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

Eruption of bullae within psoriatic plaques: a rare adverse effect of narrow-band ultraviolet B (NB-UVB) phototherapy

The sudden eruption of bullae within psoriatic plaques is an uncommon adverse effect of narrow-band UVB phototherapy (TL-01 radiation). We report the case of a 49-year-old man who developed a bullous eruption after several NB-UVB treatments and will review important aspects of this unusual phototherapy complication

Metastatic squamous cell carcinoma of the vulva mimicking primary varicella-zoster virus infection

We present a case of metastatic vulvar squamous cell carcinoma (SCC) mimicking a primary varicella-zoster virus (VZV)-like eruption. Although rare, a number of cutaneous metastases have been reported in a zosteriform pattern including solid malignancies (breast, colon, lung, and bladder), hematologic malignancies (B-cell lymphoma, T-cell lymphoma, non-Hodgkin lymphoma), and cutaneous malignancies, most notably melanoma. There are 7 published cases of metastatic SCC arising as a zosteriform eruption, but we present an unusual case that mimics primary varicella eruption both morphologically and histologically