Reflectance confocal microscopic visualization of melanocytic bodies in the stratum corneum overlying acral lentiginous melanoma.

BACKGROUND: We present a case of RCM evaluation of ALM surgical margins demonstrating intracorneal melanocytic bodies overlying subsequently confirmed melanoma in situ by histopathology. CASE PRESENTATION: A 73-year-old male with a history of acral lentiginous melanoma (ALM) of the right great toe presented to our clinic for evaluation of positive surgical margins. The positive margin was localized for examination and subsequent biopsy with reflectance confocal microscopy (RCM) which allowed targeted re-resection of the area of concern. Three punch biopsies were obtained in the area of concern, which confirmed residual melanoma in situ. Immunostains confirmed the cellular remnants in the stratum corneum were melanocytic. To correlate the intra stratum corneum findings seen with confocal to the histopathology, a 3D rendering of a stack of images was used to demonstrate the location. DISCUSSION: Typically, acral surfaces are challenging to examine with RCM due to the limited ability of light to penetrate thickened stratum corneum; however, we observed unique cellular features with confocal. Scattered hyper-reflective pleomorphic cells consistent with melanocytes were observed in the stratum corneum, although the visualized underlying epidermis appeared normal. Confocal microscopy may aid in diagnosis and management of ALM, especially in the context of positive surgical margins.

Improving dermal level images from reflectance confocal microscopy using wavelet-based transformations and adaptive histogram equalization.

OBJECTIVES: Reflectance confocal microscopy (RCM) generates scalar image data from serial depths in the skin, allowing in vivo examination of cellular features. The maximum imaging depth of RCM is approximately 250 µm, to the papillary dermis, or upper reticular dermis. Frequently, important diagnostic features are present in the dermis, hence improved visualization of deeper levels is advantageous. METHODS: Low contrast and noise in dermal images were improved by employing a combination of wavelet-based transformations and contrast-limited adaptive histogram equalization. RESULTS: Preserved details, noise reduction, increased contrast, and feature enhancement were observed in the resulting processed images. CONCLUSIONS: Complex and combined wavelet-based enhancement approaches for dermal level images yielded reconstructions of higher quality than less sophisticated histogram-based strategies. Image optimization may improve the diagnostic accuracy of RCM, especially for entities with dermal findings.

Impaired wound healing secondary to bevacizumab.

Bevacizumab is a monoclonal antibody that exerts its antitumor activity by inhibiting vascular endothelial growth factor. Consequently, it suppresses endothelial cell proliferation, vascular permeability, and angiogenesis. This inhibitory effect contributes to tumour size reduction but causes wound-healing delay, specifically during the proliferative phase, in patients receiving bevacizumab. Although surgical wound-healing complications (WHC) associated with bevacizumab have been extensively reported, there is limited literature on peripheral WHC. More importantly, the histopathology of bevacizumab-associated WHC has not been described. We present the histopathology findings of a non-healing ulcer in a patient receiving bevacizumab, providing insight into the possible aetiology of this drug's adverse reaction. Furthermore, our patient's positive response to hyperbaric oxygen suggests its possible use for treatment of bevacizumab-associated non-healing wounds.

Use of Biologics in Private Practice: Nine Years of Lessons and Learning.

Over a decade ago, the FDA approved biologics for psoriasis, which changed how the disease is treated and, in most cases, has a significant positive impact on the lives of patients. Side effects primarily identified during the investigational and research phase led to the development of specific guidelines for treatment. The treatment guidelines have been amended to incorporate better understandings of side-effects over the years that the disease has been treated. In this study, we focused on a chart review that included assessing the current guidelines and their alignment with modern patient management and the recent side effects presented. This life-cycle evaluation included over 100 patients, management of their treatment, laboratory abnormalities, criteria for choosing or changing to a different biologic, and the effects of the treatments management throughout the years. The review identified some recommended changes in the application and treatment of psoriasis with biologics. To further evidence our findings, we hope to expand this study to a larger scale with more patients.

J Drugs Dermatol. 2017;16(3):215-217.

Vitiligo: Not Simply a Skin Disease.

Melanocytes, the cells responsible for skin pigmentation, are present in other parts of the body, such as the ocular, auditory, nervous, and cardiac systems. Within these systems, their roles serve a different purpose than their classical counterparts in skin as pigment cells. Such roles include cell turnover in retinal pigment epithelium, maintenance of balance and prevention of environmental damage in the auditory neuroepithelium, role-playing as dendritic cells within the leptomeninges, and prevention of oxidative damage in adipose tissue. Vitiligo, commonly known as a skin pigmentation disorder, has also been associated with several systemic disorders, such as Vogt-Koyanagi-Harada disease and Alezzandrini, Kabuki, and MELAS syndromes. Therefore, since these conditions involve compromise of systems in which melanocytes reside, it is not surprising that vitiligo has other systemic associations. The authors present a detailed review of systemic associations of vitiligo and melanocytes' roles in other organ systems with a focus on systemic disease.

A Souvenir From France: Acrodermatitis Chronica Atrophicans Presenting in the United States.

A 70-year-old man was referred by his rheumatologist to our dermatology clinic for evaluation of dermatitis on his right arm that appeared 3 months earlier. The skin lesion was asymptomatic and the patient denied current systemic symptoms, including fever, chills, and joint pain; however, 10 months prior to this presentation he experienced arthritis in the left knee. At that time, Borrelia serology revealed positive IgG (6.07; <0.8 negative, 0.8 to 0.99 borderline, ≥1 positive) and negative IgM titers. The patient had not received treatment for Lyme disease in the past. He was referred to rheumatology for evaluation of possible Lyme disease but did not follow up until 10 months later. The arthritis has since resolved. He travels frequently to France and recalls multiple tick bites during these trips.

Histologic outcomes of excised moderate and severe dysplastic nevi.

BACKGROUND: Dysplastic nevi (DN) have been a matter of controversy since their initial description in 1978 because of differences in the clinical and histological terminology, and large studies on histological outcomes of excising moderate to severely DN have not previously been described. OBJECTIVE: To determine the clinical characteristics of DN and histologic outcomes of excised moderate and severe DN. METHODS: Retrospective chart review of patients with DN or Clark's nevi at the Dermatology Department at Rutgers-Robert Wood Johnson Medical School in Somerset, New Jersey, from January 2009 to June 2012. Three hundred ninety-three lesions from 380 patients were included in this study. MAIN OUTCOME MEASURE: Histologic results of excised moderate and severe DN. RESULTS: Thirty-four percent of DN were excised because of the presence of moderate or severe atypia, personal history of melanoma, or both. None of the excised lesions showed evidence of melanoma; 81.6% of excisions showed scar or granulation tissue. Only 14% of excised lesions were found to have residual lesions, and 4.4% showed recurrent nevi. CONCLUSION: In 134 excisions of moderate to severe DN, no melanoma was identified. Most of the excisions showed scar or granulation tissue. The rate of residual lesions after shave biopsy of moderate or severe DN was lower than after punch biopsy.

Bibliometric Analysis of the Top 100 Most Cited Papers in Mohs Surgery.

BACKGROUND: Mohs micrographic surgery is a specialized tissue-sparing technique used to treat skin cancers. OBJECTIVE: By understanding the attributes that make a research paper one of the top 100 cited papers on Mohs surgery, we hope to illuminate seminal research in this field. METHODS AND MATERIALS: The global literature about Mohs surgery published between 1900 and 2023 was searched on the Web of Science. Publication data for all results meeting the search criteria were exported and analyzed. RESULTS: In total, 4,961 publications with 81,405 citations were identified. Dermatologic Surgery was the most cited journal, with 1,073 publications. Papers from the top 100 most cited that were published in the year 2000 or prior had an average of 22.1 citations in the first five years after publication, whereas papers published after 2001 had an average of 56.0 citations in the first five years. CONCLUSION: Analysis of the most cited papers on Mohs surgery demonstrates the influential role of the Dermatological Surgery journal in advancing the field. Noteworthy studies addressing cost, safety, and efficacy have received substantial citations, reflecting their significance within the literature. A trend toward more citation in the first five years after publication over time was identified.

In Vivo View of a Reclining Demodex Mite in a Milia Cyst.

Demodex folliculorum and Demodex brevis are commonly present on facial skin and frequently noted via Reflectance Confocal Microscopy (RCM) examination. These mites inhabit follicles and are often seen in groups of two or more, although D. brevis is usually found as a solitary mite. When observed through RCM, they are typically present as refractile, round groupings seen on a transverse image plane inside the sebaceous opening, as they are vertically oriented, and their exoskeletons refract under near-infrared light. Inflammation may occur, leading to a variety of skin disorders; nonetheless, these mites are considered to be part of normal skin flora. a 59-year-old woman presented to our dermatology clinic for confocal imaging (Vivascope 3000, Caliber ID, Rochester, NY, USA) of a previously excised skin cancer for margin evaluation. She did not exhibit symptoms of rosacea or active inflammation of the skin. Incidentally, a solitary demodex mite was noted in a milia cyst nearby the scar. The mite appeared to be trapped in the keratin-filled cyst and was positioned horizontally to the image plane such that its entire body was captured in a coronal orientation as a stack. Demodex identification using RCM can provide clinical diagnostic value in the context of rosacea or inflammation; in our case, this solitary mite was thought to be part of the patient's normal skin flora. Demodex are practically ubiquitous on the facial skin of older patients and are frequently noted during RCM examination; however, the orientation of the mite referenced herein is uncommon, allowing for a unique view of its anatomy. The use of RCM to identify demodex may become more routine as access to technology grows.

Dermoscopy and skin imaging light sources: a comparison and review of spectral power distribution and color consistency.

Significance: Dermoscopes incorporate light, polarizers, and optical magnification into a handheld tool that is commonly used by dermatologists to evaluate skin findings. Diagnostic accuracy is improved when dermoscopes are used, and some major artificial intelligence (AI) projects have been accomplished using dermocopic images. Color rendering consistency and fidelity are crucial for clinical diagnostics, AI, and image processing applications. Aim: With many devices available on the market, our objective was to measure the emission spectra of various dermoscopes, compare them with other light sources, and illustrate variations in reflected colors from images of a reference sample. Approach: A spectrometer measured the spectral power distribution (SPD) produced by four dermoscope models and three alternate light sources, illustrating differences in the emission spectra. Most dermoscopes use light-emitting diodes (LEDs), which are inconsistent when compared with one another. An LED was compared with halogen, xenon-arc, and daylight sources. Images of a micro ColorChecker were acquired from several sources, and three specific colors were selected to compare in CIELAB color space. Color consistency and color fidelity measured by color rendering index (CRI) and TM-30-18 graphical vectors show variation in saturation and chroma fidelity. Results: A marked degree of variation was observed in both the emission and reflected light coming from different dermoscopes and compared with other sources. The same chromophores appeared differently depending on the light source used. Conclusions: A lack of uniform illumination resulted in inconsistent image color and likely impacted metamerism and visibility of skin chromophores in real-world settings. Artificial light in skin examinations, especially LEDs, may present challenges for the visual separation of specific colors. Attention to LEDs SPD may be important, especially as the field increases dependency on machine/computer vision.