Dermoscopy vs. reflectance confocal microscopy for the diagnosis of lentigo maligna.

BACKGROUND: Several dermoscopic and in vivo reflectance confocal microscopy (RCM) diagnostic criteria of lentigo maligna (LM)/lentigo maligna melanoma (LMM) have been identified. However, no study compared the diagnostic accuracy of these techniques. OBJECTIVE: We evaluated the diagnostic accuracy of dermoscopy and RCM for LM/LMM using a holistic assessment of the images. METHODS: A total of 223 facial lesions were evaluated by 21 experts. Diagnostic accuracy of the clinical, dermoscopic and RCM examination was compared. Interinvestigator variability and confidence level in the diagnosis were also evaluated. RESULTS: Overall diagnostic accuracy of the two imaging techniques was good (area under the curve of the sROC function: 0.89). RCM was more sensitive (80%, vs. 61%) and less specific (81% vs. 92%) than dermoscopy for LM/LMM. In particular, RCM showed a higher sensitivity for hypomelanotic and recurrent LM/LMM. RCM had a higher interinvestigator agreement and a higher confidence level in the diagnosis than dermoscopy. CONCLUSION: Reflectance confocal microscopy and dermoscopy are both useful techniques for the diagnosis of facial lesions and in particular LM/LMM. RCM is particularly suitable for the identification of hypomelanotic and recurrent LM/LMM.

Dermoscopic and reflectance confocal microscopic presentation of Hailey-Hailey disease: A case series.

BACKGROUND/PURPOSE: Hailey-Hailey disease is a rare inherited acantholytic skin disorder characterized by heterogeneous clinical presentation. Its differential diagnosis might be wide, including other genodermatoses, inflammatory, and infectious skin diseases. Although histopathology remains as diagnostic gold standard, noninvasive techniques such as dermoscopy and reflectance confocal microscopy may assist clinical examination. Herein, we aim to further characterize the dermoscopic and reflectance confocal microscopic presentation of Hailey-Hailey disease with histologic correlation. METHODS: Eight patients with Hailey-Hailey disease were consecutively recruited. All patients were examined using dermoscopy and reflectance confocal microscopy. RESULTS: In all cases, dermoscopy enabled the visualization of polymorphous vessels, including glomerular and linear-looped vessels, within a pink-whitish background. Reflectance confocal microscopy revealed wide suprabasilar partial acantholysis and clefting, crusts, dilated papillae with tortuous vessels, and inflammatory cells. Dyskeratosis, uplocated papillae, and adnexal sparing were also observed. CONCLUSION: Although definite diagnosis was obtained by histopathology in all cases, dermoscopy and reflectance confocal microscopy allowed the identification of common features (even in cases with dissimilar clinical presentation) that may support an early diagnosis of Hailey-Hailey disease, and its differentiation from other more frequent skin disorders.

Mobile teledermatology helping patients control high-need acne: a randomized controlled trial.

BACKGROUND: Acne is an important health issue with a major psychological impact in addition to the physical problems it causes. OBJECTIVES: To investigate the superiority of mobile teledermatology in the care of patients with high-need facial acne in comparison to outpatient services with particular attention to treatment efficacy, safety, and patient compliance. Further, patient satisfaction with remote care was evaluated. METHODS: Sixty-nine consecutive patients (f: 25, m: 44, median age: 19 years, range: 13-37 years) were randomly allocated to either the teleconsultation (TCA) or the outpatient consultation (OCA) arm of the trial to receive isotretinoin treatment in weight and severity-dependent dosages over 24 weeks. Acne grading was performed by one examiner using the Global Acne Severity Scale (GEA) and the total lesion counting (TLC). RESULTS: Due to noncompliance issues, 17 of 69 (24.6%) patients were excluded from the study, of who 10 had been assigned to the TCA (10/34; 29.4%) and 7 to the OCA (7/35; 20%). Both, in the TCA (GEA-score: ∆ = 2.25; TLC: ∆ = 89.08) and in the OCA (GEA-score: ∆ = 2.0; TLC: ∆ = 91.21) excellent and almost equivalent therapeutic outcomes were achieved. In the TCA, however, less patients experienced adverse reactions (P = 0.55). Even though additional live supervision would have been appreciated in some teledermatology cases, patients were satisfied with the mobile service and no consultation request was created. CONCLUSION: Mobile teledermatology is an efficient, safe and well-accepted tool among patients with high-need acne constituting at least a valuable adjunct to outpatient care services. Further larger studies would be useful to confirm our findings.

Assessment of changes in lentigo maligna during radiotherapy by in-vivo reflectance confocal microscopy: a pilot study.

BACKGROUND: Radiotherapy is an effective treatment for therapy of lentigo maligna (LM). OBJECTIVES: To investigate the usefulness of in-vivo reflectance confocal microscopy (RCM) in radiotherapy of LM and document the changes within the lesions during treatment. METHODS: A total of six lesions in six patients were investigated by RCM before, during and after radiotherapy. For diagnostic assessment three observers with experience in RCM diagnosis, blinded as to the stage of treatment, assessed the RCM images of each lesion and documented the findings by consensus. RESULTS: Epidermal disarray worsened in three patients during radiotherapy and superficial necrosis was observed in four patients. Large pagetoid round/dendritic cells decreased or even vanished during or after radiotherapy. Dilated vessels and apoptotic cells were seen in all patients during radiotherapy as well as an increase of inflammatory cells in the epidermis and dermis in most of the patients. Dendritic cells with small dendrites were observed during radiotherapy in all patients with an increase in number in three patients. Melanophages appeared in five patients at least once during the examination period. All RCM images were assessed correctly by the three observers. CONCLUSIONS: Reflectance confocal microscopy is a useful method to visualize changes during and after radiotherapy and might also be used for early detection of potential treatment failures. In addition, it might be helpful in planning radiotherapy.

Benign dermoscopic features in melanoma.

BACKGROUND: Various dermoscopic features are usually associated with benign melanocytic lesions. Our objective was to determine frequency and extension of benign dermoscopic features (BDF) in melanoma. METHODS: Retrospective review of dermoscopic images of a consecutive series of 516 histopathologically proven melanomas collected in 6 years in Graz. Correlation of BDF with mean Breslow thickness, with presence/absence of associated benign nevus component and with the pre-operative clinico-dermoscopic diagnosis, as reported on the original histopathologic reports. RESULTS: In addition to melanoma specific criteria, 42% of melanomas showed BDF. In 12.3% cases, the benign features occupied more than the half of the lesion. The BDF typical pigment network, homogeneous pattern and regular globules/cobblestone pattern had the highest frequency. BDF were associated with relatively thinner melanomas (mean Breslow thickness of 0.51 mm). The presence of BDF was observed in 67.1% of histopathologically documented nevus-associated melanoma and in 35.7% of melanoma de novo. A pre-operative clinico-dermoscopic diagnosis of melanoma was achieved in only 54.1% of cases displaying BDF. CONCLUSION: A significant proportion of melanomas may exhibit BDF. Clinicians should be aware of the presence of BDF in melanoma as possible diagnostic pitfall.

UV-induced alterations of the skin evaluated over time by reflectance confocal microscopy.

BACKGROUND: Ultraviolet radiation (UVR) induces various alterations of the skin and plays a decisive part regarding the development of melanoma and non-melanoma skin cancer. For a closer examination of these phenomena in vivo reflectance confocal microscopy (RCM) is one of the most eligible options as it represents a diagnostic tool that allows a non-invasive examination of the skin, showing microanatomical structures and individual cells. OBJECTIVES: The aim of this study was using RCM to observe alterations of the skin induced by UVR and to describe the development of these changes. In addition, the findings were compared with histological examinations of the same area. METHODS: A small area in the gluteal region of 10 healthy subjects was exposed to a threefold individual minimal erythema dose of solar-simulated UVR. The following development of the sunburn reaction was evaluated with RCM 1, 24, 72 h and 1 week after UVR exposure. Furthermore, RCM images of unexposed skin were obtained, serving as a reference. To contrast histological examination with RCM, punch biopsies were performed at each point in time. The obtained data were interpreted regarding histological and RCM-based criteria on sunburn reaction. RESULTS: All important UVR-induced alterations of the skin could be shown in RCM beginning with an inflammatory reaction (inflammatory cells, vasodilatation, oedema), containing the formation of microvesicles, followed by the appearance of apoptotic keratinocytes (sunburn cells), activated melanocytes and at last, loss of the epidermal structure. There was an excellent correlation between RCM and histological features. CONCLUSIONS: Reflectance confocal microscopy is a highly valuable tool for non-invasive monitoring of UVR-induced changes of the skin over time. Furthermore, RCM provides a more detailed visualization of inflammatory cell formation and epidermal blood flow than histological examination can.

[Multiple dark nodules on the trunk]. / Multiple dunkelblaue Knötchen am Stamm.

A 61-year-old man with dark nodules on his trunk was referred by his internist because of concern about a malignant melanoma. Clinically the nodules were blue-purple and had a maximum diameter of 5mm. The main dermoscopic features were red to blue lacunae, which were variously sized and smooth bordered. These typical findings led to certain diagnosis of multiple venous hemangiomas. No further investigation or treatment was required.

Primary cutaneous follicle center cell lymphoma with follicular growth pattern.

Cutaneous B-cell infiltrates showing a prominent follicular growth pattern with germinal centers are thought by some authors to represent either marginal zone lymphomas with reactive germinal centers or pseudolymphomas. To establish whether a true primary cutaneous follicular lymphoma exists, we studied biopsies from 15 patients with skin lesions characterized histopathologically by the presence of B-cell infiltrates with follicular pattern. Staging investigations, including bone marrow biopsy, were negative in all patients. All were negative for bcl-2 protein expression and did not present the t(14;18). In all biopsy specimens neoplastic follicles showed 1 or more morphologic or immunophenotypic criteria of malignancy (presence of a reduced mantle zone, absence of tingible body macrophages, reduced proliferation rate). In 9 specimens a monoclonal rearrangement of J(H) genes could be detected by polymerase chain reaction analysis. After laser beam microdissection, a band of the same length could be observed in 6 probes from different follicles from the same specimen, indicating the presence of the same monoclonal population of follicle center cells. Follow-up examinations in all patients revealed no evidence of extracutaneous spread (mean follow-up, 48.7 months). Our study demonstrates that primary cutaneous follicular lymphoma represents a distinct entity of the cutaneous B-cell lymphomas. (Blood. 2000;95:3922-3928)

Monoclonality of intraepidermal T lymphocytes in early mycosis fungoides detected by molecular analysis after laser-beam-based microdissection.

The identification of neoplastic lymphocytes in early lesions of mycosis fungoides is difficult because of the scarcity of the infiltrate and the presence of reactive T lymphocytes admixed with neoplastic cells. Molecular analysis of the T cell receptor gene rearrangement using the polymerase chain reaction technique demonstrates monoclonality only in a proportion of these cases. The exact location of the malignant clone is unknown, and at present it is not clear whether neoplastic cells in early lesions reside within the epidermis, the superficial dermis, or both. We analyzed skin lesions from five patients with early mycosis fungoides using the polymerase chain reaction technique after microdissection of the specimens. In each case the epidermis was separated from the dermis using a laser-beam microdissection technique. Three samples were prepared from each lesion: one containing only the epidermis, one only the superficial dermis, and one the entire specimen. A distinct band could be observed in the epidermal sample in four cases, indicating the presence of an intraepidermal monoclonal population of T lymphocytes. The dermal sample revealed a monoclonal pattern in two cases (both of them showing clonality also within the epidermis). Analysis of the entire specimen revealed a monoclonal pattern only in two cases. Our results demonstrate that intraepidermal lymphocytes in early mycosis fungoides often show a monoclonal pattern of T cell receptor gene rearrangement. Microdissection of biopsy specimens may enhance the sensitivity of the polymerase chain reaction technique.

Analysis of food dyes E 110, E 111, and E 124 in fish samples by ion pair partition HPLC.

The isomeric food dyes E 110 and E 111 can be separated by ion pair partition HPLC on reversed-phase columns. The isomer E 111 - no longer permitted in Germany - can thus be determined in dye and food samples. The determination of E 110, E 111, and E 124 in fish samples (canned saithe) is described.

[The clinical value of the cortisol secretion rate determination in paediatric endocrinology (author's transl)]. / Die klinische Bedeutung der Cortisolsekretionsratenbestimmung in der pädiatrischen Endokrinologie

The cortisol secretion rate was determined in 18 children according to a modified and simplified method. In 7 cases the determination was repeated after stimulation with synthetic ACTH. 12 of these children suffered from diseases which may affect glucocorticoidsteroid production and the remaining 6 children served as normal controls. In some cases the plasma 11-hydrocorticoid level and urinary excretion of 17-ketogenic steroids were additionally determined. Differences in adrenal function were noted in 2 patients with congenital adrenal hyperplasia (one of the salt-losing type, the other nonsalt-losing type) and 5 patients with adrenal insufficiency. A normal cortisol secretion rate was found in 3 children with diverse disturbances of carbohydrate metabolism, as well as in a child with subtotal adrenalectomy. The clinical value of the determination of the cortisol secretion rate is discussed and was found to be a more reliable indicator of glucocorticoid activity than other parameters.