[What is new in basal cell carcinoma?] / Was gibt es Neues zum Basalzellkarzinom?

BACKGROUND: Basal cell carcinoma (BCC) is the most common skin cancer in fair-skinned individuals. Although lymph node or visceral metastases are observed in less than 0.5 % of all cases, BCC can have a fatal course due to its highly invasive growth pattern. OBJECTIVES: To provide a comprehensive update on diagnosis, treatment, and prevention of BCC. MATERIALS AND METHODS: We review the current literature and recommendations of the German guidelines on treatment and prevention of skin cancer. The most pertinent developments are summarized in this review article. RESULTS: The use of optical coherence tomography and reflectance confocal microscopy can significantly improve the diagnosis of BCC compared with clinical assessment and dermoscopy alone. Mohs micrographic surgery remains the therapeutic gold standard for tumors in the head and facial area and tumors with high-risk features. The application of imiquimod, 5­fluorouracil, or photodynamic therapy should be restricted to low-risk superficial tumors. Topical inhibitors of the sonic hedgehog (SHH) pathway are currently being evaluated in early clinical trials. In contrast, vismodegib and sonidegib have been approved for the systemic treatment of locally advanced and metastatic BCC with good response rates. The most common adverse events of both agents are muscle cramps, dysgeusia, diffuse alopecia, weight loss, and fatigue. In an Australian phase III trial, oral nicotinamide (vitamin B3) reduced the occurrence of new BCC by 20 % in skin cancer patients. CONCLUSIONS: Targeted therapy with SHH inhibitors has improved the prognosis of locally advanced and metastatic BCC, albeit at the cost of a significant number of adverse events.

Pediatric dermatohistopathology--histopathology of skin diseases in newborns and infants.

While neonatal skin physiology has been thoroughly examined using non-invasive techniques in recent years, only few systematic studies and review articles addressing the histopathology of neonatal skin have been published thus far. In most cases, histopathological findings of dermatoses in neonatal skin do not significantly differ from those seen in adult skin. Nevertheless, a comprehensive knowledge of embryonic and fetal skin development as well as the microanatomical structure of neonatal skin can contribute to a better understanding of various dermatoses of infancy. In the first part of this review article, we present the histopathological features of such skin diseases, which, though generally rare, almost exclusively appear during the first weeks of life due to distinctive structural and functional features of neonatal skin. The second part is dedicated to classic dermatoses of infancy and their histopathological features.

Current diagnosis and treatment of basal cell carcinoma.

Basal cell carcinoma represents is most common tumor in fair-skinned individuals. In Germany, age-standardized incidence rates are 63 (women) and 80 (men) per 100,000 population per year. Early lesions may be difficult to diagnose merely on clinical grounds. Here, noninvasive diagnostic tools such as optical coherence tomography and confocal laser scanning microscopy may be helpful. The clinical diagnosis is usually confirmed by histology. Standard therapy consists of complete excision with thorough histological examination, either by means of micrographic surgery or, depending on tumor size and location as well as infiltration, using surgical margins of 3-5 mm or more. In particular, multiple basal cell carcinomas (such as in Gorlin-Goltz syndrome) and locally advanced as well as rarely also metastatic basal cell carcinoma may pose a therapeutic challenge. In superficial basal cell carcinoma, nonsurgical therapies such as photodynamic therapy or topical agents may be considered. In case of locally advanced or metastatic basal cell carcinoma, an interdisciplinary tumor board should issue therapeutic recommendations. These include radiation therapy as well as systemic therapy with a hedgehog inhibitor.

Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part I. Epidemiology, high-risk groups, clinical strategies, and diagnostic technology.

While most cancers have shown both decreased incidence and mortality over the past several decades, the incidence of melanoma has continued to grow, and mortality has only recently stabilized in the United States and in many other countries. Certain populations, such as men >60 years of age and lower socioeconomic status groups, face a greater burden from disease. For any given stage and across all ages, men have shown worse melanoma survival than women, and low socioeconomic status groups have increased levels of mortality. Novel risk factors can help identify populations at greatest risk for melanoma and can aid in targeted early detection. Risk assessment tools have been created to identify high-risk patients based on various factors, and these tools can reduce the number of patients needed to screen for melanoma detection. Diagnostic techniques, such as dermatoscopy and total body photography, and new technologies, such as multispectral imaging, may increase the accuracy and reliability of early melanoma detection.

Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part II. Screening, education, and future directions.

New evidence has accumulated over the past several years that supports improved melanoma outcomes associated with both clinician and patient screening. Population-based and workplace studies conducted in Australia and the Unites States, respectively, have shown decreases in the incidence of thick melanoma and overall melanoma mortality, and a year-long statewide screening program in Germany has shown a nearly 50% reduction in mortality 5 years after the screening ended. Current melanoma screening guidelines in the United States are inconsistent among various organizations, and therefore rates of both physician and patient skin examinations are low. As policymaking organizations update national screening recommendations in the United States, the latest research reviewed in part II of this continuing medical education article should be considered to establish the most effective recommendations. Patient and provider education will be necessary to ensure that appropriate patients receive recommended screening.

Systemic sclerosis - focus on dermatological aspects. Part 2: diagnostics, therapy.

Systemic sclerosis is a chronic inflammatory multiorgan disease which may involve the skin and internal organs to a varying extent. Pathogenetically the vasculature, connective tissue and the immune system are involved in a yet to be defined sequence and impact. Case history and results of physical as well as laboratory examinations will determine individually adapted further organ imaging or invasive procedures. Based on their results therapy is initiated which may include supportive measures such as physiotherapy as well as basic skin care and avoidance of any trauma. Many agents are available for the circulatory problems including Raynaud phenomenon and digital ulcers such as calcium channel blockers, ACE inhibitors and intravenous prostacyclin derivatives, as well as endothelin receptor blockers and phosphodiesterase inhibitors. Immunosuppressive and immunomodulatory agents are of varying efficacy depending on organ involvement. Though various therapeutic measures are available, beneficial effects are limited and associated with various unwanted effects. In any case, the therapy has to be individually adapted to the disease stage and course of the disease.

State of the art in non-invasive imaging of cutaneous melanoma.

BACKGROUND: This review focuses on looking at recent developments in the non-invasive imaging of skin, in particular at how such imaging may be used at present or in the future to detect cutaneous melanoma. METHODS: A MEDLINE search was performed for papers using imaging techniques to evaluate cutaneous melanoma, including melanoma metastasis. RESULTS: Nine different techniques were found: dermoscopy, confocal laser scanning microscopy (including multiphoton microscopy), optical coherence tomography, high frequency ultrasound, positron emission tomography, magnetic resonance imaging, and Fourier, Raman, and photoacoustic spectroscopies. This review contrasts the effectiveness of these techniques when seeking to image melanomas in skin. CONCLUSIONS: Despite the variety of techniques available for detecting melanoma, there remains a critical need for a high-resolution technique to answer the question of whether tumours have invaded through the basement membrane.

New developments in fluorescence diagnostics.

In the last decade, significant advances have been achieved in the direct viewing of the skin. Non-invasive analysis of various skin diseases in vivo has become possible by special skin display devices, allowing the physician to view the structure and properties of the skin in greater detail than can be achieved by simple visual examination. We review the last 100 years of fluorescence imaging development from clinical observation to advanced spectral imaging, addressing the role of fluorescence diagnostics (FD) in modern dermatology as well as the detection of autofluorescence.

New trends in dermoscopy.

The dermatologists, in their educational training, learn to observe, recognize and classify lesions in order to obtain those stereotypes that allow them to make the diagnosis. For this reason, they have not felt the need to develop means to flank examination. For some years, however, this sort of prejudice is disappearing and also dermatology has begun to make use of semiotics instrumental. Among the most tried and tested equipment in clinical practice, worth remembering the dermoscopy and digital dermoscopic analysis. The recent availability of digital cameras and phones equipped with the latest generation of optical systems capable of capturing images of pigmented lesions in epiluminescence, has further expanded the range of tools at our disposal.

Use of and beliefs about total body photography and dermatoscopy among US dermatology training programs: an update.

BACKGROUND: Total body photography (TBP) and dermatoscopy are imaging techniques used to treat patients with pigmented lesions. OBJECTIVE: We sought to describe use, training, logistics, and beliefs about these tools among residency programs and to assess changes during a 10-year period. METHODS: Surveys were sent to all directors (n = 111) and chief residents (n = 109) of US dermatology training programs. RESULTS: A total of 83 (74.8%) attendings answered the questionnaire. In all, 59 (71.1%) reported using TBP, an 11.9% increase (P = .2484) over the past decade. Reasons for using TBP included: reduces patient anxiety (81.4%), helps detect early melanoma (78.0%), and leads to fewer biopsies (66.1%). Logistical (79.2%) and financial (45.8%) constraints were reasons for not using TBP. Seventy respondents (84.3%) reported using dermatoscopy, a 40.0% increase (P = .0001) over the 10-year period. Reasons for dermatoscopy use were consistent over time: helps find melanoma in curable stage (75.7%), reduces patient anxiety (61.4%), and leads to fewer biopsies (57.1%). The most common reason for not using dermatoscopy remained lack of training (38.5%). A total of 92 (84.4%) residents completed their survey, of which 41 (44.6%) and 81 (88.0%) reported using TBP and dermatoscopy, respectively. In all, 62 (67.4%) and 79 (85.9%) respondents would prefer additional training in TBP and dermatoscopy, respectively. LIMITATIONS: Results may not be applicable to the general dermatology community. CONCLUSIONS: Use of dermatoscopy among residency programs has increased significantly during the last decade. A more modest increase in the use of TBP was observed. Barriers to diffusion of these technologies into practice persist, including insufficient logistics and training.

[What's new in clinical dermatology?]. / Quoi de neuf en dermatologie clinique ?

What's new in clinical dermatology in 2010 mainly concerns inflammatory dermatosis (mainly eczema, psoriasis), internal medicine, allergology, infections. These last years, Tropical Infectiology concentrated news, which were widely reported in What's new in clinical dermatology in 2009. We have a special regard to clinical genetics, numerous papers having dismembered news clinical entities, or having improved knowledge on well known genodermatosis. Finally, we have a special chapter for clinical approach (patients selection, influences on clinical decision, duration of skin examination, Internet use, dermoscopy…), which has been largely investigated during these last years.

Imaging skin: past, present and future perspectives.

Skin imaging modalities relevant to the range of skin conditions encountered in clinical settings are described with respect to the information provided, advantages and limitations, current status and indications for further development. The methods use the interaction of energy with the skin, penetrating to various depths in the stratum corneum, epidermis, dermis and subcutaneous layers. They include a detection system such as the retina, film or a digital array, and a processing system to deconstruct, analyze and interpret the information. Similarly, the areas of interest, or targets, have common features. The skin conditions deviate from the ideal or normal state with respect to skin integrity and function. The deviations include evidence of barrier disruption, inflammation, dispigmentation, and vascular change. The user of skin imaging is often interested in the extent and severity of disease. Part of the task in skin imaging is to establish the criteria for the normal condition. The review encompasses the past, present and future of visual assessment, photographic image collection, spectrophotometric techniques, noninvasive histology, and three dimensional scanning. The analytical techniques for processing and extracting specific parameters that inform about the underlying biological status are presented.

A North American perspective on dermoscopy: benefits, limitations, and grey zones.

Dermoscopy offers novel and cost-effective diagnostic information to guide patient care for melanocytic and non-melanocytic dermatoses. This article reviews the current use of dermoscopy, including its clinical benefits and limitations. Surveys of U.S. and Canadian dermatology residents have demonstrated a desire for improved dermoscopy teaching; an abundance of evidence calls for increasing its use in the clinical setting. Using the current evidence framework, North American dermatology training centers and professional societies should work to foster dermoscopy training and use by both dermatologists and other health care providers.

A Multicenter Survey: How Do Transplant Dermatologists Monitor Organ Transplant Recipients With Nevi?

OBJECTIVES: The incidence and mortality of melanoma are increased in organ transplant recipients. Multiple acquired common and dysplastic nevi are risk factors for melanoma. A new or changing nevus may suggest melanoma. Strategies used by transplant dermatologists to monitor nevi are unknown. Herein, we aimed to assess the methods used by transplant dermatologists for monitoring multiple acquired common nevi, dysplastic nevi, and new or changing nevi. MATERIALS AND METHODS: A questionnaire was e-mailed to 63 members of the Skin Care in Organ Transplant Patients, Europe. RESULTS: Thirty-eight (92.7%) of 41 responders reported that they instruct their patients to perform regular self-skin examinations. Of 41 responders, 41.5% prescribed screening every 6 months, 36.6% prescribed it every 12 months, 12.2% prescribed it every 3 months, and 9.7% performed screening without regular intervals. Regarding type of examination, 80.5% performed full-body skin examinations with the naked eye, 70.7% performed dermoscopy of clinically suspicious nevi, 53.6% offered dermoscopic photography of dermoscopically suspicious nevi, 36.6% provided close-up photography of clinically suspicious nevi, 34.1% performed baseline total body photography, and 24.4% conducted dermoscopy of all nevi. We also found that 7.3%, 4.9%, and 4.9% performed only full-body skin examination with the naked eye, only dermoscopy of clinically suspicious nevi, and only dermoscopy of all nevi, respectively. CONCLUSIONS: Dedicated transplant dermatologists perform a wide variety of nevi screening procedures in organ transplant recipients. Transplant dermatologists should include sequential digital dermoscopic imaging in their armamentarium to follow organ transplant recipients with melanocytic lesions. A combination of techniques is advisable for detecting early posttransplant melanomas.

A survey on the pattern of dermoscopy use among dermatologists in India.

INTRODUCTION AND BACKGROUND: Dermoscopy is being increasingly used for improving dermatological diagnosis. Use of dermoscopy in the early recognition of skin malignancies, especially melanoma, is well established. Of late, its use in general clinical dermatology is growing with the recognition of new and specific patterns in conditions such as hair disorders, inflammatory disorders, and infections/infestations. This cross-sectional survey aims to assess the common patterns of dermoscopy use by Indian dermatologists. METHODS: This was across-sectional survey. An online questionnaire was used to collect data. The questionnaire focused on the frequency of dermoscopy use by Indian dermatologists, reasons for using it or not, and the training they had received on dermoscopy. RESULTS: Of the total 150 valid responses, eighty two (54.7%) participants reported that they were using dermoscopy routinely in their clinical practice. Lack of familiarity and lack of proper training were the important reasons cited for not using dermoscopy regularly. Among the dermatologists using dermoscopy, consensus on effectiveness was highest for hair disorders. CONCLUSIONS: Dermoscopy use by dermatologists in India is mainly in the context of inflammatory dermatosis and hair disorders rather than skin tumors. Lack of familiarity with the technique appears to be main factor limiting the use of dermoscopy in India. LIMITATIONS: Small sample size is the major limitation of this study. It is possible that a large number of dermatologists who do not use dermoscopy might not have responded to the survey, there by affecting the results and their interpretation.

The future of keratinocyte skin cancer surveillance: automated image analysis to identify and monitor keratinocyte dysplasia.

Clinical assessment of actinic keratosis is known to be a variable process; however, there are currently no non-invasive alternatives for objectively assessing the condition besides excision and histopathology. While a number of technologies for examining potential actinic keratoses are under development, each of these still requires subjective human assessment. The existing approaches focus on assessing colour and texture features in clinical-scale images, such as those from dermoscopy and digital photography, and on structural or cellular characteristics in cellular-scale images, such as those from multiphoton microscopy and reflectance confocal microscopy. The future of actinic keratosis management is likely to be a combination of analysing regional photography to determine potential lesion locations and analysis of the structural and cellular features by reflectance confocal microscopy for an in vivo pathology diagnosis.

Importancia del seguimiento de lesiones melanocíticas con dermatoscopia digital para el diagnóstico temprano de melanoma / Importance of monitoring melanocytic lesions with digital dermatoscopy for diagnosis early melanoma

La dermatoscopia digital es una herramienta que permite el diagnóstico de melanomas en estadios tempranos, por medio del seguimiento de las lesiones pigmentarias a largo plazo. Se comunican tres casos de pacientes con alto riesgo de melanoma, en los cuales ‒a través del seguimiento con dermatoscopia digital‒ se realizó el diagnóstico de la enfermedad mediante la detección de cambios morfológicos, arquitecturales y de pigmentación de las lesiones estudiadas. (AU)

Digital dermoscopy is a tool that allows the early diagnosis of melanomas, through the long-term follow up of pigmentary skin lesions. We report three cases of patients with high-risk of melanoma, in which the diagnosis had been made by morphological, arquitectural and pigmentary changes observed by the digital dermoscopy follow-up. (AU)