Dermoscopy for melanoma detection and triage in primary care: a systematic review.

OBJECTIVE: Most skin lesions first present in primary care, where distinguishing rare melanomas from benign lesions can be challenging. Dermoscopy improves diagnostic accuracy among specialists and is promoted for use by primary care physicians (PCPs). However, when used by untrained clinicians, accuracy may be no better than visual inspection. This study aimed to undertake a systematic review of literature reporting use of dermoscopy to triage suspicious skin lesions in primary care settings, and challenges for implementation. DESIGN: A systematic literature review and narrative synthesis. DATA SOURCES: We searched MEDLINE, Cochrane Central, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and SCOPUS bibliographic databases from 1 January 1990 to 31 December 2017, without language restrictions. INCLUSION CRITERIA: Studies including assessment of dermoscopy accuracy, acceptability to patients and PCPs, training requirements, and cost-effectiveness of dermoscopy modes in primary care, including trials, diagnostic accuracy and acceptability studies. RESULTS: 23 studies met the review criteria, representing 49 769 lesions and 3708 PCPs, all from high-income countries. There was a paucity of studies set truly in primary care and the outcomes measured were diverse. The heterogeneity therefore made meta-analysis unfeasible; the data were synthesised through narrative review. Dermoscopy, with appropriate training, was associated with improved diagnostic accuracy for melanoma and benign lesions, and reduced unnecessary excisions and referrals. Teledermoscopy-based referral systems improved triage accuracy. Only three studies examined cost-effectiveness; hence, there was insufficient evidence to draw conclusions. Costs, training and time requirements were considered important implementation barriers. Patient satisfaction was seldom assessed. Computer-aided dermoscopy and other technological advances have not yet been tested in primary care. CONCLUSIONS: Dermoscopy could help PCPs triage suspicious lesions for biopsy, urgent referral or reassurance. However, it will be important to establish further evidence on minimum training requirements to reach competence, as well as the cost-effectiveness and patient acceptability of implementing dermoscopy in primary care. TRIAL REGISTRATION NUMBER: CRD42018091395.

Free dermis-fat graft to correct the whistle deformity in patients with cleft lip.

Vermilion notching or 'whistle deformity' is a common secondary deformity of the vermilion in patients with cleft lip. The free border of the lip is a composite structure consisting of the orbicularis oris and the overlying tissues, namely subcutaneous fat, vermilion and mucosa. A deficiency of all or one of these structures is responsible for the vermilion notch. An absolute shortage of the muscle or subcutaneous tissue necessitates the use of tissue from another source to correct the deformity. Dermis fat grafts have been used to augment the free border of the lip and correct this deformity. The technique is simple and reliable. The tissue is available in plenty, easy to harvest and could be repeated if necessary, i.e. in case of resorption. From June 1996 until January 2000 the technique was used in 10 patients. Of these 10, one was a bilateral cleft and nine were unilateral cleft lip deformities. A degree of graft resorption was seen in one patient, one had a partial graft loss due to ulceration and exposure. The first patient had a further augmentation.

Vincristine as a treatment for a large haemangioma threatening vital functions.

We report the use of vincristine to treat a large steroid resistant haemangioma of the lower face and neck. At the time of treatment the lesion had shown no signs of involution. The haemangioma was not life threatening but extension within the mouth was associated with bleeding and ulceration, which was impairing feeding and speech development. A significant improvement was seen with vincristine treatment.

"Now you see it...now you don't." Carmoisine vital dye facilitates complete removal of cutaneous neoplasia by intraoperative visual enhancement.

Patients presenting for excision of squamous cell carcinomata, including Bowen's disease, in sun-damaged skin often present with poorly defined, morphoeic or multifocal neoplasms, the extent of which can be difficult to identify intraoperatively. Use of vital staining has been commonly used to aid identification and appropriate excision of squamous lesions of the oral cavity and upper aerodigestive tract but has not been readily adopted for cutaneous lesions. We report a case of a morphoeic squamous cell neoplasm of the web space and fingers to illustrate the merits of vital staining cutaneous squamous neoplasms with the simple dye Carmoisine E122. This assists with intraoperative tumour identification and facilitates adequate oncological resection and appropriately planned reconstruction. By comparison with other methods such as Mohs, it is a simple, cheap, and rapid aid that may be used by surgeons of all grades to improve identification of the extent of the neoplasm, without special equipment.

U.K. guidelines for the management of cutaneous melanoma.

These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the U.K., they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

UK guidelines for the management of cutaneous melanoma.

These guidelines for management of cutaneous melanoma present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the UK, they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.

Meningococcal septicaemia and plastic surgery--a strategy for management.

Meningococcal septicaemia is a severe life threatening illness that is part of the spectrum of meningococcal disease. It is of particular concern to the plastic and reconstructive surgeon because as the medical and intensive care of these patients improves, more are surviving the acute phase of the septicaemia and suffering from the associated complications such as skin necrosis and extremity loss. Recently there have been several reports in the literature concerning the management of skin infarction with both skin grafting and free flap surgery. This paper will provide an update on the proposed pathophysiological mechanisms involved, summarise the present data on plastic surgical care and suggest a stratagem for future management of these difficult cases.

The impact of antenatal diagnosis on the effectiveness and timing of counselling for cleft lip and palate.

Birth of a cleft child is emotionally distressing to the parents. The opportunity for forewarning the parents is now possible with antenatal ultrasound diagnosis of the cleft. This has opened up a new chapter of antenatal counselling. We present a retrospective postal study of 124 primary cleft lip and/or palate repairs operated over the last 5 years. In our study, 30% were diagnosed antenatally and received antenatal counselling. The rest received postnatal counselling. Of those who had an antenatal diagnosis 85% felt that the diagnosis prepared them psychologically for the birth of the cleft child. A total of 92% (n = 23) of parents who had antenatal as well as postnatal counselling, as compared with 71% (n = 46) of those counselled only postnatally, said the information given to them by the counselling cleft team was detailed and satisfactory. The majority of those who felt counselling was confusing had only postnatal counselling. Of those who had antenatal diagnosis 92% said that they had never contemplated termination of pregnancy. Only one parent had actually terminated her pregnancy due solely to the antenatal diagnosis of a bilateral cleft lip and palate. Our study has highlighted the importance of antenatal diagnosis of cleft and the importance of antenatal counselling for the delivery of a cleft child to be a positive experience.

Dispersal of radioisotope labelled solution following deep dermal injection in Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is the commonest inherited disorder of connective tissue, affecting around 10 000 patients in the UK. Patients with EDS have reported that local anaesthetic is often ineffective. Patients with less severe skin laxity often have the most problems. We have postulated that this resistance to local anaesthetics is not due to the lax connective tissues as is often assumed. This study used radioactively labelled solution ((99m)Tc-pertechnetate) administered as a deep dermal injection in the forearm. The rate of dispersal of isotope was measured over 60 min and found to be identical between six patients with EDS and three controls. The effects of local anaesthetics are complex and depend on the individual chemical properties of the agent and a number of tissue factors. This study would suggest that the lack of effectiveness of local anaesthetic solutions is not due to rapid dispersal of solution. It is unlikely therefore that its lack of effect can be compensated for by simply increasing the amount used. The diagnosis of EDS should be considered in any patient who complains unexpectedly of pain during their procedure, particularly when the surgeon knows that an adequate volume of local anaesthetic has been used.

Therapeutic trends in cutaneous melanoma.

Many advances in the management of melanoma have occurred in the last few years. These make this an exciting time for clinicians and allows them to offer glimmers of hope for patients with this disease. This article looks at the therapeutic aspects of the treatment of cutaneous melanoma.

Cutaneous melanoma: diagnosis and at risk patients.

Malignant melanoma is a condition which kills many young people, yet early recognition can lead to cure. There are, however, new approaches to diagnosis and management of disease at high risk of recurrence, which raise glimmers of hope in this most capricious of conditions.

Skin replacement in Dupuytren's disease.

We have reviewed 90 rays in 67 patients who had undergone radical digital dermofasciectomy. Follow-up was from 24 to 100 months. Problems with skin grafts, moving two-point discrimination and active range of joint movement were noted. The recurrence rate in this series was 8%, a very much better figure for disease control than has been reported for standard approaches for Dupuytren's disease. Radical digital dermofasciectomy is strongly recommended for all cases of recurrent Dupuytren's disease requiring reoperation and as a primary procedure when there is significant skin involvement.

The submental island flap.

The submental island flap is a reliable source of skin of excellent colour, contour and texture match for facial resurfacing and leaves a well hidden donor site. The flap is safe, rapid and simple to raise. We report on its use in 12 cases of facial or intraoral reconstruction. Complications were few. However, there was one case of complete flap loss following its use in a reverse flow manner, due to the presence of an unreported, but constant, valve in the venous system of the face. We believe this flap to be a worthwhile addition to the existing surgical armamentarium.

Computer screening for early detection of melanoma--is there a future?

Computer image analysis in the study of pigmented lesions is critically examined and discussed in the light of the current published data. The potential for objective analysis by computers as a possible screening aid for the inexperienced clinician is discussed. The future for this technology is exciting if handled with care.

Analysis of 100 upper limb injuries using the Merseyside Accident Information Model.

More than 2 million upper limb injuries occur each year in Britain. Information about the precise sequence of events leading up to an accident may help prevention of similar injuries by alteration of the work environment or through safety education. The first impression of the cause of an accident may not identify the key event triggering it. The Merseyside Accident Information Model (MAIM; Manning, 1987) provides a structured questionnaire, based on a menu-led computer programme. This not only allows the first unforeseen event to be identified from the history, but is also the basis of a database. Pooled data can then be analyzed. We present an analysis of 100 consecutive cases presenting to one Plastic Surgery Unit.