Abstract: BACKGROUND: Reflectance confocal microscopy (RCM) has been used for over 10 years for in vivo skin imaging. However, to date no standard RCM terminology has been published. OBJECTIVE: To establish a glossary of terms for RCM evaluation of melanocytic lesions. METHODS: Prominent RCM researchers were presented with RCM images of melanocytic lesions. Reviewers evaluated RCM images for image quality, lesion architecture, and cellular details. Reviewers could utilize published descriptors or contribute unpublished terminology to describe lesion attributes. An online meeting was conducted to reach consensus that integrates and defines existing and new RCM descriptive terms. RESULTS: We present a glossary with descriptors of image quality, normal skin morphology, lesion architecture, and cellular details for RCM evaluation of melanocytic lesions. LIMITATIONS: Usefulness of the glossary in RCM diagnosis of melanocytic lesions needs to be assessed. CONCLUSION: Standardization of terminology is important toward implementation of RCM in the clinical setting.
Abstract: BACKGROUND: Mycosis fungoides (MF) is a diagnostic challenge, frequently needing multiple and sequential biopsies to establish the diagnosis. OBJECTIVE: Our aim was to evaluate lesions suggestive of MF using in vivo reflectance confocal microscopy (RCM) and to correlate confocal features with histopathologic findings. METHODS: A total of 8 lesions from 7 patients either with a history of biopsy-proven MF or with lesions clinically suggestive of MF were imaged with RCM followed by a skin punch biopsy. These 8 lesions were confirmed to be MF by histopathology: patch type (n = 3), plaque type (n = 4), and tumor type (n = 1). RESULTS: Under RCM, epidermal findings in patch lesions were subtle, as on histopathology, while the most prominent changes were observed in plaque type MF. At the level of the epidermis, weakly refractile oval to round structures within the spinous layer were observed in all MF lesions, but were difficult to distinguish from surrounding keratinocytes; these structures corresponded to epidermotropic lymphocytes on histopathology. In plaque-type lesions, vesicle-like dark spaces filled with collections of monomorphous weakly refractile oval to round cells were clearly elucidated by RCM; these structures corresponded to Pautrier's microabscesses on histopathology. RCM was also able to demonstrate spongiosis in the MF lesions, with findings of epidermal architectural disarray, areas with thickened and blurred intercellular demarcations, and epidermal cells with elongated nuclei. At the dermoepidermal junction, the basal cells surrounding the dermal papillae appeared as only faintly refractile rings on RCM. This feature corresponded with histopathologic findings of basal layer infiltration by tumor cells with permeation of rete ridges, thus, obscuring the dermoepidermal interface. Examination of the dermis under RCM for all the MF lesions showed weakly refractile structures, but was limited by loss of detail and contrast below the dermoepidermal junction. LIMITATIONS: Because of limited imaging depth, RCM did not visualize dermal infiltration by tumor cells in tumor-type MF. Epidermotropic lymphocytes appeared weakly refractile under RCM and were difficult to distinguish from surrounding keratinocytes as a result of minimal difference in contrast. Other limitations on RCM include some similarity in findings with spongiotic and lichenoid dermatitides, and an inability to distinguish specific cell types. Moreover, this study did not address the inherent heterogeneity of MF lesions, but was primarily focused on correlating RCM and hematoxylin-eosin histopathology of the included cases. CONCLUSION: Features correlating well to histopathology are observed on RCM of MF lesions; however, the specificity of these findings needs to be assessed.
Abstract: OBJECTIVES: To describe the dermoscopic features of congenital melanocytic nevi (CMN) and assess whether predominant dermoscopic patterns present in CMN are related to an individual's age (<12 years vs >or=12 years), sex, or lesional site (head, neck, and trunk vs extremities). DESIGN: Nonrandomized observational study. PATIENTS: A total of 77 consecutive patients, each with 1 CMN (n = 77 lesions), from an outpatient dermatology clinic. A diagnosis of CMN was established by (1) documentation of a melanocytic nevus during the first year of life or (2) by clinical examination and either clinical history or biopsy findings. MAIN OUTCOME MEASURES: Images of CMN were evaluated for specific dermoscopic structures and patterns. The distribution of patterns was assessed by age, sex, and lesional site. RESULTS: Most of the 77 lesions exhibited 1 of the following predominant dermoscopic patterns: reticular (18 lesions [23%]), globular (14 [18%]), or reticuloglobular (12 [16%]). Globular CMN were present in 5 of the 19 individuals who were younger than 12 years (26%) but in only 9 of the 58 individuals 12 years or older (16%). Reticular CMN were seen exclusively in the individuals who were 12 years or older. Congenital melanocytic nevi exhibiting no predominant pattern were more commonly present in the individuals younger than 12 years. Globular CMN were present in 11 head, neck, and trunk lesions (30%) compared with 3 extremity lesions (8%). Conversely, reticular CMN were present in 16 extremity lesions (40%) compared with 2 head, neck, and trunk lesions (5%). The predominant dermoscopic pattern did not vary based on sex. The most commonly observed dermoscopic structures were globules (in 64 lesions [83%]), hypertrichosis (in 61 [79%]), and reticular networks (in 55 [71%]). CONCLUSIONS: Our results suggest that the predominant dermoscopic patterns of CMN vary according to age and lesional site. These differences may inform future studies on the pathogenesis of CMN.
Abstract: OBJECTIVE: To determine the utility of reflectance confocal microscopy (RCM) in the in vivo evaluation of dermoscopic structures of melanocytic lesions. DESIGN: For each described dermoscopic feature, we evaluated by RCM at least 2 melanocytic lesions. A digital camera connected to the confocal computer enabled direct analysis of the dermoscopic structures. To ascertain precision of correlation, the orientation of the dermoscopic and RCM images were compared using a superimposed grid. SETTING: Dermatology clinic specializing in pigmented lesions. Patients Eleven patients with melanocytic lesions, including 2 melanomas, 1 Spitz nevus, 7 dysplastic nevi, and 1 compound nevus. Main Outcome Measure Direct correlation of structures seen using dermoscopy with those seen using RCM. RESULTS: There was a good correlation between the global dermoscopic pattern and findings on the 4 x 4-mm mosaic of confocal images at the level of the dermoepidermal junction. The atypical network correlated with variability in the size and shape of dermal papillae. Globules corresponded with aggregates of bright cells, and darker shades of brown on dermoscopy appeared brighter on RCM. In peripheral streaks, RCM showed dense aggregates of pleomorphic cells of variable brightness and ill-defined cellular borders. These aggregates were continuous with the bright mesh that composed the central bulk of the lesion. A blue-white veil correlated with disruption of the rimmed papillae meshlike pattern and sometimes with the presence of bright cells corresponding to melanophages. CONCLUSION: Correlating dermoscopic structures to RCM features is possible and a necessary step toward understanding the potential benefits of RCM in the clinical setting.
Abstract: OBJECTIVE: To evaluate dermoscopic features and patterns of skin lesions by using conventional and polarized light dermoscopy (PD). DESIGN: Observational study. SETTING: Dermatology clinic at Memorial Sloan-Kettering Cancer Center. PATIENTS: Ninety patients with skin lesions. INTERVENTIONS: Skin lesions were imaged via conventional nonpolarized light contact dermoscopy (NPD), polarized light contact dermoscopy (PCD), and polarized light noncontact dermoscopy (PNCD). MAIN OUTCOME MEASURES: The images from the 3 modalities were evaluated by 3 dermoscopists for colors, structures, and patterns. Level of agreement between modalities was assessed by percentage agreement and the kappa statistic. Qualitative differences between modalities were also assessed. RESULTS: Ninety lesions comprising 55 melanocytic and 35 nonmelanocytic lesions were reviewed. There was excellent agreement for overall dermoscopic patterns between modalities, with kappa values ranging from 0.88 to 1.00. There was moderate to excellent agreement for most dermoscopic colors, with the exception of blue-white veil and pink (red) color. Most dermoscopic structures had fair to perfect agreement, with the exception of milialike cysts. Qualitative assessment suggested that melanin appeared darker and blue nevi had more shades of blue on PD compared with NPD images; vessels and red areas were better visualized with PD, suggesting that PD may be helpful in identifying malignancies; milialike cysts and comedolike openings were better visualized with NPD, suggesting that NPD is more helpful for identification of seborrheic keratosis; peppering, lighter colors, and blue-white areas were more evident under NPD, facilitating recognition of regression areas; and shiny-white streaks, possibly representing fibrosis, were seen more clearly under PD. CONCLUSIONS: The capabilities of NPD, PCD, and PNCD are not equivalent, but complementary. Further studies are needed to evaluate the effect of these differences on clinical diagnosis.
Abstract: BACKGROUND: Reflectance confocal microscopy (RCM) is a high-resolution imaging tool for in vivo noninvasive evaluation of skin lesions. OBJECTIVE: We sought to describe the relevant RCM features for pigmented basal cell carcinoma (BCC). METHODS: Pigmented skin lesions with a differential diagnosis of pigmented BCC were imaged using dermoscopy and RCM, followed by excision for histologic analysis. RESULTS: RCM demonstrated aggregations of tightly packed cells with palisading, forming cordlike structures and nodules with irregular borders and variable brightness; these represented nests of pigmented basaloid tumor cells on histopathology, and blue-gray ovoid areas on dermoscopy. These tumor nests were associated with bright dendritic structures, identified histologically as either melanocytes or Langerhans cells, together with numerous bright oval to stellate-shaped structures with indistinct borders representing melanophages, and with highly refractile granules of melanin. LIMITATIONS: The pigmented BCCs imaged in this study were predominantly nodular; a different set or additional criteria may be necessary for detection of infiltrative and metatypical BCCs. CONCLUSION: RCM may permit in vivo diagnosis of pigmented BCC.
Abstract: BACKGROUND: Confidence is an important factor in decision making and may influence patient care. OBJECTIVES: To evaluate whether short-training-based dermoscopy increases confidence in the diagnosis of skin lesions. METHODS AND MATERIALS: After a 1-hour course on dermoscopy, 20 pairs of clinical and dermoscopic images of lesions were presented to 19 dermatology residents with little or no dermoscopy experience. After viewing the clinical image, they were asked to assess their confidence in the diagnosis in a seven-point scale, with 1 reflecting that the respondent was 100% confident that the lesion was benign, while number 7 reflected 100% confidence that it was malignant. The same technique was used for dermoscopic images. RESULTS: Ten of the 20 pairs of evaluations showed a significant difference (p<.05). The largest differences were observed in lesions where clinical scores suggested that participants were uncertain about the diagnosis, but tended to decide that the lesion was benign after dermoscopy. Dermoscopy did not improve confidence in the evaluation of dysplastic lesions as well as lesions with obvious clinical diagnoses. CONCLUSIONS: Short-training-based dermoscopy improved confidence in the diagnosis of clinically challenging skin lesions, but the impact was not demonstrable for clinically obvious lesions and dysplastic nevi.
Abstract: BACKGROUND: Melanocyte colonization of breast carcinoma cells may occur in those tumors that breach the epidermal-dermal interface. The resultant melanin deposition in tumor cells rarely leads to clinical pigmentation of the tumor. Typically, selective staining methods are required to detect the pigment. OBSERVATION: The authors describe a 60-year-old woman with a history of mammary carcinoma and an irregularly pigmented nodule with peripheral globules and a blue-white veil on dermoscopy, which was a clinical and dermoscopic mimic of malignant melanoma. CONCLUSIONS: Awareness of melanocyte colonization of non-melanocytic tumor cells and the dermoscopic-histologic correlations can aid in avoiding a potential pitfall, and emphasize the importance of such relationships, when using this tool.
Abstract: BACKGROUND: It has been clinically observed that patients' "normal" moles resemble each other. Whether this concept is applicable to dermoscopic practice has not been sufficiently studied. OBJECTIVE: To investigate whether physicians evaluating dermoscopic images would identify common dermoscopic profiles of nevi within individual patients. METHODS: Images of 205 nevi belonging to 18 patients were evaluated by 2 dermatologists for dermoscopic global pattern, color, and specific structures. We defined dermoscopic patterns as dominant if seen in >or= 40% of the patient's nevi; a minor pattern was defined as 20 to 39%. RESULTS: A dominant pattern was seen in 15 patients (83%). In 13 (72%) of the patients, >or= 80% of the nevi were classified into one, two, or three global patterns. The reticular global pattern was the most prevalent dominant pattern, seen in 9 patients (50%); the homogeneous pattern was the most prevalent minor pattern, seen in 16 patients (89%). CONCLUSION: Individuals tend to have one to three predominant dermoscopic nevus global patterns.
Abstract: The first step of the two-step algorithm of dermoscopy aims at differentiating melanocytic from nonmelanocytic pigmented lesions, using a stepwise evaluation for the presence of specific dermoscopic criteria. The purpose of this article is to heighten awareness of clinicians to nonmelanocytic lesions that defy the two-step algorithm, thus simulating melanocytic lesions dermoscopically. Seborrheic keratosis, solar lentigo, dermatofibroma, and supernumerary accessory nipple may present with network-like structures. Seborrheic keratosis, dermatofibroma, subcorneal hemorrhage, basal cell carcinoma (BCC), and cutaneous metastases of breast and other cancers may contain pigmented globules. Peripheral streaks can also be seen in seborrheic keratosis and BCC. Homogenous bluish pigmentation, simulating a blue nevus, can also be seen in benign vascular lesions, Kaposi sarcoma, radiation tattoo, and BCC. This overlap of features between melanocytic and nonmelanocytic lesions suggests that integration of all dermoscopic features in the lesion, rather than a stepwise evaluation, may facilitate reaching the correct diagnosis in select cases as outlined in this article.
Abstract: OBJECTIVE: To evaluate dermoscopic features and patterns of dermatofibromas using conventional and polarized light dermoscopy. DESIGN: Dermatofibromas were imaged using conventional nonpolarized contact dermoscopy (NPD), polarized contact dermoscopy (PCD), and polarized noncontact dermoscopy, followed by evaluation and comparison of dermoscopic features of the lesions. SETTING: Dermatology clinic specializing in pigmented lesions. Patients Fifty patients with dermatofibromas. RESULTS: The most common features of dermatofibromas observed with NPD and PCD were central white scarlike patches (37 [74%] and 42 [84%], respectively), brown globulelike structures (21 [42%] and 22 [44%]), vascular structures (24 [48%] and 22 [44%]), and a peripheral fine pigmented network (36 [72%] for both). A newly described feature observed with PCD was a central white patch characterized by shiny white streaks. With polarized noncontact dermoscopy, the most characteristic feature was a central pink hue or "vascular blush" (44 [88%]) and visibility of blood vessels (41 [82%]). The most common pattern identified with NPD and PCD was the combination of a peripheral pigmented network and a central white patch in 28 (56%) and 31 (62%) of lesions, respectively. With polarized noncontact dermoscopy, the most common pattern was a central pink hue with a peripheral pigmented network (23 [46%]). There was good to excellent agreement when comparing NPD with PCD images, but there was a variable level of agreement when polarized noncontact dermoscopy images were compared with NPD and PCD images. CONCLUSIONS: Conventional and polarized light dermoscopy are not equivalent but may be complementary. This study highlights some salient differences. We were able to identify new dermoscopic features and patterns not previously described with conventional dermoscopy. These new criteria can aid in the diagnosis of dermatofibroma.
Abstract: Epidermal growth factor receptor (EGFR) inhibitors are associated with unique and dramatic dermatologic side effects. Cetuximab, erlotinib, and gefitinib have been approved for patients with colorectal and non-small cell lung cancer refractory or intolerant to chemotherapy. Our aim was to describe key clinical features of common dermatologic adverse reactions among EGFR inhibitors, focusing mainly on skin toxicity, as well as to discuss the pathology, possible causes, and suggested treatments for these reactions. The most commonly encountered adverse effect was a mild skin toxicity characterized by a sterile follicular and pustular rash that may be treated empirically and usually does not require treatment modification. Although the precise mechanism for development of rash is not well defined, it is related to inhibition of EGFR-signaling pathways in the skin, and may serve as visible markers of anti-tumor activity and therapeutic efficacy. Secondary adverse reactions seen with anti-EGFR therapy include xerosis, pruritus, paronychia, hair abnormality, and mucositis.
Abstract: The increasing incidence and overall survival of patients diagnosed with melanoma of the skin are leading to an ever-increasing population of individuals with a personal history of melanoma. These patients are at risk for developing local, regional, or distant recurrence and are also at greater risk than the general population for developing a new primary melanoma. This article presents the rational for implementing surveillance strategies for patients with a history of melanoma.
Abstract: BACKGROUND: Recent retrospective studies using magnetic resonance imaging (MRI) to screen for neurocutaneous melanocytosis (NCM) among neurologically asymptomatic children with large congenital melanocytic nevi (LCMN) report high prevalence (23-30%) of asymptomatic NCM. We sought to determine prevalence of asymptomatic NCM, and current application of MRI as a screening tool. METHODS: Patients with LCMN from an Internet-based registry answered a questionnaire regarding NCM status. RESULTS: Of 379 patients with LCMN, 26 reportedly had NCM, with 17 reporting neurologic symptoms. Of 186 patients undergoing MRI, 9 reported abnormal findings without neurologic symptoms (4.8%); 80% had LCMN on the posterior axis, whereas 55% had more than 20 satellite nevi. LIMITATIONS: Study data rely on the registry members' self-reported findings and are limited by lack of independent data verification. CONCLUSION: Asymptomatic NCM (determined by MRI) may not be common, with much lower prevalence (4.8%) than previously reported. MRI is widely used for screening patients at risk for NCM, such as patients with LCMN involving the posterior axis and greater than 20 satellite nevi.
Abstract: BACKGROUND: Xerosis is a common skin condition (1) characterized by dry, rough, scaly, and itchy skin, (2) associated with a defect in skin barrier function, and (3) treated with moisturizers. People in the tropics have effectively used coconut oil as a traditional moisturizer for centuries. Recently, the oil also has been shown to have skin antiseptic effects. A moisturizer with antiseptic effects has value, but there are no clinical studies to document the efficacy and safety of coconut oil as a skin moisturizer. OBJECTIVE: This study aimed to determine the effectivity and safety of virgin coconut oil compared with mineral oil as a therapeutic moisturizer for mild to moderate xerosis. METHODS: A randomized double-blind controlled clinical trial was conducted on mild to moderate xerosis in 34 patients with negative patch-test reactions to the test products. These patients were randomized to apply either coconut oil or mineral oil on the legs twice a day for 2 weeks. Quantitative outcome parameters for effectivity were measured at baseline and on each visit with a Corneometer CM825 to measure skin hydration and a Sebumeter SM 810 to measure skin lipids. For safety, transepidermal water loss (TEWL) was measured with a Tewameter TM210, and skin surface hydrogen ion concentration (pH) was measured with a Skin pH Meter PH900. Patients and the investigator separately evaluated, at baseline and at each weekly visit, skin symptoms of dryness, scaling, roughness, and pruritus by using a visual analogue scale and grading of xerosis. RESULTS: Coconut oil and mineral oil have comparable effects. Both oils showed effectivity through significant improvement in skin hydration and increase in skin surface lipid levels. Safety was demonstrated through no significant difference in TEWL and skin pH. Subjective grading of xerosis by the investigators and visual analogue scales used by the patients showed a general trend toward better (though not statistically evident) improvement with coconut oil than with mineral oil. Safety for both was further demonstrated by negative patch-test results prior to the study and by the absence of adverse reactions during the study. CONCLUSION: Coconut oil is as effective and safe as mineral oil when used as a moisturizer.
