Assi Levi

Assessment of Sarcoptes scabiei viability in vivo by reflectance confocal microscopy

To the Editor, Scabies is caused by infestation of the skin by the mite Sarcoptes scabiei. Following penetration of the skin, the female mite excavates a burrow in the stratum corneum where it lays its eggs over a period of 2–3 weeks, causing severe itching due to a type IV hypersensitivity response [1]. Diagnosis is based on the clinical picture and confirmed by the demonstration of Sarcoptes, its eggs or, its feces in skin scrapings or by dermoscopy [2]. Treatment includes several topical scabicides or systemic ivermectine. The aim of the treatment is to kill the mite, and reapplication is arbitrarily recommended. Development of resistance to scabicides, especially to lindane, appears to be on the increase; therefore markers of treatment efficacy are required. In the laboratory setting, death of the parasite is defined as cessation of peristalsis of the gut and absence of movement of the mite over 24 hours [3], whereas no specific marker of parasite death is available in the clinical setting. Reflectance confocal microscopy (RCM) is a novel, noninvasive imaging technique which permits real-time visualization of cellular components in the skin at a resolution compatible to that of conventional histology. As opposed to conventional histopathology, RCM provides a virtual three-dimensional image of the tissue by serial “cuts” at various depths [4] .The system uses an 830-nm wavelength diode laser and provides high optical resolution (horizontal axis 2.0 μm, vertical axis 5.0 μm) to a penetration depth of 200–300 μm depending on anatomical site and skin thickness. Longo et al. [5] demonstrated S. scabiei in the skin by RCM in vivo. On the confocal images S. scabiei could be seen, along with burrow, eggs and feces.

Low-irradiance red LED traffic lamps as light source in PDT for actinic keratoses.

LED light sources for photodynamic therapy have become increasingly popular due to their narrow emission spectra that accurately match the absorption spectrum of porphyrins. Photodynamic therapy at low fluence rates has been shown to be as effective as high output irradiation for treatment of non‐melanoma skin cancers. Fifteen patients with multiple non‐hypertrophic actinic keratoses covering the scalp and the face were treated with aminolaevulinic acid photodynamic therapy using ordinary red LED traffic lamps as light source. All 15 patients improved clinically after one photodynamic therapy session. Only two patients required a second session to obtain satisfactory remission. Pain was minimal during these sessions. Red LED traffic lights constitute a simple alternative to far more complicated and expensive PDT light sources.

Noninvasive visualization of intraepidermal and subepidermal blisters in vesiculobullous skin disorders by in vivo reflectance confocal microscopy

IntroductionBullous dermatoses are characterized by skin blisteringresulting from local injury with breakdown of tissue integrityand fluid accumulation within specific layers of the skin.These disorders are traditionally classified into subcorneal,suprabasal, and subepidermal blistering by the specificlocationofthesplitintheepidermis[1, 2]. Of special interestis the group of autoimmune blistering diseases that comprisea wide spectrum of clinical presentations and are mediatedby pathogenic antibodies targeting specific adhesion mole-cules responsible for cutaneous homeostasis and integrity[3]. Diagnosis is based on the clinical picture, histology,direct and indirect immunofluorescence, immunoblotting,immunoprecipitation and immunoelectron microscopy [4, 5].Though crucial for accurate diagnosis and for selection ofspecific therapy, these techniques are cumbersome, time-consuming and unlikely to be widely available, leavingblister level determination by classical histology a keydiagnostic procedure in intraepidermal and subepidermalblistering diseases.Reflectance confocal microscopy (RCM) is a novel,noninvasive imaging technique which permits real timevisualization of cellular components in the skin at aresolution compatible with that of conventional histology[6]. RCM detects single back-scattered photons directlyfrom illuminated living tissue without prior preparation ofthe examined skin. A small pinhole in the front of thedetector allows imaging at high resolution. Contrast inconfocal images is provided by the differences in refractiveindex among the cellular organelles and structures. Melaninacts as a contrast agent in pigmented epithelia [7]. With thecurrent technology, in vivo RCM imaging is limited to adepth of approximately 300 µm which includes the entireepidermis, the papillary dermis and the upper reticulardermis. It is of interest that the depth of RCM imaging canbe increased by using the so-called “optical clearing”approach, and experimental studies utilizing gold nano-particles and osmotically active immersion liquids asoptical clearance agents have indeed increased the imagingdepth of RCM up to three times [8–11]. However, theseexperimental approaches have not yet been incorporatedinto clinically useful RCM technology. Since contrast in theimages is primarily provided by melanin, RCM has mainlybeen useful in the diagnosis of pigmented cutaneous tumorssuch as melanoma and nevi [12], and nonmelanoma skincancers [13, 14]. The use of RCM has also been reported inthe diagnosis of a variety of inflammatory skin disordersincluding psoriasis [15], contact dermatitis [16, 17], vitiligo[18], cutaneous lupus erythematosus [19, 20], folliculitis[21], and photoaging [22]. In a recent paper, Angelova-Fischer et al. [23] demonstrated the use of RCM in thediagnosis of subcorneal blisters in two patients withpemphigus foliaceus in which the dark nonrefractive blistercavity was readily visible against a background of bright,

Treatment of solar urticaria using antihistamine and leukotriene receptor antagonist combinations tailored to disease severity.

Solar urticarial (SU) is characterized by erythema, whealing, and/or pruritus occurring minutes after sun exposure. Treatment is difficult and often unsatisfactory.

Detection of living Sarcoptes scabiei larvae by reflectance mode confocal microscopy in the skin of a patient with crusted scabies.

Scabies is an intensely pruritic disorder induced by a delayed type hypersensitivity reaction to infestation of the skin by the mite Sarcoptes scabiei. The diagnosis of scabies is established clinically and confirmed by identifying mites or eggs by microscopic examination of scrapings from the skin or by surface microscopy using a dermatoscope. Reflectance-mode confocal microscopy is a novel technique used for noninvasive imaging of skin structures and lesions at a resolution compatible to that of conventional histology. Recently, the technique was employed for the confirmation of the clinical diagnosis of scabies.We demonstrate the first ever documentation of a larva moving freely inside the skin of a patient infected with scabies.

Palmar Telangiectasias: A Cutaneous Sign for Smoking

Background: Telangiectasias are permanent dilations of blood capillaries which appear in a variety of medical conditions. Cutaneous palmar telangiectasias have been postulated to be associated with smoking. Objective: To determine whether a significant correlation exists between palmar telangiectasias and smoking habits. Patients and Methods: A total of 124 volunteers participated in this observational study by allowing physical evaluation of their palms and by completing a questionnaire. Results: Palmar telangiectasias were found to be associated with current or past smoking. Neither age nor gender was found to be a co-contributor. Discussion: Palmar telangiectasias were found to constitute highly specific and sensitive markers for prolonged smoking.

Ultraviolet A1 exposure is crucial in the treatment of prurigo nodulalis using a ultraviolet A1/topical steroid combination regimen

To the Editor, Phototherapy is effective in the treatment of severe generalized pruritus. However, clinical experience dictates that most patients seek relief from their itch by topical steroids or emollients. At the Dermatology Department of the Hadassah Medical Center, the standard anti-pruritic regimen consists of concurrent phototherapy and topical steroids. Although this time-honored combination regimen has been in place at our department through generations of physicians, no systematic efforts have been made to determine which of the components is responsible for the clinical improvement that the majority of patients experience. We report here an anecdotal case report of a patient who, due to a somewhat amusing oversight, was deprived of one of the components of the traditional combination regimen. A 26-year-old male was admitted due to wide-spread prurigo nodularis developed on a background of atopic dermatitis since childhood. Prior therapeutic trials included antihistamines, cyclosporine A, topical steroid ointments and emollients, none of which brought substantial relief. During his admission, he underwent high-dose, whole-body ultraviolet A1 (UVA1) phototherapy (Fig. 1) receiving 5 weekly 90 J/cm UVA1 sessions for a total of 18 treatments (cumulative dose 1620 J/ cm). In addition, 0.1% betamethasone 17-valerate ointment was applied twice daily. However, due to the patient’s extreme height (203 cm), his lower shins and dorsal feet were not included in the exposure field during most of the treatment session, a fact only observed during the final UV sessions. As a result, skin areas from the distal third of both shins were only treated with topical steroid ointment, which was applied by the