Dermatoscopic patterns of cutaneous metastases: A multicentre cross-sectional study of the International Dermoscopy Society.

BACKGROUND: The detection of cutaneous metastases (CMs) from various primary tumours represents a diagnostic challenge. OBJECTIVES: Our aim was to evaluate the general characteristics and dermatoscopic features of CMs from different primary tumours. METHODS: Retrospective, multicentre, descriptive, cross-sectional study of biopsy-proven CMs. RESULTS: We included 583 patients (247 females, median age: 64 years, 25%-75% percentiles: 54-74 years) with 632 CMs, of which 52.2% (n = 330) were local, and 26.7% (n = 169) were distant. The most common primary tumours were melanomas (n = 474) and breast cancer (n = 59). Most non-melanoma CMs were non-pigmented (n = 151, 95.6%). Of 169 distant metastases, 54 (32.0%) appeared on the head and neck region. On dermatoscopy, pigmented melanoma metastases were frequently structureless blue (63.6%, n = 201), while amelanotic metastases were typified by linear serpentine vessels and a white structureless pattern. No significant difference was found between amelanotic melanoma metastases and CMs of other primary tumours. CONCLUSIONS: The head and neck area is a common site for distant CMs. Our study confirms that most pigmented melanoma metastasis are structureless blue on dermatoscopy and may mimic blue nevi. Amelanotic metastases are typified by linear serpentine vessels and a white structureless pattern, regardless of the primary tumour.

Clinical Features Associated with the Demand of In-Person Care by Dermatologists: An Observational Cross-Sectional Study.

Background: The factors necessitating the need for referrals for in-person evaluations by a dermatologist are not adequately understood and have not been studied using automated text mining so far. The objective of this study was to compare the prevalence of required in-person dermatologist care in the presence or absence of certain clinical features. Methods: Observational cross-sectional study of 11,661 teledermatology reports made from February 2017 to March 2020. Results: The need for dermoscopy was associated with a 348% increase in the possibility of referral for in-person dermatologist evaluations (prevalence ratio [PR]: 4.48, 95% confidence interval [CI]: 4.17-4.82). Infectious diseases were associated with a 64% lower possibility of referral (PR: 0.36, 95% CI: 0.30-0.43). Discussion: Some lesions and poorly documented cases are challenging to assess remotely. This study presents a different approach to research more detailed data from teledermatology reports, using text mining, and points out the risk magnitude for demanding dermatologic in-person care of which feature analyzed. As limitations, the variables related to lesion location, size, and extension were not analyzed and the dictionaries used were originally in Brazilian Portuguese. Conclusions: Teledermatology seems sufficient for the management of 75% of clinical cases, especially acute in young patients with inflammatory or infectious lesions. Referrals for in-person dermatologist consultations were not only strongly associated with the need for dermoscopy, but also for therapeutic reasons like surgical procedures, phototherapy, and the use of some systemic medications.

Short-Term Follow-Up of a Randomized Controlled Trial of 0.5% and 5% 5-Fluorouracil After Microneedling for Treatment of Facial Actinic Keratoses.

INTRODUCTION: Topical 5-fluorouracil (5-FU) is used to treat actinic keratosis, although side effects limit treatment. Microneedling might be a tool for reducing treatment duration. OBJECTIVE: To evaluate microneedling to promote 5-FU delivery at different concentrations (0.5% and 5%) for actinic keratoses (AKs) treatment. METHODS: Forty-four patients with facial AKs subjected to 1.0 mm microneedling on 1 side of the face were randomized into 5% 5-FU or 0.5% 5-FU groups. Evaluations of efficacy and safety were conducted on days 21 and 111. RESULTS: Forty-four patients aged 47 to 85 years were enrolled. Complete clearance of AKs was similar within groups for the side of the face treated with microneedling and 5-FU and the side treated with 5-FU alone in both the 5% and 0.5% 5-FU groups. Microneedling and 5% 5-FU was superior to microneedling and 0.5% 5-FU to reduce AKs (p = .025). Microneedling and 5% 5-FU resulted in fewer adverse effects than 5% 5-FU alone (p = .011). CONCLUSION: Topical 5% and 0.5% 5-FU delivery for 3 days after microneedling was effective for treating facial AKs and equivalent to 5% and 0.5% 5-FU alone for 15 days after 3 months of follow-up. Microneedling may potentiate 5-FU treatment, reducing treatment time without losing efficacy.

Dermoscopic Aspects of Traumatized Nevi After Dermabrasion.

BACKGROUND: Melanocytic nevi submitted to trauma can undergo clinical, dermoscopic, and even histological changes, making it difficult to differentiate them from a melanoma. OBJECTIVE: The aim of this study is to evaluate the dermoscopic changes of traumatized nevi after dermabrasion. METHODS: Dermoscopic images of acquired melanocytic nevi were compared before and 4 weeks after half of their area had undergone dermabrasion. RESULTS: The sample consisted of 50 lesions from 15 patients. The homogeneous pattern was the most frequent, followed by the reticular, cobblestone, and globular patterns. After dermabrasion, nearly half of the lesions (46%) became dermatoscopically asymmetric. Among all lesions, structureless areas, dotted vessels and erythema were the most frequent new dermoscopic structures. CONCLUSION: Trauma after dermabrasion may induce significant dermoscopic changes in melanocytic nevi. Although the global pattern did not change, most of the lesions became asymmetric, with the appearance or fading of dermoscopic structures and colors. A history of recent trauma should be investigated when evaluating pigmented lesions.

Tropomyosin-Related Kinase Receptor and Neurotrophin Expression in Cutaneous Melanoma Is Associated with a Poor Prognosis and Decreased Survival.

OBJECTIVE: Normally, activation of tropomyosin-related kinase (TRK) receptors by neurotrophins (NTs) stimulates intracellular pathways involved in cell survival and proliferation. Dysregulation of NT/TRK signaling may affect neoplasm prognosis. Data on NT and TRK expression in melanomas are limited, and it is unclear whether NT/TRK signaling pathways are involved in the origin and progression of this neoplasm. METHODS: We examined whether NT/TRK expression differs across different cutaneous melanoma grades and subtypes, and whether it is associated with melanoma prognosis and survival. A cross-sectional study was performed in which the expression of TrkA, TrkB, nerve growth factor (NGF), and brain-derived neurotrophic factor (BDNF) was analyzed by immunohistochemistry of 154 melanoma samples. We investigated NT/TRK expression associations with prognostic factors for melanoma, relapse-free survival (RFS), and overall survival (OS). RESULTS: Of the 154 melanoma samples, 77 (55.4%) were TrkA immunopositive, 81 (58.3%) were TrkB immunopositive, 113 (81.3%) were BDNF immunopositive, and 104 (75.4%) were NGF immunopositive. We found NT/TRK expression associated strongly with several clinical prognostic factors, including the tumor-node-metastasis stage (p < 0.001), histological subtype (p < 0.001), and Clark level (p < 0.05), as well as with a worse OS (p < 0.05 for all, except TrkB) and RFS (p < 0.05 for all). CONCLUSIONS: Our results show strong associations of NT/TRK expression with melanoma stage progression and a poor prognosis.

Characterization of individuals at high risk of developing melanoma in Latin America: bases for genetic counseling in melanoma.

PURPOSE: CDKN2A is the main high-risk melanoma-susceptibility gene, but it has been poorly assessed in Latin America. We sought to analyze CDKN2A and MC1R in patients from Latin America with familial and sporadic multiple primary melanoma (SMP) and compare the data with those for patients from Spain to establish bases for melanoma genetic counseling in Latin America. METHODS: CDKN2A and MC1R were sequenced in 186 Latin American patients from Argentina, Brazil, Chile, Mexico, and Uruguay, and in 904 Spanish patients. Clinical and phenotypic data were obtained. RESULTS: Overall, 24 and 14% of melanoma-prone families in Latin America and Spain, respectively, had mutations in CDKN2A. Latin American families had CDKN2A mutations more frequently (P = 0.014) than Spanish ones. Of patients with SMP, 10% of those from Latin America and 8.5% of those from Spain had mutations in CDKN2A (P = 0.623). The most recurrent CDKN2A mutations were c.-34G>T and p.G101W. Latin American patients had fairer hair (P = 0.016) and skin (P < 0.001) and a higher prevalence of MC1R variants (P = 0.003) compared with Spanish patients. CONCLUSION: The inclusion criteria for genetic counseling of melanoma in Latin America may be the same criteria used in Spain, as suggested in areas with low to medium incidence, SMP with at least two melanomas, or families with at least two cases among first- or second-degree relatives.Genet Med 18 7, 727-736.

Dermoscopic Features of Pigmented Bowen Disease: A Multicenter Study on Behalf of the Ibero-Latin American College of Dermatology (CILAD).

INTRODUCTION: Studies focused on dermoscopic aspects of pigmented Bowen disease (pBD) in Latin American population are scarce and limited to only case reports or small series. OBJECTIVES: To report dermoscopic findings in a large series of 147 pBD diagnosed in Ibero-Latin American population. METHODS: We conducted a multicentric, retrospective study on 147 histologically proven pBD under the auspices of the Dermoscopy Chapter of the Ibero-Latin American College of Dermatology. RESULTS: The study population consisted of 77 females (52%) and 70 males (48%) with a mean age of 68.6 years. 70.1% of patients had skin phototype 3, 15.6% to skin phototype 2, and 14.3% to skin phototype 4. On clinical examination, near 60% of pBD were flat, 70% presented with scales, and 90% were asymmetric. Under dermoscopy, structureless hypopigmented areas, dots brown and pink color were the most frequently observed. Regarding specific dermoscopic clues to pBD, the most prevalent were structureless hypopigmented areas, vessels arranged in linear fashion at the periphery, and pigmented lines or pigmented dots distributed in a linear fashion. Clustered, coiled, and dotted vessels were observed in 55.8%, 45.6%, and 45.6% of the cases, respectively. CONCLUSIONS: We report a large series of cases of pBD in Latin American patients, with most patients being skin phototype 3 and 4. Distinctively in our study, the pigmented structures and the clues derived from the presence of melanin were much more frequent than in previous reports in fair skin.

Total body skin examination for skin cancer screening in patients with focused symptoms.

BACKGROUND: The value of total body skin examination (TBSE) for skin cancer screening is controversial. OBJECTIVE: We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE. METHODS: In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE. RESULTS: We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas. LIMITATIONS: The impact of TBSE on skin cancer mortality was not evaluated. CONCLUSIONS: TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.

Accuracy in melanoma detection: a 10-year multicenter survey.

BACKGROUND: Early excision is the only strategy to reduce melanoma mortality, but unnecessary excision of benign lesions increases morbidity and healthcare costs. OBJECTIVE: To assess accuracy in melanoma detection based on number-needed-to-excise (NNE) values over a 10-year period. METHODS: Information was retrieved on all histopathologically confirmed cutaneous melanomas or melanocytic nevi that were excised between 1998 and 2007 at participating clinics. NNE values were calculated by dividing the total number of excised lesions by the number of melanomas. Analyses included changes in NNE over time, differences in NNE between specialized clinical settings (SCS) versus non-specialized clinical settings (NSCS), and patient factors influencing NNE. RESULTS: The participating clinics contributed a total of 300,215 cases, including 17,172 melanomas and 283,043 melanocytic nevi. The overall NNE values achieved in SCS and NSCS in the 10-year period were 8.7 and 29.4, respectively. The NNE improved over time in SCS (from 12.8 to 6.8), but appeared unchanged in NSCS. Most of the effect on NNE in SCS was due to a greater number of excised melanomas. Higher NNE values were observed in patients younger than 40 years and for lesions located on the trunk. LIMITATIONS: No data concerning the use of dermatoscopy and digital monitoring procedures were collected from the participating centers. CONCLUSION: Over the 10-year study period, accuracy in melanoma detection improved only in specialized clinics maybe because of a larger use of new diagnostic techniques such as dermatoscopy.

Indications for Digital Monitoring of Patients With Multiple Nevi: Recommendations from the International Dermoscopy Society.

Introduction: In patients with multiple nevi, sequential imaging using total body skin photography (TBSP) coupled with digital dermoscopy (DD) documentation reduces unnecessary excisions and improves the early detection of melanoma. Correct patient selection is essential for optimizing the efficacy of this diagnostic approach. Objectives: The purpose of the study was to identify, via expert consensus, the best indications for TBSP and DD follow-up. Methods: This study was performed on behalf of the International Dermoscopy Society (IDS). We attained consensus by using an e-Delphi methodology. The panel of participants included international experts in dermoscopy. In each Delphi round, experts were asked to select from a list of indications for TBSP and DD. Results: Expert consensus was attained after 3 rounds of Delphi. Participants considered a total nevus count of 60 or more nevi or the presence of a CDKN2A mutation sufficient to refer the patient for digital monitoring. Patients with more than 40 nevi were only considered an indication in case of personal history of melanoma or red hair and/or a MC1R mutation or history of organ transplantation. Conclusions: Our recommendations support clinicians in choosing appropriate follow-up regimens for patients with multiple nevi and in applying the time-consuming procedure of sequential imaging more efficiently. Further studies and real-life data are needed to confirm the usefulness of this list of indications in clinical practice.

Risk factors for early-onset basal cell carcinoma in a German institution.

BACKGROUND: Genetic predisposition and ultraviolet (UV) exposure are the most important risk factors for basal cell carcinoma (BCC). Recent reports have demonstrated an increasing incidence of BCC among younger patients. We investigated potential risk factors for sporadic BCC in a subset of young German patients. METHODS: Twenty-five patients with BCC at the age of 19 to 40 years (mean 34.4 years) were included in the study. They were selected from a total of 2,058 patients who received surgical treatment for BCC between December 2004 and November 2008. Patients were contacted by telephone interview and asked about sun habits, associated medical conditions, and lifestyle-related variables. Data were compared with interview results from sex-, age- and skin type-matched controls. RESULTS: We found 1.4% (29) of 2,058 BCC patients to be ≤40 years of age. Four patients had Gorlin-Goltz syndrome and were excluded from further analysis. Multivariate analysis showed tanning bed use (OR= 25.0; IC95%: 2.26-277.36) and smoking (OR=13.34; IC95%: 1.56-113.8) to be the most significant independent risk factors for BCC, while sunscreen use had a protective effect. CONCLUSION: BCCs in young patients were only rarely related to hereditary syndromes, but were associated with environmental carcinogens, i.e. UV radiation and smoking.

Dermoscopy of skin infestations and infections (entomodermoscopy) - Part I: dermatozoonoses and bacterial infections.

Dermoscopy is an essential in vivo diagnostic technique in the clinical evaluation of skin tumors. Currently, the same can also be said about its implications when approaching different clinical situations in Dermatology. A growing number of reports on dermatological scenarios and diseases have been published, in which dermoscopy has been of great diagnostic help. The term "entomodermoscopy" was coined to describe dermoscopic findings in skin infestations and also in dermatoses of infectious etiology. In part I of this article, the main dermoscopic descriptions of zoodermatoses and bacterial infections will be addressed. In many of them, such as scabies, pediculosis, myiasis, and tungiasis, it is possible to identify the pathogen and, consequently, attain the diagnosis more quickly and use the technique to follow-up therapeutic effectiveness. In other situations that will be described, dermoscopy can allow the observation of clinical findings with greater detail, rule out differential diagnoses, and increase the level of confidence in a clinical suspicion.

Dermoscopy of skin infestations and infections (entomodermoscopy) - Part II: viral, fungal and other infections.

In addition to the infestations and bacterial infections reported in part I, the study of entomodermoscopy also involves descriptions of dermoscopic findings of a growing number of viral and fungal infections, among others. In this article, the main clinical situations in viral infections where dermoscopy can be useful will be described, that is in the evaluation of viral warts, molluscum contagiosum, and even in recent scenarios such as the COVID-19 pandemic. As for fungal infections, dermoscopy is particularly important, not only in the evaluation of the skin surface, but also of skin annexes, such as hairs and nails. The differential diagnosis with skin tumors, especially melanomas, can be facilitated by dermoscopy, especially in the evaluation of cases of verruca plantaris, onychomycosis and tinea nigra.

Total body mapping in the follow-up of melanocytic lesions: recommendations of the Brazilian Society of Dermatology.

Total body mapping comprises photographic documentation of the entire body surface followed by digital dermatoscopy of selected melanocytic lesions, aiming to compare their evolution over time and identify new lesions. As this is an exam based on comparative analysis of serial dermoscopic body images, standardization of the technique for performing total body mapping is essential. Prepared by specialists from the Brazilian Society of Dermatology, using the modified Delphi method, this article provides recommendations for carrying out total body mapping in Brazil, regarding its indications, technical aspects, and the issuing of the report.

Demographic, Clinical, and Pathologic Features of Patients With Cutaneous Melanoma: Final Analysis of the Brazilian Melanoma Group Database.

PURPOSE: National epidemiologic data on melanoma are scarce in Brazil. The current work presents final demographic, clinical, and pathologic results from the Brazilian Melanoma Group database to detail how patients with melanoma present at diagnosis. METHODS: The online database includes patients diagnosed between 1982 and 2015 and evaluated at their centers of origin between 2001 and 2016. The primary objective was to describe the demographic, clinical, and pathologic characteristics of the patients, and secondary objectives were to investigate the association between clinical and pathologic variables of interest. RESULTS: A total of 1,596 patients were included. Median age was 52 years, 57% were women, and the majority were identified as white. Invasive melanoma was diagnosed in 1,297 patients, mostly localized, whereas 299 (19%) had in situ disease (TisN0M0). Only 165 patients had initial lymph node involvement. Fitzpatrick skin types I or II were slightly more frequent with in situ melanoma (73%) than with invasive disease (67%; P = .054). The median Breslow thickness was 0.95 mm, Clark levels 2 and 3 comprised nearly 70% of cases, and ulceration was present in 18% of patients. The mitotic rate was significantly associated with the presence of ulceration and both vascular and perineural invasion but not with margin positivity, whereas histologic regression was associated with both intratumoral and peritumoral inflammatory infiltrates. CONCLUSION: Despite the limitations of an observational, registry-based study, the current results provide a general profile of patients with cutaneous melanoma in Brazil at the time of diagnosis.

Dermatoscopy of pigmented melanocytic nevi in patients with oculocutaneous albinism.

Oculocutaneous albinism is a group of rare inherited disorders of pigmentation. Some albinos may have a certain degree of melanin production and, consequently, may develop pigmented lesions during their lives. Albinos are also at great risk for developing cutaneous malignancy, including melanomas. We report two patients with oculocutaneous albinism and pigmented melanocytic nevi and describe, as far as we known, for the first time the dermatoscopic findings in albinos' nevi. The predominant dermatoscopic pattern observed in pigmented melanocytic nevi in albino patients seems to have a similar pattern to that observed in nevi of patients with skin type I. It corresponds to light-brown coloration, reticular pattern, and central hypopigmentation.

Actinic keratoses: review of clinical, dermoscopic, and therapeutic aspects.

Actinic keratoses are dysplastic proliferations of keratinocytes with potential for malignant transformation. Clinically, actinic keratoses present as macules, papules, or hyperkeratotic plaques with an erythematous background that occur on photoexposed areas. At initial stages, they may be better identified by palpation rather than by visual inspection. They may also be pigmented and show variable degrees of infiltration; when multiple they then constitute the so-called field cancerization. Their prevalence ranges from 11% to 60% in Caucasian individuals above 40 years. Ultraviolet radiation is the main factor involved in pathogenesis, but individual factors also play a role in the predisposing to lesions appearance. Diagnosis of lesions is based on clinical and dermoscopic examination, but in some situations histopathological analysis may be necessary. The risk of transformation into squamous cell carcinoma is the major concern regarding actinic keratoses. Therapeutic modalities for actinic keratoses include topical medications, and ablative and surgical methods; the best treatment option should always be individualized according to the patient.

Clinical and dermoscopic (in vivo and ex vivo) predictors of recurrent nevi.

Recurrent nevi occur following removal of melanocytic nevi mainly after shaving excision. Due to its differential diagnosis with melanoma, its recognition can be challenging. To evaluate clinical and dermoscopic predictors of recurrent nevi. Clinical data on 224 melanocytic nevi were collected, together with dermoscopic images. Shave biopsy was performed and the underside of the surgical specimen was examined using ex vivo dermoscopy. A total of 195 lesions were followed for six months. Recurrent nevi were observed in 59 lesions. The occurrence of recurrent nevi was inversely associated with increased patient age. Darker skin phototypes and the compound nevus type were more associated with recurrence. Regarding dermoscopic features, the presence of dark brown colour, multiple colours, dots, terminal hair, and an annular-distributed pigmentation around adnexal structures were associated with recurrent nevi. Ex vivo dermoscopy showed that visible hyperpigmentation on the underside of the surgical specimen was correlated with recurrence. Multivariable analysis showed that annular hyperpigmentation and age were the most relevant predictors of recurrence. Individuals with dark skin type and young adults are at increased risk of recurrent nevi. Dermoscopy of the primary lesion and the underside of the surgical specimen are helpful in predicting recurrence after shave biopsy.