[Bronchial asthma and allergic rhinitis-The skin sample reveals a severe systemic disease]. / Asthma bronchiale und allergische Rhinitis ­ die Hautprobe offenbart eine schwerwiegende Systemerkrankung.

This article reports the case of a 30-year-old female patient who suffered for many years from initially unspecific symptoms, such as recurrent, nonallergic and noninfectious sinusitis, late-onset bronchial asthma and pronounced lymphadenopathy; however, the correct diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA) could only be made by histological investigations after the appearance of skin symptoms. The EGPA is a severe systemic disease which, if left untreated, can cause multiple organ damage and even be fatal. With adequate treatment the disease is mild in more than 90% of cases and patients can even completely recover. By making the correct diagnosis, the patient could be successfully treated and the risk of late manifestations and subsequent damage with a potentially fatal outcome was reduced.

Performance of an automated total body mapping algorithm to detect melanocytic lesions of clinical relevance.

IMPORTANCE: Total body photography for skin cancer screening is a well-established tool allowing documentation and follow-up of the entire skin surface. Artificial intelligence-based systems are increasingly applied for automated lesion detection and diagnosis. DESIGN AND PATIENTS: In this prospective observational international multicentre study experienced dermatologists performed skin cancer screenings and identified clinically relevant melanocytic lesions (CRML, requiring biopsy or observation). Additionally, patients received 2D automated total body mapping (ATBM) with automated lesion detection (ATBM master, Fotofinder Systems GmbH). Primary endpoint was the percentage of CRML detected by the bodyscan software. Secondary endpoints included the percentage of correctly identified "new" and "changed" lesions during follow-up examinations. RESULTS: At baseline, dermatologists identified 1075 CRML in 236 patients and 999 CRML (92.9%) were also detected by the automated software. During follow-up examinations dermatologists identified 334 CRMLs in 55 patients, with 323 (96.7%) also being detected by ATBM with automated lesions detection. Moreover, all new (n = 13) or changed CRML (n = 24) during follow-up were detected by the software. Average time requirements per baseline examination was 14.1 min (95% CI [12.8-15.5]). Subgroup analysis of undetected lesions revealed either technical (e.g. covering by clothing, hair) or lesion-specific reasons (e.g. hypopigmentation, palmoplantar sites). CONCLUSIONS: ATBM with lesion detection software correctly detected the vast majority of CRML and new or changed CRML during follow-up examinations in a favourable amount of time. Our prospective international study underlines that automated lesion detection in TBP images is feasible, which is of relevance for developing AI-based skin cancer screenings.

Differential Immunoexpression of Inhibitory Immune Checkpoint Molecules and Clinicopathological Correlates in Keratoacanthoma, Primary Cutaneous Squamous Cell Carcinoma and Metastases.

Beyond established anti-programmed cell death protein 1/programmed cell death ligand 1 immunotherapy, T-cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibition motif domain (TIGIT) and its ligand CD155 are promising novel inhibitory immune checkpoint targets in human malignancies. Yet, in cutaneous squamous cell carcinoma, evidence on the collective expression patterns of these inhibitory immune checkpoints is scarce. Complete tumour sections of 36 cutaneous squamous cell carcinoma, 5 cutaneous metastases and 9 keratoacanthomas, a highly-differentiated, squamoproliferative tumour, with disparately benign biologic behaviour, were evaluated by immunohistochemistry for expression of programmed cell death ligand 1 (Tumor Proportion Score, Immune Cell Score), TIGIT, CD155 and CD8+ immune infiltrates. Unlike keratoacanthomas, cutaneous squamous cell carcinoma displayed a strong positive correlation of programmed cell death ligand 1 Tumor Proportion Score and CD115 expression (p < 0.001) with significantly higher programmed cell death ligand 1 Tumor Proportion Score (p < 0.001) and CD155 expression (p < 0.01) in poorly differentiated G3-cutaneous squamous cell carcinoma compared with keratoacanthomas. TIGIT+ infiltrates were significantly increased in programmed cell death ligand 1 Immune Cell Score positive primary tumours (p = 0.05). Yet, a strong positive correlation of TIGIT expression with CD8+ infiltrates was only detected in cutaneous squamous cell carcinoma (p < 0.01), but not keratoacanthomas. Providing a comprehensive overview on the collective landscape of inhibitory immune checkpoint expression, this study reveals associations of novel inhibitory immune checkpoint with CD8+ immune infiltrates and tumour differentiation and highlights the TIGIT/CD155 axis as a potential new target for cutaneous squamous cell carcinoma immunotherapy.

[Primary hyperoxaluria type 1-a rare hereditary metabolic disorder as cause of livedo racemosa]. / Primäre Hyperoxalurie Typ 1 ­ eine seltene hereditäre Stoffwechselstörung als Ursache einer Livedo racemosa.

Livedo racemosa is characterized by a bizarrely configurated lightning figure-like appearance with striated to reticulated, livid erythematous macules and results from a reduced perfusion of the respective skin area, which can have different underlying pathophysiologies. A rare but relevant cause, especially in young patients with end-stage kidney failure, is primary hyperoxaluria type 1 (PH1), a hereditary metabolic disorder in which oxalate accumulates in the body.

[Multiple, eruptive epithelioid hemangiomas of the scalp]. / Multiple, eruptive epitheloide Hämangiome der Kopfhaut.

Epithelioid hemangioma is a benign vascular neoplasm with a characteristic histological and immunohistochemical pattern, characterized by a lymphocytic inflammatory infiltrate with admixed eosinophils and FOS­B expression. The correct diagnosis is of particular relevance, since malignant vascular tumors with differentiated epithelioid cells can also be considered in the differential diagnosis. We present a patient with multiple epithelioid hemangiomas of the scalp accompanied by severe pain and itching. The long history of multiple therapeutic attempts illustrates the limited success of currently available treatment options.

[Multimodal therapy for peristomal pyoderma gangrenosum with topical cyclosporine]. / Multimodale Therapie des peristomalen Pyoderma gangraenosum mit topischem Ciclosporin.

Pyoderma gangrenosum (PG) is a rare neutrophilic disease. Clinically it shows a rapidly evolving painful ulceration with undermined violaceous wound edges. Peristomal PG is particularly resistant to treatment due to mechanical irritation. Two cases illustrate a multimodal therapeutic concept based on topical cyclosporine, hydrocolloid dressing and systemic glucocorticoids. In one patient re-epithelialization was attained after 7 weeks and the other patient experienced downsizing of the wound edges over 5 months.

Assessment of Diagnostic Performance of Dermatologists Cooperating With a Convolutional Neural Network in a Prospective Clinical Study: Human With Machine.

Importance: Studies suggest that convolutional neural networks (CNNs) perform equally to trained dermatologists in skin lesion classification tasks. Despite the approval of the first neural networks for clinical use, prospective studies demonstrating benefits of human with machine cooperation are lacking. Objective: To assess whether dermatologists benefit from cooperation with a market-approved CNN in classifying melanocytic lesions. Design, Setting, and Participants: In this prospective diagnostic 2-center study, dermatologists performed skin cancer screenings using naked-eye examination and dermoscopy. Dermatologists graded suspect melanocytic lesions by the probability of malignancy (range 0-1, threshold for malignancy ≥0.5) and indicated management decisions (no action, follow-up, excision). Next, dermoscopic images of suspect lesions were assessed by a market-approved CNN, Moleanalyzer Pro (FotoFinder Systems). The CNN malignancy scores (range 0-1, threshold for malignancy ≥0.5) were transferred to dermatologists with the request to re-evaluate lesions and revise initial decisions in consideration of CNN results. Reference diagnoses were based on histopathologic examination in 125 (54.8%) lesions or, in the case of nonexcised lesions, on clinical follow-up data and expert consensus. Data were collected from October 2020 to October 2021. Main Outcomes and Measures: Primary outcome measures were diagnostic sensitivity and specificity of dermatologists alone and dermatologists cooperating with the CNN. Accuracy and receiver operator characteristic area under the curve (ROC AUC) were considered as additional measures. Results: A total of 22 dermatologists detected 228 suspect melanocytic lesions (190 nevi, 38 melanomas) in 188 patients (mean [range] age, 53.4 [19-91] years; 97 [51.6%] male patients). Diagnostic sensitivity and specificity significantly improved when dermatologists additionally integrated CNN results into decision-making (mean sensitivity from 84.2% [95% CI, 69.6%-92.6%] to 100.0% [95% CI, 90.8%-100.0%]; P = .03; mean specificity from 72.1% [95% CI, 65.3%-78.0%] to 83.7% [95% CI, 77.8%-88.3%]; P < .001; mean accuracy from 74.1% [95% CI, 68.1%-79.4%] to 86.4% [95% CI, 81.3%-90.3%]; P < .001; and mean ROC AUC from 0.895 [95% CI, 0.836-0.954] to 0.968 [95% CI, 0.948-0.988]; P = .005). In addition, the CNN alone achieved a comparable sensitivity, higher specificity, and higher diagnostic accuracy compared with dermatologists alone in classifying melanocytic lesions. Moreover, unnecessary excisions of benign nevi were reduced by 19.2%, from 104 (54.7%) of 190 benign nevi to 84 nevi when dermatologists cooperated with the CNN (P < .001). Most lesions were examined by dermatologists with 2 to 5 years (96, 42.1%) or less than 2 years of experience (78, 34.2%); others (54, 23.7%) were evaluated by dermatologists with more than 5 years of experience. Dermatologists with less dermoscopy experience cooperating with the CNN had the most diagnostic improvement compared with more experienced dermatologists. Conclusions and Relevance: In this prospective diagnostic study, these findings suggest that dermatologists may improve their performance when they cooperate with the market-approved CNN and that a broader application of this human with machine approach could be beneficial for dermatologists and patients.

Lymphatic vessel involvement in primary cutaneous B-cell lymphoma: A common finding?

BACKGROUND: Cutaneous B-cell lymphoma (CBCL) is part of dermatopathological routine diagnostics. However, in contrast to cutaneous T-cell lymphomas, there are only a few studies on the prevalence and possible clinical impact of lymphatic vessel involvement. Therefore, this pilot study aimed to quantify the prevalence of lymphovascular involvement in CBCL and to assess the association between lymphovascular involvement and recurrence. METHODS: Thirty-nine patients from two tertiary care hospitals diagnosed with CBCL were retrospectively identified and their biopsies were histopathologically examined for the presence of lymphatic vessel involvement using H&E stain, and CD20 and D2-40 immunohistochemistry. Clinical data were retrieved from our digital documentation files. RESULTS: Thirty patients were included in the evaluation (nPCFCL = 15, nPCMZL = 10, and nPCLBCL = 5). Lymphovascular involvement occurred in all three types of lymphoma and was present in 14/30 specimens. The presence of lymphatic involvement did not show a significant impact on recurrence rate (p = 0.150). CONCLUSIONS: This immunohistochemical pilot study shows that lymphovascular involvement is a relatively frequent finding in primary CBCL. Although no definitive conclusion can be drawn from our findings because of the small sample size, there were no strong signs of tendencies for recurrence in either group. Future studies with larger sample size are warranted to assess the possible clinical implications.

Observational study investigating the level of support from a convolutional neural network in face and scalp lesions deemed diagnostically 'unclear' by dermatologists.

BACKGROUND: The clinical diagnosis of face and scalp lesions (FSL) is challenging due to overlapping features. Dermatologists encountering diagnostically 'unclear' lesions may benefit from artificial intelligence support via convolutional neural networks (CNN). METHODS: In a web-based classification task, dermatologists (n = 64) diagnosed a convenience sample of 100 FSL as 'benign', 'malignant', or 'unclear' and indicated their management decisions ('no action', 'follow-up', 'treatment/excision'). A market-approved CNN (Moleanalyzer-Pro®, FotoFinder Systems, Germany) was applied for binary classifications (benign/malignant) of dermoscopic images. RESULTS: After reviewing one dermoscopic image per case, dermatologists labelled 562 of 6400 diagnoses (8.8%) as 'unclear' and mostly managed these by follow-up examinations (57.3%, n = 322) or excisions (42.5%, n = 239). Management was incorrect in 58.8% of 291 truly malignant cases (171 'follow-up' or 'no action') and 43.9% of 271 truly benign cases (119 'excision'). Accepting CNN classifications in unclear cases would have reduced false management decisions to 4.1% in truly malignant and 31.7% in truly benign lesions (both p < 0.01). After receiving full case information 239 diagnoses (3.7%) remained 'unclear' to dermatologists, now triggering more excisions (72.0%) than follow-up examinations (28.0%). These management decisions were incorrect in 32.8% of 116 truly malignant cases and 76.4% of 123 truly benign cases. Accepting CNN classifications would have reduced false management decisions to 6.9% in truly malignant lesions and to 38.2% in truly benign cases (both p < 0.01). CONCLUSIONS: Dermatologists mostly managed diagnostically 'unclear' FSL by treatment/excision or follow-up examination. Following CNN classifications as guidance in unclear cases seems suitable to significantly reduce incorrect decisions.

[Plexiform fibrohistiocytic tumor]. / Plexiformer fibrohistiozytärer Tumor.

Plexiform fibrohistiocytic tumors are rare, low-to-moderate malignant soft tissue tumors that occur primarily in children and adolescents and are located on the upper extremity. The diagnosis must be made histologically. We report on a young woman who presented a growing, painless lesion on the cubital fossa. Histopathology as well as the standard of treatment are discussed.

Persistent Facial Blanching after Botulinum Toxin Injection.

We report the case of a 38-year-old male patient who presented with blanching of the face after strenuous exercise or physical exertion. The symptoms regressed in a relaxed state. Three years before presentation, he underwent botulinum toxin injections in the affected areas of the face. Facial blanching is a rare side effect of botulinum toxin injection. The postulated pathophysiology involves different transmitters mainly acetylcholine as well as co-transmitters implicated in vasodilation. Usually, facial blanching resolves shortly after waning of the botulinum toxin. However, in our case, the symptoms persisted for a longer time. Till date, therapy options for post-botulinum facial blanching are lacking, mainly due to the temporary aspect of the disease.