28th Italian Melanoma Intergroup National Congress

The proceedings contain 35 papers. The topics discussed include: germline variants and prognostic factors for cutaneous melanoma in children and adolescents;association between polygenic risk score and multiple primary melanoma;Porocarcinoma: an epidemiological, clinical, and dermoscopic 20-year study;primary cutaneous melanoma and COVID-19: a hospital-based study;atypical spitz tumors: an epidemiological, clinical and dermoscopic multicenter study with 16 years of follow-up;pediatric melanoma: an epidemiological, clinical and dermoscopic multicenter study;recurrence-free survival prediction in melanoma patients by exploiting artificial intelligence techniques on melanoma whole slide images;ultra-high frequency ultrasound and machine learning approaches for the differential diagnosis of melanocytic lesions;and genetic determinants of response to therapy in a real-world setting of advanced/metastatic melanoma patients: whole-exome sequencing and CFDNA analysis.

Adversarial attacks on medical deep learning models

Introduction: Adversarial attacks are a great threat to deep learning (DL) as they can generate imperceptible perturbations in images which severely affects model performance. More worryingly, recent works have shown that medical DL models are vulnerable to such attacks. The DL process flow is susceptible to various kinds of adversarial attacks. Specifically, causative attacks occur before a model is built, during training, and exploratory attacks occur after model training, during the inference phase. Furthermore, these attacks can be exploited to compromise overall model accuracy, or influence results on specific targeted classes. This research aims to study the impact of causative and exploratory attacks for non-targeted and targeted purposes, on medical DL models built for image classification tasks. Method(s): Warping Based Backdoor Attack and Universal Adversarial Pattern Attack were selected due to their superior performance in generating imperceptible adversarial samples for non-targeted and targeted attacks. DL models were produced from both original and perturbed ISIC-2019 dermoscopic and COVID-NET chest X-ray image datasets. These models were subsequently evaluated on their classification performance. Result(s): Experiments on models achieving above 90.0% accuracy revealed that both causative and exploratory attacks could lower model accuracy by at least 45.0%. In the best-case adversarial attack scenario, model accuracy was reduced by up to 99.0%. Conclusion(s): These results provide a better understanding on the damaging nature of causative and exploratory adversarial attacks as well as vulnerability of medical DL models. The findings can serve as a starting point towards building effective defence approaches that are vital for medical systems utilising DL algorithms.

Teledermoscopy-Aided Self-Skin Examinations for Remote Triage of Skin Lesions

Purpose of Study: Teledermatology, defined as the use of technology to provide dermatology services to individuals in a remote setting, has grown considerably in popularity since the onset of the COVID-19 era. Teledermoscopy utilizes a dermatoscope attachment paired with a smartphone camera to visualize colors and microstructures within the epidermis and superficial dermis that cannot be seen with the naked eye alone. When combined with store-and-forward technology, teledermoscopy of lesions concerning for skin cancer can improve virtual referral and triage workflow. Methods Used: Our retrospective case-control study evaluated the efficacy of a smartphone dermatoscope borrow program in the remote triage of individuals with self-selected skin lesions of concern and its effect on subsequent in-person follow-up visits. A retrospective medical record review was conducted of all Oregon Health and Science University (OHSU) Department of Dermatology spot check image submissions utilizing the smartphone dermatoscopes between August 2020-2022. Dermoscopic images of skin lesions that included corresponding non-dermoscopic clinical images in their submission were included in our review (n=70). A blinded expert dermoscopist then reviewed the clinical and dermoscopic images separately and utilized standard clinical algorithms for skin cancer (ABCD criteria: asymmetry, irregular borders, multiple colors, diameter>= 6mm for clinical images;3-point checklist: dermoscopic asymmetry, atypical network, blue-white structures for dermoscopy images) to determine whether the imaged lesion should translate to an in-person visit for further evaluation. Summary of Results: Of the 70 skin lesions submitted, 59 warranted in-person evaluation from clinical (non-dermoscopic) image review compared to 29 warranting in-person evaluation from dermoscopic images of the same lesion. Thus, this is a 51% reduction of conversion to in-person consultation with the addition of smartphone dermatoscope images in virtual lesion triage (P<0.001, McNemar's Test). Conclusion(s): Implementing patient-led teledermoscopy may reduce frequency of in-person visits for benign lesions, and thus, may decrease wait times for other patients with concerning and possibly malignant lesions. Decreasing the frequency of unnecessary visits may not only improve patient quality of life, but also promote cost-effective expenditures for health systems at large.

Lesions in lockdown: mobile dermoscopy in virtual dermatology clinics

Teledermatology is a useful tool in facilitating dermatology outpatient services since the advent of COVID-19. Assessment of lesions has become difficult to facilitate in large numbers. Teledermoscopy has been used for remote lesion assessment. However, the majority of teledermoscopy has been facilitated by healthcare professionals rather than the patient themselves (Vestergaard T, Prasad S, Schuster A et al. Introducing teledermoscopy of possible skin cancers in general practice in Southern Denmark. Fam Pract 2020;37: 513-18). Patients referred with lesions deemed to be low risk are now often initially assessed via telephone consultation in conjunction with photographs of the lesion. The majority of patients are subsequently called for dermoscopy. However, many of those referred have benign lesions and could be safely discharged if dermoscopy images of the lesion were available. Low-cost mobile dermoscopy attachments are available and have been marketed to patients for self-monitoring. We compared a smartphone-compatible dermoscopy device (Dermlite HUD) with traditional dermoscopic photography to assess the feasibility of using this device to photograph skin lesions. This device has equivalent magnification (x 10) to dermatoscopes, a smaller field of view (which in all lesions still allowed complete visualization) and employs polarized light. Dermoscopic photography using the Dermlite HUD was taken of 30 consecutive lesions over a 1-month period by dermatology registrars in the dermatology department. Lesions assessed included pigmented lesions, vascular lesions, nonulcerated skin cancers and benign lesions. Images were assessed by a consultant dermatologist and compared to dermoscopic photographs taken using the standard method employed in the department. Images were compared in terms of resolution, field of view and colour quality between the two instruments as per validated image analysis (Celebi M, Mendonca T, Marques J. Dermoscopy Image Analysis, 1st edn. Boca Raton, FL: CRC Press, 2015). The photographed lesions were assessed by a consultant dermatologist and compared with the standard method. Photos taken with the smartphone attachment were found to be 97% equivalent in terms of resolution, field of view and colour quality to those taken using the standard method and 29 of 30 were deemed suitable for remote lesion assessment. Low-cost smartphone dermatoscope attachments provide images of comparable quality to those taken with a dermatoscope and camera. This offers an opportunity to facilitate fully virtual assessment of low-risk skin lesions and is of use in patients unable to travel to clinics or during lockdowns to facilitate virtual clinics.

Teledermatology and the Montgomery rule of consent

The Montgomery vs. Lanarkshire case of March 2015 is one of the most important UK judgments on informed consent. The ruling dictated that any intervention should be based on a shared decision, whereby patients are aware of all options and supported in making an informed decision. There is debate over whether patients requiring a procedure after a store-andforward teledermatology consultation need a preoperative face-to-face (F2F) appointment to comply with this consent. We evaluated patient experiences of our skin cancer teledermatology pathway, whereby patients had a telephone consultation before a surgical appointment and their first visit to the hospital was for the procedure. On average, we receive 9000 2-week-wait referrals a year. In March 2020, following the UK's nationwide lockdown, our dermatology department had 700 new referrals pending without any opportunity of F2F appointments. To meet this demand and the subsequent restrictions of the COVID-19 pandemic, we established a teledermatology service. Patients attended a community hub where a detailed history was taken and lesions photographed by a medical photographer, including dermoscopic images. Clinical images were subsequently reviewed by a consultant dermatologist. For those requiring surgical procedures, preoperative telephone consultations were conducted. Patients requiring complex procedures and those with likely highgrade malignant melanoma were offered F2F appointments. During the telephone consultation, the planned procedure was explained, with risks, benefits and alternative treatments discussed. The first 50 patients were sent a survey comprising eight questions pertaining to their experience of the new pathway. Over a 4-week period, 34 responded. Mean age was 67 years (range 29-93). Ninety-seven patients felt photographs were taken in a timely manner. All patients reported that appropriate safety and social distancing precautions were taken. All patients described an overall positive experience, felt that sufficient information was provided throughout the pathway and were happy to engage with this service should they require a similar procedure in the future. In this cohort of patients, their first visit to hospital was for a procedure. There are many benefits in reducing F2F hospital attendances. As well as reducing footfall during the pandemic, there is less lost work time and cost of travel for patients or their relatives, more efficient use of hospital facilities and reduced carbon footprint. Our survey suggests that preoperative telephone consultations are liked by patients and appropriate in meeting the requirements of Montgomery consent for a teledermatology service.

Virtual undergraduate dermatology teaching using headmount camera video

Undergraduate clinical dermatology teaching in our hospital was delivered pre-COVID-19 to fourth-year medical students via an objective structured clinical examination-style circuit education session, with preselected live patients displaying important clinical presentation signs. A combination of posters, quizzes and interactive stations (e.g. topical therapy application and cryotherapy demonstration) were also used. Feedback for this consultant-delivered clinical teaching session was always excellent. However, this format did not lend itself easily to virtual teaching when COVID-19 forced immediate changes to undergraduate teaching delivery. A particular, understandable anxiety specifically reported by students was the loss of 'hands-on' clinical teaching with patients. Despite COVID-19 restrictions, a significant number of our face-toface clinics continued and so to harness these clinical teaching opportunities, both live and recorded patient video interactions were arranged. With local university and health-board approval, we obtained written patient consent to record consultations and used secure portals offered by Microsoft Office 365 to display live videos or recorded consultations using a secure NHS Microsoft Teams group, which allowed storage of these teaching videos within its One Drive application. To mimic a 'hands-on' patient interaction, a head-mount (temporal), wireless, 4 K camera was used to mirror the view of the clinician. For skin lesion consultations, ring lamp and dermoscopy magnification examination could also be included (additional still images could also be added retrospectively to any offline video edit). Full-skin examination and general dermatology findings, such as rash pattern and distribution, were highlighted. Some surgical procedures were also recorded, including local anaesthesia infiltration, skin excisions and curettage, as well as cryotherapy administration and topical therapy application. Despite novice use of this teaching technique, video quality was good and feedback excellent, with students appreciating the efforts made to provide interactive clinical teaching during an unprecedented time. Limited existing literature highlighting the use of such teaching models has mainly come from its application in postgraduate surgical specialty intraoperative teaching. We hope the merits of these techniques can be applied to current undergraduate dermatology teaching methodology. We plan to continue to record further clinical consultations to expand our existing teaching video portfolio and are likely to continue to use this as an adjunct resource in our undergraduate teaching delivery. Depending on student feedback, we may consider future professional video recording methods from our university and medical illustration colleagues.

Unilateral multiple facial angiofibromas as a solitary manifestation of tuberous sclerosis

We describe the case of a 12-year-old boy who presented via teledermatology with a 5-6-year history of multiple lesions on the right side of his face. They were unchanged since their initial appearance at 6 years of age but were slowly increasing in number across his right cheek and extending onto the chin. Although the lesions were asymptomatic, growing older had made him feel increasingly self-conscious. He was otherwise fit and well, and attended mainstream school, with no past medical history or family history of note. Perinatal and birth history were also uneventful. On examination, he had multiple, 1-2-mm, erythematous papules confined to the right cheek and right chin. Dermoscopy showed an unusual pattern of vessels with nonspecific globules in between. The rest of the skin, hair and nails were entirely normal in appearance. There were no systemic symptoms and a detailed general and systemic examination, as well as radiological imaging, did not reveal any abnormality. An excisional biopsy was taken of one of the lesions, with histological examination demonstrating focal superficial telangiectasia with associated bland round-tospindle cell proliferation, appearances most in keeping with an angiofibroma. This correlated well clinically, apart from unilateral facial angiofibromas being the solitary finding in our patient. Facial angiofibromas - also called adenoma sebaceum - are well described as part of the cutaneous manifestations of tuberous sclerosis (TSC). Classically, these appear as a facial rash in the form of small pink or red spots across the cheeks and nose in a butterfly distribution, at between 3 and 10 years of age, increasing in size and number until adolescence. TSC is an autosomal dominant disorder with defective mammalian target of rapamycin (mTOR) signalling, characterized by hamartomas in many organs, particularly the skin, central nervous system, renal and cardiovascular systems. The clinical presentation is variable, with other well known and frequently reported cutaneous findings such as shagreen patches, ash-leaf macules and periungual fibromas. Unilateral multiple facial angiofibromas in the absence of other cutaneous or systemic manifestations of TSC - as in our patient - are rare, with only 13 reported cases. These may form part of the clinical spectrum of TSC as a probable consequence of cutaneous mosaicism in which a postzygotic genetic mutation has occurred. Our patient was referred for genetic testing, but this has been delayed as a result of the COVID-19 pandemic. Topical sirolimus 1% - an mTOR inhibitor - has been used with good effect for facial angiofibromas, and our patient also responded well to this.

Leser-Trelat sign: can it follow COVID-19 infection?

Seborrhoeic keratosis is a benign brownish-black skin lesion that is almost always seen in middle-aged and elderly populations. The sudden onset and rapid increase in size and/ or number of seborrhoeic keratoses is called the Leser-Trelat sign, suggesting a paraneoplastic manifestation of internal malignancy. However, eruptive seborrhoeic keratoses are also described in some nonmalignant conditions such as human papillomavirus infection and HIV infection. Herein, we report a case with Leser-Trelat sign in a patient following COVID-19 infection. A 50-year-old man presented to our dermatology clinic complaining of the sudden appearance of multiple warty-like lesions on his back, which had occurred 2 months after recovery from COVID-19 infection. According to his medical history, the patient presented with cough, fever and dyspnoea about 2 months prior to the appearance of his skin lesions. He was referred to a health centre, where a nasopharyngeal swab was taken, and his polymerase chain reaction test for COVID-19 was positive. In addition, bilateral patchy ground-glass infiltration was reported in his high-resolution computed tomography (HRCT) scan, all in favour of COVID- 19 infection. The patient was then treated with acetaminophen, dexamethasone (intramuscular injection), salmeterol and a fluticasone inhaler, and his symptoms improved. Two months after recovery from his mild COVID-19 infection, several small asymptomatic pigmented verrucous papules appeared on his back. Physical examination revealed multiple rough, oval-shaped, brownish papules of varying size. Dermatoscopy of the lesions was also performed. Both clinical and dermoscopic findings were in favour of seborrhoeic keratosis. In order to reach a final diagnosis, a skin biopsy was performed, and microscopic examination of the biopsy specimen showed hyperkeratosis and well-defined epidermal hyperplasia composed mainly of the proliferation of benignlooking basaloid cells and fewer squamoid cells and horn cysts and increased melanin, mostly at the dermoepidermal junction. The dermis showed no significant change. Based on the above findings, the patient was diagnosed with eruptive seborrhoeic keratosis. To determine the possible cause of this eruption, the patient was further evaluated. In his past medical history, he was generally healthy before his COVID-19 infection and had no history of comorbidities. The patient underwent a workup to rule out any internal malignancies. Laboratory tests revealed normal results and included a complete blood count, liver and kidney function tests, electrolytes, prostate-specific antigen and urine analysis. Gastrointestinal endoscopy and colonoscopy ruled out any gastrointestinal malignancy. Chest X-ray and HRCT revealed no malignant lesion. In addition, the patient's abdominopelvic sonography was normal. The patient had no family history of similar skin lesions and gave no history of any chronic inflammatory skin diseases or viral conditions. Therefore, the appearance of the Leser-Trelat sign after COVID- 19 infection was a possibility in this patient. The role of transforming growth factor-alpha and tumour necrosis-alpha in eruptive seborrhoeic keratoses, as well as in COVID-19 infection, can be a common area of interest to explore in the aetiology of this entity.

Reducing face-to-face visits for skin cancer assessment using patient-led teledermatology: a retrospective review of experience with the My Skin Selfie platform

Teledermatology has made massive progress throughout the COVID-19 pandemic, but significant debates are emerging about the correct way to use technology and deliver services in a nonpandemic future where all face-to-face (F2F) options will be available again. Some very fixed views are emerging, and it is important that future national guidelines are both evidence-based and pragmatic. Improvements in phone camera technology allow patients to take high-quality skin images. Adequate assessment of moles does require dermoscopy, but many other skin lesions can be accurately triaged without it, as was commonplace until relatively recently. There is now extensive literature confirming the ability to make safe and secure diagnoses of skin cancers using teledermatology. Debates around the optimal uses of teledermatology are now in progress. We report retrospective data from two pilot studies, for basal cell carcinoma (BCC) and 2-week wait (2WW), using patient-led skin images taken using the MySkinSelfie app and viewed on the MySkinSelfie web portal. The aim was to evaluate the number of F2F visits that had been prevented. In each pilot, patients were initially referred by their general practitioner in the usual way, without images. The BCC pilot was conducted prepandemic. Patients were sent a letter inviting them to submit images. Once images had been received, they were booked into a telephone clinic for assessment. In total, 288 patients were invited and 76 submitted images. Thirty-two (42%) needed further F2F review, 37 (49%) were booked for a surgical procedure, five (6%) were prescribed a cream and two (3%) lesions resolved. The 2WW pilot was conducted during the pandemic. Patients referred on a 2WW pathway were telephoned by administration staff and invited to submit images followed by a telephone consultation. In total, 1385 were invited and 704 submitted images. Two hundred and sixty-five (37 6%) needed further F2F review, 170 (24 1%) were booked for a surgical procedure, 219 (31 1%) were discharged and 50 (7 1%) received a cream. The agreement between diagnosis via digital images of nonpigmented skin lesions and a final diagnosis was 83%. Compared with a standard F2F model, 58% (BCC) and 62% (2WW) avoided a first F2F appointment, providing benefits for patients' travel time, infection risk and missed time at work for patients and carers. A larger prospective study is now needed to document image quality, diagnostic concordance and health economic effects with more precision.

A new era for teledermatology in the COVID-19 pandemic

We present the outcomes from the reaudit of an established UK regional teledermatology service, revealing the impact of the COVID-19 pandemic on referrals from primary to secondary care. Our teledermatology service invites general practitioners (GPs) to submit queries with attached clinical photographs regarding adult patients through the National Health Service EReferral Service. While requests in relation to skin lesions are not excluded, GPs are advised to continue referring suspected skin cancers through the usual 2-week-wait (2WW) pathway. The original audit involved data collection over 12 months before the COVID-19 pandemic. It demonstrated a functioning service providing rapid advice and guidance responses to GPs from consultant dermatologists or associate specialists. The service was reaudited over a 1-month period during the COVID-19 pandemic. Data were collected on the time taken to get a response, the types of dermatological problems in question, the quality of photos submitted and the response outcome. In October 2020, 273 requests were submitted to the service, revealing a 4.5-fold increase vs. pre-COVID-19 pandemic queries. The average response time was 0 08 days. Further referral to secondary care was advised in 20% of cases, with 26% of patients ultimately being referred in the subsequent 3 months. Forty per cent of queries related to skin lesions, a further 40% to chronic dermatoses, 14% to acute dermatoses and 4% to provide advice on therapeutic management. Most notably, there was a six-factor increase in skin lesion queries when compared with pre-COVID-19 data. Our reaudit demonstrated a teledermatology service that continues to deliver timely advice, with the vast majority of responses provided on the same day as the request. This both preserves resources in avoiding potential referrals to secondary care and saves patients from long waiting times for an outpatient appointment. The demand for teledermatology advice has risen significantly during the COVID-19 pandemic, particularly with regard to skin lesions. This may be explained by the current reduced capacity for GPs to see their patients face to face or by the initial reduction in 2WW referrals made at the beginning of the pandemic and subsequent catch-up. The proportion of response outcomes advising further referral for an outpatient appointment has also increased during the pandemic. This is often due to inappropriate queries better served by the skin cancer pathway. Furthermore, 60% of requests lacked good-quality photographs or dermoscopic images, which often left the responding clinician unable to make an adequate assessment of a skin lesion, therefore resulting in referral.

27th National IMI Congress

The proceedings contain 25 papers. The topics discussed include: altitude effect on melanoma epidemiology in the Veneto region: a pilot study;novel predisposition genes double a decreasing CDKN2A mutation rate: five years of (tele)- counselling and gene panel testing for hereditary melanoma within the Italian melanoma intergroup;genetic profiling of atypical deep penetrating NEVI (DPN);ultra-high frequency ultrasound monitoring of melanomas arising in congenital melanocytic nevi: a case series;a segmentation algorithm for skin melanoma regression;impact of the COVID-19 pandemic on primitive melanoma diagnoses at the IDI-IRCCS of Rome;a novel-algorithm combining static and dynamic features to identify melanoma in digital dermoscopy monitoring;and non-sentinel lymph node detection meanwhile sentinel lymph node biopsy in not-complete lymph node dissection era: a new technique for better staging and treating melanoma patients.

Assessment of three different dermoscopy imaging systems during a fast-track skin cancer clinic

Dermoscopy is a noninvasive diagnostic investigation based on magnification, illumination and obliteration of light scatter on the skin surface allowing better visualization of structures beneath the stratum corneum. We aimed to assess image quality of lesions evaluated at a skin cancer clinic using three different handheld dermatoscopes;the Heine Delta 20T (contact) with an iPad;the MoleScope II (noncontact) with a Samsung 7 smartphone;and the Dino-Lite Edge with direct download to a MacBook laptop (noncontact). The Heine Delta 20T and iPad is the current standard used. The MoleScope is a mobile smartphone-attachable dermatoscope. The Dino-Lite is a handheld digital microscope that connects directly to the computer via a USB port. The cost of the Heine Delta 20T is roughly 1100, the MoleScope II 260 and the Dino-Lite 600. Twenty-three lesions were imaged with each device;15 were pigmented. A total of 69 images were downloaded and transferred to Microsoft PowerPoint for review in random order. The images were scored by four consultant dermatologists, one general practitioner with a special interest and one associate specialist, blinded to the diagnoses. A score of 1-5 (poor- excellent) was attributed to each category: (i) detail/dermoscopic features;(ii) colour discrimination;(iii) magnification. Each assessor recorded whether - based on the image alone - they could make a diagnosis. The lesions were basal cell carcinoma (n = 6), seborrhoeic keratosis (n = 4), lichenoid keratosis (n = 1), benign naevi (n = 4), dysplastic naevi (n = 2), melanoma (n = 1), blue naevus (n = 1), sebaceous gland hyperplasia (n = 1), ruptured cyst (n = 1), pyogenic granuloma (n = 1) and dermatofibroma (n = 1). The mean score for each device and category was calculated as follows. (i) Heine: detail = 3.2, colour = 3 3, magnification = 3 2 (overall score = 3 2);46 2% felt able to make a diagnosis. (ii) MoleScope: detail = 2 5, colour = 2 7, magnification 2 5 (overall score = 2 6);43 5% felt able to make a diagnosis. (iii) Dino-Lite: detail = 3 2, colour = 3 2, magnification = 3 6 (overall score = 3 3);57 2% felt able to make a diagnosis. Analysis on a PC screen allowed greater magnification than is generally employed in clinic, which may have affected assessors. The Heine is not primarily designed for digital dermoscopy. It requires two operators for image capture, whereas the other systems require only one. The MoleScope remains the most 'mobile', whereas the Dino-Lite is attached to a laptop/PC. Both the MoleScope and Dino-Lite can be used as noncontact dermatoscopes, avoiding contact medium use. Considering the current COVID-19 pandemic, these devices are less time consuming, more convenient and easier to clean. Overall, the Dino-Lite produced the best images. Despite the MoleScope scoring lower, it was comparable for diagnostic ability. It is proposed that the MoleScope and Dino-Lite systems may be optimal for use in teledermatology to facilitate virtual clinics.

Potential impact of remote consultations in primary care on teledermatology and 2-week wait (2WW) suspected skin cancer referrals: the need for a range of innovative approaches for pre-2WW triage

Managing the increasing number of 2-week wait (2WW) suspected skin cancer referrals to specialist National Health Service (NHS) dermatology services is challenging. Currently, once received, these referrals cannot be redirected back to the referrer and data show that around only 6% of these referrals are relevant skin cancers. The use of teledermatology, including dermoscopic images, for pre-2WW triage has therefore been advocated. Current recommendations expect that these images will be taken in a primary care setting by a member of the primary care team as part of a face-to-face interaction. In response to the COVID-19 pandemic, NHS England now recommends that all general practices should be using a total triage model, using telephone or online consultation systems for all patients contacting the practice, to reduce footfall and thereby protect patients and staff. It is speculated that this change in primary care practice will continue for the foreseeable future. The aim of this study was to review the impact of primary care remote consultation activity on 2WW skin cancer referrals. A simple questionnaire was designed to ask patients attending a 2WW appointment of the nature of their interaction in primary care prior to their 2WW referral, including the type of consultation and the responsible healthcare professional. Data were obtained from 347 consecutive patients, and 206 (59 4%) had been seen face to face. Of these, 135 (65 5%) were seen by a doctor and 71 (34 5%) by a nurse. The remaining 141 (40 6%) did not have a face-to-face consultation prior to referral. Of these 86 (61 0) were referred based on either a video consultation with an image from the patient and 55 (39 0%) following a telephone consultation only. These data are important as they show that the increasing emphasis on remote consultations in primary care means that large numbers of patients with suspected skin cancer are being referred without a face-to-face interaction and one in six were referred based on a telephone consultation only. There are two important potential implications of this. Firstly, this is likely to lead to an increase in 2WW referrals and, secondly, proposed models of pre-2WW triage using teledermatology with appropriate images (including dermoscopic) that currently require patients to attend a general practice surgery for appropriate image taking may need to be rethought. Alternative innovative approaches such as the use of community hubs for image taking or rapid-access community-based skin lesion diagnosis clinics ('spot clinics') may need to be considered.

Results of a pilot optional e-triage teledermatology advice and guidance pathway for equivocal lesions as an alternative to 2-week wait referrals in two large general practitioner networks in a city

In our hospital we receive about 200 skin 2-week wait (2WW) referrals weekly. This is a huge burden on local services. Many of these patients are discharged at the first appointment, and, for a significant proportion of referrals, the 'level of cancer concern' on the general practitioner (GP)-provided 'suspected skin cancer referral form' is rated: 'I'm unsure, it might well be cancer but there are other equally plausible explanations'. In collaboration with secondary care and community stakeholders, an innovative pilot using an optional teledermatology advice and guidance process (A&G) was implemented as a complementary pathway for patients in two large GP practice networks. Conventional 2WW faceto- face referrals could be initiated as normal;however, at the GP's discretion an alternative teledermatology e-triage A&G pathway was introduced for lesions equivocal for malignancy. A model where healthcare assistants (HCAs) maintained a weekly clinic in each of the practices was designed and implemented. The HCA received training and undertook a lesion history via proforma and macroscopic and dermatoscopic photographs, which were subsequently uploaded to the National Health Service e-referral service. A consultant dermatologist reviewed the A&G e-triage request within 72 h and either provided advice or recommended 2WW referral, which was then actioned via the outpatient appointment centre, without further need for GP action. The pilot commenced in November 2021. Over 2 months (November-December 2021 inclusive) 101 e-triage A&G requests were made and 212 conventional 2WW face-to-face referrals. Of the A&G e-triage requests 70 (69.3%) were returned with advice and the patient did not require onward referral. In total 70/313 (22.4%) of the skin lesion episodes were retained in primary care with advice. Since the initiation of the pilot, there are signs that A&G requests and 2WW referrals are changing, with increased uptake in A&G e-triage. Comparing the referral behaviours of the two practice networks before and after the pilot is a challenge given the short period of the pilot and the event of COVID-19 on referral patterns. However, in November- December 2019 (pre-community COVID-19 in the UK), the two practices sent 201 2WW referrals juxtaposed with 212 intrapilot (November-December 2021). This demonstrates a more sustainable number of 2WW referrals and in keeping with previous levels at a period when locally skin 2WW referrals are increasing. Fiscally, given that many of the A&G e-triage requests would have resulted in a face-to-face 2WW referral a cost saving has been made. Our interim data demonstrate the development and implementation of an optional A&G e-triage pathway as an alternative approach for equivocal lesions and it has resulted in retention of 22.4% of would-be 2WW referrals in primary care. Community stakeholders and engagement has been crucial for the project. Our 6-month pilot data will be presented.

Nail ridging in rheumatoid arthritis patients and relation to disease activity: An integrated rheumatology-dermatology multi-centre study

Aim of the work: To evaluate the frequency of nail ridging (NR) in patients with rheumatoid arthritis (RA) and to study its relation to disease activity. Patients and methods: 230 RA patients and 97 matched controls from Helwan, Ain Shams and Mansoura university hospitals were studied. Disease activity score (DAS28) was assessed. NR has been searched for in all patients. The number of affected fingers was recorded. NR was determined by a magnifying lens, seen by naked eye or seen and felt. Dermoscopic photography of the NR using Dermalite DL4 3Gen dermatoscope has been recorded. Results: The median age of patients was 49 years (42–58 years);they were 221 females and 19 males (F:M 11.1:1) with a disease duration 9 years (5–11 years). Their DAS28 was 3.6 (2.9–4.6). NR was significantly increased in RA cases vs. control;73% vs 20%;p < 0.001. In patients, NR was detected by a magnifying lens in 32.6%, seen in 27% and seen and felt in 13.5%. Joint deformities were significantly higher in those with NR. DAS28 was a significant independent predictor of NR;for every one-point increase in DAS28, there was a 153 times higher odds to exhibit NR at a sensitivity of 93.5%, specificity 80.3% and at a diagnostic accuracy of 90%. Conclusion: NR is a frequent finding in RA. An integrated rheumatological- dermatological clinical evaluation may be helpful and further studies are required to prove the importance of this sign for follow up of RA patients.

Hand Eczema: Diagnostic approach and management

Hand eczema (HE) is a chronic inflammatory disorder of the hand with a prevalence of 14.5% worldwide. The incidence of HE has increased considerably during Coronavirus-19 (COVID-19) pandemic due to increased hand hygiene practice. Despite not affecting the mortality rate, HE can decrease the patient's quality of life significantly and increase morbidity. In general, HE can be classified based on its onset, etiology, precipitating factors, and clinical morphology. The diagnosis of HE is established through history taking and physical examination, however, several diagnostic tests should be performed to identify the etiology and exclude the differential diagnosis, including dermoscopic examination, histopathological examination, patch test, and prick test. In addition to diagnostic tests, the severity of HE should also be established to determine the appropriate therapy and monitor the therapeutic responses. After HE is identified, comprehensive management should be provided immediately so that HE will not progress into a chronic disorder which will further decrease the patient's quality of life.

Differential diagnosis of malformations of lymphatic vessels in dermatological practice

Lymphangiomas (LG) are uncommon, rare congenital anomalies or acquired lymphatic dilations of a benign flow that can involve the skin [1, 2]. There are main groups of lymphangiomas: 1) a superficial variant, characterized by grouped vesicles (circumscriptum lymphangioma), 2) a deeper variant in the form of a cavernous lymphangioma. The prevalence of LG may be focal or diffuse. Secondary acquired LG with a rarer frequency are known [3, 4]. LG can be one of the manifestations of a symptom complex, for example, Gorham-Stout syndrome, which is characterized by progressive osteolysis [5]. The rare occurrence of LG, clinical diversity, undulating course of congenital forms, the possibility of an acquired nature of the disease causes a high risk of diagnostic errors in establishing the final diagnosis. At the Department of Dermatovenereology, Cosmetology and Additional Professional Education of Smolensk State Medical University for the period from 2018 to 2021, 5 patients (age from 5 to 17 years) with LG were observed. Of these: in four children, the disease existed from birth, in one girl it had an acquired character and developed after covid infection [4]. Gender characteristics: 4 girls (5, 6, 12 and 17 years old) and 1 boy (9 years old). All patients are urban residents. The time to establish the final diagnosis from the moment of seeking medical help ranged from 15 months to 12 (!) years, the average value being 6.5 years. The range of diagnoses of LG 'masks': herpetic infection, molluscum contagiosum, atopic dermatitis, contact dermatitis, epidermolysis bullosa. A frequent change in diagnoses was established in the same patient. Clinical case 1. The boy is 12 years old. The debut of skin lesions from birth and progression to 3 years of age, then spontaneous regression within 4 years (without signs of dermatosis). From 7 years to the present, there has been an increase in the number of rashes. Localization: the skin of the lateral surface of the trunk. Features of the rash: flesh-colored and/or reddish- purple bubbles. A pathognomonic symptom of 'frog calves' is found. The frequent autodestructive effect on the rash provokes its subsequent progression. Family history: his father is a liquidator of the atomic catastrophe in Chernobyl. Previous diagnoses: molluscum contagiosum, herpes zoster. Clinical case 2. The girl is 17 years old. The debut of the disease from birth. Lack of progression up to 5 years of age (up to 5 years of age did not apply to dermatologists). At the age of 5, she began to engage in rhythmic gymnastics (she continues to practice professionally at the present time) and noted an active increase in the number and size of the elements of the rash. She repeatedly consulted dermatologists: diagnoses of molluscum contagiosum (laser removal), herpetic infection (courses of antiherpetic therapy without effect) were assumed. The diagnosis was established 12 years after the moment of seeking medical help. Unilateral location of the rash along the inner surface of the right upper limb with transition to the axillary region;on the right lateral surface of the body, the right inguinal-femoral fold and the inner surface of the right thigh. Focuses of a rash in the form of different sizes of vesicular elements with a tendency to lymphorrhea and oozing, areas of maceration around. Single elements with a hemorrhagic component. The patient notes an increase in the inflammatory response and vesicle lymphorrhea after each workout. Dermatoscopy: yellow-pink lacunae alternating with single dark red lacunae. Histological examination: multiple dilated lymphatic vessels in the papillary and reticular dermis. Clinical case 3. Girl 6 years old. Sick from birth. The diagnosis of LG of the genitals was established at the age of 1, 5 years. Due to the localization of the rash in the external genital area, the girl's parents (at the age of 1 month) consulted an obstetrician-gynecologist, who suggested a hemangioma and referred to a dermatologist. The disease is of a family nature her grandmother (on the maternal side) and her lder brother have similar rashes on the skin of the trunk and in the mouth. The diagnosis was verified by histological examination. The pathological process is localized in the area of the labia majora and labia minora: multiple vesicular rashes with translucent contents, easily traumatized and accompanied by itching, were found. Conclusions: LG is a multidisciplinary problem, which is caused by mimicry of manifestations, varied localization and prevalence of the rash. To verify the diagnosis, the following algorithm should be followed: 1) the debut more often at birth or in the first months of life (with the exception of acquired forms of LG);2) the nature of evolution: a stable state or slow progression in the absence of traumatic factors;3) clinical features: the formation of grouped deep vesicles that resemble 'frog eggs'. The color of the bubbles is transparent or red-purple due to the hemorrhagic component. LG lesions may have hemangioma components. It should be remembered about the frequent localization of LG on the mucous membrane of the cheeks, tongue and floor of the oral cavity, which can manifest itself as bleeding from the elements of the rash when chewing or when providing dental care;4) biopsy reveals dilated lymphatic vessels in the upper layers of the dermis.

Application of teledermatology during the first wave of the COVID-19 pandemic in Hungary

During the first wave of the COVID-19 pandemic, outpatient care was limited and it resulted in developing an asynchronous teledermatology system. The aim of our retrospective study was to provide quantitative data the first time about use of teledermatology in the Hungarian healthcare system between March 25 and July 13, 2020. The number of cases, regional distribution and type of diagnoses were analyzed. We also followed up patients who were referred to in-person dermoscopic examination. A total of 10.287 teledermatology consultations were completed at our department. 5.967 (58%) patients were female and 4.320 (42%) patients were male with a mean age of 32.7±22.5 years. 5.967 (58%) cases were from the capital city and its metropolitan area and 32% was from other regions of Hungary. The most common diagnosis was dermatitis, followed by skin infections and pigmented skin lesions. In 1.440 cases, the patient was referred to a dermoscopic examination. Teledermatological examination raised also the diagnosis of malignant skin cancer in 190 patients. Later it was confirmed in 111 cases based on dermoscopic examination. Melanoma was confirmed in 14%, squamous cell carcinoma in 15%, basal cell carcinoma in 63% and other malignancies in 8%. We compared the presumed diagnosis given during the teledermatology consultation with the personal examination. The sensitivity of our system proved to be 87% with a specificity of 86% for diagnosing malignant skin lesions. In addition to the large number of general skin conditions, life-threatening diseases were screened, using teledermatology under the first wave of the COVID- 19 pandemic. The correct diagnosis and treatment of most diseases is a significant achievement. Overall, use of asynchronous teledermatology was an outstanding method during the pandemic period and it has the potential to become an important part of patient care in the future.

The Impact of the Pandemic on Dermatology Residency Training in Turkey: Descriptive Studies

Objective: It has raised drastic changes in the routine flow-through of daily life since the beginning of the coronavirus disease-2019 pandemic. One of these is also the education and training of life from the cradle to the grave. We aimed to investigate the pandemic's impact on the dermatology residents' knowledge, skill, and experience levels in this study. Material and Methods: This descriptive research was conducted on dermatology residents from Turkey. The demographic characteristics, the residency duration, teledermatology use, number of outpatients, bedside visits, diagnostic diversity among inpatients, and bed occupancy rates were recorded. Before and after the pandemic in various dermatology-related issues, self-assessment levels of competence were also questioned with the visual analogue scale. Results: A total of 88 residents, 57 (64.8%) women, were included in the study. Sixty nine (78.4%) residents have worked in a pandemic hospital, 81 (92.0%) of the participants thought the pandemic had a negative effect on residency training. Issues such as the decrease in occupancy rates of dermatology service and diagnostic diversity of the inpatients, interrupted physicians' bedside visits, markedly reduced training time, and the inability to conduct theoretical exams reinforced this negative perception (p=0.005, p=0.023, p=0.003, p=0.011, p<0.001;respectively). There was a significant decrease compared to the expected level in the issues such as biological agent therapy, phototherapy, and dermato-surgery and dermatoscopy, although it varied according to the residency duration (p<0.05). Conclusion: Our study revealed that the pandemic affects the dermatology residents more negatively in terms of practical skills and experiences rather than theoretical knowledge level.