The Natural Evolution of Nevi with Peripheral Globules.

BACKGROUND: Peripheral globules (PG) in melanocytic lesions represent a concerning dermoscopic feature since they might be present in growing nevi and melanomas. Their natural evolution has not been fully elucidated, and an age-based management approach has been recommended. OBJECTIVES: The aim of this study was to calculate the growth rate of lesions with PG and investigate possible association with age, sex, location, and the global dermoscopic pattern. METHODS: We retrospectively selected the lesions of interest from a cohort of Caucasian patients who underwent sequential digital dermoscopy monitoring. Lesions with PG distributed at 75% or more of their circumference with available follow-up images or histopathologic report were included. The surface area was automatically calculated with the help of an incorporated tool used in the acquisition of the images. The images were also evaluated by independent investigators for the presence of pre-defined criteria. Growth-curve models were used to assess the growth rate. The outcome variable was the area of nevi in mm2, and scatterplots with Lowess curves were used to present the mean change of nevi during follow-up. RESULTS: A total of 208 lesions from 98 patients with a median age of 36 years (range 15-75) were included. The median follow-up time was 18 months (range 4-48). The mean growth rate for all nevi was 0.16 mm2/month (95% CI, 0.14-0.18, p < 0.001), ranging from -0.29 to 0.61 mm2/month. The growth rate was higher in nevi with a homogeneous dermoscopic pattern (p < 0.001). The number of peripheral globules during follow-up varied from increasing to complete disappearance. None of the lesions developed any melanoma-specific structure at follow-up. CONCLUSION: Nevi with PG grew at a mean rate of 0.16 mm2/month, and the growth rate was independent of age, gender, or anatomic location. Nevi with homogeneous pattern demonstrated the highest growth rate in our cohort. None of the monitored nevi with PG developed melanoma-specific criteria at follow-up.

Acral Melanocytic Nevi in a High-Risk Population: Prevalence, Clinical Characteristics and Dermatoscopic Patterns.

BACKGROUND: The prevalence of acral nevi and their dermatoscopic patterns have been mainly studied in Asian populations. Few data exist on the prevalence and clinico-dermatoscopic morphology of acral nevi in white populations. OBJECTIVES: The aim of this study was to assess the prevalence of acral nevi and evaluate their features in a cohort of Caucasian individuals at high risk for skin cancer. METHODS: We prospectively examined the palms and soles of 680 high-risk patients who underwent total body clinical and dermatoscopic documentation, as a part of their routine follow-up, between January 2016 and March 2020 at a skin cancer referral center in Greece. RESULTS: Overall, 334 acral lesions were detected in 217 (37.0%) of 585 patients in the study. The presence of acral nevi was associated with 2.6 higher odds of a total nevus count higher than 50 (OR: 2.6, p < 0.05, confidence intervals [CI]: 1.11-6.09). Of 334 acral nevi, 65.0% were clinically flat and 35.0% were clinically palpable. Palpable lesion had 19-fold higher probability of being located on the sole (OR: 19.44, p < 0.05, CI: 3.91-96.7). The parallel furrow pattern was present in 147 lesions (44.0%). In 76 lesions (22.8%), we observed a previously undefined pattern consisting of wavy lines, which was correlated with clinically palpable lesions (p < 0.001). The third most common pattern was homogeneous (10.5%), followed by the fibrillar (8.7%), the lattice-like (7.2%), the reticular (3.6%), and globular (3.3%). CONCLUSION: We observed a higher prevalence of benign acral melanocytic lesions than expected, probably related to our cohort selection of patients at high risk for developing skin cancer. Our study confirms the previously described dermatoscopic patterns and provides novel insights into the dermatoscopic morphology of acral palpable nevi, for which we described a new benign pattern consisting of wavy lines.

Dermoscopic Clues of Histopathologically Aggressive Basal Cell Carcinoma Subtypes.

Background: The group of histopathologically aggressive BCC subtypes includes morpheaform, micronodular, infiltrative and metatypical BCC. Since these tumors are at increased risk of recurring, micrographically controlled surgery is considered the best therapeutic option. Although dermoscopy significantly improves the clinical recognition of BCC, scarce evidence exists on their dermoscopic criteria. Aim: To investigate the dermoscopic characteristics of histopathologically aggressive BCC subtypes. Materials and Methods: Dermoscopic images of morpheaform, micronodular, infiltrative and metatypical BCC were analyzed for the presence of predefined variables. Descriptive and analytical statistics were performed. Results: Most histopathologically aggressive BCCs were located on the head and neck. Infiltrative was the most common subtype. All subtypes, except micronodular BCC, rarely displayed dermoscopic pigmentation. The most frequent dermoscopic features of infiltrative BCC were arborizing vessels (67.1%), shiny white structures (48.6%) and ulceration (52.9%). The features prevailing in morpheaform BCC were arborizing vessels (68.4%), ulceration (n = 12, 63.2%) and white porcelain areas (47.4%). Micronodular BCC was typified by milky red structureless areas (53.8%), arborizing vessels (53.8%), short fine telangiectasias (50%), ulceration (46.2%) and blue structures (57.7%). The most common findings in metatypical BCC were arborizing vessels (77.8%), shiny white structures (66.7%), ulceration (62.9%) and keratin mass (29.6%). Limitations: Study population of only white skin and relatively small sample size in some groups. Conclusions: Our study provided data on the clinical, dermoscopic and epidemiological characteristics of histopathologically aggressive BCCs.

Dermoscopic Predictors of Benignity and Malignancy in Equivocal Lesions Predominated by Blue Color.

BACKGROUND: Blue color in dermoscopy can be seen in a wide range of benign and malignant lesions, melanocytic or not. Some blue-colored dermoscopic criteria have been associated with specific tumors, such as blue-white veil with melanoma and homogeneous blue with blue nevi. However, when blue color occupies a large part of the lesion's surface, the dermoscopic assessment might be particularly challenging. OBJECTIVE: To identify dermoscopic predictors associated with benignity and malignancy in tumors characterized by a predominant dermoscopic presence of blue color. METHODS: We retrospectively screened our institutional database for tumors exhibiting blue color in at least 50% of their surface with available histopathologic diagnosis. Lesions with blue color covering less than 50% of their extent and lesions not histopathologically assessed were excluded. The dermoscopic images were evaluated for the presence of predefined criteria, including the characteristics of the blue color, coexisting colors, and the vascular structures. RESULTS: Of 91 included tumors, 53 were benign (35 blue nevi, 10 angiomas, and 8 seborrheic keratoses) and 38 malignant (12 melanomas and 26 basal cell carcinomas). Our analysis revealed 3 potent dermoscopic predictors of benignity: extension of blue color in more than 75% of the surface, diffuse distribution of blue color, and absence of vessels, posing a 2.3-fold, 5.6-fold, and 6.7-fold increased probability of benignity, respectively. In contrast, asymmetric distribution of blue color, blue clods, coexistence of gray color and linear vessels were significantly predictive of malignancy, posing a 8.9-fold, 2.8-fold, 13.5-fold, and 10.4-fold increased probability, respectively. CONCLUSION: In predominantly blue tumors, the probability of malignancy is high when blue color is seen in clods or is asymmetrically distributed and when gray color or linear vessels coexist. In contrast, a diffuse distribution of blue color, its expansion in more than 75% of the surface, and the absence of vessels are highly suggestive of a benign tumor.

Evaluation of dermatoscopic criteria for early detection of squamous cell carcinoma arising on an actinic keratosis.

BACKGROUND: Advanced squamous cell carcinoma (SCC) can be discriminated easily from actinic keratosis (AK) based on clinical and dermatoscopic features. However, at the initial stage of dermal invasion, SCC might still be clinically flat and discrimination from AK remains challenging, even with the addition of dermatoscopy. OBJECTIVE: The aim of this study was to investigate the clinical and dermatoscopic criteria that could suggest early invasion and serve as potent predictors to discriminate early SCC from AK. METHODS: Clinical and dermatoscopic images of histopathologically diagnosed AKs and early SCCs were evaluated for the presence of predefined criteria by 3 independent investigators. RESULTS: A total of 50 early SCCs and 45 AKs were included. The main positive dermatoscopic predictors of early SCC were dotted/glomerular vessels (odds ratio [OR] 3.83), hairpin vessels (OR 12.12), and white structureless areas (OR 3.58), whereas background erythema represented a negative SCC predictor (OR 0.22). LIMITATIONS: The retrospective evaluation of images. Moreover, the differential diagnosis included in the study is restricted between AK and early SCC. CONCLUSIONS: We identified potent predictors for the discrimination of AK and early SCC that may better guide management decisions in everyday clinical practice.

Melanoma: Staging and Follow-Up.

Cancer staging is the process determining to which extent a cancer has spread and where it is located in the body. A thorough staging is of utmost importance, not only because it provides the most accurate prognostic estimation, but also because several crucial decisions, such as the treatment choice and the follow-up strategy, vary according to the tumor's stage. The current staging system for melanoma is based on the 8th edition of TNM classification issued by the American Joint Committee on Cancer (AJCC) in 2017. It includes a clinical and a pathological staging, both consisting of 5 stages (0-IV). The stage of a melanoma is determined by several factors, among which the Breslow thickness, the pathological presence or absence of ulceration in the primary tumor, the presence and the number of tumor-involved regional lymph nodes, the presence or absence of in-transit, satellite and/or microsatellite metastases, and the presence of distant metastases. Following melanoma diagnosis, an accurate medical workup, in line with the stage and the physical examination, should be performed. A continuous patient monitoring is fundamental to detect a potential relapse or a second primary melanoma and should be lifelong. However, there is still no universally adopted follow-up strategy program and different follow-up schemes have been suggested. Future prospective studies are needed to evaluate different follow-up protocols according to the adopted therapy, as novel recent therapies (targeted and immunotherapies) are being increasingly used. Key MessagesProper staging is of utmost importance because it provides accurate prognostic estimation. Several crucial decisions, such as the treatment choice and the follow up strategy, are based on the tumor stage.Physical examination during staging procedure and follow-up visits are important to avoid unnecessary imaging and laboratory tests that could increase the patients' anxiety. A personalized approach taking into consideration the patient's risk factors, is strongly recommended.Melanoma patients should be kept under surveillance lifelong due to an increased risk of developing a second primary melanoma and the risk of recurrence. Higher intensity follow-up strategies during the first 5 years are recommended due to higher rates of regional or distant relapse.

Dermatoscopy of melanoma according to type, anatomic site and stage.

The indisputable contribution of dermatoscopy in early diagnosis of melanoma is widely recognized. In the last quinquennium, new data concerning specific melanoma subtypes have come to light. The dermatoscopic morphology of superficial spreading melanoma (SSM) has been extensively investigated in the literature. Atypical network, irregular dots, irregular globules, irregular streaks and irregular blotch correspond to histopathologic alterations at the level of the junction, blue-white veil and atypical vessels suggest intradermal growth, whereas regression structures, negative network and white shiny streaks might reflect junctional or dermal alterations. The list of melanoma specific criteria has been recently updated to include features that typify early melanoma, such as irregular hyperpigmented areas and prominent skin markings and features seen in melanoma on sun damaged skin such as angulated lines. Nodular melanoma lacks most of the aforementioned criteria and is typified by the coexistence of blue and black color, atypical vessels and pink color. Lentigo maligna dermatoscopic criteria mainly develop at the outline of the follicular openings. However, at an early stage these features might be very subtle and the diagnosis should be based on the exclusion of benign tumors (inverse approach). Acral lentiginous melanoma is typified by a parallel ridge pattern, but also SSM criteria should be taken into consideration. The diagnosis of subungual melanoma is based on the assessment of the color and characteristics of the pigmented nail band. For the diagnosis of mucosal melanoma, the assessment of colors is more informative than the assessment of structures and the detection of blue, white or gray should raise the suspicion of melanoma. White shiny streaks and regression structures are the most common features of desmoplastic melanoma. The diagnosis of nevoid melanoma might be highly challenging and require information on the lesion's history. Melanoma on small- and medium-sized congenital nevi is typified by an eccentric location of the suspicious area, negative network and gray angulated lines. Recent advances in knowledge on the dermatoscopic characteristics of peculiar subtypes of the tumor significantly enrich the diagnostic armamentarium of clinicians. The challenge of the forthcoming years is to better characterize biologically aggressive melanomas and to optimize the screening strategies so as to identify them.

Accuracy of dermoscopic criteria for the differential diagnosis between irritated seborrheic keratosis and squamous cell carcinoma.

BACKGROUND: Even with the addition of dermoscopy, a significant morphologic overlap exists between irritated seborrheic keratosis (ISK) and squamous cell carcinoma (SCC). OBJECTIVE: The aim of this study was to investigate the dermoscopic criteria that could serve as potent predictors for the differential diagnosis between ISK and SCC. METHODS: Dermoscopic images of histopathologically diagnosed ISKs and SCCs were evaluated by 3 independent investigators for the presence of predefined criteria. RESULTS: A total of 104 SCCs and 61 ISKs were included. The main dermoscopic predictors of SCC were dotted vessels (odds ratio [OR], 10.4), branched linear vessels (OR, 5.30), white structureless areas (OR, 6.78), white circles surrounding follicles (OR, 23.45), a diffuse irregular (OR, 2.55) or peripheral (OR, 2.8) vessel arrangement, and a central scale arrangement (OR, 3.35). Dermoscopic predictors of ISK were hairpin vessels (OR, 0.38), a diffuse regular vessel arrangement (OR, 0.39 and OR, 0.36), and white halos surrounding vessels covering more than 10% of the lesion (OR, 0.29 and OR, 0.12). LIMITATIONS: First, the retrospective design of the study; second, the differential diagnosis included in the study was restricted to ISK and SCC. CONCLUSIONS: We confirmed the significant morphologic overlap between ISK and SCC, but we also identified potent predictors for the differential diagnosis between these 2 entities.

Real-life data on basal cell carcinoma treatment: Insights on clinicians' therapeutic choices from an institutional hospital registry.

Basal cell carcinoma (BCC) is the most common skin cancer in white skin individuals. The treatment of choice is surgical excision, but several other therapeutic choices are available and might also be efficient and cost-effective in selected cases of low-risk BCC or when surgery is complicate or contraindicated. The aim of the current study was to analyze the applied treatments for BCC in the real-life practice of a tertiary hospital, and investigate factors associated to the tumor and the patients that might influence the treatment selection of clinicians. Data on all BCCs treated from 1st January 2018 to 31st December 2019 were extracted. A total of 751 BCCs from 585 patients were included. The baseline characteristics of patients and tumors, the type of applied treatment and the histopathologic report when available were analyzed. Most tumors were located on the head/neck (64.2%). The most frequently applied treatment was surgical excision (580/751, 77.2%). In 22.8% of tumors a nonsurgical treatment was selected. The most frequently selected alternative treatments were, imiquimod, cryosurgery, their combination (immunocryosurgery), and vismodegib. A pretreatment diagnosis of superficial BCC was associated with a 12-fold increased probability of selecting a nonsurgical treatment except of vismodegib. Every added year of age increased the probability of selecting a nonsurgical treatment by 3-fold. Every added mm of diameter increased the possibility of vismodegib use by 4%. Surgery is the most frequently applied BCC treatment, but nonsurgical modalities do also have an essential role in real settings.

Dermoscopy of pagetoid reticulosis, with dermoscopic-pathologic correlation.

Pagetoid reticulosis (PR), also known as Woringer-Kolopp disease, is a rare variant of mycosis fungoides with distinctive clinicopathologic features. It clinically manifests as a solitary, erythematous, gradually enlarging, scaly, or verrucous plaque on the lower extremities, and due to its indolent course and nonspecific clinical features, may remain undiagnosed for years. In the current study, we describe the clinical and dermoscopic characteristics of a rare case of PR disease and correlate them with the corresponding histopathologic findings. Dermoscopy may prove beneficial in early diagnosis of this rare entity.

Dermoscopy of Spitz/Reed naevi and management.

Since their first description by Sophie Spitz, Spitz nevi have been a subject of controversy among clinicians for many decades, and remain a clinical conundrum until today as their etiology, morphology, biological behavior and natural evolution is still not totally clear. This is because their clinical, dermoscopic and histopathologic features sometimes overlap with those of melanoma, rendering the management of spitzoid lesions particularly difficult. In addition, cases of histopatologically equivocal lesions do exist and their classification might sometimes be very challenging. Among several terms that have been used to describe these morphologically "intermediate" lesions, atypical Spitz tumor (AST) is the most widely used. The aim of this review paper was to describe the dermoscopic patterns and structures seen in Spitz/Reed nevi, spitzoid melanoma and AST. Finally, this article provides an evidence-based update on the available options for the management of spitzoid lesions, before and after histopathologic diagnosis.

Pyoderma gangrenosum and pyogenic arthritis presenting as severe sepsis in a rheumatoid arthritis patient treated with golimumab.

Rheumatoid arthritis is a systemic autoimmune disease resulting in joint destruction and deformities, but also associated with extraarticular and systemic manifestations. The later devastating conditions, such as the development of rheumatoid vasculitis, are more frequently encountered in seropositive patients and their incidence has been attenuated after the introduction of biologic disease modifying drugs, such as anti-tumor necrosis factor alpha (TNFa) agents, which generally have considerably contributed to the better control and long-term outcomes of the disease. Interestingly, autoimmune syndromes may, rarely, present in patients without a positive history after the initiation of treatment. We present a rare case of a woman with seronegative rheumatoid arthritis who developed pyoderma gangrenosum whistle on treatment with golimumab, a fully humanized anti TNFa antibody. The recording of this as well as analogous paradoxical autoimmune syndromes in association with the individual patient characteristics will render treating physicians aware of potential adverse reactions and assist in the understanding of the cytokine driven pathophysiological mechanisms underlying these disorders.