Francesco Lacarrubba

Dermatoscopy: Alternative uses in daily clinical practice

Dermatoscopy, also known as dermoscopy, epiluminescence microscopy, or surface microscopy, is a noninvasive technique allowing rapid and magnified (× 10) in vivo observation of the skin with the visualization of morphologic features often imperceptible to the naked eye. Videodermatoscopy (VD) represents the evolution of dermatoscopy and is performed with a video camera equipped with lenses providing higher magnification (× 10 to × 1000). Over the past few years, both dermatoscopy and VD have been demonstrated to be useful in a wide variety of cutaneous disorders, including ectoparasitic infestations, cutaneous/mucosal infections, hair and nail abnormalities, psoriasis, and other dermatologic as well as cosmetologic conditions. Depending on the skin disorder, both dermatoscopy and VD may be useful for differential diagnosis, prognostic evaluation, and monitoring response to treatment. Nowadays, it represents an important and relatively simple aid in daily clinical practice.

Videodermatoscopy Enhances Diagnostic Capability in Some Forms of Hair Loss

AbstractBackground: Videodermatoscopy is a non-invasive technique that allows in vivo skin observation at high magnifications. Objective: The goal of this study was to determine if videodermatoscopy enhances diagnostic capability beyond standard clinical observation in three series of patients: one group of patients with overt alopecia areata (AA), one with overt androgenetic alopecia (AGA), and one with hair loss with no apparent diagnostic features. Methods: The first group consisted of 200 patients affected by acute (140 patients) and chronic (60 patients) AA, and the second group of 100 patients affected by AGA. In both groups, the clinical diagnosis was confirmed by pull tests and trichograms. The third group consisted of 50 patients with clinically undifferentiated hair loss. In all groups, videodermatoscopy was performed at magnifications ranging from 20× to 600×. Results: In acute AA (n = 140), three videodermatoscopy patterns were identified, characterized by: (i) ‘exclamation point’ and/or ‘cadaveric’ hairs (n = 62); (ii) ‘vellus’ hairs, in some cases with increased proximal shaft thickness and pigmentation (n = 38); and (iii) coexistence of all the features from (i) and (ii) [n = 40].In chronic AA (n = 60), in those cases who were recently converted to chronic form from acute AA (n = 35), videodermatoscopy showed a scalp skin that appeared smooth and thin, with evident follicular openings. In cases of long-standing chronic AA (n = 25), hair follicle openings appeared to be obstructed by keratotic plugs. However, whether the two follicular patterns were related to disease duration or to some unknown factors is unclear. In some patients with chronic AA, videodermatoscopy also revealed hair regrowth, which appeared either as homogeneous, indicating early disease remission (upright ‘vellus’ hairs), or as sparse, thin, and twisted vellus hairs that were usually lost in a few weeks time.In AGA patients, videodermatoscopy observation allowed an accurate assessment of the ratios of miniaturized to normal hairs, a finding that was interpreted as a prognostic feature. Interestingly, videodermatoscopy clearly demonstrated the hair abnormalities corresponding to both diseases in those patients with concomitant causes of hair loss, as we observed in five patients simultaneously affected by AA and AGA.In the third group, videodermatoscopy allowed identification of early or minimal forms of AA (n = 20), AGA with mild hair loss of the centro-parietal area of the scalp (n = 20), and scarring alopecia (n = 10). Conclusion: The results indicate that videodermatoscopy represents a very useful tool in the evaluation of hair loss, both for differential diagnosis (especially in early, transitional and mild forms) and for prognostic evaluation. It allows rapid, detailed, and non-invasive observation of the scalp skin and hair, and it provides high-resolution quality imaging.

Mesotherapy for skin rejuvenation: assessment of the subepidermal low-echogenic band by ultrasound evaluation with cross-sectional B-mode scanning

ABSTRACT:  Skin‐targeted ultrasound is a noninvasive technique that has been extensively used to evaluate age‐related dermal changes, and the presence of a subepidermal low‐echogenic band (SLEB) has been related to chronic UVR exposure in several studies. Since SLEB echogenicity is photoage‐related, the aim of this study was to evaluate, through ultrasound imaging, the effects on skin photoaging of mesotherapy, a treatment approach currently used in cosmetic dermatology for skin rejuvenation. Twenty women (mean age: 46.7 range 40–60 years) with physical signs of moderate photoaging on the dorsum of the hands were enrolled and treated with multiple microinjections of hyaluronic acid (HA) salts of biotechnological origin (1.000 Kd) every week for 4 weeks. In all subjects, ultrasound evaluation was performed at each visit and 1 week after the last treatment to evaluate SLEB echogenicity changes during treatment. At the end of study, a statistically significant (p < 0.001) increase of SLEB echogenicity (with a mean increase of pixel numbers equal to 31.3%) was observed in 15 of 19 subjects who completed the study. Our preliminary study suggests that mesotherapy with HA may be an effective treatment for skin photoaging, as confirmed by ultrasound. Follow‐up investigations on larger series of patients are necessary to further evaluate the safety, effectiveness, and duration of effect of this possible therapeutic approach to skin photoaging.

Possible applications of videodermatoscopy beyond pigmented lesions.

Videodermatoscopy (VD) is a noninvasive technique which involves in vivo skin observation by a video camera equipped with lenses that currently allow magnifications ranging from × 4 to × 1000. The images obtained are visualized on a highdefinition monitor and may be stored on a personal computer, in order to identify and compare changes over time. VD is widely used in the differential diagnosis of pigmented skin lesions by epiluminescence microscopy, which involves the application of a liquid (oil, alcohol, or water) to the skin to eliminate light reflection; recently, new systems have used polarized light, obtaining similar results without the need for liquids. VD allows the rapid, magnified observation of the skin surface, and has been used in other areas of dermatology, alone or with epiluminescence microscopy, with variable results.

Topical pharmacotherapy for skin cancer Part II. Clinical applications

The purpose of the paper is to provide an in-depth, evidence-based analysis of the clinical use of topical treatments for skin cancer. A comprehensive review of topical drugs has been performed, including 5-fluorouracil, imiquimod, diclofenac, ingenol mebutate, retinoids, resiquimod, piroxicam, dobesilate, and betulinic acid. The evaluated studies were rated according to their level of evidence level (I-V), as indicated by recent guidelines for evidence-based medicine, The Oxford 2011 Levels of Evidence. Therapeutic response is generally related to tumor type, extent, and localization, and also to patient compliance. Careful patient selection is required in order to achieve the desired goal of complete tumor clearance.

The use of imiquimod 5% cream for the treatment of basal cell carcinoma as observed in Gorlin's syndrome

Summary Gorlins syndrome (naevoid basal cell carcinoma) is an autosomal dominant tumour‐predisposition syndrome. It typically consists of multiple basal cell carcinomas (BCCs) of the skin, odontogenic keratocysts of the jaw, various skeletal abnormalities and lamellar falx calcifications. Four patients with multiple facial and trunk BCCs (superficial and nodular) consistent with Gorlins syndrome are reported. Imiquimod 5% cream was topically applied to the lesions 3–5 times a week for 8–14 weeks. Two of the patients suffered mild to severe erythema and developed superficial erosions but did not discontinue treatment. Imiquimod 5% cream successfully treated 13 out of 17 BCCs in these patients with Gorlins syndrome, with no patient suffering a relapse at the follow‐up visit.

Cutaneous vascular patterns in psoriasis

Microvascular abnormalities are a characteristic feature of psoriasis and play a crucial role in its pathogenesis. Investigational studies have shown that activated keratinocytes in lesional skin undergo an accelerated epidermal cell turnover and are a major source of pro‐angiogenic cytokines, like as VEGF, ESAF, PDECGE/TP, TNF‐α, TGF‐α and PDGF, suggesting that the epidermis is capable of inducing vascular proliferation. On the other hand, microvascular alterations are essential for the development and persistence of the psoriatic lesions as they provide cellular and tissue nutrition to hyperplastic keratinocytes and promote inflammatory cell migration. Also, dilated and slightly tortuous blood vessels within dermal papillae represent one of the earliest detectable histological changes for all stages of lesional development. Videodermatoscopy is a new non invasive imaging technique able to identify modifications of microvascular architecture in vivo and such evaluation will be useful for the dermatologist both for diagnostic and prognostic evaluation, as well as for post‐therapeutic follow‐up. In this review, the role of microvascular abnormalities in the pathogenesis of psoriasis as well as the mechanisms underlying vascular changes and their primary therapeutic implications will be reviewed and discussed.

Topical pharmacotherapy for skin cancer: Part I. Pharmacology

Topical pharmacotherapy represents an effective alternative treatment for superficial skin cancer, primarily actinic keratoses and basal cell carcinomas. We provide an in-depth analysis of the pharmacologic aspects of available topical drugs for the treatment of primary skin tumors. In particular, we evaluate the mechanisms of action, formulations and indications, side effects, and contraindications of 5-fluorouracil, imiquimod, diclofenac, ingenol mebutate, and retinoids. Moreover, the characteristics of some investigational molecules (ie, resiquimod, piroxicam, dobesilate, and betulinic acid) are presented.

Advances in the use of topical imiquimod to treat dermatologic disorders

Imiquimod (IQ) is an immune-response modifying agent, first approved by FDA for the topical treatment of external genital and perianal warts in 1997. It induces, through stimulation of Toll-like receptors (TLRs) localized on the surface of antigen-presenting cells, synthesis and release of several endogenous pro-inflammatory cytokines such as interferon-α (IFN-α), tumor necrosis factor-α (TNF-α) and interleukins (IL) 6 and 12, which in turn stimulate both the innate and acquired immune pathways, resulting in upregulation of natural antiviral and antitumor activity. IQ 5% cream has been used for the treatment of a wide variety of dermatologic conditions in which the immune system is thought to play a role in regression of the disease. In some disorders, such as genital and perianal warts, actinic keratoses, basal cell carcinomas, Bowen’s disease and molluscum contagiosum, relative safety and efficacy are supported by randomized controlled trials of IQ. However, it is common for patients to experience local skin reactions, which can range from mild to severe in intensity, but usually resolve 1–2 weeks after interrupting treatment. Additional randomized trials are encouraged to assess safety and efficacy of IQ in the treatment of an even wider range of cutaneous disorders.

Topical imiquimod treatment of superficial and nodular basal cell carcinomas in patients affected by basal cell nevus syndrome: a preliminary report

BACKGROUND: Imiquimod 5% cream has been shown to be effective in the treatment of superficial basal cell carcinomas (sBCCs). OBJECTIVE: To evaluate the efficacy, safety and compliance of imiquimod 5% cream for the treatment of sBCCs and nodular BCCs (nBCCs) in patients affected by basal cell nevus syndrome. PATIENTS/METHODS: Three patients (two male, one female) were enrolled in the study. Nine tumors (five sBCCs and four nBCCs), all ranging in size from 0.5 cm to 1 cm, were treated. Treatment consisted for sBCCs of three weekly applications and for nBCCs of five weekly applications for 8 weeks. Histological examination was performed at the beginning and at the end of the study. For small tumors, similar-appearing lesions were removed for baseline histological confirmation. Follow-up was performed at 1-week intervals in order to carefully detect any change. RESULTS: Three sBCCs cleared clinically after 4 weeks of treatment and two nBCCs after 8 weeks. The remaining four lesions showed excellent clinical responses with evident (>50%) size reduction at 6 weeks, but no further improvement. Histological examination with multiple-step sections confirmed complete clearing for those lesions showing clinical resolution, except for one nBCC that showed scant tumor remnants. Local adverse effects (itching, erythema and bleeding) were mild and did not prompt discontinuation of treatment. No systemic side effects were noted. CONCLUSIONS: Imiquimod 5% cream is an effective therapeutic option for both sBCC and nBCC in patients with basal cell nevus syndrome. The treatment was very well received by all patients engaged in the study, who stated their appreciation for a topical treatment rather than multiple surgical excisions. A higher number of applications and longer treatment periods are required for nBCCs.