Reflectance confocal microscopy in pediatric dermatology: A state-of-the-art review.

Reflectance confocal microscopy is an innovative imaging modality, which noninvasively provides an optical image to aid in the diagnosis of skin lesions. While performing a skin biopsy for histopathologic analysis is the gold standard to definitively diagnose skin disease, this may prove to be more difficult in the pediatric population. This will occasionally necessitate sedation or general anesthesia as an approach, which carries a number of different risks. Reflectance confocal microscopy is an exciting new avenue in the support of diagnosing skin pathology, with the goal of improving pediatric patient tolerance and experience when examining epidermal and superficial dermal skin lesions. This review discusses the utility of reflectance confocal microscopy for pediatric dermatology patients pertaining to melanocytic and non-melanocytic skin neoplasms and inflammatory and infectious skin diseases in children.

Surgical Margin Mapping of Melanoma In Situ Using In Vivo Reflectance Confocal Microscopy Mosaics.

BACKGROUND: Melanoma in situ (MIS) can have poorly defined borders and subclinical extension that makes margin control challenging. Reflectance confocal microscopy (RCM) is a promising noninvasive technique that can be used to assess subclinical spread. OBJECTIVE: To optimize surgical margins of histology-proven MIS using RCM mosaics. MATERIALS AND METHODS: Prospective review of 22 patients with histology-proven MIS who underwent RCM margin mapping prior to staged excision, between August 1, 2018, and August 13, 2020, at the Department of Dermatology, University of New Mexico, School of Medicine. RESULTS: Twenty patients (91%) had tumor clearance on the first stage using a 3-mm surgical margin after confocal margin mapping. CONCLUSION: Reflectance confocal microscopy margin mapping using the mosaic device tends to clear MIS in one stage, and the use of the handheld device may improve the accuracy for difficult anatomic areas. Current Procedural Terminology codes for RCM do not reflect the time required and complexity of the procedure. Reflectance confocal microscopy margin mapping prior to excision has the potential to decrease the number of stages needed for melanoma removal, reduce treatment time, and cost.

Dermatologists are more likely than oncologists to prescribe skin-directed therapies for early-stage cutaneous T-cell lymphoma: a retrospective review.

Early-stage cutaneous T-cell lymphoma (CTCL) is managed effectively with skin-directed therapies such as topical medications, phototherapy, and local ionizing radiation. Patients with CTCL often seek care from both dermatologists and oncologists. Our study aimed to compare the frequency that skin-directed treatments were prescribed to patients managed by each of these specialties. Overall, we found there was a statistically detectable relationship between the presence or absence of oncologist involvement and the likelihood that a patient would be prescribed skin-directed therapies (P=0.0003). Of the oncologists included in the study, 66% opted for management revolving around systemic rather than skin-directed therapies. However, when a dermatologist and oncologist worked together in a patient's care, the number of patients receiving skin-directed therapies increased to 100%. Our study suggests that patients with early stage CTCL may benefit from having a dermatologist involved in their care.

BRAF inhibitor and hairy cell leukemia-related transient acantholytic dermatosis.

Grover disease (GD) is an acquired, nonfamilial, nonimmune mediated, transient or persistent acantholytic dermatosis. Herein, we present a 72-year-old man who had clinical and histopathologic findings of GD following two weeks of treatment with vemurafenib without MEK inhibitor. The patient was successfully treated with topical emollients and a high-potency corticosteroid. Meanwhile, vemurafenib was temporarily discontinued. Drug-induced GD has increasingly been reported in patients on BRAF inhibitor monotherapy as an immune-related adverse event. The cutaneous side effects seem to arise secondary to a paradoxical activation of the mitogen-activated protein kinase signaling of BRAF inhibitor treatment, leading to keratinocyte proliferation. Although the pathogenesis of GD has not been delineated, there is suggestion of activation of T lymphocytes, particularly helper cells under the action of pro-inflammatory cytokines, resulting in proliferation of keratinocytes. Combination therapy with a MEK inhibitor appears to prevent BRAF-induced GD. Given that there is a higher prevalence of GD in patients with hematologic malignancy, a direct causal relationship between the initiation of vemurafenib therapy and development of GD in this case may be difficult to establish.

Generalized basaloid follicular hamartoma syndrome versus Gorlin syndrome: A diagnostic challenge.

Basaloid follicular hamartoma is a relatively rare benign neoplasm of follicular origin that can be mistaken histologically for basal cell carcinoma, but hereditary forms of basaloid follicular hamartoma are associated with nevoid basal cell carcinoma syndrome, or Gorlin syndrome. The pathophysiology of basaloid follicular hamartoma development involves mutations in the patched gene, which is also causative in nevoid basal cell carcinoma syndrome. We present a mother and daughter with basaloid follicular hamartomas, with genetic testing confirming patched gene mutation in the daughter.

Moonlighting in residency: a dermatology perspective.

BACKGROUND: Moonlighting refers to the practice of medicine outside one's training institution in exchange for financial compensation. High medical debt-to-income ratios drive residents to seek additional compensation during residency. OBJECTIVE: To gather information to establish the current practices of moonlighting and to better understand the thoughts and experiences of dermatology residency program directors regarding moonlighting. METHODS: All allopathic and osteopathic dermatology residency program directors in the United States and Puerto Rico received a blinded survey between February 1, 2017 and April 1, 2017 through an email link. RESULTS: Response rate was 47.0%. Of the programs that responded, 63.16% allowed moonlighting. In three regions, 100% of programs allowed moonlighting. The geographic area with the lowest percentage of programs permitting moonlighting was New England with 25%. LIMITATIONS: This survey only reflects the field of dermatology and beliefs/policies of program directors. CONCLUSION: This survey highlighted that training programs allowing moonlighting tend to have a more positive outlook on the practice than programs who do not. Results revealed trends that suggest that states in regions with less access to dermatologic care were more inclined to allow moonlighting.

Automated identification of abnormal respiratory ciliary motion in nasal biopsies.

Motile cilia lining the nasal and bronchial passages beat synchronously to clear mucus and foreign matter from the respiratory tract. This mucociliary defense mechanism is essential for pulmonary health, because respiratory ciliary motion defects, such as those in patients with primary ciliary dyskinesia (PCD) or congenital heart disease, can cause severe sinopulmonary disease necessitating organ transplant. The visual examination of nasal or bronchial biopsies is critical for the diagnosis of ciliary motion defects, but these analyses are highly subjective and error-prone. Although ciliary beat frequency can be computed, this metric cannot sensitively characterize ciliary motion defects. Furthermore, PCD can present without any ultrastructural defects, limiting the use of other detection methods, such as electron microscopy. Therefore, an unbiased, computational method for analyzing ciliary motion is clinically compelling. We present a computational pipeline using algorithms from computer vision and machine learning to decompose ciliary motion into quantitative elemental components. Using this framework, we constructed digital signatures for ciliary motion recognition and quantified specific properties of the ciliary motion that allowed high-throughput classification of ciliary motion as normal or abnormal. We achieved >90% classification accuracy in two independent data cohorts composed of patients with congenital heart disease, PCD, or heterotaxy, as well as healthy controls. Clinicians without specialized knowledge in machine learning or computer vision can operate this pipeline as a "black box" toolkit to evaluate ciliary motion.

Imaging of Mohs micrographic surgery sections using full-field optical coherence tomography: a pilot study.

BACKGROUND: Full-field optical coherence tomography (FF-OCT) is a new noninvasive imaging technique that can see down to the cellular level without tissue preparation or contrast agents. OBJECTIVE: To use FF-OCT to image Mohs micrographic surgery specimens and verify the ability of a dermatopathologist to identify or exclude malignancy. MATERIALS AND METHODS: Two Mohs surgeons supplied 18 Mohs sections from 11 patients. Each section was scanned using the FF-OCT, and a dermatopathologist blinded to the diagnosis examined the images for malignancy. The FF-OCT images were then compared with the intraoperative hematoxylin and eosin (H&E)-stained frozen sections for concordance. RESULTS: All 9 FF-OCT images interpreted as negative for malignancy were in agreement with the H&E frozen sections. Six of the remaining FF-OCT images were correctly interpreted as positive for malignancy, and three were deferred because malignancy could not be confirmed or excluded. CONCLUSION: Malignancy in Mohs sections can correctly be identified or excluded using FF-OCT. Although not ready for clinical use in its current state, FF-OCT has the potential to be incorporated into the Mohs workflow in the future.

Registration of Magnetic Resonance Image Series for Knee Articular Cartilage Analysis: Data from the Osteoarthritis Initiative.

OBJECTIVE: Although conventional radiography is used to assess osteoarthritis in a clinical setting, it has limitations, including an inability to stage early cartilage degeneration. There is a growing interest in using quantitative magnetic resonance imaging to identify degenerative changes in articular cartilage, including the large multicentered study, the Osteoarthritis Initiative (OAI). There is a demand for suitable image registration and segmentation software to complete this analysis. The objective of this study was to develop and validate the open source software, ImageK, that registers 3 T MRI T2 mapping and double echo steady state (DESS) knee MRI sequences acquired in the OAI protocol. METHODS: A C++ library, the insight toolkit, was used to develop open source software to register DESS and T2 mapping image MRI sequences using Mattes's Multimodality Mutual information metric. RESULTS: Registration was assessed using three separate methods. A checkerboard layout demonstrated acceptable visual alignment. Fiducial markers placed in cadaveric knees measured a registration error of 0.85 voxels. Measuring the local variation in Mattes's Mutual Information metric in the local area of the registered solution showed precision within 1 pixel. In this group, the registered solution required a transform of 56 voxels in translation and 1 degree of rotation. CONCLUSION: The software we have developed, ImageK, provides free, open source image analysis software that registers DESS and T2 mapping sequences of knee articular cartilage within 1 voxel accuracy. This image registration software facilitates quantitative MRI analyses of knee articular cartilage.