WATCH VIDEO ABSTRACT: Dermatoporosis: Strategies for Rebuilding the Extracellular Matrix of the Skin.

Dermatoporosis as a disease entity is relatively newly described, the title conceived as recently as 2007. The background of chronic skin fragility, bruising, and atrophy appears to start in some patients as early as their mid-forties, but is full blown over the age of 65 years. The dehydration and fragility of the skin with recurrent bruising and breakdown were initially attributed to increased vessel fragility and permeability thought to be associated with inherent vascular tissue defects in a milieu of increased inflammation and extracellular matrix (ECM) degradation. It has subsequently been demonstrated that this ECM breakdown directly affects the structural support system of the superficial vessels, leading to stretch, increased permeability, and vulnerability to mechanical damage. Add to that the ECM atrophy and general accumulation of non-functional metabolic waste products in the form of fragmented collagen, elastin, and increased circulating glycation end products, and it becomes apparent that much of the problem resides in a structural defect, non-functioning, dehydrated, senescent cellular matrix and unsupported vascular system that presents as dermatoporotic characteristics. This paper describes a strategy of ECM replacement to counteract these foundational deficiencies. J Drugs Dermatol. 2023;22(9): doi:10.36849/JDD.7549.

Combining Nd:YAG laser with optical coherence tomography for nonsurgical treatment of basal cell carcinoma.

BACKGROUND: Effective and aesthetically appealing management options are needed for basal cell carcinoma (BCC), the most common skin cancer. The Nd:YAG laser shows promise, but most studies use biopsy to demonstrate tumor clearance. Optical coherence tomography (OCT) could allow good tumor margin control while enabling recurrence monitoring. OBJECTIVE: Determine the efficacy of the Nd:YAG laser to treat BCCs while controlling for tumor margin with OCT. METHODS: A 1064-nm Nd:YAG laser was applied to treat 119 BCCs in 102 patients, where tumor margins were approximated using OCT. Lesions were treated every 2 months until no residual tumor remained; patients were monitored for 1 year after treatment completion for clinical and subclinical recurrences. Outcomes were analyzed retrospectively. RESULTS: Most BCCs cleared after one treatment (85/119, 70.4%). Several factors were significantly associated with a suboptimal response, that is, those with recurrence or requiring ≥2 treatments: lesion size >5 mm (p = 0.03), focal sclerosing subtype (p = 0.018), and immunosuppression (p = 0.039). Midface location, patient compliance, and diagnosis method were codependent variables (r2 = 0.2011, p = 0.0008). All BCCs (119/119) demonstrated complete clinical and subclinical tumor clearance 2 months after final laser treatment. By 1 year, overall clinical recurrence rate (RR) was 1.7% (2/119) and cumulative subclinical RR was 4.2% (5/119). Upon excluding immunosuppressed patients, clinical RR and combined subclinical RR for primary BCC were 1% (1/98) and 2% (2/98), respectively, and 0% (0/17) and 11.8% (2/17), respectively, for recurrent BCC. CONCLUSIONS: The Nd:YAG nonablative laser can offer an effective treatment for BCCs when used with noninvasive diagnostic tools such as OCT.

Transforming the treatment of psoriasis to the 21st century: Detecting subclinical therapeutic response to secukinumab using optical coherence tomography as a prognostic indicator.

BACKGROUND: Optical coherence tomography (OCT) is a noninvasive imaging device that scans the skin up to 2 mm in depth. OCT can capture real-time epidermal thickness (ET) measurements and detect subclinical changes in inflammatory skin diseases like eczema and psoriasis. © 2022 Wiley Periodicals LLC. OBJECTIVE: To determine if measuring ET with OCT can detect a subclinical therapeutic response in psoriasis treated with the biological therapy, secukinumab (an IL-17A antagonist). DESIGN: Phase IV, single-center, open-label, and single-arm study. PARTICIPANTS: Twenty-six consecutive patients with moderate to severe plaque psoriasis. MEASUREMENTS: Clinical, dermoscopic, and OCT images were obtained at each visit. The clinician measured disease severity with the Investigator's Global Assessment (IGA) and Psoriasis Area And Severity Index (PASI). OCT was used to scan the ET at the center of lesional skin (ET-L), along the border, and normal skin (ET-N) on the same body plane; their difference was noted as ΔET. RESULTS: Initially, ET-L was greater than ET-N (p < 0.0001), their differences decreased throughout the study, and there were no significant differences at Week 16 (p = 0.48). Twenty-four (92%) patients achieved a 50% reduction in PASI score (PASI50); they had lower ΔET at Weeks 0, 1, 3, 4, and 8 compared to those who did not clear (p < 0.04). Having a lower ΔET at Week 4 was associated with a shorter time to reach PASI50 (p = 0.02). CONCLUSION: ET measurements using OCT can detect an early subclinical response to secukinumab compared to clinical scoring and identify nonresponders as early as 4 weeks.

Combining Reflective Confocal Microscopy and Dynamic Optical Coherence Tomography to Diagnose Melanoacanthoma: Case Report.

ABSTRACT: Few reported cases discuss distinguishing between melanoma and melanoacanthoma, a seborrheic keratosis (SK) variant, using noninvasive imaging devices. We present a case of a 38-year-old man with Fitzpatrick skin type IV with an asymmetric black papule showing clinical and dermoscopic features of both melanoma and SK. Reflectance confocal microscopy (RCM) and dynamic optical coherence tomography (d-OCT) were used for further evaluation. RCM revealed acanthotic epidermis with a mixed honeycomb and cobblestone pattern, polycyclic bulbous rete ridges, and bright plump cells within entrapped, edged, dermal papillae, compatible with pigmented SK. Also noted were a population of fairly uniform bright dendritic cells scattered quite evenly at all levels of the epidermis and the notable absence of concomitant features of a melanocytic neoplasm (roundish Pagetoid cells, sheets of roundish or dendritic cells at the dermal-epidermal junction, junctional thickenings, and melanocytic nests), suggesting melanoacanthoma. d-OCT showed well-circumscribed, regular, epidermal acanthosis, superficial rounded hypodense structures, normal vascular flow, and notable absence of wiry or contoured vessels, features typically seen in SKs and benign lesions, respectively. Similarly, histologic examination revealed characteristics of pigmented SK containing a population of evenly dispersed dendritic melanocytes (decorated using Melan-A stain) confirming a diagnosis of melanoacanthoma. This case highlights the advantages of incorporating both RCM and d-OCT into clinical practice to noninvasively differentiate melanoma from its clinical mimickers.

Imaging in cutaneous surgery.

Skin cancer is the most commonly diagnosed cancer in the USA. Mohs micrographic surgery is a microscopically controlled surgical technique that excises lateral and deep surgical margins while also sparing function and achieving a good cosmetic outcome. Given the increasing incidence in skin cancer worldwide and its associated treatment costs, techniques are being developed to improve the time and cost efficacy of this procedure. The use of noninvasive imaging, both in vivo and ex vivo, has the potential to increase efficiency of diagnosis and surgical management of skin cancers. These devices are useful in delineating lateral and deep tumor margins prior to surgery in vivo as well as to detect residual tumor ex vivo virtually in real time.

Differentiation of Basal Cell Carcinoma Subtypes in Multi-Beam Swept Source Optical Coherence Tomography (MSS-OCT).

BACKGROUND: Optical coherence tomography (OCT) is a technique that enables real-time in-vivo examination of tissue. This technology provides the clinician with the potential to use a non-invasive tool in the identification and diagnosis of many skin lesions. However, the diagnostic features of basal cell carcinoma have not yet been described with comparison to their histopathology.
OBJECTIVES: To identify and describe key features of basal cell carcinoma (BCC) and its subtypes as they present in multi-beam Swept Source - OCT (MSS-OCT), and to correlate those against conventional histopathology.
METHODS: A total of 40 lesions were assessed by MSS-OCT prior to biopsy. 60-slice OCT images of the lesions were obtained and correlated with histology sections taken in the same plane. OCT scans were assessed retrospectively by a panel to determine the OCT criteria for BCC and its subtypes.
RESULTS: The following diagnostic criteria were identified: hyporeflective ovoid structures (40/40), dark halo boundaries (38/40), epidermal thinning (28/40), and collagen compression (14/40). Lesional tissue also showed a destruction of layers when compared to the surrounding normal tissue. In addition to the shared criteria, other subtypes showed distinct diagnostic criteria.
CONCLUSION: With its higher sensitivity, using MSS-OCT allowed for non-invasive, accurate identification of the key diagnostic features of BCC and its subtypes with high correlation to the histopathologic features found with biopsy.

J Drugs Dermatol. 2016;15(5):545-550.

Speckle-variance optical coherence tomography: a novel approach to skin cancer characterization using vascular patterns.

Non-invasive imaging devices are currently being utilized in research and clinical settings to help visualize, characterize, anddiagnose cancers of the skin. Speckle-variance optical coherence tomography (svOCT) is one such technology that offers considerable promise for non-invasive, real time detection of skin cancers given its added ability to show changes in microvasculature. We present four early lesions of the face namely sebaceous hyperplasia, basal cell skin cancer, pigmented actinic keratosis, and malignant melanoma in situ that each display different important identification markers on svOCT. Up until now, svOCT has mainly been evaluated for lesion diagnosis using transversal (vertical) sections. Our preliminary svOCT findings use dynamic en face (horizontal) visualization to differentiate lesions based on their specific vascular organizations. These observed patterns further elucidate the potential of this imaging device to become a powerful tool in patient disease assessment.

Optical coherence tomography imaging of erythematotelangiectatic rosacea during treatment with brimonidine topical gel 0.33%: a potential method for treatment outcome assessment.

BACKGROUND: Patients with moderate to severe rosacea often seek treatment to reduce erythema and vascular markings. Few studies have looked at the effectiveness of the novel treatment, brimonidine topical gel 0.33%, trademark name Mirvaso®, in the treatment of rosacea. We report the use of optical coherence tomography (OCT) scanning to monitor the effectiveness of Mirvaso® on in vivo skin. OCT is a non-invasive optical imaging technique that can provide high-resolution imaging of vessel and cellular morphology. OCT may be useful as a pre-treatment assessment tool for identifying possible morphologic features in the skin that may serve as outcome predictors. OCT may also serve as a monitoring tool in the treatment of rosacea. OBJECTIVE: To examine and describe how OCT skin morphology changes when exposed to brimonidine topical gel 0.33% in the treatment of erythematotelangiectatic rosacea. METHODS: Normal in vivo telangiectasias and erythematous patches and papules were examined prior to treatment clinically, dermatoscopically, and through OCT scans. Brimonidine topical gel 0.33% was applied to the face and OCT images were acquired at defined time intervals: baseline; immediately (<5 minutes) after application; 4 hours after application; and after 2 weeks' once daily application. OCT morphology was then described. RESULTS: OCT imaging showed an increase in the mean gray value (MGV), a measure of dermal reflectivity, corresponding to a decrease in dermal edema. MGV measurements for the nasal telangiectasia were: baseline, MGV 10,471 (standard deviation [SD] 6,847); immediate, MGV 15,634 (SD 8,983); after 4 hours, MGV 16,357 (SD 7,647); and after 2 weeks, MGV 15,505 (SD 6,870). MGV measurements for the chin erythema were: baseline, MGV 8,850 (SD 4,969); immediate, MGV 10,799 (SD 5,266); after 4 hours, MGV 12,419 (SD 6,714); and after 2 weeks, MGV 13,395 (SD 6,170). No significant change in vessel lumen diameter was appreciated. Vessel lumen diameter for the facial papule ranged from 0.13 mm at baseline, 0.09 mm immediately after treatment, 0.09 mm after 4 hours, and 0.11 mm after 2 weeks. CONCLUSIONS: OCT scanning showed a decrease in the dermal hyporeflectivity of the dermis consistent with a decrease in dermal edema. The OCT scans obtained did not show any significant change in vessel lumen diameter. These results may reflect an increase in vascular tone, which can be attributable to the clinical improvement and decreased erythema noted in the patient. This technology could potentially be used for the non-invasive in vivo monitoring of other topical treatments.

Optical coherence tomography-based optimization of mohs micrographic surgery of Basal cell carcinoma: a pilot study.

BACKGROUND: Optical coherence tomography (OCT) is a noninvasive imaging technique that uses a low-power infrared laser to image up to 2 mm beneath the skin's surface. OBJECTIVE: To test the feasibility and diagnostic value of using in vivo OCT to define excision margins before Mohs micrographic surgery (MMS) of basal cell carcinoma (BCC). METHODS: Patients with biopsy confirmed BCC undergoing MMS were recruited (n = 52). Excision margins defined by experienced dermatologists were compared with those of OCT-assessed borders and validated with histologic assessments. RESULTS: Forty-one (79%) lesions were clear after one MMS procedure; 11 (21%) lesions required a second MMS stage after excision of the clinician-predicted boundary. Generally, the OCT instrument indicated that the estimated clinical margin was 0.4-mm larger than the OCT margin. For lesions requiring a single MMS stage, OCT indicated that lesions were 1.4 ± 1.3 mm smaller than the Mohs excision. Before excision of lesions requiring more than one MMS stage, OCT always indicated that the lesion boundary would extend outside the planned MMS defect boundary. CONCLUSIONS: The present study shows the prospective utility of using OCT to refine clinically estimated borders for MMS. OCT assessment has the potential to reduce the excised area without compromising the integrity of tumor-free borders.

Glitter Effects of Nail Art on Optical Coherence Tomography.

Optical coherence tomography (OCT) is a noninvasive imaging technology that can visualize nail morphology in diseases such as psoriatic arthritis or onychomycosis. We recommend removal of glitter nail art to properly assess nail pathology and decrease diagnostic delay.

Novel treatment of female-pattern androgenetic alopecia with injected bimatoprost 0.03% solution.

Female-pattern androgenetic alopecia is a very common disorder that has been associated with extreme psychological morbidity. Few treatments have documented utility and many physicians are often overwhelmed with how little is pharmacologically available to treat this condition. Novel treatments that are effective, safe, less costly and simple are in high demand. We report a case of female-pattern androgenetic alopecia that failed to respond to a novel treatment with injected bimatoprost solution. Hypothetically, the treatment should have been effective and although we did not have success, this report suggests critical points to consider in the future of prostaglandin analogs, as well as other therapies being considered for the treatment of female-pattern hair loss.

Evaluating Onychomycosis Outcomes 2 Months into an 11-month-long Efinaconazole Regimen: The Role of Optical Coherence Tomography.

BACKGROUND: Onychomycosis affects 43 million people in the United States and Europe. Topical therapies can be effective but require lengthy and costly regimens without an established method for predicting the treatment outcome. OBJECTIVE: We studied the role of optical coherence tomography (OCT), a noninvasive imaging device approved by the United States Food and Drug Administration, in evaluating onychomycosis treatment outcomes. METHODS: This investigator-initiated prospective clinical study recruited subjects from two urban medical centers. A total of 34 subjects with mild-to-moderate onychomycosis, confirmed using periodic acid-Schiff (PAS) staining, were treated with topical efinaconazole for 48 weeks, at which time a final PAS result was obtained. RESULTS: A positive final PAS result was associated with fungal findings on OCT and with nonclearance of fungal findings by week 12. A negative final PAS was associated with the absence of fungal findings by week 12. OCT findings at Week 8 may suggest a 77% chance of mycological nonclearance or 82% chance of clearance. These predictive values are higher than the currently documented mycological cure rate of 54%. Clinical examination data had no predictive value alone or in concert with OCT. CONCLUSION: We recommend OCT imaging be performed at the end of the second month of treatment to inform shared decision-making regarding whether or not to continue efinaconazole for nine additional months. OCT's ability to evaluate onychomycosis outcome in patients on topical efinaconazole both earlier and more reliably than nonimaging variables may improve the care given to and reduce the cost of onychomycosis for millions of patients.

Mobile App Usage Among Dermatology Residents in America.

Mobile applications (apps) have been a growing part of medicine for the last decade. Our cross-sectional online survey studied the role of apps in dermatology resident training. The demographic results and response rate suggest that our study sample is representative of the target population of dermatology residents in America. Our survey highlights the increasing role of apps in dermatology resident training, differences in priorities among different years of residency, and differences in information utilization between sexes. This knowledge should help guide standardization, quality assurance, and formal integration of medical mobile apps into traditional dermatology teaching.

Optical coherence tomography.

During the past decade, noninvasive imaging has emerged as a valuable tool in clinical dermatology and dermatologic research. Optical coherence tomography (OCT) is one such type of noninvasive imaging. OCT uses the principle of interferometry to produce real-time images. A low-power diode laser shines infrared light onto tissues, which reflects back to an optical fiber interferometer. Using time delay and the backscattered light intensity, a two-dimensional image akin to an ultrasound is rendered. We review the history, types, and modalities of OCT, plus the many applications of frequency domain, high definition, and dynamic OCT in practice, including its utility in diagnosis, monitoring, and grading disease severity in a variety of cutaneous conditions.

A randomized, double-blinded, placebo-controlled, multicenter, efficacy and safety study of 3.75% imiquimod cream following cryosurgery for the treatment of actinic keratoses.

OBJECTIVE: Evaluate cryosurgery followed by 3.75% imiquimod cream to treat actinic keratoses (AK). METHODS: Adults with > or =10 AKs on the face underwent cryosurgery of five to 14 lesions. Subjects with > or =5 lesions remaining were randomized to 3.75% imiquimod or placebo cream applied to the entire face daily for two two-week cycles. Efficacy was assessed through week 26. RESULTS: For the cryosurgery/3.75% imiquimod (n=126) and cryosurgery/placebo (n=121) groups, respectively, median total AK reductions were 86.5 and 50 percent, and proportions of subjects with complete clearance were 30.2 and 3.3 percent (P < 0.0001, both). Analyzing cryosurgery-treated lesions only, median reductions were 100 and 80 percent (P = 0.0008), and subject complete clearance rates were 59.5% and 29.8% (P < 0.001), respectively. Only one subject discontinued for a treatment-related adverse event (cryosurgery/3.75% imiquimod group). LIMITATIONS: Cryosurgery was performed per usual study center practice and not standardized. CONCLUSION: A short, cyclical treatment course of field-directed daily 3.75% imiquimod cream following lesion-directed cryosurgery was well tolerated and provided additional therapeutic benefits to cryosurgery alone.

Allergic contact dermatitis: patch testing results at Mount Sinai Medical Center.

Patch testing is an important diagnostic tool commonly used to identify allergens responsible for allergic contact dermatitis, especially in cases where the diagnosis is not clearly apparent. The authors report the patch test results from 2004-2008 and compare the results with the North American Contact Dermatitis Group and Mayo Clinic. Four hundred thirty-four patients with suspected allergic contact dermatitis underwent standardized patch testing with a tray consisting of 50 allergens at Mount Sinai Medical Center. Two hundred ninety patients (66.8%) had positive reactions to at least one allergen. The most frequent contact allergens included nickel sulfate (13%), fragrance mix (9.6%), propylene glycol (7.8%), neomycin sulfate (6.6%), thimerosal (6.4%), bacitracin (6.2%), and sodium gold thiosulfate (5.8%).