Dermoscopic Findings in Intraepidermal Carcinoma: an Interobserver Agreement Study.

INTRODUCTION: A wide range of descriptive terms have been used for dermoscopic findings in intraepidermal carcinoma (IEC) and the clinical diagnostic accuracy of IEC can be challenging. Furthermore, dermoscopic findings in IEC have only rarely been evaluated in fair-skinned populations. OBJECTIVES: To measure the interobserver agreement between dermatologists for dermoscopic findings in IEC. Furthermore, to describe the frequency of these findings in a predominantly fair-skinned population. METHODS: One hundred dermoscopic images of histopathologically verified IECs were collected. The 11 most common dermoscopic findings described in previous studies were re-defined in a new terminology in a pre-study consensus meeting. Images were assessed by eight experienced international dermoscopists. The frequency of findings and the interobserver agreement was analyzed. RESULTS: Scales (83%), dotted/glomerular vessels (77%), pinkish-white areas (73%) and hemorrhage (46%) were the most commonly present dermoscopic findings. Pigmented structures were found in 32% and shiny white structures (follicular or stromal) in 54% of the IEC. Vascular structures (vessels and/or hemorrhage) could be seen in 89% of the lesions. Overall, the interobserver agreement for the respective dermoscopic findings was poor to moderate, with the highest kappa values noted for scales (0.55) and hemorrhage (0.54) and the lowest for pinkish-white areas (0.015). CONCLUSION: Our results confirm those of previous studies on dermoscopy in IEC, including the frequency of pigmented structures despite the fair-skinned population. The interobserver agreement was relatively low. The proposed new terminology and our findings can hopefully serve as a guideline for researchers, teachers and students on how to identify IEC.

Dermoscopic Evaluation of Inflammatory Nail Disorders and Their Mimics.

Nail dermoscopy (onychoscopy) is a valuable diagnostic tool for evaluating diseases in the nail apparatus. It is non-invasive, allowing clinicians to prioritize particular nails for biopsy. Thus, it can improve diagnostic accuracy and expedite treatment. Evaluating inflammatory nail disorders using onychoscopy is a relatively new approach to clinical assessment and has the potential to augment clinical care. This review highlights key dermoscopic features of major inflammatory nail disorders, including trachyonychia, nail psoriasis, nail lichen planus, onychotillomania, nail lichen striatus and allergic contact dermatitis due to artificial nails. It also illustrates their management and differential diagnoses, including onychomycosis, onycholysis, nail dystrophy due to systemic amyloidosis and malignant nail tumours. Limitations of this review included the low amount of literature on this topic and non-standardized terminology used among research-ers. As onychoscopy is a relatively new technique, further studies and standardization of terminology are warranted to consolidate the role of dermoscopy in evaluating inflammatory nail disorders.

The impact of incomplete clinical information and initial biopsy technique on the histopathological diagnosis of cutaneous melanoma.

BACKGROUND/OBJECTIVES: Increased rates of histopathological misdiagnosis of melanoma have been associated with incisional punch more so than shave biopsy when compared with complete excisional biopsy. It is unknown how the increasing utilisation of shave biopsy may impact melanoma diagnosis. The extent to which the provision of clinical information to the pathologist may improve diagnostic accuracy remains unclear. This study assessed the impact of both initial biopsy technique and provision of adequate clinical information to pathologists on the accuracy of histopathological diagnosis of melanoma and disease progression. METHODS: We conducted a retrospective cohort with nested case-control study of all histopathological false-negative and false-positive melanoma diagnoses from January 2014 to May 2019 from the Victorian Melanoma Service electronic database. Cases were assessed for the initial biopsy type, provision of clinical information on pathology request forms and disease progression associated with false-negative diagnosis. RESULTS: Partial shave biopsy had higher odds of false-negative (OR 5.19, 95% CI 2.89-9.32; P < 0.001) and false-positive diagnoses (OR 1.95, 95% CI 1.45-2.63; P < 0.001) of melanoma when compared with elliptical excisional biopsy. These odds ratios were comparable with those found with incisional punch biopsy. Providing the suspected clinical diagnosis to pathologists also reduced the odds of false-negative diagnosis with melanoma progression by 3.8-fold (P = 0.02). CONCLUSION: The choice of initial biopsy technique and providing the suspected clinical diagnosis to pathologists are important for correct histopathological diagnosis of cutaneous melanoma and prevention of further disease progression.

Methods of melanoma detection and of skin monitoring for individuals at high risk of melanoma: new Australian clinical practice.

INTRODUCTION: The evidence-based national clinical practice guidelines for the management of cutaneous melanoma published in 2008 are currently being updated. This article summarises the findings from multiple chapters of the guidelines on different methods of melanoma detection and of monitoring the skin for patients at high risk of melanoma. Early detection of melanoma is critical, as thinner tumours are associated with enhanced survival; therefore, strategies to improve early detection are important to reduce melanoma-related mortality. MAIN RECOMMENDATIONS: Clinicians who perform skin examinations for the purpose of detecting skin cancer should be trained in and use dermoscopy. The use of short term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual melanocytic lesions of concern. The use of long term sequential digital dermoscopy imaging to detect melanomas that lack dermoscopic features of melanoma is recommended to assess individual or multiple melanocytic lesions for routine surveillance of high risk patients. The use of total body photography should be considered in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi. There is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of primary melanoma. MANAGEMENT OVERVIEW: Determining the relative indications for each diagnostic method and how each method should be introduced into the surveillance of a patient requires careful consideration and an individualised approach.

Clinical practice guidelines for the diagnosis and management of melanoma: melanomas that lack classical clinical features.

INTRODUCTION: A Cancer Council Australia multidisciplinary working group is currently revising and updating the 2008 evidence-based clinical practice guidelines for the management of cutaneous melanoma. While there have been many recent improvements in treatment options for metastatic melanoma, early diagnosis remains critical to reducing mortality from the disease. Improved awareness of the atypical presentations of this common malignancy is required to achieve this. A chapter of the new guidelines was therefore developed to aid recognition of atypical melanomas. Main recommendations: Because thick, life-threatening melanomas may lack the more classical ABCD (asymmetry, border irregularity, colour variegation, diameter > 6 mm) features of melanoma, a thorough history of the lesion with regard to change in morphology and growth over time is essential. Any lesion that is changing in morphology or growing over a period of more than one month should be excised or referred for prompt expert opinion. Changes in management as a result of the guidelines: These guidelines provide greater emphasis on improved recognition of the atypical presentations of melanoma, in particular nodular, desmoplastic and acral lentiginous subtypes, with particular awareness of hypomelanotic and amelanotic lesions.

Subungual fibro-osseous pseudotumour of the toe.

Subungual fibro-osseous pseudotumour of the toe is a rare osseous soft tissue tumour of which only six cases have been described in the literature. We present a case in a teenage boy that posed an instructive diagnostic challenge and discuss the distinguishing features of the various differential diagnoses. The subungual location is very rare. For such tumours, radiology is as vital as histopathology in making a diagnosis and excluding neoplasia. Accurate diagnosis requires careful clinico-pathological and radiological correlation. These sorts of lesions may present to the dermatologist, not always the foot surgeon.

Efficacy of imiquimod cream, 5%, for lentigo maligna after complete excision: a study of 43 patients.

OBJECTIVE: To determine the efficacy of imiquimod cream, 5%, in the treatment of lentigo maligna (LM). DESIGN: Open-label before-and-after interventional study. SETTING: A multidisciplinary melanoma clinic at a major tertiary hospital. PATIENTS: Forty-three patients with biopsy-proven LM of greater than 5 mm in diameter completed this study. INTERVENTIONS: Imiquimod cream, 5%, was applied to the lesion 5 days a week for 12 weeks. The original lesion was excised with a 5-mm margin. MAIN OUTCOME MEASURES: The primary outcome was histopathologic evidence of LM in the excision specimen assessed independently by 2 of 3 dermatopathologists. Visible inflammation during treatment and macroscopic clearance were recorded. RESULTS: When 5 of the 43 patients with discordant histopathologic assessment of the excision specimen were excluded, 20 of 38 patients (53% [95% confidence interval, 36%-69%]) demonstrated histopathologic clearance of LM after imiquimod treatment. Visible inflammation was significantly associated with histopathologic clearance (P = .04), but the positive predictive value was low (62%). Macroscopic clearance showed some association with histopathologic clearance (P = .11). Dermatopathologist concordance for all 43 specimens was substantial (κ = 0.77; 95% confidence interval, 0.57-0.96). CONCLUSIONS: Imiquimod cream, 5%, has limited efficacy in the treatment of LM when determined by histopathologic assessment of the entire treated area. The clinical signs of visible inflammation during treatment and apparent lesion clearance cannot be relied on to assess efficacy.

PlayStation purpura.

A 16-year-old boy presented with a number of asymptomatic pigmented macules on the volar aspect of his index fingers. Dermoscopy of each macule revealed a parallel ridge pattern of homogenous reddish-brown pigment. We propose that these lesions were induced by repetitive trauma from a Sony PlayStation 3 (Sony Corporation, Tokyo, Japan) vibration feedback controller. The lesions completely resolved following abstinence from gaming over a number of weeks. Although the parallel ridge pattern is typically the hallmark for early acral lentiginous melanoma, it may be observed in a limited number of benign entities, including subcorneal haematoma.

Cutaneous melanoma--atypical variants and presentations.

BACKGROUND: The incidence of melanoma continues to rise in Australia. General practitioners treat the majority of skin cancers affecting Australians. In the past decade, there has been improved uptake of dermoscopy by GPs who realise its value in the assessment of pigmented and nonpigmented lesions. OBJECTIVE: This article outlines those variants or presentations of melanoma that create diagnostic difficulty for all clinicians. Practice tips regarding clinical features or useful dermoscopic clues are included. DISCUSSION: A clinical overview of lentigo maligna, acral lentiginous and subungual melanoma, nodular melanoma, desmoplastic melanoma, verrucous melanoma and hypomelanotic melanoma is presented. Dermoscopy has become a vital diagnostic aid in the assessment of all skin lesions. Its value in the diagnosis of melanoma is highlighted where relevant. Expert dermatopathology assessment is equally as crucial in reaching a correct diagnosis, especially for some of these atypical variants.

Dermatoscopy aids in the diagnosis of the solitary red scaly patch or plaque-features distinguishing superficial basal cell carcinoma, intraepidermal carcinoma, and psoriasis.

BACKGROUND: Intraepidermal carcinoma (IEC), superficial basal cell carcinoma (sBCC), and psoriasis are common entities that may all present as well-defined, brightly erythematous plaques. Currently, there are limited data on the dermatoscopic features that differentiate these diagnoses. OBJECTIVE: We sought to describe the most significant morphologic findings seen on dermatoscopy of IEC, sBCC, and psoriasis, and formulate a diagnostic model based on these features. METHOD: We conducted a retrospective observational study using macrophotography and dermatoscopy to evaluate the presence or absence of dermatoscopic features and formulated diagnostic models for each diagnosis. A convenient sample of 300 lesions was collected from 255 patients from two hospital dermatology clinics and 4 private dermatology practices. These comprised 150 cases of sBCC, 100 cases of psoriasis, and 50 cases of IEC. RESULTS: The most significant dermatoscopic features of IEC were a clustered vascular pattern, glomerular vessels, and hyperkeratosis. When all 3 features were observed together, the diagnostic probability for IEC was 98%. sBCCs were characterized by a scattered vascular pattern, arborizing microvessels, telangiectatic or atypical vessels, milky-pink background, and brown dots/globules; the diagnostic probability was 99% if 4 of these 6 features were identified. For psoriasis, the significant features identified were a homogenous vascular pattern, red dots, and light-red background, yielding a diagnostic probability of 99% if all 3 features were present. LIMITATIONS: Lack of evaluation of interobserver/intraobserver reproducibility is a limitation. CONCLUSION: Dermatoscopy is valuable in the diagnosis and differentiation of IEC, sBCC, and psoriasis because of consistent dermatoscopic morphology.