untitled to respond to the survey, thus creating response bias and overestimating the beneficial effect of photography. Overall, this survey study revealed that dermatopa- thologists find clinical photography most beneficial in the diagnosis of inflammatory skin diseases, and they would like to receive photographs more frequently. They prefer a convenient method of delivery, most commonly a printed- out photograph attached to the requisition slip. Accepted for Publication: June 4, 2010. Author Affiliations: Department of Dermatology (Drs Mohr and Hood) and Epidemiology and Biostatistics Core (Mr Indika), Eastern Virginia Medical School, Norfolk. Correspondence: Dr Mohr, Department of Dermatology, Eastern Virginia Medical School, 721 Fairfax Ave, Ste 200, Norfolk, VA 23507 (melinda.mohr@gmail.com). Author Contributions: All authors had full access to all of the data in the report and take responsibility for the in- tegrity of the data and the accuracy of the data analysis. Study concept and design: Mohr and Hood. Acquisition of data: Mohr. Analysis and interpretation of data: Mohr, In- dika, and Hood. Drafting of the manuscript: Mohr and In- dika. Critical revision of the manuscript for important intel- lectual content: Hood. Statistical analysis: Indika. Study supervision: Hood. Financial Disclosure: None reported. Additional Contributions: We thank the members of the ASDP who participated in this study and the Epidemiol- ogy and Biostatistics Core at Eastern Virginia Medical School, Norfolk, and Old Dominion University, Norfolk, for assisting with statistical analysis. 1. Fogelberg A, Ioffreda M, Helm KF. The utility of digital clinical photographs in dermatopathology. J Cutan Med Surg. 2004;8(2):116-121. 2. Kutzner H, Kempf W, Schärer L, Requena L. Optimizing dermatopathologic diagnosis with digital photography and internet: the significance of clinico- pathologic correlation [in German]. Hautarzt. 2007;58(9):760-768. PRACTICE GAPS Submitting Clinical Photographs to Dermatopathologists to Facilitate Interpretations A dvances in immunohistochemical stains, molecu-lar analysis, and laboratory technology have fa-cilitated dermatopathologic diagnostic accuracy. Nevertheless, patients and clinicians are often frustrated when dermatopathologists render nonspecific diagnoses, which may lead to diagnostic and/or therapeutic uncer- tainty. Given the importance of clinicopathologic correla- tion (CPC), a practice gap exists between what dermato- pathologists desire and what the clinicians provide.1,2 Mohr et al point out that one of the most important tools used to assist accurate dermatopathologic diagno- sis is the information supplied on the dermatopathology form accompanying tissue specimens. They also report that dermatopathologists find the addition of a clinical photograph useful in rendering a microscopic diagno- sis, especially when dealing with inflammatory skin dis- eases. The use of clinical photographs may be particu- larly helpful when dermatopathologists receive specimens with an inadequate clinical description on the dermato- pathology form, which may be more of a concern with specimens submitted by nondermatologists who have less CPC experience. Although clinical photographs are desired, it is ex- tremely infrequent for a dermatopathologist to be pro- vided with one. Barriers to sending clinical photographs with biopsy specimens include the time it takes to create and implement standard operating procedures (SOP), which include identifying the body region to be photo- graphed, obtaining consent from the patient, taking the digital photograph, downloading the photographic file, la- beling the photograph, and either printing or electroni- cally sending the picture to the pathologist. Other barri- ers are limited computer file storage space; costs of obtaining 1 or more digital cameras for the physician office; and com- pliance with the secure data transfer standards of the Health Insurance Portability and Accountability Act and Health Information Technology for Economic and Clinical Health. It is also possible that some patients may object to pho- tography, particularly of specific body parts. This gap between what dermatopathologists desire and what the clinicians provide can be narrowed by improv- ing the quality of information supplied by the clinician to the dermatopathologist. Education directed at office efficiency should include instruction on efficient pro- cesses to incorporate patient photography. Mohr et al un- derscore that patient care will benefit when clinicians im- prove the quality and quantity of the information provided, and they encourage incorporation of photog- raphy as part of routine biopsy procedures. Develop- ment of a more comprehensive way of communicating information to dermatopathologists is needed. Clinician- friendly pathology forms and reminder systems to in- clude clinical photographs may help. Considering patient volume and increasing time limi- tations of office visits, it would optimal for clinicians to train an assistant to take and process the photographs for relevant patients. The SOP should be defined for this process to assist personnel in implementation without loss of efficiency. Creating an SOP for a proper and com- plete provision of information including completion of requisition forms and taking clinical photographs will help establish uniformity of photographic information to the dermatopathologist. Hard copies of photographs are not always neces- sary. Digital technology provides a variety of media to safely transmit images, including secure Internet con- nections and storage on compact discs and flash drives, to protect the confidentiality of patient photographic in- formation, usually considered personal health informa- tion. Data transfer between dermatologists and derma- topathologists can be optimized to maximize the quality of dermatopathology diagnosis. Melinda R. Mohr, MD S. H. Sathish Indika, MS Antoinette F. Hood, MD Alejandra Vivas, MD Robert S. Kirsner, MD, PhD (REPRINTED) ARCH DERMATOL/ VOL 146 (NO. 11), NOV 2010 WWW.ARCHDERMATOL.COM 1308 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 Author Affiliations: Department of Dermatology and Cu- taneous Surgery, University of Miami Miller School of Medicine, Miami, Florida. Correspondence: Dr Kirsner, Department of Dermatol- ogy and Cutaneous Surgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave, RMSB, Room 2023-A, Miami, FL 33136 (rkirsner@med.miami.edu). Financial Disclosure: None reported. 1. Kutzner H, Kempf W, Schärer L, Requena L. Optimizing dermatopathologic diagnosis with digital photography and internet: the significance of clinico- pathologic correlation [in German]. Hautarzt. 2007;58(9):760-768. 2. Fogelberg A, Ioffreda M, Helm KF. The utility of digital clinical photographs in dermatopathology. J Cutan Med Surg. 2004;8(2):116-121. Lentiginous Melanoma In Situ Treatment With Topical Imiquimod: Need for Individualized Regimens M elanoma in situ, lentiginous type (LM), is a pre-cursor lesion for invasive malignant mela-noma, lentiginous type (LMM). Already the most prevalent subtype of in situ melanoma, LM has been shown to be increasing in incidence.1 Currently, nonsur- gical patients with LM have no treatment alternative but irradiation and so must endure the associated adverse ef- fects of this treatment. In addition, recurrence following standard therapies is unacceptably high (8%-20%).2 For these reasons, a new effective therapy for LM that pro- vides local control, prevents progression to LMM, and de- creases morbidity and mortality is clinically desirable. Small studies have reported successful treatment of LM with imiquimod, 5%, cream. The present case series highlights 15 LM lesions in 14 patients treated with topi- cal imiquimod. Histologic tissue specimens obtained be- fore, during, and after treatment were evaluated to as- sist in directing patient management and in providing objective posttreatment histopathologic response. Methods. This study was approved by the Saint Louis Uni- versity institutional review board. After diagnostic bi- opsy, patients were offered surgical excision or treat- ment with topical imiquimod, 5%. The risks of each treatment were thoroughly discussed. Patients began imi- quimod therapy with topical application 5 to 7 times each week, and this regimen was altered based on clinical re- sponse. Patients kept a log of treatment days and were observed closely during treatment. Pretreatment and post- treatment assessments were performed histologically and clinically in all patients. Intratreatment 4-mm punch bi- opsy specimens were obtained in 6 of the 14 patients. Imi- quimod treatment was discontinued only after the tu- mor clinically resolved with no remaining inflammatory response and biopsy specimens showed no residual tu- mor histologically. Results. We report 15 LM lesions in 14 patients treated effectively with imiquimod, 5%, cream as determined by clinical and histopathologic assessment. The patient de- mographics, treatment applications, and histologic and clinical findings are summarized in the Table. Patients were treated over 12 to 20 weeks with a range of 47 to 106 treatment applications (average, 79.5). All patients agreed to posttreatment biopsies, and 6 of the 14 agreed to intratreatment biopsies. Biopsies were performed dur- Table. Patient Characteristics and Treatment Summary Patient No./ Sex/Age, y Lesion Location Type of Lesion Treatment Duration, d Findings of Intratreatment Histologic Evaluation Findings of Posttreatment Histologic Evaluation Clinical Posttreatment Follow-up, mo 1/F/82 Cheek New 65 NP Prominent basilar pigmentation and solar lentigo, at 2 and 13 mo, respectively 31 2/M/90 Cheek Recurrence 100 NP Postinflammatory hyperpigmentation, 2 mo 28 3/M/80 Cheek Recurrence 84 NP Dermal scar, actinic keratosis, 10 mo 30 4/M/59 Scalp Recurrence 62 NP Dermal fibrosis, 4 mo 21 5/M/82 Nose Recurrence 84 NP Dermal fibrosis, 2 mo 20 6/M/86 Neck New 106 Postinflammatory pigment alteration, 47 d Postinflammatory pigment alteration, 0 mo 21 7/M/77 Scalp New 60 NP Postinflammatory pigment alteration, 1 mo 14 8/F/71 Nose New 85 NP Solar lentigo, 12 mo 32 9/F/95 Cheek New 84 Lichenoid dermatitis, postinflammatory pigment alteration, 60 d Vacuolar interface dermatitis, PIPA, solar elastosis, 0, 2, and 4 mo, respectively 11 10/M/78 Cheek Recurrence 84 Lichenoid dermatitis, 71 d Solar elastosis, solar lentigo, 2 mo 6 11/F/70 Nose New lesion 47 Lichenoid dermatitis, 26 d Dermal lymphocytic infiltrate, 1 mo 1 12/F/71 Nose New 104 Melanoma in situ, junctional melanocytic proliferation, dense lichenoid infiltrate, 84 d Lichenoid dermatitis, 0 mo 0 13/M/65 Scalp New 48 NP Solar elastosis, actinic keratosis, 0 mo 21 14a/M/87 Neck New 100 Melanoma in situ, 40 d Solar elastosis, actinic keratosis, 0 mo 1 14b/M/87 Lateral canthus New 80 NP Solar elastosis, actinic keratosis, 0 mo 1 Abbreviations: NP, not performed; PIPA, postinflammatory pigment alteration. (REPRINTED) ARCH DERMATOL/ VOL 146 (NO. 11), NOV 2010 WWW.ARCHDERMATOL.COM 1309 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021