectively. Biologics were associated with a better confounder-corrected drug survival than methotrexate (hazard ratio [HR], 2.23; 95% CI, 1.21-4.10; P = .01). Discontinuation owing to lack of response was comparable (HR, 1.64; 95% CI, 0.80-3.36; P = .18). Conclusions and Relevance Methotrexate and biologics appear to be associated with improvement in pediatric psoriasis, although biologics seem to be associated with greater reduction in psoriasis severity scores and higher drug survival rates than methotrexate in the real-world setting. Additional studies directly comparing these medications should be performed for confirmation

Chevron nails: a normal variant in the pediatric population

A 7-month-old girl was evaluated for V-shaped ridging of the fingernails consistent with chevron nails. Chevron nails are a normal variant in the pediatric population that is frequently outgrown. This case nicely demonstrates this normal finding that has so rarely been reported in the literature

The Integrated Skin Exam film: an educational intervention to promote early detection of melanoma by medical students

BACKGROUND: Knowledge of the skin cancer examination (SCE) and its practice remain relevant competency gaps among medical students. OBJECTIVE: We elaborate on a method of SCE known as the Integrated Skin Exam and discuss the development of an instructional film that illustrates its principles. We assess the tool\u27s effect on knowledge, attitudes, and perceptions related to the SCE. METHODS: Second-year students among 8 randomized schools viewed the film and completed pre-post questionnaires. RESULTS: After viewing The Integrated Skin Exam film, students demonstrated improved melanoma knowledge, including identification of high-risk demographic groups (61% vs 42.9%, P \u3c .001), high-risk anatomic sites in women (88.6% vs 46.5%, P \u3c .001) and men (92.1% vs 34.8%, P \u3c .001), and the ABCDEs of melanoma (98.4% vs 91.2%, P \u3c .001). Students demonstrated increased confidence in the SCE (66.93% vs 16.40%, P \u3c .001) and augmented intentions to practice it (99.05% vs 13.9%, P \u3c .001). A greater proportion (70.4% vs 41.9%, P \u3c .001) of students thought less than 3 minutes were required to integrate SCE into the routine examination. LIMITATIONS: Longitudinal impact of the film was not assessed. CONCLUSION: The Integrated Skin Exam film introduces an integrated approach to the SCE that addresses knowledge gaps, mitigates perceived barriers, and augments intention related to practice of the SCE

The deep penetrating nevus

The deep penetrating nevus (DPN), also known as the plexiform spindle cell nevus, is a pigmented lesion that commonly arises on the head and neck in the first few decades of life. Histopathologically, the DPN is wedge-shaped and contains melanocytes that exhibit deep infiltration into the dermis. Given these features, DPN may clinically and histopathologically mimic malignant melanoma, sparking confusion about the appropriate evaluation and management of these lesions. The goal of this review is to summarize the clinical and histopathological features of DPN and to discuss diagnostic and treatment strategies for dermatologists

Scalp sarcoidosis: a sign of systemic sarcoidosis

Sarcoidosis is a systemic disease often with cutaneous manifestations. Scarring alopecia of the scalp is a rare form of cutaneous sarcoidosis. Herein, we describe a case of sarcoidosis of the scalp mimicking discoid lupus

Primary livedoid vasculopathy associated with mononeuritis multiplex

A 40-year-old woman presented with painful ulcerations on the bilateral lower extremities. A biopsy confirmed the diagnosis of livedoid vasculopathy (LV). She was treated initially with aspirin and pentoxifylline, and with the addition of dipyridamole she has had no recurrence of her ulcerations to date. Despite this positive response to treatment she reported numbness and paresthesias in her legs. Nerve conduction studies confirmed a diagnosis of mononeuritis multiplex. This case highlights mononeuritis multiplex as a rarely described complication of LV, and suggests that early recognition of symptoms and a multidisciplinary approach are necessary for optimal management of this condition

Scalp sarcoidosis: a sign of systemic sarcoidosis

Sarcoidosis is a systemic disease often with cutaneous manifestations. Scarring alopecia of the scalp is a rare form of cutaneous sarcoidosis. Herein, we describe a case of sarcoidosis of the scalp mimicking discoid lupus

Child abuse masquerading as a soft tissue sarcoma

Pediatric fasciitides are rare benign lesions that may clinically mimic a malignant sarcoma. Nodular fasciitis, the most common of these fasciitides, rarely occurs in children younger than 5 years of age. Often there is a history of preceding trauma. Herein, we report the case of a 5-month-old boy diagnosed with nodular fasciitis in the setting of nonaccidental trauma