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Competing Interests: Conflicts of interest None disclosed.

Background: Lentigo maligna (LM) can mimic benign, flat, pigmented lesions and can be challenging to diagnose., Objective: To describe a new dermatoscopic feature termed "perifollicular linear projections (PLP)" as a diagnostic criterion for LM on the face., Methods: Retrospective study on reflectance confocal microscopy and dermatoscopy images of flat facial pigmented lesions originating from 2 databases. PLP were defined as short, linear, pigmented projections emanating from hair follicles. Dermatoscopy readers were blinded to the final histopathologic diagnosis., Results: From 83 consecutive LMs, 21/83 (25.3%) displayed "bulging of hair follicles" on reflectance confocal microscopy and 18 of these 21 (85.7%), displayed PLP on dermatoscopy. From a database of 2873 consecutively imaged and biopsied lesions, 252 flat-pigmented facial lesions were included. PLP was seen in 47/76 melanomas (61.8%), compared with 7/176 lesions (3.9%) with other diagnosis (P < .001). The sensitivity was 61.8% (95% CI, 49.9%-72.7%), specificity 96.0% (95% CI, 92.9%-98.4%). PLP was independently associated with LM diagnosis on multivariate analysis (OR 26.1 [95% CI, 9.6%-71.0])., Limitations: Retrospective study., Conclusion: PLP is a newly described dermatoscopic criterion that may add specificity and sensitivity to the early diagnosis of LM located on the face. We postulate that PLP constitutes an intermediary step in the LM progression model., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2023 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Given the results of the recent KEYNOTE-716 trial, the performance of sentinel lymph node (SLN) biopsy for patients with clinical stage IIB/C melanoma has been questioned., Objective: Determine the utility of SLN status in guiding the recommendations for adjuvant therapy., Methods: Patients with clinical stage IIB/C cutaneous melanoma who underwent wide local excision and SLN biopsy between 2004 and 2011 were identified from the Surveillance, Epidemiology, and End Results database. Two prognostic models, with and without SLN status, were developed predicting risk of melanoma-specific death (MSD). The primary outcome was net benefit at treatment thresholds of 20% to 40% risk of 5-year MSD., Results: For the 4391 patients included, the 5-year MSD rate was 46%. The model estimating 5-year MSD risk that included SLN status provided greater net benefit at treatment thresholds from 30% to 78% compared to the model without SLN status. The added net benefit for the SLN biopsy-containing model persisted in subgroup analysis of patients in different age groups and with various T stages., Limitations: Retrospective study., Conclusions: A prognostic model with SLN status estimating patient risk for 5-year MSD provides superior net benefit compared to a model with primary tumor staging factors alone for threshold mortality rates ≥30%., Competing Interests: Conflicts of interest Bartlett receives institutional research support from SkylineDx and discloses an honorarium from Excite International. Karakousis is a PI of an investigator-initiated trial with institutional support by Merck and serves on the Merck advisory board. The other authors have no conflict to disclose., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Conflicts of interest None disclosed.

Competing Interests: Conflicts of interest Dr Marghoob declares research support from Incyte and Amryt Pharma and serves on the advisory board of Alira Health. Dr Rotemberg is an expert advisor for Inhabit Brands, Inc. Dr Rajadhyaksha owns equity in Caliber ID (formerly, Lucid Inc). The Vivascope is the commercial version of an original laboratory prototype that was developed by Dr Rajadhyaksha when he was at Massachusetts General Hospital, Harvard Medical School. Drs Cordova, Chen, Halpern, Kentley, Kose, Lee, Marchetti, Markova, Navarrete-Dechent, Nehal, Rossi, Sahu, and Jain and Authors Mehta, Oh, Harris, Kurtansky, and Sun have no conflicts of interest to declare.

Competing Interests: Conflicts of interest Drs Yamada and Prow have a conflict of interest with Trajan Scientific & Medical Pty Ltd as they are currently commercializing microbiopsy. Drs Jain, Busam, Marchetti, and Halpern and authors Autuori, Everett, Harris, and Orlow do not have any conflicts of interest to disclose.

Skin cancer is the most commonly diagnosed cancer worldwide. Understanding the natural history of skin cancer provides the framework for the creation of prevention and control strategies that aim to reduce the skin cancer burden. Based on the target (individual vs population), disease stage, and risk factors (modifiable vs nonmodifiable), strategies can be categorized into 4 levels-health promotion (also known as primordial prevention), primary prevention, secondary prevention, and tertiary prevention. This is the first of a 2-part review, which will cover the epidemiology, risk factors, primordial prevention, and primary prevention of melanoma and keratinocyte skin cancers. In particular, we highlight preventive strategies centered on mitigating the impact of modifiable risk factors and potential interventions for health promotion and primary prevention of skin cancer. Summaries of existing recommendations, challenges, opportunities, and future directions are also discussed., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Skin cancer is the most commonly diagnosed cancer worldwide. Understanding the natural history of skin cancer will provide a framework for the creation of prevention and control strategies that aim to reduce skin cancer burden. The strategies include health promotion, primary prevention, secondary prevention, and tertiary prevention. Health promotion and primary prevention were covered in the first part of this 2-part review. The second part covers the secondary and tertiary prevention of skin cancer. In particular, preventive strategies centered on the early detection of skin cancer, the prevention of disease progression, clinical surveillance, and educational and behavioral interventions are highlighted. The summaries of existing recommendations, challenges, opportunities, and future directions are discussed., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Reflectance confocal microscopy (RCM) allows accurate, noninvasive, in vivo diagnosis for skin cancer. However, its impact on physicians' diagnostic confidence and management is unknown., Objectives: We sought to assess the physicians' diagnostic confidence and management before and after RCM of equivocal skin lesions., Methods: Prospective, 2-center, observational study. During clinical practice, 7 dermatologists recorded their diagnostic confidence level (measured in a scale from 0 to 10), diagnosis, and management before and after RCM of clinically/dermoscopically equivocal lesions that raised concern for skin cancer. We also evaluated the diagnostic accuracy before and after RCM., Results: We included 272 consecutive lesions from 226 individuals (mean age, 53.5 years). Diagnostic confidence increased from 6.2 to 8.1 after RCM (P < .001) when RCM confirmed or changed the diagnosis. Lesion management changed in 33.5% cases after RCM (to observation in 51 cases and to biopsy/excision in 31 cases). After RCM, the number needed to excise was 1.2. Sensitivity for malignancy before and after RCM was 78.2% and 85.1%, respectively. Specificity before and after RCM was 78.8% and 80%, respectively., Limitations: Small sample size, real-life environment, and different levels of expertise among RCM users., Conclusion: Physicians' diagnostic confidence and accuracy increased after RCM when evaluating equivocal tumors, frequently resulting in management changes while maintaining high diagnostic accuracy., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The number needed to biopsy (NNB) ratio for melanoma diagnosis is calculated by dividing the total number of biopsies by the number of biopsied melanomas. It is the inverse of positive predictive value (PPV), which is calculated by dividing the number of biopsied melanomas by the total number of biopsies. NNB is increasingly used as a metric to compare the diagnostic accuracy of health care practitioners., Objective: To investigate the association of NNB with the standard statistical measures of sensitivity and specificity., Methods: We extracted published diagnostic accuracy data from 5 cross-sectional skin cancer reader studies (median [min-max] readers/study was 29 [8-511]). Because NNB is a ratio, we converted it to PPV., Results: Four studies showed no association and 1 showed a negative association between PPV and sensitivity. All 5 studies showed a positive association between PPV and specificity., Limitations: Reader study data., Conclusions: An individual health care practitioner with a lower NNB is likely to have a higher specificity than one with a higher NNB, assuming they practice under similar conditions; no conclusions can be made about their relative sensitivities. We advocate for additional research to define quality metrics for melanoma detection and caution when interpreting NNB., (Copyright © 2020 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Computer vision has promise in image-based cutaneous melanoma diagnosis but clinical utility is uncertain., Objective: To determine if computer algorithms from an international melanoma detection challenge can improve dermatologists' accuracy in diagnosing melanoma., Methods: In this cross-sectional study, we used 150 dermoscopy images (50 melanomas, 50 nevi, 50 seborrheic keratoses) from the test dataset of a melanoma detection challenge, along with algorithm results from 23 teams. Eight dermatologists and 9 dermatology residents classified dermoscopic lesion images in an online reader study and provided their confidence level., Results: The top-ranked computer algorithm had an area under the receiver operating characteristic curve of 0.87, which was higher than that of the dermatologists (0.74) and residents (0.66) (P < .001 for all comparisons). At the dermatologists' overall sensitivity in classification of 76.0%, the algorithm had a superior specificity (85.0% vs. 72.6%, P = .001). Imputation of computer algorithm classifications into dermatologist evaluations with low confidence ratings (26.6% of evaluations) increased dermatologist sensitivity from 76.0% to 80.8% and specificity from 72.6% to 72.8%., Limitations: Artificial study setting lacking the full spectrum of skin lesions as well as clinical metadata., Conclusion: Accumulating evidence suggests that deep neural networks can classify skin images of melanoma and its benign mimickers with high accuracy and potentially improve human performance., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Multiple BRCA1-associated protein 1 (BAP1)-inactivated melanocytic tumors (BIMTs) have been associated with a familial cancer syndrome involving germline mutations in BAP1., Objectives: We sought to describe the clinical and dermoscopic features of BIMTs., Methods: This was a retrospective, multicenter, case-control study. Participating centers contributed clinical data, dermoscopic images, and histopathologic data of biopsy-proven BIMTs. We compared the dermoscopic features between BIMTs and control patients., Results: The dataset consisted of 48 BIMTs from 31 patients (22 women; median age 37 years) and 80 control patients. Eleven patients had a BAP1 germline mutation. Clinically, most BIMTs presented as pink, dome-shaped papules (n = 24). Dermoscopically, we identified 5 patterns: structureless pink-to-tan with irregular eccentric dots/globules (n = 14, 29.8%); structureless pink-to-tan with peripheral vessels (n = 10, 21.3%); structureless pink-to-tan (n = 7, 14.9%); a network with raised, structureless, pink-to-tan areas (n = 7, 14.9%); and globular pattern (n = 4, 8.5%). The structureless with eccentric dots/globules pattern and network with raised structureless areas pattern were only identified in BIMT and were more common in patients with BAP1 germline mutations (P < .0001 and P = .001, respectively)., Limitations: Limitations included our small sample size, retrospective design, the absence of germline genetic testing in all patients, and inclusion bias toward more atypical-looking BIMTs., Conclusions: Dome-shaped papules with pink-to-tan structureless areas and peripheral irregular dots/globules or network should raise the clinical suspicion for BIMT., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Dermatologic conditions cause morbidity and mortality among hospitalized cancer patients. An improved understanding is critical for implementing clinical and research programs in inpatient oncodermatology., Objective: To characterize inpatient dermatology consultations at a large comprehensive cancer center., Methods: Retrospective database query of new admissions and medical record review of initial inpatient dermatology consultations comparing inpatients consulted and not consulted during January-December 2015., Results: In total, 412 of 11,533 inpatients received 471 dermatology consultations (54% male, median age 59.5 years). Patients with hematologic cancers were 6 times more likely to receive dermatologic consultations compared with nonhematologic cancers (odds ratio 6.56, 95% confidence interval 5.35-8.05, P < .0001). Patients consulted by a dermatologist had a significantly longer length of stay than inpatients not consulted by dermatology (median 11 vs 5 days, P < .0001). Among the 645 dermatologic conditions diagnosed, the most common categories were inflammatory diseases, infections, and drug reactions; the most frequent conditions were contact dermatitis, herpes zoster, and chemotherapy-induced drug eruptions., Limitations: The study's retrospective nature and single-institution setting are potential limitations., Conclusion: Hematologic malignancies are a significant risk factor for dermatology inpatient consultations. A significantly longer length of stay was associated with dermatology consultations, suggesting high comorbidities in these patients. Increased dermatologic care of these inpatients might improve quality of life, dermatologic health, and ability to receive anticancer agents., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Computer vision may aid in melanoma detection., Objective: We sought to compare melanoma diagnostic accuracy of computer algorithms to dermatologists using dermoscopic images., Methods: We conducted a cross-sectional study using 100 randomly selected dermoscopic images (50 melanomas, 44 nevi, and 6 lentigines) from an international computer vision melanoma challenge dataset (n = 379), along with individual algorithm results from 25 teams. We used 5 methods (nonlearned and machine learning) to combine individual automated predictions into "fusion" algorithms. In a companion study, 8 dermatologists classified the lesions in the 100 images as either benign or malignant., Results: The average sensitivity and specificity of dermatologists in classification was 82% and 59%. At 82% sensitivity, dermatologist specificity was similar to the top challenge algorithm (59% vs. 62%, P = .68) but lower than the best-performing fusion algorithm (59% vs. 76%, P = .02). Receiver operating characteristic area of the top fusion algorithm was greater than the mean receiver operating characteristic area of dermatologists (0.86 vs. 0.71, P = .001)., Limitations: The dataset lacked the full spectrum of skin lesions encountered in clinical practice, particularly banal lesions. Readers and algorithms were not provided clinical data (eg, age or lesion history/symptoms). Results obtained using our study design cannot be extrapolated to clinical practice., Conclusion: Deep learning computer vision systems classified melanoma dermoscopy images with accuracy that exceeded some but not all dermatologists., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Few studies have characterized reference values of normal human skin microanatomy parameters., Objective: To quantify histologic measurements of epidermal thickness, melanocyte density, hair follicle density, and eccrine gland density as a function of age and anatomic site., Method: We searched the PubMed, Embase, Web of Science, and Cochrane databases for articles published through May 25, 2017. Two reviewers independently screened 2016 articles; 327 relevant articles and 151 additional articles found via forward or reference citations underwent full-text review by 1 of 4 reviewers for relevance, data extraction, and critical appraisal. Weighted averages, meta-analysis, and meta-regression were used in statistical analysis., Results: A total of 56 articles were included; when all anatomic locations were used, the overall estimates for epidermal thickness, melanocyte density, hair follicle density, and eccrine gland density were 99.75 μm (95% confidence interval [CI], 83.25-116.25), 955.05 cells/mm 2 (95% CI. 880.89-1029.21), 1.40 hairs/mm 2 (95% CI. 0.91-1.89), and 1.28 glands/mm 2 (95% CI. 0.91-1.64), respectively., Limitations: There was significant data heterogeneity across studies, possibly because of differences in histological techniques and absence of standardized microanatomy definitions., Conclusions: We established summary estimates for normal human skin microanatomy parameters., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Melanocytic nevi are a strong phenotypic marker of cutaneous melanoma risk. Changes in nevi during childhood and adolescence make these prime periods for studying nevogenesis. Insights gained by the study of nevi in childhood have implications for melanoma detection in both adults and children. A more comprehensive understanding of the morphologic characteristics of nevi in different anatomic locations, in association with the patient's age and pigmentary phenotype may aid in the identification of melanomas. When monitoring melanocytic lesions over time, it is essential to differentiate normal from abnormal change. This review summarizes the rapidly expanding body of literature relevant to nevus phenotype, particularly in the context of our experience with the Study of Nevi in Children (SONIC) Project., Competing Interests: The authors have no conflict of interest to declare., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Limited data exist regarding cutaneous involvement of adult T-cell leukemia/lymphoma (ATLL), particularly in the United States., Objective: We sought to characterize clinical and histopathologic features of ATLL in patients with skin involvement., Methods: We retrospectively identified patients with ATLL from a single institution given a diagnosis during a 15-year period (1998-2013). Patients were categorized by the Shimoyama classification and stratified into skin-first, skin-second, and skin-uninvolved courses., Results: The study population included 17 skin-first, 8 skin-second, and 29 skin-uninvolved cases. Skin-first patients (6 acute, 1 lymphoma, 4 chronic, 6 smoldering) were overwhelmingly of Caribbean origin (94%). They had longer median symptom duration (11.9 vs 1.9 months, P < .001) and overall survival (26.7 vs 10.0 months, P < .001) compared with skin-second/skin-uninvolved patients. Cutaneous lesion morphology at diagnosis included nodulotumoral (35%), multipapular (24%), plaques (24%), patches (12%), and erythroderma (6%). After initial skin biopsy, 14 of 17 received a non-ATLL diagnosis, most commonly mycosis fungoides (47%). Notable histopathologic findings from 43 biopsy specimens included greater than or equal to 20:1 CD4:CD8 ratio (79%), angiocentrism (78%), CD25(+) (71%), large cell morphology (70%), CD30(+) (68%), epidermal infiltration of atypical lymphocytes (67%) forming large Pautrier-like microabscesses (55%), and folliculotropism (65%)., Limitations: This was a retrospective, single-center, tertiary referral center study with small sample size., Conclusion: Skin-first patients with ATLL in the United States are diagnostically challenging. Familiarity with clinicopathologic features may aid in diagnosis., (Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)