Summer 2011 - Dermatology Foundation

A DERMATOLOGY FOUNDATION PUBLICATION SPONSORED BY MEDICIS, THE DERMATOLOGY COMPANY® VOL. 30 NO. 2

SUMMER 2011

DERMATOLOGY FOCUS ™

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Also In This Issue

Where Are They Now: Suephy C. Chen, MD, MS

DF Clinical Symposia: Proceedings 2011–Part II ADVANCES IN DERMATOLOGY The Dermatology Foundation presented its annual 3-day symposia series in March. This highly regarded cutting-edge program provides the most clinically relevant knowledge and guidance for making the newest advances accessible and usable. A daily provocative keynote talk precedes topic-focused, peer-reviewed caliber presentations. This year’s topics were: Acne & Related Disorders; Autoimmunity & Inflammation; Human Appearance; Cutaneous Oncology; Women’s & Children’s Health; and Diseases of the Hair & Scalp. The Proceedings appear in the Spring (Part I) and Summer (Part II) issues. Stuart R. Lessin, MD, and Jack S. Resneck, Jr., MD—Program Co-Chairs

KEYNOTE ADDRESS Signature Nevi Jean L. Bolognia, MD Introduction. People who have an increased number of moles tend to be consistent in the type of mole they produce, and the repetitive type for a given patient is that patient’s signature nevus. It is important to recognize a signature nevus because members of the signature “family” that do not have superimposed changes can be followed clinically, rather than biopsied. It is the mole beyond the confines of a patient’s signature family— the so-called “ugly duckling”—that may require biopsy. Dr. Bolognia’s list of signature nevi includes the 6 types that are easier to assess: solid brown, fried egg, “eclipse,” cockarde/cockade/target, those with perifollicular hypopigmentation, and halo nevi. Their recognition leads to reduction in unnecessary biopsies, scarring, and anxiety. The remaining 3 types—small dark brown-black, solid pink, and white—can be

2012 Research Funding Applications Due October 17 DF Introduces New Dermpath Research Award challenging even after the signature nevus is recognized. Solid Brown Nevi. These oval or round nevi show a regular pigment network or globular pattern on dermoscopy. Because of their uniform color, they are easy to follow clinically. Fried Egg Nevi. Due to their relatively large size, these nevi often “draw the attention of pediatricians as well as patients and their families, leading to unneeded surgery and significant scarring.” Unfortunately, they are sometimes erroneously labeled as pre-melanomas. Two components are present—a more elevated portion (the “yolk”) surrounded by a less elevated portion (likened to the egg “white”). These nevi age in typical fashion—the “yolk” becomes a flabby, thick dermal nevus and the “white” gradually fades into the surrounding skin. Multiple fried egg nevi represent a phenotypic marker for an entire skin at risk. Very occasionally, one of these nevi develops a suspicious superimposed change and a biopsy can be performed. Bolognia outlined the advantages of saucerization biopsies, especially for nevi on the back. Eclipse Nevi. This benign tan-centered nevus has a uniform or stellate brown rim that is continuous or discontinuous. It is a common type of nevus on the scalp of children and there may be multiple such nevi on the scalp. In a child, the presence of scalp nevi is often an omen for moliness as an adult. A histologic feature of benign nevi in special sites, including the scalp, may be misinterpreted as worrisome for melanoma. Thus these nevi should be examined by a dermatopathologist.

Life History of a Pigmented Nevus

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2012 DF Clinical Symposia ADVANC ES IN D ER M ATO LO GY

February 8–12, 2012 The Ritz-Carlton, Naples, Florida

Registration Begins in September! dermatologyfoundation.org/symposia COMPELLING TOPICS Surgery, Oncology, & Aesthetics Diagnostics & Therapeutics Infectious Diseases

Medical Dermatology Pediatric Dermatology Chronic Wounds & Wound Healing

SPECIAL FEATURED TALK Agents of Bioterrorism: Cutaneous Manifestations Boris D. Lushniak, MD, MPH Deputy Surgeon General Department of Health & Human Services

RAVE REVIEWS “ A great meeting—the best I attend!” “ This meeting always has the best speakers & the latest material.” “ It has the most concentrated presentations by field experts.” “ So much clinically relevant, useful material for daily clinical practice.” EXPERT FACULTY Beth A. Drolet, MD

Wilson J. Liao, MD

Janet A. Schlechte, MD

Medical College of Wisconsin

University of California, San Francisco

University of Iowa

University of Iowa

Ashfaq A. Marghoob, MD

State University of New York

Dee Anna Glaser, MD

Memorial-Sloan Kettering Cancer Center

Janet A. Fairley, MD

St. Louis University

Heidi H. Kong, MD, MHSc National Cancer Institute

Carrie L. Kovarik, MD University of Pennsylvania

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Seth J. Orlow, MD, PhD New York University

Marta J. Petersen, MD University of Utah

Daniel M. Siegel, MD, MS Marta J. Van Beek, MD, MPH University of Iowa

David T. Woodley, MD University of Southern California

Albert C. Yan, MD University of Pittsburgh

The DF Clinical Symposia provides 16 AMA PRA Category 1 Credits™. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Yale School of Medicine and the Dermatology Foundation. The Yale School of Medicine is accredited by the ACCME to provide continuing medical education to physicians.

Shaping the Future of Dermatology

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Dermatology Foundation

Signature Melanocytic Nevi • Solid brown • “Fried egg” (brown center) • Eclipse—tan with brown rim • Cockarde/cockade/target • Perifollicular hypopigmentation • Halo • Small dark brown-black ± thin brown rim (lentiginous nevi) • Solid pink (often skin phototype 1) • Nonpigmented (white) Cockarde/Cockade/Target Nevi. These names describe acquired compound melanocytic nevi with a target configuration—a central pigmented papule, then a tan rim, and finally a pigmented annulus. If the central papule is deleted mentally, the lesion resembles an eclipse nevus so it should come as no surprise that patients can have both types of nevi in their signature family. Perifollicular Hypopigmentation. In general, this common benign phenomenon is most apparent in congenital melanocytic nevi or in areas where there are pigmented terminal hairs, e.g., scalp, mons pubis. If it is within the body of the nevus, a narrow white rim is seen around the follicular opening. However, perifollicular hypopigmentation at the periphery of an acquired nevus creates a notch, which leads to an irregular border and asymmetry. Some patients produce obvious perifollicular hypopigmentation in many of their nevi.

Eclipse Nevi

Perifollicular Hypopigmentation

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DERMATOLOGY FOCUS A PUBLICATION OF THE DERMATOLOGY FOUNDATION Sponsored by

Medicis, The Dermatology Company ® Editors-in-Chief David J. Leffell, MD—Professor of Dermatology Yale School of Medicine, New Haven, CT

Mary M. Tomayko, MD, PhD—Asst Professor of Dermatology Yale School of Medicine, New Haven, CT

Executive Director Sandra Rahn Benz Communications Director Christine M. Boris Please address correspondence to:

David J. Leffell, MD & Mary M. Tomayko, MD, PhD Editors, Dermatology Focus c/o The Dermatology Foundation 1560 Sherman Avenue, Evanston, Illinois 60201 Tel: 847-328-2256 Fax: 847-328-0509 e-mail: [email protected]

Published for the Dermatology Foundation by Robert B. Goetz—Designer, Production Sheila Sperber Haas, PhD—Managing Editor, Writer This issue of Dermatology Focus is distributed without charge through an educational grant from Medicis, The Dermatology Company ®. The opinions expressed in this publication do not necessarily reflect those of the Dermatology Foundation or Medicis, The Dermatology Company ®. © Copyright

2011 by the Dermatology Foundation

Halo Nevi. Patient age is critical in determining the significance of multiple new halo nevi. They are most commonly observed in adolescents with numerous nevi. Although the vast majority of these nevi have a benign appearance, clinical examination of each nevus is recommended. A new onset of multiple halo nevi in an older adult raises the possibility of an immune reaction against a cutaneous melanoma or ocular melanoma, and thus a complete skin examination needs to be performed. After the central nevus has turned pink and disappeared, the white macule eventually repigments in nearly all patients, but this can take years. Small Dark Brown-Black. When they are the signature nevus, these lentiginous nevi, some of which have a thin brown rim and central fine scale, create a “cheetah-like” pattern. Because they can number in the hundreds and are often admixed with multiple solar lentigines, this phenotype is very challenging. In addition, the center portion has a very dark homogenous appearance by dermoscopy. Any lesion that develops a persistent pink or red color or has irregularities such as scalloping in the border gets biopsied, and thus the number of biopsies performed in these patients is higher than in others. Alternating examinations between two dermatologists is also recommended. Solid Pink Nevi. These are more difficult to assess clinically and via dermoscopy. Clinically, the darkest red lesion, the firm lesions (rather than the mushy pink intradermal nevi), and those nevi with irregular borders require the most attention. Again, a second pair of eyes is recommended. (Continued on page 5)

www.dermatologyfoundation.org

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62 Leaders Society Members Are New Supporters of Dermatology’s Future The Dermatology Foundation welcomes the dermatologists named below who have joined their colleagues in the Leaders Society ranks this year. We are grateful for their forward-looking decision to invest $1,500 each year to expand the scientific progress that advances patient care. (As of August 12, 2011) ARIZONA Richard A. Bernert, MD ARKANSAS Lance B. Henry, MD CALIFORNIA Susan Amaturo, MD Gregory M. Bricca, MD Serena M. Mraz-Gernhard, MD Dale R. Westrom, MD, PhD Andrea Willey, MD COLORADO Robert P. Dellavalle, MD, PhD James C. Huff, MD FLORIDA Lowella E. Esperanza, MD Ronald C. Knipe, MD Laertes A. Manuelidis, MD Natalie Lama Monticciolo, DO Stephen A. Spencer, MD GEORGIA A. Damian Dhar, MD Paula Nelson, MD

HAWAII George M. Martin, MD Charles Mauro, IV, MD IDAHO Earl R. Stoddard, MD INDIANA Rebecca L. Bushong, MD M. Kathleen McTigue, MD Minati D. Swofford, MD KENTUCKY Vilma C. Fabre, MD LOUISIANA Eric M. Finley, MD William P. Long, MD G. William Poche, MD Adrien A. Stewart, MD Alun Wang, MD, PhD MARYLAND Debra L. Bailey, MD Jane T. Chew, MD Gail R. Goldstein, MD

White Nevi. These extremely rare nevi resemble multiple white seborrheic keratoses or idiopathic guttate hypomelanosis, but histologically there is significant cellular atypia. Of the 5 patients described to date, 4 had melanoma. One patient was homozygous for polymorphisms in the melanocortin receptor-1 gene that are seen in red-haired individuals.

MINI-SYMPOSIUM: CUTANEOUS ONCOLOGY Lessons Learned From a Multidisciplinary Melanoma Program Timothy M. Johnson, MD Introduction. Dr. Johnson discussed fundamental lessons/guidelines that evolved via the 20-year experience of a highvolume, collegial, collaborative, multidisciplinary program. Lesson 1. When a melanoma is diagnosed as a thin lesion by incisional biopsy, yet a significant amount of lesion remains, further microstaging may be helpful. In 250 patients, Johnson et al. documented that excising the residual lesion revealed a clinically significant greater Breslow depth that resulted in up-staging in 21%, with 10% becoming candidates for sentinel-node biopsy (SNB). When patients have substantial residual lesion following a thin diagnosis, Johnson prepares them for further microstaging by explaining that in such cases, the initial assessment to find the deepest portion is not always reliable, whether by incisional biopsy www.dermatologyfoundation.org

MASSACHUSETTS Terence J. Harrist, MD Beatriz Tapia-Centola, MD Elsa Velazquez, MD MICHIGAN Steven K. Grekin, DO MINNESOTA Mimi Lam, MD Stephen R. Tan, MD MISSISSIPPI Angela B. Wingfield, MD NEW HAMPSHIRE Stephen P. Brady, MD NEW JERSEY Kenneth Grossman, MD NEW YORK Snehal P. Amin, MD Mario E. Lacouture, MD Jeffrey R. LaDuca, MD, PhD Michael J. Mulvaney, MD David S. Orentreich, MD Nanette B. Silverberg, MD Lynn Silverstein, MD

OHIO Bruce P. Guido, MD OREGON Eric L. Simpson, MD PENNSYLVANIA George Cotsarelis, MD SOUTH CAROLINA John M. Humeniuk, MD Oswald L. Mikell, MD TEXAS Linda J. DeLoach Banta, MD Rebecca Kelso, MD Anh V. Nguyen, MD David W. Powell, MD UTAH Brian Williams, MD VIRGINIA Cynthia H. Dent, MD WISCONSIN John S. Cantieri, MD James E. Ethington, MD Kristina Kleven, MD David R. Puchalsky, MD

or clinical inspection. He describes the two-step process that will do this accurately. Step 1 is complete excision of the remaining lesion with 1–2 mm margins. Step 2 is wide local excision with margins to be determined ± SNB based on final microstaging Lesson 2. “Stage is the most powerful predictor of survival and the most powerful indicator of how we provide treatment.” Johnson discussed the American Joint Committee on Cancer’s most current set of staging criteria—published in 2009—and the first to profit from the wealth of long-term SNB-associated data. For the primary lesion, tumor thickness as Breslow depth is still the most important criterion. Mitotic rate—clearly associated with worsening prognosis—appears for the first time for thin lesions and replaces Clark level. (See a comprehensive discussion in J Clin Oncol., 2011;29:2199–205.) Increasing depth, mitotic rate, and number of involved nodes, plus ulceration, all indicate poorer prognosis. But not all ultra-thin lesions have a good outcome, and not all lymph node involvement ends in death. http://www.melanomaprognosis.org/ provides a valuable staging algorithm. Lesson 3. Consider the tests that are truly necessary once the diagnosis has been made. “The findings on a good history and physical exam—a focused review of systems, plus a full-body skin exam to look for other melanomas and careful palpation of regional lymph nodes—will, to a great extent, drive any further workup.” Tests are indicated when they provide accurate information for: (1) staging and prognosis; (2) detecting an early metastasis with potential outcome benefit; or (3) avoiding the morbidity of an extensive procedure by detection of distant metastases. Remember that most tests (other than SNB) have relatively low sensitivity and specificity. Summer 2011

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Lesson 4. The SNB era has taught us to look for the interval node and unexpected drainage pathways. The interval node—in the space between the primary lesion and the SLN in the conventional basin—contains metastatic disease with the same frequency as the SLN. Because melanoma can drain anywhere, you need to feel everywhere. Lesson 5. A dermatology-based multidisciplinary melanoma program optimizes patient care and education, and enables collection and analysis of the retrospective and prospective data that will produce critical new knowledge. In 2006, Johnson’s melanoma program initiated this same approach to treating and studying Merkel cell carcinoma, now led by Dr. Christopher Bichakjian. Advances in knowledge will appear in the coming 5 years.

Microstaging Accuracy Is Not Always Reliable by Incisional Biopsy or Inspection • Step 1: Completely excise the remaining lesion with 1-2 mm margins; then • Step 2: WLE ± SLNB based on final microstaging

Initial punch biopsy: Melanoma in situ

Complete excision: 1.4 mm

Complete excision: 0.98 mm, (adnexal extension to 1.90 mm)

Guidelines for Workup/Staging in Asymptomatic Patients • Local disease .1 mm diameter it is another warning sign, because the possibility of skip areas escalates the risk of incomplete excision. “Do not get lulled into a false sense of security” if the initial nerve resection looks clear. Continue to search. Postoperative radiation treatment is recommended. Clinical Factors. Early recurrence suggests the need to re-examine the initial slides—possibly getting some cytokeratin studies—for overlooked single-cell involvement or perineural involvement. Tumors >2 cm have a 3-fold greater rate of metastasis due to the likelihood for poor differentiation and single-cell pathology. Two patient groups—those with solid organ transplants and those with lymphoproliferative disease—have a highly increased risk of SCC and also risk features associated with metastasis.

Differentiation Well-Differentiated

Moderate

• Well-nested • Nests well demarcated • Evidence of squamous differentiation • Little single-cell invasion • Little cellular atypia

• Less well-nested • Nests may be poorly demarcated • Less squamous differentiation • More single-cell invasion • More cellular atypia

Poor

Single-Cell SCC

Mary E. Maloney, MD Introduction. Treating high-risk nonmelanoma skin cancers, and squamous cell carcinoma (SCC) in particular, highlights Dr. Maloney’s practice. She discussed her histologic and clinical guidelines for recognizing tumors likely to recur and/or metastasize, illustrating liberally with histologic and clinical slides. Differentiation. Degree of differentiation is critical. Welldifferentiated SCC are defined, with demarcated nests, evidence of squamous differentiation, and little single-cell invasion or cellular atypia. These characteristics are less pronounced in moderate differentiation, with some nests lying free and in deeper tissues. “Poorly differentiated tumors are the ones we worry about the most.” The more differentiated characteristics are almost absent, and there can be extensive single-cell spread. Maloney adds a fourth category— single-cell or unnested SCC—which is typified by particularly high risk of recurrence. “They are very frightening” because they do not www.dermatologyfoundation.org

• Little or no nesting • Small clumps of cells • Poor squamous differentiation • May have extensive single-cell spread • Cells markedly atypical • Single-cell tumor

(also called unnested) • Poorly differentiated • Poorly marginated • May require special stains for identification • Very high risk of recurrence

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Help the DF Recognize Outstanding Dermatologists Nomination Deadline: September 30, 2011 Each year the Dermatology Foundation takes great pleasure in recognizing exceptional dermatologists—those role models whose outstanding career contributions have profoundly benefited the specialty over many years. We urge you to nominate your peers for the 2011 honorary awards so that the specialty can celebrate their career accomplishments and enduring contributions to dermatology. The Clark W. Finnerud Award honors the dedicated part-time volunteer teacher of medical students and residents. This exemplary dermatologist spends countless hours teaching, largely without compensation, as a labor of love. Although respected and greatly appreciated in the local community, this devoted voluntary teacher is seldom recognized on a national level for this long-term contribution to educating future generations of dermatologists. The Practitioner of the Year honorary award recognizes a member of the specialty who demonstrates exemplary service as a clinical dermatologist in private practice. This outstand-

Clinical Features • None to help distinguish single-cell SCC on initial presentation • Early recurrence suggests careful evaluation of the original tissue for this and/or perineural tumor • Size >2 cm related to a 3-fold increase in rate of metastasis – Large tumors may be more predisposed to poor differentiation/single-cell pathology.

KEYNOTE ADDRESS Photoprotection, Skin Types, and Vitamin D Henry W. Lim, MD Introduction. The increasing importance ascribed to the various health benefits of vitamin D, often called “the sunshine vitamin,” plus the dermatology community’s keen awareness of the health dangers to the skin from sun exposure require maintaining acceptable vitamin D levels without sacrificing effective sun protection. Dr. Lim discussed the sources of vitamin D and factors that affect vitamin D synthesis, then outlined the basic recommendations in the recent Institute of Medicine (IOM) report. They relate only to vitamin D’s role in skeletal health, not its extra-skeletal roles. Note: Some studies use conventional units (ng/mL) of measurement for serum levels of vitamin D; others use SI units—Système Internationale—(nmol/L). Use the conversion factor 2.496 to multi8

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ing practitioner is also an active part-time teacher and/or investigator and plays significant roles in professional organizations. To nominate a colleague for either award, please submit a letter of recommendation to the DF office for receipt no later than September 30, 2011. Be sure to include any background information that supports the nominee for the award and his/her curriculum vitae. Awards will be presented at the DF Annual Meeting of Membership on March 17, 2012 in San Diego. The DF staff is happy to answer any questions you may have: 847.328.2256 or [email protected].

ply conventional units or divide SI units. Some studies define inadequacy as