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McNeil AJ, Parks K, Liu X, Jiang B, Coco J, McCool K, Fabbri D, Duhaime EP, Dawant BM, Tkaczyk ER. Crowdsourcing Skin Demarcations of Chronic Graft-Versus-Host Disease in Patient Photographs: Training Versus Performance Study. JMIR DERMATOLOGY 2023; 6:e48589. [PMID: 38147369 PMCID: PMC10777279 DOI: 10.2196/48589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 10/02/2023] [Accepted: 10/24/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Chronic graft-versus-host disease (cGVHD) is a significant cause of long-term morbidity and mortality in patients after allogeneic hematopoietic cell transplantation. Skin is the most commonly affected organ, and visual assessment of cGVHD can have low reliability. Crowdsourcing data from nonexpert participants has been used for numerous medical applications, including image labeling and segmentation tasks. OBJECTIVE This study aimed to assess the ability of crowds of nonexpert raters-individuals without any prior training for identifying or marking cGHVD-to demarcate photos of cGVHD-affected skin. We also studied the effect of training and feedback on crowd performance. METHODS Using a Canfield Vectra H1 3D camera, 360 photographs of the skin of 36 patients with cGVHD were taken. Ground truth demarcations were provided in 3D by a trained expert and reviewed by a board-certified dermatologist. In total, 3000 2D images (projections from various angles) were created for crowd demarcation through the DiagnosUs mobile app. Raters were split into high and low feedback groups. The performances of 4 different crowds of nonexperts were analyzed, including 17 raters per image for the low and high feedback groups, 32-35 raters per image for the low feedback group, and the top 5 performers for each image from the low feedback group. RESULTS Across 8 demarcation competitions, 130 raters were recruited to the high feedback group and 161 to the low feedback group. This resulted in a total of 54,887 individual demarcations from the high feedback group and 78,967 from the low feedback group. The nonexpert crowds achieved good overall performance for segmenting cGVHD-affected skin with minimal training, achieving a median surface area error of less than 12% of skin pixels for all crowds in both the high and low feedback groups. The low feedback crowds performed slightly poorer than the high feedback crowd, even when a larger crowd was used. Tracking the 5 most reliable raters from the low feedback group for each image recovered a performance similar to that of the high feedback crowd. Higher variability between raters for a given image was not found to correlate with lower performance of the crowd consensus demarcation and cannot therefore be used as a measure of reliability. No significant learning was observed during the task as more photos and feedback were seen. CONCLUSIONS Crowds of nonexpert raters can demarcate cGVHD images with good overall performance. Tracking the top 5 most reliable raters provided optimal results, obtaining the best performance with the lowest number of expert demarcations required for adequate training. However, the agreement amongst individual nonexperts does not help predict whether the crowd has provided an accurate result. Future work should explore the performance of crowdsourcing in standard clinical photos and further methods to estimate the reliability of consensus demarcations.
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Affiliation(s)
- Andrew J McNeil
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, United States
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, United States
| | - Kelsey Parks
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Xiaoqi Liu
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, United States
| | - Bohan Jiang
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, United States
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, United States
| | - Joseph Coco
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nasvhille, TN, United States
| | | | - Daniel Fabbri
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nasvhille, TN, United States
| | | | - Benoit M Dawant
- Department of Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, United States
| | - Eric R Tkaczyk
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN, United States
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Electrical and Computer Engineering, Vanderbilt University, Nashville, TN, United States
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nasvhille, TN, United States
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Marks ME, Botta RK, Abe R, Beachkofsky TM, Boothman I, Carleton BC, Chung WH, Cibotti RR, Dodiuk-Gad RP, Grimstein C, Hasegawa A, Hoofnagle JH, Hung SI, Kaffenberger B, Kroshinsky D, Lehloenya RJ, Martin-Pozo M, Micheletti RG, Mockenhaupt M, Nagao K, Pakala S, Palubinsky A, Pasieka HB, Peter J, Pirmohamed M, Reyes M, Saeed HN, Shupp J, Sukasem C, Syu JY, Ueta M, Zhou L, Chang WC, Becker P, Bellon T, Bonnet K, Cavalleri G, Chodosh J, Dewan AK, Dominguez A, Dong X, Ezhkova E, Fuchs E, Goldman J, Himed S, Mallal S, Markova A, McCawley K, Norton AE, Ostrov D, Phan M, Sanford A, Schlundt D, Schneider D, Shear N, Shinkai K, Tkaczyk E, Trubiano JA, Volpi S, Bouchard CS, Divito SJ, Phillips EJ. Updates in SJS/TEN: collaboration, innovation, and community. Front Med (Lausanne) 2023; 10:1213889. [PMID: 37901413 PMCID: PMC10600400 DOI: 10.3389/fmed.2023.1213889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/31/2023] [Indexed: 10/31/2023] Open
Abstract
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a predominantly drug-induced disease, with a mortality rate of 15-20%, that engages the expertise of multiple disciplines: dermatology, allergy, immunology, clinical pharmacology, burn surgery, ophthalmology, urogynecology, and psychiatry. SJS/TEN has an incidence of 1-5/million persons per year in the United States, with even higher rates globally. One of the challenges of SJS/TEN has been developing the research infrastructure and coordination to answer questions capable of transforming clinical care and leading to improved patient outcomes. SJS/TEN 2021, the third research meeting of its kind, was held as a virtual meeting on August 28-29, 2021. The meeting brought together 428 international scientists, in addition to a community of 140 SJS/TEN survivors and family members. The goal of the meeting was to brainstorm strategies to support the continued growth of an international SJS/TEN research network, bridging science and the community. The community workshop section of the meeting focused on eight primary themes: mental health, eye care, SJS/TEN in children, non-drug induced SJS/TEN, long-term health complications, new advances in mechanisms and basic science, managing long-term scarring, considerations for skin of color, and COVID-19 vaccines. The meeting featured several important updates and identified areas of unmet research and clinical need that will be highlighted in this white paper.
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Affiliation(s)
- Madeline E. Marks
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ramya Krishna Botta
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Thomas M. Beachkofsky
- Departments of Dermatology and Medicine, Uniformed Services University, Bethesda, MD, United States
| | - Isabelle Boothman
- The SFI Centre for Research Training in Genomics Data Science, Dublin, Ireland
| | - Bruce C. Carleton
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia and the British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ricardo R. Cibotti
- National Institute of Arthritis and Musculoskeletal and Skin (NIAMS), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Roni P. Dodiuk-Gad
- Department of Dermatology, Emek Medical Center, Afula, Israel
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Dermatology, Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Christian Grimstein
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Akito Hasegawa
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Jay H. Hoofnagle
- Liver Disease Research Branch, Division of Digestive Diseases and Nutrition of NIDDK, National Institutes of Health (NIH), Bethesda, MD, United States
| | - Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Benjamin Kaffenberger
- Department of Dermatology, Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Daniela Kroshinsky
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rannakoe J. Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Michelle Martin-Pozo
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Robert G. Micheletti
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Keisuke Nagao
- National Institute of Arthritis and Musculoskeletal and Skin (NIAMS), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Suman Pakala
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Amy Palubinsky
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Helena B. Pasieka
- Departments of Dermatology and Medicine, Uniformed Services University, Bethesda, MD, United States
- The Burn Center, MedStar Washington Hospital Center, Washington, D.C., DC, United States
- Department of Dermatology, MedStar Health/Georgetown University, Washington, D.C., DC, United States
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Melissa Reyes
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, MD, United States
| | - Hajirah N. Saeed
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Jeffery Shupp
- Department of Surgery, Plastic and Reconstructive Surgery, Biochemistry, and Molecular and Cellular Biology, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, D.C., DC, United States
| | - Chonlaphat Sukasem
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jhih Yu Syu
- Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Mayumi Ueta
- Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Wan-Chun Chang
- Division of Translational Therapeutics, Department of Pediatrics, Faculty of Medicine, University of British Columbia and the British Columbia Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Patrice Becker
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Disease, Bethesda, MD, United States
| | - Teresa Bellon
- Drug Hypersensitivity Laboratory, La Paz Health Research Institute (IdiPAZ), Madrid, Spain
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
| | - Gianpiero Cavalleri
- The SFI Centre for Research Training in Genomics Data Science, Dublin, Ireland
| | - James Chodosh
- University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Anna K. Dewan
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Arturo Dominguez
- Department of Dermatology and Internal Medicine, UT Southwestern Medical Center, Dallas, TX, United States
| | - Xinzhong Dong
- Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Elena Ezhkova
- Department of Cell, Developmental, and Regenerative Biology and Dermatology, Black Family Stem Cell Institute, Mount Sinai School of Medicine, New York, NY, United States
| | - Esther Fuchs
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - Jennifer Goldman
- Division of Pediatric Infectious Diseases and Clinical Pharmacology, Children’s Mercy, Kansas City, MO, United States
| | - Sonia Himed
- College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Simon Mallal
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Alina Markova
- Department of Dermatology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, United States
| | - Kerry McCawley
- Stevens-Johnson Syndrome Foundation, Westminster, CO, United States
| | - Allison E. Norton
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David Ostrov
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, United States
| | - Michael Phan
- Division of Pharmacovigilance-I, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Arthur Sanford
- Division of Trauma, Surgical Critical Care, and Burns, Loyola University Medical Center, Chicago, IL, United States
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
| | - Daniel Schneider
- Department of Psychiatry and Surgery, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, D.C., DC, United States
| | - Neil Shear
- Department of Dermatology, Emek Medical Center, Afula, Israel
| | - Kanade Shinkai
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, United States
| | - Eric Tkaczyk
- Department of Veterans Affairs, Vanderbilt Dermatology Translational Research Clinic (VDTRC.org), Nashville, TN, United States
| | - Jason A. Trubiano
- Department of Infectious Diseases and Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Simona Volpi
- National Human Genome Research Institute (NHGRI), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Charles S. Bouchard
- Department of Opthalmology, Loyola University Medical Center, Chicago, IL, United States
| | - Sherrie J. Divito
- Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Elizabeth J. Phillips
- Center for Drug Interactions and Immunology, Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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Saknite I, Kwun S, Zhang K, Hood A, Chen F, Kangas L, Kortteisto P, Kukkonen A, Spigulis J, Tkaczyk ER. Hyperspectral imaging to accurately segment skin erythema and hyperpigmentation in cutaneous chronic graft-versus-host disease. JOURNAL OF BIOPHOTONICS 2023; 16:e202300009. [PMID: 36942511 DOI: 10.1002/jbio.202300009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 06/18/2023]
Abstract
In 51 lesions from 15 patients with the inflammatory skin condition chronic graft-versus-host-disease, hyperspectral imaging accurately delineated active erythema and post-inflammatory hyperpigmentation. The method was validated by dermatologist-approved confident delineations of only definitely affected and definitely unaffected areas in photographs. A prototype hyperspectral imaging system acquired a 2.5 × 3.5 cm2 area of skin at 120 wavelengths in the 450-850 nm range. Unsupervised extraction of unknown absorbers by endmember analysis achieved a comparable accuracy to that of supervised extraction of known absorbers (melanin, hemoglobin) by chromophore mapping: 0.78 (IQR: 0.39-0.85) vs. 0.83 (0.53-0.91) to delineate erythema and 0.74 (0.57-0.87) vs. 0.73 (0.52-0.84) to delineate hyperpigmentation. Both algorithms achieved higher specificity than sensitivity. Whereas a trained human confidently marked a median of 7% of image pixels, unsupervised and supervised algorithms delineated a median of 14% and 27% pixels. Hyperspectral imaging could overcome a fundamental practice gap of distinguishing active from inactive manifestations of inflammatory skin disease.
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Affiliation(s)
- Inga Saknite
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Riga, Latvia
| | - Shinwho Kwun
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathy Zhang
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexis Hood
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Fuyao Chen
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | - Janis Spigulis
- Biophotonics Laboratory, Institute of Atomic Physics and Spectroscopy, University of Latvia, Riga, Latvia
| | - Eric R Tkaczyk
- Vanderbilt Dermatology Translational Research Clinic, Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
- Dermatology Service and Research Service, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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Lovis C, Weber J, Liopyris K, Braun RP, Marghoob AA, Quigley EA, Nelson K, Prentice K, Duhaime E, Halpern AC, Rotemberg V. Agreement Between Experts and an Untrained Crowd for Identifying Dermoscopic Features Using a Gamified App: Reader Feasibility Study. JMIR Med Inform 2023; 11:e38412. [PMID: 36652282 PMCID: PMC9892985 DOI: 10.2196/38412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/28/2022] [Accepted: 10/16/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Dermoscopy is commonly used for the evaluation of pigmented lesions, but agreement between experts for identification of dermoscopic structures is known to be relatively poor. Expert labeling of medical data is a bottleneck in the development of machine learning (ML) tools, and crowdsourcing has been demonstrated as a cost- and time-efficient method for the annotation of medical images. OBJECTIVE The aim of this study is to demonstrate that crowdsourcing can be used to label basic dermoscopic structures from images of pigmented lesions with similar reliability to a group of experts. METHODS First, we obtained labels of 248 images of melanocytic lesions with 31 dermoscopic "subfeatures" labeled by 20 dermoscopy experts. These were then collapsed into 6 dermoscopic "superfeatures" based on structural similarity, due to low interrater reliability (IRR): dots, globules, lines, network structures, regression structures, and vessels. These images were then used as the gold standard for the crowd study. The commercial platform DiagnosUs was used to obtain annotations from a nonexpert crowd for the presence or absence of the 6 superfeatures in each of the 248 images. We replicated this methodology with a group of 7 dermatologists to allow direct comparison with the nonexpert crowd. The Cohen κ value was used to measure agreement across raters. RESULTS In total, we obtained 139,731 ratings of the 6 dermoscopic superfeatures from the crowd. There was relatively lower agreement for the identification of dots and globules (the median κ values were 0.526 and 0.395, respectively), whereas network structures and vessels showed the highest agreement (the median κ values were 0.581 and 0.798, respectively). This pattern was also seen among the expert raters, who had median κ values of 0.483 and 0.517 for dots and globules, respectively, and 0.758 and 0.790 for network structures and vessels. The median κ values between nonexperts and thresholded average-expert readers were 0.709 for dots, 0.719 for globules, 0.714 for lines, 0.838 for network structures, 0.818 for regression structures, and 0.728 for vessels. CONCLUSIONS This study confirmed that IRR for different dermoscopic features varied among a group of experts; a similar pattern was observed in a nonexpert crowd. There was good or excellent agreement for each of the 6 superfeatures between the crowd and the experts, highlighting the similar reliability of the crowd for labeling dermoscopic images. This confirms the feasibility and dependability of using crowdsourcing as a scalable solution to annotate large sets of dermoscopic images, with several potential clinical and educational applications, including the development of novel, explainable ML tools.
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Affiliation(s)
| | - Jochen Weber
- Dermatology Section, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Konstantinos Liopyris
- Department of Dermatology, Andreas Syggros Hospital of Cutaneous and Venereal Diseases, University of Athens, Athens, Greece
| | - Ralph P Braun
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
| | - Ashfaq A Marghoob
- Dermatology Section, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Elizabeth A Quigley
- Dermatology Section, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kelly Nelson
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | | | - Allan C Halpern
- Dermatology Section, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Veronica Rotemberg
- Dermatology Section, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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