Abstract: Teledermoscopy has become in the last years one of the most florid reality of teledermatology. Parallel to the achievement of dermoscopy in clinical settings, teledermoscopy has grown in different fields, namely tele-education and teleconsulting. Blogs, atlases, discussion forums, on line courses and Diploma Courses do not only offer a second opinion consultation but give the opportunity to residents in dermatology and dermatologists with different level of expertise in dermoscopy to easily learn at home, to train or to improve their level in dermoscopy. On the other side, in some countries demand for melanoma screening has led to commercialization of "teledermoscopy" by different companies. Images nowadays can be transmitted over telecommunication networks not only via e-mail or a specific web application but also with last generation cellular phones. This reality opens the new incoming field of mobile teledermatology. Mobile teledermoscopy is a new horizon that might become in the future the basis of the self examination of pigmented skin lesions as a screening tool for malignant cutaneous tumors or to follow-up of high risk patients.
Abstract: Leprosy is characterized by spectrum of histologically different granulomatous skin lesions that reflects the patient's immune response to Mycobacterium leprae. Presence, frequency, and distribution of both CD4+ CD25+ FoxP3+ T regulatory cells (T-regs) and CD123+ plasmacytoid dendritic cells in leprosy have never been investigated. We performed a retrospective immunohistochemical study on 20 cases of leprosy [tuberculoid tuberculoid (TT): 1 patient; borderline tuberculoid (BT): 3 patients; borderline lepromatous (BL): 5 patients; lepromatous lepromatous (LL): 5 patients; borderline borderline in reversal reaction (BB-RR): 1 patient; BT-RR: 2 patients; and erythema nodosum leprosum (ENL): 3 patients]. FoxP3-positive cells were present in 95% of the cases with an average density of 2.9% of the infiltrate. Their distribution was not related to granulomatous structures or special locations. There was no statistical difference of FoxP3 expression between TT, BT, BL, and LL, whereas a statistical significant increment (P = 0.042) was observed in patients affected by reversal leprosy reactions (BT-RR and BB-RR) compared with patients affected by ENL and patients with nonreactional disease forms (BL, LL, BT, TT). CD123 expression was not observed in any of the biopsy specimens evaluated; with the exception of 2 cases of ENL, in which a focal positivity for CD123 was observed. Our results show that plasmacytoid dendritic cells are not involved in the immune response against M. leprae while T-regs are present in leprosy skin lesions. These data raise the question if T-regs have a pathogenetic role in HD as previously demonstrated in Leishmania major and Mycobacterium tuberculosis.
Abstract: BACKGROUND: Palmo-plantar psoriasis (PPP) is a disabling condition that significantly impairs quality of life. PPP tends to be resistant to conventional therapies and may last for several years. Topical treatments are usually ineffective. Systemic therapy with oral retinoids and psoralen plus ultraviolet A is frequently required, although it rarely leads to remission. STUDY DESIGN: We conducted an open-label, pilot study to evaluate treatment of PPP with efalizumab, an anti-CD11a monoclonal antibody approved for the treatment of chronic, refractory moderate to severe plaque psoriasis in adults. METHODS: Five patients with severe PPP received efalizumab treatment for 24 weeks. RESULTS: All five patients responded favourably by week 12 and showed further improvement at week 24 of uninterrupted therapy. Mean physician-assessed severity scores and patient-reported outcome scores improved almost 75% after 12 weeks and 90% after 24 weeks. At week 32, three patients maintained the response seen at week 24, while two patients suspended efalizumab. CONCLUSIONS: Efalizumab therapy was well tolerated and effective in five patients with severe PPP, allowing a significant improvement in quality of life.
Abstract: A new resorbable filler, Matridex, became commercially available during the last years with scarce evidence regarding side effects. A 43-year-old woman complained of multiple, painful, reddish, nonulcerated, hard nodules on both cheeks and periocular regions. Four weeks before, she had been injected by a general practitioner with Matridex for aesthetic purposes to correct wrinkles in the same areas of the nodular eruption. Histopathology showed a diffuse suppurative granulomatous reaction with the presence of multinucleate giant cells and many neutrophils involving the entire dermis. No areas of caseation were observed. The inflammatory granulomatous reaction surrounded 2 different types of nonpolarizing, bluish, exogenous material: one arranged in filamentous structures and the second composed by large spherical particles. All nodules were incised and drained; the patient received systemic antibiotic treatment for 2 consecutive weeks. The nodules progressively regressed and almost complete resolution was seen after 6 months. Matridex is a new resorbable filler constituted by a mixture of nonanimal-stabilized hyaluronic acid (HA), cross-linked HA, and dextranomer microspheres. Foreign body reactions have been described in association with other HA fillers, but a granulomatous reaction after the injection of Matridex has not been reported yet. Interestingly, in our patient, we were able to identify both fragments of HA: the filamentous particles and the spherical particles of dextranomer microspheres within the infiltrate, these last giving a characteristic and recognizable appearance to the histopathological picture.
Abstract: BACKGROUND: Thrombocytopenia has been reported to be associated with efalizumab therapy, but has only sporadically been reported with other anti-tumor necrosis factor alfa (TNF-alpha) agents. OBJECTIVE: To describe the frequency of thrombocytopenia in a cohort of patients who underwent biological therapies for psoriasis. METHODS: This was a retrospective observational study of 93 patients. RESULTS: One hundred eighteen courses of biological therapies were administered to 93 patients. Four of 67 patients who received anti-TNF-alpha agents developed drug-induced thrombocytopenia during treatment, compared with none of the 51 patients receiving efalizumab therapy. The platelet count recovered after suspension of anti-TNF-alpha agents in 3 patients and relapsed after re-exposure in two patients. The overall estimated frequency of thrombocytopenia in our cohort was 4.30% (95% confidence interval [CI], 0% to 6.2%). LIMITATIONS: These findings should be validated in larger studies. CONCLUSIONS: Drug-induced thrombocytopenia is a potential side effect of anti-TNF-alpha agents. Immediate monitoring of platelet counts is recommended if autoimmunity is suspected.
Abstract: Summary Phaeohyphomycosis is a distinct mycotic infection of the skin or internal organs caused by darkly pigmented (dematiaceous) fungi, which are widely distributed in the environment. Phaeohyphomycosis is most frequently an opportunistic infection in immunosuppressed patients (HIV, corticotherapy, transplant patients) or is frequently associated with chronic diseases and diabetes. The spectrum of the disease is broad and includes superficial infections, onychomycosis, subcutaneous infections, keratitis, allergic disease, pneumonia, brain abscesses and disseminated disease. Rarely, immunocompetent patients may be affected. We describe two new cases of subcutaneous phaeohyphomycosis in immunocompetent patients: in the first patient, the causative agent was Exophiala jeanselmei, a common cause of phaeohyphomycosis; and in the second, Cladophialophora carrionii, which could be identified by culture. Cladophialophora carrionii is mainly the aetiological agent of chromoblastomycosis and only rarely the cause of phaeohyphomycosis. The first patient was treated with surgical excision and oral itraconazole, and the second patient responded to oral itraconazole only. Lesions improved in both patients and no recurrence was observed at follow-up visits.
Abstract: Mobile telemedicine integrates wireless communications for different telemedical applications, such as mobile phones and personal digital assistants, and with the implementation of modern wireless telecommunication, wireless local area network and satellite communication is a reality. New generation cellular phones or personal digital assistants have overcome limitations of image quality seen in older devices and, with dermatology being a visual profession, mobile teledermatology is perhaps the most recent development in this field. Mobile teledermatology may provide a triage service aimed toward management of patients with emergent skin disease or for follow-up with patients requiring systemic treatment. Teledermoscopy enables rapid transmission of dermoscopic images via e-mail or specific web-application and studies have demonstrated a high, 91%, concordance between face-to-face diagnosis and remote diagnosis of such images. Further to this, telediagnosis of melanocytic skin neoplasms achieved a diagnostic accuracy of 83% versus the conventional histopathologic diagnosis. Mobile teledermoscopy is the combination of such approaches enabling transfer of images captured with cellular phones coupled with a pocket dermatoscope and preliminary studies have demonstrated the feasibility and potential of its use in triage of pigmented lesions. Such applications are of benefit to physicians in enabling easy storage of data for follow-up or referral of images for expert second opinion and may facilitate a "person-centered health system" for patients with numerous moles and pigmented skin lesions who could forward images for evaluation. The incidence of skin cancers has reached epidemic proportions among whites and the trend is still going upward. Mobile teledermatology and teledermoscopy may be implemented as a triage or screening tool for malignant tumors to facilitate early detection and diagnosis, which is crucial for improved patient outcomes. While the legal aspects concerning teleconsultations need to be evaluated, the communications technologies provide a unique opportunity for physicians and patients alike and we foresee a place for these tools in dermatology soon.
Abstract: Radiation therapy, even at low doses, can induce a wide spectrum of vascular skin proliferations ranging from nonmalignant ones, such as benign lymphangiomatous papules (BLAP), to frankly malignant pathologies, such as angiosarcoma. We describe a 50-year-old Caucasian woman with a past history of uterine rhabdomyosarcoma, treated 22 years prior with surgical excision, chemotherapy, and radiotherapy. She presented with a few skin-colored papules and a clear discharge located in the previously irradiated area (right inguinal region). Histopathology showed a proliferation of irregular, interanastomosing vascular channels, thin walled and lined by prominent endothelial cells with focally hobnail features. Cytological atypia of endothelial cells, mitotic figures, hemorrhagic areas, and necrosis were not observed. The endothelial cells expressed D2-40 and CD31. A diagnosis of BLAP following radiotherapy for uterine rhabdomyosarcoma was made. The patient was treated with complete excision using electrodessication. At the 20-month follow-up visit the patient was still free of recurrence.
Abstract: Teledermatopathology may involve real-time transmission of images from distant locations to consulting pathologists by the remote manipulation of a robotic microscope. Alternatively, the static store-and-forward option involves the single-file transmission of subjectively preselected and captured areas of microscopic images by a referring physician. The recent introduction of virtual slide systems (VSS) involves the digitization of whole slides at high resolution thus enabling the user to view any part of the specimen at any magnification. Such technology has surmounted previous restrictions caused by the size of preselected areas and specimen sampling for telepathology. In terms of client access, these VSS may be stored on a virtual slide server, made available on the Web for remote consultation by pathologists via an integrated virtual slide client network. Despite store-and-forward teledermatopathology being the most frequently used and less expensive approach to teledermatopathology, VSS represents the future in this discipline. The recent pilot studies suggest that the use of remote expert consultants in diagnostic dermatopathology can be integrated into daily routine, teleconsultation, and teleteaching. The new technology enables rapid and reproducible diagnoses, but despite its usability, VSS is not completely feasible for teledermatopathology of inflammatory skin diseases as the performance seems to be influenced by the availability of complete clinical data. Improvements in the diagnostic facility will no doubt follow from further development of the VSS, the slide processor, and of course training in the use of virtual microscope. Undoubtedly, as technology becomes even more sophisticated in the future, VSS will overcome the present drawbacks and find its place in all facets of teledermatopathology.
Abstract: Multiple blue nevi have rarely been reported, and the majority of the lesions are located on the trunk and lower extremities. The blue nevus is a rare lesion on genital mucosa and may cause confusion in differential diagnosis with other pigmented lesions such as genital melanocytic macules, lentigo simplex, and malignant melanoma. Here, we describe an unusual patient who presented with a sudden onset in adulthood of multiple blue nevi on the glans penis. The epiluminescence examination revealed a substantially homogenous bluish pigmentation, which led us to favor a diagnosis of blue nevus, whereas not entirely excluding the possibility of a regressing melanoma or a metastatic melanoma. Because of the well-known diagnostic value of the blue hue in the diagnosis of malignancy by dermoscopy, a careful examination of these lesions should be made in order to minimize any risk of misclassification with melanoma.
Abstract: BACKGROUND: Sebaceous carcinoma (SC) is a rare, aggressive, malignant tumor that is derived from adnexal epithelium of sebaceous glands that are distributed mostly in the skin of the head, neck, and hair-bearing regions of the body. OBJECTIVE: To discuss the clinical and histologic features and the prognosis of the extraocular SC. METHOD: We report a case of SCs of the scalp arising from a previous lesion clinically compatible with a nevus sebaceous. The lesion was surgically excised completely. RESULTS: The postoperative course was free of complications, and the patient was clinically free of disease at her recent follow-up 2 years after treatment. CONCLUSIONS: The absence of metastasis or cutaneous recurrence in our patient, notwithstanding the size of the lesion and its late removal, almost 25 years after the first signs of its growth, confirms a much improved prognostic behavior for extraocular SCs.
Abstract: BACKGROUND: Simplified algorithms for dermoscopy in melanoma diagnosis were developed in order to facilitate the use of this technique by non-experts. However, little is known about their reliability compared with classic pattern analysis when taught to untrained observers. OBJECTIVES: To investigate the diagnostic performance of three different methods, i.e. classic pattern analysis and two of the most used algorithms (the ABCD rule of dermoscopy and the seven-point check-list) when used by newly trained residents in dermatology to diagnose melanocytic lesions. Methods Five residents in dermatology (University of Florence Medical School) were submitted to a teaching programme in dermoscopy based on both formal lessons and training and self-assessment using a newly developed, interactive CD-ROM on dermoscopy. The performance of the three diagnostic methods was analysed in a series of 200 clinically equivocal melanocytic lesions including 44 early melanomas (median thickness 0.30 mm; 25th-75th percentile 0.00-0.58 mm). RESULTS: Pattern analysis yielded the best mean diagnostic accuracy (68.7%), followed by the ABCD rule (56.1%) and the seven-point check-list (53.4%, P = 0.06). The best sensitivity was associated with the use of the seven-point check-list (91.9%), which, however, provided the worst specificity (35.2%) of the methods tested. The interobserver reproducibility, as shown by kappa statistics, was low for all the methods (range 0.27-0.33) and did not show any statistical difference among them. CONCLUSIONS: Pattern analysis, i.e. simultaneous assessment of the diagnostic value of all dermoscopy features shown by the lesion, proved to be the most reliable procedure for melanoma diagnosis to be taught to residents in dermatology.
