Clinics in dermatology最新文献

Patients experiencing or having experienced trafficking frequently interact with the health care system, highlighting the need for health care providers to be equipped with the appropriate tools to serve these patients effectively. The third part of this series focuses on navigating encounters with trafficked persons within the dermatology clinic, emphasizing the importance of trauma-informed, patient-centered care. We reviewed the barriers trafficked patients face and mechanisms to overcome them, the importance of comprehensive needs assessments, and the implementation of effective health care protocols. We additionally review the role of dermatologists in mandatory reporting and the use of appropriate International Classification of Diseases, Tenth Revision codes for documenting a potential trafficking victim encounter in the electronic medical record. We conclude with recommendations for specialized training, emphasizing the critical role dermatologists play in identifying and supporting trafficked patients within the health care system.

Human trafficking is a pervasive global health and human rights issue. The skin often bears the early and most visible signs of abuse and exploitation. Despite the visible nature of their trauma, affected patients frequently go unrecognized within health care settings due to a lack of standardized guidelines for identifying the dermatologic manifestations of trafficking. Herein, we address these challenges by equipping dermatologists and health care teams with the necessary tools to recognize, treat, and report the skin signs of human trafficking. In doing so, we hope to emphasize the importance of early identification and intervention, as well as bring awareness to critical signs, including dermatologic evidence of abuse, infectious diseases, sexually transmitted infections, substance use, and branding. In understanding this, we can bring awareness to dermatologists' critical role in caring for this patient population and their associated cutaneous manifestations. By advancing knowledge in this area, we hope to enhance the capacity of dermatologists to support trafficked individuals.

Dermatology is beginning to investigate the uses of virtual reality and augmented reality to enhance residency education and provide patients with comprehensive and interactive experiences. Although the applications of virtual reality and augmented reality to improve patient clinical care are exciting, these technologic advances may have implications for regulatory considerations, patient safety, informed consent, and privacy. We review how using artificial intelligence, virtual reality, and augmented reality can enhance patient care and deliberate the complex issues surrounding these potential innovations.

The presence of congenital melanocytic nevi (CMN) is determined in utero. The location, size, and number of CMN may be of cosmetic concern with significant psychosocial implications. They may also be associated with symptoms such as pruritus, eczema and/or xerosis, and skin fragility; however, the most medically concerning issue is the association of CMN with the risk of developing cutaneous melanoma, extracutaneous melanoma, and neurocutaneous melanocytosis. Patients with CMN are currently risk-stratified based on the projected adult maximum diameter of the largest CMN and the number of CMN (satellites) present. In small and medium CMN, the absolute risk of developing cutaneous melanoma is estimated to be approximately 0.3% with a relative risk of 9.5. Although patients with large CMN are at increased risk for developing primary cutaneous melanoma within the CMN, they are also at increased risk for developing primary melanoma within the central nervous system in association with central nervous system melanocytic deposits, an entity known as neurocutaneous melanocytosis. The absolute risk for developing melanoma in patients with large CMN is estimated to be between 1.25% and 10% with a relative risk between 52 and 1,046. Regarding the risk for the presence of neurocutaneous melanocytosis, the risk correlates with the number of CMN, with the lowest risk in those with a single CMN and with risk escalation as the number of CMN increases. We provide an overview of the existing evidence about the risk of melanoma and neurocutaneous melanocytosis in patients with CMN. The role of clinical examination, dermatoscopy, magnetic resonance imaging scanning of the central nervous system, and the role of surgery in the management of CMN of varying sizes is discussed.

The incidence of melanoma has risen rapidly, at least until recently, while the mortality rate has changed only a little, a phenomenon suggestive of overdiagnosis, which can be defined as the diagnosis as "melanoma" of a lesion that would not have had the competence to cause death or symptoms even if it had not been excised. Overdiagnosis has been attributed to efforts at early diagnosis ("overdetection") and to changes in criteria resulting in diagnosis as melanoma of lesions previously termed nevi ("overdefinition"). In terms of overdefinition, there is evidence that criteria for the histopathologic diagnosis of melanoma have changed over a period of approximately two decades. Specialization may play a role in overdefinition; research has shown that when pathologists interpret the same lesion, dermatopathologists are more likely to diagnose low-stage (American Joint Committee on Cancer T1a) melanomas and general and/or surgical pathologists are more likely to diagnose atypical nevi. An important subset that contributes to overdiagnosis is melanomas that lack the property of tumorigenic vertical growth phase, thus lacking metastatic competence and perhaps not warranting diagnosis as overt melanomas. Studies have defined subsets of patients with very low-stage lesions diagnosed as melanomas in which observed survival has been 100%. In the past, many of these lesions would have been diagnosed as nevi, constituting overdefinition. Other key characteristics for very low-risk (or no-risk) lesions that are currently termed invasive "melanomas" include low Breslow thickness, Clark's level II invasion, absence of mitoses, and clinically, lack of observed or experienced dynamic changes. We propose a provisional terminology for diagnosing extremely low-risk subgroups as "melanocytic neoplasms of low malignant potential," aimed at reducing the negative personal and social effects of a cancer diagnosis for patients whose health and wellbeing are in reality not affected by an overdiagnosed "melanoma." With additional confirmation and appropriate consensus, it is likely that some of these subgroups can be reclassified as atypical or dysplastic nevi.

It has long been recognized that the histopathologic differential diagnosis between Spitz nevus and melanoma is sometimes extraordinarily difficult. Both can be composed of large oval to spindled melanocytes with abundant cytoplasm and large nuclei. Genomic studies over the last decade have clarified that Spitz tumors have diverse genetic initiating events, and that for each of these, there are benign, intermediate grade, and malignant lesions. Another discovery is that some melanomas can resemble Spitz tumors morphologically but have conventional initiating mutations (eg, BRAF and NRAS). The current World Health Organization definition of Spitz tumors restricts the spectrum to neoplasms with an activating mutation affecting the MAP kinase pathway, mostly fusions involving kinase genes. Whether splitting off Spitz tumors from other neoplasms that are only morphologically spitzoid will stand the test of time is uncertain, but for now, it does bring order to what has been a complex area. The recognition of Spitz melanoma will enable classification, follow-up, and the delineation of rational treatment guidelines for this important group of tumors, most of which are in young people. The author reviewed the logic of the World Health Organization definition of Spitz tumors, the spectrum of tumors produced by initiating mutations, and problems with the definition of Spitz melanoma and provides an example of this rare entity in the context of related tumors.

Blue nevus-like lesions constitute a category of melanocytic lesions that are clinically identified by their blue coloration. Histologically, they exhibit two primary features: a dermal location and intense pigmentation. The latest World Health Organization classification categorizes blue melanocytic lesions into benign entities (dermal melanocytoses, blue nevus, and deep penetrating nevus), melanocytic tumors with low-to-intermediate malignant potential (pigmented epithelioid melanocytoma), and malignant lesions (blue nevus-like melanoma and melanoma arising in blue nevi). Clinically, blue nevi are enduring and stable lesions, displaying a structureless blue pigmentation clinically and dermatoscopically, with a straightforward histologic diagnosis. On the contrary, lesions with recent onset and/or rapid growth are more commonly associated with diagnoses falling within the intermediate part of the spectrum or with melanoma. These lesions often present with a blue color along with additional features such as black blotches, irregular vessels, and irregular pigmented globules. They typically emerge de novo without recognizable precursors, and they pose significant challenges for patient management. Melanoma on a blue nevus is an exceedingly rare entity with only a few cases described to date. Histologically, differentiating between lesions with intermediate malignant potential and melanoma is always challenging, necessitating a comprehensive evaluation of all morphologic findings of the lesion.

Mucosal melanomas (MuM) are rare malignant tumors arising from the epithelia lining the inner mucosal surfaces of the body. Unlike cutaneous melanoma, understanding of MuM is limited among pathologists and clinicians alike, primarily due to rarity of these tumors. MuM are characterized by genetic alterations quite distinct from cutaneous melanomas; however, their causative and promoting factors are unknown. These melanomas are characteristically diagnosed at a later stage due to their occult locations, leading to a worse prognosis. Dedicated staging systems for MuM exist only for sinonasal and conjunctival melanomas. Risk stratification of patients with MuM, particularly those arising from the anogenital area, is challenging. Recent studies have shown that minor modifications of the American Joint Committee on Cancer eighth edition cutaneous melanoma staging system can group patients fairly robustly; however, the proposed T-categorization systems have yet to be validated in larger cohorts. We summarize the demographic, clinical, histopathologic, and molecular features of common subtypes of MuM and highlight the outstanding needs in this field.