Line-Field Confocal Optical Coherence Tomography for the Diagnosis of Skin Tumors: A Systematic Review and Meta-Analysis.

A line-field confocal optical coherence tomography (LC-OCT) combines confocal microscopy and optical coherence tomography into a single, rapid, easy-to-use device. This meta-analysis was performed to determine the reliability of LC-OCT for diagnosing malignant skin tumors. PubMed, EMBASE, Web of Science databases, and the Cochrane Library were searched for research studies in the English language from inception till December 2023. To assess quality and the risk of bias, the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) was used. The sensitivity and specificity of each study were calculated. The bivariate summary sensitivity and specificity were calculated using the linear mixed model. Five studies with 904 reported per lesion analyses in our study; the specificity and sensitivity ranged from 67% to 97% and 72% to 92%, respectively. The pooled specificity and sensitivity were 91% (95% CI: 76-97%) and 86.9% (95% CI: 81.8-90.8%), respectively. The summary sensitivity and specificity from the bivariate approach are 86.9% (95% CI: 81.8-90.8%) and 91.1% (95% CI: 76.7-97.0%), respectively. The area under the curve is 0.914. LC-OCT shows great sensitivity and specificity in diagnosing malignant skin tumors. However, due to the limited number of studies included in our meta-analysis, it is premature to elucidate the true potential of LC-OCT.

Spesolimab: A Review of the First IL-36 Blocker Approved for Generalized Pustular Psoriasis.

OBJECTIVE: This article reviews clinical trial data that assesses the safety, efficacy, and clinical application of spesolimab, an interleukin-36 (IL-36) blocker, for the treatment of generalized pustular psoriasis (GPP). DATA SOURCES: A review of the literature was conducted using the search terms: "spesolimab," "BI 655130," and "spevigo" in MEDLINE (PubMed) and Clinicaltrials.gov from January 1, 1950 to October 31, 2023. STUDY SELECTION AND DATA EXTRACTION: Relevant articles in English relating to the pharmacodynamics, pharmacokinetics, efficacy, and safety of spesolimab were included. DATA SYNTHESIS: In one phase 2 clinical trial evaluating single dose IV spesolimab for GPP flares at day 8, 54% of patients receiving spesolimab had a GPP physician global assessment (GPPGA) pustulation subscore of 0, and 43% had a GPPGA total score of 0 compared with 6% and 11% for the placebo group, respectively. Another phase 2 clinical trial assessing subcutaneous spesolimab found 23% of patients in low-dose, 29% in medium-dose, and 10% of high-dose spesolimab had flares by week 48 compared with 52% of the placebo group. Hazard ratios for time to GPP flare compared with placebo were 0.16 (P = 0.0005), 0.35 (P = 0.0057), and 0.47 (P = 0.027) for the spesolimab groups, respectively. Infection rates were similar across treatment and placebo groups, and severe adverse events such as drug reactions with eosinophilia and systemic symptom (DRESS), cholelithiasis, and breast cancer occurred with spesolimab. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS: Spesolimab is a first-in-class IL-36 monoclonal antibody receptor antagonist approved for the treatment of acute GPP flares. It is a safe and effective therapeutic agent in preventing future GPP flares, with no current comparator trials with other GPP agents. CONCLUSION: Spesolimab is a safe and effective treatment for acute GPP flares in adults. Future clinical trials can establish safety and efficacy compared with other agents.

Ex vivo confocal microscopy features of common benign lesions that mimic non-melanoma skin cancers: Towards clinical integration.

Ex vivo confocal microscope (EVCM) rapidly images freshly excised tissue at a histopathological resolution. EVCM features of keratinocyte skin cancers are well-established, but those of benign clinical mimickers remain scarce. We describe EVCM features of common benign lesions and compare them with their malignant differentials. EVCM was used to image 14 benign and 3 cancer tissues. We compared EVCM features of benign lesions with corresponding histopathology and with those of keratinocyte cancers. Key features of benign lesions were identified and differentiated from malignant lesions. Elastin and fat appeared prominent in EVCM; while koilocytes and melanin were difficult to identify. Visualization of entire epidermis was challenging due to difficulty of tissue flattening during imaging. Benign lesions can be differentiated from keratinocyte cancers with EVCM. Using EVCM, a rapid, bedside diagnosis and management of skin neoplasms is possible, especially in a remote location without a histopathology lab.

A Review of the Efficacy of Topical Statins for Treating Disseminated Superficial Actinic Porokeratosis.

Porokeratosis is a rare group of acquired or hereditary dermatoses characterized by linear or annular plaques with a keratotic border. DSAP is the most common porokeratosis, and lesions range from asymptomatic to pruritic circular pink to brown macules, papules, or plaques surrounded by a raised border. DSAP carries about 7.5-10% risk of malignant transformation to SCC or BCC. While in the past DSAP has been widely treated with topical diclofenac, ingenol mebutate, topical vitamin D analog, 5-fluorouracil, imiquimod, photodynamic therapy, retinoids, cryotherapy, and laser therapy, these therapies have shown limited efficacy and have caused adverse effects including inflammatory reactions, hyperpigmentation, pain, and erythema. Recently, a formulation of topical statin and cholesterol has surfaced as a new and promising treatment for DSAP which has shown clinical improvement with a tolerable adverse effect profile when compared to the current therapies. Of the 8 case studies with a total of 20 patients with DSAP, 90% (18/20) reported clinical improvement with various forms of topical statin therapy. While promising, larger randomized controlled trials are needed to evaluate the long-term use of topical statins for DSAP. J Drugs Dermatol. 2023;22(10):     doi:10.36849/JDD.7540.

The role of reflectance confocal microscopy in the diagnosis and management of pigmentary disorders: A review.

BACKGROUND: Reflectance confocal microscopy (RCM) has quickly transitioned from a research tool to an adjunct diagnostic bedside tool, providing the opportunity for noninvasive evaluation of skin lesions with histologic resolution. RCM is an optical imaging technique that uses near-infrared excitation wavelengths and safe low-power lasers. En-face images of different skin layers (up to the superficial dermis) are acquired in grayscale based on the reflective indices of tissue components. Melanin has the highest reflective index (contrast) and appears bright on RCM. AIMS: We present a review of the current literature on the use of RCM in the diagnosis and management of pigmentary disorders. METHODS: We reviewed PubMed and Ovid Medline databases from January 2000 to June 2021, using MeSH key terms: "reflectance confocal microscopy, confocal laser scanning microscopy, pigmentary disorders, treatment, melasma, vitiligo, freckles, solar lentigo, lentigo, tattoo, complications, melanoma, skin cancers, pigmented lesions, post inflammatory, melanin, photoaging" to identify studies and review articles discussing the use of RCM in the diagnosis and management of pigmentary disorders. RESULTS: RCM findings of pigmentary disorders were divided into the following categories: (1) disorders of increased pigmentation (post-inflammatory hyperpigmentation, melasma, Riehl's melanosis, solar lentigines, ephelides, hori nevus, naevus of Ota, café-au-lait macules, melanocytic nevus, melanoma, nevus spilus, labial mucosal melanosis, and mucosal melanoma), (2) disorders of decreased pigmentation or depigmentation (post-inflammatory hypopigmentation, vitiligo, nevus depigmentosus, halo nevus), and (3) exogenous pigmentation (tattoo, ochronosis). CONCLUSION: RCM has been explored and proven valuable for the evaluation and management of pigmentary disorders including melasma, vitiligo, solar lentigines, tattoo, and tattoo-related complications.

Subacute cutaneous lupus erythematosus with a psoriasiform presentation: A diagnostic clinical conundrum.

Key Clinical Message: For practitioners experiencing worsening psoriasis, subacute cutaneous lupus erythematosus (SCLE) with a psoriasiform presentation should be ruled out. Initial treatment for a presumptive diagnosis of psoriasis using hydroxychloroquine or ultraviolet phototherapy may cause SCLE to worsen. Abstract: Psoriasiform subacute cutaneous lupus erythematosus is an unusual presentation scarcely reported in literature. We report a case of a 54-year-old man who presented with an itchy, papulosquamous rash of the upper extremities and face for 7 months. The initial physical examination revealed the classical morphology of psoriasis. One and a half years after the diagnosis of clinical worsening, the patient noticed a new papular eruption on the right posterior upper arm. A skin biopsy was performed, confirming a diagnosis of subacute cutaneous lupus erythematosus. This case report highlights the importance of considering rare presentations of cutaneous lupus erythematosus and therapeutic challenges in management.

Efficacy of Intralesional Vitamin D3 for Treatment of Verruca Vulgaris: A Randomized Control Study.

Cutaneous warts are benign epithelial lesions caused by human papillomavirus and are common entities, affecting nearly 10 percent of the United States population. While most warts spontaneously resolve, the immunocompromised are susceptible to recalcitrant warts which often require medical treatment. Most current therapies use either physical or chemical destruction for wart removal, but these treatments are associated with adverse effects. Intralesional vitamin D3 has the potential to demonstrate a stronger treatment response due to its ability to stimulate the immune system at the injection site via cell-mediated immunity. We sought to test the efficacy of intralesional vitamin D3 for wart treatment in a sample size of 70 patients over a three-month period. Efficacy was determined as "excellent" if there was greater than a 90-percent reduction in both size and number of lesions, "good" if there was a 60 to 89-percent reduction, and "fair" if there was less than a 60-percent reduction. Treatment efficacy was excellent in 20 (28.6%) patients, good in 29 (41.4%) patients, fair in 18 (25.7%) patients, and poor in three (4.3%) patients. Patients in the younger age group had a higher treatment efficacy compared to other treatment groups. Thus, intralesional vitamin D3 has promising qualities as a treatment for cutaneous warts and should be considered at the clinician's disposal. Vitamin D is an innovative approach for treating warts without the various side effects posed by other commonly used agents. The unique features of this treatment modality including its simplicity, safety, and efficiency make it a promising option for a very common cutaneous condition.

Role of VivaScope 2500 ex vivo confocal microscopy in skin pathology: Advantages, limitations, and future prospects.

BACKGROUND: Vivascope 2500 ex vivo confocal microscopy (EVCM) is an emerging optical imaging device that allows nuclear level resolution of freshly excised tissues. EVCM provides, rapid real-time pathological examination in many subspecialties of pathology including skin, prostate, breast, liver, etc. In contrast to traditional time-consuming frozen sectioning and histological analysis. AIMS: To evaluate the current state of EVCM utilization. MATERIALS AND METHODS: This study highlights the advantages, limitations, and prospects of EVCM in skin pathology. RESULTS: Our findings demonstrate that EVCM is a promising adjunctive tool to assess margins in Mohs surgery and to provide rapid, accurate diagnosis of cutaneous tumors, infectious and inflammatory diseases. CONCLUSION: EVCM is a revolutionary device that can be used as an adjunct to paraffin-fixed, hematoxylin and eosin-stained slides and frozen sectioning. Additional refinements are required before EVCM can be used as an alternative to frozen sectioning or traditional tissue processing.

Tear Trough Filler Techniques Utilizing Hyaluronic Acid: A Systematic Review.

BACKGROUND: Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face, including the tear trough. Despite well-documented risks, there is no standardized, evidence-based approach to inject filler in this area, be it using a hypodermic needle or a microcannula. The authors, therefore, sought to establish a preference between the two methods to facilitate progression toward standardization and prevention of adverse events. METHODS: This is a systematic review of articles discussing hyaluronic acid tear trough injection techniques performed in vivo and related outcomes. Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science, and Embase to yield relevant articles published before February of 2020. All selected articles incorporated discrete patient cases and were analyzed by a variety of variables assessing evidence strength, outcomes, technique, and patient safety. RESULTS: After appraisal, 42 articles met eligibility criteria: 20 using needles, 12 using cannulas, and 10 focusing on adverse events. Level III was the most commonly awarded evidence grade, corresponding to retrospective, nonexperimental descriptive studies. There were no statistically significant differences in reported aesthetic results, patient satisfaction, or incidence of adverse events across the needle-based and cannula-based articles. Some technique trends, such as targeted anatomical plane and needle position, emerged in subsequent articles. CONCLUSION: Given that there were no statistically significant differences in patient safety or outcomes, an evidence-based preference for needle or cannula injection into the tear trough cannot be made at this time. Current inconsistencies make tear trough injection procedures difficult to replicate, making standardization based on avoidance of adverse events not feasible.

Multicentric reticulohistiocytosis with dermatomyositis-like features: A case report with dermoscopy and reflectance confocal microscopy findings.

Multicentric reticulohistiocytosis (MRH) is an insidious-onset, non-Langerhans-cell histiocytosis (NLCH) affecting the joints and skin. Early diagnosis is important to prevent destructive arthritis and disease-related complications. Reflectance confocal microscopy (RCM) is a technique that allows the visualization of the epidermis and superficial dermis noninvasively on a horizontal plane with quasi-histologic images of the skin. RCM features of NLCH including Rosai-Dorfman disease, adult xanthogranuloma (AXG), and juvenile xanthogranuloma (JXG) have been reported. However, RCM features of MRH have not been described previously. Here we present the RCM features of a case of MRH with dermoscopic and histopathologic features.

A case of dermatofibrosarcoma protuberans and reflectance confocal microscopy of a post-surgical skin graft.

Dermatofibrosarcoma protuberans (DFSP) is an overall rare malignancy yet is one of the most common cutaneous sarcomas. The diagnosis of DFSP is typically made following histopathologic examination of the lesion, classically revealing a storiform pattern of spindle cells with elongated nuclei infiltrating the dermis and subcutis. Surgical excision is the standard treatment. Local recurrence is estimated to occur in 20-50% of cases, thus frequent postsurgical monitoring is required. Noninvasive imaging modalities offer a potential alternative to multiple repeat biopsies. We report the first case where reflectance confocal microscopy accompanied clinical examination in monitoring for DFSP recurrence postsurgical excision.

Updated review on prognostic factors in mycosis fungoides and new skin lymphoma trials.

BACKGROUND: Ten-year survival rates in mycosis fungoides (MF) broadly varies, however, there is no standardized prognostic index available. This is presumably due to low prevalence, heterogeneity, and diagnostic challenges in MF. Recent studies have focused on identifying objective prognostic indices by using different parameters for survival determinants. The Cutaneous Lymphoma International Prognostic Index (CLIPI) and the Prospective Cutaneous Lymphoma International Prognostic Index (PROCLIPI) represent prototypical studies that identify prognostic factors, seeking to improve management and outcomes in early-stage MF. Detecting these factors and stratifying MF patients according to their disease progression risk may help to manage these patients more efficiently. AIMS: Review the current literature to determine the risk factors determining prognosis in MF. METHODOLOGY: A Comprehensive literature search was performed using electronic online databases "PubMed" and "Google Scholar" using key words 'prognostic factor', 'prognostic indicator', 'mycosis fungoides', 'Sezary syndrome', 'Skin Lymphoma', 'Cutaneous Lymphoma'. Articles published in English language were considered for the review. RESULTS: The strongest prognostic factor in MF patients is the stage of the disease. T stage and the presence of extracutaneous disease are the most important factors for survival. Other factors that are associated with worse prognosis are male gender, age >60, presence of plaques, folliculotropism, eosinophilia and lymph node stage above N1/Nx. Elevated LDH was associated with later tumor stages and large cell phenotype at diagnosis had a better prognosis. KIR3DL2 was associated with malignant transformation. CONCLUSION: The PROCLIPI study has assessed risk factors collected in MF patients from different countries and across different ethnicities following a rigorous clinicopathologic process. The findings presented here illustrated that disease prognosis in early stages depends on many contributing factors. Detection and stratification of such factors may allow a personalized approach to management of these patients.

Langerhans Cells as Morphologic Mimickers of Atypical Melanocytes on Reflectance Confocal Microscopy: A Case Report and Review of the Literature.

Pagetoid spread of melanocytes in the epidermis is a common indicator of melanocytic atypia, both histopathologically and with reflectance confocal microscopy (RCM). Specifically on RCM, large, bright, atypical dendritic and/or roundish cells are characteristic of melanoma. However, intraepidermal Langerhans cells (ILC) create the potential for diagnostic ambiguity on RCM. We describe one case of a pigmented facial lesion that was initially diagnosed as lentigo maligna (LM) due to numerous atypical perifollicular dendritic cells on RCM. Additionally, we present the findings of a literature review for similar reported cases conducted by searching the following terms on PubMed: reflectance confocal microscopy, RCM, lentigo maligna, melanoma, Langerhans cells, dendritic cells, and atypical cells. In our case, the lesion was determined to be a solar lentigo on histopathology. Immunohistochemistry (IHC) with CD1a identified the atypical-appearing cells as ILC, as it did in 54 reported cases of benign lesions (benign melanocytic nevus, Sutton/halo nevus, labial melanotic macule, and solar lentigo) misdiagnosed as malignant on RCM (melanoma, lip melanoma, lentigo maligna, and LM melanoma). According to our case and the literature, both ILC and atypical melanocytes can present with atypical-appearing dendritic and/or roundish cells under RCM. Currently, there is no method to distinguish the two without IHC. Therefore, the presence of pagetoid cells should continue to alert the confocalist of a potential neoplastic process, prompting biopsy, histopathologic diagnosis, and IHC differentiation.

Reflectance confocal microscopy evaluation of pigmented lesions on tattooed skin.

The evaluation of pigmented lesions on tattooed skin poses a diagnostic challenge for dermatologists, as a nevus may be partially or completely obscured by tattoo pigment. Because of incidences of melanoma arising from tattooed skin, the current gold standard is to biopsy these lesions. Reflectance confocal microscopy (RCM) is a noninvasive imaging modality used in the diagnosis and management of skin diseases that may allow for diagnosis, while preserving the tattoo design. Retrospective chart review was conducted to identify pigmented lesions on or near tattooed skin that were evaluated with RCM. Confocal characteristics and diagnoses were recorded and analyzed. Nineteen lesions from 15 patients were retrospectively reviewed. Tattoo pigment did not hinder evaluation and diagnosis of pigmented lesions on RCM. About 94.7% of lesions were diagnosed as benign melanocytic nevi by an expert confocal reader. One lesion was confocally diagnosed as melanocytic nevus with atypia but was found to be an inflamed melanocytic nevus on histology. Tattoo pigment particles were differentiated from other hyper-refractile entities by an expert confocal reader based on size, morphology, and clinical correlation. RCM may provide a solution to the diagnostic challenge of pigmented lesions on or near tattooed skin.