INTRODUÇÃO: Onicomicose é a infecção fúngica das unhas e é considerada a onicopatia mais frequente em adultos. Representa até 50% das lesões ungueais, sendo necessária confirmação diagnóstica com exame complementar que demostre a presença do fungo na unha, sendo o exame micológico direto e a cultura para fungos os mais utilizados. A dermatoscopia é um exame não invasivo, rápido e de baixo custo cujos padrões para onicomicose relatados na literatura em estudos retrospectivos chegam a 100% de sensibilidade e especificidade. Deste modo realizamos um estudo prospectivo para comparar a dermatoscopia frente ao exame micológico. MÉTODOS: Estudo prospectivo, transversal avaliando 109 pacientes e 202 unhas com suspeita diagnóstica de onicomicose. Os padrões dermatoscópicos encontrados foram descritos através de fotografias digitais. A sensibilidade e especificidade dos padrões de onicomicose distal-lateral foram determinados de acordo com o resultado do exame micológico. RESULTADOS: Foram significativos (p < 0,05) para o diagnóstico de onicomicose distal lateral e tiveram sensibilidade/especificidade calculadas os padrões: borda recortada (80,2% / 65,3%), borda linear (12,6% / 42,9%), estrias irregulares (81,1% / 65,3%), estrias finas/regulares (9,9% / 59,2%); e as cores branco (93,7% / 18,4%), amarelo (63,1% / 71,4%) e laranja (10,8% / 100%). Após análise multivariada stepwise forward os padrões de estrias irregulares, borda linear e cor amarela mantiveram significância estatística (p < 0,05). DISCUSSÃO: Os achados deste trabalho prospectivo estão de acordo com a literatura mostrando que há correlação entre o exame micológico e a dermatoscopia. Todavia, não ratifica a sensibilidade e especificidade de 100% encontrada em estudo retrospectivo para os padrões de borda recortada e borda linear. Também não demonstrado na literatura, as cores amarela, branca e laranja foram também estatisticamente significativas para o diagnóstico. CONCLUSÃO: A dermatoscopia correlaciona bem com a história natural da infecção fúngica e com o exame micológico, sendo um exame promissor para o diagnóstico de onicomicose. Sugerimos que futuros estudos comparem a dermatoscopia com exames considerados padrão-ouro (ex: microscopia de fluorescência e PCR) para detectar exames falso negativos / BACKGROUND: Onychomycosis is defined as a fungal infection of the nail and is considered the most common onychopathy in adults. It represents up to 50% of nail diseases and demonstration of the fungal pathogen is necessary for diagnostic confirmation. Direct mycological examination and fungal culture are commonly used for this purpose. Dermoscopy is a noninvasive, fast and inexpensive exam, reaching 100% diagnostic sensitivity and specificity for onychomycosis in retrospective studies. Thus, we conducted a prospective study to compare dermoscopy with mycological examination. METHODS Prospective, cross-sectional study with 109 patients and 202 nails evaluated. Dermoscopic patterns were described using digital photography and their sensitivity and specificity for distal-lateral onychomycosis were determined. RESULTS: Statistically significant (p < 0.05) patterns and colors for the diagnosis of distal-lateral onychomycosis and respective sensitivity / specificity: jagged edge (80.2% / 65.3%), linear edge (12.6% / 42 , 9%), longitudinal irregular streaks (81.1% / 65.3%), longitudinal fine / regular streaks (9.9% / 59.2%); white color (93.7% / 18.4%), yellow color (63.1% / 71.4%) and orange color (10.8% / 100%). After a stepwise forward multivariate analysis irregular streaks, linear edge and yellow color remained statistically significant (p < 0.05). DISCUSSION: Findings of this prospective study are in agreement with the literature showing that there is correlation between mycological examination and dermoscopy. However, this study does not agree with 100% sensitivity and specificity found in retrospective studies for jagged edge and linear edge patterns. In addition, white, yellow and orange colors were also statistically significant for the diagnosis of onychomycosis. CONCLUSION: Dermoscopy correlates well with the natural history of fungal nail infection and mycological examination, and we consider it a promising method for the diagnosis of onychomycosis. We suggest that future studies compare dermoscopy with a gold standard exam (ex: fluorescence microscopy, PCR) to detect false negative cases

Diss. (sammanfattning) Göteborg : Göteborgs universitet, 2008. / Härtill 4 uppsatser.

Diss. (sammanfattning) Göteborg : Univ., 2009. / Härtill 4 uppsatser.

Introdução: O conhecimento sobre nevos na gestação é escasso. Existem relatos de crescimento e mudança no padrão dermatoscópico, com formação de novas estruturas e alterações de pigmentação e da arquitetura da rede pigmentar. A maioria dos estudos nesta área são relatos de caso e estudos prospectivos em que foram avaliados poucos nevos por gestante. Objetivo: Analisar mudanças no mapeamento corporal de gestantes e nas estruturas dermatoscópicas dos nevos melanocíticos destas pacientes. Método: Foram avaliados um total de 703 nevos melanocíticos provenientes de 18 gestantes, no primeiro e terceiro trimestres. Foi realizado exame de mapeamento corporal total e dermatoscopia digital e as imagens foram comparadas em relação à formação de novas lesões; mudanças nas estruturas dermatoscópicas (crescimento, mudanças pigmentares, padrão pigmentar, mudanças de rede pigmentar, glóbulos e pontos, novas áreas estruturas vasculares, novas estrias, novas áreas sem estruturas); associação de crescimento de nevos com relação à localização, ao fototipo, ao risco de melanoma, às estruturas dermatoscópicas e à faixa etária; e associação de fototipo e risco de melanoma com estruturas dermatoscópicas. Resultados: Na comparação das imagens do mapeamento corporal, tiveram 44% de pacientes com novas lesões, variando de 1 a 5 lesões por paciente. Todas as pacientes com novas lesões tiveram pelo menos uma das lesões localizada nos membros superiores. Com relação à avaliação dos 703 nevos melanocíticos, 10.4% tiveram hiperpigmentação e 5.8% tiveram hipopigmentação. As mudanças nas estrtuturas dermatoscópicas foram: 23% de mudanças de rede pigmentar, 3.2% de formação de novos vasos, 1.7% de novas estrias, 1% de novas áreas sem estruturas e 55% de crescimento de nevos. Os nevos que cresceram se localizavam com maior frequencia no abdômen (87.1%; p < 0.001), foram mais frequentes nas pacientes que tinham maior risco de melanoma (45% ; p = 0.019), tiveram mais mudanças de rede pigmentar (27.1% ; p = 0.014) e maior formação de glóbulos/pontos (16% ; p < 0.001). Houve uma associação entre formação de estrias e fototipo (p = 0.012), sendo mais frequente nos fototipos II (2.7%), se comparados com fototipos III (1.3%) e IV (0%). Conclusão: Novos nevos melanocíticos podem aparecer na gestante, especialmente nos membros. Um parcela dos nevos pré-existentes se altera na gestação. Crescimento dos nevos parecem ocorrer mais frequentemente em pacientes de alto risco para desenvolver melanoma. O aparecimento de novas estrias é mais frequente em fototipos mais baixos. / Background: Melanocytic nevi might vary in size and number in pregnant women and the differential diagnosis with melanoma may be challenging. Dermoscopy improves the accuracy of pigmented lesions evaluation. Little is known about the dermoscopic changes in melanocytic nevi during pregnancy. Objectives: This study aims to describe changes in total body photography of pregnant women and dermoscopy aspects of their melanocytic nevi. Methods: A total of 703 melanocytic nevi were evaluated from 18 pregnant women, in the first and in the third trimester of gestation. Total body photography and digital dermoscopy were made and the images obtained from the first and third trimesters were compared for new lesions formation; changes in dermoscopic aspects (enlargement, pigmentation changes, pigmentation pattern, network changes, globules and dots, new vascular structures, new streaks, new structureless area); association of nevi enlargement with body location, skin type, risk melanoma, dermoscopy structures and age group; and association of skin type and risk of melanoma with dermoscopy structures. Results: When comparing the total body photography, there were 44% of patients with new lesions, ranging from 1 to 5 new lesions per patient. All patients with new lesions presented at least one of them on the upper limbs. Regarding dermoscopic evaluation of the 703 melanocytic nevi, 10.4% had hyperpigmentation and 5.8% had hypopigmentation. Regarding the dermoscopic structures, there were 23% of network changes, 12.4% new globules/dots, 3.2% of new vessels formation, 1.7% of new streaks, 1.0% of new structureless area, and 55.0% nevi increased in size when comparing the first and third trimesters. These lesions that increased in size were more likely to be seen in the abdomen (87.1%; p<0.001), were more frequent in patients with high risk of melanoma (45.0% ; p=0.019), had more network changes (27.1% ; p=0.014) and new globules and dots formation (16.0% ; p<0.001). An association between streaks formation and skin type was significant (p=0.012) and was more frequent in skin type II (2.7%), when compared to skin type III (1.3%) and IV (0%). Conclusions: New melanocytic nevi may occur in pregnant women, especially on the limbs. A portion of the pre-existing melanocytic nevi changes in pregnancy. Nevi enlargement seem to occur more frequently in high risk melanoma patients. Appearance of new streaks are more frequent in fair skin types.

Introdução: O conhecimento sobre nevos na gestação é escasso. Existem relatos de crescimento e mudança no padrão dermatoscópico, com formação de novas estruturas e alterações de pigmentação e da arquitetura da rede pigmentar. A maioria dos estudos nesta área são relatos de caso e estudos prospectivos em que foram avaliados poucos nevos por gestante. Objetivo: Analisar mudanças no mapeamento corporal de gestantes e nas estruturas dermatoscópicas dos nevos melanocíticos destas pacientes. Método: Foram avaliados um total de 703 nevos melanocíticos provenientes de 18 gestantes, no primeiro e terceiro trimestres. Foi realizado exame de mapeamento corporal total e dermatoscopia digital e as imagens foram comparadas em relação à formação de novas lesões; mudanças nas estruturas dermatoscópicas (crescimento, mudanças pigmentares, padrão pigmentar, mudanças de rede pigmentar, glóbulos e pontos, novas áreas estruturas vasculares, novas estrias, novas áreas sem estruturas); associação de crescimento de nevos com relação à localização, ao fototipo, ao risco de melanoma, às estruturas dermatoscópicas e à faixa etária; e associação de fototipo e risco de melanoma com estruturas dermatoscópicas. Resultados: Na comparação das imagens do mapeamento corporal, tiveram 44% de pacientes com novas lesões, variando de 1 a 5 lesões por paciente. Todas as pacientes com novas lesões tiveram pelo menos uma das lesões localizada nos membros superiores. Com relação à avaliação dos 703 nevos melanocíticos, 10.4% tiveram hiperpigmentação e 5.8% tiveram hipopigmentação. As mudanças nas estrtuturas dermatoscópicas foram: 23% de mudanças de rede pigmentar, 3.2% de formação de novos vasos, 1.7% de novas estrias, 1% de novas áreas sem estruturas e 55% de crescimento de nevos. Os nevos que cresceram se localizavam com maior frequencia no abdômen (87.1%; p < 0.001), foram mais frequentes nas pacientes que tinham maior risco de melanoma (45% ; p = 0.019), tiveram mais mudanças de rede pigmentar (27.1% ; p = 0.014) e maior formação de glóbulos/pontos (16% ; p < 0.001). Houve uma associação entre formação de estrias e fototipo (p = 0.012), sendo mais frequente nos fototipos II (2.7%), se comparados com fototipos III (1.3%) e IV (0%). Conclusão: Novos nevos melanocíticos podem aparecer na gestante, especialmente nos membros. Um parcela dos nevos pré-existentes se altera na gestação. Crescimento dos nevos parecem ocorrer mais frequentemente em pacientes de alto risco para desenvolver melanoma. O aparecimento de novas estrias é mais frequente em fototipos mais baixos. / Background: Melanocytic nevi might vary in size and number in pregnant women and the differential diagnosis with melanoma may be challenging. Dermoscopy improves the accuracy of pigmented lesions evaluation. Little is known about the dermoscopic changes in melanocytic nevi during pregnancy. Objectives: This study aims to describe changes in total body photography of pregnant women and dermoscopy aspects of their melanocytic nevi. Methods: A total of 703 melanocytic nevi were evaluated from 18 pregnant women, in the first and in the third trimester of gestation. Total body photography and digital dermoscopy were made and the images obtained from the first and third trimesters were compared for new lesions formation; changes in dermoscopic aspects (enlargement, pigmentation changes, pigmentation pattern, network changes, globules and dots, new vascular structures, new streaks, new structureless area); association of nevi enlargement with body location, skin type, risk melanoma, dermoscopy structures and age group; and association of skin type and risk of melanoma with dermoscopy structures. Results: When comparing the total body photography, there were 44% of patients with new lesions, ranging from 1 to 5 new lesions per patient. All patients with new lesions presented at least one of them on the upper limbs. Regarding dermoscopic evaluation of the 703 melanocytic nevi, 10.4% had hyperpigmentation and 5.8% had hypopigmentation. Regarding the dermoscopic structures, there were 23% of network changes, 12.4% new globules/dots, 3.2% of new vessels formation, 1.7% of new streaks, 1.0% of new structureless area, and 55.0% nevi increased in size when comparing the first and third trimesters. These lesions that increased in size were more likely to be seen in the abdomen (87.1%; p<0.001), were more frequent in patients with high risk of melanoma (45.0% ; p=0.019), had more network changes (27.1% ; p=0.014) and new globules and dots formation (16.0% ; p<0.001). An association between streaks formation and skin type was significant (p=0.012) and was more frequent in skin type II (2.7%), when compared to skin type III (1.3%) and IV (0%). Conclusions: New melanocytic nevi may occur in pregnant women, especially on the limbs. A portion of the pre-existing melanocytic nevi changes in pregnancy. Nevi enlargement seem to occur more frequently in high risk melanoma patients. Appearance of new streaks are more frequent in fair skin types.

Skin cancer rates continue to rise affecting millions of individuals annually. While cutaneous malignant melanoma comprises a fraction of total skin cancers diagnosed, melanoma is associated with a poor prognosis and higher mortality rate when compared to other forms of skin cancer. The greatest risk factor for skin cancer is the amount of ultraviolet light exposure making skin cancer the most common preventable form of cancer. In conjunction with primary prevention, part of secondary prevention measures involves performing routine skin examinations. According to data from the National Health Interview Survey, only 8% of individuals who had seen a primary care provider in the previous 12 months had a skin examination performed (Johnson et al., 2017). A low rate of skin examination can largely be attributed to current professional guidelines from the United States Preventative Services Task Force (2016) not supporting routine skin screening of all patients. Despite the recommendation, primary care providers are consistently faced with the need to evaluate skin lesions. Other barriers identified include lack of training and practical screening methods. Dermoscopy is a noninvasive technique for identifying skin lesions. Based on the need for improved screening practices and identified barriers, a brief educational session and resource on skin cancer and dermoscopy was presented to primary care providers at an urban family practice clinic in eastern North Dakota. Following the educational session, a three-month implementation period provided time for providers to implement their knowledge and dermoscopy skills in practice. The purpose of the project was to increase knowledge, improve accuracy of identifying skin lesions, and increase provider confidence using dermoscopy. Evaluation using a pre-implementation survey of providers in the clinic found the primary care providers felt comfortable with their baseline knowledge of skin cancer but did not feel confident in their ability to use a dermoscope. Most of the participating providers deemed their level of knowledge regarding dermoscopy to be at a novice level. Results of the post-implementation found providers felt more comfortable using dermoscopy and knowledge in dermoscopy overall improved from novice to advanced beginner or competent.

This roundtable discussion will give family medicine educators and researchers an opportunity to come together and strategize about how to increase the penetration of dermoscopy within our residency programs. Attendees can include family physicians with years of expertise in dermoscopy along with beginners wondering how to get started. We will share ideas about how to learn dermoscopy along with a handout listing the many free online and digital resources available. A discussion will be facilitated about best methods for teaching dermoscopy to interested residents and faculty. We will also share current research and provide opportunities to collaborate on new research into the best methods for teaching dermoscopy. Upon completion of this session, participants should be able to: Identify online and digital resources for learning and teaching dermoscopy. Discuss the pros and cons of the various dermoscopic algorithms that can be the foundation for a dermoscopy curriculum in a family medicine residency. Collaborate to launch research to help inform family medicine educators about the most effective methods for teaching dermoscopy.

Community health outreach workers (CHOWs) have been demonstrated to increase CRC screening patient education for vulnerable, medically underserved patients as well as increase CRC screening rates in rural populations.1,2 This project examined the effectiveness of CHOWs in increasing CRC screening rates among low-income, underserved ethnic minorities in Portland, Maine. Eligible patients were ages 50-75; due for CRC screening; enrolled in Medicaid or had no health insurance; and spoke Arabic, English, French, Kinyarwanda, Somali, Spanish or Vietnamese. Seven CHOWs were trained in CRC screening outreach and assigned to patients from their own ethnic communities where they employed culturally sensitive interventions to reduce barriers to CRC screening. CHOWs attempted contact with patients by phone four times prior to sending a language-specific letter to patients recommending CRC screening. CHOWs offered fecal immunochemical testing (FIT) or colonoscopy and provided tailored education and frequent reminders for colonoscopies, explanations about procedures for bowel preps, transportation to colonoscopies, reminders and instructions for FIT completion as well as assistance with health insurance and financial barriers. Upon completion of this session, participants should be able to: Define the role of a community health outreach worker (CHOW) in CRC screening. State three common sociocultural barriers patients experience for CRC screening. Identify the efficacy of CHOWs in increasing CRC screening rates.

Le mélanome acro-lentigineux (ALM) est le 4ème sous-type histologique de mélanome et représente moins de 10% des mélanomes. Beaucoup de controverses entourent ce sous-type rare, comme un plus mauvais pronostic. L’objectif de notre travail était de mieux caractériser l’ALM sur le plan épidémiologique, clinique, histologique, et évolutif et d’identifier d’éventuels facteurs pronostiques. Entre 1996 et 2004, 126 cas d’ALMs (6% des mélanomes) ont été répertoriés et suivis dans le service de dermatologie de l’Hôpital de l’Hôtel-Dieu, Lyon. Toutes les lames histologiques ont été récupérées et systématiquement relues. Les analyses statistiques ont été réalisées par comparaison de sous-groupes, calculs et comparaison des courbes de survie par la méthode de Kaplan-Meier et le test de Log-Rank, et recherche de facteurs pronostiques indépendants en utilisant le modèle de régression logistique de Cox. La survie médiane sans récidive et spécifique étaient respectivement de 10,1 et 13,5 ans. Le taux de survie à 5 ans était de 76%. Dans la première partie de notre travail, nous avons étudié toutes les caractéristiques épidémiologiques et cliniques de l’ALM, afin de mieux comprendre l’histoire clinique. Les hommes avaient un plus mauvais pronostic ainsi que les formes achromiques. La seconde partie est une étude détaillée des particularités anatomo-pathologiques des ces tumeurs, avec une évaluation de leur signification pronostique. L’analyse multivariée des facteurs pronostiques a permis de souligner l’impact de l’index mitotique et de la présence de microsatellites en histologie. Enfin, la troisième partie de notre travail avait pour but de préciser les critères dermoscopiques d’aide au diagnostic de l’ALM, dont le retard diagnostique est fréquent. A partir d’une des plus grandes séries de cas d’ALM, notre travail souligne le caractère distinct de ce sous-type de mélanome, dont le mauvais pronostic est vraisemblablement lié à un stade avancé au diagnostic, la dermoscopie constituant une aide précieuse pour un diagnostic plus précoce. / Acral Lentiginous Melanoma (ALM) is the fourth main histological subtype of melanoma and accounts for less than 10% of all melanomas. Many controversies surround this rare subtype, as a poorer prognosis. The aim of our study was to investigate the distinctive epidemiological, clinical and histological characteristics and outcome of ALM, and to evaluate their prognostic values in order to identify independent prognostic factors. Between 1996 and 2004, 126 patients with ALMs (6% of all melanomas) were retrieved and followed up at the Department of Dermatology, Hôtel-Dieu University Hospital, Lyon, France. All histological material were systematically reexamined. Statistical analysis was performed by comparing the baseline characteristics of subgroups with appropriate tests. ALM-specific and disease-free survivals were estimated using the Kaplan-Meier method and compared using the Log-Rank test. A Cox proportional hazards model was used to identify independent prognostic factors. The median disease-free and ALM-specific survivals were 10.1 and 13.5 years, respectively. The 5-year survival rate was 76%. In the first part of this study, we reviewed patient demographics, the initial presentation of the lesion, and clinical outcome. Male gender and amelanosis were significantly associated with a poorer prognosis. The second part is a detailed analysis of histopathological features, with evaluation of their prognostic value. The presence of microsatellites and a high mitotic rate appeared to be of particular importance in predicting the outcome of ALM. Then, the third part emphasized all dermoscopic features of ALM, in order to improve recognition of suspicious cases and to permit an earlier diagnosis. This large register-based review of ALM shows that ALM is an unusual subtype of melanoma that exhibits distinctive epidemiological, clinical and pathological features. The classical poorer prognosis is mainly due to a more advanced stage at the time of diagnosis. Dermoscopy could be helpful to improve the diagnostic accuracy in such locations.

Purpose: Automatic border detection is the first and most crucial step for lesion segmentation and can be very challenging, due to several lesion characteristics. There are many melanoma border-detecting algorithms that perform poorly on dermoscopy images of basal cell carcinoma (BCC), which is the most common skin cancer. One of the reasons for poor lesion detection performance is that there are very few algorithms that detect BCC borders, because they are difficult to segment, even for dermatologists. This difficulty is due to low contrast, variation in lesion color and artifacts inside/outside the lesion. Segmentation that has adequate lesion-feature capture, with acceptable tolerance, will facilitate accurate feature segmentation, thereby maximizing classification accuracy. Methods: The main objective of this research was to develop an effective BCC border detecting algorithm whose accuracy is better than the existing melanoma border detectors that have been applied to BCCs. Fifteen auto-thresholding techniques were implemented for BCC lesion segmentation; but, only five were selected for use in algorithm development. A novel technique was developed to automatically expand BCC lesion borders, to completely circumscribe the lesion. Two error metrics were used that better measure Type II (false-negative) errors: Relative XOR error and Lesion Capture Ratio (a novel error metric). Results: On training and test sets of 1023 and 119 images, respectively, based on two error metrics, five thresholding-based algorithms outperformed two state-of-the-art melanoma segmentation techniques, in segmenting BCCs. Five algorithms generated borders that appreciably better matched dermatologists’ hand-drawn borders which were used as the “gold standard.” Conclusion: The five developed algorithms, which included solutions for image-vignetting correction and border expansion, to achieve dermatologist-like borders, provided more inclusive and therefore, feature-preserving border detection, favoring better BCC classification accuracy, for future work.