BOCA RATON, FLA. – Experience with various lasers for the treatment and prophylaxis of nonmelanoma skin cancers is increasing, and the outcomes are promising.

One setting where lasers have particular potential is in patients with multiple basal cell carcinomas, Dr. Keyvan Nouri said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

BCCs tend to have telangiectasias, and by specifically targeting the tumor vasculature, the BCC burden can be decreased or eliminated by laser treatment with little damage to surrounding skin. An ablative approach can also eliminate premalignant cells, said Dr. Nouri, professor of dermatology and otolaryngology and director of Mohs, dermatologic, and laser surgery at the University of Miami.

Studies using this approach have been conducted over the past several years using CO₂, Er:YAG, pulsed-dye, and alexandrite lasers.

The 10,600-nm CO₂ laser achieves a depth of 15-200 mcm in a single pass, which is adequate for coagulating the epidermis and superficial dermis, and for eliminating squamous cells at risk for evolution to actinic keratosis or squamous cell carcinoma. It also is partially effective for eliminating cells en route to basal cell carcinoma, he said, noting that deeper treatment can be achieved with multiple passes or protocol modifications.

In one study using this CO₂ laser, 14 patients with diffuse facial AKs underwent resurfacing and experienced significant long-term reduction in AK burden (Dermatol. Surg. 1997;23:885-9). In another report of two patients with a history of multiple nonmelanoma skin cancer who were treated with two-pass CO₂ resurfacing, no new lesions developed in the treated area at 33 and 52 months (Dermatol. Surg. 1999;25:513-16).

In a randomized controlled study of 34 patients, no differences in outcomes were seen at 5 years regardless of whether patients were treated with the CO₂ laser, a 30% trichloroacetic acid peel, or 5% fluorouracil cream twice daily for 3 weeks. All of the treatments reduced AK counts by 83%-92%, and reduced the incidence of nonmelanoma skin cancers, compared with control groups (Dermatol. Surg. 1999;25:729-32), Dr. Nouri said.

In three of his patients with basal cell nevus syndrome, the Ultrapulse CO₂ laser also proved effective for treatment. Postoperative Mohs micrographic surgical sections verified complete histologic clearance, and the patients had minimal scarring at follow-up (Dermatol. Surg. 2002;28:287-90).

A high-energy pulsed CO₂ laser has also been used to treat a squamous cell carcinoma in situ on the nose with one pass (at 250 mJ, 8 W). In that case, no recurrence had occurred at 5 months’ follow-up, and the cosmetic result was excellent, Dr. Nouri said.

In a series of patients with nodular and superficial BCCs, a combination of curettage and one or two passes with the high-energy pulsed CO₂ laser was also effective, with no histologic evidence or residual tumor and no known recurrences.

In another study, the pulsed CO₂ laser was effective for treating 30 neoplasms, including 17 BCCs and 13 SCCs (Arch. Dermatol. 1998;134:1247-52). Two or three passes were used (at 500 mJ and 2-4 W). Treatment with a 4-mm margin and three passes is recommended for complete vaporization of neoplasms using this laser, Dr. Nouri said. Also, one SCC in situ in that study was incompletely ablated after three passes, so this modality alone is not recommended for thick or keratotic lesions, he said.

More recently, fractional laser resurfacing and pulsed-dye laser treatment have also shown promise for nonmelanoma skin cancers. In a pilot study of 28 patients with mild to moderate actinic damage who were treated with a fractional Er:YAG laser (2,940 nm) with one to four treatments at 4-week intervals, 75% had excellent results and the other 25% had good results. The effects were maintained at up to 9 months (Dermatol. Surg. 2008;34:1048-53).

And the 595-nm pulsed-dye laser has been used successfully to target tumor vasculature in glottal dysplasia and SCCs. Depending on fluence and spot size, the 595-nm pulsed-dye laser can penetrate skin to thicknesses ranging from 0.75 to 1.25 mm, which encompasses most BCCs, Dr. Nouri said.

In one study, a single treatment on seven BCCs resulted in histologic clearance of only one tumor (Lasers Med. Sci. 2003;18:125-6), but in two other studies of patients with superficial BCCs, this laser was associated with no clinical recurrences at a minimum follow-up of 1 year in 16 of 20 BCCs (Lasers Med. Sci. 2005;20:147-8; Dermatol. Ther. 2008; 21:402-5).

In another study, 20 BCCs treated with four 595-nm pulsed-dye laser treatments at 2-week intervals showed that nearly all BCCs less than 1.5 cm responded completely, compared with about 17% of controls. Larger BCCs had a complete response rate of 25% vs. 0% in controls.

Tumors with an incomplete response showed a significant reduction in tumor burden following treatment, with residual histologic tumor burden ranging from less than 1% to 29% of the original clinical tumor diameter, compared with 13%-68% residual tumor burden for the corresponding controls.

The investigators took the study one step further, treating 14 patients with a total of 20 BCCs on the trunk or extremities with four treatments at 3- to 4-week intervals; 19 of 20 BCCs had a complete clinical response, regardless of size and histological subtype (Lasers Surg. Med. 2009; 41:417-22). The investigators concluded that the 595-nm pulsed-dye laser is a "novel, quick, and relatively nonpainful treatment" for BCCs when used in the appropriate clinical setting, Dr. Nouri said.

As for the long-pulse alexandrite laser, it is selective like the pulsed-dye laser, but has deeper penetration, and may be helpful in significantly reducing tumor burden with a single treatment, he said.

In 15 of 18 patients with basal cell nevus syndrome who were treated in one study, a complete clinical response was seen at follow-ups of 2 and 7 months (Lasers Surg. Med. 2010;42:68-71).

No particular laser has emerged as the ideal tool for the treatment or prevention of skin cancer, but work is ongoing. More research is needed to confirm the observations made thus far, as well as to optimize treatment parameters, but the findings to date are encouraging, Dr. Nouri said, noting that he is confident that laser and light sources will eventually be used more for both medical and oncologic purposes.

Dr. Nouri disclosed that he has received grants or research support from Aesthera, CureLight, and Omnilux.

BOCA RATON, FLA. – Experience with various lasers for the treatment and prophylaxis of nonmelanoma skin cancers is increasing, and the outcomes are promising.

One setting where lasers have particular potential is in patients with multiple basal cell carcinomas, Dr. Keyvan Nouri said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

BCCs tend to have telangiectasias, and by specifically targeting the tumor vasculature, the BCC burden can be decreased or eliminated by laser treatment with little damage to surrounding skin. An ablative approach can also eliminate premalignant cells, said Dr. Nouri, professor of dermatology and otolaryngology and director of Mohs, dermatologic, and laser surgery at the University of Miami.

Studies using this approach have been conducted over the past several years using CO₂, Er:YAG, pulsed-dye, and alexandrite lasers.

The 10,600-nm CO₂ laser achieves a depth of 15-200 mcm in a single pass, which is adequate for coagulating the epidermis and superficial dermis, and for eliminating squamous cells at risk for evolution to actinic keratosis or squamous cell carcinoma. It also is partially effective for eliminating cells en route to basal cell carcinoma, he said, noting that deeper treatment can be achieved with multiple passes or protocol modifications.

In one study using this CO₂ laser, 14 patients with diffuse facial AKs underwent resurfacing and experienced significant long-term reduction in AK burden (Dermatol. Surg. 1997;23:885-9). In another report of two patients with a history of multiple nonmelanoma skin cancer who were treated with two-pass CO₂ resurfacing, no new lesions developed in the treated area at 33 and 52 months (Dermatol. Surg. 1999;25:513-16).

In a randomized controlled study of 34 patients, no differences in outcomes were seen at 5 years regardless of whether patients were treated with the CO₂ laser, a 30% trichloroacetic acid peel, or 5% fluorouracil cream twice daily for 3 weeks. All of the treatments reduced AK counts by 83%-92%, and reduced the incidence of nonmelanoma skin cancers, compared with control groups (Dermatol. Surg. 1999;25:729-32), Dr. Nouri said.

In three of his patients with basal cell nevus syndrome, the Ultrapulse CO₂ laser also proved effective for treatment. Postoperative Mohs micrographic surgical sections verified complete histologic clearance, and the patients had minimal scarring at follow-up (Dermatol. Surg. 2002;28:287-90).

A high-energy pulsed CO₂ laser has also been used to treat a squamous cell carcinoma in situ on the nose with one pass (at 250 mJ, 8 W). In that case, no recurrence had occurred at 5 months’ follow-up, and the cosmetic result was excellent, Dr. Nouri said.

In a series of patients with nodular and superficial BCCs, a combination of curettage and one or two passes with the high-energy pulsed CO₂ laser was also effective, with no histologic evidence or residual tumor and no known recurrences.

In another study, the pulsed CO₂ laser was effective for treating 30 neoplasms, including 17 BCCs and 13 SCCs (Arch. Dermatol. 1998;134:1247-52). Two or three passes were used (at 500 mJ and 2-4 W). Treatment with a 4-mm margin and three passes is recommended for complete vaporization of neoplasms using this laser, Dr. Nouri said. Also, one SCC in situ in that study was incompletely ablated after three passes, so this modality alone is not recommended for thick or keratotic lesions, he said.

More recently, fractional laser resurfacing and pulsed-dye laser treatment have also shown promise for nonmelanoma skin cancers. In a pilot study of 28 patients with mild to moderate actinic damage who were treated with a fractional Er:YAG laser (2,940 nm) with one to four treatments at 4-week intervals, 75% had excellent results and the other 25% had good results. The effects were maintained at up to 9 months (Dermatol. Surg. 2008;34:1048-53).

And the 595-nm pulsed-dye laser has been used successfully to target tumor vasculature in glottal dysplasia and SCCs. Depending on fluence and spot size, the 595-nm pulsed-dye laser can penetrate skin to thicknesses ranging from 0.75 to 1.25 mm, which encompasses most BCCs, Dr. Nouri said.

In one study, a single treatment on seven BCCs resulted in histologic clearance of only one tumor (Lasers Med. Sci. 2003;18:125-6), but in two other studies of patients with superficial BCCs, this laser was associated with no clinical recurrences at a minimum follow-up of 1 year in 16 of 20 BCCs (Lasers Med. Sci. 2005;20:147-8; Dermatol. Ther. 2008; 21:402-5).

In another study, 20 BCCs treated with four 595-nm pulsed-dye laser treatments at 2-week intervals showed that nearly all BCCs less than 1.5 cm responded completely, compared with about 17% of controls. Larger BCCs had a complete response rate of 25% vs. 0% in controls.

Tumors with an incomplete response showed a significant reduction in tumor burden following treatment, with residual histologic tumor burden ranging from less than 1% to 29% of the original clinical tumor diameter, compared with 13%-68% residual tumor burden for the corresponding controls.

The investigators took the study one step further, treating 14 patients with a total of 20 BCCs on the trunk or extremities with four treatments at 3- to 4-week intervals; 19 of 20 BCCs had a complete clinical response, regardless of size and histological subtype (Lasers Surg. Med. 2009; 41:417-22). The investigators concluded that the 595-nm pulsed-dye laser is a "novel, quick, and relatively nonpainful treatment" for BCCs when used in the appropriate clinical setting, Dr. Nouri said.

As for the long-pulse alexandrite laser, it is selective like the pulsed-dye laser, but has deeper penetration, and may be helpful in significantly reducing tumor burden with a single treatment, he said.

In 15 of 18 patients with basal cell nevus syndrome who were treated in one study, a complete clinical response was seen at follow-ups of 2 and 7 months (Lasers Surg. Med. 2010;42:68-71).

No particular laser has emerged as the ideal tool for the treatment or prevention of skin cancer, but work is ongoing. More research is needed to confirm the observations made thus far, as well as to optimize treatment parameters, but the findings to date are encouraging, Dr. Nouri said, noting that he is confident that laser and light sources will eventually be used more for both medical and oncologic purposes.

Dr. Nouri disclosed that he has received grants or research support from Aesthera, CureLight, and Omnilux.

BOCA RATON, FLA. – Experience with various lasers for the treatment and prophylaxis of nonmelanoma skin cancers is increasing, and the outcomes are promising.

One setting where lasers have particular potential is in patients with multiple basal cell carcinomas, Dr. Keyvan Nouri said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

BCCs tend to have telangiectasias, and by specifically targeting the tumor vasculature, the BCC burden can be decreased or eliminated by laser treatment with little damage to surrounding skin. An ablative approach can also eliminate premalignant cells, said Dr. Nouri, professor of dermatology and otolaryngology and director of Mohs, dermatologic, and laser surgery at the University of Miami.

Studies using this approach have been conducted over the past several years using CO₂, Er:YAG, pulsed-dye, and alexandrite lasers.

The 10,600-nm CO₂ laser achieves a depth of 15-200 mcm in a single pass, which is adequate for coagulating the epidermis and superficial dermis, and for eliminating squamous cells at risk for evolution to actinic keratosis or squamous cell carcinoma. It also is partially effective for eliminating cells en route to basal cell carcinoma, he said, noting that deeper treatment can be achieved with multiple passes or protocol modifications.

In one study using this CO₂ laser, 14 patients with diffuse facial AKs underwent resurfacing and experienced significant long-term reduction in AK burden (Dermatol. Surg. 1997;23:885-9). In another report of two patients with a history of multiple nonmelanoma skin cancer who were treated with two-pass CO₂ resurfacing, no new lesions developed in the treated area at 33 and 52 months (Dermatol. Surg. 1999;25:513-16).

In a randomized controlled study of 34 patients, no differences in outcomes were seen at 5 years regardless of whether patients were treated with the CO₂ laser, a 30% trichloroacetic acid peel, or 5% fluorouracil cream twice daily for 3 weeks. All of the treatments reduced AK counts by 83%-92%, and reduced the incidence of nonmelanoma skin cancers, compared with control groups (Dermatol. Surg. 1999;25:729-32), Dr. Nouri said.

In three of his patients with basal cell nevus syndrome, the Ultrapulse CO₂ laser also proved effective for treatment. Postoperative Mohs micrographic surgical sections verified complete histologic clearance, and the patients had minimal scarring at follow-up (Dermatol. Surg. 2002;28:287-90).

A high-energy pulsed CO₂ laser has also been used to treat a squamous cell carcinoma in situ on the nose with one pass (at 250 mJ, 8 W). In that case, no recurrence had occurred at 5 months’ follow-up, and the cosmetic result was excellent, Dr. Nouri said.

In a series of patients with nodular and superficial BCCs, a combination of curettage and one or two passes with the high-energy pulsed CO₂ laser was also effective, with no histologic evidence or residual tumor and no known recurrences.

In another study, the pulsed CO₂ laser was effective for treating 30 neoplasms, including 17 BCCs and 13 SCCs (Arch. Dermatol. 1998;134:1247-52). Two or three passes were used (at 500 mJ and 2-4 W). Treatment with a 4-mm margin and three passes is recommended for complete vaporization of neoplasms using this laser, Dr. Nouri said. Also, one SCC in situ in that study was incompletely ablated after three passes, so this modality alone is not recommended for thick or keratotic lesions, he said.

More recently, fractional laser resurfacing and pulsed-dye laser treatment have also shown promise for nonmelanoma skin cancers. In a pilot study of 28 patients with mild to moderate actinic damage who were treated with a fractional Er:YAG laser (2,940 nm) with one to four treatments at 4-week intervals, 75% had excellent results and the other 25% had good results. The effects were maintained at up to 9 months (Dermatol. Surg. 2008;34:1048-53).

And the 595-nm pulsed-dye laser has been used successfully to target tumor vasculature in glottal dysplasia and SCCs. Depending on fluence and spot size, the 595-nm pulsed-dye laser can penetrate skin to thicknesses ranging from 0.75 to 1.25 mm, which encompasses most BCCs, Dr. Nouri said.

In one study, a single treatment on seven BCCs resulted in histologic clearance of only one tumor (Lasers Med. Sci. 2003;18:125-6), but in two other studies of patients with superficial BCCs, this laser was associated with no clinical recurrences at a minimum follow-up of 1 year in 16 of 20 BCCs (Lasers Med. Sci. 2005;20:147-8; Dermatol. Ther. 2008; 21:402-5).

In another study, 20 BCCs treated with four 595-nm pulsed-dye laser treatments at 2-week intervals showed that nearly all BCCs less than 1.5 cm responded completely, compared with about 17% of controls. Larger BCCs had a complete response rate of 25% vs. 0% in controls.

Tumors with an incomplete response showed a significant reduction in tumor burden following treatment, with residual histologic tumor burden ranging from less than 1% to 29% of the original clinical tumor diameter, compared with 13%-68% residual tumor burden for the corresponding controls.

The investigators took the study one step further, treating 14 patients with a total of 20 BCCs on the trunk or extremities with four treatments at 3- to 4-week intervals; 19 of 20 BCCs had a complete clinical response, regardless of size and histological subtype (Lasers Surg. Med. 2009; 41:417-22). The investigators concluded that the 595-nm pulsed-dye laser is a "novel, quick, and relatively nonpainful treatment" for BCCs when used in the appropriate clinical setting, Dr. Nouri said.

As for the long-pulse alexandrite laser, it is selective like the pulsed-dye laser, but has deeper penetration, and may be helpful in significantly reducing tumor burden with a single treatment, he said.

In 15 of 18 patients with basal cell nevus syndrome who were treated in one study, a complete clinical response was seen at follow-ups of 2 and 7 months (Lasers Surg. Med. 2010;42:68-71).

No particular laser has emerged as the ideal tool for the treatment or prevention of skin cancer, but work is ongoing. More research is needed to confirm the observations made thus far, as well as to optimize treatment parameters, but the findings to date are encouraging, Dr. Nouri said, noting that he is confident that laser and light sources will eventually be used more for both medical and oncologic purposes.

Dr. Nouri disclosed that he has received grants or research support from Aesthera, CureLight, and Omnilux.

SEOUL, SOUTH KOREA – The nonablative fractionated thulium laser at 1,927-nm wavelength is a promising new noninvasive therapy for actinic keratoses.

The laser was actually developed for superficial skin resurfacing, an application for which it is particularly well suited because the 1,927-nm wavelength minimizes patient discomfort. But while investigating the device for improvement of pigmentation, Dr. Roy G. Geronemus noted incidentally that patients were also achieving "a rather dramatic resolution" of multiple facial actinic keratoses (AKs). So he decided to conduct a formal examination of the laser’s performance for this purpose, he said at the World Congress of Dermatology

To date, in 15 patients followed for 1-6 months after the last of several thulium laser treatment sessions for multiple facial AKs, the mean clearance of the lesions was 84%-91%.

"This compares very favorably to other modalities that are out there, including the topical chemotherapies, immunomodulatory agents, and photodynamic therapy. The advantage of this is not only do you improve the AKs, but you’re also getting the cosmetic benefit simultaneously," said Dr. Geronemus, medical director of the Laser and Skin Surgery Center of New York.

Patients received up to four treatments at 2- to 6-week intervals. The laser setting was 5-20 mJ, with 30%-70% coverage per session. Topical anesthetic was utilized for 1 hour, supplemented as needed by intramuscular ketorolac.

After a single treatment a mean of 63% of AKs were cleared. After two, 84%, and after three, 85%.

The laser therapy was well tolerated. The average pain score during treatment was 2.7 on a 0-9 scale. No scarring or infections have occurred. Mild redness and peeling typically lasted 4-5 days.

Dr. Geronemus said he and his colleagues have also found that the 1,927-nm fractionated thulium laser brings about "dramatic improvement" in actinic cheilitis, and is also highly effective for the thorny problem of enlarged facial pore size.

Dr. Geronemus is a shareholder in Solta Medical, which markets the 1,927-nm fractionated thulium laser. He also is on the advisory boards of numerous dermatologic laser manufacturers.

SEOUL, SOUTH KOREA – The nonablative fractionated thulium laser at 1,927-nm wavelength is a promising new noninvasive therapy for actinic keratoses.

The laser was actually developed for superficial skin resurfacing, an application for which it is particularly well suited because the 1,927-nm wavelength minimizes patient discomfort. But while investigating the device for improvement of pigmentation, Dr. Roy G. Geronemus noted incidentally that patients were also achieving "a rather dramatic resolution" of multiple facial actinic keratoses (AKs). So he decided to conduct a formal examination of the laser’s performance for this purpose, he said at the World Congress of Dermatology

To date, in 15 patients followed for 1-6 months after the last of several thulium laser treatment sessions for multiple facial AKs, the mean clearance of the lesions was 84%-91%.

"This compares very favorably to other modalities that are out there, including the topical chemotherapies, immunomodulatory agents, and photodynamic therapy. The advantage of this is not only do you improve the AKs, but you’re also getting the cosmetic benefit simultaneously," said Dr. Geronemus, medical director of the Laser and Skin Surgery Center of New York.

Patients received up to four treatments at 2- to 6-week intervals. The laser setting was 5-20 mJ, with 30%-70% coverage per session. Topical anesthetic was utilized for 1 hour, supplemented as needed by intramuscular ketorolac.

After a single treatment a mean of 63% of AKs were cleared. After two, 84%, and after three, 85%.

The laser therapy was well tolerated. The average pain score during treatment was 2.7 on a 0-9 scale. No scarring or infections have occurred. Mild redness and peeling typically lasted 4-5 days.

Dr. Geronemus said he and his colleagues have also found that the 1,927-nm fractionated thulium laser brings about "dramatic improvement" in actinic cheilitis, and is also highly effective for the thorny problem of enlarged facial pore size.

Dr. Geronemus is a shareholder in Solta Medical, which markets the 1,927-nm fractionated thulium laser. He also is on the advisory boards of numerous dermatologic laser manufacturers.

SEOUL, SOUTH KOREA – The nonablative fractionated thulium laser at 1,927-nm wavelength is a promising new noninvasive therapy for actinic keratoses.

The laser was actually developed for superficial skin resurfacing, an application for which it is particularly well suited because the 1,927-nm wavelength minimizes patient discomfort. But while investigating the device for improvement of pigmentation, Dr. Roy G. Geronemus noted incidentally that patients were also achieving "a rather dramatic resolution" of multiple facial actinic keratoses (AKs). So he decided to conduct a formal examination of the laser’s performance for this purpose, he said at the World Congress of Dermatology

To date, in 15 patients followed for 1-6 months after the last of several thulium laser treatment sessions for multiple facial AKs, the mean clearance of the lesions was 84%-91%.

"This compares very favorably to other modalities that are out there, including the topical chemotherapies, immunomodulatory agents, and photodynamic therapy. The advantage of this is not only do you improve the AKs, but you’re also getting the cosmetic benefit simultaneously," said Dr. Geronemus, medical director of the Laser and Skin Surgery Center of New York.

Patients received up to four treatments at 2- to 6-week intervals. The laser setting was 5-20 mJ, with 30%-70% coverage per session. Topical anesthetic was utilized for 1 hour, supplemented as needed by intramuscular ketorolac.

After a single treatment a mean of 63% of AKs were cleared. After two, 84%, and after three, 85%.

The laser therapy was well tolerated. The average pain score during treatment was 2.7 on a 0-9 scale. No scarring or infections have occurred. Mild redness and peeling typically lasted 4-5 days.

Dr. Geronemus said he and his colleagues have also found that the 1,927-nm fractionated thulium laser brings about "dramatic improvement" in actinic cheilitis, and is also highly effective for the thorny problem of enlarged facial pore size.

Dr. Geronemus is a shareholder in Solta Medical, which markets the 1,927-nm fractionated thulium laser. He also is on the advisory boards of numerous dermatologic laser manufacturers.

DANA POINT, CALIF. – Despite significant advances in dermatology in recent years, little progress has been made in reducing actinic keratoses and skin cancers, Dr. Mark G. Rubin said at the SDEF Summit in Aesthetic Medicine.

"The take-home message to me in all this is, don’t get actinic keratoses," said Dr. Rubin, who practices dermatology in Beverly Hills, Calif. "We really don’t have a great therapy, so it’s important for your patients and for yourself that you limit the amount of ultraviolet light that you get, because we don’t have a wonderful treatment option for patients at this point."

That message is especially important for immunosuppressed organ transplant patients, who face an incidence of skin cancer 64-250 times higher than that of the general population.

"Immunosuppressed patients grow four times as many squamous cells than basal cells, which is the reverse of the ratio of these cancers in immunocompetent patients," he said. "Those particular tumors are much more aggressive and have a higher incidence of metastasis. Sun protection is tremendously important in these patients."

In a randomized trial of 120 transplant patients, 60 patients applied 2 mg/cm² of sunscreen with an SPF greater than 50 to the head, neck, forearms, and hands daily for 24 months, while 60 patients in the control group did not apply any sunscreen (Br. J. Derm. 2009;161 [Suppl. 3]:78-84). Both groups of patients had an equal number of AKs at the start of the trial, but at the end of 24 months, 82 new AKs developed in the control group compared with none in the sunscreen treatment group. In addition, eight patients in the control group developed squamous cell carcinoma, compared with none in the sunscreen group, while nine patients in the control group developed basal cell epithelioma, compared with two in the sunscreen group.

While fluorouracil in the form of Efudex 2% and 5%, Fluoroplex 1%, and Carac 0.5% has been a mainstay of AK treatment, imiquimod in the form of Aldara Cream 5% and Zyclara Cream 3.75% "has probably been the most popular recently," said Dr. Rubin, also of the University of California, San Diego. Another treatment option is diclofenac in the form of Solaraze 3%.

"None of these are fun therapies for patients," he said. "It’s hard to get patients to apply 5-FU more than once. They’ll do it once, hate the experience, and ask, ‘What do you have now doc, because I’m never facing that again.’ It’s made some of the other products like Solaraze, Carac, and Aldara more popular because they’re a little less brutal for the patient. But it’s important to realize that any of these products are going to impact your patients’ daily life. They’re all going to cause some redness, swelling, crusting, stinging, and burning that will go on for a period of weeks if not months, depending on the product that you use and the protocol that you follow."

A review of multiple trials suggests that these medical therapies show complete clearing of AKs in 36%-58% of patients within 1-4 months post treatment.

"It’s important to differentiate between reducing the overall bulk of precancer and eradication, or complete clearance," Dr. Rubin added. "You really want to look at complete clearance, because if you just improved it and the keratosis is smaller, 6 months later it will be back and look like you never touched it. Unless you’ve eradicated the lesion, you’re wasting your time."

Systemic retinoids such as Acitretin and Etretinate are another treatment option, yet they are not a long-term solution given their propensity to cause multiple side effects, including chapped lips, dry eyes, headaches, and hyperlipidemia.

"It’s almost unfair to put a patient on these because they’ll love it for awhile, and then you have to take it away, and then they’ll do horribly – unless you’re doing this with a second plan where you put the patient on it for 6 months to stabilize them before moving on to another treatment option, such as photodynamic therapy, which may be reasonable," Dr. Rubin said.

Chemical peels have some value for decreasing AKs in immunocompetent patients, but the results are no better than with topical medications, he said. The deeper the destruction, the better the result.

"Some actinic keratoses and squamous cell in situ go down the hair follicles," Dr. Rubin said. "If you’re not chasing it down the hair follicle you’re leaving the root behind in a lot of these patients, and that’s what creates a lot of these recurrences. Medical therapies are moderately effective if you look at them a couple of months later. But response rates are not wonderful, and the relapse rates are really terrible."

Dr. Rubin disclosed that he has received research support and consulting fees from Medicis. SDEF and this news organization are owned by Elsevier.

DANA POINT, CALIF. – Despite significant advances in dermatology in recent years, little progress has been made in reducing actinic keratoses and skin cancers, Dr. Mark G. Rubin said at the SDEF Summit in Aesthetic Medicine.

"The take-home message to me in all this is, don’t get actinic keratoses," said Dr. Rubin, who practices dermatology in Beverly Hills, Calif. "We really don’t have a great therapy, so it’s important for your patients and for yourself that you limit the amount of ultraviolet light that you get, because we don’t have a wonderful treatment option for patients at this point."

That message is especially important for immunosuppressed organ transplant patients, who face an incidence of skin cancer 64-250 times higher than that of the general population.

"Immunosuppressed patients grow four times as many squamous cells than basal cells, which is the reverse of the ratio of these cancers in immunocompetent patients," he said. "Those particular tumors are much more aggressive and have a higher incidence of metastasis. Sun protection is tremendously important in these patients."

In a randomized trial of 120 transplant patients, 60 patients applied 2 mg/cm² of sunscreen with an SPF greater than 50 to the head, neck, forearms, and hands daily for 24 months, while 60 patients in the control group did not apply any sunscreen (Br. J. Derm. 2009;161 [Suppl. 3]:78-84). Both groups of patients had an equal number of AKs at the start of the trial, but at the end of 24 months, 82 new AKs developed in the control group compared with none in the sunscreen treatment group. In addition, eight patients in the control group developed squamous cell carcinoma, compared with none in the sunscreen group, while nine patients in the control group developed basal cell epithelioma, compared with two in the sunscreen group.

While fluorouracil in the form of Efudex 2% and 5%, Fluoroplex 1%, and Carac 0.5% has been a mainstay of AK treatment, imiquimod in the form of Aldara Cream 5% and Zyclara Cream 3.75% "has probably been the most popular recently," said Dr. Rubin, also of the University of California, San Diego. Another treatment option is diclofenac in the form of Solaraze 3%.

"None of these are fun therapies for patients," he said. "It’s hard to get patients to apply 5-FU more than once. They’ll do it once, hate the experience, and ask, ‘What do you have now doc, because I’m never facing that again.’ It’s made some of the other products like Solaraze, Carac, and Aldara more popular because they’re a little less brutal for the patient. But it’s important to realize that any of these products are going to impact your patients’ daily life. They’re all going to cause some redness, swelling, crusting, stinging, and burning that will go on for a period of weeks if not months, depending on the product that you use and the protocol that you follow."

A review of multiple trials suggests that these medical therapies show complete clearing of AKs in 36%-58% of patients within 1-4 months post treatment.

"It’s important to differentiate between reducing the overall bulk of precancer and eradication, or complete clearance," Dr. Rubin added. "You really want to look at complete clearance, because if you just improved it and the keratosis is smaller, 6 months later it will be back and look like you never touched it. Unless you’ve eradicated the lesion, you’re wasting your time."

Systemic retinoids such as Acitretin and Etretinate are another treatment option, yet they are not a long-term solution given their propensity to cause multiple side effects, including chapped lips, dry eyes, headaches, and hyperlipidemia.

"It’s almost unfair to put a patient on these because they’ll love it for awhile, and then you have to take it away, and then they’ll do horribly – unless you’re doing this with a second plan where you put the patient on it for 6 months to stabilize them before moving on to another treatment option, such as photodynamic therapy, which may be reasonable," Dr. Rubin said.

Chemical peels have some value for decreasing AKs in immunocompetent patients, but the results are no better than with topical medications, he said. The deeper the destruction, the better the result.

"Some actinic keratoses and squamous cell in situ go down the hair follicles," Dr. Rubin said. "If you’re not chasing it down the hair follicle you’re leaving the root behind in a lot of these patients, and that’s what creates a lot of these recurrences. Medical therapies are moderately effective if you look at them a couple of months later. But response rates are not wonderful, and the relapse rates are really terrible."

Dr. Rubin disclosed that he has received research support and consulting fees from Medicis. SDEF and this news organization are owned by Elsevier.

DANA POINT, CALIF. – Despite significant advances in dermatology in recent years, little progress has been made in reducing actinic keratoses and skin cancers, Dr. Mark G. Rubin said at the SDEF Summit in Aesthetic Medicine.

"The take-home message to me in all this is, don’t get actinic keratoses," said Dr. Rubin, who practices dermatology in Beverly Hills, Calif. "We really don’t have a great therapy, so it’s important for your patients and for yourself that you limit the amount of ultraviolet light that you get, because we don’t have a wonderful treatment option for patients at this point."

That message is especially important for immunosuppressed organ transplant patients, who face an incidence of skin cancer 64-250 times higher than that of the general population.

"Immunosuppressed patients grow four times as many squamous cells than basal cells, which is the reverse of the ratio of these cancers in immunocompetent patients," he said. "Those particular tumors are much more aggressive and have a higher incidence of metastasis. Sun protection is tremendously important in these patients."

In a randomized trial of 120 transplant patients, 60 patients applied 2 mg/cm² of sunscreen with an SPF greater than 50 to the head, neck, forearms, and hands daily for 24 months, while 60 patients in the control group did not apply any sunscreen (Br. J. Derm. 2009;161 [Suppl. 3]:78-84). Both groups of patients had an equal number of AKs at the start of the trial, but at the end of 24 months, 82 new AKs developed in the control group compared with none in the sunscreen treatment group. In addition, eight patients in the control group developed squamous cell carcinoma, compared with none in the sunscreen group, while nine patients in the control group developed basal cell epithelioma, compared with two in the sunscreen group.

While fluorouracil in the form of Efudex 2% and 5%, Fluoroplex 1%, and Carac 0.5% has been a mainstay of AK treatment, imiquimod in the form of Aldara Cream 5% and Zyclara Cream 3.75% "has probably been the most popular recently," said Dr. Rubin, also of the University of California, San Diego. Another treatment option is diclofenac in the form of Solaraze 3%.

"None of these are fun therapies for patients," he said. "It’s hard to get patients to apply 5-FU more than once. They’ll do it once, hate the experience, and ask, ‘What do you have now doc, because I’m never facing that again.’ It’s made some of the other products like Solaraze, Carac, and Aldara more popular because they’re a little less brutal for the patient. But it’s important to realize that any of these products are going to impact your patients’ daily life. They’re all going to cause some redness, swelling, crusting, stinging, and burning that will go on for a period of weeks if not months, depending on the product that you use and the protocol that you follow."

A review of multiple trials suggests that these medical therapies show complete clearing of AKs in 36%-58% of patients within 1-4 months post treatment.

"It’s important to differentiate between reducing the overall bulk of precancer and eradication, or complete clearance," Dr. Rubin added. "You really want to look at complete clearance, because if you just improved it and the keratosis is smaller, 6 months later it will be back and look like you never touched it. Unless you’ve eradicated the lesion, you’re wasting your time."

Systemic retinoids such as Acitretin and Etretinate are another treatment option, yet they are not a long-term solution given their propensity to cause multiple side effects, including chapped lips, dry eyes, headaches, and hyperlipidemia.

"It’s almost unfair to put a patient on these because they’ll love it for awhile, and then you have to take it away, and then they’ll do horribly – unless you’re doing this with a second plan where you put the patient on it for 6 months to stabilize them before moving on to another treatment option, such as photodynamic therapy, which may be reasonable," Dr. Rubin said.

Chemical peels have some value for decreasing AKs in immunocompetent patients, but the results are no better than with topical medications, he said. The deeper the destruction, the better the result.

"Some actinic keratoses and squamous cell in situ go down the hair follicles," Dr. Rubin said. "If you’re not chasing it down the hair follicle you’re leaving the root behind in a lot of these patients, and that’s what creates a lot of these recurrences. Medical therapies are moderately effective if you look at them a couple of months later. But response rates are not wonderful, and the relapse rates are really terrible."

Dr. Rubin disclosed that he has received research support and consulting fees from Medicis. SDEF and this news organization are owned by Elsevier.

BOCA RATON, FLA. – Pediatric melanoma can be difficult to predict, as the known risk factors in adults typically don't apply in children, but one exception is in the setting of giant congenital melanocytic nevi.

Giant congenital melanocytic nevi (CMN) are rare, occurring in fewer than 1 in 100,000 live births, but the estimated incidence of soft tissue melanoma in association with such nevi, based on a number of retrospective studies, is about 4%, said Dr. Seth J. Orlow at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Interestingly, the risk of melanoma of the central nervous system or other internal site is slightly higher at about 5% (J. Am. Acad. Dermatol. 1979;1:123-300) , said Dr. Orlow, chair of dermatology and a professor of pediatric dermatology at New York University.

The risk of melanoma in association with giant CMN across the lifetime is up to 10%. The risk appears based on findings from several prospective trials that half of that risk is concentrated in the first 5 years of life, he said.

The greatest risk, in his experience, is in children with giant CMN involving the scalp or posterior axial location, and in particular in those with satellite congenital nevi.

"The child who is born with multiple small congenital nevi – in fact, even if they don't have a giant congenital nevus with multiple small congenital nevi – has a risk factor," he said. Giant CMN by itself doesn't seem to be much of an issue, he noted.

To date there have been no reports of melanoma developing within a satellite nevus, despite some of these patients having up to 100 congenital nevi for years, he said.

When melanomas do arise in patients with giant CMN, they can be very difficult to recognize early, he added. In addition to those that arise in the central nervous system, some develop in the dermis or below, and in some cases no primary site can be found.

The risk of melanoma in children who have medium-sized CMN is much lower than with giant CMN and is estimated at less than 0.1% over the lifetime, he noted.

In one study of 227 patients with medium CMN followed for nearly 7 years, no melanomas developed (J. Am. Acad. Dermatol. 1998;39:428-33). Findings from another study involving information from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program database showed that the risk is about 1 in 10,000 patients before puberty, and 1 in 4,000 patients over the lifetime (Pediatr. Dermatol. 1994;11:204-8).

Thus it appears that most of the medium CMN occur after puberty, and they tend to arise at the dermal-epidermal junction, Dr. Orlow said.

The risk with small CMN can't be quantified, but is "much, much, much lower," he said.

Dr. Orlow had no disclosures relevant to his presentation.

BOCA RATON, FLA. – Pediatric melanoma can be difficult to predict, as the known risk factors in adults typically don't apply in children, but one exception is in the setting of giant congenital melanocytic nevi.

Giant congenital melanocytic nevi (CMN) are rare, occurring in fewer than 1 in 100,000 live births, but the estimated incidence of soft tissue melanoma in association with such nevi, based on a number of retrospective studies, is about 4%, said Dr. Seth J. Orlow at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Interestingly, the risk of melanoma of the central nervous system or other internal site is slightly higher at about 5% (J. Am. Acad. Dermatol. 1979;1:123-300) , said Dr. Orlow, chair of dermatology and a professor of pediatric dermatology at New York University.

The risk of melanoma in association with giant CMN across the lifetime is up to 10%. The risk appears based on findings from several prospective trials that half of that risk is concentrated in the first 5 years of life, he said.

The greatest risk, in his experience, is in children with giant CMN involving the scalp or posterior axial location, and in particular in those with satellite congenital nevi.

"The child who is born with multiple small congenital nevi – in fact, even if they don't have a giant congenital nevus with multiple small congenital nevi – has a risk factor," he said. Giant CMN by itself doesn't seem to be much of an issue, he noted.

To date there have been no reports of melanoma developing within a satellite nevus, despite some of these patients having up to 100 congenital nevi for years, he said.

When melanomas do arise in patients with giant CMN, they can be very difficult to recognize early, he added. In addition to those that arise in the central nervous system, some develop in the dermis or below, and in some cases no primary site can be found.

The risk of melanoma in children who have medium-sized CMN is much lower than with giant CMN and is estimated at less than 0.1% over the lifetime, he noted.

In one study of 227 patients with medium CMN followed for nearly 7 years, no melanomas developed (J. Am. Acad. Dermatol. 1998;39:428-33). Findings from another study involving information from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program database showed that the risk is about 1 in 10,000 patients before puberty, and 1 in 4,000 patients over the lifetime (Pediatr. Dermatol. 1994;11:204-8).

Thus it appears that most of the medium CMN occur after puberty, and they tend to arise at the dermal-epidermal junction, Dr. Orlow said.

The risk with small CMN can't be quantified, but is "much, much, much lower," he said.

Dr. Orlow had no disclosures relevant to his presentation.

BOCA RATON, FLA. – Pediatric melanoma can be difficult to predict, as the known risk factors in adults typically don't apply in children, but one exception is in the setting of giant congenital melanocytic nevi.

Giant congenital melanocytic nevi (CMN) are rare, occurring in fewer than 1 in 100,000 live births, but the estimated incidence of soft tissue melanoma in association with such nevi, based on a number of retrospective studies, is about 4%, said Dr. Seth J. Orlow at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Interestingly, the risk of melanoma of the central nervous system or other internal site is slightly higher at about 5% (J. Am. Acad. Dermatol. 1979;1:123-300) , said Dr. Orlow, chair of dermatology and a professor of pediatric dermatology at New York University.

The risk of melanoma in association with giant CMN across the lifetime is up to 10%. The risk appears based on findings from several prospective trials that half of that risk is concentrated in the first 5 years of life, he said.

The greatest risk, in his experience, is in children with giant CMN involving the scalp or posterior axial location, and in particular in those with satellite congenital nevi.

"The child who is born with multiple small congenital nevi – in fact, even if they don't have a giant congenital nevus with multiple small congenital nevi – has a risk factor," he said. Giant CMN by itself doesn't seem to be much of an issue, he noted.

To date there have been no reports of melanoma developing within a satellite nevus, despite some of these patients having up to 100 congenital nevi for years, he said.

When melanomas do arise in patients with giant CMN, they can be very difficult to recognize early, he added. In addition to those that arise in the central nervous system, some develop in the dermis or below, and in some cases no primary site can be found.

The risk of melanoma in children who have medium-sized CMN is much lower than with giant CMN and is estimated at less than 0.1% over the lifetime, he noted.

In one study of 227 patients with medium CMN followed for nearly 7 years, no melanomas developed (J. Am. Acad. Dermatol. 1998;39:428-33). Findings from another study involving information from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) Program database showed that the risk is about 1 in 10,000 patients before puberty, and 1 in 4,000 patients over the lifetime (Pediatr. Dermatol. 1994;11:204-8).

Thus it appears that most of the medium CMN occur after puberty, and they tend to arise at the dermal-epidermal junction, Dr. Orlow said.

The risk with small CMN can't be quantified, but is "much, much, much lower," he said.

Dr. Orlow had no disclosures relevant to his presentation.

SEOUL, SOUTH KOREA – Serial monitoring of melanoma tumor marker levels in peripheral blood using a novel quantitative real-time reverse-transcriptase polymerase chain reaction method after surgical resection of melanoma has shown promise for the early detection of patients at high risk for disease progression.

The real-time polymerase chain reaction (PCR) assay measures circulating levels of five markers unique to melanoma cells: glycoprotein 100 (gp100), melanoma antigen gene-3 (MAGE-3), tyrosinase, melanoma marker A (Melan-A), and melanoma inhibitory activity (MIA) protein, Dr. Spyridon Gkalpakiotis explained at the World Congress of Dermatology.

He reported on 65 patients who underwent peripheral blood testing and analysis of the five markers every 3 months for the first 2 years after resection of their stage II or III melanoma, for a total of 2,925 PCR assays.

Twenty-six patients experienced elevated test results. All 26 relapsed during 5 years of follow-up; the 5-year survival rate in this group was 65%.

In contrast, only 1 of 39 patients with consistently negative real-time PCR assays experienced disease progression; 5-year survival in PCR-negative patients was 97%, reported Dr. Gkalpakiotis of Charles University in Prague.

MAGE-3 was expressed in 21 patients with disease progression. The next most sensitive markers of melanoma progression were MIA and gp100.

Dr. Gkalpakiotis declared having no financial conflicts.

SEOUL, SOUTH KOREA – Serial monitoring of melanoma tumor marker levels in peripheral blood using a novel quantitative real-time reverse-transcriptase polymerase chain reaction method after surgical resection of melanoma has shown promise for the early detection of patients at high risk for disease progression.

The real-time polymerase chain reaction (PCR) assay measures circulating levels of five markers unique to melanoma cells: glycoprotein 100 (gp100), melanoma antigen gene-3 (MAGE-3), tyrosinase, melanoma marker A (Melan-A), and melanoma inhibitory activity (MIA) protein, Dr. Spyridon Gkalpakiotis explained at the World Congress of Dermatology.

He reported on 65 patients who underwent peripheral blood testing and analysis of the five markers every 3 months for the first 2 years after resection of their stage II or III melanoma, for a total of 2,925 PCR assays.

Twenty-six patients experienced elevated test results. All 26 relapsed during 5 years of follow-up; the 5-year survival rate in this group was 65%.

In contrast, only 1 of 39 patients with consistently negative real-time PCR assays experienced disease progression; 5-year survival in PCR-negative patients was 97%, reported Dr. Gkalpakiotis of Charles University in Prague.

MAGE-3 was expressed in 21 patients with disease progression. The next most sensitive markers of melanoma progression were MIA and gp100.

Dr. Gkalpakiotis declared having no financial conflicts.

SEOUL, SOUTH KOREA – Serial monitoring of melanoma tumor marker levels in peripheral blood using a novel quantitative real-time reverse-transcriptase polymerase chain reaction method after surgical resection of melanoma has shown promise for the early detection of patients at high risk for disease progression.

The real-time polymerase chain reaction (PCR) assay measures circulating levels of five markers unique to melanoma cells: glycoprotein 100 (gp100), melanoma antigen gene-3 (MAGE-3), tyrosinase, melanoma marker A (Melan-A), and melanoma inhibitory activity (MIA) protein, Dr. Spyridon Gkalpakiotis explained at the World Congress of Dermatology.

He reported on 65 patients who underwent peripheral blood testing and analysis of the five markers every 3 months for the first 2 years after resection of their stage II or III melanoma, for a total of 2,925 PCR assays.

Twenty-six patients experienced elevated test results. All 26 relapsed during 5 years of follow-up; the 5-year survival rate in this group was 65%.

In contrast, only 1 of 39 patients with consistently negative real-time PCR assays experienced disease progression; 5-year survival in PCR-negative patients was 97%, reported Dr. Gkalpakiotis of Charles University in Prague.

MAGE-3 was expressed in 21 patients with disease progression. The next most sensitive markers of melanoma progression were MIA and gp100.

Dr. Gkalpakiotis declared having no financial conflicts.

BOCA RATON, FLA. – Pigmented Spitz nevi, and even atypical Spitzoid melanocytic tumors, are unlikely to be melanoma in children.

"Boy, does this create controversy," noted Dr. Seth J. Orlow at the meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Pigmented Spitz nevi and atypical Spitzoid melanocytic tumors (ASMT) can appear suddenly and grow rapidly in children. Part of the problem is that these lesions have been shown to be associated with microscopic foci in draining lymph nodes in children who have been subjected to sentinel lymph node biopsy.

In some cases, this has been used as a basis for a diagnosis of melanoma.

"It turns logic upside down, but it's no proof of anything – only that the child has Spitz nevus," said Dr. Orlow, chair of dermatology and the Samuel Weinberg professor of pediatric dermatology at New York University.

Spitz nevi are common, and typically appear as pink-red papules on the face that are less than 1 cm in diameter. However, they can also develop as pigmented lesions, particularly on the limbs.

Although a pigmented lesion in a child is likely a Spitz nevus, the dermatoscope is particularly helpful for confirming the diagnosis, as Spitz nevi have a very characteristic starburst or peripheral globule appearance.

"This is one of those examples where having a dermatoscope really changes things I do," Dr. Orlow said, explaining that although he tends to assume that a pigmented lesion in a child is a Spitz nevus, seeing the typical pattern that is diagnostic of a Spitz nevus is reassuring for both him and the patient’s parents.

Even with ASMT (a subset of Spitzlike growths with features such as mitoses that are associated with melanoma), the risk of melanoma is minimal, he noted.

Although interobserver agreement on diagnosis and prognosis is poor with these lesions, data show that the prognosis is favorable in patients both with and without positive lymph nodes. In one recent study of 11 children with ASMT and positive lymph nodes, all remained disease free at an average of 47 months’ follow-up. By comparison, two of five children younger than age 18 years with histologically unambiguous melanoma and positive sentinel lymph nodes died from metastatic melanoma (Am. J. Surg. Pathol. 2009;33:1386-95).

This finding is not surprising, because these are not melanomas, Dr. Orlow said.

What are pediatric dermatologists' attitudes about Spitz nevi and ASMTs?

Findings from a recent Web-based survey of 350 pediatric dermatologists conducted by Dr. Orlow and his associates showed that academic pediatric dermatologists are most comfortable following Spitz nevi clinically, and are more likely to do so than are those in private practice. It also showed that both never seeing an unambiguous melanoma in a child and believing that Spitz nevi are not precursors to melanoma are – not unexpectedly – predictors of following patients clinically, Dr. Orlow said.

Also, clinicians observe both involution and evolution of Spitz nevi to more banal nevus subtypes as evidence of their benign nature, he said.

Of all those surveyed, only two (who were in private practice) had reported that a death resulting from melanoma had occurred in a patient of theirs.

"Not a single pediatric dermatologist at any academic medical center had ever seen a death from an atypical Spitz nevus in their entire career" he concluded.

Dr. Orlow had no disclosures relevant to his presentation.

BOCA RATON, FLA. – Pigmented Spitz nevi, and even atypical Spitzoid melanocytic tumors, are unlikely to be melanoma in children.

"Boy, does this create controversy," noted Dr. Seth J. Orlow at the meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Pigmented Spitz nevi and atypical Spitzoid melanocytic tumors (ASMT) can appear suddenly and grow rapidly in children. Part of the problem is that these lesions have been shown to be associated with microscopic foci in draining lymph nodes in children who have been subjected to sentinel lymph node biopsy.

In some cases, this has been used as a basis for a diagnosis of melanoma.

"It turns logic upside down, but it's no proof of anything – only that the child has Spitz nevus," said Dr. Orlow, chair of dermatology and the Samuel Weinberg professor of pediatric dermatology at New York University.

Spitz nevi are common, and typically appear as pink-red papules on the face that are less than 1 cm in diameter. However, they can also develop as pigmented lesions, particularly on the limbs.

Although a pigmented lesion in a child is likely a Spitz nevus, the dermatoscope is particularly helpful for confirming the diagnosis, as Spitz nevi have a very characteristic starburst or peripheral globule appearance.

"This is one of those examples where having a dermatoscope really changes things I do," Dr. Orlow said, explaining that although he tends to assume that a pigmented lesion in a child is a Spitz nevus, seeing the typical pattern that is diagnostic of a Spitz nevus is reassuring for both him and the patient’s parents.

Even with ASMT (a subset of Spitzlike growths with features such as mitoses that are associated with melanoma), the risk of melanoma is minimal, he noted.

Although interobserver agreement on diagnosis and prognosis is poor with these lesions, data show that the prognosis is favorable in patients both with and without positive lymph nodes. In one recent study of 11 children with ASMT and positive lymph nodes, all remained disease free at an average of 47 months’ follow-up. By comparison, two of five children younger than age 18 years with histologically unambiguous melanoma and positive sentinel lymph nodes died from metastatic melanoma (Am. J. Surg. Pathol. 2009;33:1386-95).

This finding is not surprising, because these are not melanomas, Dr. Orlow said.

What are pediatric dermatologists' attitudes about Spitz nevi and ASMTs?

Findings from a recent Web-based survey of 350 pediatric dermatologists conducted by Dr. Orlow and his associates showed that academic pediatric dermatologists are most comfortable following Spitz nevi clinically, and are more likely to do so than are those in private practice. It also showed that both never seeing an unambiguous melanoma in a child and believing that Spitz nevi are not precursors to melanoma are – not unexpectedly – predictors of following patients clinically, Dr. Orlow said.

Also, clinicians observe both involution and evolution of Spitz nevi to more banal nevus subtypes as evidence of their benign nature, he said.

Of all those surveyed, only two (who were in private practice) had reported that a death resulting from melanoma had occurred in a patient of theirs.

"Not a single pediatric dermatologist at any academic medical center had ever seen a death from an atypical Spitz nevus in their entire career" he concluded.

Dr. Orlow had no disclosures relevant to his presentation.

BOCA RATON, FLA. – Pigmented Spitz nevi, and even atypical Spitzoid melanocytic tumors, are unlikely to be melanoma in children.

"Boy, does this create controversy," noted Dr. Seth J. Orlow at the meeting of the Florida Society of Dermatology and Dermatologic Surgery.

Pigmented Spitz nevi and atypical Spitzoid melanocytic tumors (ASMT) can appear suddenly and grow rapidly in children. Part of the problem is that these lesions have been shown to be associated with microscopic foci in draining lymph nodes in children who have been subjected to sentinel lymph node biopsy.

In some cases, this has been used as a basis for a diagnosis of melanoma.

"It turns logic upside down, but it's no proof of anything – only that the child has Spitz nevus," said Dr. Orlow, chair of dermatology and the Samuel Weinberg professor of pediatric dermatology at New York University.

Spitz nevi are common, and typically appear as pink-red papules on the face that are less than 1 cm in diameter. However, they can also develop as pigmented lesions, particularly on the limbs.

Although a pigmented lesion in a child is likely a Spitz nevus, the dermatoscope is particularly helpful for confirming the diagnosis, as Spitz nevi have a very characteristic starburst or peripheral globule appearance.

"This is one of those examples where having a dermatoscope really changes things I do," Dr. Orlow said, explaining that although he tends to assume that a pigmented lesion in a child is a Spitz nevus, seeing the typical pattern that is diagnostic of a Spitz nevus is reassuring for both him and the patient’s parents.

Even with ASMT (a subset of Spitzlike growths with features such as mitoses that are associated with melanoma), the risk of melanoma is minimal, he noted.

Although interobserver agreement on diagnosis and prognosis is poor with these lesions, data show that the prognosis is favorable in patients both with and without positive lymph nodes. In one recent study of 11 children with ASMT and positive lymph nodes, all remained disease free at an average of 47 months’ follow-up. By comparison, two of five children younger than age 18 years with histologically unambiguous melanoma and positive sentinel lymph nodes died from metastatic melanoma (Am. J. Surg. Pathol. 2009;33:1386-95).

This finding is not surprising, because these are not melanomas, Dr. Orlow said.

What are pediatric dermatologists' attitudes about Spitz nevi and ASMTs?

Findings from a recent Web-based survey of 350 pediatric dermatologists conducted by Dr. Orlow and his associates showed that academic pediatric dermatologists are most comfortable following Spitz nevi clinically, and are more likely to do so than are those in private practice. It also showed that both never seeing an unambiguous melanoma in a child and believing that Spitz nevi are not precursors to melanoma are – not unexpectedly – predictors of following patients clinically, Dr. Orlow said.

Also, clinicians observe both involution and evolution of Spitz nevi to more banal nevus subtypes as evidence of their benign nature, he said.

Of all those surveyed, only two (who were in private practice) had reported that a death resulting from melanoma had occurred in a patient of theirs.

"Not a single pediatric dermatologist at any academic medical center had ever seen a death from an atypical Spitz nevus in their entire career" he concluded.

Dr. Orlow had no disclosures relevant to his presentation.

Yes - Surgeons Are Softening Criteria for Who Gets Mohs.

By David S. Becker, M.D.

The practice of Mohs micrographic surgery is in some cases drifting away from the classic indications that used to make up most of our practice.

There are different published criteria for cases indicated for Mohs surgery, but these often include patients with recurrent or incompletely excised skin cancers, aggressive histology, or poorly defined margins. Other classic indications include tumors larger than 0.4 cm in high-risk H-zone locations, larger than 1 cm elsewhere on the face, or larger than 2 cm on the trunk or extremities.

Some of these listed criteria would not include a 3-mm basal cell carcinoma on the nose or ear, an 8-mm basal cell carcinoma on the cheek or forehead, or a 1.5-cm lesion on the pretibial skin, but I often have had each of these referred to me for Mohs surgery.

What's driving us to soften these traditional indications for Mohs surgery? Patients, referring dermatologists, dermatopathologists, and Mohs surgeons each may play a role.

Patients love Mohs surgery for many reasons. For one, we do a good job. Perhaps they've had previous Mohs surgery with good results or their friends have, or they have looked online and found that Mohs has the best cure rate. Or, they may have had a bad experience with a prior treatment.

It's not uncommon for patients to do research, and then want to play a role in determining their medical care. If they demand Mohs surgery, and I don't think it's indicated, it can lead to a contentious consultation.

One young man with a squamous cell carcinoma on his chest recently told me that he had researched the cure rates of treatments and he wanted Mohs surgery. He was almost certainly correct that if the sole criteria for therapy were best cure rate, Mohs would be the choice.

There are only two downsides to Mohs versus excision in a case like this: One, the patient has to spend more time in the office for Mohs surgery; and two, it is perhaps overutilization of medical resources. Good luck trying to explain that to patients. They don't care about overutilization of resources.

Who else drives this drift toward enhanced Mohs utilization? Referring dermatologists. They may have an interest in maximizing utilization of a Mohs surgeon in their practice, while some dermatologists have truly been burned, that is, had a patient with a metastatic squamous cell carcinoma or difficult recurrences, and they want the greater certitude of cure from Mohs surgery.

Sometimes the referring dermatologist says the patient is a VIP or relative and asks me to make an exception. If you start making exceptions, pretty soon you're seeing a lot of patients who don't necessarily meet the classic criteria for Mohs surgery.

The next set of people who are driving this drift in overutilization is dermatopathologists. We have dermatopathologists being overly cautious and prudent in ways they may not have been 10-15 years ago. Something that might have been diagnosed as actinic keratosis 20 years ago might now be called actinic keratosis with extension to the base, "squamous cell carcinoma cannot be excluded," or superficially invasive squamous cell carcinoma.
Mohs surgeons also drive the drift in utilization. We do it because that's what we like to do, or because we work for someone and we want to do what they tell us to do, or we have a referring dermatologist whom we want to please. And we want to keep our patients happy too.

It may be time to reconceptualize the indications for Mohs surgery. Should patient demand or anxiety be an indication? Should the referring dermatologist's or Mohs surgeon's instincts about a given lesion be an indication? Should any small lesion on the face be an indication?
Finally, who should decide when to do Mohs surgery? Should it be patients? They want some autonomy and to play a role in managing their own care, and are often educated in doing so.

Should it be the referring dermatologist? They understand the history of a given lesion and know the patient and the response to prior therapies.
Should the Mohs surgeon decide? We have the most experience with cutaneous malignancies, and in many cases we're the best suited to decide who needs Mohs and who doesn't.

Or, finally, should it be the government or insurers? I think that because we have allowed this drift in utilization to go forward, that may be who ultimately is deciding.

Dr. Becker is a Mohs surgeon in private practice in New York. He said he has no relevant conflicts of interest. His comments were presented at the American College of Mohs Surgery meeting.

No -  Mohs Surgery Is Being Properly Utilized.

By Gary Monheit, M.D.

Mohs micrographic surgery is not overutilized, it's increasingly utilized.

A recent study reported a twofold increase in the proportion of Mohs surgery being done in Medicare patients from 2001 to 2006, while the rate of excisions has remained stable. So what's driving this increased utilization of Mohs surgery?

Is it greedy surgeons applying Mohs micrographic surgery to actinic keratoses on the arms and trunk? The few surgeons who are utilizing it inappropriately need to be controlled, but I don't believe this is the main reason for the increased utilization.

In most cases, increased Mohs utilization is appropriate. Mohs is a superior and much more cost-effective modality than excision and it has a greater cure rate, which is now being recognized.

The vision of Dr. Frederic E. Mohs was a change in the treatment of skin cancer. He was tired of seeing recurrences with excision. He realized that if things were accurately mapped out, physicians would have a better understanding of how to treat tumors, spare tissue, and reduce costs.

Brilliantly, it was a merger of surgery and histopathology controlled by one practitioner, the Mohs surgeon. Results of surgical treatment approach 100% the first time.

Should this be done for all nonmelanoma skin cancers at all locations? Should patients be cured the first time rather than risk recurrences? Is this cost effective for most tumors?

Twenty years ago, 50% or more of the Mohs surgeries that I did were on patients with tumors that had undergone two surgical excisions with recurrences that were covered up with flaps. I'm very happy to say that now I'm curing patients with a primary basal cell carcinoma the first time I operate.

We are having a cancer epidemic. The annual incidence of nonmelanoma skin cancer is a staggering 3.5 million, according to a recent study involving epidemiologic databases and the National Cancer Institute (Arch. Dermatol. 2010;146:283-7). And, I think the incidence is much higher.

The same study reported a 4.2% annual growth rate. That would predict a 23% growth rate in Mohs micrographic surgery from 2001 to 2006. Instead, we had a 70% growth rate.

What accounts for this? I believe the high growth rate is driven by what I call the "miracle of Mohs surgery." Five-year recurrence rates after Mohs are 1% for primary basal cell carcinomas, compared with 10% for surgical excision in well-controlled studies, and 4% after Mohs surgery for recurrent basal cell carcinomas, as opposed to 17% for excision.

Studies have found that 18%-32% of facial basal cell carcinomas are incompletely excised and require a second procedure. Repeat excisions create larger defects and worse cosmetic outcomes. Complete re-excisions are challenging after flap repairs. But with Mohs, one procedure does it all.
Studies have shown that Mohs surgery is superior financially because it is more cost effective than traditional excision if you include the costs of re-excision and pathology, and re-repair and treatment of recurrences after excisions.

Patients also are twice as satisfied with Mohs surgery, another study found (Dermatol. Surg. 2009;35:1041-9).

We've got an epidemic of cancer, and we have recognition that Mohs is the best technique for treatment. Patients with tumors that would have been excised and recurred are being referred initially for Mohs surgery. Simple primary lesions that are in the right areas should be treated with Mohs.

Does increased utilization of Mohs surgery translate to greater expense in treating skin cancer? The data show that for primary lesions and recurrences, the cost savings is greater with Mohs surgery. Insurance companies are starting to recognize that, but we can't let insurance companies govern simply by cost.

We really don't know for sure what's driving the increase in Mohs micrographic surgery utilization. However, I do believe that the superiority of the technique, which is becoming more recognized and established, and the epidemic of skin cancer have produced this high rate of utilization.

The growth rate reflects recognition of the unparalleled value of Mohs micrographic surgery as we confront the skin cancer epidemic.

Dr. Monheit is a Mohs surgeon in private practice in Birmingham, Ala., and has directed Mohs fellowship programs for 25 years. He said he has no other relevant conflicts of interest. These remarks were presented at the American College of Mohs Surgery meeting.

Yes - Surgeons Are Softening Criteria for Who Gets Mohs.

By David S. Becker, M.D.

The practice of Mohs micrographic surgery is in some cases drifting away from the classic indications that used to make up most of our practice.

There are different published criteria for cases indicated for Mohs surgery, but these often include patients with recurrent or incompletely excised skin cancers, aggressive histology, or poorly defined margins. Other classic indications include tumors larger than 0.4 cm in high-risk H-zone locations, larger than 1 cm elsewhere on the face, or larger than 2 cm on the trunk or extremities.

Some of these listed criteria would not include a 3-mm basal cell carcinoma on the nose or ear, an 8-mm basal cell carcinoma on the cheek or forehead, or a 1.5-cm lesion on the pretibial skin, but I often have had each of these referred to me for Mohs surgery.

What's driving us to soften these traditional indications for Mohs surgery? Patients, referring dermatologists, dermatopathologists, and Mohs surgeons each may play a role.

Patients love Mohs surgery for many reasons. For one, we do a good job. Perhaps they've had previous Mohs surgery with good results or their friends have, or they have looked online and found that Mohs has the best cure rate. Or, they may have had a bad experience with a prior treatment.

It's not uncommon for patients to do research, and then want to play a role in determining their medical care. If they demand Mohs surgery, and I don't think it's indicated, it can lead to a contentious consultation.

One young man with a squamous cell carcinoma on his chest recently told me that he had researched the cure rates of treatments and he wanted Mohs surgery. He was almost certainly correct that if the sole criteria for therapy were best cure rate, Mohs would be the choice.

There are only two downsides to Mohs versus excision in a case like this: One, the patient has to spend more time in the office for Mohs surgery; and two, it is perhaps overutilization of medical resources. Good luck trying to explain that to patients. They don't care about overutilization of resources.

Who else drives this drift toward enhanced Mohs utilization? Referring dermatologists. They may have an interest in maximizing utilization of a Mohs surgeon in their practice, while some dermatologists have truly been burned, that is, had a patient with a metastatic squamous cell carcinoma or difficult recurrences, and they want the greater certitude of cure from Mohs surgery.

Sometimes the referring dermatologist says the patient is a VIP or relative and asks me to make an exception. If you start making exceptions, pretty soon you're seeing a lot of patients who don't necessarily meet the classic criteria for Mohs surgery.

The next set of people who are driving this drift in overutilization is dermatopathologists. We have dermatopathologists being overly cautious and prudent in ways they may not have been 10-15 years ago. Something that might have been diagnosed as actinic keratosis 20 years ago might now be called actinic keratosis with extension to the base, "squamous cell carcinoma cannot be excluded," or superficially invasive squamous cell carcinoma.
Mohs surgeons also drive the drift in utilization. We do it because that's what we like to do, or because we work for someone and we want to do what they tell us to do, or we have a referring dermatologist whom we want to please. And we want to keep our patients happy too.

It may be time to reconceptualize the indications for Mohs surgery. Should patient demand or anxiety be an indication? Should the referring dermatologist's or Mohs surgeon's instincts about a given lesion be an indication? Should any small lesion on the face be an indication?
Finally, who should decide when to do Mohs surgery? Should it be patients? They want some autonomy and to play a role in managing their own care, and are often educated in doing so.

Should it be the referring dermatologist? They understand the history of a given lesion and know the patient and the response to prior therapies.
Should the Mohs surgeon decide? We have the most experience with cutaneous malignancies, and in many cases we're the best suited to decide who needs Mohs and who doesn't.

Or, finally, should it be the government or insurers? I think that because we have allowed this drift in utilization to go forward, that may be who ultimately is deciding.

Dr. Becker is a Mohs surgeon in private practice in New York. He said he has no relevant conflicts of interest. His comments were presented at the American College of Mohs Surgery meeting.

No -  Mohs Surgery Is Being Properly Utilized.

By Gary Monheit, M.D.

Mohs micrographic surgery is not overutilized, it's increasingly utilized.

A recent study reported a twofold increase in the proportion of Mohs surgery being done in Medicare patients from 2001 to 2006, while the rate of excisions has remained stable. So what's driving this increased utilization of Mohs surgery?

Is it greedy surgeons applying Mohs micrographic surgery to actinic keratoses on the arms and trunk? The few surgeons who are utilizing it inappropriately need to be controlled, but I don't believe this is the main reason for the increased utilization.

In most cases, increased Mohs utilization is appropriate. Mohs is a superior and much more cost-effective modality than excision and it has a greater cure rate, which is now being recognized.

The vision of Dr. Frederic E. Mohs was a change in the treatment of skin cancer. He was tired of seeing recurrences with excision. He realized that if things were accurately mapped out, physicians would have a better understanding of how to treat tumors, spare tissue, and reduce costs.

Brilliantly, it was a merger of surgery and histopathology controlled by one practitioner, the Mohs surgeon. Results of surgical treatment approach 100% the first time.

Should this be done for all nonmelanoma skin cancers at all locations? Should patients be cured the first time rather than risk recurrences? Is this cost effective for most tumors?

Twenty years ago, 50% or more of the Mohs surgeries that I did were on patients with tumors that had undergone two surgical excisions with recurrences that were covered up with flaps. I'm very happy to say that now I'm curing patients with a primary basal cell carcinoma the first time I operate.

We are having a cancer epidemic. The annual incidence of nonmelanoma skin cancer is a staggering 3.5 million, according to a recent study involving epidemiologic databases and the National Cancer Institute (Arch. Dermatol. 2010;146:283-7). And, I think the incidence is much higher.

The same study reported a 4.2% annual growth rate. That would predict a 23% growth rate in Mohs micrographic surgery from 2001 to 2006. Instead, we had a 70% growth rate.

What accounts for this? I believe the high growth rate is driven by what I call the "miracle of Mohs surgery." Five-year recurrence rates after Mohs are 1% for primary basal cell carcinomas, compared with 10% for surgical excision in well-controlled studies, and 4% after Mohs surgery for recurrent basal cell carcinomas, as opposed to 17% for excision.

Studies have found that 18%-32% of facial basal cell carcinomas are incompletely excised and require a second procedure. Repeat excisions create larger defects and worse cosmetic outcomes. Complete re-excisions are challenging after flap repairs. But with Mohs, one procedure does it all.
Studies have shown that Mohs surgery is superior financially because it is more cost effective than traditional excision if you include the costs of re-excision and pathology, and re-repair and treatment of recurrences after excisions.

Patients also are twice as satisfied with Mohs surgery, another study found (Dermatol. Surg. 2009;35:1041-9).

We've got an epidemic of cancer, and we have recognition that Mohs is the best technique for treatment. Patients with tumors that would have been excised and recurred are being referred initially for Mohs surgery. Simple primary lesions that are in the right areas should be treated with Mohs.

Does increased utilization of Mohs surgery translate to greater expense in treating skin cancer? The data show that for primary lesions and recurrences, the cost savings is greater with Mohs surgery. Insurance companies are starting to recognize that, but we can't let insurance companies govern simply by cost.

We really don't know for sure what's driving the increase in Mohs micrographic surgery utilization. However, I do believe that the superiority of the technique, which is becoming more recognized and established, and the epidemic of skin cancer have produced this high rate of utilization.

The growth rate reflects recognition of the unparalleled value of Mohs micrographic surgery as we confront the skin cancer epidemic.

Dr. Monheit is a Mohs surgeon in private practice in Birmingham, Ala., and has directed Mohs fellowship programs for 25 years. He said he has no other relevant conflicts of interest. These remarks were presented at the American College of Mohs Surgery meeting.

Yes - Surgeons Are Softening Criteria for Who Gets Mohs.

By David S. Becker, M.D.

The practice of Mohs micrographic surgery is in some cases drifting away from the classic indications that used to make up most of our practice.

There are different published criteria for cases indicated for Mohs surgery, but these often include patients with recurrent or incompletely excised skin cancers, aggressive histology, or poorly defined margins. Other classic indications include tumors larger than 0.4 cm in high-risk H-zone locations, larger than 1 cm elsewhere on the face, or larger than 2 cm on the trunk or extremities.

Some of these listed criteria would not include a 3-mm basal cell carcinoma on the nose or ear, an 8-mm basal cell carcinoma on the cheek or forehead, or a 1.5-cm lesion on the pretibial skin, but I often have had each of these referred to me for Mohs surgery.

What's driving us to soften these traditional indications for Mohs surgery? Patients, referring dermatologists, dermatopathologists, and Mohs surgeons each may play a role.

Patients love Mohs surgery for many reasons. For one, we do a good job. Perhaps they've had previous Mohs surgery with good results or their friends have, or they have looked online and found that Mohs has the best cure rate. Or, they may have had a bad experience with a prior treatment.

It's not uncommon for patients to do research, and then want to play a role in determining their medical care. If they demand Mohs surgery, and I don't think it's indicated, it can lead to a contentious consultation.

One young man with a squamous cell carcinoma on his chest recently told me that he had researched the cure rates of treatments and he wanted Mohs surgery. He was almost certainly correct that if the sole criteria for therapy were best cure rate, Mohs would be the choice.

There are only two downsides to Mohs versus excision in a case like this: One, the patient has to spend more time in the office for Mohs surgery; and two, it is perhaps overutilization of medical resources. Good luck trying to explain that to patients. They don't care about overutilization of resources.

Who else drives this drift toward enhanced Mohs utilization? Referring dermatologists. They may have an interest in maximizing utilization of a Mohs surgeon in their practice, while some dermatologists have truly been burned, that is, had a patient with a metastatic squamous cell carcinoma or difficult recurrences, and they want the greater certitude of cure from Mohs surgery.

Sometimes the referring dermatologist says the patient is a VIP or relative and asks me to make an exception. If you start making exceptions, pretty soon you're seeing a lot of patients who don't necessarily meet the classic criteria for Mohs surgery.

The next set of people who are driving this drift in overutilization is dermatopathologists. We have dermatopathologists being overly cautious and prudent in ways they may not have been 10-15 years ago. Something that might have been diagnosed as actinic keratosis 20 years ago might now be called actinic keratosis with extension to the base, "squamous cell carcinoma cannot be excluded," or superficially invasive squamous cell carcinoma.
Mohs surgeons also drive the drift in utilization. We do it because that's what we like to do, or because we work for someone and we want to do what they tell us to do, or we have a referring dermatologist whom we want to please. And we want to keep our patients happy too.

It may be time to reconceptualize the indications for Mohs surgery. Should patient demand or anxiety be an indication? Should the referring dermatologist's or Mohs surgeon's instincts about a given lesion be an indication? Should any small lesion on the face be an indication?
Finally, who should decide when to do Mohs surgery? Should it be patients? They want some autonomy and to play a role in managing their own care, and are often educated in doing so.

Should it be the referring dermatologist? They understand the history of a given lesion and know the patient and the response to prior therapies.
Should the Mohs surgeon decide? We have the most experience with cutaneous malignancies, and in many cases we're the best suited to decide who needs Mohs and who doesn't.

Or, finally, should it be the government or insurers? I think that because we have allowed this drift in utilization to go forward, that may be who ultimately is deciding.

Dr. Becker is a Mohs surgeon in private practice in New York. He said he has no relevant conflicts of interest. His comments were presented at the American College of Mohs Surgery meeting.

No -  Mohs Surgery Is Being Properly Utilized.

By Gary Monheit, M.D.

Mohs micrographic surgery is not overutilized, it's increasingly utilized.

A recent study reported a twofold increase in the proportion of Mohs surgery being done in Medicare patients from 2001 to 2006, while the rate of excisions has remained stable. So what's driving this increased utilization of Mohs surgery?

Is it greedy surgeons applying Mohs micrographic surgery to actinic keratoses on the arms and trunk? The few surgeons who are utilizing it inappropriately need to be controlled, but I don't believe this is the main reason for the increased utilization.

In most cases, increased Mohs utilization is appropriate. Mohs is a superior and much more cost-effective modality than excision and it has a greater cure rate, which is now being recognized.

The vision of Dr. Frederic E. Mohs was a change in the treatment of skin cancer. He was tired of seeing recurrences with excision. He realized that if things were accurately mapped out, physicians would have a better understanding of how to treat tumors, spare tissue, and reduce costs.

Brilliantly, it was a merger of surgery and histopathology controlled by one practitioner, the Mohs surgeon. Results of surgical treatment approach 100% the first time.

Should this be done for all nonmelanoma skin cancers at all locations? Should patients be cured the first time rather than risk recurrences? Is this cost effective for most tumors?

Twenty years ago, 50% or more of the Mohs surgeries that I did were on patients with tumors that had undergone two surgical excisions with recurrences that were covered up with flaps. I'm very happy to say that now I'm curing patients with a primary basal cell carcinoma the first time I operate.

We are having a cancer epidemic. The annual incidence of nonmelanoma skin cancer is a staggering 3.5 million, according to a recent study involving epidemiologic databases and the National Cancer Institute (Arch. Dermatol. 2010;146:283-7). And, I think the incidence is much higher.

The same study reported a 4.2% annual growth rate. That would predict a 23% growth rate in Mohs micrographic surgery from 2001 to 2006. Instead, we had a 70% growth rate.

What accounts for this? I believe the high growth rate is driven by what I call the "miracle of Mohs surgery." Five-year recurrence rates after Mohs are 1% for primary basal cell carcinomas, compared with 10% for surgical excision in well-controlled studies, and 4% after Mohs surgery for recurrent basal cell carcinomas, as opposed to 17% for excision.

Studies have found that 18%-32% of facial basal cell carcinomas are incompletely excised and require a second procedure. Repeat excisions create larger defects and worse cosmetic outcomes. Complete re-excisions are challenging after flap repairs. But with Mohs, one procedure does it all.
Studies have shown that Mohs surgery is superior financially because it is more cost effective than traditional excision if you include the costs of re-excision and pathology, and re-repair and treatment of recurrences after excisions.

Patients also are twice as satisfied with Mohs surgery, another study found (Dermatol. Surg. 2009;35:1041-9).

We've got an epidemic of cancer, and we have recognition that Mohs is the best technique for treatment. Patients with tumors that would have been excised and recurred are being referred initially for Mohs surgery. Simple primary lesions that are in the right areas should be treated with Mohs.

Does increased utilization of Mohs surgery translate to greater expense in treating skin cancer? The data show that for primary lesions and recurrences, the cost savings is greater with Mohs surgery. Insurance companies are starting to recognize that, but we can't let insurance companies govern simply by cost.

We really don't know for sure what's driving the increase in Mohs micrographic surgery utilization. However, I do believe that the superiority of the technique, which is becoming more recognized and established, and the epidemic of skin cancer have produced this high rate of utilization.

The growth rate reflects recognition of the unparalleled value of Mohs micrographic surgery as we confront the skin cancer epidemic.

Dr. Monheit is a Mohs surgeon in private practice in Birmingham, Ala., and has directed Mohs fellowship programs for 25 years. He said he has no other relevant conflicts of interest. These remarks were presented at the American College of Mohs Surgery meeting.

BOCA RATON, FLA. – The risk factors for melanoma are well established in adults, as is the well-known ABCD method for self-evaluation for the disease, but assessing risk and recognizing melanoma in children are far less clear cut.

The typical risk factors, such as a history of changing moles, white race, and sun sensitivity, don't seem to apply in children to the degree they do in adults, and although the ABCDs (asymmetry, border irregularity, color variations, diameter over 6 mm) have withstood the test of time in adults, for whom they were developed, they don’t necessarily apply in children, Dr. Seth J. Orlow said at the meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The relatively recent addition of an E to the ABCD method adds an element that is applicable to assessment of suspected melanoma in children, noted Dr. Orlow, chair of dermatology and the Samuel Weinberg professor of pediatric dermatology at New York University.

The E stands for evolving, and it refers to any unexpected change in a mole. It is the word "unexpected" that is important when it comes to moles in children, because in many cases – such as with Spitz nevi – some change is normal, he noted.

Adding to the challenge of predicting and diagnosing melanoma in children is the fact that the disease is very rare in this population, he said.

Based on information from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program database from 1973 to 2001, only 95 of 140,206 cases of melanoma were in children under age 10 years. Compared with older children with melanoma, those in this age group who had melanoma were more likely to be nonwhite; have metastatic disease; show nodular histology; have primary tumors on the head, face, and neck; and have a history of other cancer (J. Clin. Oncol. 2005;23:4735-41).

Among the melanoma patients younger than 10 years old, survival was about 90%, which was comparable to that in individuals aged 10-19 years and 20-24 years. Among those under age 20, survival was 100% if the melanoma was in situ, and 96%, 77%, and 57% if it was localized, regional, or distant, respectively.

Dr. Orlow noted that findings from other series over the years have also underscored the rarity of pediatric melanomas: Children's Hospital of Boston reported only 23 cases over 36 years, a Montreal hospital reported only 13 cases over 22 years, and Istituto Nazionale Tumor reported only 33 cases over 25 years. Many of the cases included nodular or amelanotic disease, reinforcing other data suggesting that children tend to have a different presentation than adults. For example, studies have shown that about 20% of melanomas are nodular in adults, compared with 30%-40% in children, and about 10%-20% of melanomas in adults are amelanotic, compared with about 30% in children.

Dr. Orlow noted that his own experience over 21 years underscores the rarity and differences of melanoma in children, compared with adults.

He has encountered only five authentic cases (excluding giant congenital melanocytic nevi), including one that he said "made the most sense" because it involved a 12-year-old boy from Chernobyl, the site of a 1986 large-scale explosion at a nuclear power plant in Ukraine. Radiation levels at that site remain high to this day. The child had a lesion on his lower back and innumerable dysplastic nevi. The boy's mother also had a history of melanoma as a child.

The other cases included one involving a 12-year old Ashkenazic Jewish girl with a less than 1-mm-thick lesion on her shoulder, one involving a 14-year-old Peruvian Indian girl with deeply pigmented skin and a 1-mm-thick lesion on her fingertip, one involving a 15-year old Ashkenazic/Sephardic boy with xeroderma pigmentosum C and two melanomas in situ, and one involving a 16-year-old Jamaican girl with very deeply pigmented skin who had an 8-mm-deep lesion on her posterior thigh and who died of her disease within 3 months.

"I think this list is typical in that it shows you that these are not people you would necessarily predict to have a problem," he said.

Children seem to differ from adults not only in terms of who gets melanoma, but also in terms of how they develop the disease.

Molecular alterations appear to differ in children, Dr. Orlow noted. While BRAF/NRAS pathway genetic mutations are present in 50%-70% of adults with superficial spreading melanomas, and mutations in the c-KIT gene are present in acral lentiginous and mucosal melanomas in adults, in children melanomas appear to have an increased incidence of deletion of c-KIT as well as mutations in the CDKN2A gene, according to one study (J. Invest. Dermatol. 2009;129:1759-68).

The workup and treatment of children with pediatric melanoma are well established. The prognostic value of sentinel lymph node biopsy – which is well established in adults – is also believed to apply in children. There is no evidence regarding lymph node dissection in either adults or children, although it is used frequently. Risks of lymph node dissection include infection and lymphedema, he noted.

As for treatment, adjuvant therapy includes high-dose interferon-alpha, which is approved for use in adults but not children. It has been used in several case series in children. Risks include fever, malaise, neutropenia, and abnormal liver function tests.

While there remains a great deal to learn about melanoma in children, there are several fallacies about the disease that dermatologists should know. The top five falacies, according to Dr. Orlow, are:

• Any new mole that appears suddenly in a child, or a mole that has grown over the past 6 months, should prompt concern about melanoma just as it does in adults. Reality: The appearance of new nevi in children is normal, and it is also normal for nevi to grow and evolve until they reach their zenith.

• Nevi on the scalp are particularly worrisome and should be removed because they are difficult to follow. Reality: The scalp is a common site for nevi to arise in white children. Such nevi will often have a targetlike appearance or resemble a fried egg. Many resolve by adulthood.

• All atypical/dysplastic nevi must be removed. Reality: Even in patients with the highest risk, such as those with familial atypical mole melanoma syndrome, more than 50% of melanomas will not have any evidence of a preexisting nevus.

• If melanocytic cells are found in a sentinel lymph node biopsy, it must be melanoma. Reality: Such cells can be found in the lymph nodes of children with Spitz nevi, atypical spitzoid melanocytic tumors, and blue nevi.

• We can prevent most prepubertal melanomas by applying our experience with melanoma and melanoma risk in adults. Reality: Such melanomas are unusual both clinically and with respect to the patients in whom they arise.

Dr. Orlow had no disclosures relevant to his presentation.

BOCA RATON, FLA. – The risk factors for melanoma are well established in adults, as is the well-known ABCD method for self-evaluation for the disease, but assessing risk and recognizing melanoma in children are far less clear cut.

The typical risk factors, such as a history of changing moles, white race, and sun sensitivity, don't seem to apply in children to the degree they do in adults, and although the ABCDs (asymmetry, border irregularity, color variations, diameter over 6 mm) have withstood the test of time in adults, for whom they were developed, they don’t necessarily apply in children, Dr. Seth J. Orlow said at the meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The relatively recent addition of an E to the ABCD method adds an element that is applicable to assessment of suspected melanoma in children, noted Dr. Orlow, chair of dermatology and the Samuel Weinberg professor of pediatric dermatology at New York University.

The E stands for evolving, and it refers to any unexpected change in a mole. It is the word "unexpected" that is important when it comes to moles in children, because in many cases – such as with Spitz nevi – some change is normal, he noted.

Adding to the challenge of predicting and diagnosing melanoma in children is the fact that the disease is very rare in this population, he said.

Based on information from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program database from 1973 to 2001, only 95 of 140,206 cases of melanoma were in children under age 10 years. Compared with older children with melanoma, those in this age group who had melanoma were more likely to be nonwhite; have metastatic disease; show nodular histology; have primary tumors on the head, face, and neck; and have a history of other cancer (J. Clin. Oncol. 2005;23:4735-41).

Among the melanoma patients younger than 10 years old, survival was about 90%, which was comparable to that in individuals aged 10-19 years and 20-24 years. Among those under age 20, survival was 100% if the melanoma was in situ, and 96%, 77%, and 57% if it was localized, regional, or distant, respectively.

Dr. Orlow noted that findings from other series over the years have also underscored the rarity of pediatric melanomas: Children's Hospital of Boston reported only 23 cases over 36 years, a Montreal hospital reported only 13 cases over 22 years, and Istituto Nazionale Tumor reported only 33 cases over 25 years. Many of the cases included nodular or amelanotic disease, reinforcing other data suggesting that children tend to have a different presentation than adults. For example, studies have shown that about 20% of melanomas are nodular in adults, compared with 30%-40% in children, and about 10%-20% of melanomas in adults are amelanotic, compared with about 30% in children.

Dr. Orlow noted that his own experience over 21 years underscores the rarity and differences of melanoma in children, compared with adults.

He has encountered only five authentic cases (excluding giant congenital melanocytic nevi), including one that he said "made the most sense" because it involved a 12-year-old boy from Chernobyl, the site of a 1986 large-scale explosion at a nuclear power plant in Ukraine. Radiation levels at that site remain high to this day. The child had a lesion on his lower back and innumerable dysplastic nevi. The boy's mother also had a history of melanoma as a child.

The other cases included one involving a 12-year old Ashkenazic Jewish girl with a less than 1-mm-thick lesion on her shoulder, one involving a 14-year-old Peruvian Indian girl with deeply pigmented skin and a 1-mm-thick lesion on her fingertip, one involving a 15-year old Ashkenazic/Sephardic boy with xeroderma pigmentosum C and two melanomas in situ, and one involving a 16-year-old Jamaican girl with very deeply pigmented skin who had an 8-mm-deep lesion on her posterior thigh and who died of her disease within 3 months.

"I think this list is typical in that it shows you that these are not people you would necessarily predict to have a problem," he said.

Children seem to differ from adults not only in terms of who gets melanoma, but also in terms of how they develop the disease.

Molecular alterations appear to differ in children, Dr. Orlow noted. While BRAF/NRAS pathway genetic mutations are present in 50%-70% of adults with superficial spreading melanomas, and mutations in the c-KIT gene are present in acral lentiginous and mucosal melanomas in adults, in children melanomas appear to have an increased incidence of deletion of c-KIT as well as mutations in the CDKN2A gene, according to one study (J. Invest. Dermatol. 2009;129:1759-68).

The workup and treatment of children with pediatric melanoma are well established. The prognostic value of sentinel lymph node biopsy – which is well established in adults – is also believed to apply in children. There is no evidence regarding lymph node dissection in either adults or children, although it is used frequently. Risks of lymph node dissection include infection and lymphedema, he noted.

As for treatment, adjuvant therapy includes high-dose interferon-alpha, which is approved for use in adults but not children. It has been used in several case series in children. Risks include fever, malaise, neutropenia, and abnormal liver function tests.

While there remains a great deal to learn about melanoma in children, there are several fallacies about the disease that dermatologists should know. The top five falacies, according to Dr. Orlow, are:

• Any new mole that appears suddenly in a child, or a mole that has grown over the past 6 months, should prompt concern about melanoma just as it does in adults. Reality: The appearance of new nevi in children is normal, and it is also normal for nevi to grow and evolve until they reach their zenith.

• Nevi on the scalp are particularly worrisome and should be removed because they are difficult to follow. Reality: The scalp is a common site for nevi to arise in white children. Such nevi will often have a targetlike appearance or resemble a fried egg. Many resolve by adulthood.

• All atypical/dysplastic nevi must be removed. Reality: Even in patients with the highest risk, such as those with familial atypical mole melanoma syndrome, more than 50% of melanomas will not have any evidence of a preexisting nevus.

• If melanocytic cells are found in a sentinel lymph node biopsy, it must be melanoma. Reality: Such cells can be found in the lymph nodes of children with Spitz nevi, atypical spitzoid melanocytic tumors, and blue nevi.

• We can prevent most prepubertal melanomas by applying our experience with melanoma and melanoma risk in adults. Reality: Such melanomas are unusual both clinically and with respect to the patients in whom they arise.

Dr. Orlow had no disclosures relevant to his presentation.

BOCA RATON, FLA. – The risk factors for melanoma are well established in adults, as is the well-known ABCD method for self-evaluation for the disease, but assessing risk and recognizing melanoma in children are far less clear cut.

The typical risk factors, such as a history of changing moles, white race, and sun sensitivity, don't seem to apply in children to the degree they do in adults, and although the ABCDs (asymmetry, border irregularity, color variations, diameter over 6 mm) have withstood the test of time in adults, for whom they were developed, they don’t necessarily apply in children, Dr. Seth J. Orlow said at the meeting of the Florida Society of Dermatology and Dermatologic Surgery.

The relatively recent addition of an E to the ABCD method adds an element that is applicable to assessment of suspected melanoma in children, noted Dr. Orlow, chair of dermatology and the Samuel Weinberg professor of pediatric dermatology at New York University.

The E stands for evolving, and it refers to any unexpected change in a mole. It is the word "unexpected" that is important when it comes to moles in children, because in many cases – such as with Spitz nevi – some change is normal, he noted.

Adding to the challenge of predicting and diagnosing melanoma in children is the fact that the disease is very rare in this population, he said.

Based on information from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program database from 1973 to 2001, only 95 of 140,206 cases of melanoma were in children under age 10 years. Compared with older children with melanoma, those in this age group who had melanoma were more likely to be nonwhite; have metastatic disease; show nodular histology; have primary tumors on the head, face, and neck; and have a history of other cancer (J. Clin. Oncol. 2005;23:4735-41).

Among the melanoma patients younger than 10 years old, survival was about 90%, which was comparable to that in individuals aged 10-19 years and 20-24 years. Among those under age 20, survival was 100% if the melanoma was in situ, and 96%, 77%, and 57% if it was localized, regional, or distant, respectively.

Dr. Orlow noted that findings from other series over the years have also underscored the rarity of pediatric melanomas: Children's Hospital of Boston reported only 23 cases over 36 years, a Montreal hospital reported only 13 cases over 22 years, and Istituto Nazionale Tumor reported only 33 cases over 25 years. Many of the cases included nodular or amelanotic disease, reinforcing other data suggesting that children tend to have a different presentation than adults. For example, studies have shown that about 20% of melanomas are nodular in adults, compared with 30%-40% in children, and about 10%-20% of melanomas in adults are amelanotic, compared with about 30% in children.

Dr. Orlow noted that his own experience over 21 years underscores the rarity and differences of melanoma in children, compared with adults.

He has encountered only five authentic cases (excluding giant congenital melanocytic nevi), including one that he said "made the most sense" because it involved a 12-year-old boy from Chernobyl, the site of a 1986 large-scale explosion at a nuclear power plant in Ukraine. Radiation levels at that site remain high to this day. The child had a lesion on his lower back and innumerable dysplastic nevi. The boy's mother also had a history of melanoma as a child.

The other cases included one involving a 12-year old Ashkenazic Jewish girl with a less than 1-mm-thick lesion on her shoulder, one involving a 14-year-old Peruvian Indian girl with deeply pigmented skin and a 1-mm-thick lesion on her fingertip, one involving a 15-year old Ashkenazic/Sephardic boy with xeroderma pigmentosum C and two melanomas in situ, and one involving a 16-year-old Jamaican girl with very deeply pigmented skin who had an 8-mm-deep lesion on her posterior thigh and who died of her disease within 3 months.

"I think this list is typical in that it shows you that these are not people you would necessarily predict to have a problem," he said.

Children seem to differ from adults not only in terms of who gets melanoma, but also in terms of how they develop the disease.

Molecular alterations appear to differ in children, Dr. Orlow noted. While BRAF/NRAS pathway genetic mutations are present in 50%-70% of adults with superficial spreading melanomas, and mutations in the c-KIT gene are present in acral lentiginous and mucosal melanomas in adults, in children melanomas appear to have an increased incidence of deletion of c-KIT as well as mutations in the CDKN2A gene, according to one study (J. Invest. Dermatol. 2009;129:1759-68).

The workup and treatment of children with pediatric melanoma are well established. The prognostic value of sentinel lymph node biopsy – which is well established in adults – is also believed to apply in children. There is no evidence regarding lymph node dissection in either adults or children, although it is used frequently. Risks of lymph node dissection include infection and lymphedema, he noted.

As for treatment, adjuvant therapy includes high-dose interferon-alpha, which is approved for use in adults but not children. It has been used in several case series in children. Risks include fever, malaise, neutropenia, and abnormal liver function tests.

While there remains a great deal to learn about melanoma in children, there are several fallacies about the disease that dermatologists should know. The top five falacies, according to Dr. Orlow, are:

• Any new mole that appears suddenly in a child, or a mole that has grown over the past 6 months, should prompt concern about melanoma just as it does in adults. Reality: The appearance of new nevi in children is normal, and it is also normal for nevi to grow and evolve until they reach their zenith.

• Nevi on the scalp are particularly worrisome and should be removed because they are difficult to follow. Reality: The scalp is a common site for nevi to arise in white children. Such nevi will often have a targetlike appearance or resemble a fried egg. Many resolve by adulthood.

• All atypical/dysplastic nevi must be removed. Reality: Even in patients with the highest risk, such as those with familial atypical mole melanoma syndrome, more than 50% of melanomas will not have any evidence of a preexisting nevus.

• If melanocytic cells are found in a sentinel lymph node biopsy, it must be melanoma. Reality: Such cells can be found in the lymph nodes of children with Spitz nevi, atypical spitzoid melanocytic tumors, and blue nevi.

• We can prevent most prepubertal melanomas by applying our experience with melanoma and melanoma risk in adults. Reality: Such melanomas are unusual both clinically and with respect to the patients in whom they arise.

Dr. Orlow had no disclosures relevant to his presentation.

In Tanzania, where some of the oldest human fossils have been found, and where Mt. Kilimanjaro rises above the clouds, a group of international dermatologists are hoping to help a very vulnerable population.

The region has one of the highest incidences of albinism in the world.

Although the condition is rare in the western world, it is quite common in sub-Saharan Africa (Dermatol. Clin. 2011;29:79-87). The rate is as high as 1 in 1,400 people, compared with about 1 in 37,000 in the U.S.

Patients with albinism are subject to discrimination, stigma, and even murder.

Photos courtesy of the patients and staff of the Regional Dermatology Training Centre, Tanzania

But, another important concern is the health of patients with albinism whose pink skin is exposed to the African sunshine, and where many occupations are outdoors and in the field.

Many of the locals with albinism die of cancer before age 40; in fact, fewer than 2% make it to their 40th birthday. And almost all of the children with albinism show signs of sun damage before age 10.

Due to lack of funding, many can't afford hats to protect themselves; due to lack of education, many don't know the linkage between sun damage and skin cancer, according to Dr. David McLean, the secretary-general of the International League of Dermatological Societies (ILDS), a nongovernmental organization affiliated with the World Health Organization.

(An audio interview with Dr. McLean is available at the end of this blog.)

Dr. McLean has been visiting the region for the past two decades, helping to establish and grow the Regional Dermatology Training Center (RDTC), an ILDS program, in the town of Moshi in Tanzania.

He is also part of a group who recently spearheaded a project to make hats with a 7.5-cm rim available to the albinism population in Tanzania.

Called "Hats on for Skin Health," a collaboration between the ILDS and Stiefel, the project is a global effort to raise funds for the purchase of hats and other protective items for patients with albinism in Tanzania.

The items will be distributed by the RDTC, which manages a mobile skin care clinic that regularly visits people with albinism living in the region and educates the locals, especially parents, about albinism. The lesson they try to get across, said Dr. McLean, is to let their children play outdoors, but cover them up first.

The group located a hat manufacturer in Moshi, which is currently producing template models for children and adults. Many of the workers, said Dr. McLean, have albinism. "We think that's definitely part of the solution going forward," he said.

The cost of manufacturing a hat in Africa? Less than $2.50, and the hats are expected to last for at least 10 years.

To start the campaign, Stiefel, a subsidiary of GlaxoSmithKline, donated $25,000, and Dr. McLean hopes that dermatologists, other professionals, and even the public, will get involved with the campaign.

"Our people are on the ground there. We know what happens to every donated dollar," said Dr. McLean.

The group expects to have hand out at least 15,000 hats in the next year. Visit www.hatsonforskinhealth.org to learn more.

— Naseem S. Miller (@NaseemSMiller)

In Tanzania, where some of the oldest human fossils have been found, and where Mt. Kilimanjaro rises above the clouds, a group of international dermatologists are hoping to help a very vulnerable population.

The region has one of the highest incidences of albinism in the world.

Although the condition is rare in the western world, it is quite common in sub-Saharan Africa (Dermatol. Clin. 2011;29:79-87). The rate is as high as 1 in 1,400 people, compared with about 1 in 37,000 in the U.S.

Patients with albinism are subject to discrimination, stigma, and even murder.

Photos courtesy of the patients and staff of the Regional Dermatology Training Centre, Tanzania

But, another important concern is the health of patients with albinism whose pink skin is exposed to the African sunshine, and where many occupations are outdoors and in the field.

Many of the locals with albinism die of cancer before age 40; in fact, fewer than 2% make it to their 40th birthday. And almost all of the children with albinism show signs of sun damage before age 10.

Due to lack of funding, many can't afford hats to protect themselves; due to lack of education, many don't know the linkage between sun damage and skin cancer, according to Dr. David McLean, the secretary-general of the International League of Dermatological Societies (ILDS), a nongovernmental organization affiliated with the World Health Organization.

(An audio interview with Dr. McLean is available at the end of this blog.)

Dr. McLean has been visiting the region for the past two decades, helping to establish and grow the Regional Dermatology Training Center (RDTC), an ILDS program, in the town of Moshi in Tanzania.

He is also part of a group who recently spearheaded a project to make hats with a 7.5-cm rim available to the albinism population in Tanzania.

Called "Hats on for Skin Health," a collaboration between the ILDS and Stiefel, the project is a global effort to raise funds for the purchase of hats and other protective items for patients with albinism in Tanzania.

The items will be distributed by the RDTC, which manages a mobile skin care clinic that regularly visits people with albinism living in the region and educates the locals, especially parents, about albinism. The lesson they try to get across, said Dr. McLean, is to let their children play outdoors, but cover them up first.

The group located a hat manufacturer in Moshi, which is currently producing template models for children and adults. Many of the workers, said Dr. McLean, have albinism. "We think that's definitely part of the solution going forward," he said.

The cost of manufacturing a hat in Africa? Less than $2.50, and the hats are expected to last for at least 10 years.

To start the campaign, Stiefel, a subsidiary of GlaxoSmithKline, donated $25,000, and Dr. McLean hopes that dermatologists, other professionals, and even the public, will get involved with the campaign.

"Our people are on the ground there. We know what happens to every donated dollar," said Dr. McLean.

The group expects to have hand out at least 15,000 hats in the next year. Visit www.hatsonforskinhealth.org to learn more.

— Naseem S. Miller (@NaseemSMiller)

In Tanzania, where some of the oldest human fossils have been found, and where Mt. Kilimanjaro rises above the clouds, a group of international dermatologists are hoping to help a very vulnerable population.

The region has one of the highest incidences of albinism in the world.

Although the condition is rare in the western world, it is quite common in sub-Saharan Africa (Dermatol. Clin. 2011;29:79-87). The rate is as high as 1 in 1,400 people, compared with about 1 in 37,000 in the U.S.

Patients with albinism are subject to discrimination, stigma, and even murder.

Photos courtesy of the patients and staff of the Regional Dermatology Training Centre, Tanzania

But, another important concern is the health of patients with albinism whose pink skin is exposed to the African sunshine, and where many occupations are outdoors and in the field.

Many of the locals with albinism die of cancer before age 40; in fact, fewer than 2% make it to their 40th birthday. And almost all of the children with albinism show signs of sun damage before age 10.

Due to lack of funding, many can't afford hats to protect themselves; due to lack of education, many don't know the linkage between sun damage and skin cancer, according to Dr. David McLean, the secretary-general of the International League of Dermatological Societies (ILDS), a nongovernmental organization affiliated with the World Health Organization.

(An audio interview with Dr. McLean is available at the end of this blog.)

Dr. McLean has been visiting the region for the past two decades, helping to establish and grow the Regional Dermatology Training Center (RDTC), an ILDS program, in the town of Moshi in Tanzania.

He is also part of a group who recently spearheaded a project to make hats with a 7.5-cm rim available to the albinism population in Tanzania.

Called "Hats on for Skin Health," a collaboration between the ILDS and Stiefel, the project is a global effort to raise funds for the purchase of hats and other protective items for patients with albinism in Tanzania.

The items will be distributed by the RDTC, which manages a mobile skin care clinic that regularly visits people with albinism living in the region and educates the locals, especially parents, about albinism. The lesson they try to get across, said Dr. McLean, is to let their children play outdoors, but cover them up first.

The group located a hat manufacturer in Moshi, which is currently producing template models for children and adults. Many of the workers, said Dr. McLean, have albinism. "We think that's definitely part of the solution going forward," he said.

The cost of manufacturing a hat in Africa? Less than $2.50, and the hats are expected to last for at least 10 years.

To start the campaign, Stiefel, a subsidiary of GlaxoSmithKline, donated $25,000, and Dr. McLean hopes that dermatologists, other professionals, and even the public, will get involved with the campaign.

"Our people are on the ground there. We know what happens to every donated dollar," said Dr. McLean.

The group expects to have hand out at least 15,000 hats in the next year. Visit www.hatsonforskinhealth.org to learn more.

— Naseem S. Miller (@NaseemSMiller)

A closely watched experimental drug has excited melanoma oncologists and patients with a 63% reduction in the relative risk of death from metastatic melanoma when compared with standard therapy in a phase III trial that had enrolled 675 newly diagnosed patients. Vemurafenib (better known as PLX4032) targets the BRAF V600E mutation found in 40%-60% of melanoma patients. It is only the second melanoma drug to extend the lives of melanoma patients in a randomized clinical study.

The first such agent, ipilimumab (Yervoy), was approved earlier this year, and the melanoma community expects the Food and Drug Administration will award an indication to vemurafenib based on the new data from the BRIM-3 trial. We talked with Dr. Paul Chapman – lead author of the BRIM-3 study — about vemurafenib. He also hypothesized how clinicians would decide which drug — vemurafenib (assuming approval) vs. ipilimumab to use for their patients.

A closely watched experimental drug has excited melanoma oncologists and patients with a 63% reduction in the relative risk of death from metastatic melanoma when compared with standard therapy in a phase III trial that had enrolled 675 newly diagnosed patients. Vemurafenib (better known as PLX4032) targets the BRAF V600E mutation found in 40%-60% of melanoma patients. It is only the second melanoma drug to extend the lives of melanoma patients in a randomized clinical study.

The first such agent, ipilimumab (Yervoy), was approved earlier this year, and the melanoma community expects the Food and Drug Administration will award an indication to vemurafenib based on the new data from the BRIM-3 trial. We talked with Dr. Paul Chapman – lead author of the BRIM-3 study — about vemurafenib. He also hypothesized how clinicians would decide which drug — vemurafenib (assuming approval) vs. ipilimumab to use for their patients.

A closely watched experimental drug has excited melanoma oncologists and patients with a 63% reduction in the relative risk of death from metastatic melanoma when compared with standard therapy in a phase III trial that had enrolled 675 newly diagnosed patients. Vemurafenib (better known as PLX4032) targets the BRAF V600E mutation found in 40%-60% of melanoma patients. It is only the second melanoma drug to extend the lives of melanoma patients in a randomized clinical study.

The first such agent, ipilimumab (Yervoy), was approved earlier this year, and the melanoma community expects the Food and Drug Administration will award an indication to vemurafenib based on the new data from the BRIM-3 trial. We talked with Dr. Paul Chapman – lead author of the BRIM-3 study — about vemurafenib. He also hypothesized how clinicians would decide which drug — vemurafenib (assuming approval) vs. ipilimumab to use for their patients.