High-frequency (22-MHz) ultrasound for assessing the depth of basal cell carcinoma invasion.

BACKGROUND: High-frequency ultrasound (HFUS) has been studied in the diagnosis and therapeutic management of basal cell carcinoma (BCC). The accuracy of this method for location of deep margins remains unknown. This study evaluates HFUS for localization of deep surgical margins in BCC. MATERIALS AND METHODS: Ultrasound images of 83 lesions from 67 patients with clinical and dermoscopic diagnosis of BCC were compared with histopathological findings. Pearson's correlation coefficient was used to assess the relationship between thickness as measured by HFUS and histopathology. RESULTS: A strong correlation between HFUS and histopathological measurements was identified (r = 0.9744, P < .001). HFUS had sensitivity of 96%, specificity of 84%, and accuracy of 91% for measurement of deep tumor margins. Factors affecting tumor measurement on HFUS include marked basophilic degeneration of collagen, presence of peritumoral hypertrophic glands or hair follicles, fibrosis, and dense inflammatory changes related to the tumor itself or to prior procedures. CONCLUSION: High-frequency ultrasound was effective in localizing deep tumor margins in BCC. Therefore, we believe that this diagnostic imaging method is important when selecting a therapeutic approach, considering Mohs micrographic surgery, and evaluating the surgical site.

Evaluation of diagnostic criteria of actinic keratosis through reflectance confocal microscopy.

BACKGROUND: The diagnosis of actinic keratosis (AK) is based on clinical evaluation and confirmed by histopathological analysis (HA). The challenge is to establish the correct diagnosis with a minimally invasive assessment. The aim of this study is to validate the analysis of AK by reflectance confocal microscopy (RCM), a cellular resolution, noninvasive imaging method and to determine the relevant parameters for diagnosis, compared to HA, by calculating the sensitivity (S), specificity (E), positive predictive value (PPV), and negative predictive value (NPV) of each criterion. MATERIALS AND METHODS: Through clinical examination, 25 AKs were selected for dermoscopy and RCM evaluation followed by shaving excision for HA. Statistical analysis was done by hypothesis tests (McNemar for binary and Wilcoxon for continuous variables). RESULTS: There was no significant difference between RCM and HA for 5 of the 6 parameters analyzed. The criteria that were statistically relevant were as follows: parakeratosis (p-value 0.449690; S 90%; PPV 78.26%), hyperkeratosis (p-value 0.248213; S 87.5%; E 100%; PPV 100%; NPV 25%), dyskeratosis (p-value 0.617075; S 85.71%; E 75%; PPV 94.74%; NPV 50%), spinous layer keratinocyte atypia classified as mild, moderate or severe (P-value 0.145032) and inflammation in epidermis (P-value 1.000000; S 75%; E 20%; PPV 78.95%; NPV 16.67%). RCM could not adequately measure inflammation in dermis (P-value 0.013328), despite good sensitivity (68%) and PPV (100%). CONCLUSION: RCM proved to be an effective method for the diagnosis of AK, contributing to the selection of the most appropriate treatment option.

Reflectance confocal microscopy in actinic keratosis-Comparison of efficacy between cryotherapy protocols.

BACKGROUND: Actinic keratosis (AK) incidence is increasing. Due to the risk of progression to squamous cell carcinoma, early detection and treatment are essential. The method stated in the European Consensus is cryotherapy, but there is no standard protocol defined for better results. OBJECTIVES: To compare two different cryotherapy protocols for AK using reflectance confocal microscopy (RCM) as a noninvasive imaging method for evaluation. METHODS: A self-controlled clinical trial was proposed to compare the efficacy of cryotherapy in two different application protocols. Grade II AKs in the forearms were submitted to freezing and thawing time of 10 seconds for 1 cycle (group A) or 2 cycles (group B). At baseline and 4 weeks after treatment, the same dermatologists assessed RCM evaluation (thickness of horny layer, parakeratosis, dyskeratosis, atypia in spinous layer, fibrosis, and presence of inflammatory cells in epidermis and dermis). RESULTS: We examined 24 AK lesions in each group. Statistical evaluation of the results evidenced superior response after 2 cycles of cryotherapy in parakeratosis and number of inflammatory cells in epidermis. CONCLUSION: Both protocols are effective in clearing clinical AK. Two cycles are not generating more side effects (fibrosis) and could reduce the risk of recurrence (better "clearance" of parakeratosis).

Concordance among in vivo reflectance confocal microscopy, trichoscopy, and histopathology in the evaluation of scalp discoid lupus.

BACKGROUND: Reflectance confocal microscopy (RCM) has been used for the evaluation of several inflammatory skin conditions, including skin discoid lupus erythematosus (DLE), and has been correlated with conventional histopathology (HP). However, RCM is not being widely used in trichology. Few reports and just preliminary data suggest the use of RCM as a complementary tool in alopecias. OBJECTIVES: To correlate the major RCM features of scalp DLE with trichoscopy and HP findings of biopsy specimens obtained from the same lesions. METHODS: This is an observational, analytical, and cross-sectional study involving 12 patients with a clinically established diagnosis of scalp DLE. Patients underwent global clinical photograph, trichoscopy, and RCM examination in the same site followed by two 4-mm punch biopsy specimens for HP analysis. Inter-methods agreement among RCM imaging, trichoscopy, and horizontal histopathology sections (HHS) were calculated using Cohen Kappa (k) statistics. RESULTS: Statistical analysis of the agreement between RCM and HP features disclosed an overall agreement similar to skin DLE. Seven of the eleven features evaluated had agreement superior to 75%. We also evaluated RCM features associated with three of their corresponding trichoscopic findings for further investigation of their agreement with HP. Statistical analysis showed an enhancement with agreement of 86% when the non-invasive techniques are used together. CONCLUSION: Consistent correlation between RCM and HP observed in our study supports the reliability of RCM in the diagnosis of scalp DLE. RCM may be considered a promising tool for scalp DLE microscopic evaluation and presents similar RCM features to DLE in other body sites. By associating clinical, trichoscopic and RCM evaluation, dermatologists will have a non-invasive arsenal for the assessment of hair and scalp disorders, benefiting patients.

Performance of mycology and histopathology tests for the diagnosis of toenail onychomycosis due to filamentous fungi: Dermatophyte and non-dermatophyte moulds.

Improvement of laboratory diagnosis of onychomychosis is important so that adequate treatment can be safely implemented. To evaluate and compare the performance of mycological and histopathological examinations in onychomycoses caused by dermatophyte and non-dermatophyte moulds. Patients with lateral/distal subungual onychomycosis in at least one hallux were enrolled in the protocol and assessed via mycological and histopathological tests. The isolation of filamentous fungi was considered the gold standard. Test performance was evaluated through sensitivity, specificity and positive and negative predictive values. A total of 212 patients were enrolled in the study. Direct microscopy (DM) was positive in 57.5% patients, and cultures in 34.4%. Among these patients, 23.3% were positive for dermatophytes, with Trichophyton rubrum the most frequently isolated, and 86.3% were positive for non-dermatophytes, with Neoscytalidium dimidiatum predominance. Histopathology was positive in 41.0% samples. Direct microscopy showed better sensitivity for non-dermatophyte moulds (P=.000) and nail clipping was more specific for dermatophyte (P=.018). Histopathology of the distal nail plate is a valuable complementary tool for the diagnosis of onychomycosis caused by dermatophytes and direct microscopy is especially useful for non-dermatophyte molds.

Reflectance confocal microscopy - Consensus terminology glossary in Brazilian Portuguese for normal skin, melanocytic and non-melanocytic lesions.

BACKGROUND: Currently, there is no uniform and official terminology in Portuguese for reflectance confocal microscopy analysis, despite the increasing number of Brazilian dermatologists using this new tool. OBJECTIVE: To present the terminology in Brazilian Portuguese for the description of reflectance confocal microscopy and establish the first Brazilian consensus on terms related to normal skin and cutaneous tumors. METHODS: 10 Brazilian specialists from different institutions and states of Brazil were selected to evaluate the best corresponding terms in Portuguese for normal skin, melanocytic and non-melanocytic tumors. The terms used were translated from international consensuses in the English language. The modified Delphi method was used to create the consensus in 3 steps. RESULTS: The terms considered the most appropriate in the Portuguese language to describe the findings of normal skin, melanocytic and non-melanocytic lesions in the reflectance confocal microscopy analysis were presented. STUDY LIMITATIONS: The limitations of the present study include the number of participants and limited regional representation (only two of the five Brazilian regions were represented). CONCLUSION: This Brazilian consensus represents an opportunity for dermatologists and physicians specializing in cutaneous oncology to become familiar with reflectance confocal microscopy, propagating the technique in clinical and research environments to stimulate national and international publications on this subject.

Verrucous carcinoma of the tongue.

A 75-year-old woman with full dentures had a progressive growth on the tongue for the past 15 years. She reported ulceration of the lesion 4 months prior that was accompanied by pain and odinophagia. She denied addiction to alcohol or tobacco. On examination, there was an ulcerated, vegetating, verrucous lesion, with yellow-whitish areas intermingled with erythematous areas, being infiltrated and having well-defined borders, on almost all areas of the back of the tongue (Figure 1). No adjacent lymphadenopathy was found. Biopsy of the tongue was compatible with verrucous carcinoma demonstrating squamous cell neoplasia with prevailing areas of rounded borders. There were "tunnels" filled with parakeratotic material surrounded by an extensive inflammatory response, plus isolated foci of neutrophils inside the tumor (Figure 2). There were relatively well-differentiated neoplastic cells with little cytological atypia. In addition, there were several foci of individual or grouped dyskeratotic cells (Figure 3), plus tunnelling of parakeratotic material and an intratumor inflammatory response (Figure 4). Following surgical removal, the woman underwent chemotherapy and radiation treatment.

De novo melanoma and melanoma arising from pre-existing nevus: in vivo morphologic differences as evaluated by confocal microscopy.

BACKGROUND: Although in the majority of melanomas there is no evidence of pre-existing melanocytic nevus, it is believed that malignant transformation may sometimes occur within a benign precursor. OBJECTIVES: We sought to describe the morphologic features of de novo melanoma and melanoma arising from nevi by means of in vivo confocal microscopy, and to correlate them with their corresponding histopathologic features. METHODS: A total of 113 consecutive, histopathologically proven melanoma cases, 33 arising from a nevus and 80 occurring de novo, were imaged by confocal microscopy and retrospectively evaluated. Cyto-architectural features preferentially expressed in melanomas arising from nevi and in de novo melanomas were defined. RESULTS: By confocal microscopy, abrupt transition, localized distribution of junctional atypical cells, and the presence of dense dermal nests were the most helpful criteria for categorizing a melanoma as arising from a nevus. Melanomas arising from common and congenital nevi were predominantly composed of roundish, monomorphous cells, whereas melanomas arising either de novo or from dysplastic nevi were characterized by markedly pleomorphic cells. LIMITATIONS: The study is retrospective. CONCLUSION: Confocal microscopy is effective in identifying melanoma even when a nevus is simultaneously present, confirming the clinical usefulness of this methodology. Moreover, distinctive features were observed in de novo melanomas and melanomas arising from nevi, permitting accurate distinction between the two groups. Finally, differences in cell morphology, easily detectable by confocal microscopy, seemed to characterize different melanoma types.

Primary adenoid cystic carcinoma of the skin.

We report a case of primary adenoid cystic carcinoma of the skin in a 44-year-old Brazilian man that was present for 6 years with no metastasis. It is a rare malignant neoplasm of the eccrine gland. Metastases have been found in a few cases, usually to the lungs or lymph nodes. This neoplasm microscopically presents with large nests of cells with adenoid or cribriform features and many epithelial small solid islands. Histopathologic analysis is necessary for diagnosis.

Photorejuvenation with topical methyl aminolevulinate and red light: a randomized, prospective, clinical, histopathologic, and morphometric study.

BACKGROUND: Photodynamic therapy (PDT) is an option for skin rejuvenation. Although many studies report clinical improvement with PDT in photodamaged skin, histologic and morphometric evidence is not documented in most cases. OBJECTIVE: To evaluate clinical and histopathologic changes induced by methyl aminolevulinate (MAL)-PDT and to morphometrically quantify collagen and elastic fibers in skin remodeling induced by MAL-PDT in photodamaged skin. METHODS AND MATERIALS: Fourteen patients were treated with two sessions of MAL-PDT. The light source was a light-emitting diode: 635 nm, 37 J/cm(2). Skin biopsies were performed before and 3 and 4 months after treatment. All fragments were stained using the hematoxylin-eosin, orcein, and picrosirius techniques. Morphometric studies were done of three samples from each patient. RESULTS: Global clinical improvement was observed in 10 of 14 patients. The histopathologic study showed increased collagen fibers 3 and 6 months after treatment. The decrease in the amount of elastic fiber was statistically significant 3 (p=.016) and 6 (p=.008) months after treatment. The increase in the amount of collagen fiber was statistically significant 6 months after treatment (p=.048). CONCLUSION: Clinical improvement with regard to texture, firmness, wrinkle depth, skin coloration, and clearance of actinic keratoses was observed. Histopathologic and morphometric studies were consistent with the clinical findings.

Melanonychia associated with subungual follicular inclusions: report of three cases.

Melanonychia is the change in the coloration of the nail plate resulting from the deposition of melanin. Among its causes are melanocytic hyperplasia, melanocytic activation and nail melanoma. Subungual follicular inclusions are histological findings of unknown etiology, possibly related to trauma. We present three cases of melanonychia of different etiologies with subungual follicular inclusions, an association that has not been well described and with an indefinite pathogenesis.

Combined high-frequency and Doppler ultrasound in early diagnosis of atrophoderma of Pasini and Pierini.

Atrophoderma of Pasini and Pierini is a skin disorder affecting dermal collagen and is clinically characterized by well-defined plaques of depressed skin. Histopathological changes are subtle, and in most cases, the diagnosis requires a comparative study with healthy skin from the same anatomical site. High frequency ultrasound is a useful imaging method for diagnosis of atrophic skin changes. A case is presented in which ultrasound can support the clinical and the histopathological diagnosis of atrophoderma of Pasini and Pierini.

Reflectance confocal microscopy - Consensus terminology glossary in Brazilian Portuguese for normal skin, melanocytic and non-melanocytic lesions

Abstract Background: Currently, there is no uniform and official terminology in Portuguese for reflectance confocal microscopy analysis, despite the increasing number of Brazilian dermatologists using this new tool. Objective: To present the terminology in Brazilian Portuguese for the description of reflectance confocal microscopy and establish the first Brazilian consensus on terms related to normal skin and cutaneous tumors. Methods: 10 Brazilian specialists from different institutions and states of Brazil were selected to evaluate the best corresponding terms in Portuguese for normal skin, melanocytic and non-melanocytic tumors. The terms used were translated from international consensuses in the English language. The modified Delphi method was used to create the consensus in 3 steps. Results: The terms considered the most appropriate in the Portuguese language to describe the findings of normal skin, melanocytic and non-melanocytic lesions in the reflectance confocal microscopy analysis were presented. Study limitations: The limitations of the present study include the number of participants and limited regional representation (only two of the five Brazilian regions were represented). Conclusion: This Brazilian consensus represents an opportunity for dermatologists and physicians specializing in cutaneous oncology to become familiar with reflectance confocal microscopy, propagating the technique in clinical and research environments to stimulate national and international publications on this subject.

Acurácia da teledermatoscopia móvel na avaliação de lesões cutâneas pigmentadas / The accuracy of mobile teledermatoscopy in the assessment of pigmented skin lesions

Neste estudo transversal, comparamos o diagnóstico feito por meio da teledermatoscopia ao diagnóstico histopatológico. Fotos convencionais e dermatoscópicas de 31 lesões pigmentadas foram enviadas a um dermatologista experiente por meio do aplicativo WhatsApp® Messenger. Todas as lesões foram excisadas e examinadas por um dermatopatologista. A acurácia global da teledermatoscopia móvel foi de 90,32%. Em relação à capacidade de a teledermatoscopia definir malignidade da lesão pigmentada, a especificidade foi de 81,8% e a sensibilidade de 100%. Nossos resultados fornecem evidências adicionais sobre a confiabilidade da teledermatoscopia móvel, com alta sensibilidade e precisão.

In this cross-sectional study, we compared the diagnosis made through teledermatoscopy with histopathological diagnosis. Conventional and dermoscopic photos of 31 pigmented lesions were taken and sent to an experienced dermatologist using the WhatsApp® Messenger application. A dermatopathologist excised and examined all lesions. The global accuracy of mobile teledermatoscopy was 90.32%. Regarding the ability of teledermatoscopy to define malignancy of the pigmented lesion, the specificity was 81.8% and the sensitivity was 100%. Our results provide additional evidence of the reliability of mobile teledermatoscopy with high sensitivity and accuracy.

Trichoscopy of Noncicatricial Pressure-induced Alopecia Resembling Alopecia Areata.

Pressure-induced alopecia is an unusual cause of hair loss, and reports of its trichoscopic features are scarce. In this paper, we describe a case of pressure-induced alopecia in which trichoscopic and histopathological findings overlap with those described for alopecia areata.

Loose Anchoring of Anagen Hairs and Pili Torti due to Erlotinib.

Erlotinib is a selective epidermal growth factor receptor inhibitor utilized in the treatment of solid tumors. Cutaneous side effects, including changes in hair texture and alopecia, have been described. In this case report, we describe two patients with a new finding of loose anagen hairs and pili torti leading to nonscarring marginal and diffuse alopecia and discuss potential mechanisms underlying erlotinib-induced hair changes.

High frequency ultrasound with color Doppler in dermatology.

Ultrasonography is a method of imaging that classically is used in dermatology to study changes in the hypoderma, as nodules and infectious and inflammatory processes. The introduction of high frequency and resolution equipments enabled the observation of superficial structures, allowing differentiation between skin layers and providing details for the analysis of the skin and its appendages. This paper aims to review the basic principles of high frequency ultrasound and its applications in different areas of dermatology.