Mobile teledermatology: a feasibility study of 58 subjects using mobile phones.

We investigated the diagnostic agreement between teledermatology based on images from a mobile phone camera and face-to-face (FTF) dermatology. Diagnostic agreement was assessed for two teledermatologists (TD) in comparison with FTF consultations in 58 subjects. In almost three-quarters of the cases (TD1: 71%; TD2: 76%), the telediagnosis was fully concordant with the FTF diagnosis. Furthermore, the diagnosed diseases were almost all in the same diagnostic category (TD1: 97%; TD2: 90%). If mobile teledermatology had been used for remote triage, TD1 could have treated 53% subjects remotely and 47% subjects would have had to consult a dermatologist FTF. TD2 could have treated 59% subjects remotely, whereas 41% subjects would have had to consult a dermatologist FTF. Forty-eight subjects responded to a questionnaire, of whom only 10 had any concerns regarding teledermatology. Thirty-one subjects stated that they would be willing to pay to use a similar service in future and suggested an amount ranging from euro5 to euro50 per consultation (mean euro22) (euro = pound0.7, US $1.4). These results are encouraging as patient acceptance and reimbursement represent potential obstacles to the implementation of telemedicine services.

Giant pilomatricoma.

A 52-year-old man was examined for an ulcerated, rapidly growing reddish nodule. It was 5.5 cm high with an 11 x 6-cm base and located on the left clavicle. The lesion had been present for approximately 7 years, and the patient complained occasional burning and pain. Clinical differential diagnoses included cutaneous lymphoma, sarcoma, squamous cell carcinoma, and cutaneous metastasis. Histopathologic examination revealed a well-circumscribed tumor involving the whole dermis and the subcutis and composed of partially confluent aggregates of matrical cells admixed with eosinophilic cornified material containing shadow cells. In addition, multinucleated giant cells, areas of calcification and metaplastic ossification, edema, and hemorrhage were also observed. On the basis of histopathologic features, the diagnosis of pilomatricoma was made. Our report highlights an unusual clinical appearance of pilomatricoma that made us consider a variety of primary or secondary cutaneous neoplasms in its differential diagnosis.

Feasibility and diagnostic agreement in teledermatopathology using a virtual slide system.

We investigated the feasibility and diagnostic agreement of a virtual slide system (VSS) in teledermatopathology. Forty-six biopsy specimens from inflammatory skin diseases were selected and scanned with a VSS at the Research Unit of Teledermatology, Medical University of Graz, Graz, Austria. Images were stored on a virtual slide server on which a specific Web application suited for telepathology (http://telederm.org/research/dermatopath/) runs. Twelve teleconsultants from 6 different countries reviewed the 46 cases, working directly on the Web application. Telediagnoses agreed with gold standard and conventional diagnosis with an average of 73% and 74%, respectively. Complete concordance among all teleconsultants with gold standard and conventional diagnosis was found in 20% of the cases. In 10 cases in which complete clinical data were missing, the average agreement of telediagnosis with gold standard diagnosis and conventional diagnosis decreased to 65% and 66%, respectively. Only 3 of 4 cases of inflammatory skin diseases were correctly diagnosed remotely with VSS. The system that we have used, despite its usability, is not completely feasible for teledermatopathology of inflammatory skin disease. Moreover, the performance seems to have been influenced by the availability of complete clinical data and by the intrinsic difficulty of the pathology of inflammatory skin diseases.

Hypoepiluminescence microscopy of pigmented skin lesions: new approach to improve recognition of dermoscopic structures.

BACKGROUND: Hypoepiluminescence microscopy (HELM) is a new dermoscopic approach for analysis of pigmented skin lesions (PSLs) after surgical excision. OBJECTIVES: The objective was to verify whether this method could provide additional morphologic information for diagnostic or didactic purposes compared to conventional epiluminescence microscopy (ELM). PATIENTS AND METHODS: Thirty-one PSLs from 30 patients were consecutively evaluated by ELM and, after excision, by HELM. For HELM examination, the lesion was positioned on a glass slide and illuminated from above with a halogen lamp and from underneath with an LED source. All lesions were subsequently examined histopathologically. RESULTS: In 11 of 31 (35.5%) lesions, a typical pigment network, as assessed by ELM, appeared bidimensional with HELM. In 9 lesions (9/31; 29%) ELM showed a gray-blue area, while HELM allowed us to distinguish 5 lesions (5/9, 55.5%) with gray area predominant showing a lichenoid lymphocytic infiltration and few melanophages from the other 4 lesions (4/9, 44,5%) with heavy dermal accumulation of pigmented melanocytes or melanophages where a blue area was clearly visible at HELM. In 9 other cases (29%), ELM analysis revealed a central homogeneous dark brown/black pigmentation that in 7 cases was seen under HELM examination to consist of globules. CONCLUSIONS: HELM is particularly useful in evaluating heavily PSLs or structures located in the reticular dermis.

Blue-whitish veil-like structure as the primary dermoscopic feature of combined nevus.

The combined nevus is a clinical simulator of melanoma, and clinical examination alone can be inadequate to diagnose this melanocytic pigmented skin lesion. Dermoscopy is a useful tool to differentiate the features related to each type of nevus. We report two cases of combined nevi dermoscopically characterized by a diffuse blue-whitish pigmentation similar to the blue-whitish veil, suggesting the diagnosis of melanoma.

Imiquimod 5% cream in the treatment of Bowen's disease and invasive squamous cell carcinoma.

BACKGROUND: Imiquimod has been successfully used for treatment of various epithelial cutaneous neoplasms. OBJECTIVE: Our aim was to evaluate the efficacy and tolerability of imiquimod 5% cream for treatment of Bowen's disease and invasive squamous cell carcinoma (SCC) in patients who were unsuitable candidates for surgery. METHOD: Five Bowen's disease lesions and 7 invasive SCC lesions on 10 patients were treated with imiquimod once daily 5 times a week for a maximum of 16 weeks. RESULTS: After 8 to 12 weeks of treatment, 4 of 5 Bowen's disease lesions (80%) and 5 of 7 invasive SCCs (71.4%) showed complete clinicopathologic regression. The remaining 3 lesions showed partial regression after 16 weeks of treatment. No recurrence has been detected after a follow-up period of 24 to 38 months (mean, 31 months). LIMITATIONS: The study is an open-label clinical trial on a small number of selected patients, with lack of excision with serial step sections. CONCLUSION: Topical application of imiquimod 5% cream might represent an alternative topical treatment to surgery in selected cases of Bowen's disease and invasive SCC.

The protean spectrum of non-Hodgkin lymphomas with prominent involvement of subcutaneous fat.

BACKGROUND: Subcutaneous T-cell lymphoma (STCL) represents a controversial entity and a confused concept in the field of cutaneous T-cell lymphomas (CTCLs). Recently, alpha/beta+/CD8+ STCL has been recognized by the new World Health Organization (WHO)-European Organization for Research and Treatment of Cancer (EORTC) classification of primary cutaneous lymphomas as a distinct entity in the group of CTCLs. OBSERVATIONS: We reviewed a series of 53 biopsies from 26 patients (F : M = 19:7; median age: 48; range 18-87) of cutaneous B- and T-cell lymphomas characterized by prominent involvement of the subcutaneous tissue. We could classify our cases according to the following seven categories--(i) STCL: n = 16; (ii) extranodal NK/T-cell lymphoma, nasal type: n = 2; (iii) cutaneous gamma/delta T-cell lymphoma: n = 2; (iv) anaplastic CD30+ large T-cell lymphoma: n = 1; (v) diffuse large B-cell lymphoma, secondary cutaneous: n = 3; (vi) lymphoplasmacytic lymphoma, secondary cutaneous: n = 1; (vii) specific cutaneous manifestations of myelogenous leukemia: n = 1. CONCLUSIONS: We demonstrated the protean nature of lymphomas with prominent involvement of the subcutaneous fat tissues. The term STCL should be restricted to a homogeneous group of cases characterized morphologically by an exclusive involvement of subcutaneous tissues, immunohistochemically by a T-cytotoxic alpha/beta phenotype, and biologically by a relatively good prognosis.

Rimming of adipocytes by neoplastic lymphocytes: a histopathologic feature not restricted to subcutaneous T-cell lymphoma.

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare cytotoxic T-cell lymphoma of the skin presenting with histopathologic features simulating those of a lobular panniculitis. The presence of neoplastic T-lymphocytes forming a rim around the individual fat cells in the subcutaneous lobules, so-called "rimming" of adipocytes, is considered a characteristic morphologic feature of this type of cutaneous lymphoma. In this study we reviewed a series of 45 biopsy specimens of primary and secondary cutaneous B- and T-cell lymphomas and one of myeloid leukemia involving the subcutaneous tissues and showing rimming of adipocytes (subcutaneous panniculitis-like T-cell lymphoma: n = 16; mycosis fungoides, tumor stage: n = 3; aggressive epidermotropic CD8(+) T-cell lymphoma: n = 2; cutaneous gamma/delta T-cell lymphoma: n = 4; extranodal NK/T-cell lymphoma, nasal type: n = 4; cutaneous medium-large pleomorphic T-cell lymphoma, NOS: n = 5; CD4(+)/CD56(+) hematodermic neoplasm (blastic NK-cell lymphoma): n = 7; secondary cutaneous large B-cell lymphoma: n = 3; secondary cutaneous lymphoplasmacytic lymphoma: n = 1; specific cutaneous manifestations of acute myelogenous leukemia: n = 1). We could demonstrate that rimming of adipocytes by neoplastic cells can be recognized not only in subcutaneous panniculitis-like T-cell lymphoma, but also in several different entities of malignant lymphoma with skin involvement. Precise classification of cases with prominent involvement of the subcutaneous tissues can only be achieved upon precise correlation of clinicopathologic and phenotypic features. Rimming of adipocytes should not be considered specific of subcutaneous panniculitis-like T-cell lymphoma.

Dermoscopic evolution of a congenital combined nevus in childhood.

BACKGROUND: A combined nevus most commonly consists of a blue nevus in combination with a Clark or Spitz nevus. Dermoscopically, combined nevus can mimic melanoma owing to the presence of dermoscopic features common to both types of lesions. Benign clinical and dermoscopic changes can occur in nevi over time, especially in children and young adults. OBJECTIVE: To describe the dermoscopic evolution of a congenital combined nevus showing unusual dermoscopic features. METHODS: Digital dermoscopic analysis was performed at the initial visit and after 8 months. The lesion was surgically excised and histopathologically examined. RESULTS: An asymptomatic plaque with a central blue area and peripheral brown pigmentation located on the back of a 13-year-old boy was diagnosed dermoscopically as combined nevus. Dermoscopic analysis 8 months later showed color changes from steel blue to gray-blue and black in the central area of the lesion, an increased number of blue-black dots or globules, and peripheral irregular streaks. Histopathology revealed typical features of a congenital combined nevus (blue nevus + compound nevus). CONCLUSION: Over time, congenital combined nevus may show clinical and dermoscopic changes in size, color, and structure. Surgical excision is recommended when clinical and dermoscopic features are equivocal and the diagnosis of melanoma cannot be ruled out.