Franco Dinotta

Use of dermatoscopy and videodermatoscopy in therapeutic follow-up: a review

Dermatoscopy (DE) is a noninvasive technique that allows a rapid and magnified in vivo observation of the skin surface with the visualization of morphologic features invisible to the naked eye. It is performed using manual devices without computer assistance, which generally allows ×10 magnifications. Videodermatoscopy (VD) represents the evolution of DE and is performed using a video camera equipped with optic fibers and lenses that currently allow magnifications ranging from ×10 to ×1000. Both DE and VD have been demonstrated to have further applications in dermatology apart from their use in differential diagnosis of pigmented skin lesions. In several disorders, they may be useful in differential diagnosis, prognostic evaluation, and in evaluating the response to treatment. This article focuses on the use of DE and VD in therapeutic follow‐up. Although VD systems using high magnifications may not be cost‐effective in all cases, VD represents a more reliable noninvasive and easy‐to‐use tool in therapeutic follow‐up both for in‐office dermatology as well as for clinical investigations.

Treating skin cancer with topical cream

Importance of the field: Topical pharmacotherapy is an approach to consider in selected skin cancers. Noninvasive, tissue-sparing, topical, self-administered treatments represent a highly desirable alternative option, both in aged and unhealthy patients who may be poor surgical candidates, as well as in relatively young subjects with lesions located on cosmetically sensitive areas wishing to avoid disfiguring scars. This paper reviews and discusses the use of topical pharmacotherapy in the treatment of skin cancer. Areas covered in this review: This paper examines the existing literature and updates current knowledge of topical pharmacotherapy for skin cancer using fluorouracil, imiquimod, diclofenac and retinoids. What the reader will gain: There is a gap between current and best practice in that the use of pharmacotherapy in the treatment of skin cancer is only partially known. The purpose of this paper is to provide an in-depth knowledge on this topic; consequently, the readers should be able to consider new strategies in their practice. Take home message: Topical pharmacotherapy represents an option for treatment of actinic keratoses and selected basal cell carcinomas. Moreover, preliminary reports indicate imiquimod to be effective for skin or mucosal cancers such as Bowens disease, erythroplasia of Queyrat and lentigo maligna.

The use of videodermatoscopy to monitor treatment of scabies and pediculosis

Abstract A great pitfall for scabies and pediculosis therapeutic studies to date is that primary and secondary study outcomes are indirectly assessed (presence or absence of live parasites, including eggs, determined by gross clinical inspection) and data time points are non-standardized (highly variable) relative to the time of therapeutic application. Videodermatoscopy (VD) is a non-invasive technique that allows a rapid and magnified in vivo observation of the skin up to ×1000 with the visualization of morphologic features invisible to the naked eye. Utilization of VD in establishing highly definitive and precise quantitative data products used in the treatment of scabies and pediculosis provides enormous advantages in the quest to establish reproducible quantitative methodology for efficacy studies in these parasitoses. VD enhances the monitoring of clinical response to treatment in scabies and pediculosis and allows determination of the optimal timing of drug application both in vivo and ex vivo. This may be particularly important in minimizing risk of overtreatment, reducing the potential for side effects, and enhancing patient compliance.

Photoletter to the editor: Exogenous pigmentation of the sole mimicking in situ acral melanoma on dermoscopy.

The parallel ridge pattern, characterized by a parallel band-like pigmentation of the ridges of the surface skin markings, represents the most important dermoscopic feature of in situ acral melanoma. A case of a young girl who showed a plantar pigmented brown macule likely due to prolonged contact with black rubber shoes, revealing a parallel ridge pattern on dermoscopy, is reported and discussed. Although parallel ridge pattern is highly suspicious of early melanoma, exogenous pigmentation should be considered as differential diagnosis in case of rapid onset acral pigmented macules.

Incidence of onychomycosis among psoriatic patients with nail involvement: a descriptive study

Nail changes are reported in 15–55% of psoriasis patients; both fingernails and toenails can be involved. Patients suffering from psoriatic arthritis are more commonly affected by this clinical condition (75–86%) (Natarajan V et al. Indian J Dermatol Venereol Leprol 2010;76:723). Dystrophic nails can clinically mimic onychomycosis and differential diagnosis can be difficult. Onychomycosis is a nail infection caused by dermatophytic as well as non-dermatophytic fungi and it is the most common nail disease. Males are most commonly affected by onychomycosis and incidence increases with increasing age, irrespective of sex (Salomon J et al. Kor J Med Mycol 2003; 8:43–7). Numerous clinical conditions, such as diabetes mellitus, immunodepression and peripheral vasculopathy can predispose patients to onychomycosis. Onychomycosis in psoriasis patients has a lower response to systemic treatment than in the general population (Shemer A et al. Mycoses 2009; 53: 340–3). We examined 305 patients with nail changes, 174 females and 131 males. We used a nail scraping to carry out a microscopic examination with Periodic Acid-Schiff stain, a second-line diagnostic tool that increases markedly the diagnostic yield. We also examined samples by fungal culture using Sabouraud s Dextrose Agar with cycloheximide at 25 C, inspected daily for 4 weeks. Patients who had practiced topical or systemic antifungal therapy in the 2 months before the study were excluded from the research. Ten per cent of patients (31 ⁄ 305) had psoriasis, while 90% (274 ⁄ 305) were affected by a pathology other than psoriasis. Eighty-seven per cent (27 ⁄ 31) of psoriasis patients had vulgar psoriasis, 3% (1 ⁄ 31) exclusively had fingernails involvement and 10% (3 ⁄ 31) showed palmoplantar involvement. Sixteen in 31 psoriasis patients were female, 15 were male, with a mean age of 49.4 (range 15–71) and a median age of 51. Fifty-two per cent (16 ⁄ 31) of psoriasis patients had a positive familiar anamnesis for psoriasis and 16.1% (5 ⁄ 13) showed positive familiar anamnesis for psoriatic onychopathy. As proposed by Rich and Scher, severity of nail disease was determined according to the Nail Psoriasis Area Severity Index (NAPSI), and the severity of skin disease was assessed according to the Psoriasis Area Severity Index (PASI). The mean PASI score in psoriasis patients was 9.6 (range 0–32) and the mean NAPSI score was 34 (range 8–75). Most of patients utilised drugs for psoriasis: 65% (20 ⁄ 31) applied topical therapy (corticosteroids and analogous of vit. D), 16% (5 ⁄ 31) underwent systemic therapy (retinoids, immunosuppressive drugs and biologic drugs), 9.5% (3 ⁄ 31) used UVB-NB phototherapy and 9.5% (3 ⁄ 31) did not receive any therapy. Positive mycological cultures were obtained from 41.9% (13 ⁄ 31) of psoriasis patients with nail involvement. One psoriasis patient with onychomycosis had diabetes mellitus (1 ⁄ 13, 7.7%), while the remaining 12 patients (12 ⁄ 13, 92.3%) with psoriatic nail disease and onychomycosis did not have any other predisposing conditions to onychomycosis. Mostly involved sites were fingernails, 53.8% (7 ⁄ 13), both fingernails and toenails, 30.8% (4 ⁄ 13). Toenails involvement was lower, with a percentage of 15.45% (2 ⁄ 13) (Fig. 1). Among the psoriasis patients with onychomycosis, 1 (1 ⁄ 13) also suffered from psoriatic arthritis. The onset of nail changes in psoriasis patients affected by onychomycosis took place in 10 cases, 16 years (range 10–30 years) on average, after diagnosis of psoriasis and in three cases it was concurrent. In psoriasis patients not affected by onychomycosis, nail involvement occurred in 16 cases after 9.1 years (range 2–20 years) on average and in two cases it was concurrent. The mean PASI of psoriasis Correspondence: M. R. Bongiorno, Department of Dermatology, University of Palermo, via del Vespro 131, 90123 Palermo, Italy. Tel.: +390916554002. Fax: +390916554022. E-mail: mariarita.bongiorno@unipa.it

Dermatoscopy of Parasitic and Infectious Disorders

The use of dermatoscopy in the diagnosis and management of parasitic and infectious skin disorders has been defined as entodermoscopy, and several studies have confirmed its advantages in dermatology. Dermatoscopic patterns of several parasitic, viral, and fungal skin infections have been identified and herein described. A noninvasive, fast, and accurate diagnosis plays an important role in containing the spread of contagious skin disorders.

Sixteen‐Year‐Old Girl with Papules and Nodules on the Face and Upper Limbs

A 7-year-old boy was referred to the dermatology outpatient clinic with pruritic erythematous papules all over his body sparing the face, palms, and soles. His father reported that the eruption had initially started on his left leg about 2 years earlier and then had slowly spread to involve his wrists, forearms, feet, ankles, abdomen, and chest. Treatment with topical corticosteroid ointment and oral antihistamines produced some improvement, but the rash did not totally disappear. A small tense bulla had been noticed on his leg just before presentation to our service. He was otherwise healthy. There was no family history of skin diseases. Dermatologic examination revealed widespread distribution of slightly erythematous macules, hyperpigmented macules, and flat-topped papules (Fig. 1). A few erythematous eroded lesions were also seen (Fig. 2). There was a single tense bulla 1 cm in diameter on the left leg on a base of normalappearing skin (Fig. 3). There were no mucosal lesions. Punch biopsies were taken from a papule and the border of the bulla (Fig. 4) for histopathology and from normal skin for immunofluorescence studies.

Congenital Malalignment of the Great Toenails: A Review

Congenital malalignment of the great toenail is an underestimated dystrophic disorder of unknown origin characterized by lateral deviation of the nail plates, which are not parallel to the major axis of the distal phalanx. It usually presents in infancy or childhood, while late onset is uncommon. Treatment depends on the degree of deviation. If minimal, a conservative and expectant attitude, based on prevention and treatment of possible complications, is recommended because of the possibility of spontaneous regression of the nail deviation. Surgical therapy may be considered in patients with severe or complicated forms.

Treatment of ichthyosis vulgaris with a urea-based Emulsion: Videodermatoscopy and confocal microscopy evaluation

BACKGROUND Ichthyosis vulgaris is a common disorder of keratinization caused by mutations in the filaggrin gene and clinically characterized by variable degree of xerosis. METHODS Five patients affected by ichthyosis vulgaris and moderate to severe xerosis of the lower limbs, were treated twice daily for 30 days with an emulsion containing 10% urea, ceramides, and natural moisturizing factors (NMF). Evaluation was performed at baseline and at the end of treatment by clinical examination, Visual Analogue Scale to quantify itch, videodermatoscopy (VD), and reflectance confocal microscopy (RCM). Patients were also asked to provide an acceptability rating of the product based on spreadability, absorbency, odor, pleasantness and ease of application. RESULTS At the end of treatment the tested urea-based emulsion resulted in a significant clinical improvement of xerosis in all patients. The product determined a remarkable reduction of itch, it was well tolerated and it had a good cosmetic acceptability. VD and RCM objectively confirmed the reduction/disappearance of scales and the improvement/normalization of furrows size and morphology. CONCLUSIONS The tested urea-based emulsion represents a valid option for the treatment of xerosis in patients affected by ichthyosis vulgaris. VD and RCM confirmed to be useful non-invasive techniques for the therapeutic monitoring of this condition.

A red-violaceous papular lesion in a young girl. Targetoid haemosiderotic haemangioma.

A 19-year-old girl presented with a 5-month history of an asymptomatic lesion on her right forearm. Physical examination showed a red-violaceous, papular lesion of 10 × 5 mm in size, surrounded by a yellowish area that gradually expanded peripherally (Fig. 1). The patient denied an history of previous trauma to the area. Dermoscopy revealed the A Red-violaceous Papular Lesion in a Young Girl: A Quiz