A. Ferrari

Clinically equivocal melanocytic skin lesions with features of regression: a dermoscopic-pathological study.

Backgroundu2002 Benign melanocytic skin lesions may be difficult to differentiate from melanoma both clinically and dermoscopically. One of the most confounding dermoscopic features, commonly seen in melanoma but in our experience also in melanocytic naevi, is represented by the so‐called blue–white structures (BWS).

Dermoscopic diagnosis by a trained clinician vs. a clinician with minimal dermoscopy training vs. computer-aided diagnosis of 341 pigmented skin lesions: a comparative study

Backgroundu2003In the last few years digital dermoscopy has been introduced as an additional tool to improve the clinical diagnosis of pigmented skin lesions.

Instrument-, age- and site-dependent variations of dermoscopic patterns of congenital melanocytic naevi: a multicentre study

Backgroundu2002 Recently, we identified and described dermoscopic aspects, present with a higher frequency in congenital melanocytic lesions with respect to acquired naevi. We also classified small‐ and medium‐sized congenital naevi (CN) into nine subtypes according to their macroscopic and dermoscopic aspects.

Seven-point checklist of dermoscopy revisited

Backgroundu2002 Most dermoscopic algorithms to diagnose melanoma were established more than 10u2003years ago and have been tested primarily on clear‐cut melanomas and excised melanocytic naevi.

Differentiation between pigmented Spitz naevus and melanoma by digital dermoscopy and stepwise logistic discriminant analysis

Epiluminescence light microscopy (ELM) has proven useful in the diagnosis of pigmented skin lesions (PSLs). However, in some cases this technique does not sufficiently increase the diagnostic accuracy in distinguishing pigmented Spitz naevi (PSNs) from melanoma. With the aim of obviating these problems of qualitative interpretation, methods based on the mathematical analysis of PSLs, such as digital dermoscopy analysis (DDA), have recently been developed. In the present study we used a digital dermoscope (DBDermo-MIPS, DellEva-Burroni) to analyse PSNs and melanomas with similar clinical and dermoscopic features for any correlation between variables and to determine its discriminating power with respect to histological diagnosis. The 100 lesions underwent histological examination by three experienced dermatopathologists and were identified as PSNs (43) or melanomas (57). Thirty-six parameters were identified as possible discriminating variables and were grouped in four categories: geometry, colour, texture, and islands of colour. Statistical analysis was used to identify the variables with the highest discriminating power. Stepwise discriminant analysis selected only four variables: entropy, minimum diameter, red lesion value and peripheral dark (the means of these variables were higher in melanomas than in PSNs). Thus the combined use of digital dermoscopy and stepwise logistic discriminant analysis made it possible to single out the best objective variables for distinguishing PSN and melanoma.

A 9‐month, randomized, assessor‐blinded, parallel‐group study to evaluate clinical effects of film‐forming medical devices containing photolyase and sun filters in the treatment of field cancerization compared with sunscreen in patients after successful photodynamic therapy for actinic keratosis

DEAR EDITOR, Actinic keratosis (AK) is a precancerous lesion caused by chronic exposure to sunlight. Photodynamic therapy (PDT) is a well-established therapeutic approach for the treatment of AK. PDT is effective in clearance of AK lesions and improving field cancerization. However, > 20% of patients need a second procedure in the following months after the first treatment. After PDT, sun protection strategies are important in order to reduce the risk of new lesions or the need for another session of PDT. A film-forming medical class II device containing photolyase, a DNA-repairing enzyme with a broad photoprotection action (Eryfotona AK-NMSC Fluid; Isdin, Barcelona, Spain), has been shown, in open clinical studies, to induce both subclinical and clinical improvements in patients with AK. This product seems to be more effective than sunscreen products in improving clinical outcomes (clearance of AK lesions) and field cancerization. So far, there are no published controlled data regarding the use of Eryfotona vs. sunscreen in patients with AK after successful PDT treatment. We assessed the efficacy of Eryfotona vs. sunscreen in the development of new AKs in patients with AK after successful PDT. In a prospective, two-arm, parallel-group, 9-month, assessor-blinded, comparative trial, immunocompetent patients between the age of 40 and 85 years with multiple AKs of the face and/or scalp suitable for PDT treatment, were enrolled. This study (clinical trial number: ISRCTN12347628) was conducted between January 2014 and June 2015. After obtaining institutional review board approval and written informed consent from the participants, 30 patients (22 men; mean age 69 years) with a total of 225 AK lesions (7 5 lesions per patient) were included. Exclusion criteria were age < 18 or > 75 years, presence of skin tumours, xeroderma pigmentosum and a history of skin conditions other than AK which might interfere with the study evaluations. Patients were randomized 1 : 1 to Eryfotona (n = 15) or to sunscreen (n = 15) Sunscrean SPF 50+ (Fotoprotector, ISDIN, Barcelona, Spain). The primary outcome of the study was the evolution of new AK lesions in the previous PDT-treated area or in another area. The secondary outcome of the study was the need to perform new PDT or other lesion-targeted or field-cancerization targeted therapies. Eryfotona or sunscreen were applied in the treatment evaluation area (scalp and face) for nine consecutive months, in the morning and 4–6 h later. For each application, patients were instructed to apply a total of 2 5 fingertip units for both products. All patients completed the trial. Table 1 summarizes the patient demographics and AK characteristics at baseline. At baseline, the mean SD number of AK lesions was 6 6 2 8 in the Eryfotona group and 8 4 3 0 in the sunscreen group. All patients underwent one standardized session of methylaminolaevulinate PDT using a 630-nm light-emitting diode lamp at 37 J cm . Immediately after PDT (evaluation performed 2 weeks after the procedure) mean SD residual lesions were 2 0 2 0 in the Eryfotona group and 0 6 0 5 in the sunscreen group (nonsignificant). A progressive increase of AK lesions was observed in the sunscreen group, with a mean SD number of lesions of 3 6 3 8 at the end of study period (month 9). In contrast, a significant reduction of AK lesions was observed at month 9 in patients in the Eryfotona group, with a mean SD number of lesions of 1 0 1 1 in comparison with baseline and with the comparator group (P < 0 01). Evolution of new AK lesions after PDT is shown in Figure 1. In the sunscreen group, 13 of 15 patients (87%) presented new AK lesions during the study: in 10 patients new lesions appeared in the area previously treated

A 9-month, randomized, assessor-blinded parallel-group study to evaluate clinical effects of a film-forming medical devices containing photolyase and sun-filters in the treatment of cancerization field in comparison with sunscreen in patients after successful PDT for Actinic Keratosis.

DEAR EDITOR, Actinic keratosis (AK) is a precancerous lesion caused by chronic exposure to sunlight. Photodynamic therapy (PDT) is a well-established therapeutic approach for the treatment of AK. PDT is effective in clearance of AK lesions and improving field cancerization. However, > 20% of patients need a second procedure in the following months after the first treatment. After PDT, sun protection strategies are important in order to reduce the risk of new lesions or the need for another session of PDT. A film-forming medical class II device containing photolyase, a DNA-repairing enzyme with a broad photoprotection action (Eryfotona AK-NMSC Fluid; Isdin, Barcelona, Spain), has been shown, in open clinical studies, to induce both subclinical and clinical improvements in patients with AK. This product seems to be more effective than sunscreen products in improving clinical outcomes (clearance of AK lesions) and field cancerization. So far, there are no published controlled data regarding the use of Eryfotona vs. sunscreen in patients with AK after successful PDT treatment. We assessed the efficacy of Eryfotona vs. sunscreen in the development of new AKs in patients with AK after successful PDT. In a prospective, two-arm, parallel-group, 9-month, assessor-blinded, comparative trial, immunocompetent patients between the age of 40 and 85 years with multiple AKs of the face and/or scalp suitable for PDT treatment, were enrolled. This study (clinical trial number: ISRCTN12347628) was conducted between January 2014 and June 2015. After obtaining institutional review board approval and written informed consent from the participants, 30 patients (22 men; mean age 69 years) with a total of 225 AK lesions (7 5 lesions per patient) were included. Exclusion criteria were age < 18 or > 75 years, presence of skin tumours, xeroderma pigmentosum and a history of skin conditions other than AK which might interfere with the study evaluations. Patients were randomized 1 : 1 to Eryfotona (n = 15) or to sunscreen (n = 15) Sunscrean SPF 50+ (Fotoprotector, ISDIN, Barcelona, Spain). The primary outcome of the study was the evolution of new AK lesions in the previous PDT-treated area or in another area. The secondary outcome of the study was the need to perform new PDT or other lesion-targeted or field-cancerization targeted therapies. Eryfotona or sunscreen were applied in the treatment evaluation area (scalp and face) for nine consecutive months, in the morning and 4–6 h later. For each application, patients were instructed to apply a total of 2 5 fingertip units for both products. All patients completed the trial. Table 1 summarizes the patient demographics and AK characteristics at baseline. At baseline, the mean SD number of AK lesions was 6 6 2 8 in the Eryfotona group and 8 4 3 0 in the sunscreen group. All patients underwent one standardized session of methylaminolaevulinate PDT using a 630-nm light-emitting diode lamp at 37 J cm . Immediately after PDT (evaluation performed 2 weeks after the procedure) mean SD residual lesions were 2 0 2 0 in the Eryfotona group and 0 6 0 5 in the sunscreen group (nonsignificant). A progressive increase of AK lesions was observed in the sunscreen group, with a mean SD number of lesions of 3 6 3 8 at the end of study period (month 9). In contrast, a significant reduction of AK lesions was observed at month 9 in patients in the Eryfotona group, with a mean SD number of lesions of 1 0 1 1 in comparison with baseline and with the comparator group (P < 0 01). Evolution of new AK lesions after PDT is shown in Figure 1. In the sunscreen group, 13 of 15 patients (87%) presented new AK lesions during the study: in 10 patients new lesions appeared in the area previously treated

Histopathologic interobserver agreement on the diagnosis of melanocytic skin lesions with equivocal dermoscopic features: a pilot study

Aims and background Dermoscopy (dermatoscopy, skin surface microscopy, epiluminescence microscopy) has been increasingly employed in recent years for the preoperative detection of cutaneous melanoma, and dermatoscopic features of pigmented skin lesions have been previously defined using histopathology (HP) as the “key to the code”. The aim of the present study was to evaluate the interobserver agreement on the HP diagnosis in a series of epiluminescence microscopy equivocal melanocytic skin lesions. Study design Ten melanocytic skin lesions were selected on the basis of diagnostic disagreement of at least 2 out of 9 epiluminescence microscopy observers. The histologic specimens from the 10 lesions were examined by 9 HP observers. The agreement of the HP diagnoses was calculated by means of Fleiss k statistics. Results The overall HP agreement was less than excellent (k = 0.5). When considering the prevailing epiluminescence microscopic and HP diagnoses, 2 cases were shown to be epiluminescence microscopy false-negative melanomas. Virtually no agreement was found among epiluminescence microscopy observers in 4 cases (40%) or among HP observers in 3 cases (30%). However, only one pigmented skin lesion remained un-classifiable on epiluminescence microscopy as well as HP. Conclusions When at least 2 epiluminescence microscopy experts disagree in the evaluation of a given melanocytic skin lesion, even HP consultations may give equivocal results. The need to establish more reliable epiluminescence microscopic and HP criteria by performing an improved and meticulous clinicopathologic correlation, e.g. by using telecommunication via Internet, is emphasized.

Noninvasive assessment of benign pigmented genital lesions using reflectance confocal microscopy

DEAR EDITOR, Pigmented genital lesions include a wide variety of disorders such as melanocytic tumours (naevi, melanoma), epithelial hyperpigmentation without prominent melanocytic hyperplasia (genital melanosis, lentigo and postinflammatory pigmentation) and nonmelanocytic lesions (vulvar intraepithelial neoplasia, seborrhoeic keratosis, angiokeratoma). Genital melanosis presents as single or multiple macules with variable size and colour, and arises commonly on the labia minora, or on the glans penis in male subjects. The possibility of malignant transformation of genital melanosis remains unclear. Generally, genital naevi are pigmented and show typical dermoscopic and histopathological features. However, atypical melanocytic naevus of the genital type (AMNGT), a small subset of melanocytic lesions, shares clinical and histological features overlapping those of melanoma. Melanomas of the glans penis and vulva are rare (1–7% of all melanomas), and the only curative treatment is immediate surgery after early detection. Genital melanomas are usually asymptomatic in the early stage and are discovered during routine gynaecological and dermatological examination, as well as self-examination. Therefore, in such cases the ABCDE rule (asymmetry, border, colour, diameter, evolution) cannot be applied. The value of dermoscopy in pigmented skin lesions compared with Table 1 Reflectance confocal microscopy features, their incidence in all cases and P-values