In Vivo Reflectance Confocal Microscopy as a Response Monitoring Tool for Actinic Keratoses Undergoing Cryotherapy and Photodynamic Therapy.

Reflectance confocal microscopy (RCM) presents a non-invasive method to image actinic keratosis (AK) at a cellular level. However, RCM criteria for AK response monitoring vary across studies and a universal, standardized approach is lacking. We aimed to identify reliable AK response criteria and to compare the clinical and RCM evaluation of responses across AK severity grades. Twenty patients were included and randomized to receive either cryotherapy (n = 10) or PDT (n = 10). Clinical assessment and RCM evaluation of 12 criteria were performed in AK lesions and photodamaged skin at baseline, 3 and 6 months. We identified the RCM criteria that reliably characterize AK at baseline and display significant reduction following treatment. Those with the highest baseline odds ratio (OR), good interobserver agreement, and most significant change over time were atypical honeycomb pattern (OR: 12.7, CI: 5.7-28.1), hyperkeratosis (OR: 13.6, CI: 5.3-34.9), stratum corneum disruption (OR: 7.8, CI: 3.5-17.3), and disarranged epidermal pattern (OR: 6.5, CI: 2.9-14.8). Clinical evaluation demonstrated a significant treatment response without relapse. However, in grade 2 AK, 10/12 RCM parameters increased from 3 to 6 months, which suggested early subclinical recurrence detection by RCM. Incorporating standardized RCM protocols for the assessment of AK may enable a more meaningful comparison across clinical trials, while allowing for the early detection of relapses and evaluation of biological responses to therapy over time.

Reflectance confocal microscopy for the diagnosis of skin infections and infestations.

Reflectance confocal microscopy (RCM) is a noninvasive real-time imaging technique that has been widely used for the diagnosis of skin cancer. More recently, it has been reported as a useful tool for the diagnosis and management of several inflammatory and infectious skin disorders. This article provides an overview of the current available applications of RCM use in cutaneous infections and infestations. PubMed was used to search the following terms in various combinations: reflectance confocal microscopy, skin, hair, nail, infection, parasitosis, mycosis, virus, bacteria. All papers were accordingly reviewed. In most cutaneous infections or infestations, the main alterations are found in the epidermis and upper dermis, where the accuracy of confocal microscopy is nearly similar to that of histopathology. The high resolution of this technique allows the visualization of most skin parasites, fungi, and a few bacteria. Although viruses cannot be identified because of their small size, viral cytopathic effects can be observed on keratinocytes. In addition, RCM can be used to monitor the response to treatment, thereby reducing unnecessary treatments.

[Mobile teledermatology in the treatment of chronic ulcers]. / Mobile Teledermatologie in der Behandlung chronischer Ulzera.

BACKGROUND: Treatment of chronic ulcers is challenging. Advanced age, comorbidities, and a lack of medical knowledge of the caretaker's relatives are additional burdens. This study analyses if patient driven teledermatology could support them in the treatment of leg ulcers. Another purpose was the evaluation of savings in time and costs through telemedicine. PATIENTS AND METHODS: Over a period of approximately 6 months, 50% of the patients were treated in an ambulant setting, the other 50% used mainly teledermatology. The tele-group used an application to upload their pictures, clinical results, and history. After examination, the expert sent back a treatment plan and a date for the next teleconsultation. RESULTS: In all, 40 patients-20 in the tele-group and 20 in the control group-(18 women, 22 men; median age: 75 years [39-88 years]) were included in the study. A total of 4 patients managed the teleconsultation on their own, while 3 patients were supported by relatives and 11 by nurses. Overall, 196 outpatient treatments took place in the control group (1.6 visits/patient/month), compared to 97 outpatient treatments (0.6 visits/patient/month) and 182 teledermatology consults (1.3/patient/month) in the tele-group. Six patients were only treated in the teledermatology setting. CONCLUSIONS: Results from this study suggest that teledermatology is well qualified for the treatment of chronic ulcers; at the same time teledermatology is able to reduce the number of outpatient treatments, in some cases teleconsultation alone is possible. This decreases waiting time and travel costs for patients. Mobile teledermatology for treatment of ulcers was well-accepted among the patients.

Diagnostic impact of reflectance confocal microscopy as a second-level examination for facial skin lesions.

BACKGROUND AND OBJECTIVE: Benign and malignant facial skin lesions may be difficult to differentiate clinically and with dermoscopy. The present study aimed to evaluate the potential utility of in vivo reflectance confocal microscopy (RCM) as a second-level examination for facial skin neoplasms. PATIENTS AND METHODS: Retrospective and blinded evaluation of 160 consecutive facial lesions was carried out in two separate steps. Clinical and dermoscopic images were assessed first, followed by combined evaluation of clinical/dermoscopic and RCM images. Our study included 60 % malignant lesions, comprising 43 % melanomas, 9 % basal cell carcinomas, 5 % in situ squamous cell carcinomas and 3 % lymphomas. RESULTS: Ancillary RCM significantly improved diagnostic specificity for the detection of malignancy compared to clinical/dermoscopic evaluation alone (58 % vs 28 %). However, sensitivity was slightly lower for RCM-based image evaluation (93 % vs 95 %) due to misclassification of one in situ SCC and one lymphoma. In terms of melanoma diagnosis, RCM-based image evaluation was generally superior; sensitivity was only slightly increased (88 % vs 87 %), but melanoma specificity was significantly higher (84 % vs 58 %). CONCLUSION: RCM is a valuable diagnostic adjunct for facial skin lesions; unnecessary biopsies in this cosmetically sensitive area could be reduced by one third without missing a melanoma.

Survey on the status of teledermatology in Austria.

BACKGROUND: The use of digital communication media is becoming increasingly important, with the primary aim of improving both treatment quality and patients' quality of life. In an effort to optimize telemedicine in the field of dermatology, we conducted a survey among dermatologists in Austria. METHODS: Statistical analysis of a questionnaire that was developed by a working group and sent to 769 Austrian dermatologists. RESULTS: Overall, 243 dermatologists (132 women/111 men) participated in the survey. Forty-seven percent of male respondents and 55 % of female respondents had already received requests for teledermatology consultations. Seventy-three percent felt that telemedicine was able to contribute to relieving the economic burden on the health care system. Telecommunication between dermatologists and experts (in a given field of dermatology) was deemed to be particularly useful. While telemedicine was also considered to be appropriate for patient follow-up, it was viewed to be less useful for initial consultations. Roughly 50 % of respondents used telemedicine to get a second opinion; one-third used it for initial consultations. CONCLUSIONS: Our survey shows that the majority of participants consider teledermatology to be a useful supplement to the current practice of dermatology. Given its particular usefulness for triage purposes, teledermatology can help reduce the number of trips to the hospital and subsequent waiting times. This in turn leads to cost reduction and saves time for both patients and doctors. Legal regulations that include provisions for appropriate reimbursement of physicians would make using teledermatology more attractive.

Correlation of Reflectance Confocal Microscopy and Dermatopathology Findings in a Case of Acrodermatitis Chronica Atrophicans.

Acrodermatitis chronica atrophicans (ACA) that is characterized by thin, papery dry, translucent, and alopecic patches with visible superficial veins is a late cutaneous manifestation of Lyme borreliosis. Clinical findings, a history of exposure to tick bite, and serology are helpful for the diagnosis of ACA and sometimes a biopsy is performed to rule out other infectious or inflammatory processes. In this study, we report reflectance confocal microscopy (RCM) findings in a case of ACA. RCM examination revealed a flattened surface with broadened skin folds, a flattened dermoepidermal junction with few papillae and less bright basal cells and multiple small bright reflecting spots in the dermis. To the best of our knowledge, this is the first description of the RCM findings in this disorder.

Noninvasive RCM for Differentiation of Melanotic Macules From Melanocytic Lesions-Blinded Evaluation of a Series of 42 Pigmented Macules.

BACKGROUND: Differentiation of melanotic macules from melanocytic lesions, most importantly of melanoma, is a common problem on clinical-dermoscopic examination. OBJECTIVE: To assess the value of noninvasive reflectance confocal microscopy (RCM) in the differential diagnosis of melanotic macules and melanocytic lesions. PATIENTS AND METHODS: Reflectance confocal microscopy images of 42 pigmented macules on mucocutaneous junctions of genitalia and lips, including 31 melanotic macules, 6 nevi, and 5 melanomas, were retrospectively and independently assessed in a blinded manner by one expert observer and 2 less experienced observers together. RESULTS: The authors differentiated 3 subtypes of melanotic macules; 2 subtypes ("solar lentigo type" and regular subtype of "dendritic type" melanotic macules) could be classified with confidence as benign by all RCM investigators, comprising 64% of melanotic macules. The third subtype (irregular subtype of "dendritic type" melanotic macules; 36%) displaying RCM features overlapping with melanoma was difficult to differentiate and should be biopsied not to miss a melanoma. The RCM differentiation between melanotic macules and nevi was easily performed. CONCLUSION: RCM has the potential to increase the diagnostic accuracy in the noninvasive differentiation of pigmented macules on mucocutaneous junctions.

Dermoscopic characteristics of melanoma according to the criteria "ulceration" and "mitotic rate" of the AJCC 2009 staging system for melanoma.

OBJECTIVE: The present study was conducted to identify possible dermoscopic patterns, associated with mitotic rate > 1/mm2, histological ulceration in melanoma and metastatic disease. METHODS: For this retrospective data analysis all clinical and dermoscopic digital images of primary malignant melanomas between 2008 and 2013 documented at the Department of Dermatology Graz were included, using the internal image data-base. 550 patients with 559 melanomas were included. RESULTS: While clinical or dermoscopic analysis considered ulceration to be present in 120 (21.5%) and 117 (20.9%) of all lesions, respectively, histopathology reported ulceration in only 96 cases (17.2%). The presence of milky-red areas, shiny-white streaks, a blue-white veil and blue-grey areas in dermoscopy is highly correlated with histological ulceration and a mitotic rate > 1/mm2. The dermoscopic patterns shiny-white streaks, milky-red areas and blue-white veil were also significantly associated with development of distant metastases. CONCLUSION: Our study proves a significant correlation between the dermoscopic patterns "blue white veil", "milky-red areas"and "shiny-white streaks"and the histological findings "ulceration"and "mitotic rate > 1/mm2". Furthermore these dermoscopic patterns are highly related to distant metastases. Thus, dermoscopy renders earlier prognostic statements possible.

Teledermoscopy in High-risk Melanoma Patients: A Comparative Study of Face-to-face and Teledermatology Visits.

Teledermoscopy is considered a reliable tool for the evaluation of pigmented skin lesions. We compared the management decision in face-to-face visits vs. teledermatology in a high-risk melanoma cohort using total-body photography, macroscopic and dermoscopic images of single lesions. Patients were assessed both face-to face and by 4 remote teledermatologists. Lesions identified as suspicious for skin cancer by face-to-face evaluation underwent surgical excision. The teledermatologists recommended "self-monitoring", "short-term monitoring", or "excision". A 4-year monitoring was completed in a cohort of participating subjects. The general agreement, calculated by prevalence and bias-adjusted κ (PABAK), showed almost perfect agreement (PABAK 0.9-0.982). A total of 23 lesions were excised; all teledermatologists identified the 9 melanomas. The greatest discrepancy was detected in "short-term monitoring". During 4-year monitoring one melanoma was excised that had been considered benign. In conclusion, melanoma identification by experts in pigmented lesions appears to be equivalent between face-to-face and teledermatological consultation.

The use of dermatoscopy in diagnosis and therapy of nonmelanocytic skin cancer.

Today, dermatoscopy is an integral part of every clinical skin examination, as it markedly enhances the early detection of melanocytic and nonmelanocytic skin cancer (NMSC) compared to naked-eye inspection. Besides its diagnostic use, this noninvasive method is increasingly important in the selection of as well as the response assessment to various therapies used for NMSC, including basal cell carcinoma, actinic keratoses, squamous cell carcinoma, and also rare tumors such as Merkel cell carcinoma, angiosarcoma, or dermatofibrosarcoma protuberans. Thus, dermatoscopy is a valid tool for the preoperative assessment of tumor margins in basal cell carcinoma, but also for follow-up of actinic keratoses after topical treatment. The present article presents an overview on the use of dermatoscopy in the diagnosis and therapy of various types of NMSC.