Alex Llambrich

Dermoscopic Evaluation of Amelanotic and Hypomelanotic Melanoma

OBJECTIVE To determine the predictive dermoscopic features of amelanotic and hypomelanotic melanoma. DESIGN A total of 105 melanomas (median Breslow thickness, 0.76 mm), 170 benign melanocytic lesions, and 222 nonmelanocytic lesions lacking significant pigment (amelanotic, partially pigmented, and light colored) were imaged using glass-plate dermoscopy devices and scored for 99 dermoscopic features. Diagnostic models were derived from and tested on independent randomly selected lesions. SETTING Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES Sensitivity, specificity, and odds ratios for individual features and models for the diagnosis of melanoma and malignancy. RESULTS The most significant negative predictors of melanoma were having multiple (>3) milialike cysts (odds ratio, 0.09; 95% confidence interval, 0.01-0.64), comma vessels with a regular distribution (0.10; 0.01-0.70), comma vessels as the predominant vessel type (0.16; 0.05-0.52), symmetrical pigmentation pattern (0.18; 0.09-0.39), irregular blue-gray globules (0.20; 0.05-0.87), and multiple blue-gray globules (0.28; 0.10-0.81). The most significant positive predictors were having a blue-white veil (odds ratio,13; 95% confidence interval, 3.9-40.0), scarlike depigmentation (4.4; 2.4-8.0), multiple blue-gray dots (3.5; 1.9-6.4), irregularly shaped depigmentation (3.3; 2.0-5.3), irregular brown dots/globules (3.2; 1.8-5.6), 5 to 6 colors (3.2; 1.6-6.3), and predominant central vessels (3.1; 1.6-6.0). A simple model distinguishing melanomas from all nonmelanomas had a sensitivity of 70% and a specificity of 56% in the test set. A model distinguishing all malignant lesions from benign lesions had a sensitivity of 96% and a specificity of 37%. Conclusion Although the diagnostic accuracy of dermoscopy for melanoma lacking significant pigment is inferior to that of more pigmented lesions, features distinguishing the former from benign lesions can be visualized on dermoscopic evaluation.

Dermoscopy of Dermatofibromas: A Prospective Morphological Study of 412 Cases

OBJECTIVE To describe the dermoscopic features, including vascular structures and patterns associated with dermatofibromas in a large series of cases. DESIGN Digital dermoscopic images of the prospectively collected dermatofibromas were evaluated for the presence of multiple structures and patterns. SETTINGS Dermatofibromas were collected in the Departments of Dermatology of the Hospital de Sant Pau i Santa Tecla, Tarragona, Spain, and Hospital de Sant Llatzer, Palma de Mallorca, Spain. PATIENTS A total of 412 dermatofibromas (from 292 patients) with complete documentation were collected. MAIN OUTCOME MEASURES Frequency and intraobserver and interobserver agreement of the dermoscopic structures and patterns in dermatofibromas. RESULTS A total of 19 morphological dermoscopic structures were evaluated. Pigment network was observed in 71.8% (3% atypical pigment network), white scarlike patch in 57.0%, and a white network in 17.7%. Different vascular structures were observed in 49.5% (dotted vessels in 30.6%). Ten dermoscopic patterns were observed. The most common pattern seen in our series (34.7% of cases) was central white patch and peripheral pigment network, but in 65.3% of the cases, dermatofibromas presented different patterns including simulators of melanoma. CONCLUSION The most common pattern associated with dermatofibroma is the classic dermoscopic pattern (pigment network and central white patch), but this tumor has a wide range of presentations.

Dermoscopy of cutaneous leishmaniasis

Summary Background Dermoscopy has been proposed as a diagnostic tool in the case of skin infections and parasitosis but no specific dermoscopic criteria have been described for cutaneous leishmaniasis (CL).

Dermoscopy of pyogenic granuloma: a morphological study

Background  Pyogenic granuloma is a common, benign, vascular lesion of the skin and mucous membranes which is a simulator of amelanotic/hypomelanotic melanoma and other tumours.

Dermoscopic evaluation of nodular melanoma

IMPORTANCE Nodular melanoma (NM) is a rapidly progressing potentially lethal skin tumor for which early diagnosis is critical. OBJECTIVE To determine the dermoscopy features of NM. DESIGN Eighty-three cases of NM, 134 of invasive non-NM, 115 of nodular benign melanocytic tumors, and 135 of nodular nonmelanocytic tumors were scored for dermoscopy features using modified and previously described methods. Lesions were separated into amelanotic/hypomelanotic or pigmented to assess outcomes. SETTING Predominantly hospital-based clinics from 5 continents. MAIN OUTCOME MEASURES Sensitivity, specificity, and odds ratios for features/models for the diagnosis of melanoma. RESULTS Nodular melanoma occurred more frequently as amelanotic/hypomelanotic (37.3%) than did invasive non-NM (7.5%). Pigmented NM had a more frequent (compared with invasive non-NM; in descending order of odds ratio) symmetrical pigmentation pattern (5.8% vs 0.8%), large-diameter vessels, areas of homogeneous blue pigmentation, symmetrical shape, predominant peripheral vessels, blue-white veil, pink color, black color, and milky red/pink areas. Pigmented NM less frequently displayed an atypical broadened network, pigment network or pseudonetwork, multiple blue-gray dots, scarlike depigmentation, irregularly distributed and sized brown dots and globules, tan color, irregularly shaped depigmentation, and irregularly distributed and sized dots and globules of any color. The most important positive correlating features of pigmented NM vs nodular nonmelanoma were peripheral black dots/globules, multiple brown dots, irregular black dots/globules, blue-white veil, homogeneous blue pigmentation, 5 to 6 colors, and black color. A model to classify a lesion as melanocytic gave a high sensitivity (>98.0%) for both nodular pigmented and nonnodular pigmented melanoma but a lower sensitivity for amelanotic/hypomelanotic NM (84%). A method for diagnosing amelanotic/hypomelanotic malignant lesions (including basal cell carcinoma) gave a 93% sensitivity and 70% specificity for NM. CONCLUSIONS AND RELEVANCE When a progressively growing, symmetrically patterned melanocytic nodule is identified, NM needs to be excluded.

Dermoscopic Findings of Pilomatricomas

Background: To the best of our knowledge, no specific dermoscopic criteria have been described in the medical literature for the diagnosis of pilomatricomas. Objectives: To evaluate the morphological findings of pilomatricomas under dermoscopic observation. Material and Methods: Dermoscopic examination (using the Dermlite Foto; 3Gen, LLC, Dana Point, Calif., USA) of 10 patients with pilomatricomas was performed to evaluate specific dermoscopic criteria and patterns. Results: The most frequently occurring dermoscopic features were found to be: irregular white structures (80%) and white streaks (70%); vascular structures in all lesions (reddish homogeneous area in 90%, hairpin vessels in 70%, linear-irregular vessels in 70% and dotted vessels in 40%); ulceration (60%), and structureless gray-blue areas in 20% of cases. The results of our study reveal that the absence of specific dermoscopic criteria for other skin tumors and the presence of irregular white structures and polymorphous/atypical vessels is the most frequent dermoscopic pattern in pilomatricomas. Conclusions: Dermoscopy may be a useful tool for improving the recognition of pilomatricomas. However, dermoscopy does not assure 100% diagnostic accuracy and pilomatricomas may represent in some cases, above all in elderly patients, a dermoscopic pitfall, being difficult to differentiate dermoscopically from other lesions, such as melanoma or basal cell carcinoma.

Photoinduced lichenoid reaction by thioridazine

Photosensitivity reactions to the phenotiazine derivates are well known, but they are infrequent in patients treated with thioridazine. Three patients treated with thioridazine for several years visited our clinic with a photoinduced lichenoid reaction while under treatment with this antipsychotic drug. The first case, a 72-year-old woman who was being treated with thioridazine (Meleril; Novartis Farmaceutica, Barcelona, Spain) for 4 years, presented with well-delimited hyperpigmented papular lesions on exposed areas, mainly on face and neck. Phototest revealed a diminished minimal erythema dose (MED) to ultraviolet B (UVB) light. A skin biopsy showed residual incontinentia pigmenti. Suggested diagnosis was photoinduced reaction by thioridazine. After withdrawal of this medication, the lesions disappeared progressively during the next 6 years. The second case, a 63-year-old woman treated with thioridazine (Meleril) for several years, also showed maculo-papular pigmented skin lesions on face, neck and forearms. In this case phototesting was not performed and the histological study of lesions demonstrated a lichenoid dermatitis. The diagnosis of photoinduced lichenoid reaction by thioridazine was considered. Treatment was withdrawn and after 8 years skin lesions had completely disappeared. The third case, a 72-year-old women treated with thioridazine (Meleril) consulted us because she presented papular pigmented skin lesions on the face, neck and back of hands since last summer. Phototesting did not show alterations of MED to UVB or UVA and the skin biopsy revealed a lichenoid reaction. In this case thioridazine was also withdrawn and we have observed a slight progressive improvement of lesions. In summary these three patients under treatment with thioridazine, presented with identical appearing photo-distributed skin lesions that showed a lichenoid dermatitis pattern by histological examination and could be related to the thioridazine treatment. Thioridazine is an antipsychotic drug that belongs to the phenothiazine group. This pharmacologic group also includes promazine, chlorpromazine, perphenazine and fluphenazine. It is well known that all these drugs show photosensitizing capacity and it is accepted that thioridazine does so. Since 1967, when Satanove published the first case of photoallergy caused by thioridazine (1), only few cases of this adverse event have been reported (2–4). This fact could be considered as surprising if we take into account that this drug has been widely used. Therefore a low photosensitizing potential should be considered for thioridazine. Moreover, in a recent article, Elisei et al. (5) studied the mechanism by which three phenothiazine derivates (perphenazine, fluphenazine and thioridazine) may induce skin photosensitization. They estimate that the action spectrum of these drugs photosensitization is situated in the UVB band, although wavelengths higher than 400 nm also may be implicated. We consider that this fact can really be significant because it might explain that patients may not experience clearly photosensitivity and the development of the lesions is initially unnoticed by the patient. We think that although photoinduced lichenoid reactions by thioridazine are infrequent, its extremely characteristic clinical features make it easy to diagnose, despite the low frequency of these patients. So, the presence of an hyperpigmented papular eruption in a patient treated with thioridazine developing progressively without clear evidence of objective photosensitivity, must lead us to suspect the possibility of a photoinduced reaction by this drug.

Initial Evaluation, Diagnosis, Staging, Treatment, and Follow-up of Patients with Primary Cutaneous Malignant Melanoma. Consensus Statement of the Network of Catalan and Balearic Melanoma Centers

The consensus statement on the management of primary cutaneous melanoma that we present here was based on selection, discussion, review, and comparison of recent literature (including national and international guidelines). The protocols for the diagnosis, treatment, and follow-up used in the hospital centers throughout Catalonia and the Balearic Isles belonging to the Network of Catalan and Balearic Melanoma Centers were also considered. The main objective of this statement was to present the overall management of melanoma patients typically used in our region at the present time. As such, the statement was not designed to be an obligatory protocol for health professionals caring for this group of patients, and neither can it nor should it be used for this purpose. Professionals reading the statement should not therefore consider it binding on their practice, and in no case can this text be used to guarantee or seek responsibility for a given medical opinion. The group of dermatologists who have signed this statement was created 3 years ago with the aim of making our authorities aware of the importance of this complex tumor, which, in comparison with other types of cancer, we believe does not receive sufficient attention in Spain. In addition, the regular meetings of the group have produced interesting proposals for collaboration in various epidemiological, clinical, and basic applied research projects on the subject of malignant melanoma in our society.

Dermoscopy of tumours arising in naevus sebaceous: a morphological study of 58 cases

Naevus sebaceous is a congenital hamartoma commonly associated with the development of secondary neoplasms. There are sparse data relating to the dermoscopy of tumours arising in naevus sebaceous.

Development of a Human in vivo Method to Study the Effect of Ultraviolet Radiation and Sunscreens in Melanocytic Nevi

Background: Ultraviolet radiation (UVR) plays an important role in the development of melanocytic lesions. Sunscreens have shown an impact in the prevention of UVR damage; however, their role in melanocytes has not been well established. The aim was to design and validate an in vivo human model to study the influence of UVR and sunscreen protection on nevi. Methods: A model describing clinical, dermoscopic, histopathological and molecular changes after UVR with or without protection was elaborated. Two UVB minimal erythema doses were irradiated on 4 nonsuspicious nevi from 4 patients; previously one half of each lesion was protected, in 2 cases with a physical opaque material and in the other 2 lesions by applying a high physical and chemical protection sunscreen (containing octocrylene, Parsol 1789, titanium dioxide, Mexoryl SX™, Mexoryl XL™). Lesions were excised 7 days afterwards. Results: After 7 days, clinical and dermoscopic changes (more pigmentation, erythema, dotted vessels, blurred network) were noted comparing the lesions before and after irradiation, especially when comparing both sides of each nevus (protected and nonprotected). Histopathological and immunohistochemical studies demonstrated marked melanocytic activation on nonprotected areas and a high proliferation index of keratinocytes. Both physical and sunscreen protections seem to avoid these changes. Conclusion: A useful and secure human model to study the UVR influence, and efficacy of sunscreens, on melanocytic lesions was developed. In vivo and ex vivo differences between irradiated nevus versus irradiated nevus plus sunscreen or physical protection were found.