Cambio espontáneo en un nevus melanocítico común / Spontaneous Change in a Common Melanocytic Nevus

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Fiabilidad de la teledermatología de almacenamiento en un escenario real / Interobserver Reliability of Store-and-Forward Teledermatology in a Clinical Practice Setting

INTRODUCCIÓN Y OBJETIVOS: Aunque existen múltiples estudios de fiabilidad diagnóstica en teledermatología de almacenamiento (TDA), aún no se ha demostrado una fiabilidad elevada para enfermedad general cutánea en un escenario real. DERMATEL-2 fue un estudio aleatorizado de concordancia diagnóstica en TDA en condiciones de práctica clínica. MATERIAL Y MÉTODOS: Pacientes remitidos desde atención primaria fueron aleatorizados en 3 grupos: TDA; híbrida videoconferencia-almacenamiento (VC-TDA) y grupo control (GC). Este artículo se centra en el grupo de almacenamiento. Médicos de atención primaria tomaron datos y fotografías clínicas remitiéndolas a distancia. Cada consulta de TDA fue evaluada por 3 dermatólogos diferentes (D1, D2, D3). Todos los pacientes fueron finalmente vistos por el mismo dermatólogo (D1) en la consulta presencial (CP). Dos dermatólogos adicionales (D4, D5) evaluaron las concordancias TDA-CP. RESULTADOS: Se aleatorizaron un total de 457 pacientes 4-4-2: 192 TDA, 176 VC-TDA y 89 GC; 200 varones y 257 mujeres, 0-86 años. Se incuyó enfermedad tumoral (49,4%), inflamatoria (25,7%), anexial (11%), infecciosa (9,4%) y otros (4,4%). Hubo 170 pacientes de TDA válidos para el análisis, rindiendo 510 teleconsultas-TDA. La imagen (71,2%), la historia clínica (91,2%) y la confianza diagnóstica (81,4%) fueron de calidad alta. En el 58,4% fue posible el manejo exclusivo on-line. Los acuerdos interobservador (completo/agregado) TDA-CP fueron 0,72/0,90 para el diagnóstico y 0,61/0,80 en el tratamiento. El acuerdo diagnóstico se correlacionó con la calidad de la imagen (p < 0,001), la confianza diagnóstica (p < 0,001), la necesidad de consulta presencial (p < 0,001) y la calidad de la historia clínica (p = 0,013). CONCLUSIÓN: La fiabilidad diagnóstica de la TDA en condiciones de práctica clínica es elevada. Los dermatólogos pueden predecir errores diagnósticos analizando su confianza diagnóstica y la calidad de las fotografías

INTRODUCTION AND OBJECTIVES: Although many studies have evaluated the diagnostic reliability of store-and-forward (SF) teledermatology, the reliability of the technique for the diagnosis of general skin conditions in a clinical practice setting has never been demonstrated. We evaluated the reliability of SF teledermatology in clinical practice by analyzing the diagnostic agreement achieved in a subgroup of patients from the DERMATEL-2 study. MATERIAL AND METHODS: Patients referred from primary care settings were randomized to 3 groups: SF, a combination of videoconferencing and SF technology (VC-SF), and a control group. This article focuses on the SF group. Clinical data were recorded and photographs taken by primary care physicians, who forwarded the data digitally. Each SF consultation package was assessed by 3 dermatologists (D1, D2, D3). Subsequently all the patients were assessed by a single dermatologist (D1) in a face-to-face (FF) consultation. Finally, 2 other dermatologists (D4,D5) assessed the agreement between the diagnoses obtained by SF and FF. RESULTS: In total, 457 patients (200 males and 257 females) aged between 2 months and 86 years were randomized (192 to SF, 176 to VC-SF, and 89 to the control group). The diagnostic categories were as follows: tumors (49.4%), inflammatory (25.7%), adnexal (11%), infectious (9.4%) and other processes (4.4%). Since 170 patients had SF consultations deemed valid for analysis, the study included a total of 510 SF assessments. Most of the images and clinical records were of high quality (71.2% and 91.2% respectively), and diagnostic confidence was high in 81.4% of the cases studied. In 58.4% of cases the condition was managed exclusively by teledermatology. Levels of complete and aggregate interobserver agreement between SF and FF evaluators were 0.72 and 0.90, respectively, for diagnosis and 0.61 and 0.80 for treatment. Diagnostic agreement correlated with the image quality (P < 0.001), diagnostic confidence (P < 0.001), felt need for conventional consultation (P < .001), and the quality of the clinical record (P = 0.013). CONCLUSION: The interobserver reliability of SF diagnosis in clinical practice is good. Dermatologists are able to predict errors in diagnosis by analyzing their own diagnostic confidence and evaluating the quality of the images

Interobserver reliability of store-and-forward teledermatology in a clinical practice setting.

INTRODUCTION AND OBJECTIVES: Although many studies have evaluated the diagnostic reliability of store-and-forward (SF) teledermatology, the reliability of the technique for the diagnosis of general skin conditions in a clinical practice setting has never been demonstrated. We evaluated the reliability of SF teledermatology in clinical practice by analyzing the diagnostic agreement achieved in a subgroup of patients from the DERMATEL-2 study. MATERIAL AND METHODS: Patients referred from primary care settings were randomized to 3 groups: SF, a combination of videoconferencing and SF technology (VC-SF), and a control group. This article focuses on the SF group. Clinical data were recorded and photographs taken by primary care physicians, who forwarded the data electronically. Each SF consultation package was assessed by 3 dermatologists (D1,D2,D3). Subsequently all the patients were assessed by a single dermatologist (D1) in a face-to-face consultation. Finally, 2 other dermatologists (D4,D5) assessed the agreement between the diagnoses obtained by SF and FF. RESULTS: In total, 457 patients (200 males and 257 females) aged between 2 months and 86 years were randomized (192 to SF, 176 to VC-SF, and 89 to the control group). The diagnostic categories were as follows: tumors (49.4%), inflammatory (25.7%), adnexal (11%), infectious (9.4%) and other processes (4.4%) Since 170 patients had consultations deemed valid for analysis, the study included a total of 510 SF assessments. Most of the images and clinical records were of high quality (71.2% and 91.2% respectively), and diagnostic confidence was high in 81.4% of the cases studied. In 58.4% of cases the condition was managed exclusively by teledermatology. Levels of complete and aggregate interobserver agreement between SF and face-to-face evaluators were 0,72 and 0.90, respectively, for diagnosis and 0.61 and 0.80 for treatment. Diagnostic agreement correlated with the image quality (P < .001), diagnostic confidence (P<.001), felt need for conventional consultation (P<.001), and the quality of the clinical record (P=.013). CONCLUSION: The interobserver reliability of SF diagnosis in clinical practice is good. Dermatologists are able to predict errors in diagnosis by analyzing their own diagnostic confidence and evaluating the quality of the images.

Pilomatrixomas múltiples / Multiple pilomatricomas

El pilomatrixoma es un tumor benigno, relativamente frecuente, que deriva de las células de la matriz del pelo. En general aparece en la infancia comoun nódulo duro localizado en la cabeza y cuello. Suelen estar cubiertos por una superficie epidérmica normal pero en ocasiones es anetodérmica. Lamayoría de los pilomatrixomas son solitarios y raramente aparecen como lesiones múltiples. La presencia de pilomatrixomas múltiples puede ser esporádica,familiar o asociarse a enfermedades de las cuales solo está bien documentado con la enfermedad de Steinert. Presentamos un nuevo caso depilomatrixomas múltiples esporádicos, siendo uno de ellos anetodérmico y revisamos la literatura (AU)

Pilomatricoma is a relatively common benign neoplasm of hair matrix cells, which typically presents as a firm skin-colored nodule on the head and neckin young people. Sometimes the overlying skin may be anetodermic. While most lesions are solitary, multiple pilomatricomas may be present. Multiplepilomatricoma may be sporadic, familial o associated to myotonic dystrophy. The association of multiple pilomatricomas with myotonic dystrophy iswell documented. We report a case of multiple and sporadic pilomatricomas, being one of them anetodermic and review literature (AU)

Encías “en fresa” como manifestación inicial de enfermedad de Wegener / “Strawberry” gingiva as first manifestation of Wegener’s granulomatosisn

La enfermedad de Wegener se define como una vasculitis sistémica necrotizante granulomatosa, que afecta predominantemente al tracto respiratoriosuperior e inferior y al riñón aunque al inicio esta triada no siempre está presente. Presentamos el caso de una paciente con encías “en fresa” comomanifestación inicial. Este tipo de afectación oral es muy rara y clínicamente se caracteriza por el aspecto granular y friable de la encía afecta. El conocimientode esta infrecuente pero característica manifestación precoz del Wegener es importante para hacer un diagnóstico precoz e instaurar tratamientolo antes posible (AU)

Wegener’s granulomatosis is a systemic necrotizing and granulomatous vasculitis that predominantly affects the upper and lower respiratory tract andkidneys. Sometimes this classic triad is not present initially. We report a patient with “strawberry” gingiva as first sign of Wegener. It is characterized byan exophytic hyperplasia and friable and granular appearence. The recognition of this uncommon but characteristic sign would help in early diagnosisand treatment (AU)

Síndrome trófico del trigémino / Trigeminal trophic syndrome

El síndrome trófico del trigémino es una entidad rara, en la que se desarrollan úlceras tróficas en el territorio del trigémino como consecuencia de lalesión de dicho nervio. Los pacientes refieren de forma constante parestesias y manipulación repetida en las áreas afectas. El síndrome trófico del trigéminodebe ser incluido en el diagnóstico diferencial de las úlceras crónicas de la cara y cuero cabelludo, fundamentalmente cuando son unilaterales yasintomáticas. Presentamos un caso de STT secundario a un neurinoma del acústico (AU)

Trigeminal trophic syndrome is a rare entity in which cutaneous trophic ulcers develop in trigeminal area after a damage to this nerve. The majority ofpatients report paraesthesias and repetitive manipulation in the trigeminal area. It should be considerated in patients with chronic nonhealing ulcersof the face and scalp, specially when are unilateral and painless. We report a case of TTS following an acoustic neuroma (AU)

Hiperplasia epitelial focal / Focal epithelial hyperplasia

La hiperplasia epitelial focal es una enfermedad poco frecuente de la mucosa oral producida por el virus del papiloma humano. Aparece una proliferación epitelial benigna de predominio en la mucosa del labio inferior. Se asocia fundamentalmente a los serotipos 13 y 32 y existe un claro predominio racial, en indios americanos y esquimales. Presentamos el caso de una chica de 17 años ecuatoriana, con múltiples lesiones papulosas en labio inferior y superior compatibles clínica e histológicamente con hiperplasia epitelial focal. En el estudio por reacción en cadena de la polimerasa se detectó el virus del papiloma humano serotipo 13

Focal epithelial hyperplasia is a rare disease of the oral mucosa caused by the human papilloma virus (HPV). It appears as a benign epithelial growth, usually in the mucosa of the lower lip. It is mainly associated with HPV serotypes 13 and 32 and there is a clear racial predilection for the disease in Native Americans and Eskimos. We describe the case of a 17-year-old girl from Ecuador with multiple papular lesions in both lips that were clinically and histologically consistent with focal epithelial hyperplasia. Analysis by polymerase chain reaction detected HPV serotype 13

[Focal epithelial hyperplasia]. / Hiperplasia epitelial focal.

Focal epithelial hyperplasia is a rare disease of the oral mucosa caused by the human papilloma virus (HPV). It appears as a benign epithelial growth, usually in the mucosa of the lower lip. It is mainly associated with HPV serotypes 13 and 32 and there is a clear racial predilection for the disease in Native Americans and Eskimos. We describe the case of a 17-year-old girl from Ecuador with multiple papular lesions in both lips that were clinically and histologically consistent with focal epithelial hyperplasia. Analysis by polymerase chain reaction detected HPV serotype 13.

Tiña inflamatoria de la cabeza / Inflammatory tinea capitis

La tiña de la cabeza es un cuadro infeccioso relativamente frecuente, con manifestaciones clínicas muy variadas, lo que conlleva que, en ocasiones, su diagnóstico se retrase. Presentamos el caso de una niña de 4 años con una tiña inflamatoria, de localización interparietal y de un mes de evolución, que fue diagnosticada y tratada previamente de abscesos múltiples de cuero cabelludo. El diagnóstico de tiña inflamatoria de la cabeza tipo querion de Celso y su confirmación mediante visión directa es fácil. si tenemos en cuenta este cuadro y los antecedentes epidemiológicos (contacto con animales entre otros). Es importante establecer un diagnóstico precoz para iniciar cuanto antes el tratamiento oportuno y así evitar una alopecia cicatricial residual inestética secundaria al proceso inflamatorio

Tinea capitis is a relatively common fungal infection with highly variable clinical manifestations, a circumstance that can delay its diagnosis. We present the case of a 4-year-old girl with an interparietal inflammatory lesion that had developed one month earlier. She had initially been diagnosed with and treated for multiple scalp abscesses. Inflammatory tinea capitis (kerion celsi) is frequently misdiagnosed; nevertheless, its diagnosis on the basis of direct visual inspection is easy when there is a high degree of suspicion and knowledge of the epidemiological background (prior contact with animals, among others). The microscopic examination and culture of samples obtained from the scalp are rapid and simple diagnostic procedures. Early diagnosis and prompt initiation of the proper treatment are essential to prevent scarring alopecia secondary to the inflammatory process

Dermatitis granulomatosa periorificial infantil / Childhood granulomatous periorificial dermatitis

La dermatitis granulomatosa periorificial infantil (DGPI) es un cuadro exclusivamente cutáneo, benigno y poco frecuente. Aparece en niños en edad prepuberal, y es más frecuente en la raza negra. Clínicamente, se caracteriza por la presencia de pápulas asintomáticas alrededor de la boca, los párpados y la nariz. En la biopsia se observan granulomas perifoliculares y los cultivos microbiológicos son negativos. Aunque las lesiones se resuelven de forma espontánea en unos meses, el tratamiento con antibióticos orales o tópicos puede acelerar la curación. Esta enfermedad puede considerarse una variante de la dermatitis perioral. Desde el punto de vista práctico, es importante descartar una sarcoidosis o una infección (AU)

Púrpura anular telangiectásica de Majocchi infantil / Childhood purpura annularis telangiectodes ( Majocchi's disease)

Las enfermedades denominadas púrpuras pigmentarias crónicas, entre las que se encuentra la púrpura anular telangiectásica de Majocchi, son un grupo de enfermedades crónicas, inocuas y rebeldes al tratamiento. Normalmente, aparecen entre la cuarta y la séptima décadas de la vida, y son infrecuentes en la infancia. Presentamos el caso de una niña de 13 años de edad con lesiones generalizadas, que afectan incluso la cara, compatibles con el diagnóstico de púrpura anular telangiectásica de Majocchi. Destaca la buena respuesta de las lesiones al tratamiento con furoato de monometasona tópico y ácido ascórbico oral (AU)

Phenytoin hypersensitivity syndrome with positive patch test. A possible cross-reactivity with amitriptyline.

A 34-year-old woman, after 2 weeks of treatment with phenytoin and amitriptyline, developed fever and cutaneous lesions consisting of a generalized maculopapular rash and eosinophilia. Her biochemical data showed abnormal liver functions with increased levels of SGOT, SGPT, LDH, gamma-glutamyl transpeptidase and alkaline phosphatase. The skin biopsy pattern was compatible with phenytoin drug eruption of the erythemamultiforme-like type (lymphocytic exocytosis, isolated dyskeratotic cells, vacuolation of basal cells and incontinence of pigment). The patch tests were positive with phenytoin (patch test biopsy showed a typical eczematous pattern). The patch test with amitriptyline was negative. An oral challenge with amitriptyline showed an erythematous maculopapular rash. The challenge with phenytoin was not carried out because the previously abnormal liver function tests contraindicated the challenge. Although there are a few cases reported, the patch tests could be useful for diagnosing phenytoin allergy. Cross-reactivity between phenytoin and amitriptyline is possible.