Dermatoscopic Patterns in Vitiligo.

Vitiligo is a chronic, acquired autoimmune pigmentary skin disease, most times it can be diagnosed clinically. Dermoscopy can confirm vitiligo in a non-invasive way. It is a diagnostic technique that visualizes sub-macroscopic morphological structures which correspond with specific histological structures. It detects subtle changes in the pigment pattern, evaluates vitiligo activity, attempts of re-pigmentation, leucotrichia, and differentiates it from other hypo pigmentary disorders. Most dermatoscopic clues used to assess vitiligo activity are found at the perifollicular level in the center and edge of the lesion. Perifollicular pigmentation is present in both active lesions and treated pigmented lesions with treatment. However, perifollicular depigmentation represents poor response, in treated lesions, and poor prognosis in untreated ones. The center of the lesion has reduced and/or absent pigment network, in active and stable lesions. If on dermoscopy the center of the lesion shows islands of pigment, erythema, or telangiectasias, re-pigmentation is suggested. At the periphery of the lesion, unstable vitiligo usually shows up as a diffuse border, trichrome pattern, micro-Koebner/comet tail phenomenon, satellite lesions, or a tapioca sago pattern. In stable lesions it is more frequent to find well defined or trichromic border. Pigmented lesions commonly present sharp borders and marginal or perilesional hyperpigmentation.

Dermatoscopic Patterns in Childhood Vitiligo and Their Association With Reflectance Confocal Microscopy Findings.

INTRODUCTION: The diagnosis of vitiligo is mainly based on clinical findings. However, dermoscopy or reflectance confocal microscopy (RCM) could be useful for assessing its progression (stability, pigmen-tation, or depigmentation). OBJECTIVES: To evaluate the correlation of dermatological findings by dermoscopy and RCM in pediatric vitiligo. METHODS: We conducted a cross-sectional, descriptive, and analytical clinical study. Pediatric patients with vitiligo of both sexes, aged > 1 year and < 18 years, with all spectrums of the disease were includ-ed. Vitiligo lesions were evaluated clinically, by dermoscopy, and microscopy. RESULTS: A total of 40 patients with vitiligo were included. Eight dermoscopic patterns were found: reduced/absent pigment network, perifollicular pigmentation, trichromic, tapioca sago, perifollicular depigmentation, starburst, leukotrichia, and erythema. Skin with a normal pigment network showed complete dermal papillary rings and half-rings. Skin with reduced/absent pigment network also had an absence of papillary rings or only showed half-rings and was more common in unstable vitiligo. The trichrome pattern only showed half-rings. The Tapioca sago pattern showed complete papillary rings and appeared in younger patients. Perifollicular pigmentation showed half-rings and complete rings and did not show associations. The diffuse borders did not present complete papillary structures. It was found that vitiligo duration time of fewer than 24 months (Odds Ratio 4.56, CI 1.09-18.99) and absent papillary rings (OR 2.75, CI 1.01-7.51) are associated with unstable prognosis. CONCLUSIONS: Certain dermatoscopic and microscopic findings, such as the reduction/absence of the pigment network, tapioca sago pattern, and absence of papillary rings, can be used to assess the stabil-ity of the disease and provide insight into the clinical behaviour of vitiligo.

Human leukocyte antigen Class II alleles associated with acral lentiginous melanoma in Mexican Mestizo patients: A case-control study.

Background Melanoma is an aggressive cutaneous cancer. Acral lentiginous melanoma is a melanoma subtype arising on palms, soles, and nail-units. The incidence, prevalence and prognosis differ among populations. The link between expression of major histocompatibility complex Class II alleles and melanoma progression is known. However, available studies report variable results regarding the association of melanoma with specific HLA Class II loci. Aims The aim of the study was to determine HLA Class II allele frequencies in acral lentiginous melanoma patients and healthy Mexican Mestizo individuals. Methods Eighteen patients with acral lentiginous melanoma and 99 healthy controls were recruited. HLA Class II typing was performed based on the sequence-specific oligonucleotide method. Results Three alleles were associated with increased susceptibility to develop acral lentiginous melanoma, namely: HLA-DRB1*13:01; pC = 0.02, odds ratio = 6.1, IC95% = 1.4-25.5, HLA-DQA1*01:03; pC = 0.001, odds ratio = 9.3, IC95% = 2.7-31.3 and HLA-DQB1*02:02; pC = 0.01, odds ratio = 3.7, IC95% = 1.4-10.3. Limitations The small sample size was a major limitation, although it included all acral lentiginous melanoma patients seen at the dermatology department of Dr. Manuel Gea González General Hospital during the study period. Conclusion HLA-DRB1*13:01, HLA-DQB1*02:02 and HLA-DQA*01:03 alleles are associated with increased susceptibility to develop acral lentiginous melanoma in Mexican Mestizo patients.

Acral lentiginous melanoma: Basic facts, biological characteristics and research perspectives of an understudied disease.

Acral lentiginous melanoma is a histological subtype of cutaneous melanoma that occurs in the glabrous skin of the palms, soles and the nail unit. Although in some countries, particularly in Latin America, Africa and Asia, it represents the most frequently diagnosed subtype of the disease, it only represents a small proportion of melanoma cases in European-descent populations, which is partially why it has not been studied to the same extent as other forms of melanoma. As a result, its unique genomic drivers remain comparatively poorly explored, as well as its causes, with current evidence supporting a UV-independent path to tumorigenesis. In this review, we discuss current knowledge of the aetiology and diagnostic criteria of acral lentiginous melanoma, as well as its epidemiological and histopathological characteristics. We also describe what is known about the genomic landscape of this disease and review the available biological models to explore potential therapeutic targets.

Noninvasive Imaging Tools in the Diagnosis and Treatment of Skin Cancers.

In the 1980s, the increasing incidence of skin cancers prompted the development of noninvasive medical devices to improve skin cancer diagnosis in daily dermatology practice. As a result of the development of these noninvasive techniques, diagnosis is now established earlier and with better accuracy. These advances are of great benefit to high-risk patients, who previously would have had to undergo several excisions. In this review, we focus on the classic technique of dermoscopy and the more recent digital version, as well as on advanced noninvasive imaging techniques, such as reflectance confocal microscopy and optical coherence tomography. On the basis of their specific features, these noninvasive medical devices can be used not only to diagnose and monitor melanoma and nonmelanoma skin cancers but also to choose the best therapy and follow the patient's response to treatment in vivo.

Melanoma: a global perspective.

Most of our current knowledge of melanoma is derived from the study of patients from populations of European descent, for whom public health, sun protection initiatives and screening measures have appreciably decreased disease mortality. Notably, some melanoma subtypes that most commonly develop in other populations are not associated with exposure to ultraviolet (UV) light, suggesting a different disease aetiology. Further study of these subtypes is necessary to understand their risk factors and genomic architecture, and to tailor therapies and public health campaigns to benefit patients of all ethnic groups.

Cutaneous malakoplakia masquerading as pyoderma gangrenosum.

Cutaneous malakoplakia is a rare infection-related granulomatous disease frequently associated with immunocompromised states. Foamy macrophages containing basophilic granules, called the Michaelis-Gutman bodies, are pathognomonic. We report a case of cutaneous malakoplakia in a 77-year-old male with pyoderma gangrenosum and a 2-year history of a non-healing malleolar ulcer treated successfully with cotrimoxazole.

Low-Dose 0.5% 5-Fluorouracil/10% Salicylic Acid Topical Solution in the Treatment of Actinic Keratoses.

BACKGROUND: Actinic keratosis (AK) lesions have the potential to develop into invasive squamous cell carcinomas (SCCs), and approaches to treatment are evolving to try to reduce the burden of SCC. OBJECTIVE: To present the published clinical research surrounding the use of 0.5% 5-fluorouracil with 10% salicylic acid (low-dose 5-FU/SA) for the treatment of hyperkeratotic AKs. METHOD: A review of published clinical evidence for low-dose 5-FU/SA for the treatment of AKs. The articles were selected following a MEDLINE database search of the combined terms fluorouracil, salicylic acid and actinic keratosis which represent the peer review publications of clinical studies that primarily investigate the use of Actikerall in AK. RESULTS: Combining low-dose 5-FU with keratolytic SA is associated with high rates of histologic clearance, reduction in lesion number/area, and sustained clinical response in clinical study and the clinical practice setting. Low-dose 5-FU/SA has also been evaluated using imaging to detect the progression of subclinical AK lesions through a course of the field-directed treatment. CONCLUSION: Low-dose 5-FU/SA is an effective and well-tolerated treatment option licensed for the lesion-directed treatment of mild-to-moderate hyperkeratotic AK lesions.

Atypical dermoscopic presentation of an acral congenital melanocytic nevus in an adult: parallel ridge pattern and its histologic correlation.

Acral melanoma is the most frequent subtype in the Asian and Mexican mestizo populations. Dermoscopy is a noninvasive diagnostic technique that helps the differential diagnosis of pigmented skin lesions on acral volar skin. We, herein, present a case of acral congenital melanocytic nevus with a parallel ridge dermoscopic pattern. Since the parallel ridge pattern in a melanocytic lesion of the acral skin is classically ascribed to melanoma, the present case can be definitely labeled as "atypical" and worth of being elucidated in its histopathological correlates.

Imiquimod 5% as Adjuvant Therapy for Incompletely Excised Infiltrative Nodular Basal Cell Carcinoma and Dermoscopy to Monitor Treatment Response.

INTRODUCTION: A relatively novel application for dermoscopy is its use in the monitoring of topical treatment response for non-melanoma skin cancer. Basal cell carcinoma (BCC) is the most frequent type of skin cancer in humans. Surgical excision is still considered the "gold-standard" of treatment. However, a number of topical therapies are now available for the treatment of different types of basal cell carcinoma. CASE REPORT: This case report exemplifies the usefulness of dermoscopy in the monitoring of residual disease after incomplete surgical excision and also in the monitoring of topical treatment response. Imiquimod 5% cream acts as a topical immune response modifier promoting a Th-1 immune response enhancing the removal of neoplastic cells and has proven to reduce deregulated Hedgehog (HH)/GLI signal strength independent of Toll-like receptor signaling, which makes it a valuable adjuvant topical therapy for the treatment of basal cell carcinoma. CONCLUSION: Imiquimod 5% cream is a valuable adjuvant therapy for the treatment of incompletely excised BCC. This case report adds further evidence to the usefulness of dermoscopy in the assessment and monitoring of treatment outcome.

Dermoscopic patterns in patients with a clinical diagnosis of onychomycosis-results of a prospective study including data of potassium hydroxide (KOH) and culture examination.

BACKGROUND: Onychomycosis is the most common nail disease, representing 50% of cases affecting the nail apparatus. The diagnosis is made by clinical examination along with the KOH exam of the nail and culture of the sample. However, not all dermatologists have access to a mycology lab. OBJECTIVE: To determine the correlation between KOH examination and dermoscopic patterns in patients with clinical diagnosis of onychomycosis. PATIENTS/METHODS: A descriptive, open, observational, prospective, cross-sectional study of 178 patients with clinical suspicion of onychomycosis was conducted. All patients underwent clinical examination, dermoscopy with a DermLite PHOTO dermatoscope (3Gen, San Juan Capistrano, CA, USA), KOH assessment and culture analysis. The most frequent dermoscopic patterns were identified and their correlation with the clinical subtype of onychomycosis was analyzed. RESULTS: The study included 178 patients with clinical suspicion of onychomycosis. Of these, 155 (87.1%) had positive direct KOH examination for onychomycosis. Eighty-seven patients (56.13%) presented with clinical onychomycosis pattern of total dystrophic onychomycosis (TDO), 67 (43.23%) with distal lateral subungual onychomycosis (DLSO), 1 (0.65%) with trachyonychia). Dermoscopic patterns of onychomycosis showed the following frequencies: the spiked pattern was present in 22 patients (14.19%), longitudinal striae pattern in 51 patients (32.9%) and linear edge pattern in 21 patients (13.55%). We identified a pattern described as "distal irregular termination" in 41 patients with TDO and 26 with DLSO. CONCLUSIONS: This is the fist study conducted in a Mexican population that uses dermoscopy as a diagnostic tool along with the KOH examination for the diagnosis of onychomycosis. Dermoscopy may be used as an important diagnostic tool when evaluating nail disease. However, it should not be used as the only diagnostic criteria for onychomycosis.

Melanoma incidence increases in the elderly of Catalonia but not in the younger population: effect of prevention or consequence of immigration?

All cases of MM diagnosed in 23 hospitals in Catalonia, from 2000 to 2007 were recorded and melanoma incidence calculated and adjusted for the European standard population via the direct method. The age standardised rate/100,000 inhabitants varied from 6.74 in 2000 to 8.64 in 2007 for all melanomas and from 4.79 to 5.80 for invasive MMs; the Breslow thickness was stable during the period. The increase in invasive melanoma incidence in the elderly was remarkable, the crude rate/100,000 inhabitants increasing from 11.04 (2000) to 15.49 (2007) in the 60-64 year population, while remaining more stable in the 30-34 year range, from 3.97 in 2000 to 4.55 in 2007, and with a tendency to decrease from 5.1 in 2000 to 2.5 in 2007 for the age range of 25-29 years. These lower age ranges are much more affected by immigration. Despite the large immigrant population (nearly one million immigrants arrived in Catalonia during the study period from countries with a low melanoma incidence), melanoma incidence in our region has risen considerably and this trend is likely to persist in the near future.

Monitoring treatment of field cancerisation with 3% diclofenac sodium 2.5% hyaluronic acid by reflectance confocal microscopy: a histologic correlation.

Visual inspection may fail to accurately evaluate field cancerisation (subclinical actinic keratoses [AKs]). We aimed to describe field cancerisation by confocal reflectance microscopy and changes induced by the application of 3% diclofenac sodium gel in 2.5% hyaluronic acid. Fourteen male patients, > 50 years old, with AKs on the bald scalp were included. Clinical examination, confocal microscopy and histological study of clinically visible lesions and "normal appearing" adjacent skin before and after treatment was completed. Reflectance confocal microscopy showed a decrease in scaling (p = 0.001) and atypia of the honeycomb pattern (p = 0.001) at 2 weeks of treatment. Changes in parakeratosis, inflammation and dermal collagen remodelling were also observed. Histology correlated with confocal features in AK and subclinical AK. Reflectance confocal microscopy was useful in the evaluation of field cancerisation and monitoring of treatment response. A rapid improvement in epidermal atypia was observed.

Infundibulocystic basal cell carcinoma: dermoscopic findings and histologic correlation.

UNLABELLED: Infundibulocystic basal cell carcinoma is a rare variant. It was first described in 1987 and proposed as a new basal cell carcinoma (BCC) subtype by Ackerman and Walsh in 1990. Dermoscopy is a noninvasive diagnostic technique that allows prompt identification of many types of BCC. However, dermoscopic findings for the infundibulocystic variant have not been reported. In our patient the dermoscopic findings were maple leaf-like areas in the periphery of the tumor, multiple scattered blue-gray dots and globules, short, fine telangiectasia and chrysalis or white-shiny streaks. All these structures had an underlying anatomopathological correlation. CONCLUSION: According to our case report, dermoscopy findings may aid to clearly diagnose this unusual BCC variant with proper histopathological correlation.

In Vivo Noninvasive Imaging of Healthy Lower Lip Mucosa: A Correlation Study between High-Definition Optical Coherence Tomography, Reflectance Confocal Microscopy, and Histology.

In recent years, technology has allowed the development of new diagnostic techniques which allow real-time, in vivo, noninvasive evaluation of morphological changes in tissue. This study compares and correlates the images and findings obtained by high-definition optical coherence tomography (HD-OCT) and reflectance confocal microscopy (RCM) with histology in normal healthy oral mucosa. The healthy lip mucosa of ten adult volunteers was imaged with HD-OCT and RCM. Each volunteer was systematically evaluated by RCM starting in the uppermost part of the epithelium down to the lamina propia. Afterwards, volunteers were examined with a commercially available full-field HD-OCT system using both the "slice" and the "en-face" mode. A "punch" biopsy of the lower lip mucosa was obtained and prepared for conventional histology. The architectural overview offered by "slice" mode HD-OCT correlates with histologic findings at low magnification. In the superficial uppermost layers of the epithelium, RCM imaging provided greater cellular detail than histology. As we deepened into the suprabasal layers, the findings are in accordance with physiological cellular differentiation and correlate with the images obtained from conventional histology. The combined use of these two novel non-invasive imaging techniques provides morphological imaging with sufficient resolution and penetration depth, resulting in quasihistological images.

[Ulcerative colitis and sclerosing cholangitis associated with elastosis perforans. A case review]. / Colitis ulcerativa y colangitis esclerosante asociadas a elastosis perforante. Presentación de un caso.

Transepidermal elimination is a mechanism by which altered dermal extracellular material is discharged through the epidermis. Perforating elastosis is a rare disease characterized by the transepidermal elimination of abnormal elastic fibers. Clinically it manifests as skin-colored keratotic papules that may coalesce and form arcuate or serpiginous plaques. It affects mostly males, predominantly younger than 30-years-old. We present a case of a male patient with inflammatory bowel disease and sclerosing cholangitis associated with perforating elastosis. To our knowledge, this is the first description of inflammatory bowel disease associated with perforating elastosis.

Petechial and purpuric eruption induced by lidocaine/prilocaine cream: a rare side effect.

Lidocaine/prilocaine cream is a topical anesthetic commonly used in pediatric and dermatologic practice to obtain local anesthesia. Common side effects include: transient skin blanching, erythema, urticaria, allergic contact dermatitis, irritant contact dermatitis, and hyperpigmentation. The authors report a petechial and purpuric reaction after the application of lidocaine/prilocaine cream. This is a rare side effect, since to our knowledge only few case reports have been documented in literature.