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PubMedDate not supplied

Changing paradigms in dermatology: new ways to examine the skin using noninvasive imaging methods.

Detailed visualization of the skin in the practice of dermatology is key to a comprehensive examination and accurate diagnosis. Advancements in digital dermoscopy, microscopy, imaging and photography have formed an impressive arsenal with which dermatologists can offer state-of-the-art patient care while streamlining their clinical practice and improving their academic and research capacities. Many types of advanced imaging are used in the biologic sciences at the bench; however, our paper reviews the clinical, noninvasive in vivo human applications of these emerging technologies. Our experiences with these instruments reinforce such reviews.

Dermatology↗

PubMed2003

Adoption of new technologies for early detection of melanoma in dermatologic practice.

The identification and diagnosis of early melanoma will reduce unnecessary operations and may be important in reducing mortality from melanoma and impacting cost savings to the health system. New technologies are being developed and used at some specialized centers to facilitate the detection and diagnosis of early melanoma for patients at high risk. These technologies include but are not limited to digital photography, dermoscopy, computerized image analysis systems, and confocal scanning laser microscopy. To most effectively implement these novel approaches, it is important to identify the key factors that influence the adoption or diffusion of new medical technologies. We propose patient-, physician-, and health care system-related factors that influence the diffusion of new technologies for the early detection of skin cancer. Studies involving physicians and patients in a variety of clinical settings need to be conducted to achieve a greater understanding of the barriers to the adoption of these new technologic tools that are intended to aid in skin cancer screening.

Dermatology↗

PubMed1997

Influence of UVB therapy on dermoscopic features of acquired melanocytic nevi.

BACKGROUND: Exposure to UV radiation can lead to clinical, histologic, and ultrastructural changes in acquired melanocytic nevi. OBJECTIVE: We investigated whether UVB therapy can induce changes in melanocytic nevi detectable by dermoscopy. METHODS: Eighty acquired melanocytic nevi of 13 patients (10 females, 3 males; mean age, 28 years; range, 13 to 62 years) undergoing UVB therapy were documented under standardized conditions by means of a Dermaphot apparatus before and at the end of suberythemal UVB therapy. The mean duration of therapy was 8 weeks (range, 2 to 17 weeks) and the mean total UVB dose was 1120 mJ/cm2 (range, 247 to 2771 mJ/cm2). During UV irradiation, 40 nevi were left unprotected and 40 nevi were protected from UV exposure in a randomized manner. Color dermoscopic images of nevi before and after UVB therapy were projected side by side and examined blindly by five investigators. Fifteen different features were evaluated in the nevi. RESULTS: Unprotected nevi became more irregular (p < or = 0.01) and darker brown (p < or = 0.03) by the end of the therapy, whereas the protected nevi showed no significant changes. CONCLUSION: Suberythemal UVB therapy can lead to changes in the dermoscopic image of acquired melanocytic nevi, presumably by activating melanocytes.

Adolescent↗

PubMed2002

The dilemma of the dysplastic nevus.

There are few areas in dermatology that provoke as much controversy as dysplastic nevus. Over the past decade, there have been significant strides made in terms of understanding the biology and etiology of the lesion. Distinct and reliable clinical and histologic features have been delineated. In this article, the management of patients with dysplastic nevi and the role for dermoscopy, photographic surveillance, genetic mapping and counseling, chemoprevention, and nevi removal are discussed.

Diagnosis, Differential↗

PubMed2001

Typical dermoscopic patterns of benign melanocytic nevi.

Dermoscopy often is an effective diagnostic tool for differentiating benign and malignant pigmented skin lesions. The observed dermoscopic structures and patterns of lesions provide valuable sources of information that are not accessible by routine clinical examination. Recognition and interpretation of these dermoscopic structures and patterns require training and experience. Mentioned here are some fundamental guidelines for differentiating malignant and benign lesions. Some of the classic patterns associated with a list of benign melanocytic nevi also have been illustrated. Additional research is needed to identify other patterns of these benign lesions. More importantly, analysis of the prevalence of various patterns associated with the various benign lesions will be helpful to clinicians having the responsibility of making in vivo diagnoses of benign compared with malignant melanocytic neoplasms.

Dermatology↗

PubMed2001

Seborrheic keratoses, solar lentigines, and lichenoid keratoses. Dermatoscopic features and correlation to histology and clinical signs.

Evaluation of the three benign lesions discussed here form the basis for dermoscopic evaluation of other pigmented skin lesions. The features of seborrheic keratosis, including [figure: see text] the various forms of fissures, comedo-like openings, and milia-like cysts, often allow easy interpretation of seborrheic keratosis; however, similar structures are commonly associated with melanocytic neoplasms, notably congenital nevi. Understanding solar lentigo and its dermoscopy features allows for the appreciation of pigment networks common in lentiginous melanocytic nevi and melanoma. The lichenoid keratosis is the model for lichenoid inflammation elsewhere, notably in halo nevi, regressing melanoma, and other melanocytic neoplasms with significant host inflammatory reactions.

Dermatology↗

PubMed1999

[Clinical differential diagnosis of pigmented skin changes and contribution of epiluminescence microscopy].

The differential diagnosis of skin pigmented lesions is an everyday challenge for the physician. The main goal is the early diagnosis of malignant melanoma because its prognosis is directly correlated with its thickness at the time of the excision. Identification criterion of invasive melanoma have been recognized in the past, like bleeding or ulceration. More subtle clinical criterion have been identified and are summarized in the ABCDE rule (Asymmetry, irregular Border, variegation in Colour, Dimension and Enlargement). A knowledge of the various kind of skin pigmented lesions should help the physician to differentiate benign lesions from suspicious or frankly malignant ones, in order to set up the indication for an histological procedure or for a subsequent follow-up of the patient. More recently, skin surface biomicroscopy, or dermoscopy, has revealed invisible structures to naked eye, allowing to enhance the clinical diagnosis of skin pigmented lesions, but a specific education is needed.

Diagnosis, Differential↗

PubMed2000

Detection of solid pigment in dermatoscopy images using texture analysis.

BACKGROUND/AIMS: Epiluminescence microscopy (ELM), also known as dermoscopy or dermatoscopy, is a non-invasive, in vivo technique, that permits visualization of features of pigmented melanocytic neoplasms that are not discernable by examination with the naked eye. ELM offers a completely new range of visual features. One such feature is the solid pigment, also called the blotchy pigment or dark structureless area. Our goal was to automatically detect this feature and determine whether its presence is useful in distinguishing benign from malignant pigmented lesions. METHODS: Here, a texture-based algorithm is developed for the detection of solid pigment. The factors d and a used in calculating neighboring gray level dependence matrix (NGLDM) numbers were chosen as optimum by experimentation. The algorithms are tested on a set of 37 images. A new index is presented for separation of benign and malignant lesions, based on the presence of solid pigment in the periphery. RESULTS: The NGLDM large number emphasis N2 was satisfactory for the detection of the solid pigment. Nine lesions had solid pigment detected, and among our 37 lesions, no melanoma lacked solid pigment. The index for separation of benign and malignant lesions was applied to the nine lesions. We were able to separate the benign lesions with solid pigment from the malignant lesions with the exception of only one lesion, a Spitz nevus that mimicked a malignant melanoma. CONCLUSION: Texture methods may be useful in detecting important dermatoscopy features in digitized images and a new index may be useful in separating benign from malignant lesions. Testing on a larger set of lesions is needed before further conclusions can be made.

Journal Article↗

PubMed2002

The gold standard for photographing pigmented skin lesions for diagnostic purposes: contact versus distant imaging.

BACKGROUND: It is mandatory that a new diagnostic method be validated by comparison with a well-established reference procedure before being introduced for use in clinical practice. In the field of pigmented skin lesions (PSL), clinical examination should be considered the reference procedure for new diagnostic methods, such as dermoscopy. However, it has not yet been established which is the best photographic procedure for obtaining the most informative clinical images to be used in a formal diagnostic setting. METHODS: In this study we investigated the diagnostic information provided by the two most popular methods currently used for clinical photographing of PSL: "contact" images obtained with a Dermaphot (Heine Ltd) at original x 10 magnification without oil application and "distant" images obtained with a macro objective from a distance of 10 cm. RESULTS: Two experienced dermatologists observed clinical images of a series of 57 PSL (11 melanomas, 31 melanocytic nevi, 10 pigmented basal cell carcinomas, and four other diagnoses). The degree of concordance between the diagnoses based on "contact" and "distant" images (melanoma/non-melanoma) was very good (k = 0.819). Regarding histology, the degree of concordance was better when the diagnosis was based on "contact" images (k = 0.54) than "distant" images (k = 0.47). In particular, "contact" images were superior to "distant" images for diagnosis of non-melanoma lesions (specificity of melanoma diagnosis 87.7% vs. 83.6%), but we found no difference in melanoma detection (73% of sensitivity for both methods). CONCLUSIONS: Although the two photographic procedures appear to provide similar levels of diagnostic information, the "contact" method seems to provide a higher specificity for melanoma diagnosis.

Basal Cell Carcinoma↗

PubMed2003

A beneficial effect of a short-term formal training course in epiluminescence microscopy on the diagnostic performance of dermatologists about cutaneous malignant melanoma.

BACKGROUND: Epiluminescence microscopy (ELM) is a useful tool, which, in the hands of experienced dermatologists successfully helps in the diagnosis of early cutaneous malignant melanoma (CMM). As all imaging diagnostic methods, ELM also requires preliminary training of the physicians. OBJECTIVE: The aim of the study was to evaluate a possible beneficial effect of a short-term formal training course in ELM on the diagnostic performance of dermatologists about CMM. METHODS: The test group consisted of 32 dermatologists. Tests were performed in the beginning and in the end of the teaching course. Every time a total 50 histologically proven pigmented skin lesions (PSLs) photographed without oil immersion-Surface microscopy (SM) and with oil immersion-ELM was presented by slide projection. To assess the effect on the diagnostic performance before and after short- term training the data concerning diagnoses were analysed for the following: sensitivity, specificity, positive predictive value, and negative predictive value, index of suspicion and diagnostic accuracy. RESULTS: Before the training course the implementation of ELM leads to relative increasing of all studied indicators of ELM diagnosis towards SM diagnosis, but differences are not statistically significant (P > 0.05). After the course there is an improvement of diagnostic performance of dermatologists by ELM, manifested by enhancement of all indicators. The changes of the sensitivity, negative predictive value and diagnostic accuracy of ELM diagnosis was statistically significant (P < 0.05). CONCLUSION: The short-term formal course in ELM has a beneficial effect on the diagnostic performance of dermatologists about CMM. The improvement of early detection of CMM requires dermatologists enhanced training and higher qualification in the field of dermoscopy.

Clinical Competence↗

PubMed2005

In vivo assessment of melanocytic nests in nevi and melanomas by reflectance confocal microscopy.

In vivo reflectance confocal microscopy is a novel technique for the noninvasive study and diagnosis of the skin. The aim of this study was to describe and characterize the cytological and architectural aspects of cell clusters in melanocytic lesions observed by confocal microscopy, and to correlate them with routine histopathology. A total of 55 melanocytic lesions comprising 20 melanomas, 25 acquired nevi and 10 Spitz nevi were studied by means of reflectance confocal microscopy, dermoscopy and routine histopathology. Three different types of cell clusters at confocal microscopy observation (dense, sparse cell and cerebriform clusters) were identified and correlated with histopathology. Dense clusters appeared characteristic for benign lesions, although present in 13 out of 20 melanomas. Sparse cell clusters were more frequently observable in melanomas, but also sporadically present in one Spitz nevus. Moreover, cerebriform clusters were exclusively observed in five out of 20 melanomas. Confocal microscopy allowed the in vivo characterization of aspects of melanocytic nests and their exact correlation with histopathology.

Humans↗

PubMed1999

Dermatoscopic pitfalls in differentiating pigmented Spitz naevi from cutaneous melanomas.

Epiluminescence microscopy (ELM, skin surface microscopy, dermoscopy, dermatoscopy) is a valuable method for improving the diagnostic accuracy in pigmented skin lesions. Specific ELM criteria are already recognized for differentiating pigmented Spitz naevi (PSN) from cutaneous melanomas (CM). Our purpose was to describe the ELM appearance of a series of PSN with emphasis on PSN and CM with overlapping features. Thirty-six consecutive patients with PSN, and three cases of CM (selected from a larger database) exhibiting ELM 'spitzoid' features, were evaluated clinically, dermatoscopically and histopathologically. Most PSN (27 of 36; 75%) displayed two typical ELM patterns, namely, the starburst (19 of 36; 53%) or the globular pattern (eight of 36; 22%), which were correlated to different histopathological findings. In nine of 36 (25%) PSN, atypical ELM features which are more commonly seen in CM were observed. These PSN with an atypical pattern were characterized by an uneven distribution of colours and structures, and an irregular diffuse pigmentation resembling blue-white veil or irregular extensions (black blotches). These atypical lesions mostly occurred in children and showed no history of growth. In contrast, in three examples of CM, the typical ELM criteria of malignancy were less recognizable and either the characteristic starburst or globular pattern usually seen in PSN was present. These three lesions occurred in adults and had a recent history of change in colour, shape or size. The overlap in ELM features of some PSN and CM represents a major diagnostic pitfall when ELM examination is considered alone. In these atypical cases, clinical history including the age of the patient may be the only clue to enable a correct diagnosis.

Adolescent↗

PubMed2000

Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy.

BACKGROUND: Skin surface microscopy (oil epiluminescence microscopy, dermoscopy, dermatoscopy) has been shown to increase the diagnostic accuracy of melanoma. However, all studies to date have been in an expert setting. OBJECTIVES: To determine whether primary care physicians (PCP) (general practitioners) could improve their melanoma diagnosis using surface microscopy after a short education intervention. METHODS: Seventy-four practising PCP completed a pretest of 50 melanomas and 50 atypical non-melanoma pigmented skin lesions (PSL) containing matched clinical and surface microscopy photographs. PCP were randomized between a surface microscopy education intervention or control group, followed by an identical post-test. RESULTS: Following training there was a significant improvement in the post-test vs. pretest in both clinical melanoma diagnosis (62.7% vs. 54.6%; P = 0.007) and surface microscopy melanoma diagnosis (75.9% vs. 57.8%; P = 0.000007). No difference was found in the control group between the post-test vs. pretest clinical melanoma diagnosis (53.7% vs. 50.6%; P = 0.21) or the surface microscopy melanoma diagnosis (54.8% vs. 52.9%; P = 0.56). Following training there was a significant improvement in the diagnosis of melanoma using surface microscopy vs. clinical diagnosis (75.9% vs. 62.7%; P = 0.000007), which was absent in the control group (54.8% vs. 53.7%; P = 0.59). No significant difference was found in clinical vs. surface microscopy post-test results for non-melanoma PSL in either the intervention group or control group. Improvement in the sensitivity for the diagnosis of melanoma with surface microscopy was seen without a decrease in specificity; this indicated that the effect should occur without increasing the number of needless excisions. CONCLUSIONS: All PCP in countries where melanoma leads to significant mortality should be trained in skin surface microscopy.

Clinical Competence↗

PubMed2003

Long-term dermoscopic follow-up of melanocytic naevi: clinical outcome and patient compliance.

BACKGROUND: Digital dermoscopy for the follow-up of melanocytic naevi (MN) is becoming more common in dermatological private practice. OBJECTIVES: To evaluate the clinical outcome, including the patient's compliance, in a long-term follow-up of single MN. METHODS: Criteria for the selection of MN for follow-up: clinically suspicious without dermoscopically atypical features, or typical for the patient. Clinical outcome measures: number of detected malignant melanomas (MM) and/or atypical MN; quantity, quality, and differences in morphological changes between 'low-risk' patients (no MM in history and < 50 MN) and 'high-risk' patients (MM in history and/or > 50 MN). Compliance: the number of patients who joined a recommended follow-up scheme. RESULTS: No MM was found in 145 consecutive patients (mean age 28 years, 54% female) during a 4-year period (median follow-up per patient: 24 months; ranging 4-45; at least three visits). In five patients (3%), seven histologically proven atypical MN were shown on whole body examination at sites other than those documented. A total of 1968 images in 177 'low-risk' and 95 'high-risk' MN were analysed: 37% (n = 65) of 'low-risk' and 32% (n = 30) of 'high-risk' MN showed dermoscopic changes (difference not statistically significant), none were suspicious for MM. Compliance, evaluated within a separate database of 303 consecutive patients (mean age 32 years, 52% female) over a 6-month period, was only 46%, although recall letters were used. CONCLUSIONS: (i) In our setting of daily routines in dermatological private practices long-term follow-up of a single MN seems not to be helpful for the detection of MM. (ii) A whole body examination must be done at each visit. (iii) The clinician's experience of the type and number of possible morphological changes in MN is crucial in order to avoid unnecessary excisions. (iv) The patient's compliance might be an important problem. (v) Cost-effectiveness has yet to be analysed.

Adult↗

PubMed2003

Cutaneous endometriosis: non-invasive analysis by epiluminescence microscopy.

The clinical appearance of cutaneous endometriosis can share some features with malignant melanoma, thus representing a possible cause for concern in both patient and clinician. In recent years, the use of epiluminescence microscopy (ELM, dermoscopy) has proved useful in improving the accuracy of diagnosis of pigmented skin lesions. The purpose of this study was to analyse the dermoscopic features of cutaneous endometriosis with histopathological correlation. We studied a case which showed homogeneous reddish pigmentation, regularly distributed. Within this typical pigmentation there were small red globular structures, but more defined and of a deeper hue, which we called 'red atolls'. ELM thus revealed a distinctive pattern in cutaneous endometriosis.

Adult↗

PubMed2002

Interobserver agreement on dermoscopic features of pigmented basal cell carcinoma.

BACKGROUND: A dermoscopic method based on the absence of a pigment network and the presence of at least one of six positive features has been described for diagnosis of pigmented basal cell carcinoma (BCC). OBJECTIVE: To evaluate the observers' global agreement and interobserver agreement on each dermoscopic parameter of the method recently proposed. METHODS: Dermoscopic images of 56 pigmented BCCs were examined by five observers with different degrees of experience in dermoscopy. RESULTS: An overall full agreement was reached for the absence of pigment network (k = 1). Very good agreement was detected for the presence of spoke wheel areas (k = 0.85) and arborizing vessels (k = 0.72), and good agreement was shown for ulceration (k = 0.49) and multiple blue-gray globules (k = 0.41). No agreement was identified on large blue-gray ovoid nests (k = 0.28) and leaflike areas (k = 0.26). CONCLUSION: We confirm the reproducibility of the method and show that ulceration, spoke wheel areas, and arborizing tel- angiectases represent the most robust positive parameters.

Basal Cell Carcinoma↗

PubMed2002

Pitfall in pigmentation: pseudopods in the nail plate.

BACKGROUND: We present here a patient with an unusual type of nail plate pigmentation featuring pseudopod formation. OBJECTIVE: To identify additional dermoscopic criteria. METHODS: Dermoscopy of the nail with control biopsy. RESULTS: Pseudopods of the nail resulted from erythrocytes entrapped between the layers of the nail plate. CONCLUSION: Pseudopod formation of the nail may represent a diagnostic criterion to distinguish hemorrhage and melanoma of the nail apparatus.

Biopsy↗

PubMed2001

Pointillist nevi.

BACKGROUND: Atypical melanocytic nevi and cutaneous melanoma are often marked by variation in color. However, there are examples of "benign" explanations for irregularities in pigmentation, such as perifollicular hypopigmentation or hyperpigmentation. OBJECTIVE: The purpose of this study was to correlate the clinical and histologic features of 3 unusual melanocytic nevi consisting exclusively of multiple, tiny, dark brown to black dots on a skin-colored background, which we have termed pointillist nevi. METHODS: Histologic examination was performed of the single pointillist nevus from each of 3 patients (all women; aged 28, 39, and 47 years). RESULTS: The diameters of the pointillist nevi were 2, 3.5, and 5.5 mm. Individual dots were approximately 0.1-0.25 mm. Each of the 3 nevi showed a different histologic correlate for the dots, either (1) discrete, densely pigmented, junctional melanocytic nests; (2) isolated dermal pigmented melanocytic nests; or (3) discrete clusters of melanophages in the papillary dermis. CONCLUSION: Pointillist nevi are benign melanocytic nevi with histologic correlates similar to those of the "brown globules" observed by dermoscopy in uniformly pigmented nevi. However, the dots seen in pointillist nevi can be visualized without magnification. The clinical and histologic features of pointillist nevi add to the spectrum of unusual patterns of pigmentation that may be encountered in benign melanocytic lesions.

Adult↗