Abstracts from the 3rd World Congress of Dermoscopy, May 17 to 19, 2012, Brisbane Australia

Citation: Abstracts from the 3rd World Congress of Dermoscopy, May 17 to 19, 2012, Brisbane Australia. Dermatol Pract Conc. 2012;2(2 suppl):16. http://dx.doi.org/10.5826/dpc.0202a16.

Copyright: ©2012. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstracts, 3rd World Congress of Dermoscopy, 2012

Dermoscopy in non-pigmented eccrine poromas. Study of Mexican cases

B. Carlos-Ortega1, A. DomÍnguez-Espinosa2, R. Quiñones-Venegas3, R. Gonzalez RamÍrez4

1 Hospital de Especialidades Centro Médico La Raza, Instituto Mexicano del Seguro Social, Mexico City, Mexico; 2 Hospital General de Zona 8 “Gilberto Flores Izquierdo” Instituto Mexicano del Seguro Social, Mexico City, Mexico; 3 Instituto Dermatológico de Jalisco, Guadalajara, Mexico; 4 Servicios Médicos U.A.N.L., Monterrey, Mexico

Background: Non pigmented eccrine poroma is a benign tumor that can have dermoscopic features mimicking malign neoplasias. The characteristic vascular pattern of this tumor hasn’t been established. We found a scarcely reported vascular pattern, which can be useful to distinguish this tumor from malignant ones and propose a new nomenclature to these vessels due their similarity with the common calla flower and cherry blossoms tree.

Observations: We study 10 proven Mexican cases of eccrine poroma and nearly half of them presented irregular linear and branched vessels with semi-elliptical, circular or semicircular endings, we called them “chalice-form” and “cherry-blossoms” vessels. The structureless pink-white areas were the most common finding and some vascular patterns reported in other studies were barely found.

Conclusions: Due to the variability in the dermoscopic patterns found in non pigmented eccrine poroma, further studies are required to establish the specificity of these vessels, however they hasn’t been reported in other benign or malign neoplasias so, if seen, they can be an useful key leading to the diagnostic of eccrine poroma.

Basal cell carcinoma: dermoscopy vascular features of different subtypes

John Pyne1, Devendra Sapkota1, Jian Cheng Wong2

1 School of Medicine, The University of Queensland, Brisbane, Australia; 2 School of Mathematics and Statistics, The University of New South Wales, Sydney, Australia

Background: Basal cell carcinoma is a common tumour, which presents with various subtypes. These subtypes usually display vascular features, which are readily identified using dermoscopy.

Objective: Dermoscopy vascular features of superficial, superficial and nodular, nodular and combined aggressive subtypes were compared for diagnostic discrimination.

Method: Dermoscopy vascular features were recorded in vivo for 1098 consecutive BCC. Cases with potential confounding from previous intervention were excluded. These vascular features included branching, serpentine, dot, glomerular, loop and linear vessels, the proportions of pink, central verses peripheral vessel distribution and the presence of large vessels. Kappa values were calculated for each defined vascular feature.

Results: Different subtypes of BCC have distinctive vascular features. Superficial BCC (n=284) have more than half the tumour area pink (85%) and absent large vessels (93%), CI 85%-95%. Nodular BCC (n=230) are characterized by large vessels (46%, CI 39%-52%, P<0.001) compared to other subtypes, as well as less dot, coil and loop vessels. Aggressive BCC (n=213) display a tumour area with no pink (12%) or less than half the area pink (27%) and absent vessels in the central tumour area (22%, P<0.001) compared to other subtypes.

Kappa values for all recorded features ranged from 0.48 to 1.0.

Limitations: Aggressive subtypes within the combined aggressive group were not assessed separately. All data was recorded using non polarized dermoscopy.

Conclusions: Diagnostic discrimination between different subtypes of BCC is facilitated by vascular feature assessment. The lower limb has different variation in BCC vessel features, compared to other anatomic sites.

Dots/globules on dermoscopy in nail-apparatus melanoma

Yuji Inoue1, Scott W Menzies2, Satoshi Fukushima1, Hazuki Nishi-Kogushi1, Azusa Miyashita1, Shinichi Masukuchi1, Faith Muchemwa1,3, Toshiro Kageshita4, Hironobu Ihn1

1 Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan; 2 Melanoma Diagnostic Centre, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia; 3 Department of Immunology, University of Zimbabwe college of Health Sciences, Harare, Zimbabwe; 4 Kageshita Dermatological Clinic, Kumamoto Japan

Introduction: Dermoscopic features of nail apparatus melanoma are different from those of other sites. Ronger et al. described seven dermoscopic features of melanonychia.

Methods: Features of dermoscopic examination of 31 patients with nail apparatus melanomas were reviewed retrospectively.

Results: A brownish discoloration of the background and irregular lines were the most common feature, followed by and (micro-) Huchinson’s sign. Dots/globules were seen in 8 of 31 cases (25.8%).

Conclusions: Dermoscopy was very useful in the diagnosis of nail-apparatus melanoma, and dots/globules might be the one of features of nail apparatus melanoma.

Reference

1. Ronger S, Touzet S, Ligeron C, et al. Dermoscopic examination of nail pigmentation. Arch Dermatol. 2002; 38:1327-33.

Complex dermatoscopy diagnostics of melanoma

D. Sokolov1, I. Boulytcheva1, G. Vorozhtsov2, S. Kuzmin2, A. Makhson1, V. Sokolov2

1 Moscow City Oncological Hospital N62, Moscow, Russian Federation; 2 SUE “ISCC “Intermedbiophyschem,” Moscow, Russian Federation

Introduction: In spite of the fact that frequency of melanoma makes 3-5 % of all primary malignant tumors of skin, it is the main reason of death of patients in oncodermatology. Over the last 6 years complex dermatoscopy examination has been intensively used in clinical practice of Moscow Oncological Hospital no. 62 for the detection and characterization of melanoma and other pigmented skin lesions.

Method: Complex dermatoscopy diagnostics include digital photo, Zoom-photo, standard and microdermatoscopy, fluorescent dermatoscopy. At the first stage, we take digital photos and perform computer mapping of the patient’s skin. At the second stage, zoom-photo with a 10-fold enlargement is taken for each suspicious lesion. At the third stage, we perform a standard dermatoscopy with a 10-fold enlargement, microdermoscopy with a 120-fold enlargement and a fluorescent dermatoscopy with 5-ALA (Alasens). Applying the complex method of dermatoscopy diagnostics we studied the reliability of characteristics describing malignant and benign pigmented skin lesions in 497 patients with 1735 pigmented skin lesions (280 non-melanocytic, 1271 melanocytic lesions (65 melanoma, 259 dysplastic nevi)). The data of the complex dermatoscopic investigation were compared to the results of morphological investigation of surgery samples.

Results: Sensitivity and specificity dermatoscopy diagnostics of melanoma has made 92 % and 72 % accordingly. Consider high efficiency, non-invasive character of method of complex dermatoscopy diagnostics of melanoma of skin it should be used first of all for examination in groups of high risk of melanoma. This scientific trial is supported by Moscow.

Circumscribed palmar hypokeratosis: correlation between histopathological patterns and dermoscopic findings

Machiko Nishimura, Wataru Nishie, Shinichi Nakazato, Ikue Nemoto-Hasebe, Yasuyuki Fujita, Hiroshi Shimizu

Department of Dermatology, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido

Circumscribed palmar hypokeratosis (CPH) is a rare skin disorder that typically develops on the palms of middle-aged women. CPH is clinically characterized by well-demarcated, slightly scaling erythema that is sometimes difficult to differentiate from Bowen’s disease and porokeratosis of Mibelli. CPH is usually diagnosed by its clinical and histopathological features. We present a 61-year-old Japanese female presented with a 10-year history of a well-demarcated, 6×6-mm asymptomatic erythema on the right palm. We show an apparent correspondence between the dermoscopic findings and histopathological features of the lesional skin, which indicates that the pathogenesis of CPH is associated not only with abnormal keratinization but also with hyper vascular formation.

Effect of narrowband UVB phototherapy on melanocytic naevi

C. Y. Lin, A. Oakley, M. Rademaker, S. Hill, A. Yung

Department of Dermatology, Waikato Hospital, Hamilton, New Zealand

Introduction: Melanocytic naevi have been observed to undergo morphological changes following exposure to narrowband ultraviolet B (NBUVB). We aimed to analyse changes occurring in naevi exposed to NBUVB in a large cohort.

Method: 51 subjects referred for phototherapy had macro and dermoscopic images of prominent melanocytic naevi taken immediately prior to NBUVB treatment; after 10 exposures; after 30 exposures or at the end of the treatment course if earlier; and 3 months after discontinuing treatment.

Four dermatologists, by consensus, examined each naevi for specific clinical and dermoscopic features, at each time point. The size (area) of each naevus was determined by plenimetry.

Preliminary results: 36 of 51 patients had complete sets of images. The most common global dermoscopic pattern in the 440 naevi examined, were reticular (50%) and globular (32%).

Following NBUVB exposure, 45% of reticular naevi displayed changes in local features with blurring or merging of lines. Increase in colour intensity and in the number of dots/globules was observed in 63% of globular naevi.

167 naevi (40%) underwent change in size following UV exposure. Of these, 54% (91/167) decreased in size, with median area reduction of 8% (0.9%-42%); whilst 46% (76/167) increased in size, with median area increase of 9% (1%-76%). The trend was for these naevi to return to their pre-treatment size after phototherapy.

Of the 440 naevi reviewed, none displayed changes suspicious of malignancy.

Conclusion: Around half of exposed naevi undergo size/morphological changes following a course of NBUVB. Size changes tended to revert to pre-treatment values 3 months after discontinuing phototherapy.

Dermoscopy and reflectance confocal microscopy to aid in the detection of lentigo maligna recurrence after treatment

S. Segura1, F. Gallardo1, A. Toll1, C. Barranco2, I. Membrive3, R. M. Pujol1

1 Department of Dermatology, Hospital del Mar, Barcelona, Spain; 2 Department of Pathology, Hospital del Mar, Barcelona, Spain; 3 Department of Radiotherapy, Hospital del Mar, Barcelona, Spain

Introduction: Distinguishing between recurrence of lentigo maligna (LM) and postinflammatory hyperpigmentation after treatment may be challenging. Reflectance confocal microscopy (RCM) and dermoscopy might be of help in this clinical setting.

Methods: We performed dermoscopy and RCM in 7 patients that showed pigmentation in areas previously treated for LM. Previous treatments were radiotherapy (4), cryotherapy (2) and surgical excision (1). Correlation between RCM findings and histological/immunohistochemical features was evaluated.

Results: Two cases treated with radiotherapy exhibited blue-gray granules around hair follicle openings under dermoscopy. RCM exam correlated these structures with widespread plump cells in the upper dermis without other features suggesting recurrence of LM, definitely excluded in the biopsy. In 3 cases (2 radiotherapy, 1 surgery) dermoscopy showed irregular brown pigmentation, areas with fingerprint-like structures and focal grayish dots. In these cases RCM demonstrated widespread dendritic bright cells at basal and suprabasal layers. No evidence of LM was detected on histology, but immunohistochemistry showed positive Langerhans’ cells at suprabasal layers and dendritic HMB-45-positive melanocytes at the basal layer. The two cases that had been treated with cryotherapy did not show clear-cut dermoscopic criteria for LM. However, RCM was highly suggestive of melanoma that was histologically confirmed.

Conclusion: RCM can be useful in the monitoring of LM after treatment. In photodamaged skin, the visualization of widespread dendritic cells in basal and suprabasal layers by RCM may mimic a recurrence of LM. These structures correlate with activated nonmalignant HMB45-positive melanocytes and Langerhans’ cells and may represent a pitfall in the confocal evaluation of these lesions.

Dermatoscopy of patients with radiation-induced pigmented basal cell carcinoma

F. Moeineddin, H. Ghaninejad, H. Moslehi, A. H. Rajaee

Department of Dermatology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran

Introduction: Dermatoscopy is one of several non-invasive approaches that use to improve the diagnostic accuracy. It has been applied in the diagnosis of skin tumors such as Basal cell carcinoma (BCC).

Method: One hundred lesions from 39 patients (28 men and 11 women) were included in this study. All patients had a past history of childhood radiation therapy, primarily for treatment of tinea capitis. They presented with lesions that were morphologically highly suspicious to be pigmented BCC. Using a digital dermatoscope, all lesions were photographed and evaluated for the presence of Menzies BCC criteria and other features. All lesions were subsequently, underwent biopsy.

Results: When combined with clinical diagnosis, Menzies dermatoscopic criteria for BCC diagnosis have 100% sensitivity and 90.9% specificity. Tree like vessels, maple leaf-like structures and spoke wheel patterns were only seen in BCC lesions. Large gray-blue globules were seen in 76.4%, blue gray ovoid nest in 66.3%, arborizing vessels in 63%, maple leaf like pattern in 45%, ulceration in 43.8% and spoke wheel pattern in 28% of BCC lesions. The results confirmed the usefulness of dermatoscopy for better decision-making in the clinically suspected BCC lesions after radiation.

References

1. Soyer HP, Kerl H. Surface microscopy of pigmented cutaneous tumors.

Ann Dermatol Venereol. 1993;120:15-20.

2. Menzies SW, Westerhoff K, et al. Surface microscopy of pigmented basal cell carcinoma. Arch Dermatol. 2000;136:1012-6.

A blueprint for staging of murine melanocytic lesions in genetically modified mice

Lynlee L. Lin1,2, Elizabeth M.T. Wurm1, Blake Ferguson2, Duncan Lambie 3, Tarl W. Prow1, Graeme J. Walker2, H. Peter Soyer 1

1 Dermatology Research Centre, The University of Queensland, School of Medicine, Brisbane, Queensland, Australia; 2 Skin Carcinogenesis Laboratory, Queensland Institute of Medical Research, Brisbane, Queensland, Australia; 3 Anatomical Pathology, Princess Alexandra Hospital, Brisbane, Queensland, Australia

It is well known that when mice are engineered with mutations in molecular pathways that drive human malignant melanoma (MM) development, they too develop the disease. Little attention has been paid, however, to the natural history of naevi and melanomas developing in mouse models, and how this relates to the particular mutation the animal carries. Gaining the knowledge of the behaviour of each individual mouse lesion provides a relevant link for translation of information obtained from the mouse model to the corresponding clinical condition. The ultimate goal of the mouse MM model is to gain understanding of how certain mutations influence lesion dynamics, and to provide appropriate models for preclinical evaluation of melanoma therapies. We recently reported the development melanocytic lesions, along the spectrum of naevus to MM, in Cdk4R24C/R24C::Tyr-NrasQ61K mice. We followed the development of lesions over time using digital photography and dermoscopy to correlate the clinical appearance with histopathologic features of melanocytic lesions developing in this model. We have identified essentially two types of lesions and studied their respective growth patterns. We developed a staging system, based on the level of extension in to the dermis, which offers a practical linkage between murine MM models and standard clinical diagnosis. We will discuss how we have used these methods to help us understand the development of melanomas in mice carrying other mutations (e.g., in the p53 and Arf genes) that result in a very different mode of tumour progression than we see in the original model.

Refining mole phenotype with anatomic distribution and dermoscopic patterns of clinically dysplastic nevi: A pilot study

L. Smith, D. Polsky

The Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, New York, New York, USA

Introduction: Individuals with increased quantities of clinically dysplastic nevi (DN), such as those with the Atypical Mole Syndrome (AMS), have an elevated melanoma risk. Little is known, however, about the influence of qualitative mole phenotypic factors on melanoma risk, such as anatomic distribution and dermoscopic appearance of DN.

Objective: To compare the anatomic distribution and dermoscopic appearance of DN among AMS patients with or without a personal history of melanoma.

Method: We conducted a retrospective case-control study of clinical and dermoscopic images from 22 AMS patients with or without a personal history of melanoma (11 cases and 11 controls, respectively) using MoleMap software. The anatomic location and dermoscopic pattern for each DN was analyzed.

Results: 676 of 1822 lesions met criteria for DN. 391of 676 (58%) DN were located on cases compared to 285/676 (42%) located on controls. Cases had more DN on the legs than controls (29% vs. 15%, p = 0.009), and fewer DN on the chest (7% vs. 14%, p = 0.009). Disorganized globular DN and homogeneous DN, were more common among cases than controls (18% vs. 11%, p = 0.0126; 18% vs. 6%, p = 0.001, respectively). DN exhibiting peripheral network with central globules were more frequent in controls (20% vs. 3%, p = 0.002).

Conclusion: These data suggest that DN exhibit significantly different anatomic distributions and dermoscopic patterns among AMS patients with or without a melanoma history. These differences may be helpful in improving melanoma risk prediction among high-risk individuals with increased quantities of DN.

Dermatoscopy of genital warts

H. Dong1, D. Shu1, T. M. Campbell2, J. FrÜhauf3, H. P. Soyer2, R. Hofmann-Wellenhof3

1 Department of Dermatology, the First Teaching Hospital, University of Zhengzhou, Zhengzhou, China; 2 Dermatology Research Center, the University of Queensland, School of Medicine, Brisbane, Australia; 3 Department of Dermatology, Medical University of Graz, Graz, Austria

Background: Genital warts may mimic a variety of conditions, thus complicating their diagnosis and treatment. The recognition of early flat lesions presents a diagnostic challenge.

Objective: We sought to describe the dermatoscopic features of genital warts, unveiling the possibility of their diagnosis by dermatoscopy.

Methods: Dermatoscopic patterns of 61 genital warts from 48 consecutively enrolled male patients were identified with their frequencies being used as main outcome measures.

Results: The lesions were examined dermatoscopically and further classified according to their dermatoscopic pattern. The most frequent finding was an unspecific pattern, which was found in 15/61 (24.6%) lesions; a fingerlike pattern was observed in 7 (11.5%), a mosaic pattern in 6 (9.8%), and a knoblike pattern in 3 (4.9%) cases. In almost half of the lesions, pattern combinations were seen, of which a fingerlike/knoblike pattern was the most common, observed in 11/61 (18.0%) cases. Among the vascular features, glomerular, hairpin/dotted, and glomerular/dotted vessels were the most frequent finding seen in 22 (36.0%), 15 (24.6%), and 10 (16.4%) of the 61 cases, respectively. In 10 (16.4%) lesions no vessels were detected. Hairpin vessels were more often seen in fingerlike (x2 = 39.31, P = .000) and glomerular/dotted vessels in knoblike/mosaic (x2 = 9.97, P = .008) pattern zones; vessels were frequently missing in unspecified (x2 = 8.54, P = .014) areas.

Conclusions: There is a correlation between dermatoscopic patterns and vascular features reflecting the life stages of genital warts; dermatoscopy may be useful in the diagnosis of early-stage lesions.

Comparison of the sensitivity and specificity of the dermoscopic findings of alopecia areata, androgenetic alopecia, and cicatricial alopecia

U. Gunay1, M. T. Sahin1, G. Dinc-Horasan2, S. Ozturkcan1

1 Department of Dermatology, Celal Bayar University, Medical Faculty, Manisa, Turkey; 2 Departments of Public Health, Celal Bayar University, Medical Faculty, Manisa, Turkey

Introduction: The aim of this study was to compare the specificity and sensitivity of the dermoscopic findings of alopecia areata (AA), androgenetic alopecia (AGA) and cicatricial alopecia.

Method: A total of 99 patients with alopecia (37 AA, 39 AGA, 23 cicatricial alopecia) were admitted to our study. An informed consent form was signed by the patients and volunteers, followed by dermoscopic examination and photography.

Results: Yellow dots, exclamation mark, broken hairs, black dots were more specific for AA; reduced follicular ostia, white patches, white dots, blue-grey dots, red dots, keratin plugs, branching capillaries, tufted follicle and perifollicular scales were more frequently observed in cicatricial alopecia. Hair diameter diversity, perifollicular pigmentation and peripilar erythema were mostly observed in AGA. Yellow dots with short vellus hairs were observed both in AA and AGA. Reduced hair diameter was observed in significant ratio both in AA and cicatricial alopecia. Unlike previous studies, “yellow dots” were observed nearly equally both in AA and AGA. “Short vellus hair” was observed frequently both in AGA and AA. Moreover, we revealed “reduced hair diameter” in AA and “honeycomb-like erythema” in cicatricial alopecia, which have never been reported before in previous dermoscopic and trichoscopic studies that were carried in different alopecia types.

Conclusion: We think that our study is unique and important not only because it is the first study in literature to compare the clinical and dermoscopic findings of AA, AGA, and cicatricial alopecia, but also evaluating the specificity and sensitivity of these findings.

Dermoscopic analysis of synchronous melanoma: 5 years’ experience at a tertiary skin cancer clinic in the United Kingdom

S. J. Arnold, J. C. R. Bowling

Department of Dermatology, Churchill Hospital, Oxford, United Kingdom

The incidence of multiple primary melanoma ranges from 2-12% in various studies, with the majority of second primary melanomas detected within the first three years. In particular, many patients in this group have more than one melanoma at presentation (synchronous melanoma).

Clinicopathological studies of patients with multiple primary melanomas have found that most subsequent melanomas are less invasive than the initial melanoma, however many do not have the typical clinical or dermoscopic appearances of melanoma.

Patients with multiple benign naevi frequently show a predilection for certain dermoscopic patterns across all of their naevi (the concept of ‘moles breed true’). Furthermore, dysplastic naevi or melanomas are frequently first detected due to their difference from surrounding benign naevi: the ‘ugly duckling sign.’

We sought to determine whether synchronous melanomas in individual patients had similar dermoscopic profiles. Therefore, the dermoscopic appearances of synchronous melanomas arising in patients attending a tertiary skin cancer clinic in the United Kingdom from 2005-2010 were reviewed.

We found that patients with synchronous melanomas may not show a predilection for any particular dermoscopic pattern. Therefore, unlike benign naevi, multiple primary melanomas do not ‘breed true’; these ‘ugly ducklings’ need to be assessed, clinically and dermoscopically, on an individual basis.

Usefulness of dermoscopy during laser or IPL treatments

Domenico Piccolo

Department of Dermatology, University of L’Aquila, L’Aquila, Italy

Dermoscopy is a non-invasive instrumental method for the in-vivo study of pigmented skin lesions. This technique allows for viewing the parameters that would otherwise be invisible to the naked eye. Over recent years dermoscopy has proved to be extremely useful even on dermatological pathologies of an inflammatory origin and skin parasitosis. The introduction of the new laser and intense pulsed light systems has made it possible to cure pathologies difficult to treat with the instruments available to doctors ten years ago.

The use of dermoscopy has proved to be particularly important immediately after treatment for observing positive or negative results, any side effects, or early signs of relapses. In this way the patient and the doctor know with good approximation what they can expect from a specific treatment. The constant application of dermoscopy to laser and IPL treatment can also be useful for educational purposes in order to better understand how to interpret the dynamics of specific pathologies and the results which the different types of lesions and skin may have when crossed by a laser beam or luminous energy. The use of dermoscopy before surgical excision of a given melanocytic lesion with CO2 laser is also indispensable for medical-legal purposes. The dermoscopic image of the lesion immediately after treatment is important for demonstrating the absence or residual presence of pigment as well as the depth reached and the absence of any thermal damages. Dermoscopy is a particularly useful method for predicting the therapeutic success of the vascular treatments. The dermoscopic exam performed before treatment makes it possible to quantify the number and gauge of the vessels to be treated and the presence of any photodamage. The reaction of the vessel immediately after IPL or Nd-Yag laser treatment can be of two types: coagulation of the vessel with colour change from red to blue or contraction of the vessel with disappearance or reduction in size. These epiphenomena are clearly visible with the help of dermoscopy.

In our experience, dermoscopy has demonstrated to be an extraordinary instrument for determining any possible adverse events immediately after laser or IPL treatment. This allows physicians to provide suitable therapy in advance and inform the patient about any possible undesirable effects.

Our results demonstrated that dermoscopy can definitely be considered a first choice exam of great validity, above all due to the exactness and extreme accuracy in identifying the target to be hit. In most cases this has made it possible to immediately predict the treatment results. The dermoscopic exam performed some time after treatment demonstrated that it is indispensable for verifying the final results, especially in the cases of epithelial tumours treated with PDT. On concluding this study we suggest that the dermoscopic exam should be an integral part of all laser and IPL treatments.

Visual language in dermoscopy: A tool for novices and experts

T. O’Brien, Z. Assarian

Geelong Dermatology, Geelong, Australia

Visual language refers to the integration of shapes (symbols or signals), images (codes or objects) and words (text and speech) into a single communication unit.

The broad concept of shape can be subdivided into the basic elements of visual language: dot, line, shape and colour. These are the raw materials of all visual information. Dermoscopic images are made up of these basic elements.

Reading these elements abstractly can help both the learner and expert in dermoscopic diagnosis.

Does it look like melanoma? The effect of sunless tanning on dermoscopy of pigmented skin lesions-a pilot study

J. DahlÉn Gyllencreutz1, K. Bengtsson BostrÖm2, K. Terstappen1

1 Department of Dermatology, Skaraborg Hospital, SkÖvde, Sweden; 2 R&D Centre Skaraborg Primary Care

Background: The use of dermoscopy has led to an improvement in diagnosing malignant melanoma (MM), which is important for the prognosis of the patient. Sunless tanning agents containing dihydroxyacetone (DHA) could lead to a decrease in UV exposure decreasing the risk for MM. Importantly, DHA has been reported to change the dermoscopic image and could thus endanger the diagnostic improvement of dermoscopy.

Objective: To investigate if the use of DHA can lead to changes that simulate a real, clinically relevant dermoscopic change suggesting malignant transformation in facial solar lentigo/ initial seborrheic keratosis (SL/ISK) or in nevi on the body.

Method: Seven patients with 25 pigmented skin lesions (PLS) were photographed resulting in 38 dermoscopic images. Photographs were taken before, one week after and 1-2 months after the use of DHA. Two dermatologists separately evaluated the dermoscopic features according to Menzies’ method (lesions on the body) or Pattern analysis (facial lesions).

Results: In facial PSLs unclear dermoscopic lesions were registered by both evaluators significantly more often after DHA use than before (42 vs.12 %, p=0,021 and 69 vs.19 %, p=0.001). Furthermore, follicular pigmentation that partly mimics that of lentigo maligna was also seen significantly more often after DHA use than before (80 vs.12%, p

Conclusion: Dermatologists that come across unclear dermoscopic findings, especially in facial PLS, should ask about the use of DHA.

A survey of US dermatology chief residents with regard to the nature, significance, and management of dysplastic nevi

T. P. Wu, L. Smith, T. Newlove, C. Hwa, J. A. Stein, D. Polsky

Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, New York, USA

Introduction: A 2002 survey of fellows of the American Academy of Dermatology found substantial variation in the management of dysplastic nevi and attitudes toward their biological significance.

Objective: To assess the attitudes and practices of newly graduated US dermatologists with respect to dysplastic nevi and compare these findings with those from the 2002 survey.

Methods: An online survey was sent to 139 chief residents of US Dermatology Training Programs.

Results: A 59% response rate was achieved. All residents accept the dysplastic nevus as a clinical entity, and all report access to a dermatoscope in clinic. 98% agree that dysplastic nevi mark persons at increased risk for melanoma, compared to 59% of AAD fellows in 2002. 94% of chief residents use dermoscopy to manage pigmented lesions, compared to 23% of AAD fellows in 2002. Although 92% of chief residents report receiving dermoscopy training, only 48% train with a pigmented lesion specialist. Among those training without a specialist, less than half receive classroom or bedside teaching compared to 77% of those who train with a specialist. Of those who train with a specialist, 77% agree that dermoscopy can help differentiate melanoma from benign lesions, compared to 46.5% of those who train without a specialist (p=0.0067).

Conclusion: Residents are receiving a more unified message regarding the biological significance of dysplastic nevi and nearly all use dermoscopy as a diagnostic tool. Additionally, specialists can provide dedicated instruction to trainees fostering greater confidence in the utility of dermoscopy for the management of pigmented lesions.

Reference

1. Tripp JM, Kopf AW, Marghoob AA, Bart RS. Management of dysplastic nevi: a survey of fellows of the American Academy of Dermatology. J Am Acad Dermatol. 2002;46:674-82.

Dermoscopy in dark-skinned people: the experience of the National Institute for Health, Migration and Poverty (NIHMP) in Rome (Italy)

V. Padovese, M. Valenzano, G. Franco, R. Fazio, R. Testa, G. Costanzo, C. Mirisola

National Institute for Health, Migration and Poverty (NIHMP), Rome (Italy)

Little is known about dermoscopy in dark-skinned people and whether it can influence diagnostic performance. Conditions as diverse as inflammatory and infective dermatoses, tumours and pigmented and non-pigmented skin lesions have been documented in white population but few studies report dermoscopic features in dark skin. Moreover, clinical diagnosis in skin of darker color is made difficult by unusual presentations, annular patterns and absence of erythema.

The aim of this study is to assess whether dermoscopy can be a useful diagnostic tool in dark skinned population and compare dermoscopic features in the different phototypes.

Migrants of ethnic skin attending the dermatology department of NIHMP in Rome affected by inflammatory and infective dermatoses, tumours and pigmented skin lesions underwent dermoscopic examination after clinical evaluation.

We present a case series and document how the routine use of dermoscopy can guide the dermatologist in diagnosing skin lesions of difficult interpretation and accurately classify pigmented lesions.

References

1. Bowling J, Argenziano G, Azenha A, Bandic J, Bergman R et al. Dermoscopy key points: recommendations from the international dermoscopy society. Dermatology. 2007;214:3-5.

2. de Giorgi V, Trez E, Salvini C, et al. Dermoscopy in black people. Br J Dermatol. 2006;155:695-9.

Apoptosis in seborrheic keratoses: an open door to a new dermoscopic score

Olga Simionescu1, Bogdan O. Popescu1,2, Mariana Costache1,2, Emilia Manole2, Stefan Spulber3, Mihaela Gherghiceanu2, Andreas Blum4

1 Carol Davila’ University of Medicine and Pharmacy, Bucharest, Romania; 2 Victor Babes’ National Institute of Pathology, Bucharest, Romania; 3 Karolinska Institutet, Stockholm, Sweden; 4 Private and Teaching Practice of Dermatology, Konstanz, Germany

Background: The aetiology of seborrheic keratoses (SK), the most common benign epithelial tumours, and any relationship with malignancy are not yet known. As a protective anti-cancer mechanism, apoptosis reflects cellular loss as a reaction to proliferative activity.

Objectives: The objective of this study was to quantify apoptosis in different SK types (acanthotic, hyperkeratotic, reticulated, irritated, and clonal) and correlate the dermoscopic picture with apoptosis rate.

Methods: After a qualitative and quantitative analysis of dermoscopic images, we defined a new quantitative dermoscopic score (C3V2F, crypts, millia cysts, colours, hairpin vessels, irregular vessels, fissures) from 0 to 22, which enabled us to establish cut-offs correlating with apoptosis rates.

Results: All five SK forms were associated with lower apoptosis rates compared to normal skin. A C3V2F score >10 and greater number of crypts and colours reflected a higher apoptosis rate, which implies a benign character of evolution. In contrast, the presence of irregular vessels on more than 50% of the lesion surface implied a lower rate of apoptosis and probably associated with a risk of malignant transformation. Based on the dermoscopic information, we used multiple regression to establish a model for estimating the rate of apoptosis with a 0.7 prediction interval (approximately 1 standard deviation).

Conclusions: The new C3V2F score could be valuable for the clinical evaluation of possible SK prognosis and decisions regarding excision.

Evaluating the first step of the dermatoscopic 2-step method in non-sun damaged and chronically sun damaged patients

P. Tschandl1, C. Rosendahl2, H. Kittler1

1 Department of Dermatology, Medical University of Vienna, Vienna, Austria; 2 School of Medicine, University of Queensland, Brisbane, Australia

Usage of the diagnostic two-step method in teaching dermatoscopy is widely accepted and was approved in a consensus meeting in 2003. The differentiation of melanocytic and non-melanocytic lesions (“the first step”) contains the risk of misclassification and can therefore lead to wrong diagnoses. This risk is inherent especially when applied by dermatoscopists at a beginning level, the most frequent users of published algorithms.

The present study aimed to evaluate the frequency of misclassifications according to the first step. We included 707 consecutive cases from 553 patients (mean age: 54.7 years, SD: ±18.1 years) with (n=331) and without (n=222) chronically sun-damaged skin. The cases were collected from a tertiary referral center at a University hospital in Europe and from a Primary Care Skin Cancer Clinic in Brisbane (Australia). Dermatoscopic images were evaluated in a blinded fashion for the presence of features described in the 2-step algorithm to determine their melanocytic or non-melanocytic origin. Mucosal, genital and non-pigmented lesions were excluded. The sensitivity of the first step was 97.1% for patients with chronic sun-damage and 96.8% for patients without or moderate sun damaged skin. The specificity was 33.6% for patients with chronic sun-damage and 67.9% for patients without or moderate sun-damaged skin. The most common reasons for misclassification were a pigmented network in 69 cases and an absence of any given features in 74 cases.

References

1. Argenziano G et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol. 2003;48(5):679-93.

2. Marghoob AA, Braun R. Proposal for a revised 2-step algorithm for the classification of lesions of the skin using dermoscopy. Arch Dermatol. 2010;146(4):426-8.

Pigmented actinic keratosis: Brazilian cases

Mauricio Nascimento

Pigmented actinic keratoses play a difficult role in the differential diagnosis of lentigo maligna on the face. However some helpful hints as neighborhood sign, rough appearance, abrupt interruption of pigment pseudo network could help in such diagnosis. The authors present a visual set of lesions illustrating this concept.

References

1. Schiffner R, Schiffner-Rohe J, Vogt T, et al. Improvement of early recognition of lentigo maligna using dermatoscopy. J Am Acad Dermatol. 2000;42:25-32.

2. Cognetta AB, Stolz W, Katz B, Tullos J, Gossain S. Dermatoscopy of lentigo maligna. Dermatol Clin. 2001;19:307-18.

3. Katz B, Rao B. Pigmented actinic keratosis. In: Marghoob AA, Braun RP, Kopf AW. Atlas of Dermoscopy. London: Taylor & Francis, 2005: 86-90.

4. Zalaudek I; Ferrara G, Leinweber B, Mercogliano A, D’Ambrosio A, Argenziano G. Pitfalls in the clinical diagnosis of pigmented actinic keratosis. J Am Acad Dermatol. 2005;53:1071-4.

Observation of a five year high risk clinic for primary melanoma

FJ Moloney1,2,3, P. Guitera1,3, E. Coates1,2,3, N. Haass1,2,3, K. Ho1, R. Khoury, G. Mann3,4, SW Menzies1,3

1 Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 2 Department of Dermatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 3 University of Sydney, Sydney, New South Wales, Australia; 4 Westmead Millennium Institute, Westmead Hospital, Sydney, New South Wales, Australia

Introduction: While Australia has the highest worldwide melanoma incidence, certain subpopulations are at extreme risk and early melanoma diagnosis is crucial. Knowledge of the role of clinical imaging techniques in this group is somewhat limited.

Objective: To determine for extreme high risk patients the natural history and role of total body photography (TBP) and sequential digital dermoscopy imaging (SDDI) in early primary melanoma detection.

Method: 312 patients at extreme melanoma risk were monitored six monthly after baseline TBP over a 5 year period. Inclusion criteria were ≥1 of: (1) CDKN2A or CDK4 mutation; (2) ≥3 first/second degree relatives with previous melanoma and a personal melanoma history; (3) Dysplastic Naevus Syndrome and a personal melanoma history; (4) History of ≥2 primary melanomas.

All patients were screened against TBP at each visit with SDDI short term (3 months) and long term (≥6 months) monitoring employed following established criteria and atypical lesions were excised.

Results: The median follow-up time was 3.5 years (IQR: 2.4-4.2 years). 79 primary melanomas were detected, 16 at baseline visit and 63 subsequently. Median Breslow thickness was 0.12 mm (IQR: in situ-0.60mm).

38.1% were detected using TBP and 39.7% with SDDI. Five melanomas, including three desmoplastic melanomas, were ≥1mm Breslow thickness (including three desmoplastic and one scalp melanoma). 142 BCCs and 64 SCCs were excised and the overall benign to malignant excision ratio was 1.4:1 and 4.2:1 for melanocytic lesions.

Conclusion: Monitoring extreme risk patients with TBP and SDDI assisted with the effective early diagnosis of primary melanoma. Hyper-vigilance for difficult to detect thick melanoma subtypes is crucial.

Automated detection and analysis of pigment networks, streaks and scale for melanoma diagnosis on dermoscopic images

Maryam Sadeghi1,2,3, Tim K. Lee1,2,3, David I. McLean3, Harvey Lui2,3, M. Stella Atkins1,3

1 School of Computing Science, Simon Fraser University, Vancouver, Canada; 2 Cancer Control Research and Integrative Oncology, BC Cancer Agency, Vancouver, Canada; 3 Photomedicine Institute, Department of Dermatology and Skin Science, UBC, Vancouver, Canada

Introduction: With recent advances in skin imaging technologies there has been an increasing demand for image processing techniques in computer aided-diagnosis of pigmented skin lesions using dermoscopy images. Our work follows a relatively new trend in clinical dermatology to identify specific ‘dermoscopic structures’ such as streaks, scale, and pigment network, which are used to aid the diagnosis of malignant melanoma.

Method: Irregular pigment network and streaks are two important positive features of melanoma and scale seems to be a negative feature based on our studies on the dry polarized contact dermoscopy. We present a novel approach to detect, segment, analyze and visualize pigment network, streaks, and scale in dermoscopic images, according to their clinical definitions. Three important dermoscopic structures (pigment network, streaks, and scale) are modeled based on the structural (shape), geometric (spatial arrangement), chromatic and textural features defined by experts in dermoscopy. Our approach has several steps; pre-processing that includes image enhancement and automatic skin lesion segmentation, object detection using morphologic techniques, and feature extraction and classification into irregular or regular structures. The presence and absence of these structures can be used for malignancy detection in skin lesions.

Results: Our results over 945 images show an accuracy of 92% on pigment network detection, 82% on typical-atypical pigment network classification, 78.5% on streaks detection, 83.5% on regular-irregular streaks classification and 84% on scale detection.

Melanoma invasiveness depends on preventive behavior and total number of nevi. A retrospective study in 176 patients

A. Kardynal 1 , M. Slowinska1, J. Sicinska 1, M. Maj1, A. Rakowska1, J. Czuwara1, E. Kowalska-Oledzka1, E. Piekarczyk1, B. Goralska-Zaleska1, M. Lukomska1, O. Warszawik1, M. Kurzeja1, A. Wiergowska1, A. Nasierowska-Guttmejer2, L. Rudnicka1,3

1 Dept. Dermatology CSK MSWIA, Warsaw, Poland; 2 Dept. Pathology CSK MSWIA, Warsaw, Poland; 3 Faculty of Health Sciences, Warsaw Medical University, Warsaw, Poland

Introduction: High melanoma-related mortality rates remain a problem in Poland. The aim of the study was to evaluate melanoma invasiveness depending on dermoscopy screenings, preventive behavior and clinical findings.

Method: A retrospective study based on revised medical records between years 2004-2011 and completed questionnaires of patients diagnosed with melanoma.

Results: In the analyzed timeframe 176 patients were diagnosed in our department with melanoma (57%-F, 43%-M). A total of 38,4% were diagnosed as melanomas in situ. Among invasive melanomas mean Breslow thickness was 1.03 mm. About 80% of melanoma patients were phototype I-II, what corresponds to usual numbers in Polish population. A history of sun burns recorded 83,6% of patients with melanoma and 69,3% of healthy control. About 60% of patients had more than 50 nevi. In this group mean Breslow thickness was 1,32 mm and 46,6% of melanomas were in situ. In patients with less than 50 nevi mean Breslow thickness was 2,25 mm and 32,7% of melanomas were in situ. About 60% of patients were never screened for melanoma. In this group 35% of melanoma were in situ, and mean Breslow thickness was 1,77mm (1,35 mm-F, 2,77 mm-M). Within patients screened for melanoma at least once 49% of melanomas were in situ and mean Breslow thickness was 0,89 mm -F and 1,18 mm-M patients.

Conclusions: Thickness of melanoma (in Breslow scale) is significantly lower in patients who had a history of at least one dermoscopy screening prior to diagnosis and in patients who have multiple nevi.

Dermoscopy use in the next generation: A survey of dermatology trainees

P. Piliouras1,2, P. Buettner3, H.P. Soyer4

1 Department of Dermatology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia; 2 School of Medicine, James Cook University, Townsville, Queensland, Australia; 3 Skin Cancer Research Group, School of Public Health, Townsville, Queensland, Australia; 4 Dermatology Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia

Introduction: The use of dermoscopy is rapidly expanding. The dermatoscope is now used in everyday practice. We sought to investigate the use of dermoscopy in Australian dermatology trainees.

Method: An invitation to complete a web-based survey was sent via e-mail. The survey was composed of a combination of questions from a standardized survey of the International Dermoscopy Society, a previous published dermoscopy survey of Australian consultant dermatologists and questions posed by us. Two-sided Fisher’s exact tests, chi-square tests and exact chi-square tests for trend were used to assess differences between Australian consultant dermatologists (n=99) and trainee dermatologists (n=44). A significance level of 0.05 was assumed. The statistical analysis was conducted using SPSS release 18 (IBM SPSS Inc, Chicago, IL).

Results: The response rate was 55% (44 out of 88 trainees). There were 31.8% (n=14) male and 68.2% (n=30) female respondents. The mean age was 33 years (SD=5.41). All respondents used dermoscopy with the majority (54.5%, n=24) using a dermatoscope for 3-5 years. When asked whether a dermatoscope was an essential tool for a trainee dermatologist, 95.5% (n=42) responded yes. When comparing consultants and trainees, there was a significant difference in their answers when questions concerning identifying melanoma early in the curable stage, use in non-pigmented tumours, helping to improve record keeping, documentation for medical liability and anticipation for future use of dermoscopy were asked (p<0.05).

An index of diagnostic difficulty for malignant melanoma

J. F. Kreusch

Dermatological Practice, Luebeck, Germany

Introduction: Comparing diagnostic skills for identifying malignant melanoma strongly depends on characteristics of the tumors analyzed. For benchmarking diagnostic studies on melanoma the average tumor thickness is neither representing clinical nor dermoscopic difficulty of diagnosis. It is evident that an investigator encountering only large, dark and asymmetric lesions has to face less diagnostic problems as compared to another one excising small, symmetric and possibly hypopigmented melanoma, too. Most important for cost efficiency in health care systems is the benign-malignant ratio of excisions with suspect of melanoma. Comparing the ratios of different investigators cannot be made without taking diagnostic difficulty of the lesions into account.

Methods: A two-step procedure is presented including clinical as well as dermoscopic features contributing to the diagnostic difficulty of a given lesion. First, a lesion must be considered worthy of examination by dermoscopy. An index of clinical diagnostic difficulty characterizes these lesions. In a second step, certain dermoscopic criteria must be present to raise suspicion of malignancy. A score of features is presented to define diagnostic difficulty of melanoma for both steps. The index of diagnostic difficulty ranges from zero to infinite and thus comprises easy-to-diagnose classical melanoma as well as so-called featureless melanoma, fairly impossible to spot in the skin. Examples are demonstrated.

Conclusion: In future studies, the average index of difficulty of melanoma with the study population should be calculated in order to compare benchmark results of various centres.

Is reflectance confocal microscopy a useful aid in diagnosis of regressive lesions?

Elisabeth M.T. Wurm, Edith Arzberger, Rainer Hofmann-Wellenhof Department of Dermatology, Medical University of Graz, Austria

Regressive cutaneous lesions are a significant diagnostic challenge as they lack distinct clinical and dermoscopic features. Reflectance confocal microscopy (RCM) is a tool for non-invasive diagnosis of melanocytic skin lesions that has been shown to be useful in diagnosis of non-pigmented skin lesions. Little is known, however, about the value of RCM in diagnosis of regressive lesions. We will present a case series of regressive lesions including clinical, dermoscopic and RCM images as well as histopathological diagnoses, and discuss specific features that, in our view, might be of use in diagnosis of these challenging lesions.

Clinical and dermatoscopic characteristics of melanocytic nevi in Turkish young people with 18-25 years old

A. ÖztÜrk, E. Arca, G. AÇikgÖz, Z. Kurumlu

GÜlhane Military Medical Academy, School of Medicine, Department of Dermatology, Ankara, Turkey

Background and aim: Melanoma is a malign tumor of the skin. Malign transformation in the already existing nevus is the most seen etiological factor for melanoma. This study was done to determine the clinical and dermatoscopic characteristics of melanocytic nevi in Turkish young people with 18-25 years old.

Material and methods: A total of 688 young people from the patients and students of GÜlhane Military Medical Academy, School of Medicine, and Department of Dermatology were included in the study. A questionnaire was applied including age, sex, sunblock use, and sunburn history. On clinical examination, we evaluated number of nevi, location of nevi and skin type. Nevi that are equal or greater than 3mm were examined dermatoscopically, recorded and scored by using pattern analysis, ABCD total dermoscopic score, 7 point checklist, Menzies algorithm, 3 point checklist and CASH algorithm.

Results: Totally 668 young people were physically examined in this study (268 of which were women and 400 of which were men). The most common skin phototype in both sexes was type 3 (91.6% of women, 85.25% of men). A total of 453 nevi were examined dermatoscopically. The most common localization of nevi was on the head and neck region (n=144; 31.8%), followed by anterior trunk and abdomen (n=128; 28.3%), back (n=122; 26.9%) and extremities (n=45; 9.9%). The most common dermatoscopic global feature was the globular pattern (n=135; 29.8%), followed by reticular pattern (n=88; 19.4%), and cobblestone pattern (n=64; 8.8%).

Conclusion: This is the first study about the characteristics of melanocytic nevi at this age group and lays the foundation for future studies that will elucidate the relationship between nevi, dermatoscopic pattern and the other factors in a population-based cohort.

Dermoscopy of alopecia neoplastica

R. M. Bakos, T. S. Souza, R. Heck

Department of Dermatology, Hospital de ClÍnicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

Introduction: Alopecia neoplastica is a rare disorder that in most cases represents metastatic breast cancer. Dermoscopy might be a useful tool in clinical evaluation.

Case report: A 72 year-old woman reported asymptomatic localized hair loss with a progressive course during the past 4 months. She presented a past history of breast adenocarcinoma diagnosed 5 years ago. On physical examination there was a mildly indurated, slightly erythematous plaque of alopecia on parietal scalp. Dermoscopy reveals only overlying telangiectasias diffusely distributed. Biopsy proved a metastatic carcinoma compatible with a mammary origin.

Discussion: In woman, breast cancer is the most common malignancy that metastasizes to the skin. Alopecia neoplastica is a rare asymptomatic manifestation of cutaneous metastases and it might present as single or multiple slightly erythematous round plaques of alopecia, usually with peripheral telangiectasias. The clinical picture may mimic several dermatoses and therefore the diagnosis might be delayed. Dermoscopy might be an important diagnostic tool, mainly on the exclusion of other dermatoses with already described dermoscopy patterns such as alopecia areata, which presents for example short “exclamation mark” hairs and yellow dots, discoid lupus erythematous, that shows follicular plugs and red dots, and tinea capitis, which exhibits broken and comma hairs. In conclusion, alopecia neoplastica is an uncommon cutaneous disease. Although it lacks a characteristic dermoscopic pattern, dermoscopy might be helpful in its evaluation especially when dermoscopic features of other common dermatoses are not present and should lead dermatologists to perform histologic examination in such cases.

Acral melanoma in Spain; retrospective study of 275 cases in a referral center

Cristina Carrera1,3, AdriÀ Gual1, Alba DÍaz2, Susanna NoguÉs1, Adriana P. GarcÍa2, LlÙcia AlÓs2, Antoni Vilalta1, Josep Palou1, Susana Puig1, 3, Josep Malvehy1, 3

1 Melanoma Unit, Department of Dermatology, Hospital ClÍnic de Barcelona, IDIBAPS, Barcelona, Spain; 2 Department of Pathology, Hospital ClÍnic de Barcelona, IDIBAPS, Barcelona, Spain; 3 CIBER Enfermedades Raras, Instituto de Salud Carlos III, Barcelona, Spain

Introduction: Acral melanomas (AM) can be misdiagnosed in early stages and it has postulated that the delay in the detection could be the main cause of a poor prognosis.

Methods: Retrospective clinical-prognostic, dermoscopic and histopathologic review of AM in a referral unit from 1986 to 2010.

Results: 275 AM were included (61% women; mean age of 56y, range 12-96). The most frequent location was on feet (83%), 60% were ulcerated 20% achromic. Dermoscopically (68 cases) multicomponent global pattern was the most frequent (35%), parallel ridge pattern could be identified in up to 50% of cases. More than 40% presented blue whitish veil and streaks. 60% of achromic tumours showed milky red areas and/or atypical vessels, and were correlated to higher Breslow index. At the time of consultation in our Unit all showed dermoscopic clues of malignancy. Histopathologically they consisted in acral lentiginous melanoma (ALM) 57%, superficial spreading (SSM) 30% (75% women), and nodular (NM) 6%. 24% were in situ melanomas whereas the mean Breslow thickness of invasive cases was 3.02mm. In a mean follow-up of 55.16 months 27% died due to melanoma. Prognostic factors by multivariate analysis were age at diagnosis, Breslow, and histopathologic subtype. ALM and NM presented a poorer outcome than SSM (OR 10.95, p0.02).

Conclusions: Diagnosis of AM in our population is delayed and dermoscopy could help to identify difficult lesions, especially achromic tumours. In addition to misdiagnosis, subtypes of ALM and NM presented a poorer prognosis after been adjusted by age and Breslow.

Dermoscopy of common inflammatory skin diseases of the face

M. Maj1, M. Kurzeja1, A. Rakowska1, M.Slowinska1, M. Olszewska2, L. Rudnicka1, 3

1 Department of Dermatology, Central Clinical Hospital MSWiA, Warsaw, Poland; 2 Department of Dermatology, Warsaw Medical University, Poland; 3 Faculty of Health Sciences, Warsaw Medical University, Poland

Introduction: Skin inflammation of the face can be caused by different factors such as infections, allergies, physical and chemical agents and reactions due to medications. Skin inflammatory diseases are often accompanied by patches, blisters, dryness of the skin, burning and itching, which affect the appearance and texture of the skin. Differential diagnosis may be difficult. We investigated, whether dermoscopy may aid differential diagnosis of inflammatory skin diseases of the face.

Method: A total of 50 patients with nummular lesions on the face were included into the study (pemphigus vulgaris, pemphigus foliaceous, discoid lupus erythematosus, subacute cutaneous lupus erythematosus, atopic dermatitis, psoriasis, seborrheic dermatitis, rosacea, tinea, pityrosporum folliculitis, sycosis). Videodermoscopy was performed with Fotofinder 2.

Results: In dermoscopy of pemphigus vulgaris and pemphigus foliaceous we observed: bloody-red, sharply demarcated, polygonal areas, glomerular vessels and peripherally attached linear scales. In discoid lupus erythematosus most characteristic dermoscopy features were: thick arborizing vessels, fine scaling and large, keratotic plugs. In seborrheic dermatitis fine arborizing vessels and yellowish scaling were most prominent. Dermoscopy of psoriasis showed regularly distributed globular vessels. UV-enhanced dermoscopy (UVED) may be beneficial in differential diagnosis of Microsporum canis infections and Pityrosporum folliculitis.

In conclusion, dermoscopy may be applied in differential diagnosis of inflammatory diseases of the face.

Cutaneous malignant melanoma metastases (CMMM): dermoscopic features and differential diagnosis

Karem Ortiz, Joanne Costa, Gabriel Salerni,Valeria Borges, Cristina Carrera, Susana Puig, Josep Malvehy

Melanoma Unit, Department of Dermatology, Hospital Clinic, Barcelona, Spain

Cutaneous metastases of melanoma can be confused with other skin lesions. Dermoscopy could be helpful in the differential diagnosis.

We described the distinctive dermoscopic patterns of CMMM assessing their sensitivity and specificity performing a retrospective study of 146 dermoscopic images of CMMM from 42 patients attended in our institution since 2002 to 2009. First, two investigators established six dermoscopic patterns of CMMM. The correlation of 75 dermoscopic images with their distinctive patterns was assessed by 4 independent dermatologists. Finally, a pool of 163 dermoscopic images including CMMM and non-metastatic lesions were evaluated by the same four dermatologists in order to assess the diagnostic utility of the dermoscopic patterns to recognize CMMMs.

The six dermoscopic patterns of CMMM were blue nevus-like, nevus-like globular and non-globular, angioma-like, vascular and unspecific. When CMMM were classified accordingly to these patterns, agreement between the investigators and the four dermatologists ranged from ? = 0.56 to 0.7. The interobserver agreement was good (> 80% for angioma-like, nevus-like and blue nevus-like patterns).

71 CMMM, 16 angiomas, 22 blue nevus, 15 malignant melanoma (unspecific or globular pattern), 11 seborrheic keratosis, 15 melanocytic nevus with globular pattern and 13 pink lesions with vascular pattern were evaluated by 4 dermatologists showing an overall sensitivity of 68% (between 54.9-76%) and specificity of 80% (between 68.5-93.5) for the diagnosis of CMMM that varies according to the experience of the observer and point out the difficulty in the identification of some metastases. Nevertheless, the majority of the lesions were correctly identified as CMMMs.

References

1. Bono R, Giampetruzzi AR, Concolino F, et al. Dermoscopic patterns of cutaneous melanoma metastases. Melanoma Res. 2004;14(5):367-73.

2. Minagawa A, Koga H, Sakaizawa K, et al. Dermoscopic and histopathological findings of polymorphous vessels in amelanotic cutaneous metastasis of pigmented cutaneous melanoma. Br J Dermatol. 2009;160:1134-6.

An innovative primary care physician training program in dermoscopy in underserved and rural communities in Pennsylvania

R. I. Neves1, L. Kanzleiter-Keister2

1 Penn State Hershey Melanoma Center, Pennsylvania State University, Department of Surgery, Division of Plastic Surgery. Hershey, Pennsylvania, USA; 2 Department of Family and Community Medicine, Pennsylvania State University, College of Medicine. Hershey, Pennsylvania, USA

Pennsylvania is a very rural state within the United States with many health care concerns. Of the 67 counties within the Commonwealth, 52 are designated as primary care shortage areas with significant concerns of access to primary health care services. The economic backbone of this state is agriculture, lumbering and mining, which require long hours of exposure to the environment. Health indices of the Commonwealth demonstrate an increase in skin cancer and melanoma incidence. With a minimum of six months or greater to schedule an appointment with a dermatologist, the Department of Family Medicine and The Penn State Hershey Melanoma Center developed an education and training program for primary care physicians in dermoscopy to:

  • Develop an educated primary care physician workforce in rural and underserved areas skilled in the use of dermoscopy
  • Increase access to screening and early detection interventions for skin lesions through primary care to prevent progression of the disease
  • Decrease cost to health care interventions through early detection and better diagnosis accuracy

This workshop describes the educational content, instructional methods and evaluative processes used to train primary care physicians to become competent and skilled in the use of dermoscopy and confident in the delivery of primary and secondary interventions. The facilitator also explore the lessons learned in the pilot dermoscopy training session implemented in the Department of Family and Community Medicine at Penn State College of Medicine which served to frame the changes in curriculum and instructional media applied in the first training series.

References

1. Argenziano G, Puig S, Zalaudek I, et al. Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol. 2006;24:1877-82.

2. Carli P, De Giorgi V, Crocetti E, et al. Improvement of malignant/benign ratio in excised melanocytic lesions in the ‘dermoscopy era’: A retrospective study 1997-2001. Br J Dermatol. 2004;150:687-92.

Teledermoscopy using handheld dermoscope coupled with smartphone

John Paoli1, Alex BÖrve2, Carin Sandberg1, Karin Terstappen3

1 Department of Dermatology, Sahlgrenska University Hospital, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 2 Department of Orthopaedics, Sahlgrenska University Hospital, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 3 Department of Dermatology, KÄrnsjukhuset, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, SkÖvde, Sweden

New mobile phones, so-called smartphones, with built-in digital cameras used in combination with customized dermoscopes can hopefully be used to carry out teledermoscopic evaluations of suspicious skin lesions. In this study, we included 69 melanocytic and non-melanocytic lesions in which malignancy was suspected upon clinical and dermoscopic examination by a dermatologist during a face-to-face visit. Prior to biopsy or excision, clinical and dermoscopic digital photographs were taken with a smartphone and a dermoscope that could be fitted directly onto the smartphone. The suspected diagnosis, the level of diagnostic difficulty and the management decision was provided and later compared to the histopathological report. Furthermore, the image quality was assessed. These same parameters were also provided by two experienced dermoscopists who independently reviewed the clinical and dermoscopic photographs together with relevant clinical information but without seeing the patient and without knowledge of the histopathological report. We will report on the diagnostic accuracy of the dermatologist meeting the patient face-to-face compared to histopathology, the diagnostic accuracy of the two teledermatologists, the interobserver agreement between the two teledermatologists and between the teledermatologists and the dermatologist meeting the patient face-to-face. We will also present the image quality of this innovative dermoscopic technology and discuss the potential of using this method for teledermoscopy between primary care physicians and dermatologists.

Teledermoscopy in Serbia: more than two years of experience in five centers

J. Bandic1, D. Dobrosavljevic2, B. Spasic3, S. Cvetkovic3, S. Dimitrijevic3, M. Davidovic3, Lj. Stanisic3, S. Kovacevic4, S. Jesic5, D. Nikolic6, S. Rogozarski7, T. Reza7, Z. Manasijeviá7, Z. Ceranic3, S. Vjetrov7, M. Bandic1, M. Strbac1, M. Surla1 and M. Vasilevski1

1 ORS Hospital Belgrade, Belgrade, Serbia; 2 Klinicki Centar Srbije, Belgrade, Serbia; 3 Opsta bolnica Leskovac, Leskovac, Serbia; 4 S-medica Loznica, Loznica, Serbia; 5 Dermatolog, Uzice, Serbia; 6 KBC Bezanijska kosa, Belgrade, Serbia; 7 Dom zdravlja Pancevo, Pancevo, Serbia

Introduction: Teledermoscopy is a rapidly developing field of dermatology and teledermatology. Many studies have described its advantages and disadvantages with special emphasis to shorten waiting lists, make dermatologist consultation easy accessible and in reducing the costs of examination of pigmented skin lesions (PSL). A non-commercial teledermatology network based on store-and-forward operation was established in Serbia in 2009.

Method: Six dermatologists, two surgeons and three general practitioners trained in dermoscopy from five towns in Serbia equipped with Teleskin Teledermoscopy System® obtained clinical and dermoscopic images of the suspicious PSL. The images were sent using store-and-forward system in order to obtain expert second opinion and recommendation concerning excision of the PSL.

Results: Total of 2528 patients with 3153 PSL was enrolled into the study from July 1st 2009.-December 1st 2011. Dermoscopical diagnoses were: 1800 melanocytic nevi, 84 melanomas, 697 seborrheic keratoses, 122 angiomas, 87 dermatofibromas and 341 basocellular carcinomas. Interobserver agreement between dermatologists and experts was a perfect agreement (first and second opinion) for melanoma K value > 0.89 (0,79-0,92), for melanocytic nevus K value > 0,92 (0,85-0,94), for seborrheic keratosis K value > 0,89 (0,75-0,92), for angioma K value > 0,93 (0,78-0,96), for dermatofibroma K value > 0,86 (0,49-0,94) and for basal cell carcinoma K value > 0,95 (0,84-0,98 ). Between general practitioners and experts, moderate to perfect (0,60-0,92) agreement was obtained for most of the lesions. And at the end, between surgeons and experts, K value was substantial to perfect (0,67-0,83) for all lesions.

Conclusion: In our experience, this large teledermoscopy study provided data that teledermoscopy is more reliable concerning melanocytic lesions vs. non-melanocytic lesions. Apart from its teaching potential, the use of teledermoscopy as a triage tool offers the potential to improve the healthcare access and delivery, both in general practice and on specialist level.

References

1. Tan E, Oakley A, Soyer HP, Haskett M, Marghoob A, Jameson M and Rademaker M. Interobserver variability of teledermoscopy: an international study. Br J Dermatol. 2010;163: 1276-81.

2. Fabbrocini G, Balato A, Rescigno O, Mariano M, Scalvenzi M, Brunetti B. Telediagnosis and face-to-face diagnosis reliability for melanocytic and non-melanocytic ‘pink’ lesions. J Eur Acad Dermatol Venereol. 2008;22:229-34.

Dermoscopic findings in biopsy-proven poromas: A case series

A. Shalom1, O. Schien1, C. Landi2, A. Marghoob3, B. Carlos4, A. Scope3,5

1 Department of Plastic Surgery, Assaf Harofeh Medical Center, Zerifin, Israel; 2 Dermatologic Unit, Surgical Department “Infermi” Hospital, Rimini, Italy; 3 Dermatology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; 4 Dermatology Service, Hospital de Especialidades, Mexico City, Mexico; 5 Dermatology Department, Sheba Medical Center, Ramat Gan, Israel

Background: Poromas are often misdiagnosed as skin cancers.

Objectives: To describe clinical and dermoscopic features of biopsy-proven poromas.

Methods and materials: Biopsy-proven poromas were retrospectively collected from image-database of four hospitals. Data collected included patient’s demographics and anatomic location of lesions. Clinical and dermoscopic images were analyzed.

Results: In all, 19 patients (10 males, mean age 64, range 35-90 years) contributed 19 biopsy-proven poromas. Nine lesions (47%) were on the foot and 10 (53%) on leg, thigh, trunk or face. Mean size was 7.8 mm; plantar poromas were larger than poromas elsewhere on the body (10 versus 5 mm, p<0.01). On dermoscopy, common vascular patterns were glomerular vessels in 10 cases (53%), looped in 9 (47%) and leaf and flower-like vessels in 8 (42%). Additional dermoscopic features included structureless areas in 15 cases (79%) and interlacing white cords in 9 (47%). In retrospective search through image-database of 5200 excised lesions, interlacing white cords were found in 2of 201 melanomas (2%).

Conclusions: Among biopsied poromas, about half arose on non-acral skin. Leaf and flower-like vessels may be a unique dermoscopic feature of poromas. While interlacing white cords are commonly seen in poromas, they are rarely seen in melanoma.

Grey-blue areas in the melanocytic lesions: how important are they?

Rodica Cosgarea, Loredana Ungureanu

Department of Dermatology, University of Medicine “Iuliu Ha?ieganu” Cluj-Napoca, Romania

Introduction: The dermatoscopic structures, which are suggestive for melanoma, are in general well defined and some of them have a stronger diagnostic value. The blue or grey-blue colour can be found in some melanomas but also in some melanocytic nevi.

Method: We evaluated the dermoscopies of 152 melanomas and 123 atypical nevi recommended for excision. The melanoma group was divided in four subgroups in accordance with the thickness of melanoma: in situ, under 1 mm, between 1-2 mm and more than 2 mm. We registered the following dermatoscopic structures: grey-blue areas with different patterns (globules, net with lines and holes, structureless, grey dots with peppering aspect), blue-whitish veil and white areas. We analyzed the frequency of every structure in each group of lesions.

Results: We found that grey-blue areas are high suggestive for melanoma in all the four types of patterns: the reticular ones are most frequently encountered in thin melanomas and the structureless blue areas in thicker melanomas. The whitish-blue veil was most frequently found in the thicker melanomas. The blue areas were also found in dysplastic nevi but in a lower degree in comparison with melanomas.

Conclusions: The grey-blue structures are relevant for melanoma in high degree, even for very thin melanomas.

References

1. Bassoli S, Borsari S, Ferrari C, et al. Grey-blue regression in melanoma in situ-evaluation on 111 cases. J Skin Cancer. 2011;2011:180980.

2. Massi D, De Giorgi V, et al. Diagnostic significance of the blue hue in dermoscopy of melanocytic lesions. Am J Dermatopathol. 2001;23(5):463-9.

Is it necessary to perform eye examination for patients with cutaneous dysplastic nevi?

I. Kilinc Karaarslan A. Yagci 2, A. Tuna T. Ozkapu M. Palamar2, F. Ozdemir1

1 Ege University, Medical Faculty, Department of Dermatology, Izmir, Turkey; 2 Ege University, Medical Faculty, Department of Ophthalmology, Izmir, Turkey

Introduction: Regular dermatological examination for patients with dysplastic nevi is indicated. However, the literature on whether those patients should also be examined by ophthalmologists or not regarding a relation between ocular melanoma and cutaneous dysplastic nevi is limited. In this study we aimed to screen the eyes of our patients who had been followed-up with the diagnosis of cutaneous dysplastic nevi.

Method: We examined the eyes of 110 patients with dysplastic nevi (47 had the diagnosis of dysplastic nevus syndrome type A, B, C, D1 or D2) for any lesion and compared the results with a control group consisted of 110 sex, age and skin-type matched patients without a diagnosis of dysplastic nevi or melanoma.

Results: No ocular melanoma was detected in any of the groups. The frequency of the conjunctival nevi, iris nevi, choroidal nevi and conjunctival acquired melanosis were similar in both groups. Iris freckles were detected more frequently in the study group. Conjunctival racial hyperpigmentation was detected more frequently in the control group (p<0.05).

References

1. Toth-Molnar E, Olah J, Dobozy A, Hammer H. Ocular pigmented findings in patients with dysplastic naevus syndrome. Melanoma Res. 2004;14(1):43-7.

2. Hurst EA, Harbour JW, Cornelius LA. Ocular melanoma: a review and the relationship to cutaneous melanoma. Arch Dermatol. 2003;139(8):1067-73.

Dermatoscopic features of a series of non-facial non-acral lentiginous growth pattern melanomas

Jeffrey Keir

Northern Rivers Skin Cancer Clinic, Ballina, New South Wales, Australia

Introduction: Dermatoscopic features of facial lentigo maligna (LM) and acral lentiginous melanoma are well described. Lentiginous growth pattern (LGP) melanoma, including LM, is increasing in diagnostic incidence but the dermatoscopic features of non-acral non-facial LGP melanomas are not yet described. Early recognition of LGP melanomas is important, as these tend to lack BRAF mutations that are a target of therapies for metastatic melanoma.

Method: A 12-month case series of melanomas detected in a primary care skin cancer clinic was imaged clinically and dermatoscopically before biopsy. Dermatoscopic images were assessed for proposed clues to LGP melanoma, including: lentigo-like pigment patterns associated with a lack of lentigo-like border; atypical follicular pigmentation patterns; geometric/polygonal pigment patterns and grey structures. The results of this were compared for statistical significance between groups of non-facial non-acral melanomas categorised by the following histologically reported growth patterns: LGP, mixed lentiginous and nested growth pattern, and superficial spreading melanoma (SSM).

Results: 66 melanomas (12 invasive) were diagnosed in 59 patients: 11 facial, 1 acral, 54 non-facial/non-acral (23 LGP, 13 mixed pattern, 14 SSM, 1 desmoplastic, 3 not specified). The following were associated with non-facial non-acral LGP and mixed pattern melanomas over SSM: a disorganized lentigo-like pigment pattern lacking a lentigo-like border (p<0.001); atypical follicular pigmentation patterns (p<0.05); and rhomboidal shapes (p<0.05). Mixed pattern melanomas and SSM were more likely to have structureless pink areas than were LGP melanomas (P<0.05). SSM were more likely to be invasive at diagnosis (p<0.05).

Conclusion: LGP melanomas may have a specific pattern of dermatoscopic features. Further multicentre study is required.

Dermoscopic features of clear-cell acanthoma

G. Lyons1, A. J. Chamberlain2, J. W. Kelly2

1 Occupational Dermatology Research and Education Centre (ODREC), Skin and Cancer Foundation, Melbourne, Australia; 2 The Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia

Background: Clear-cell acanthoma is a rare benign epidermal tumour. The dermoscopic features appear fairly unique.

Objectives: To delineate the key features of clear-cell acanthoma on dermoscopy.

Methods: We reviewed the dermoscopic features of all published cases of clear-cell acanthoma in the literature to date and report 4 new cases of our own.

Results: All cases featured scattered pinpoint dotted or larger red globules. The majority of cases showed the typical ‘string of pearls’ or linear arrangement. This characteristic linear arrangement of red globules is ultimately reticular and strikingly symmetric when fully developed. In some cases, the pattern is incomplete or partly developed but still recognisable. Other features such as crusting, hyperkeratosis or a peripheral collarette may be present.

Conclusion: Clear cell acanthoma has distinctive dermoscopic features that help in reaching a confident clinical diagnosis and minimizing the need for biopsy.

Reference

1. Degos R, Civatte J. Clear-cell acanthoma. Experience of 8 years. Br J Dermatol. 1970;83:248-54.

Dermoscopic characteristics of Merkel cell carcinoma

C. Jalilian, A. J. Chamberlain, M. Haskett, C. Rosendahl, J. Keir, H. Beck, P. Varghese, M. Goh, A. Mar, S. Hosking, I. Hussain, C. McLean, J. W. Kelly

Victorian Melanoma Service, The Alfred Hospital, Melbourne, Australia

Merkel cell carcinoma (MCC) is an aggressive cutaneous malignancy with a high mortality rate. Diagnosis is often delayed. No case series analysing the dermoscopic features of MCC have been published. Clinical and dermoscopic images of biopsy proven MCCs were analysed in a retrospective manner with existing dermoscopic criteria being scored independently by three dermatologist. The most frequent clinical features were cherry red colour, shiny and well-circumscribed nodules. Significant dermoscopic features include linear irregular and poorly focused vessels, milky pink areas, white areas and architectural disorder. Pigmented structures were absent for all lesions. The dermoscopic features described here should help achieve earlier diagnosis of MCC, which facilitates timely treatment.

Dermoscopic aspects of cutaneous gastric carcinoma metastases

R. M. Bakos, G. F. Escobar, J. Ribar, M. Q. Tubone

Department of Dermatology, Hospital de ClÍnicas de Porto Alegre, Porto Alegre, Brazil

Cutaneous metastases might be the initial presentation of internal malignancies in 22% of patients. 1 Up to 10% of all visceral malignant tumors develop cutaneous metastases, which represent 2% of all skin tumors. However, skin metastases from signet ring cell gastric carcinoma are uncommon. We present the dermoscopic aspects of a patient with gastric adenocarcinoma and multiple skin nodules.

Case report: A 55-year-old man presented with a progressive generalized cutaneous eruption. Examination revealed asymptomatic small erythematous firm nodules. Dermoscopy showed a polymorphous vascular pattern. One year prior to this event, this patient had been submitted to a partial gastrectomy due to a poorly differentiated, diffuse type, signet-ring cell gastric adenocarcinoma. Histologic and immunohistochemical studies of the lesions confirmed progression of the neoplasia to the skin.

Discussion: Few reports have described the dermoscopic features of non-melanoma cutaneous metastases. An atypical vascular pattern was observed in one report of skin metastases of thyroid carcinoma and this feature was considered pathognomonic for neoplastic neovascularization, both benign and malign, concluding that such lesions should be biopsied. To our knowledge, no reports analyzed the dermoscopic features of gastric carcinoma metastases. We observed a prominent atypical vascular pattern, demonstrating that this feature might also be observed in nodular lesions of cutaneous metastases of gastric carcinoma. This report emphasizes that cutaneous metastases of internal malignancies might have its initial presentation on the skin and that dermoscopy is an important diagnostic tool in evaluating such lesions.

References

1. Nashan D, MÜller ML, Braun-Falco M, Reichenberger S, Szeimies RM, Bruckner-Tuderman L. Cutaneous metastases of visceral tumours: a review. J Cancer Res Clin Oncol. 2009;135:1-14.

2. De Giorgi V, Alfaioli B, Massi D, et al. Solitary cutaneous metastasis as the first sign of relapse of thyroid carcinoma: a clinical, dermoscopic-pathologic case study. Dermatol Surg. 2009;35:523-6.

3. Aneiros-Fernandez J, Husein-ElAhmed H, Arias-Santiago S, et al. Cutaneous metastasis as first clinical manifestation of signet ring cell gastric carcinoma. Dermatol Online J. 2010;16:9.

Dermoscopic aspects of extragenital lichen sclerosus

R. M. Bakos, G. F. Escobar, A. C. Fischer, A. Cartel

Department of Dermatology, Hospital de ClÍnicas de Porto Alegre, Porto Alegre, Brazil

Lichen sclerosus (LS) is an unusual chronic inflammatory skin disease. Although it may affect all areas of the body, only 15% compromises the extragenital area. Initial lesions are porcelain white papules, plaques or atrophic patches. We present the dermoscopy aspects of two patients with extragenital LE.

Case report: Patient 1: A 19-year-old woman, presented with a 2-year history of two pruritic whitish plaques on her left upper back. Dermoscopy showed a whitish-pink background, surrounded by linear vascular structures and hairpin-like vessels. Yellowish areas were also visualized.

Patient 2: A 59-year-old woman, presented with a 5-month history of asymptomatic hyperchromic plaques on her axillas. Dermoscopy showed irregularly distributed black granules, predominantly over whitish areas. Discrete follicular plugging was also observed.

Discussion: Dermoscopy of extragenital lichen sclerosus has been described in previous reports. Garrido-RÍos et al studied four women with extragenital LS and described, as major dermoscopic findings, whitish areas with comedo-like openings in the center of the lesions, which corresponded to follicular plugging and atrophy of the epidermis. Moreover, Kimura et al reported one case, with comedo-like openings, telangiectasias on a whitish-pink background and red-violet to brown-red perifollicular ovoid structures, corresponding to follicular plugging.

In our patients, we observed linear vascular structures, hairpin-like vessels and irregularly distributed black granules, predominantly over whitish areas. Contrasting with the prior descriptions, follicular plugging was discrete. In conclusion, we present a different dermoscopic pattern of extragenital LE, which may aid the clinical diagnosis of this unusual skin disorder.

References

1. MonsÁlvez V, Rivera R, Vanaclocha F. Lichen sclerosus. Actas Dermosifiliogr. 2010;101:31-8.

2. Kimura A, Kambe N, Satoh T, Togawa Y, Suehiro K, Matsue H. Follicular keratosis and bullous formation are typical signs of extragenital lichen sclerosus. J Dermatol. 2010;38:834-6.

3. Farris DR, Hardy D, Kagen MH, Don PC, Weinberg JM. Extragenital pigmented lichen sclerosus. J Eur Acad Dermatol Venereol. 2000;14:322-4.

4. Garrido-RÍos AA, Alvarez-Garrido H, Sanz-MuÑoz C, Aragoneses-Fraile H, Manchado-LÓpez P, Miranda-Romero A. Dermoscopy of extragenital lichen sclerosus. Arch Dermatol. 2009;145:1468.

Double comparison of teledermoscopy: Interobserver variability and relation to histopathology

J. Bandic¹, D. Dobrosavljevic², I. Drljevic³, N. Pesic4, S. Kamberova4, D. Nikolic,1 M. Strbac1, N. Vuckovic5, Z. Janjic5, M. Bandic¹

1 ORS Hospital Belgrade, Belgrade, Serbia; 2 Klinicki Centar Srbije, Beograd, Serbia; 3 Klinicki Centar Univerziteta u Sarajevu, Bosnia and Herzegovina; 4 Klinicki Centar Skopje, Skopje, Macedonia; 5 Klinicki Centar Vojvodine, Novi Sad, Serbia

Introduction: Teledermoscopy, with all its pros and cons, allows for a grand entrance of new perspectives, and not only for Pigmented Skin Lesions (PSL). Regardless of good interobserver concordance, literature still lacks the data about the comparison of teledermoscopic diagnoses to histopathologic (HP) ones.

Method: 5 experts from different centers in Serbia, Bosnia and Herzegovina, and Macedonia are included in the study. During a two-month period, they will establish clinical and dermoscopic diagnoses on 1000 patients with 1000 histologically verified Pigmented Skin Lesions, through use of The Teledermoscopy Network. 1000 PSL contain: 130 melanomas, 230 basal cell carcinomas, 450 melanocytic lesions, 150 seborrheic keratoses, 20 angiomas and 20 dermatofibromas. Each patient has, other than personal, the following data: age, sex, skin phototype and melanoma risk factors. Each lesion has: a clinical image, anatomic localization, ABCDE clinical information and a dermoscopic image.

Design of the study: In the course of 2011 Jadran Bandic has selected the material for the study from the ORS Hospital database in Belgrade. During the period spanning February 1 to April 1 2012, Marijana Bandic will include 20 new cases daily (100 per week, over the course of 10 weeks with week 11 reserved for cases that get left behind for any reason) into The Teledermoscopy Network. Clinical diagnosis will be the one to be established first, with the dermoscopic image being made available for review and diagnosis after the clinical diagnosis has been made. Clinical diagnosis will not be made available for correction.

Results: The study will show results of accordance amongst experts in relation to HP diagnosis, for every PSL type and not only the relation between dermoscopic vs. HP diagnosis, but also relation between clinical and HP diagnosis.

Discussion: We believe that the right path for teledermoscopy is to be directed towards primary healthcare. In order for that path to be realised it is necessary for experts to provide background education and quick an efficient control, until the arrival of an automated process. The validity of this opinion will be pointed out by the expected results.

References

1. Warshaw EM, Lederle FA, Grill JP, et al. Accuracy of teledermatology for pigmented neoplasms. J Am Acad Dermatol. 2009;61:753-65.

2. Tan E, Yung A, Jameson M, et al. Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT). Br J Dermatol. 2010; 162:803-11.

Early melanoma with halo eczema (Meyerson’s phenomenon)

Lisa Byrom1, Karl Rodins2, and Jim Muir3

1 Mackay Base Hospital, Mackay, Australia.; 2 Greenslopes Hospital, Brisbane, Australia; 3 Mater Hospital and private practice, Brisbane, Australia

We present a case of a 49-year-old man who presented with a solitary atypical pigmented lesion with a surrounding halo of dermatitis. Dermoscopy showed a pigment network at the periphery with areas of scar-like depigmentation, negative pigment network and erythema. The lesion was treated preoperatively with a potent topical corticosteroid resulting in a reduction of inflammation. Histology showed an early Clark level 1 melanoma arising within a severely dysplastic compound melanocytic naevus. There was an adjacent perivascular chronic inflammatory cell infiltrate with occasional eosinophils. Minimal, though definite spongiosis with parakeratosis was also present. The scar was subsequently re-excised achieving appropriate excision margins for melanoma in situ. Six months later, there was recurrence of dermatitis at the scar with no evidence of recurrent melanoma. To our knowledge, melanoma with Meyerson phenomenon has not been reported in the literature. This case highlights that all lesions should be evaluated on clinical and dermoscopic grounds regardless of the presence or absence of eczema. Our case adds yet another entity that may display Meyerson phenomenon and consequently a halo of eczema cannot be considered a reassuring sign when evaluating melanocytic lesions.

Analysis of CDKN2A alelic variants in Mexican patients with malignant melanoma: preliminary study

B. Carlos-Ortega1, J. LÓpez-Valdez2,3, G. GÓmez1, H. Urueta-Cuellar4, J. Toral-LÓpez5, L. Marques-Valdemar6, S. Cuevas-Covarrubias4, L. GonzÁlez-Huerta4

1 Centro MÉdico Nacional “La Raza” IMSS, MÉxico; 2 D.F. Hospital Centenario Miguel Hidalgo, Aguascalientes, MÉxico; 3 Universidad CuauhtÉmoc Aguascalientes, Aguascalientes, Mexico; 4 Hospital General de MÉxico, MÉxico; 5 D.F. Centro MÉdico Ecatepec, Cuernavaca, MÉxico; 6 ISSEMyM, Instituto de BiologÍa, UNAM, MÉxico, D.F.

Background: CDKN2A and CK4 are high penetrance genes associated to high risk of melanoma. CDKN2A is a tumor suppressor gene located in 9p21, it is composed by 4 exons, which code for p14 and p16. Isoform p16 acts as a tumour suppressor gene, which binds to CDK4 and CDK6, inhibiting linking with cycline D1, thus avoiding both formation of CDK/cycline d1 complex and cell cycle. CDKN2A is inactivated by some different ways: intragenic mutations, homocygotic deletion and CpG islands hypermetilation on its promoter causing some different neoplasms such as pancreatic adenocarcinoma and malignant melanoma.

Aim: To identify alelic variants which could (or could not) influence risk (predisposition) of MM in Mexican patients.

Materials and methods: Genomic DNA was obtained from peripheral blood samples. Alpha isoform codifying region of CDKN2A was amplified, after that automatized sequenciation in a ABI310 sequencer was performed.

Results: Twenty-eight patients with MM Analysis of codifying and intronic regions of p16 showed 2 polymorphous heterocygotic variants: c.-2G>A in 4 patients with MM and p.I49T in 11 patients with MM. Both variants were also identified in healthy controls.

Conclusions: Our study found 2 different variants in melanoma patients: c.-2G>A which–to our knowledge-has not been reported and p.I49T which partially influences in the binding to cyclin D1-CDK4/6 complex, and inhibition of cellular growth and proliferation. As well as presence of other alelic variants in genes involved in melanoma development, considering also studying influencing environmental factors.

Shiny white streaks in malignant melanoma: a sign of thick tumours

Cristina Carrera, Priscilla Ishioka, Danielle Shitara, Yarel Alonso-Pinedo, Leyla Palacios-Bejarano, Susana Puig, Josep Malvehy

Melanoma Unit, Department of Dermatology, Hospital ClÍnic de Barcelona, IDIBAPS, Barcelona, Spain

CIBER Enfermedades Raras, Instituto de Salud Carlos III, Barcelona, Spain

Introduction: In the context of melanocytic tumours white shiny streaks (SWS) or chrysalides have been related to malignant melanoma. It still remains unclear the biological significance of this dermoscopic criterion.

Methods: Systematic study of SWS in 125 melanomas (56% in situ; 44% invasive with mean Breslow 1.7 mm (48%<1mm)) and 305 melanocytic nevi consecutively excised in a Melanoma Unit of a referral Hospital in Barcelona.

Results: SWS were present in 5 nevi (4.67%) compared to 41 melanomas (38,32%) (24 SSMM (58,5%), 11 LMM (26.8%), 3 NM (7.4%), 3 others (7.3%)). The presence of SWS correlated with a 10.33 fold risk of harboring a diagnosis of invasive melanomas when compared to in situ melanomas (OR: 10.33, IC 95% 3.812-28.014, p<0.005). Among invasive melanoma, SWS had 4.46 fold risk to be thick melanomas (Breslow>1mm) (OR 4.46, IC95% 1.444-13.792 p=0.009). SWS were also observed more frequently in MM with black (p<0.05), gray, white or red colours (p<0.001); structureless area, blue whitish veil, regression, atypical blotch, multicomponent (all p<0.001) or unspecific pattern (p<0,05), polymorphic vessels and milky red globules (both p<0.001) but not with dotted vessels (p =0.792). The mean TDS score for melanomas with SWS was 6.61 and without SWS 5.62 (p<0.05). SWS were also observed in 3 cases with TDS

Conclusions: SWS in the context of a melanocytic tumour is associated to malignancy, and to invasive melanoma, with a higher Breslow thickness and higher TDS. In some few cases the presence of SWS was seen in MM with TDS of benignity.

Use of dermoscopy as aid for the diagnosis of extramammary Paget disease (EMPD), and clinical assessment after brachytherapy

A. M. Carrozzo1, P. Donati2, L. Muscardin2, A. Distefani1,3, C. Cipriani4, F. A. Sedda5

1 Department of Dermatology, University Of Tor Vergata, Rome, Italy; 2 Department of Dermatopathology, Ircss San Gallicano Rome, Italy; 3 Department of Anatomic Pathology, University Of Tor Vergata, Rome, Italy; 4 Department of Nuclear Medicine, S. Eugenio Hospital, Rome, Italy; 5 Department of Uttmat, Enea, Casaccia, Italy

Extramammary Paget’s disease (EMPD) is a rare, usually non-invasive intraepithelial adenocarcinoma, preferentially localized on genitals in postmenopausal women in their sixth-seventh decade of life. EMPD may or may not be associated with an underlying malignancy. The diagnosis is obtained by histopathology and immunohistochemistry. In the last few years, dermoscopy, besides pigmented lesions, has been increasingly employed also for the evaluation of non-pigmented skin tumours and inflammatory diseases, such as for assessment after therapies. We report five cases of EMPD: 4 women and 1 man, aged from 65 to 79 years old, with lesions localized on the vulva, perianal region and glans penis, which we evaluated by dermoscopy. In 5/5 cases, dermoscopic examination revealed a repetitive pattern characterized by a diffuse pinkish background mottled with crimson and bright white irregular structures, grossly mixed together, occasionally forming a sort of thick reticulation; this picture was reminiscent for us of a raspberry slush. In all 5 cases histopathology subsequently confirmed the diagnosis of EMPD. Whereas there is no standard treatment, as alternative to surgery, we treated our patients by superficial brachytherapy. This new therapy, successfully utilized for non-melanocytic skin tumors, basically consists in a superficial high dose brachytherapy, characterized by the use of a radioactive beta-emitting isotope, rhenium188, incorporated in a specially formulated inert synthetic resin. An histological examination confirmed the clinical-dermoscopic healing of our patient’s lesions. Thanks to dermoscopy, we could better identify the extent of the tumor and follow up our patient after therapy.

Imaging of an atypical naevus spilus with in vivo confocal microscopy

E. Coates1,2,4, M. Laing1,3, A. Jopp-McKay3, P. Guitera1,3

1 Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 2 Department of Dermatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 3 Melanoma Institute Australia, Sydney, New South Wales, Australia; 4 University of Sydney, Sydney, New South Wales, Australia

Introduction: A naevus spilus, or speckled lentiginous naevus (SLN), is characterised by darkly pigmented macules or papules on a background of light-brown pigmentation. It is usually present at birth as a “cafÉ-au-lait” macule, with often widespread darker pigmented macules often developing years to decades later. The importance of close follow-up is underlined by case reports of melanoma developing within naevus spili.

Case summary: A 54-year-old lady with no prior melanoma history presented with a pigmented lesion on her lateral thigh present since birth. Clinical examination revealed a 4x5cm cafÉ-au-lait macule with superimposed maculopapular speckles, consistent with naevus spilus. Dermoscopy showed a darker focus within the lesion though no classic melanoma features.

In-vivo reflectance confocal microscopy demonstrated multiple atypical bright large cells with upward migration and a disarranged epidermis consistent with melanoma-in-situ. The remainder of the lesion contained only monomorphous small bright cells organised around a very regular papillae ring. Histopathology of a targeted biopsy taken from the atypical area noted could not exclude a melanoma-in-situ.

Conclusion: Malignant melanoma arising in a naevus spilus is a rare event. The cafÉ-au-lait macule is often present at birth and the darker pigmented speckles that develop subsequently in number and size over many years are challenging to monitor.

In-vivo reflectance confocal microscopy is a well-proven laser imaging technique for pigmented lesions, allowing non-invasive examination of the epidermis. We propose its use in identifying areas of dynamic change in clinically and dermoscopically equivocal lesions, thereby assisting in the early detection of melanoma arising in a naevus spilus.

Melanoma detection in high risk patients: a case series

E. Coates1,2,3, F.J. Moloney1,2,3, P. Guitera1,3, N. Haass1,2,3, K. Ho1, R. Khoury1, G. Mann3,4, S.W. Menzies1,3

1 Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 2 Department of Dermatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 3 University of Sydney, Sydney, New South Wales, Australia; 4 Westmead Millennium Institute, Westmead Hospital, Sydney, New South Wales, Australia

Introduction: Australia has the highest worldwide incidence of cutaneous melanoma. Certain subpopulations are at extreme risk and early detection in this group is critical to reducing disease mortality.

Clinical imaging techniques permit early melanoma diagnosis and improved patient prognosis. Regular patient and doctor examination of total body photography (TBP) baseline images enables identification of changing or new atypical skin lesions.

Sequential digital dermoscopy imaging (SDDI) additionally permits the capture and assessment of successive dermoscopic images over short term (average 3 months) or long-term (≥6 months) intervals to assess for morphological change and permits detection of still featureless incipient melanomas.

Case series: A melanoma case series of extreme risk patients diagnosed with melanoma through SDDI monitoring is presented from a 312 patient cohort managed in the Sydney Melanoma Diagnostic Centre high risk melanoma clinic since 2006.

No classic dermoscopic features were present initially and only minimal changes were noted on SDDI monitoring. These included subtle lesion enlargement, regression and focal change, with the cases representing key diagnostic lessons from this extreme risk patient group.

Conclusion: Early melanoma diagnosis is crucial though can be challenged by the absence of classic diagnostic criteria. This case series reinforces the importance of the role of TBP and SDDI in monitoring patients at extreme risk of melanoma.

Reference

1. Kittler H, Guitera P, Riedl E, et al. Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging. Arch Dermatol. 2005;142(9):1113-9.

Thick melanoma detection in a five-year high risk clinic for primary melanoma

E. Coates1,2,3, F. J. Moloney1,2,3, P. Guitera1,3, N. Haass1,2,3, K. Ho1, R. Khoury1, G. Mann3,4, S. W. Menzies1,3

1 Sydney Melanoma Diagnostic Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 2 Department of Dermatology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; 3 University of Sydney, Sydney, New South Wales, Australia; 4 Westmead Millennium Institute, Westmead Hospital, Sydney, New South Wales, Australia

Introduction: Melanoma thickness is a key determinant in long-term prognosis. Thick melanomas (≥1mm