In vivo reflectance confocal microscopy imaging of melanocytic skin lesions: consensus terminology glossary and illustrative images.

BACKGROUND: Reflectance confocal microscopy (RCM) has been used for over 10 years for in vivo skin imaging. However, to date no standard RCM terminology has been published. OBJECTIVE: To establish a glossary of terms for RCM evaluation of melanocytic lesions. METHODS: Prominent RCM researchers were presented with RCM images of melanocytic lesions. Reviewers evaluated RCM images for image quality, lesion architecture, and cellular details. Reviewers could utilize published descriptors or contribute unpublished terminology to describe lesion attributes. An online meeting was conducted to reach consensus that integrates and defines existing and new RCM descriptive terms. RESULTS: We present a glossary with descriptors of image quality, normal skin morphology, lesion architecture, and cellular details for RCM evaluation of melanocytic lesions. LIMITATIONS: Usefulness of the glossary in RCM diagnosis of melanocytic lesions needs to be assessed. CONCLUSION: Standardization of terminology is important toward implementation of RCM in the clinical setting.

Differences between polarized light dermoscopy and immersion contact dermoscopy for the evaluation of skin lesions.

OBJECTIVE: To evaluate dermoscopic features and patterns of skin lesions by using conventional and polarized light dermoscopy (PD). DESIGN: Observational study. SETTING: Dermatology clinic at Memorial Sloan-Kettering Cancer Center. PATIENTS: Ninety patients with skin lesions. INTERVENTIONS: Skin lesions were imaged via conventional nonpolarized light contact dermoscopy (NPD), polarized light contact dermoscopy (PCD), and polarized light noncontact dermoscopy (PNCD). MAIN OUTCOME MEASURES: The images from the 3 modalities were evaluated by 3 dermoscopists for colors, structures, and patterns. Level of agreement between modalities was assessed by percentage agreement and the kappa statistic. Qualitative differences between modalities were also assessed. RESULTS: Ninety lesions comprising 55 melanocytic and 35 nonmelanocytic lesions were reviewed. There was excellent agreement for overall dermoscopic patterns between modalities, with kappa values ranging from 0.88 to 1.00. There was moderate to excellent agreement for most dermoscopic colors, with the exception of blue-white veil and pink (red) color. Most dermoscopic structures had fair to perfect agreement, with the exception of milialike cysts. Qualitative assessment suggested that melanin appeared darker and blue nevi had more shades of blue on PD compared with NPD images; vessels and red areas were better visualized with PD, suggesting that PD may be helpful in identifying malignancies; milialike cysts and comedolike openings were better visualized with NPD, suggesting that NPD is more helpful for identification of seborrheic keratosis; peppering, lighter colors, and blue-white areas were more evident under NPD, facilitating recognition of regression areas; and shiny-white streaks, possibly representing fibrosis, were seen more clearly under PD. CONCLUSIONS: The capabilities of NPD, PCD, and PNCD are not equivalent, but complementary. Further studies are needed to evaluate the effect of these differences on clinical diagnosis.

Correlation of dermoscopic structures of melanocytic lesions to reflectance confocal microscopy.

OBJECTIVE: To determine the utility of reflectance confocal microscopy (RCM) in the in vivo evaluation of dermoscopic structures of melanocytic lesions. DESIGN: For each described dermoscopic feature, we evaluated by RCM at least 2 melanocytic lesions. A digital camera connected to the confocal computer enabled direct analysis of the dermoscopic structures. To ascertain precision of correlation, the orientation of the dermoscopic and RCM images were compared using a superimposed grid. SETTING: Dermatology clinic specializing in pigmented lesions. Patients Eleven patients with melanocytic lesions, including 2 melanomas, 1 Spitz nevus, 7 dysplastic nevi, and 1 compound nevus. Main Outcome Measure Direct correlation of structures seen using dermoscopy with those seen using RCM. RESULTS: There was a good correlation between the global dermoscopic pattern and findings on the 4 x 4-mm mosaic of confocal images at the level of the dermoepidermal junction. The atypical network correlated with variability in the size and shape of dermal papillae. Globules corresponded with aggregates of bright cells, and darker shades of brown on dermoscopy appeared brighter on RCM. In peripheral streaks, RCM showed dense aggregates of pleomorphic cells of variable brightness and ill-defined cellular borders. These aggregates were continuous with the bright mesh that composed the central bulk of the lesion. A blue-white veil correlated with disruption of the rimmed papillae meshlike pattern and sometimes with the presence of bright cells corresponding to melanophages. CONCLUSION: Correlating dermoscopic structures to RCM features is possible and a necessary step toward understanding the potential benefits of RCM in the clinical setting.

Nonmelanocytic lesions defying the two-step dermoscopy algorithm.

The first step of the two-step algorithm of dermoscopy aims at differentiating melanocytic from nonmelanocytic pigmented lesions, using a stepwise evaluation for the presence of specific dermoscopic criteria. The purpose of this article is to heighten awareness of clinicians to nonmelanocytic lesions that defy the two-step algorithm, thus simulating melanocytic lesions dermoscopically. Seborrheic keratosis, solar lentigo, dermatofibroma, and supernumerary accessory nipple may present with network-like structures. Seborrheic keratosis, dermatofibroma, subcorneal hemorrhage, basal cell carcinoma (BCC), and cutaneous metastases of breast and other cancers may contain pigmented globules. Peripheral streaks can also be seen in seborrheic keratosis and BCC. Homogenous bluish pigmentation, simulating a blue nevus, can also be seen in benign vascular lesions, Kaposi sarcoma, radiation tattoo, and BCC. This overlap of features between melanocytic and nonmelanocytic lesions suggests that integration of all dermoscopic features in the lesion, rather than a stepwise evaluation, may facilitate reaching the correct diagnosis in select cases as outlined in this article.

Dermatologic side effects associated with the epidermal growth factor receptor inhibitors.

Epidermal growth factor receptor (EGFR) inhibitors are associated with unique and dramatic dermatologic side effects. Cetuximab, erlotinib, and gefitinib have been approved for patients with colorectal and non-small cell lung cancer refractory or intolerant to chemotherapy. Our aim was to describe key clinical features of common dermatologic adverse reactions among EGFR inhibitors, focusing mainly on skin toxicity, as well as to discuss the pathology, possible causes, and suggested treatments for these reactions. The most commonly encountered adverse effect was a mild skin toxicity characterized by a sterile follicular and pustular rash that may be treated empirically and usually does not require treatment modification. Although the precise mechanism for development of rash is not well defined, it is related to inhibition of EGFR-signaling pathways in the skin, and may serve as visible markers of anti-tumor activity and therapeutic efficacy. Secondary adverse reactions seen with anti-EGFR therapy include xerosis, pruritus, paronychia, hair abnormality, and mucositis.

Level of confidence in diagnosis: clinical examination versus dermoscopy examination.

BACKGROUND: Confidence is an important factor in decision making and may influence patient care. OBJECTIVES: To evaluate whether short-training-based dermoscopy increases confidence in the diagnosis of skin lesions. METHODS AND MATERIALS: After a 1-hour course on dermoscopy, 20 pairs of clinical and dermoscopic images of lesions were presented to 19 dermatology residents with little or no dermoscopy experience. After viewing the clinical image, they were asked to assess their confidence in the diagnosis in a seven-point scale, with 1 reflecting that the respondent was 100% confident that the lesion was benign, while number 7 reflected 100% confidence that it was malignant. The same technique was used for dermoscopic images. RESULTS: Ten of the 20 pairs of evaluations showed a significant difference (p<.05). The largest differences were observed in lesions where clinical scores suggested that participants were uncertain about the diagnosis, but tended to decide that the lesion was benign after dermoscopy. Dermoscopy did not improve confidence in the evaluation of dysplastic lesions as well as lesions with obvious clinical diagnoses. CONCLUSIONS: Short-training-based dermoscopy improved confidence in the diagnosis of clinically challenging skin lesions, but the impact was not demonstrable for clinically obvious lesions and dysplastic nevi.

[Photodynamic therapy in dermatology]. / Terapia fotodinámica en dermatología.

Photodynamic therapy (PDT) is a therapeutic modality based on the photooxidation of biological materials induced by a photosensitizer, which selectively locates itself in certain tumorous cells or tissues, so that when illuminated by a light of the right length and at a sufficient dose, these cells are destroyed. In dermatology, PDT with topical 5-aminolevulinic acid or 5-methyl aminolevulinate is very effective in the treatment of actinic keratoses, basal cell carcinomas and Bowen's disease. In addition, very promising results have been obtained in inflammatory pathologies like morphea or sarcoidosis, infections like warts, and cosmetic processes such as photoaging, among others. This article reviews the most significant aspects of PDT in dermatology. First of all, we will review the basic fundamentals of photodynamic treatment. Next, we will outline its clinical applications in dermatology, both in oncological applications and all those dermatological processes in which PDT may play a role in their management. We will also discuss its promising cosmetic application in the treatment of photoaging. We will complete the review with photodiagnosis and the different non-invasive ways to monitor the effectiveness of PDT.

Reflectance confocal microscopy of pigmented basal cell carcinoma.

BACKGROUND: Reflectance confocal microscopy (RCM) is a high-resolution imaging tool for in vivo noninvasive evaluation of skin lesions. OBJECTIVE: We sought to describe the relevant RCM features for pigmented basal cell carcinoma (BCC). METHODS: Pigmented skin lesions with a differential diagnosis of pigmented BCC were imaged using dermoscopy and RCM, followed by excision for histologic analysis. RESULTS: RCM demonstrated aggregations of tightly packed cells with palisading, forming cordlike structures and nodules with irregular borders and variable brightness; these represented nests of pigmented basaloid tumor cells on histopathology, and blue-gray ovoid areas on dermoscopy. These tumor nests were associated with bright dendritic structures, identified histologically as either melanocytes or Langerhans cells, together with numerous bright oval to stellate-shaped structures with indistinct borders representing melanophages, and with highly refractile granules of melanin. LIMITATIONS: The pigmented BCCs imaged in this study were predominantly nodular; a different set or additional criteria may be necessary for detection of infiltrative and metatypical BCCs. CONCLUSION: RCM may permit in vivo diagnosis of pigmented BCC.

Terapia fotodinámica en dermatología / Photodynamic therapy in dermatology

La terapia fotodinámica (TF) es una modalidad terapéutica basada en la fotooxidación de materiales biológicos inducida por un fotosensibilizante, el cual se localiza selectivamente en determinadas células o tejidos tumorales, de forma que al ser iluminadas con una luz de adecuada longitud y en dosis suficiente, dichas células resultan destruidas. En dermatología, la TF con ácido 5-aminolevulínico o 5-metilo aminolevulinato tópicos es muy efectiva en el tratamiento de queratosis actínicas, carcinomas basocelulares y enfermedad de Bowen. Además, se han obtenido resultados muy prometedores en patología inflamatoria como la morfea o la sarcoidosis, infecciones como las verrugas y procesos cosméticos, como el fotoenvejecimiento, entre otras. El presente artículo revisa los aspectos más relevantes de la TF en dermatología. En primer lugar se hará una revisión de los fundamentos básicos del tratamiento fotodinámico; posteriormente se expondrán sus aplicaciones clínicas en dermatología, tanto las oncológicas como todos aquellos procesos dermatológicos en los que la TF puede desempeñar un papel en su manejo, sin olvidar su prometedora aplicación cosmética en el tratamiento del fotoenvejecimiento. Finalizaremos la revisión con el fotodiagnóstico y las diferentes formas de monitorización no invasiva de la efectividad de la TF

Photodynamic therapy (PDT) is a therapeutic modality based on the photooxidation of biological materials induced by a photosensitizer, which selectively locates itself in certain tumorous cells or tissues, so that when illuminated by a light of the right length and at a sufficient dose, these cells are destroyed. In dermatology, PDT with topical 5-aminolevulinic acid or 5-methyl aminolevulinate is very effective in the treatment of actinic keratoses, basal cell carcinomas and Bowen's disease. In addition, very promising results have been obtained in inflammatory pathologies like morphea or sarcoidosis, infections like warts, and cosmetic processes such as photoaging, among others. This article reviews the most significant aspects of PDT in dermatology. First of all, we will review the basic fundamentals of photodynamic treatment. Next, we will outline its clinical applications in dermatology, both in oncological applications and all those dermatological processes in which PDT may play a role in their management. We will also discuss its promising cosmetic application in the treatment of photoaging. We will complete the review with photodiagnosis and the different non-invasive ways to monitor the effectiveness of PDT

Predominant dermoscopic patterns observed among nevi.

BACKGROUND: It has been clinically observed that patients' "normal" moles resemble each other. Whether this concept is applicable to dermoscopic practice has not been sufficiently studied. OBJECTIVE: To investigate whether physicians evaluating dermoscopic images would identify common dermoscopic profiles of nevi within individual patients. METHODS: Images of 205 nevi belonging to 18 patients were evaluated by 2 dermatologists for dermoscopic global pattern, color, and specific structures. We defined dermoscopic patterns as dominant if seen in >or= 40% of the patient's nevi; a minor pattern was defined as 20 to 39%. RESULTS: A dominant pattern was seen in 15 patients (83%). In 13 (72%) of the patients, >or= 80% of the nevi were classified into one, two, or three global patterns. The reticular global pattern was the most prevalent dominant pattern, seen in 9 patients (50%); the homogeneous pattern was the most prevalent minor pattern, seen in 16 patients (89%). CONCLUSION: Individuals tend to have one to three predominant dermoscopic nevus global patterns.

Cutaneous melanoma: surveillance of patients for recurrence and new primary melanomas.

The increasing incidence and overall survival of patients diagnosed with melanoma of the skin are leading to an ever-increasing population of individuals with a personal history of melanoma. These patients are at risk for developing local, regional, or distant recurrence and are also at greater risk than the general population for developing a new primary melanoma. This article presents the rational for implementing surveillance strategies for patients with a history of melanoma.

Asymptomatic neurocutaneous melanocytosis in patients with large congenital melanocytic nevi: a study of cases from an Internet-based registry.

BACKGROUND: Recent retrospective studies using magnetic resonance imaging (MRI) to screen for neurocutaneous melanocytosis (NCM) among neurologically asymptomatic children with large congenital melanocytic nevi (LCMN) report high prevalence (23-30%) of asymptomatic NCM. We sought to determine prevalence of asymptomatic NCM, and current application of MRI as a screening tool. METHODS: Patients with LCMN from an Internet-based registry answered a questionnaire regarding NCM status. RESULTS: Of 379 patients with LCMN, 26 reportedly had NCM, with 17 reporting neurologic symptoms. Of 186 patients undergoing MRI, 9 reported abnormal findings without neurologic symptoms (4.8%); 80% had LCMN on the posterior axis, whereas 55% had more than 20 satellite nevi. LIMITATIONS: Study data rely on the registry members' self-reported findings and are limited by lack of independent data verification. CONCLUSION: Asymptomatic NCM (determined by MRI) may not be common, with much lower prevalence (4.8%) than previously reported. MRI is widely used for screening patients at risk for NCM, such as patients with LCMN involving the posterior axis and greater than 20 satellite nevi.

Photoprotection in adolescence.

Physical changes and the establishment of personal values are characteristics of adolescence. Despite being well informed regarding sun protection and the skin cancer risks related to sun exposure, teenagers usually make little use of sunscreens and remain out in the sun for long periods. Besides the social appeal and the impression that a nice tan provides a healthy appearance, the tendency to deny long-term risks seems to influence sun exposure behaviors in this life period. Due to the strong relation between skin cancer and sun exposure in childhood and adolescence, it is important to encourage the adoption of photoprotection measures early in life. Adolescents have difficulty accepting guidance through official educational messages, and very few of them follow family recommendations. Celebrities, fashion, and the entertainment industry exert a greater influence on their choices. Thus, it is fundamental to incorporate photoprotection counseling into the medical routine, in an adolescent-driven way. This article reviews peculiarities of sun protection in adolescence and discusses the type of advice to be given to patients in this age group.

Congenital melanocytic nevi needing treatment.

Patients presenting with congenital melanocytic nevi (CMN) need individualized treatment based upon nevus size, thickness, location, risk for developing melanoma, and psychological characteristics of the patient and family. The present authors review CMN types and prognoses, as well as absolute and relative indications for treatment. Risks and benefits of several treatment options are discussed, including surgical options, such as excision, chemical peels, dermabrasion and curettage, and laser therapy. The main focus of treatment is, in all cases, to address the concern for developing melanoma, at the same time optimizing the aesthetic and functional outcomes.

Sun exposure and sun protection habits among high-school adolescents in Porto Alegre, Brazil.

Adolescents constitute an important audience for photoprotection programs. Sun exposure and sun protection habits acquired during adolescence have a significant impact on skin cancer incidence. We administered a questionnaire to 724 students about ultraviolet radiation effects, opinions about tanning, total time of sun exposure per day, photoprotection and activities in the sun. About 90% were aware of the association between sun exposure and skin cancer, and mass media was the main source of information. However, the great majority believed that tanning improved their appearance, and that it was worth taking the risk. The most prevalent outdoor activity among boys was sports; girls preferred walks and sunbathing. Sun exposure was significantly longer in summer, when 90% of the students went to the beach. About 47% reported sunscreen use in summer and only 3% reported using sunscreen during winter. These results emphasize the need for the promotion of photoprotective habits in our population and the importance of engaging physicians and school teachers in developing campaigns directed at this issue to achieve effective, long-lasting results. Adolescents are aware of the effects of ultraviolet radiation on the skin but campaigns have not successfully changed their sun exposure habits.

An Alternative Teaching Method for the Regulation of the Immune Response.

PURPOSE: Our teaching experience has shown that dealing with the molecular aspects of the immune response regulation poses several difficulties. Therefore, we developed a panel board to verify whether or not this active-learning exercise could enhance students' learning and arouse their interest in subjects that are basically theoretical and complex. METHODS: Twenty cardboard pieces labeled with the names of major regulators of the immune response and three panel boards with explanations on how major regulators work. Students had to match the cardboard pieces with the corresponding explanation. RESULTS: One hundred forty students participated in this study. The overall response of the students to the game was very positive: 95.71% considered the panel board interesting and 95% said the panel board facilitated the understanding of the subject matter. The students' grades significantly improved (P<0.0001). CONCLUSION: The results obtained show the importance of using the panel board when trying to approach a subject that is vast and complex not only for students but also for professors.