Artificial Intelligence in Teledermatology Abstract Purpose of Review This review summarizes current and prospective applications of artificial intelligence (AI) and smartphone technologies to automated diagnosis and teledermatology. Recent Findings Healthcare institutions are rapidly scaling up telehealth programs and embracing long-distance consultation. New developments in deep learning, a type of artificial intelligence, have reached dermatologist-level performance in diagnosing cases of melanoma from lesion images. The smartphone industry projects that next-generation devices and widespread adoption will put deep learning-capable hardware in the hands of consumers everywhere in the coming decade. Summary The expansion in teledermatology programs over the past decade is driven by efforts to lower cost of care, expand access to underserved areas, and improve the monitoring of chronic conditions. Although long-distance diagnosis still underperforms relative to traditional, in-person diagnosis, deep learning technologies have demonstrated the potential to achieve results on par with face-to-face care. Current mobile app diagnosis systems rely on unproven technologies which do not achieve the same standard of accuracy. Over the next few years, research in teledermatology must refine deep learning methods to work with highly variable smartphone images in order to achieve functional long-distance diagnoses.

Teledermatology in Underserved Populations Abstract Purpose of Review Teledermatology holds promise as a tool to bridge distances and enhance access for populations that are underserved by conventional means of dermatologic care. This review delineates underserved populations and examines recent investigations of teledermatology for these populations. An analysis of the benefits and ongoing challenges for teledermatology for underserved people is presented. Recent Findings Many studies demonstrate enhancement of access dermatologic service particularly when using store and forward modes. Many countries and states within the USA are beginning to reimburse for teledermatology services. There is an inherent educational benefit to healthcare providers in using teledermatology systems. However, the recent published literature tends to spotlight successes and may not balance the picture with descriptions of real-world challenges including sustainability, burden shifting, and differing cultural, ethical, and legal contexts around the world. Summary Teledermatology for underserved populations is fast becoming a useful tool for enhancing currently limited access to dermatologic services. Health systems will need to apply this tool tailored to the unique needs of each locale. Follow-up studies will be key to demonstrate durability of successful models and to learn from program challenges.

Artificial Intelligence in Skin Cancer Abstract Purpose To review recent developments in artificial intelligence for skin cancer diagnosis. Recent Findings Major breakthroughs in recent years are likely related to advancements in utilization of convolutional neural networks (CNNs) for dermatologic image analysis, especially dermoscopy. Recent studies have shown that CNN-based approaches perform as well as or even better than human raters in diagnosing close-up and dermoscopic images of skin lesions in a simulated static environment. Several limitations for the development of AI include the need for large data pipelines and ground truth diagnoses, lack of metadata, and lack of rigorous widely accepted standards. Summary Despite recent breakthroughs, adoption of AI in clinical settings for dermatology is in early stages. Close collaboration between researchers and clinicians may provide the opportunity to investigate implementation of AI in clinical settings to provide real benefit for both clinicians and patients.

Updates on Treatment Approaches for Cutaneous Field Cancerization Abstract Purpose of Review Field cancerization describes the phenomenon that multiple heterogenous mutations may arise in an area exposed to chronic carcinogenic stimuli. Advances in the understanding of cutaneous field cancerization have led to novel therapeutic approaches to the management of actinic keratoses (AKs). Herein, we review the literature on the pathophysiology and emerging research of field cancerization in dermatology. Recent Findings The classification systems for grading AK lesions are being refined with investigations focusing on their clinical utility. There is a growing shift toward field-directed treatment for AKs as the importance of field cancerization becomes clearer. Current field-directed therapies are being optimized and novel therapeutic modalities are being studied. Summary Field cancerization underlies the transformation of photodamaged skin into AKs and potentially cutaneous squamous cell carcinoma (cSCC). Clinically meaningful classification systems for AKs are needed to better inform decisions regarding treatment. As we learn more about the role of field characterization in photodamage, AKs, and cSCCs, therapeutic strategies are becoming more field-directed rather than lesion-directed.

Chronic Actinic Dermatitis: a Review Abstract Purpose of Review To update readers on the current understandings of chronic actinic dermatitis (CAD) in regard to epidemiology, clinical findings, pathophysiology, treatment, and prognosis. Recent Findings CAD is classically thought to be primarily a disease of elderly Caucasian males, though recent evidence suggests that in skin of color, the disease manifests more often in younger females. Recent studies suggest the pathogenesis of CAD involves a type-IV hypersensitivity reaction, similar to allergic contact dermatitis. There is also evidence of resistance to UV-induced immunosuppression in these patients, similar to polymorphous light eruption (PMLE). Furthermore, a lower CD4/CD8 ratio on flow cytometry in CAD patients has been correlated with increased tissue burden of disease. Photoprotection remains a mainstay of treatment, though recent evidence suggests potential efficacy of tofacitinib or short courses of narrowband UVB phototherapy as treatment options. Summary CAD is an immunologically mediated photodermatosis characterized by pruritic eczematous lesions of sun-exposed areas, most commonly seen in older Caucasian males. While the pathogenesis of the condition is not fully understood, a type-IV hypersensitivity reaction to UV-induced neoantigens is thought to play a role. Photoprotection remains the mainstay of treatment, though adjunctive treatments are rapidly emerging. Though considered a chronic condition, CAD tends to improve over time.

Advanced Squamous Cell Carcinoma: What’s New? Abstract Purpose of Review Advanced cutaneous squamous cell carcinoma (cSCC), though rare, is fatal with an 89% 5-year mortality rate. The diagnostic criteria for advanced basal cell carcinoma were recently redefined with the introduction of hedgehog inhibitors such as vismodegib. Similarly, the authors suggest redefining the diagnostic criteria of advanced cSCC given the introduction of immune checkpoint inhibitors in order to broaden the patient population that can benefit from both new and old treatment options as potential neoadjuvants. Recent Findings Cemiplimab is a programmed death-1 (PD-1) inhibitor recently FDA-approved in 2018 for advanced cSCC with improved response rates (47–50%) compared to prior treatments. Given the lack of standardization, we suggest the diagnostic criteria of advanced cSCC to consider the patient condition, age, comorbidities, immunosuppression, and cosmetic outcome when determining a treatment regimen. Patients with diffuse cSCC due to immunosuppression may benefit from acitretin, while lesions on the lip may have a poor cosmetic outcome with surgery and may benefit from neoadjuvant therapy. Summary Advanced cSCC does not have standardized diagnostic criteria likely due to the lack of treatment options until now. Additional treatment options may be beneficial to a broader patient population when redefining advanced cSCC to include factors such as immunosuppression and cosmetic outcome from the perspective of the patient.

Solar Urticaria Abstract Purpose of Review Solar urticaria (SU) is a rare photodermatosis, characterized by an abrupt onset of urticaria lesions appearing within minutes of light exposure. The disease may have a significant impact on patients’ quality of life. This review provides an overview of SU, with attention to pathogenesis, workup, differential diagnosis, and treatment. Additionally, we present our stepwise therapeutic approach. Recent Findings Treatment with omalizumab, a recombinant humanized anti-IgE antibody used as a third line treatment for SU, was shown to be beneficial in 80% of patients with antihistamine refractory disease, with 50% becoming symptom free. Summary Accurate history taking and performance of photoprovocation establish a diagnosis of SU. Determining the relevant action spectrum and minimal urticaria dose are important tools for the management of patients. In patients with isolated UVB sensitivity, broad-spectrum sunscreens may be efficacious. In others, UV hardening and antihistamines constitute first-line treatment. Omalizumab is probably the most appropriate treatment in patients with antihistamine refractory disease.

Clinic-Based Surgical Treatment for Hidradenitis Suppurativa Abstract Purpose of Review We provide an evidence-based review of current procedures and provide a practical guide to surgically treating hidradenitis suppurativa in the office setting. Recent Findings Outpatient procedural management of hidradenitis suppurativa may include incision and drainage, intralesional triamcinolone, deroofing, excision, and lasers that achieve follicular destruction. Managing recurrent lesions, scarring, and sinus tracts often requires deroofing or excision. Recurrence rates are likely similar between deroofing and excision by sharp or laser techniques, and high patient satisfaction is consistently reported. Recently published treatment guidelines support the use of a variety of procedures that can be approached in the office setting. Summary Optimizing treatment of hidradenitis suppurativa, a debilitating chronic condition, often requires a combination of procedural and medical interventions. The ability to offer a variety of surgical interventions based on patient preference in an office setting is an important asset for clinicians caring for hidradenitis suppurativa patients. In the future, research should focus on comparing the effectiveness and tolerability of these procedures in various settings.

Polymorphous Light Eruption: a Review Abstract Purpose of Review To update readers on the current understandings of polymorphous light eruption (PMLE) in regard to epidemiology, clinical findings, pathophysiology, treatment, and prognosis. Recent Findings PMLE is known to be the most common photodermatosis seen in individuals with light skin types; however, recent evidence shows that it is also commonly observed in individuals with skin of color. Resistance to UV-induced immunosuppression is now known to be an essential part of pathogenesis; this could be secondary to unique cytokine or antimicrobial peptide expressions in these patients. Photohardening, done at the onset of sunny season for patients living in temperate climate, is a commonly used and effective management. Summary PMLE is the most common photodermatosis. Lesions occur within hours after sun exposure, varying from urticarial papules, pinhead papules, to vesicles; they resolve in days to weeks without scarring. Resistance to UV-induced immunosuppression is thought to be an important contributor to the pathophysiology. Management includes photoprotection and photohardening. A 7–10-day course of oral corticosteroids is an appropriate prophylaxis for patients who plan to go to sunny locale for vacation. Though PMLE is chronic, many patients show improvement over years.

Current Advances in the Prevention, Risk, and Management of Infection in Patients Receiving Biologic Therapy for Dermatologic Disorders Abstract Purpose of Review Biologic agents such as adalimumab, etanercept, golimumab, certolizumab, ustekinumab, brodalumab, secukinumab, ixekizumab, dupilumab, alefacept, rituximab, omalizumab, tildrakizumab, and guselkumab are now indicated in the treatment of dermatologic disorders. This review reports on current prevention, risk, and management of infection in patients receiving biologic therapy for dermatologic disorders. Recent Findings Although risk of infection in patients receiving biologic agents for management of a dermatologic disorder is well-known, it appears to continue to be a low risk. However, optimal prevention and management of some infection risks remain an unmet need. Summary Although the overall risk for infection during biologic therapy for dermatologic disorders appears to remain low, there remains concern about the level of risk for reactivation of tuberculosis, as well as hepatitis B and C, and the risk for other, often uncommon, serious infection remains unknown. Continued pharmacovigilance serves to mitigate risk as well as promote optimal management of dermatologic disorders with biologic agents.