[Orchiectomy due to early syphilis]. / Frühsyphilis als Ursache einer Orchiektomie.

Granulomatous and abscessing testicular inflammations are important differential diagnoses of testicular tumors. Infectious orchitis should always be considered in unclear testicular masses with negative tumor markers. We report the case of a 45-year-old man with abscessing orchitis due to early syphilis diagnosed after orchiectomy with the suspicion of a seminoma.

Spirituality and mood pathology in severe skin conditions: a prospective observational study.

Although the association between spirituality and parameters of psychological health and disease has been investigated extensively, little evidence is available for its potential role in dermatology. In a single-centre observational prospective study, 149 outpatients (107 women) with systemic sclerosis (SSc; n = 44), lupus erythematosus (LE; n = 48), or early stage malignant melanoma (MM; n = 57) were investigated using the multidimensional inventory for religious/spiritual well-being together with the Brief Symptom Inventory for psychiatric symptoms (BSI-18). SSc patients reported the highest amount of Somatization in comparison with LE and MM patients (p < 0.05). Furthermore, in line with the previous research, spiritual dimensions, such as Hope for a better future (p < 0.01) or Hope for a better afterlife (p < 0.01), proved to be especially negatively predictive for the global amount of psychiatric symptom burden in these dermatological patient groups. Our findings suggest that greater attention should be given to spiritual issues, such as encouraging patients, imbuing them with optimism, and offering interventions that address spiritual well-being.

Mobile teledermatology helping patients control high-need acne: a randomized controlled trial.

BACKGROUND: Acne is an important health issue with a major psychological impact in addition to the physical problems it causes. OBJECTIVES: To investigate the superiority of mobile teledermatology in the care of patients with high-need facial acne in comparison to outpatient services with particular attention to treatment efficacy, safety, and patient compliance. Further, patient satisfaction with remote care was evaluated. METHODS: Sixty-nine consecutive patients (f: 25, m: 44, median age: 19 years, range: 13-37 years) were randomly allocated to either the teleconsultation (TCA) or the outpatient consultation (OCA) arm of the trial to receive isotretinoin treatment in weight and severity-dependent dosages over 24 weeks. Acne grading was performed by one examiner using the Global Acne Severity Scale (GEA) and the total lesion counting (TLC). RESULTS: Due to noncompliance issues, 17 of 69 (24.6%) patients were excluded from the study, of who 10 had been assigned to the TCA (10/34; 29.4%) and 7 to the OCA (7/35; 20%). Both, in the TCA (GEA-score: ∆ = 2.25; TLC: ∆ = 89.08) and in the OCA (GEA-score: ∆ = 2.0; TLC: ∆ = 91.21) excellent and almost equivalent therapeutic outcomes were achieved. In the TCA, however, less patients experienced adverse reactions (P = 0.55). Even though additional live supervision would have been appreciated in some teledermatology cases, patients were satisfied with the mobile service and no consultation request was created. CONCLUSION: Mobile teledermatology is an efficient, safe and well-accepted tool among patients with high-need acne constituting at least a valuable adjunct to outpatient care services. Further larger studies would be useful to confirm our findings.

Assessment of changes in lentigo maligna during radiotherapy by in-vivo reflectance confocal microscopy: a pilot study.

BACKGROUND: Radiotherapy is an effective treatment for therapy of lentigo maligna (LM). OBJECTIVES: To investigate the usefulness of in-vivo reflectance confocal microscopy (RCM) in radiotherapy of LM and document the changes within the lesions during treatment. METHODS: A total of six lesions in six patients were investigated by RCM before, during and after radiotherapy. For diagnostic assessment three observers with experience in RCM diagnosis, blinded as to the stage of treatment, assessed the RCM images of each lesion and documented the findings by consensus. RESULTS: Epidermal disarray worsened in three patients during radiotherapy and superficial necrosis was observed in four patients. Large pagetoid round/dendritic cells decreased or even vanished during or after radiotherapy. Dilated vessels and apoptotic cells were seen in all patients during radiotherapy as well as an increase of inflammatory cells in the epidermis and dermis in most of the patients. Dendritic cells with small dendrites were observed during radiotherapy in all patients with an increase in number in three patients. Melanophages appeared in five patients at least once during the examination period. All RCM images were assessed correctly by the three observers. CONCLUSIONS: Reflectance confocal microscopy is a useful method to visualize changes during and after radiotherapy and might also be used for early detection of potential treatment failures. In addition, it might be helpful in planning radiotherapy.

Proposal for a clinical-dermoscopic classification of scalp naevi.

BACKGROUND: Recent research suggests that scalp naevi differ with respect to their epidemiology, patient characteristics and morphological patterns, but currently a classification of scalp naevi is lacking. OBJECTIVES: To investigate the prevalence, together with clinical and dermoscopic features, of scalp naevi detected in persons attending a skin cancer screening programme, and to elaborate a classification of scalp naevi based on their most common morphological patterns. METHODS: Participants were recruited during the melanoma prevention programme 'sun watch' of Austrian Cancer Aid in Styria. Each participant received a clinical and dermoscopic total-body skin examination including the scalp. For each participant, demographics and clinical characteristics including number of scalp naevi were recorded. Clinical and dermoscopic photographs of at least one scalp naevus per participant were taken and evaluated for specific clinical and dermoscopic features. RESULTS: In total 867 subjects, including 119 participants (13·7%) with scalp naevi, participated in the study. Compared with those without scalp naevi, subjects with scalp naevi were significantly younger, were more often men and more often exhibited congenital naevi on the body (P < 0·01 for all). Analysis of the clinical and dermoscopic variability of scalp naevi allowed for a proposal to classify scalp naevi into six main groups, namely common, papillomatous, eclipse, congenital, blue and atypical naevus. CONCLUSIONS: Scalp naevi can be classified into six morphological groups; scalp lesions deviating from these six main patterns should be carefully managed to rule out melanoma.

Laypersons' sensitivity for melanoma identification is higher with dermoscopy images than clinical photographs.

BACKGROUND: Most melanomas are first recognized by patients themselves or by their friends and family. OBJECTIVES: To assess the ability of laypersons to identify melanomas using dermoscopy images. METHODS: This is an image-based study using laptop computers in the community. Seventeen laypersons were given a one-page educational brochure on the AC Rule for melanoma (asymmetry, colour variation). These laypersons and three expert dermoscopists completed two image sets, each containing a series of 100 pigmented skin lesions. Set 1 contained five melanomas, while set 2 contained 20 melanomas. Participants viewed a clinical image followed by a dermoscopy image for each lesion. For each image a score of 0-10 was assigned for asymmetry and colour, and then an overall assessment was made for suspicion of melanoma. Mean estimates have been calculated for sensitivity and specificity. RESULTS: Laypersons achieved a clinical sensitivity of 91·2% and a significantly higher dermoscopy sensitivity of 94·0%, P = 0·013. This improvement was not associated with a significant change in overall specificity, which for the clinical image was 64·2% and with dermoscopy was 62·0%, P = 0·97. CONCLUSIONS: These results indicate that laypersons may be able to use dermoscopy to identify more melanomas than naked eye examination alone. Further study into the practice of dermoscopy by laypersons is warranted.

Patient acceptance and diagnostic utility of automated digital image analysis of pigmented skin lesions.

BACKGROUND: Computerized analysis of pigmented skin lesions may help to increase diagnostic accuracy for melanoma, help to avoid unnecessary procedures and reduce health care costs. OBJECTIVES: We evaluated both the patient acceptance and diagnostic utility of such an analysis tool in a real clinical setting. METHODS: Two hundred nine consecutive patients (median age: 34 years, range: 2-73 years), who were concerned about a pigmented skin lesion, answered a questionnaire about their attitude towards computerized analysis and their confidence in the resulting findings. Using a dermoscopy analyser, their skin lesions (n = 219) were then grouped into the categories, benign, suspicious and malignant, and results were compared with those obtained by in-person examination of dermato-oncologic experts. RESULTS: More than half of the patients (n = 114) would accept the use of computer analysis for melanoma screening; although 16 (14.0%) patients would accept this method solely, 98 (86.0%) patients would prefer an additional in-person examination by a dermatologist. Of the 219 pigmented skin lesions, the dermoscopic experts rated 171 (78.1%) as benign, 36 (16.4%) as suspicious and 12 (5.5%) as malignant, whereas computer analysis revealed 102 (46.6%) benign, 78 (35.6%) suspicious and 39 (17.8%) malignant lesions. At the expense of specificity (48.8%), the sensitivity of computerized analysis was excellent (100%) and equal to that of in-person examination. CONCLUSIONS: Most patients would accept computer analysis for melanoma screening, some of them even without reservations. However, due to a high rate of false positive computer assessments, it cannot be recommended as a screening tool at this time.

Reflectance confocal microscopy of facial lentigo maligna and lentigo maligna melanoma: a preliminary study.

BACKGROUND: Facial lentigo maligna (LM) and lentigo maligna melanoma (LMM) may be difficult to diagnose clinically and dermoscopically. Reflectance confocal microscopy (RCM) enables the in vivo assessment of equivocal skin lesions at a cellular level. OBJECTIVES: To assess cytomorphological and architectural RCM features of facial LM/LMM. METHODS: Four women and eight men aged 58-88 years presenting with facial skin lesions suspicious of LM/LMM were included. In total, 17 lesion areas were imaged by RCM before biopsy. The histopathological diagnosis of LM was made in 15 areas; the other two were diagnosed as early LMM. RESULTS: A focal increase of atypical melanocytes and nests surrounding adnexal openings, sheets of mainly dendritic melanocytes, cord-like rete ridges at the dermoepidermal junction (DEJ) and an infiltration of adnexal structures by atypical melanocytes were found to be characteristic RCM features of facial LM/LMM. Areas with a focal increase of atypical melanocytes and nests surrounding adnexal openings were observed at the basal layer in three cases. The remaining cases displayed these changes at suprabasal layers above sheets of mainly dendritic melanocytes. Cord-like rete ridges at the DEJ and an infiltration of adnexal structures by atypical melanocytes were observed in all cases. Previously described criteria for RCM diagnosis of melanoma, such as epidermal disarray, pleomorphism of melanocytes and pagetoid spreading of atypical melanocytes, were additionally observed. CONCLUSIONS: We observed a reproducible set of RCM criteria in this case series of facial LM/LMM.

Frequency, clinical and dermoscopic features of benign papillomatous melanocytic naevi (Unna type).

BACKGROUND: Most previous studies on melanocytic naevi have not distinguished between the different types of naevi, except for some studies trying to define atypical naevi. No large, population-based studies on papillomatous or Unna-type melanocytic naevi have been performed. OBJECTIVES: To investigate the dermoscopic and clinical features of papillomatous naevi and to study some of the factors which could potentially influence their development. METHODS: Seven hundred and seven caucasians aged 1-82 years participated in a screening campaign at open-air recreation facilities in Austria. The volunteers underwent a total body examination by experienced dermatologists and answered a questionnaire. Clinical and dermoscopic images of one representative papillomatous naevus per person were taken. RESULTS: Twenty-nine per cent of the volunteers exhibited papillomatous naevi, the highest frequency being found in young adults. No correlation between the frequency of papillomatous naevi and gender, skin type, sunburns, sunbed use or hormonal factors was found. Most lesions were brown papules (median diameter 5.0 mm), located on the trunk. Dermoscopy showed a predominance of homogeneous and globular pattern, multifocal hypo/hyperpigmentation and comma vessels. Of the papillomatous naevi, 9.8% showed suspicious scores with dermoscopic algorithms. CONCLUSIONS: The lack of exogenous influencing factors and the predominance of globular dermoscopic pattern strengthen the hypothesis that papillomatous naevi belong to the same spectrum as small congenital melanocytic naevi. As the role of papillomatous naevi as precursors of melanoma remains unclear and they are frequently not recognized by the patients, one should perform dermoscopy of papillomatous naevi during skin cancer screening.

Assessing melanoma risk factors: how closely do patients and doctors agree?

OBJECTIVES: Self-examination of the skin has been associated with a reduced risk of advanced melanoma, but self-assessment has corresponded imperfectly with clinical examination by a dermatologist, and shown only moderate accuracy in identifying individuals at risk. STUDY DESIGN: Population-based screening campaign in Styria, Austria. METHODS: One thousand two hundred and twenty-three Caucasians volunteered for a free skin assessment by a dermatologist. First, they answered a questionnaire in which they assessed their own melanoma risk factors, and they were subsequently examined by a dermatologist. Kappa agreements between the two assessments were calculated. RESULTS: The overall kappa agreements on the estimated number of naevi, the assessment of skin phototype and the perception of increased melanoma risk were 0.34 [95% confidence interval (CI) 0.30-0.37], 0.28 (95%CI 0.24-0.32) and 0.24 (95% CI 0.18-0.30), respectively. Kappa agreements below 0.40 are considered poor. Stratification by age and gender revealed slightly higher scores for subgroups on single items. CONCLUSIONS: Screening for melanoma should be population based and should not be limited to self-referrals since self-assessment for melanoma risk factors is inaccurate. Educational programmes must be developed to improve self-assessment and to target populations at risk.

In vivo confocal scanning laser microscopy of common naevi with globular, homogeneous and reticular pattern in dermoscopy.

BACKGROUND: A systematic examination and comparison of confocal scanning laser microscopy (CSLM) features of benign naevi showing different dermoscopic patterns has never been performed. OBJECTIVES: Systematically to assess CSLM features of dermoscopically benign reticular, globular and homogeneous naevi and to correlate CSLM findings with dermoscopy and histopathology. METHODS: CSLM was performed on 30 naevi in 29 patients including 10 reticular, 10 globular and 10 homogeneous naevi showing a uniform pigmentation pattern with dermoscopy. Cytomorphological and architectural features of each naevus were assessed and distinct characteristics for each group of naevi were defined. CSLM features were correlated with the histopathological findings and their applicability for the diagnosis of naevi with different dermoscopic patterns was assessed by two blinded observers. RESULTS: A correct diagnosis was made in 26 and 28 of 30 cases, respectively, by two blinded observers using previously defined CSLM features. Well-defined melanocytic caps, well-defined edged papillae and black papillae concurrently with the absence of white papillae were found in all reticular naevi (10 of 10). Numerous, large junctional/dermal melanocytic nests (10 of 10), ill-defined edged papillae (eight of 10) and white papillae (nine of 10) were found in globular naevi. Homogeneous naevi showed an intermediate pattern between reticular and globular naevi: ill-defined edged papillae (10 of 10), black and white papillae within the same naevus (eight of 10) and junctional/dermal melanocytic nests (three of 10) were seen. CONCLUSIONS: Different dermoscopic patterns of benign naevi are reflected in different architectural features in CSLM. As benign naevi show a regular architecture of monomorphous melanocytes in contrast to melanomas, similar dermoscopic features of naevi and early melanomas may be differentiated by CSLM.

The additive value of second opinion teleconsulting in the management of patients with challenging inflammatory, neoplastic skin diseases: a best practice model in dermatology?

BACKGROUND: Telemedicine is the practice of healthcare using interactive processes of communication to facilitate healthcare delivery, including diagnosis, consultation and treatment, as well as education and transfer of medical data. The aim of teledermatology, just as telemedicine, is to promote best practice procedures and to improve the consistency and competence of health care. AIM: To investigate the diagnostic additive value of second opinion teleconsulting in patients with challenging dermatoses, among dermatologists working in two different dermatology departments. SETTING: Thirty-three cases of patients with challenging inflammatory and neoplastic skin diseases at the University of L'Aquila Department of Dermatology were sent for teleconsultation to the Department of Dermatology, Medical University of Graz, Austria. METHODS: All cases were selected in the outpatient service in L'Aquila. After face-to-face consultation with a local colleague had been completed, images were sent using a store-and-forward (SAF)-based system (http://www.telederm.org) to Graz. Histopathological examination together with follow-up of the patient represents the diagnostic gold standard for this study. RESULTS: Telediagnosis was correct in 26 of 33 (78.8%) cases. Sixteen of 33 cases (48.5%) had already been diagnosed face-to-face by at least one of the two dermatologists in L'Aquila. In 10 of 33 cases (30.3%), the correct diagnosis was made in teleconsultation only. CONCLUSIONS: Second opinion teleconsulting may represent an additive value in the diagnosis of numerous challenging inflammatory and neoplastic skin diseases. It may be particularly useful as a best practice model for smaller departments in order to discuss and/or to confirm diagnoses and also for the management of patients with unusual difficult dermatoses.

Two years' experience with Web-based teleconsulting in dermatology.

A non-commercial teledermatology network based on store-and-forward operation was established in April 2002. The aim was to create an easy-to-use platform for teleconsultation services, where physicians could seek diagnostic advice in dermatology from a pool of expert consultants and where they could present and discuss challenging dermatology cases with special emphasis on diagnosis and therapy. An online moderated discussion forum was added in October 2003. During the first two years, 348 health-care professionals from 45 countries registered to use the Website. A total of 783 requests for consultations were answered; 285 requests concerned pigmented skin lesions, 440 requests were from the whole range of clinical dermatology and 58 requests were about non-melanoma skin cancer. Of a total of 133 requests analysed, 80 (60%) were answered within one day, 47 (35%) within one week, five (4%) within two weeks and one (1%) consultation was answered in more than two weeks. Our experience with a discretionary, non-commercial, multilingual Website for open-access teleconsulting in dermatology appears to be successful. The Website represents an example of user-generated content, together with active interaction between users, who can present and discuss cases with remote colleagues.

Age-related prevalence of dermoscopy patterns in acquired melanocytic naevi.

BACKGROUND: Based on the dermoscopic classification of acquired melanocytic naevi, six different dermoscopic types can be distinguished by morphology (globular, globular-reticular, globular-homogeneous, reticular, reticular-homogeneous, homogeneous) and by pigment distribution (uniform, central hyperpigmentation, central hypopigmentation, peripheral hyperpigmentation, peripheral hypopigmentation, multifocal hyper/hypopigmentation). It has been suggested that most individuals harbour one predominant dermoscopic type among their naevi. OBJECTIVES: To evaluate whether the age of the patient influences the predominant naevus pattern observed in individuals with multiple acquired melanocytic naevi. METHODS: Individuals were recruited from the pigmented skin lesion clinic in Graz between July 2000 and February 2001. Individuals with at least 10 melanocytic naevi were selected consecutively until a total of 10 individuals in each of five age groups was obtained. Age groups were: 0-15 years, 16-30 years, 31-45 years, 46-60 years and > 60 years. Digitized images of acquired melanocytic naevi, defined as benign melanocytic proliferations having a diameter of at least 5 mm with a macular component and which were not apparent within the first year of life, were evaluated by dermoscopic criteria. The associations of dermoscopic features as a function of patient age were analysed. We calculated absolute numbers and frequencies, given as percentages, as well as predominance of the dermoscopic types of naevi in the different age groups. RESULTS: Analysis of 1268 naevi revealed that the globular pattern predominated in the youngest age group. By contrast, the reticular and/or homogeneous patterns were increasingly exhibited in naevi from older individuals (older than 15 years). Uniform pigmentation was most common in melanocytic naevi in the youngest age group, while central hyperpigmentation was predominantly seen in the group of individuals aged 16-30 years. CONCLUSIONS: The predominance of dermoscopic types of melanocytic naevi varies according to the individual's age. Awareness of the age-related dermoscopic predominance of melanocytic naevi might allow more accurate recognition of dermoscopic patterns of melanocytic skin lesions that are unusual with respect to the individual's age. This observation may help in the early recognition of some 'banal'-appearing melanomas. Furthermore, the observations made in this study raise interesting questions regarding naevus evolution.

Paired comparison of bathwater versus oral delivery of 8-methoxypsoralen in psoralen plus ultraviolet: A therapy for chronic palmoplantar psoriasis.

BACKGROUND: Both bath psoralen plus ultraviolet A (PUVA) and oral PUVA with 8-methoxypsoralen (8-MOP) have been successfully used for the treatment of recalcitrant palmoplantar psoriasis. This trial was designed to assess the efficacy and side effects of the different treatment modalities in a randomized half-side comparison. METHODS: Eight patients with moderate-to-severe psoriasis on soles (n = 6) and/or palms (n = 8) were randomly assigned to receive bath PUVA treatment on one side and oral PUVA on the other. Initial treatment dose was 50% of the minimal phototoxic dose evaluated for bath PUVA and oral PUVA. Treatment was given three times a week for 4 weeks. Before treatment and every week a severity index (SI) was assessed by summing the scores of erythema, infiltration, scaling and vesicles evaluated on a scale from 0 to 4. After 4 weeks of treatment the half-side trial was finished and the treatment was continued on both sides with the more effective treatment regimen. RESULTS: Both bath PUVA and oral PUVA achieved a reduction of the mean initial SI from 5.9 (95% confidence intervals (CI) 4.5-8.0) to 3.3 (1.8-6.0) (44% SI reduction, P < 0.005, Student's paired t-test) and 6.0 (5.0-7.8) to 2.9 (1.8-4.0) (52% SI reduction; P < 0.005), respectively. The statistical comparison of the entire 4-week study period revealed a significant better effect in lesions treated with oral PUVA compared with bath PUVA (P = 0.033). However, at 4 weeks, there was no significant difference between the achieved SI reduction of oral PUVA and bath PUVA. Systemic side effects (nausea and/or dizziness) were only observed after oral PUVA. CONCLUSION: This study gives evidence that in the first 4 treatment weeks oral PUVA is slightly more effective than bath PUVA but the former has more systemic side effects.

Clinical aspects and pathology of primary cutaneous B-cell lymphomas.

Primary cutaneous B-cell lymphomas (pCBCL) occur more frequently than generally believed. The most important subtypes are: marginal zone B-cell lymphoma/immunocytoma, follicle center-cell lymphoma and large B-cell lymphoma of the leg. A correct diagnosis can be rendered only in the context of knowledge of the clinical findings. Progress in terms of classification and biology is associated with the application of modern techniques including immunohistology and laser beam microdissection followed by molecular analysis. Future definitions of pCBCL will be based on their molecular abnormalities and their etiology and pathogenesis. Awareness of the special clinical behavior of pCBCL should prevent unnecessarily aggressive treatment.

No evidence for c-erbB-2 overexpression in cutaneous melanoma.

BACKGROUND: Recent studies have demonstrated the expression of the c-erbB-2 (HER-2/neu) oncoprotein in several malignant tumors and have related its overexpression with poor prognosis. Because cutaneous melanoma is a malignant tumor associated with poor prognosis, we investigated the expression of c-erbB-2 protein in cutaneous melanoma and in melanoma metastatic to the skin. MATERIALS AND METHODS: The expression of c-erbB-2 protein in 20 primary cutaneous melanomas and in 10 melanomas metastatic to the skin was investigated using a semi-quantitative immunohistochemical assay. RESULTS: No specific staining with c-erbB-2 antibody was observed in any of the 20 cases of primary malignant melanoma or 10 cases of melanoma metastatic to the skin. CONCLUSION: c-erbB-2 overexpression does not appear to play a role in the development of primary cutaneous melanoma or in the development of metastatic melanoma, indicating that mechanisms other than c-erbB-2 overexpression are involved in the pathogenesis of cutaneous melanoma.

Prognostic factors in primary cutaneous large B-cell lymphomas: a European multicenter study.

PURPOSE: Most primary cutaneous B-cell lymphomas have an excellent prognosis. However, primary cutaneous large B-cell lymphomas (PCLBCLs) of the leg have been recognized as a distinct entity with a poorer prognosis in the European Organization for Research and Treatment of Cancer (EORTC) classification. This distinction on the basis of site has been debated. Our aim was to identify independent prognostic factors in a large European multicenter series of PCLBCL. PATIENTS AND METHODS: The clinical and histologic data of 145 patients with PCLBCL were evaluated. According to the EORTC classification, 48 patients had a PCLBCL of the leg and 97 had a primary cutaneous follicle center-cell lymphoma (PCFCCL). Data from both groups were compared. Univariate and multivariate analyses of specific survival were performed using a Cox proportional hazards model. RESULTS: Compared with PCFCCL, PCLBCL-leg were characterized by an older age of onset, a more recent history of skin lesions, a more frequent predominance of tumor cells with round nuclei and positive bcl-2 staining, and a poorer 5-year disease-specific survival rate (52% v 94%; P <.0001). Univariate survival analysis in the entire study group showed that older age, a more recent onset of skin lesions, the location on the leg, multiple skin lesions, and the round-cell morphology were significantly related to death. In multivariate analysis, the round-cell morphology (P <.0001), the location on the leg (P =.002), and multiple skin lesions (P =.01) remained independent prognostic factors. The round-cell morphology was an adverse prognostic factor both in PCLBCL-leg and in PCFCCL, whereas multiple skin lesions were associated with a poor prognosis only in patients with PCLBCL-leg. CONCLUSION: With site, morphology, and number of tumors taken into account, guidelines for the management of PCLBCL are presented.