Combining Reflective Confocal Microscopy and Dynamic Optical Coherence Tomography to Diagnose Melanoacanthoma: Case Report.

ABSTRACT: Few reported cases discuss distinguishing between melanoma and melanoacanthoma, a seborrheic keratosis (SK) variant, using noninvasive imaging devices. We present a case of a 38-year-old man with Fitzpatrick skin type IV with an asymmetric black papule showing clinical and dermoscopic features of both melanoma and SK. Reflectance confocal microscopy (RCM) and dynamic optical coherence tomography (d-OCT) were used for further evaluation. RCM revealed acanthotic epidermis with a mixed honeycomb and cobblestone pattern, polycyclic bulbous rete ridges, and bright plump cells within entrapped, edged, dermal papillae, compatible with pigmented SK. Also noted were a population of fairly uniform bright dendritic cells scattered quite evenly at all levels of the epidermis and the notable absence of concomitant features of a melanocytic neoplasm (roundish Pagetoid cells, sheets of roundish or dendritic cells at the dermal-epidermal junction, junctional thickenings, and melanocytic nests), suggesting melanoacanthoma. d-OCT showed well-circumscribed, regular, epidermal acanthosis, superficial rounded hypodense structures, normal vascular flow, and notable absence of wiry or contoured vessels, features typically seen in SKs and benign lesions, respectively. Similarly, histologic examination revealed characteristics of pigmented SK containing a population of evenly dispersed dendritic melanocytes (decorated using Melan-A stain) confirming a diagnosis of melanoacanthoma. This case highlights the advantages of incorporating both RCM and d-OCT into clinical practice to noninvasively differentiate melanoma from its clinical mimickers.

Delayed Metastatic Polypoid Nodular Melanoma Diagnosis During COVID-19 Pandemic, Successful Treatment With Surgery and Nivolumab.

Patients with polypoid (pedunculated) melanoma have the poorest 5-year survival rate compared with all other variants of nodular melanoma, presenting with increased thickness, incidence of metastasis, and rates of ulceration. There are few published reports regarding the pathogenesis and treatment of polypoid melanomas. We report the successful treatment of a rapidly developing red nodular polypoid melanoma with metastasis using surgery followed by anti-PD-1 antibody nivolumab in a SARS-CoV-2-positive patient who delayed seeking care due to the COVID-19 pandemic. J Drugs Dermatol. 2021;20(12):1343-1345. doi:10.36849/JDD.6071.

Circumscribed palmoplantar hypokeratosis: a case report and review of the literature.

We describe an 84-year-old man presenting with a solitary, well-circumscribed, chronic erosion of the sole. Histopathologic examination confirmed diagnosis of circumscribed palmoplantar hypokeratosis. Circumscribed palmoplantar hypokeratosis is a rare and benign condition of unknown etiology presenting as an erosion on the palms or soles. Although lesions are typically asymptomatic, the entity is important for dermatologists and providers in other specialties to recognize, especially considering a differential diagnosis that includes neoplasia.

Seven-year itch: a perplexing case of lichen planus-lupus erythematosus overlap syndrome.

Lichen planus-lupus erythematosus overlap syndrome is a rare disorder characterized by clinical and histopathological features of both lichen planus (LP) and lupus erythematosus (LE). Cutaneous lesions commonly affect the distal arms, legs, face, and trunk and these plaques are often large, scaly, painful, and atrophic, often exhibiting hypopigmentation or a red to blue-violet color. We report a case of LP-LE overlap syndrome diagnosed in a man previously believed to have atypical lichen planus who presented with an exacerbation of exuberant pruritic erythematous scaly plaques. The patient had six separate skin biopsies all of which displayed features of LP. Because the clinical symptoms did not correlate to the histopathological picture, a seventh skin biopsy with direct immunofluorescence (DIF) was performed and immunologic markers measured. The DIF demonstrated early lupus bands; serologic testing exhibited elevated ANA and anti-SSA. These findings established the diagnosis of LP-LE overlap syndrome. The patient was started on hydroxychloroquine with short-term trials of oral prednisone during disease flares, which took place in the first three months of treatment.

Pilomatrix Carcinoma Mimicking a Pigmented Basal Cell Carcinoma.

A 76-year-old Caucasian man presented to the dermatology clinic for evaluation of a growing lesion in his right preauricular area. He first noticed the lesion several months prior to presentation but felt it had enlarged significantly in the past month. He denied any pain, pruritus, or bleeding. His medical history was significant for melanoma of the nose treated 47 years ago, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and chronic back pain. The patient reported having the melanoma treated but was unaware of any other details concerning the lesion. He denied any allergies and his medications included lisinopril, amlodipine, gabapentin, and budesonide.

TNF-inhibitor induced lupus in a patient treated with adalimumab for rheumatoid arthritis.

Anti-tumor necrosis factor induced lupus (ATIL) is a rare side effect reported in patients treated with anti-tumor necrosis factor medications such as infliximab, etanercept and adalimumab. Of the three, this condition has been least commonly reported secondary to adalimumab. In this report, we present a case of ATIL in a patient treated for rheumatoid arthritis (RA) with adalimumab. This report will increase physician awareness of the warning signs, diagnostic options and potential complications of ATIL. In this patient, adalimumab was discontinued and treatment was started, leading to improvement in the patient's status.

Treatment options for pilonidal sinus.

Pilonidal sinus disease often presents as a chronic problem in otherwise healthy hirsute men. A range of conservative techniques to surgical flaps have been employed to treat this condition. We review the literature on management of pilonidal sinus disease, including conservative and surgical techniques as well as novel laser therapy. Given current evidence, off-midline repair is now considered the standard of care; however, no statistically significant difference has been noted between primary versus secondary closure or between the Karydakis flap and Limberg flap. Treatment should be tailored to the individual, taking into account recurrent disease, recovery time, and the surgeon's comfort with the procedure.

Red, exophytic nodule of the plantar foot an unusual presentation of a pyogenic granuloma.

Pyogenic granulomas are benign vascular tumors characterized histologically by a lobular proliferation of capillaries. We report an unusual presentation of a pyogenic granuloma in an elderly patient with a bleeding red nodule on the plantar surface of the foot. Nodular exophytic plantar foot lesions often present a diagnostic challenge, as the differential diagnosis includes benign and malignant entities ranging from eccrine poroma and pyogenic granuloma to Kaposi's sarcoma and amelanotic melanoma. This case highlights the need for an adequate biopsy technique to confirm the diagnosis and guide management.

Evaluation of Optical Coherence Tomography as a Means of Identifying Earlier Stage Basal Cell Carcinomas while Reducing the Use of Diagnostic Biopsy.

OBJECTIVE: To determine the diagnostic accuracy of optical coherence tomography for basal cell carcinoma and the proportion of biopsies that could be avoided if optical coherence tomography is used to rule-in surgery. DESIGN: Multicenter, prospective, observational study. SETTING: Dermatology clinics. PARTICIPANTS: Consecutive patients with clinically challenging pink lesions suspicious for basal cell carcinoma. MEASUREMENTS: Clinical, dermoscopic, and optical coherence tomography images were obtained for all subjects. At each stage, the clinician made a diagnosis (pathology + subtype if applicable), and assessed his/her own confidence in the diagnosis. RESULTS: Optical coherence tomography significantly (p<0.01) improved sensitivity and specificity over clinical or dermoscopic evaluation. The percentage of correct diagnoses was 57.4 percent (clinical), 69.6 percent (dermoscopy), and 87.8 percent (optical coherence tomography). Optical coherence tomography significantly increased the certainty of diagnosis; clinicians indicated they were certain (>95% confident) in 17 percent of lesions examined clinically, in 38.6 percent examined with dermoscopy, and in 70 percent examined with optical coherence tomography. With the use of optical coherence tomography in the diagnosis of basal cell carcinoma, more than 1 in 3 patients could avoid a diagnostic biopsy. CONCLUSION: In a population of clinically challenging lesions, optical coherence tomography improved diagnostic certainty by a factor of four over clinical examination alone and improved diagnostic accuracy by 50 percent (57-88%). The addition of optical coherence tomography to other standard assessments can improve the false-positive rate and give a high degree of certainty for ruling in a positive diagnosis for basal cell carcinoma. A reduction of 36 percent in overall biopsies could be achieved by sending high certainty basal cell carcinoma positive optical coherence tomography diagnoses straight to surgery.