Dermoscopy Use in Africa: Determinants and Challenges.

INTRODUCTION: Dermoscopy has evolved over the years beyond distinguishing benign pigmented lesions from melanoma to diagnosing virtually all diseases in dermatology. Overwhelming evidence demonstrates its utility in improving diagnostic accuracy, reducing unnecessary biopsies and lesion monitoring. Dermoscopy is widely used in Western nations, hence most descriptions of lesions in literature are predominantly on Fitzpatrick skin types I-III. Current evidence shows that there are unique dermoscopic features in the dark skin as a result of pigment and pathological reactions. Nationwide surveys and reports have been conducted across several continents to highlight prevalence and factors influencing dermoscopy use with the hope of maximizing its apparent benefits. There are currently no such reports from Africa. OBJECTIVES: To evaluate dermoscopy use and its determinants among dermatologists in Africa. METHODS: A cross-sectional study. Online forms were e-mailed to individual practicing dermatologists and members of the African Society of Dermatologists and Venereologists. RESULTS: There were 196 respondents from 24 African countries. Half of them used dermoscopy. Training, practice settings and location, provision of dermatoscopes by institutions and knowledge of criteria were notable significant determinants. Multiple training exposures, knowledge of criteria, availability of dermatoscopes, use of both hand-held and videodermatoscopes, average number of patients seen per day, and a positive outlook towards dermoscopy were significant determinants of frequency of use. Leading impediments were lack of training and inadequate dermatoscopes in practice. CONCLUSIONS: Dermoscopy use in Africa is relatively low. Incorporating dermoscopy training into the curriculum with provision of dermatoscopes by training institutions will promote wider usage.

Dermoscopy of Cutaneous Neoplasms in Skin of Color - A Systematic review by the International Dermoscopy Society "Imaging in Skin of Color" Task Force.

Over the last few decades, dermoscopy has been showed to facilitate the non-invasive diagnosis of both benign and malignant skin tumors, yet literature data mainly comes from studies on light photo-types. However, there is growing evidence that skin neoplasms may benefit from dermoscopic assessment even for skin of color. This systematic literature review evaluated published data in dark-skinned patients (dermoscopic features, used setting, pathological correlation, and level of evidence of studies), also providing a standardized and homogeneous terminology for reported dermoscopic findings. A total of 20 articles describing 46 different tumors (four melanocytic neoplasms, eight keratinocytic tumors, 15 adnexal cutaneous neoplasms, seven vascular tumors, four connective tissue tumors, and eight cystic neoplasms/others) for a total of 1724 instances were included in the analysis. Most of them showed a level of evidence of V (12 single case reports and six case series), with only two studies featuring a level of evidence of IV (case-control analysis). Additionally, this review also underlined that some neoplasms and phototypes are underrepresented in published analyses as they included only small samples and mainly certain tones of "dark skin" spectrum (especially phototype IV). Therefore, further studies considering such limitations are required for a better characterization.

Dermoscopy of Inflammatory Dermatoses (Inflammoscopy) in Skin of Color - A Systematic Review by the International Dermoscopy Society "Imaging in Skin of Color" Task Force.

Dermoscopic patterns of inflammatory dermatoses (inflammoscopy) have been extensively studied in the recent years, though data on patients with darker phototypes (IV-VI) are sparse. The aims of this systematic review were to summarize the current state of knowledge on inflammoscopy applied to skin of color and provide a standardized nomenclature of reported findings. Besides dermoscopic features, type of setting and magnification, number of cases, and histopathological correlation were analyzed. Eighty-five papers addressing 78 different dermatoses (25 papulosquamous dermatoses, 19 hyperpigmented dermatoses, eight hypopigmented dermatoses, four granulomatous dermatoses, two sclerotic dermatoses, five facial inflammatory dermatoses, and 15 miscellaneous conditions) for a total of 2073 instances were retrieved. Only one study showed a level of evidence of III (cross-sectional study), whereas 10 and 74 displayed a level of evidence of IV (case-control studies) and V (case-series and case-reports), respectively. Moreover, our analysis also highlighted that most of papers focalized on a limited number of dermatoses, with several conditions having only single dermoscopic descriptions. Additionally, few studies compared findings among phototypes belonging to the "skin of color" spectrum. Further studies designed according to a systematic approach and considering the above-mentioned issues are therefore needed.

International Dermoscopy Society (IDS) Criteria for Skin Tumors: Validation for Skin of Color Through a Delphi Expert Consensus by the "Imaging in Skin of Color" IDS Task Force.

INTRODUCTION: A structured set of eight basic dermoscopic parameters (lines, clods, dots, circles, pseudopods, structureless, else, and vessels) including a total of 77 variables with corresponding descriptive and metaphoric vocabulary has been released for evaluation of skin tumors by the International Dermoscopy Society (IDS). OBJECTIVES: To validate the aforementioned criteria for the use in darker phototypes (phototypes IV-VI) via an expert consensus. METHODS: The two-round "Delphi method" was adopted, with an iterative process including two rounds of email questionnaires. Potential panelists were asked to take part in the procedure via email on the basis of their expertise in the dermoscopy of skin tumors in dark phototypes. RESULTS: A total of 17 participants were involved. All the original variables of the eight basic parameters reached agreement during the first round, except for "pink small clods" ("milky red globules") and "structureless pink zone" ("milky red areas"). Moreover, during the first round, panelists proposed a change of three existing items and the introduction of four new items, i.e., "black, small clods" ("black globules"), "follicular plugs", "erosions/ulcerations", and "white color around vessels" ("perivascular white halo"). All such proposals achieved agreement, thus being included in the final list, for a total of 79 items. There was consistency between the descriptive and metaphoric approaches in terms of scoring. CONCLUSIONS: Albeit most of the original items were considered applicable even for skin of color, there are some points of differences that physicians need to know. No significant preference was found between descriptive and metaphoric terminology among panelists.

Necrobiosis lipoidica of the breast associated with Crohn's disease: a case report.

BACKGROUND: Necrobiosis lipoidica located to the breast; without evidence of glucose intolerance, is extremely rare, and its association to Crohn's disease is not usual. CASE PRESENTATION: We report an interesting case of an association of necrobiosis lipoidica of the breast and Crohn's disease in a 54-year-old Moroccan woman. Skin necrobiotic changes are a characteristic feature in necrobiosis lipoidica, but they are exceptional in metastatic Crohn's disease, since there are only three published cases of necrobiotic skin lesions on the lower leg resembling erythema nodosum in metastatic Crohn's disease. CONCLUSIONS: On the basis of this rare observation, necrobiosis lipoidica without evidence of glucose intolerance should be recognized as a possible cutaneous manifestation or association of Crohn's disease.

Significance of Primary Melanoma Regression on Local Infiltrate and Outcome.

INTRODUCTION: The characteristics and the prognostic value of regression in primary melanomas are controversial. OBJECTIVES: To further characterize "hot" and "cold" tumor's stromas and to investigate the association between dermoscopy, pathology, and the prognostic implications of regression. METHODS: A 14-year-collection-based retrospective analysis was carried out on 40 patients with confirmed regressive melanomas. RESULTS: The extent of regression in dermoscopy was associated with the stage of the regression (P = 0.05) and with the MelanA patterns in histology (P = 0.02). Blue-gray and gray-brown color of the peppering (P = 0.01), and the eccentric, multifocal character of the dermoscopic regression (P = 0.05) were associated with "hot" stromas (CD8+, Granzym B+). Focal histologic regression (regressing melanomas) was associated with a good outcome (P < 0.001), while a complete regression (regressed melanomas) was associated with melanoma-related death (P < 0.001). "Hot" stromas (CD8+ were significantly associated with survival at 10 years (P = 0.044), while "hot" stromas (Granzyme B+) were associated with the locoregional extension (P = 0.016), and the initial distant metastasis (P = 0.016). CONCLUSIONS: Dermoscopic features of regression in primary melanomas were associated with the stage of regression, its extent, and the "hot" or "cold" nature of the tumor stroma, with prognostic implications.

International Dermoscopy Society criteria for non-neoplastic dermatoses (general dermatology): validation for skin of color through a Delphi expert consensus.

BACKGROUND: The International Dermoscopy Society (IDS) recently released a set of five basic dermoscopic parameters (vessels, scales, follicular findings, "other structures," and specific clues) encompassing a total of 31 subitems to standardize the use of dermoscopy in non-neoplastic dermatoses, yet they have been developed taking into account Caucasian/Asian skin, with consequent possible limitations if used in dark skin. OBJECTIVES: To validate the abovementioned criteria for the use in dark-skinned patients (phototypes IV-VI) through an expert consensus. METHODS: The two-round Delphi method was adopted, with an iterative process consisting of two rounds of email questionnaires. Potential panelists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses in skin of color. RESULTS: Twenty-two panelists took part in the validation process. All of the five originally proposed parameters and subitems reached agreement during the first round, aside from "follicular red dots." Additionally, during round 1, five new subitems were proposed (perifollicular scales distribution, follicular openings obliteration, broken hairs, eccrine pigmentation, and eccrine ostia obliteration), along with the possibility to change the denomination of parameter 3 (from "follicular findings" to "follicular/eccrine findings") and split it into two subparameters ("follicular findings" and "eccrine findings"). All such proposals reached agreement during the second round and therefore were included in the final list, for a total of 37 items. CONCLUSIONS: Although nearly all the dermoscopic criteria originally proposed by the IDS are applicable even to darker phototypes, several additional variables need to be assessed.

[Scar sarcoidosis: a usually progressive disease (about a case)]. / Sarcoïdose cutanée sur cicatrice: forme habituellement évolutive (à propos d'un cas).

The sarcoidosis is a systemic granulomatous disease. It is usually characterized by skin manifestations which may be suggestive of progressive sarcoidosis with visceral involvement. We here report a case of pulmonary sarcoidosis revealed by the reactivation of an old cutaneous scar following a trauma occurred 20 years earlier. Radiological assessment showed mediastino-pulmonary sarcoidosis stage 2. The diagnosis of sarcoidosis should be suspected in patients with any recent scar modification in order to establish early management.

Dermoscopy in general dermatology (non-neoplastic dermatoses) of skin of colour: a comparative retrospective study by the International Dermoscopy Society.

BACKGROUND: Dermoscopy has been shown to be a useful supportive tool to assist the diagnosis of several non-neoplastic dermatoses (i.e. inflammatory, infiltrative and infectious skin diseases), yet data on skin of colour is still limited. OBJECTIVES: To characterize dermoscopic features of non-neoplastic dermatoses in dark-skinned patients in order to identify possible clues that may facilitate the differential diagnosis of clinically similar conditions. MATERIALS & METHODS: Members of the International Dermoscopy Society were invited to submit cases of any non-neoplastic dermatosis developing in patients with Fitzpatrick Phototypes V-VI whose diagnosis had been confirmed by the corresponding gold standard diagnostic test. A standardized assessment of the dermoscopic images and a comparative analysis according to clinical presentation were performed. Seven clinical categories were identified: (I) papulosquamous dermatoses; (II) facial hyperpigmented dermatoses; (III) extra-facial hyperpigmented dermatoses; (IV) hypopigmented dermatoses; (V) granulomatous dermatoses; (VI) sclerotic dermatoses; and (VII) facial inflammatory dermatoses. RESULTS: A total of 653 patients (541 and 112 with Phototype V and VI, respectively) were recruited for the analysis. Thirty-six statistically significant dermoscopic features were identified for papulosquamous dermatoses, 24 for facial hyperpigmented disorders, 12 for extra-facial hyperpigmented disorders, 17 for hypopigmented disorders, eight for granulomatous dermatoses, four for sclerotic dermatoses and 17 for facial inflammatory diseases. CONCLUSION: Our findings suggest that dermoscopy might be a useful tool in assisting the diagnosis of clinically similar non-neoplastic dermatoses in dark phototypes by revealing characteristic clues. Study limitations include the retrospective design, the lack of a direct dermoscopic-histological correlation analysis and the small sample size for less common diseases.

[Dermatomyositis and rectal cancer: case study and literature review]. / Dermatomyosite et cancer rectal: à propos d'un cas avec revue de la littérature.

Dermatomyositis is a systemic idiopathic disease characterized by a combination of both muscle and skin symptoms. It is a paraneoplastic dermatosis. Its association with rectal cancer has been rarely described in the literature. We here report the case of a female patient with paraneoplastic dermatomyositis associated with metastatic rectal adenocarcinoma presenting with clinical symptoms commonly found in subjects with paraneoplastic dermatomyositis. Other complementary examinations (CPK test + EMG + skin biopsy) were performed which confirmed this diagnosis. The patient underwent chemotherapy, but after the second cycle, she experienced a rapid worsening of her general condition and died after some days in a state of multisystem organ failure. This study aims to highlight paraneoplastic dermatomyositis' aggressive nature and to update current knowledge on the importance of chemotherapy in the management of neoplastic dermatomyositis.

Dermoscopic Findings and Their Therapeutic Implications in Trichostasis Spinulosa: A Retrospective Study of 306 Patients.

BACKGROUND: Data about the contribution and the implications of dermoscopy in trichostasis spinulosa (TS) are lacking in the literature. OBJECTIVE: To describe dermoscopic features of TS in a large sample of patients and to correlate dermoscopy with clinical characteristics of the patients and therapeutic responses to medical treatments. METHODS: A descriptive study was conducted (from October 2015 to June 2016) at the Department of Dermatology of Fez in Morocco. Dermoscopic signs were divided into signs of hair retention (SHR) and follicular keratosis (FK). RESULTS: SHR was severe in 8.8% and minimal in 40.5% of all cases. Vellus hairs were observed in 81.6% of all cases and hair tufts were described in 48.7%. Dermoscopic blackhead-like structures (DBH) were found in 53.9% of all cases. FK was observed as orange-yellowish keratotic plugs in 92.7% of all cases. Therapeutic demand was significantly related to female gender (p = 0.002) and recurrences after medical treatment (p = 0.004). Complete improvement after medical treatment was only described in patients with DBH and minimal SHR (p = 0.001). CONCLUSION: Dermoscopy not only increases the accuracy of the clinical diagnosis in TS, but a new description of dermoscopic classification has also been proposed leading to therapeutic implications.

Dermoscopy of skin metastases from breast cancer: two case reports.

BACKGROUND: Cutaneous metastatic breast cancer is the most common cutaneous metastatic malignancy in women. The assessment of cutaneous metastatic disease can be perplexing because the clinical presentation appears similar to other skin malignancies like angiosarcoma or melanoma, or benign diseases like cellulitis and lymphedema. To date, only a limited number of dermoscopic images of cutaneous metastatic solid tumors, especially breast cancer, have been published. CASE PRESENTATION: The authors report two Moroccan cases highlighting dermoscopy as a quick tool to recognize skin metastasis of breast cancer in two different clinical presentations. A 51-year-old Moroccan woman presented with nodules of various sizes on and around a mastectomy scar, and a 65-year-old Moroccan woman presented with cellulitis-like lesions on her chest wall and her back. Dermoscopic features were similar in the two cases with findings of yellow central areas, polymorphic vessels, whitish bright lines, whitish structureless areas, and linear irregular fissure-like depressions on a pink-orange background. CONCLUSIONS: The recognition of dermoscopic patterns of cutaneous metastasis of breast cancer is not only useful to facilitate diagnosis at an early stage and to rule out other differentials, especially in difficult presentations such as cellulitis-like lesions or lymphedema, but it may also be used by physicians in monitoring mastectomy scars.

The rainbow pattern in dermoscopy: A zoom on nonkaposi sarcoma skin diseases.

The rainbow pattern is currently a subject of debate, it is considered the specific dermoscopic pattern of Kaposi sarcoma. We present in this research correspondence a review of 700 dermoscopic figures of different biopsy-proven skin diseases in our department of dermatology of the Hospital Hassan II of Fez. All the lesions were localized to the limbs except for one lesion of atrophic scar that was localized on the left shoulder. RP was observed in four raised lesions: one case of hypertrophic scar, one case of angiokeratoma, one case of stasis dermatitis and one case of pseudo-Kaposi. These results indicate that the RP may be observed in non-kaposi sarcoma, with new observations of RP in pseudo-Kaposi and angiokeratoma.

Beyond classic dermoscopic patterns of dermatofibromas: a prospective research study.

BACKGROUND: The usual stereotypical dermoscopic pattern associated with dermatofibromas is a pigment network and central white patch. However, this pattern may be difficult to diagnose in some variant cases. We aimed to describe dermoscopic patterns of dermatofibroma according to its histopathological subtypes, with special emphasis on new and rare dermoscopic features. METHODS: This prospective study, which was conducted between September 2015 and May 2016 in the Department of Dermatology, University Hospital Hassan II, Fez, Morocco, included 100 cases of dermatofibroma confirmed on clinical and histological grounds. Each lesion was scored for classic, previously reported, or new dermoscopic features. RESULTS: All our Moroccan patients had a dark skin phototype (Fitzpatrick scale types IV and V). A total of 14 morphological dermoscopic structures were distinguished, and 17 dermoscopic patterns were observed, with the most common pattern being the central white patch and peripheral pigment network (21%). New patterns observed in our study were a white ring around an ulceration (6%), a pigment network with a pigmented ring around follicular openings (2%), and a discreet peripheral network and starlike white patch (3%). A patchy network with white patches was significantly noted in atrophic dermatofibroma (p = 0.01); vascularization was described in both aneurysmal and hemosiderotic dermatofibromas (p = 0.002); and a white ring around an ulceration was noted in aneurysmal dermatofibroma (p < 0.001). CONCLUSIONS: We provide a description of dermoscopic patterns of dermatofibroma according to its histological subtypes in a dark skin phototype, along with a new report of a white ring around an ulceration as a significant pattern in aneurysmal dermatofibroma.

Dermoscopic Analysis of Nevus Sebaceus of Jadassohn: A Study of 13 Cases.

BACKGROUND: Nevus sebaceus of Jadassohn (NSJ) is a complex cutaneous hamartoma with various clinical appearances. AIM: To describe different dermoscopic patterns of this nevus according to its evolutionary stages. METHODS: This was an analytical study of NSJ carried out in the Department of Dermatology at the University Hospital Hassan II, Fez, Morocco. RESULTS: Thirteen patients with a NSJ were enrolled in the study. Elevated verrucous plaques were noticed in 9 patients, homogeneous tumors were described in 2 NSJ, an alopecic patch was found in 1 case, and we had 1 case of malignant transformation into basal cell carcinoma. The dermoscopic aspects of NSJ described in our study were yellowish or brown globules aggregated in clusters on a yellow background. This pattern was significantly related to the first stage of an alopecic patch (p = 0.001). Whitish-yellow lobular aspect and grayish papillary appearance were significantly related to verrucous plaques (p = 0.003). Homogeneous yellow-whitish pattern was related to nodules (p = 0.005). CONCLUSION: The establishment of specific dermoscopic features of NSJ according to its evolutionary stages is important for its diagnosis and especially its monitoring in order to detect malignant transformation.