Giant keratinocyte tumors, in particular basal cell carcinomas of the scalp area, are a serious challenge for dermatosurgeons, oncologists, and maxillofacial and reconstructive surgeons. The scalp area is limited in terms of skin mobility, and its elasticity decreases with age. The size of the tumors in this area and the degree of infiltration of the underlying tissues are important for the therapeutic choice, from surgical removal, waiting for granulations to form, and placing a split skin mesh graft (at a later stage) to performing complex rotational/transpositional or advancement flaps. Achieving an optimal aesthetic result is often the consequence of interventions carried out or based on the decisions of multidisciplinary teams. Alternatives, such as radiotherapy and targeted therapy with vismodegib, could be administered both preoperatively and postoperatively or as first-line therapy, depending on the tumor board decisions. We present the case of a 69-year-old female patient with a histopathologically proven preoperative giant basal cell carcinoma of the scalp that did not infiltrate the tabula externa. A preoperative ultrasound was performed to preserve the feeding flap arteries. Surgical treatment under general anesthesia was planned and subsequently carried out. During surgery, the surgical resection lines were in close proximity to the arterial vessels, but they remained preserved and ensured a subsequently unproblematic healing process. After the application of the rotational advancement flap technique under general anesthesia, an optimal cosmetic effect was achieved.

BACKGROUND: Skin cancer rates are at all-time highs, but the shortage of dermatologists compels patients to seek medical advice from general practitioners. A new referral pathway called the Suspected Skin Cancer (SSC) service was established to provide general practitioners in Waikato, New Zealand, with rapid diagnosis and treatment advice for lesions suspicious for skin cancer.
OBJECTIVE: The aim of this study was to assess the quantity, quality, and characteristics of referrals to the SSC teledermatology service during its first 6 months.
METHODS: A retrospective chart review of all referrals sent to the SSC teledermatology service during the first 6 months of its operation was conducted. Time to advice, diagnoses, diagnostic discordance, adherence to advice, and time to treatment were recorded. Diagnostic discordance between general practitioners, dermatologists, and pathologists was calculated.
RESULTS: The SSC service received 340 referrals for 402 lesions. Dermatologists diagnosed 256 (63.7%) of these lesions as benign; 56 (13.9%) were histologically confirmed as malignant, including 19 (4.7%) melanomas. The overall discordance between referrer and dermatologist on specific and broad (ie, benign or malignant) diagnoses for 402 lesions was 47% and 26% (κ=0.58, SD 0.07), respectively; 44% and 26% (κ=0.61, SD 0.15) between referrer and pathologist; and 18% and 12% (κ=0.82, SD 0.12) between dermatologist and pathologist. The mean time between referral submission and receiving advice was 1.02 days. The average time to action (eg, excision) was 64.8 days.
CONCLUSIONS: An electronic referral system can be an effective form of teledermatology for providing prompt diagnosis and management advice for benign and malignant skin lesions.

Because of long-term immunosuppression, solid organ transplant recipients are at increased risk for keratinocyte cancer. We matched solid organ transplant patients (n = 150), cases with keratinocyte cancers and tumor-free controls, considering the most important risk factors for keratinocyte cancer in solid organ transplant recipients. Using whole exome data of germline DNA from this patient cohort, we identified several genetic loci associated with the occurrence of multiple keratinocyte cancers. We found one genome-wide significant association of a common single nucleotide polymorphism located in EXOC3 (rs72698504). In addition, we found several variants with a p-value of less than 10-5 associated with the number of keratinocyte cancers. These variants were located in the genes CYB561, WASHC1, PITRM1-AS1, MUC8, ABI3BP, and THBS2-AS1. Using whole exome sequencing data, we performed groupwise tests for rare missense variants in our dataset and found robust associations (p < 10-6, Burden Zeggini test) between MC1R, EPHA8, EPO, MYCT1, ADGRG3, and MGME1 and keratinocyte cancer. Thus, overall, we detected genes involved in pigmentation/UV protection, tumor suppression, immunomodulation, intracellular traffic, and response to UV as genetic risk factors for multiple keratinocyte cancers in solid organ transplant recipients. We also grouped selected genes to pathways and found a selection of genes involved in the \"cellular response to UV\" to be significantly associated with multiple keratinocyte cancers.

Australia and Aotearoa New Zealand have the highest incidence of melanoma and KC in the world. We undertook a cost-of-illness analysis using Markov decision-analytic models separately for melanoma and keratinocyte skin cancer (KC) for each country. Using clinical pathways, the probabilities and unit costs of each health service and medicine for skin cancer management were applied. We estimated mean costs and 95% uncertainty intervals (95% UI) using Monte Carlo simulation. In Australia, the mean first-year costs of melanoma per patient ranged from AU$644 (95%UI: $642, $647) for melanoma in situ to AU$100,725 (95%UI: $84,288, $119,070) for unresectable stage III/IV disease. Australian-wide direct costs to the Government for newly diagnosed patients with melanoma were AU$397.9 m and AU$426.2 m for KCs, a total of AU$824.0 m. The mean costs per patient for melanoma ranged from NZ$1450 (95%UI: $1445, $1456) for melanoma in situ to NZ$77,828 (95%UI $62,525, $94,718) for unresectable stage III/IV disease. The estimated total cost to New Zealand in 2021 for new patients with melanoma was NZ$51.2 m, and for KCs, was NZ$129.4 m, with a total combined cost of NZ$180.5 m. These up-to-date national healthcare costs of melanoma and KC in Australia and New Zealand accentuate the savings potential of successful prevention strategies for skin cancer.

OBJECTIVE: Experimental studies suggested that antioxidants could protect against skin carcinomas. However, epidemiological studies on antioxidant supplement use in relation to basal-cell carcinoma (BCC) and squamous-cell carcinoma (SCC) risks yielded inconsistent findings, and few prospective studies have been conducted to date. We aimed to investigate the associations between antioxidant supplement intake and keratinocyte cancer (KC) risk.
METHODS: E3N is an ongoing prospective cohort initiated in 1990 and involving 98,995 French women aged 40-65 years at recruitment. Intakes of dietary antioxidants were estimated via a validated dietary questionnaire in 1993 and self-reported antioxidant supplement use was collected in 1995. We used Cox models to compute hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for age and skin cancer risk factors.
RESULTS: Over 1995-2014, 2426 BCC and 451 SCC cases were diagnosed among 63,063 women. We found positive relationships between vitamin A supplement use and KC risk (HR = 1.37, 95% CI 1.15-1.62), particularly with BCC (HR = 1.40, 95% CI 1.17-1.69); and between vitamin E supplement use and risks of both BCC (HR = 1.21, 95% CI 1.03-1.52) and SCC (HR = 1.43, 95% CI 1.03-1.99). Intake of beta-carotene supplements was associated with an increased SCC risk (HR = 1.59, 95% CI 1.00-2.54). Vitamin C supplement use was not associated with KC risk. We found similar results when considering total antioxidant intake.
CONCLUSIONS: Intakes of vitamin A or E supplements were associated with an increased KC risk in women. Further studies with information on doses and duration of supplement use and the ability to examine their underlying mechanisms are needed.

Non-melanoma skin cancer (NMSC) is the most common type of cancer in the UK and Ireland, accounting for approximately 20% of all new malignancies recorded, with evidence of increasing incidence. Surgical excision is regarded as the gold standard treatment for such lesions; however, incomplete excision incurs both physical and financial strain on patients and the healthcare service. Our aim is to identify which anatomical regions of the head and neck pose greater risk of incomplete excision and raise awareness for future surgical practice. Manual data collection was carried out on all patients admitted to the OMFS department for surgical excision of NMSCs between January 2016 and December 2017. Information collected included clinical notes and MDT outcomes. NMSCs excised via Mohs surgery. All tumours incompletely excised and requiring further treatment were noted with particular emphasis on the site of the lesion within the head and neck region, and the location of the positive margin on the specimen itself. A total of 506 NMSCs were excised (307 BCC, 199 SCC). Of these, 7.8% (n=24) and 6.0% (n=12), respectively, required further treatment due to incomplete excision. The incompletely exised lesions were predominately located on the nose (13.3%), temple (15.0%), and ear (12.8%). Our results demonstrate that our department is successfully excising NMSCs with minimal cases requiring further management. This study has identified anatomical profiles posing a higher risk of incomplete removal. Alongside the conventionally challenging sites of the nose and ear, we have highlighted additional risk within the temporal region. We therefore propose that Mohs surgery or a two-stage procedure should be considered as management for the temple at future MDTs.

It is known that actinic keratoses (AKs) can progress to invasive squamous cell carcinoma (SCC). The histological PRO grading of AKs is based on the growth pattern of basal keratinocytes and relates to their progression risk. AKs can be non-invasively characterized by line-field confocal optical coherence tomography (LC-OCT). The aim of the study was to define criteria for an LC-OCT grading of AKs based on the PRO classification and to correlate it with its histological counterpart. To evaluate the interobserver agreement for the LC-OCT PRO classification, fifty AKs were imaged by LC-OCT and biopsied for histopathology. PRO histological grading was assessed by an expert consensus, while two evaluator groups separately performed LC-OCT grading on vertical sections. The agreement between LC-OCT and histological PRO grading was 75% for all lesions (weighted kappa 0.66, 95% CI 0.48-0.83, p ≤ 0.001) and 85.4% when comparing the subgroups PRO I vs. PRO II/III (weighted kappa 0.64, 95% CI 0.40-0.88, p ≤ 0.001). The interobserver agreement for LC-OCT was 90% (Cohen\'s kappa 0.84, 95% CI 0.71-0.91, p ≤ 0.001). In this pilot study, we demonstrated that LC-OCT is potentially able to classify AKs based on the basal growth pattern of keratinocytes, in-vivo reproducing the PRO classification, with strong interobserver agreement and a good correlation with histopathology.

Cutaneous melanoma (CM) and keratinocyte cancer (KC) cause considerable morbidity and mortality. We analysed long-term trends of CM and KC in different white populations.
Age-standardised (European Standard Population 2013) incidence and mortality rates (ASIR, ASMR) of CM were extracted from cancer registries in Denmark, New Zealand and the US SEER-Database. ASIRs of KC were sourced from registries of the German federal states Saarland and Schleswig-Holstein, and from Scotland. Age-period-cohort models were used to project melanoma incidence trends.
In Denmark between 1943 and 2016, melanoma ASIR increased from 1.1 to 46.5 in males, and from 1.0 to 48.5 in females, estimated to reach 60.0 and 73.1 in males and females by 2036. Melanoma mortality in Denmark (1951-2016) increased from 1.4 to 6.7 (males) and 1.2 to 3.7 (females). In New Zealand between 1948 and 2016, ASIR increased from 2.7 to 81.0 (males) and from 3.8 to 54.7 (females), slight declines are estimated by 2036 for both genders. Melanoma mortality increased six-fold in New Zealand males between 1950 and 2016; smaller increases were observed in females. We observed three- to four-fold increases in melanoma incidence in US whites, predicted to rise to 56.1 and 36.2 in males and females until 2036. Melanoma mortality also increased among US whites between 1970 and 2017, female melanoma mortality remained stable. Similar trends are shown for KC.
In white populations, incidence of CM and KC significantly increased. CM incidence continues to rise in the short term but is predicted to decline in future.

OBJECTIVE: Sunscreen use has been shown to reduce the incidence of skin cancers. Internet purchasing allows access to internationally sourced sunscreens, despite varying accepted active ingredients and regulations around the world.
OBJECTIVE: To determine the compliance of international sunscreen products advertised on the internet with the current Australian sunscreen standard (AS/NZS 2604:2012).
METHODS: Six sunscreen-related search queries were executed on Google between January-November 2018. Qualitative analysis of the search results to determine compliance with the current Australian sunscreen standard (AS/NZS 2604:2012) was performed by collecting descriptive data, including listed active ingredients of each advertised product. These were compared against the AS/NZS 2604:2012 list of permitted active ingredients. The compliance status of each product, and reasons for non-compliance were annotated. A multiple regression contingency table test was performed to determine whether compliance was associated with the products\' country of origin, and a post hoc analysis was performed to identify countries with significant differences in discrepancy in compliance rate.
RESULTS: Execution of the sunscreen-related search queries on Google generated 1350 results. Only 613 of the 1291 (47.5%) included products were compliant with the AS/NZS 2604:2012 permitted sunscreen active ingredients. 552 of 1291 products were non-compliant due to insufficient information advertised. Australia, India and South Korea had significantly lower than expected compliance rates.
CONCLUSIONS: Online marketing of sunscreen products from other countries has a significantly lower than expected compliance rate with the AS/NZS 2604:2012 permitted sunscreen active ingredients, with many lacking the disclosure of the active ingredients. Advertising regulations for online suppliers need to be tightened to ensure that online consumers purchasing sunscreen products can make informed decisions, as the international E-commerce market rapidly expands.

BACKGROUND: Keratinocyte cancers, also referred to as non-melanoma skin cancers (NMSCs), are one of the most common malignant skin tumors. We performed a retrospective analysis of lesions from patients of a private dermatology practice to evaluate the use of electrical impedance spectroscopy (EIS) in detecting keratinocyte malignancies. The aim of the study is to assess the accuracy of the technique and to rate its use as supportive tool in NMSC diagnosis.
METHODS: The period evaluated ranges from September 2015 to November 2019. In total, 1712 lesions from 951 patients were included. All lesions suspicious for malignancy were gauged with the Nevisense device. Excised lesions were sent in for histopathological classification, and the results were compared to the Nevisense score.
RESULTS: A total of 767 lesions (44.8%) received a negative score (0-3) from the Nevisense system and 945 lesions (55.2%) a positive score (4-10). The combination of the dermatologist\'s visual assessment plus the technical determined Neviscore resulted in the excision of 52.5% of all 1712 suspicious lesions whereof 15% were found to be malignant. The sensitivity of Nevisense was 98.4% for NMSC detection.
CONCLUSIONS: Electrical impedance spectroscopy was found to be a valuable adjunct support tool in clinical decisions for cases with suspicion for NMSC.