Dermoscopy of skin parasitoses, bites and stings: a systematic review of the literature.

Besides classic applications, dermoscopy has gained significant appreciation also for non-tumoral dermatoses (general dermatology). In this field, skin parasitoses (infestations), bites and stings have been reported among the conditions that may benefit most from dermoscopic examination. However, published data on this topic are sparse and often lack a standardized analytical approach. In this systematic review of the literature, we sought to summarize available data on dermoscopy of cutaneous parasitoses, bites and stings, analysing dermoscopic features and used setting (polarization or not/magnification), pathological correlation and level of evidence of published studies as well as trying to align dermoscopic terminology of reported findings following a standardized methodology. A total of 150 publications addressing 29 different dermatoses and reporting 96 different dermoscopic findings were included in the analysis. Most of them displayed a level of evidence of V (113 single case reports and 36 case series), with only one study featuring a level of evidence of IV (case-control study). Additionally, our analysis also displayed poor uniformity in the terminology used in published articles (even for the same dermatosis). Therefore, albeit promising, dermoscopy of cutaneous parasitoses, bites and stings needs future systematized studies for a better characterization.

Moderate-to-severe atopic dermatitis in adolescents treated with dupilumab: A multicentre Italian real-world experience.

BACKGROUND: Moderate-to-severe atopic dermatitis (AD) in the adolescence is a high burden disease, and its treatment can be very challenging due to paucity of approved systemic drugs for this age and their side-effects. Dupilumab was recently approved for treatment of adolescent AD. OBJECTIVES: A multicentre, prospective, real-world study on the effectiveness and safety of dupilumab in adolescents (aged from ≥12 to <18 years) with moderate-to-severe AD was conducted. The main AD clinical phenotypes were also examined. METHODS: Data of adolescents with moderate-to-severe AD treated with dupilumab at label dosage for 16 weeks were collected. Treatment outcome was assessed by EASI, NRS itch, NRS sleep loss and CDLQI scores at baseline and after 16 weeks of treatment. The clinical scores were also evaluated according to clinical phenotypes. RESULTS: One hundred and thirty-nine adolescents were enrolled in the study. Flexural eczema and head and neck eczema were the most frequent clinical phenotypes, followed by hand eczema and portrait-like dermatitis. Coexistence of more than 1 phenotype was documented in 126/139 (88.5%) adolescents. Three patients (2.1%) contracted asymptomatic SARS-CoV-2 infection and 1 of the discontinued dupilumab treatment before the target treatment period. A significant improvement in EASI, NRS itch, NRS sleep loss and CDLQI was observed after 16 weeks of treatment with dupilumab. This outcome was better than that observed in clinical trials. Dupilumab resulted effective in all AD phenotypes, especially in diffuse eczema. Twenty-eight (20.1%) patients reported adverse events, conjunctivitis and flushing being the most frequent. None of patients discontinued dupilumab due to adverse event. CONCLUSIONS: Dupilumab in adolescent AD showed excellent effectiveness at week 16 with consistent improvement of all clinical scores. Moreover, dupilumab showed a good safety profile also in this COVID-19 pandemic era.

Dermoscopic spectrum of mycosis fungoides: a retrospective observational study by the International Dermoscopy Society.

BACKGROUND: The dermoscopic features of classic patch stage mycosis fungoides (MF) have been described, but data on plaque and tumoral stage as well as rarer MF subtypes is limited. OBJECTIVE: To evaluate dermoscopic morphology and dermoscopic-pathological correlations of classic MF stages and investigate dermoscopic features of MF variants. METHODS: Patients with histopathologically confirmed lesions of classic MF (patch, plaque and tumoral stage) or folliculotropic, erythrodermic and poikilodermatous MF were included. Standardized evaluation of dermoscopic pictures of the included MF variants and comparative analysis and dermoscopic-pathological correlation assessment of different stages of classic MF were performed. RESULTS: A total of 118 instances were included (75 classic MF, 26 folliculotropic MF, 9 erythrodermic MF and 8 poikilodermatous MF). Linear/linear-curved vessels and white scales in the skin furrows were significantly associated with patch-stage MF, while clustered dotted vessels were related to plaque-stage MF and peripheral linear vessels with branches, ulceration and red globules separated by white lines to tumour-stage MF. Moreover, patchy white scales were significantly more common in patches and plaques compared to tumours, whereas focal bright white structureless areas were related to plaque and tumoral stage. Vessels histopathologically corresponded to dilated vascular structures in the dermis, orange structureless areas to either dermal hemosiderin (patch/plaque stage) or dense cellular infiltration (tumours), bright white lines/structureless areas to dermal fibrosis and ulceration to loss of epidermis. The main dermoscopic findings of folliculotropic MF were lack of hairs, dilated follicles and follicular plugs, while erythrodermic MF was mainly characterized by linear/dotted vessels, patchy white scales and focal orange structureless areas and poikilodermatous MF by focal white and brown structureless areas, white patchy scales and brown reticular lines. CONCLUSION: Dermoscopy may allow a more precise characterization of classic MF and reveal clues suggestive of the main MF variants.

Clinical and dermatoscopic predictors of squamous cell carcinoma of the lips: a case-control, multicentric study.

BACKGROUND: Squamous cell carcinoma of the lip accounts for 20% of all oral carcinomas. Its diagnosis may be challenging because it clinically resembles actinic cheilitis and inflammatory lesions of the lips. OBJECTIVES: To determine clinical and dermatoscopic predictors of squamous cell carcinoma of the lip vs. other lip lesions. METHODS: Multicentre retrospective morphological study, including histologically confirmed cases of squamous cell carcinoma of the lip and controls consisting of actinic cheilitis and inflammatory lesions of the lips. Clinical and dermatoscopic images were evaluated for the presence of predefined criteria. Crude and adjusted odds ratios and corresponding 95% confidence intervals were calculated by univariate and multivariate logistic regression respectively. RESULTS: A total of 177 lip lesions were evaluated, 107 (60.5%) were squamous cell carcinomas and 70 (39.5%) were controls. The most frequent dermatoscopic criteria of lip squamous cell carcinoma were scales (100%), white halos (87.3%) and ulceration (79.4%). The majority of squamous cell carcinomas displayed polymorphic vessels (60.8%), with linear (68.6%) and hairpin (67.6%) being the most frequent types. Multivariate logistic regression analysis showed that clinical predictors of lip squamous cell carcinoma were exophytic appearance and clinical hyperkeratosis, with 43-fold and 6-fold higher probability respectively. White clods and ulceration in dermoscopy presented a 6-fold and 4-fold increased risk for squamous cell carcinoma respectively. CONCLUSIONS: A scaly lesion with exophytic growth, dermatoscopically displaying white clods, ulceration and linear and hairpin vessels is very likely a squamous cell carcinoma of the lip.

Dermoscopy of porokeratosis: results from a multicentre study of the International Dermoscopy Society.

BACKGROUND: The diagnosis of porokeratosis can be challenging, and knowledge about its dermoscopic features is limited. OBJECTIVES: To describe the dermoscopic features of porokeratosis of Mibelli and disseminated superficial actinic porokeratosis (DSAP) and the frequency of these features in a larger case series. The interobserver concordance was also assessed. METHODS: In this retrospective cohort study, members of the International Dermoscopy Society contributed macroscopic and dermoscopic images of histopathologically verified cases of porokeratosis of Mibelli or DSAP. Three observers independently reviewed the collected images to identify the presence of predefined dermoscopic features. Following this, a consensus meeting was held to agree upon which dermoscopic features were present in each lesion. RESULTS: In total, 78 clinical and dermoscopic images of porokeratoses were collected. The most common dermoscopic feature was keratin rim, which was present in 74 lesions (92.3%). The most common vascular structures were dotted or glomerular vessels which were present in almost half of the cases (48.7%). Other relatively frequent dermoscopic findings were as follows: non-peripheral scales (44.9%), grey-brown dots or pigmentation along the keratin rim (38.5%), and light-brown pigmentation within the keratin rim (33.3%). Shiny white structures and blood spots or erosions along the keratin rim were findings never before described in porokeratosis and were detected in 16.7% and 17.9% of the lesions, respectively. Dermoscopic findings in porokeratosis of Mibelli and DSAP were similar except for fewer blood spots or erosions along the keratin rim and more light-brown pigmentation within the keratin rim in DSAP. The interobserver concordance ranged from 0.44 (moderate) to 0.84 (almost perfect). CONCLUSIONS: The dermoscopic hallmark of porokeratosis is the keratin rim, a finding also allowing for almost perfect interobserver agreement. Pigmentation or erosions along the keratin rim, vascular structures, as well as scales, pigmentation or shiny white structures within the keratin rim are additional dermoscopic clues.

Knuckle pads mimic early psoriatic arthritis.

Knuckle pads or Garrod's nodes are a rare, non-inflammatory condition. They consist of benign, well-circumscribed fibro-adipose tissue over the small joints of hands and feet. Knuckle pads may be under-diagnosed and mistaken for early arthritis. The rheumatologist should perform an accurate differential diagnosis in which he can be helped by ultrasound and by other colleagues, such as the dermatologist. Ultrasound is considered useful in the assessment of the thickening of the subcutaneous tissue, located usually on the extensor site of proximal interphalangeal and metacarpophalangeal hand joints. Dermoscopy may play a role in detecting epidermal and dermal changes. We hereby report the case of a female patient with knuckle pads mimicking psoriatic arthritis.

Standardization of dermoscopic terminology and basic dermoscopic parameters to evaluate in general dermatology (non-neoplastic dermatoses): an expert consensus on behalf of the International Dermoscopy Society.

BACKGROUND: Over the last few years, several articles on dermoscopy of non-neoplastic dermatoses have been published, yet there is poor consistency in the terminology among different studies. OBJECTIVES: We aimed to standardize the dermoscopic terminology and identify basic parameters to evaluate in non-neoplastic dermatoses through an expert consensus. METHODS: The modified Delphi method was followed, with two phases: (i) identification of a list of possible items based on a systematic literature review and (ii) selection of parameters by a panel of experts through a three-step iterative procedure (blinded e-mail interaction in rounds 1 and 3 and a face-to-face meeting in round 2). Initial panellists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses. RESULTS: Twenty-four international experts took part in all rounds of the consensus and 13 further international participants were also involved in round 2. Five standardized basic parameters were identified: (i) vessels (including morphology and distribution); (ii) scales (including colour and distribution); (iii) follicular findings; (iv) 'other structures' (including colour and morphology); and (v) 'specific clues'. For each of them, possible variables were selected, with a total of 31 different subitems reaching agreement at the end of the consensus (all of the 29 proposed initially plus two more added in the course of the consensus procedure). CONCLUSIONS: This expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This tool, if adopted by clinicians and researchers in this field, is likely to enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology. What's already known about this topic? Over the last few years, several papers have been published attempting to describe the dermoscopic features of non-neoplastic dermatoses, yet there is poor consistency in the terminology among different studies. What does this study add? The present expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This consensus should enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology.

Autologous micrografts and methotrexate in plantar erosive lichen planus: healing and pain control. A case report.

Erosive lichen planus is an uncommon variant of lichen planus. We report a case of longstanding and refractory plantar ELPs causing disabling and opiate-resistant pain treated with 'classic' meshed skin graft combined with Rigenera®  micrografts. After approximately 9 months follow-up, no clinical recurrence or pain were observed. Erosive lichen planus (ELP) is an uncommon variant of lichen planus, involving oral cavity and genitalia and, less often plantar areas, where it usually presents with chronic erosions of the soles, along with intense, disabling pain and progressive loss of toenails. An abnormal immune cellular response (CD8+ lymphocytes and macrophages) and the consequent altered production of multiple mediators (interleukin-12, interferon-γ, tumor necrosis factor-α, RANTES and MMP-9), seem to play a crucial role in the pathogenesis, although the etiology remains uncertain. From a histological point of view, ELP shows keratinocyte apoptosis, intense inflammatory response and basal epithelial keratinocytes TNF-α overexpression. Several therapies have been proposed, with variable and controversial results. While topical corticosteroids and topical calcineurin inhibitors are the treatments of choice for localized forms, short pulses of systemic glucocorticoids, phototherapy, and systemic immunosuppressants are recommended for generalized cases. Surgery has been reported as a possible therapeutic option in refractory and stable cases with localized lesions, either alone or with cyclosporine. Herein, we report a case of longstanding and refractory plantar ELPS causing disabling and opiate-resistant pain treated with 'classic' meshed skin graft combined with Rigenera® micrografts.

Dermoscopy in the differential diagnosis between malar rash of systemic lupus erythematosus and erythematotelangiectatic rosacea: an observational study.

BACKGROUND: Malar rash is one of the three cutaneous diagnostic criteria of systemic lupus erythematosus (SLE). Although its clinical recognition is often straightforward, the differential diagnosis with erythematotelangiectatic rosacea may sometimes be challenging. OBJECTIVE: To describe dermoscopic features of SLE malar rash and investigate the accuracy of dermoscopy for the differential diagnosis with erythematotelangiectatic rosacea. METHODS: A representative dermoscopic image of target areas was evaluated for the presence of specific features. Fisher's test was used to compare their prevalence between the two cohorts, and accuracy parameters (specificity, sensitivity, and positive and negative predictive values) were evaluated. RESULTS: Twenty-eight patients were included in the analysis, of which 13 had SLE malar rash and 15 erythematotelangiectatic rosacea. The main dermoscopic features of malar rash were reddish/salmon-coloured follicular dots surrounded by white halos ('inverse strawberry' pattern), being present in 53.9% of the cases, while network-like vessels (vascular polygons) turned out to be the main feature of erythematotelangiectatic rosacea, with a prevalence of 93.3%. The comparative analysis showed that the 'inverse strawberry' pattern was significantly more common in SLE malar rash, with a specificity of 86.7%, while vascular polygons were significantly more frequent in rosacea, with a specificity of 92.3%. CONCLUSION: Dermoscopy may be a useful support to distinguish SLE malar rash and erythematotelangiectatic rosacea by showing peculiar features.

Dermoscopic features of mammary Paget's disease: a retrospective case-control study by the International Dermoscopy Society.

BACKGROUND: Mammary Paget's disease (MPD) is a rare intraepidermal adenocarcinoma of the nipple-areola complex, associated with an underlying breast cancer in approximately 90% of cases. Delayed diagnosis of MPD is common. Its dermoscopic features have been ill defined in the literature. OBJECTIVES: To determine the clinical and dermoscopic features of MPD versus other dermatologic entities that involve nipple and areola. METHODS: Members of the IDS were invited to submit any case of histologically confirmed MPD, as well as other benign and malignant dermatoses that involve the nipple and areola complex. A standardized evaluation of the dermoscopic images was performed and the results were statistically analyzed. RESULTS: Sixty-five lesions were included in the study, 22 (33.8%) of them MPD and 43 (66.2%) controls. The most frequent dermoscopic criteria of MPD were white scales (86.4%) and pink structureless areas (81.8%), followed by dotted vessels (72.7%), erosion/ulceration (68.2%) and white shiny lines (63.6%). The multivariate analysis showed that white scales and pink structureless areas were significant predictors of MPD, posing a 68-fold and a 31-fold probability of MPD, respectively. Split of the population into pigmented and non-pigmented lesions showed that in pigmented MPD, pink structureless areas, white lines and grey granules and dots are positive predictors of the disease. Among non-pigmented lesions, pink structureless areas, white lines, erosion/ulceration and white scales served as predictors of MPD. CONCLUSIONS: The most frequent profile of an individual with MPD is an elderly female with unilateral, asymptomatic, erythematous plaque of the nipple, dermoscopically displaying pink structureless areas, fine white scales, dotted and a few short linear vessels. In case of pigmentation we may also observe brown structureless areas and pigmented granules. LIMITATIONS: Small sample size, retrospective design.

Accuracy of dermoscopy in distinguishing erythroplasia of Queyrat from common forms of chronic balanitis: results from a multicentric observational study.

BACKGROUND: Clinical differentiation of erythroplasia of Queyrat (EQ) and chronic forms of balanitis may be challenging, especially in early phases or in overlapping cases. Dermoscopy has been shown to be a useful supportive tool in facilitating the distinction between tumoral and inflammatory skin conditions; yet, data on EQ and balanitis are scarce or sparse. OBJECTIVES: To systematically assess the dermoscopic features of both EQ and common forms of chronic balanitis and to investigate the accuracy of dermoscopy in distinguishing these conditions. METHODS: Subjects with EQ or chronic balanitis confirmed histologically or microbiologically (for infectious forms) were recruited. A representative dermoscopic image of a target lesion was retrospectively assessed for the presence of specific morphological findings. A correlation matrix was created using Spearman's rho. Proportions of dermoscopic variables scoring among different conditions were compared with the non-parametric Pearson's chi-square test. RESULTS: A total of 81 lesions (14 EQ, 23 psoriasis, 31 Zoon plasma cell balanitis and 13 candidal balanitis) from 81 patients were included in the study. Glomerular vessels (both clustered and diffusely distributed) were highly predictive for the diagnosis of EQ, while diffuse dotted vessels were strongly associated with psoriatic balanitis. Finally, Zoon plasma cell balanitis was characterized by orange structureless areas (focal or diffuse) and focused linear curved vessels, whereas cottage cheese-like structures (sparse white coating corresponding to Candida yeast colonies growth) showed a strong correlation with candidal balanitis. CONCLUSIONS: Erythroplasia of Queyrat and balanitis may display different dermoscopic patterns, thereby bearing the usefulness of dermoscopy as a supportive non-invasive tool for the recognition and differential diagnosis of such conditions.

Dermoscopy of Erythromelanosis Follicularis Faciei et Colli / Dermatoscopia de erythromelanosis folicular faciei et colli

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