Je-Ho Mun

Clinical and dermoscopic characteristics of extramammary Paget disease: a study of 35 cases

DEAR EDITOR, Extramammary Paget disease (EMPD) is a rare malignant tumour characterized by erythematous scaly patches or plaques occurring in apocrine-gland-bearing skin such as the vulva, penis, scrotum, perineum, perianal area and axilla. Because of its nonspecific clinical presentation and low incidence, EMPD can be a challenge to diagnose. Therefore, its misdiagnosis as an inflammatory or infectious skin condition (eczema, psoriasis or candidiasis) is common, and EMPD lesions may worsen before appropriate treatment is initiated. Early diagnosis and treatment of EMPD are crucial for a favourable prognosis, because a delayed diagnosis can result in a more extensive lesion, dermal invasion or distant metastasis. Although the utility of dermoscopy has been reported for various pigmented and nonpigmented tumours, the dermoscopic patterns of EMPD have rarely been reported in the literature. Investigation of clinical and dermoscopic patterns of EMPD could elucidate further characteristics of this rare tumour. For this study patients were recruited from dermatology clinics at two university hospitals in South Korea between 2006 and 2014. We identified 35 patients with histopathologically confirmed EMPD and available clinical and dermoscopic images. For the control group we included 46 EMPD-mimicking lesions on the genital or perianal area: 22 eczematous dermatitis (ED), 16 fungal infection (FI), seven Bowen disease (BD) and one basal cell carcinoma (BCC). This study was conducted in accordance with the principles of the Declaration of Helsinki, and institutional approval and informed patient consent were obtained. Demographic data were collected and images were acquired using a dermoscope (DermLite II Pro HR or DL3; 3Gen, San Juan Capistrano, CA, U.S.A.). Three board-certified dermatolo-

Improvement in skin wrinkles from the use of photostable retinyl retinoate: a randomized controlled trial

Background  Photoaged skin can be treated with retinoids, which are natural and synthetic vitamin A derivatives. However, these are photounstable and can cause skin irritation, which is a major limitation in their use in general cosmetics. Retinyl retinoate, which is an ester of all‐trans retinoic acid (RA) and all‐trans retinol, has reduced toxicity due to blocking of the carboxyl end group of RA and higher skin regeneration activity than retinol.

Dermoscopic patterns of fungal melanonychia: A comparative study with other causes of melanonychia

Background: Diagnosing fungal melanonychia (FM) is often difficult because it mimics melanonychia caused by other factors. Dermoscopy is helpful in the setting of nail pigmentation. However, the diagnostic characteristics of FM on dermoscopy are not fully elucidated. Objective: We sought to determine the dermoscopic characteristics of FM. Methods: We evaluated the dermoscopic patterns of FM diagnosed at 2 university hospitals from January 2010 to February 2016. We included nail matrix melanocytic activation, nail matrix nevi, and nail unit malignant melanomas as control groups for comparison. Results: In all, 18 FM, 24 melanocytic activation of the nail matrix, 27 nail matrix nevi, and 11 malignant melanoma cases were analyzed. Statistical analysis revealed that yellow color, multicolor pattern, nonlongitudinal homogenous pattern, reverse triangular pattern, subungual keratosis, white or yellow streaks, and scales on the nail were more frequent in FM. However, gray color, longitudinal pattern, and pseudo‐Hutchinson sign were less frequent in FM than in controls. Limitations: This was a retrospective study from 2 university hospitals, with a small sample size. Conclusion: The results revealed distinctive dermoscopic patterns for FM. Therefore, dermoscopy can be a useful ancillary tool for diagnosing FM.

Dermoscopic features of digital mucous cysts: A study of 23 cases

Digital mucous cysts (DMC) are common benign myxoid cysts typically located on the fingers and toes. Recently, dermoscopic patterns of DMC were reported. However, only a small number of cases were described in the published work; therefore, information on this topic is scarce in the published work. We investigated dermoscopic patterns of histopathologically diagnosed DMC. In total, 23 cases were enrolled in this study. Polarized dermoscopy revealed vascular patterns in 13 cases (56.5%), with arborizing vascular patterns, dotted vessels, linear vessels and polymorphous vessels in eight (34.8%), three (13.0%), one (4.3%) and one (4.3%) case, respectively. Red‐purple lacunas, ulceration, nail dystrophy and white shiny structures were detected in five (21.7%), two (8.7%), seven (30.4%) and six cases (26.1%), respectively. We report the largest case series regarding dermoscopic features of DMC to date. Dermoscopy can be used as a helpful adjuvant and non‐invasive tool in the diagnosis of DMC.

Discrimination of Basal Cell Carcinoma from Normal Skin Tissue Using High-Resolution Magic Angle Spinning 1H NMR Spectroscopy.

High-resolution magic angle spinning nuclear magnetic resonance (HR-MAS NMR) spectroscopy is a useful tool for investigating the metabolism of various cancers. Basal cell carcinoma (BCC) is the most common skin cancer. However, to our knowledge, data on metabolic profiling of BCC have not been reported in the literature. The objective of the present study was to investigate the metabolic profiling of cutaneous BCC using HR-MAS 1H NMR spectroscopy. HR-MAS 1H NMR spectroscopy was used to analyze the metabolite profile and metabolite intensity of histopathologically confirmed BCC tissues and normal skin tissue (NST) samples. The metabolic intensity normalized to the total spectral intensities in BCC and NST was compared, and multivariate analysis was performed with orthogonal partial least-squares discriminant analysis (OPLS-DA). P values < 0.05 were considered statistically significant. Univariate analysis revealed 9 metabolites that showed statistically significant difference between BCC and NST. In multivariate analysis, the OPLS-DA models built with the HR-MAS NMR metabolic profiles revealed a clear separation of BCC from NST. The receiver operating characteristic curve generated from the results revealed an excellent discrimination of BCC from NST with an area under the curve (AUC) value of 0.961. The present study demonstrated that the metabolite profile and metabolite intensity differ between BCC and NST, and that HR-MAS 1H NMR spectroscopy can be a valuable tool in the diagnosis of BCC.

Assessment of a Predictive Scoring Model for Dermoscopy of Subungual Melanoma In Situ

Importance Subungual melanoma in situ (SMIS) is a malignant neoplasm that requires early diagnosis and complete surgical excision; however, little is known about the usefulness of the detailed dermoscopic features of longitudinal melanonychia (LM) to predict the diagnosis of SMIS. Objectives To investigate the characteristic dermoscopic findings of SMIS and to establish a predictive scoring model for the diagnosis of SMIS in patients with adult-onset LM affecting a single digit. Design, Setting, and Participants A cohort study of 19 patients with biopsy-proven SMIS and 26 patients with benign LM diagnosed in a tertiary referral hospital in Seoul, South Korea, from September 1, 2013, to July 31, 2017. Main Outcomes and Measures Patient demographics, frequency of specific dermoscopic findings, and a predictive scoring model. Results Of the total 45 patients with pigmented nails, the 19 patients with SMIS included 14 women and had a mean (SD) age of 52.0 (14.4) years, and the 26 patients with benign LM included 18 women and had a mean (SD) age of 48.1 (13.2) years. Asymmetry (odds ratio [OR], 34.00; 95% CI, 3.88-297.70), border fading (OR, 9.33; 95% CI, 2.37-36.70), multicolor (OR, 11.59; 95% CI, 2.21-60.89), width of the pigmentation of at least 3 mm (OR, 5.31; 95% CI, 1.01-28.07), and presence of the Hutchinson sign (OR, 18.18; 95% CI, 2.02-163.52) were features of LM that were significantly associated with SMIS. A predictive scoring model incorporating these dermoscopic features of SMIS was assessed. The model, ranging from 0 to 8 points, showed a reliable diagnostic value (the receiver operating characteristic curve had an area under the curve [C statistic] of 0.91) in differentiating SMIS from benign LM at a cutoff value of 3, with a sensitivity of 89% and a specificity of 62%. Conclusions and Relevance This study suggests characteristic dermoscopic features for SMIS. A predictive scoring model based on these morphologic features may help differentiate SMIS from benign LM.

Cutaneous epithelioid hemangioendothelioma treated with Mohs micrographic surgery.

Epithelioid hemangioendothelioma (EHE) is a rare malignant vascular tumor. Most reported cases arose in soft tissues or parenchymatous organs, but EHE can occur on the skin. The disease was initially described as a low-grade malignant neoplasm but has recently been classified as a fully malignant neoplasm. The known treatment for EHE is wide excision, but no patients were treated using Mohs micrographic surgery (MMS) in the literature.

Association between Breslow Thickness and Dermoscopic Findings in Acral Melanoma

Background Dermoscopy is a useful tool for the diagnosis of acral melanomas (AMs). However, little is known about the influence of tumor thickness on the dermoscopic findings of AM. Objective To investigate the affect Breslow thickness (BT) has on the dermoscopic patterns of AM. Methods Data on cases of AM on the glabrous skin were collected from 4 university hospitals. We investigated the frequency of each dermoscopic feature of AM according to the BT. Statistical analysis was performed to investigate the association between the specific dermoscopic patterns and BT. Results Multivariable analysis revealed that the colors red (odds ratio [OR] 16.482, 95% confidence interval [CI] 3.605‐99.016); blue (OR 7.092; 95% CI 1.707‐37.435); and white (OR 5.048, 95% CI 1.152‐22.897) were more common in AM with BT >2 mm than those with BT ≤2 mm. Regarding patterns, atypical vascular (OR 34.589, 95% CI 6.458‐305.852); blue‐white veils (OR 9.605, 95% CI 1.971‐72.062); and ulcers (OR 5.084, 95% CI 1.145‐24.152) were more frequently detected in cases with BT >2 mm than those with BT ≤2 mm. Limitations A retrospective study design and small sample size. Conclusion This study showed an association between dermoscopic patterns and tumor thickness among patients with AM. Dermoscopy can be a useful adjuvant tool for predicting BT in AM.

Acquired digital arteriovenous malformation presenting as erythronychia

Dear Editor, Acquired digital arteriovenous malformation (ADAVM) is a unique type of vascular anomaly involving the digits, especially the periungual region. The possible etiologies include minor trauma, surgical procedures or inflammation of the arteries and veins. Here, we present a unique case of ADAVM presenting as erythronychia, with the dermoscopic findings. A 40-year-old female patient, with no previous medical history, presented with painless purple pigmentation on the left index fingernail. The lesion had developed 6 years earlier and did not change in size thereafter. The patient was a professional florist. Therefore, she used her hands a lot. However, the patient did not recall any overt trauma to the finger. Physical examination showed an erythematous discoloration on the distal half of the nail bed, with a 3-mm reddish macule around the proximal nail fold (Fig. 1a). Local heat and pulsation were absent. Dermoscopic investigation revealed a purple structureless pattern on the distal two-thirds of the nail and dotted vessels on the proximal nail fold (Fig. 1b,c). Our primary differential diagnosis included a subungual hemorrhage; however, there was no change after 2 months of follow up. Therefore, an incisional biopsy of the nail bed was performed. Histopathological analysis revealed conspicuous vascular proliferation composed of thickand thin-walled vessels in the dermis (Fig. 1d). The vascular structures stained positively for CD31. Based on the clinical and histopathological findings, a diagnosis of ADAVM was finally made. Acquired digital arteriovenous malformation was first described by McCulley et al. in 1997. Clinically, it usually presents as a purpuric nodule located on the periungual area. Histopathology of ADAVM is characterized by abnormal proliferation of thinand thick-walled dilated vessels in the dermis. Dermoscopy can be a helpful adjuvant diagnostic tool in the differential diagnosis of periungual or ungual tumors. However, dermoscopic features of ADAVM are scarcely described in the published work to date. Yang and Ohara first reported three cases of periungual ADAVM with several dilated, tortuous vessels within a milky red background in an irregularly shaped area. Cuesta et al. reported dermoscopic patterns on ADAVM, as a mixture of blue-red lacunae, milky red areas and winding red vessels. However, to our knowledge, dermoscopic findings of ADAVM affecting the nail bed and presenting as an erythronychia have not been reported to date. In the present case, the dermoscopic pattern of the subungual lesion showed a purple structureless pattern on the affected nail.

Superficial acral fibromyxoma with bony change: Successful treatment with en bloc nail excision using a full-thickness skin graft

Superficial acral fibromyxoma (SAF) is a rare benign myxoid neoplasm of soft tissues that is usually located in acral sites, particularly the ungual region of the fingers and toes. Treatment of SAF is difficult because it may cause bony changes that are detectable on radiological examination and shows high recurrence rates (approximately 24%). The common treatment options for SAF include local excision, Mohs micrographic surgery (MMS), and amputation. We report successful treatment of a large ungual SAF in a patient who underwent en bloc nail excision using a full-thickness skin graft (FTSG).