Joseph Bikowski

Gowden's disease. A cutaneous marker of breast cancer

Cowdens disease features facial trichilemmomas (a benign tumor of follicular epithelium), acral keratoses on the limbs, and oral mucosal papillomas and fibromas; it may also involve thyroid, gastrointestinal tract, ovaries, uterus, and breasts. Among 32 known cases of Cowdens disease, 21 are women, in 10 of whom breast cancer has already developed (bilateral in 4). The 11 women in whom breast cancer has not yet developed have fibroadenomas, fibrocystic disease, virginal hypertrophy of the breasts, and malformations of nipples and areolae. Their median age is only 36 years. Two have mothers with breast cancer and in one both mother and maternal grandmother had breast cancer. Dermatologic lesions, including pathognomonic multiple facial trichilemmomas, precede the development of malignancy and can identify women with a high risk of developing breast cancer.

The dermatopathology of Cowden's syndrome*

During the past 2 years we have studied eighty‐nine biopsy specimens from nineteen patients with Cowdens syndrome. Among fifty‐three facial lesions, twenty‐nine were trichilemmomas. Twenty‐ three of the others were consistent with trichilemmoma, showed a non‐specific benign verrucous acanthoma, or were not diagnostic; one was a bluenaevus. All fourteen oral mucosal biopsy specimens were benign fibromas. Nineteen of twenty‐two biopsy specimens from the hands and feet showed the pattern of benign keratosis. Multiple trichilemmomas were found in all patients with Cowdens syndrome, but at times several biopsy specimens were required before a diagnostic picture was un‐ covered. All patients with multiple facial trichilemmomas were found to have Cowdens syndrome. The combination of multiple facial trichilemmomas, oral fibromas, and benign acral keratoses enables one to diagnose Cowdens syndrome at a stage before serious internal complications develop.

Acne severity grading: Determining essential clinical components and features using a Delphi consensus

BACKGROUND There are multiple global scales for acne severity grading but no singular standard. OBJECTIVE Our objective was to determine the essential clinical components (content items) and features (property-related items) for an acne global grading scale for use in research and clinical practice using an iterative method, the Delphi process. METHODS Ten acne experts were invited to participate in a Web-based Delphi survey comprising 3 iterative rounds of questions. RESULTS In round 1, the experts identified the following clinical components (primary acne lesions, number of lesions, extent, regional involvement, secondary lesions, and patient experiences) and features (clinimetric properties, ease of use, categorization of severity based on photographs or text, and acceptance by all stakeholders). In round 2, consensus for inclusion in the scale was established for primary lesions, number, sites, and extent; as well as clinimetric properties and ease of use. In round 3, consensus for inclusion was further established for categorization and acceptance. Patient experiences were excluded and no consensus was achieved for secondary lesions. LIMITATIONS The Delphi panel consisted solely of the United States (U.S.)-based acne experts. CONCLUSION Using an established method for achieving consensus, experts in acne vulgaris concluded that an ideal acne global grading scale would comprise the essential clinical components of primary acne lesions, their quantity, extent, and facial and extrafacial sites of involvement; with features of clinimetric properties, categorization, efficiency, and acceptance.

Acne image analysis: lesion localization and classification

Acne is a common skin condition present predominantly in the adolescent population, but may continue into adulthood. Scarring occurs commonly as a sequel to severe inflammatory acne. The presence of acne and resultant scars are more than cosmetic, with a significant potential to alter quality of life and even job prospects. The psychosocial effects of acne and scars can be disturbing and may be a risk factor for serious psychological concerns. Treatment efficacy is generally determined based on an invalidated gestalt by the physician and patient. However, the validated assessment of acne can be challenging and time consuming. Acne can be classified into several morphologies including closed comedones (whiteheads), open comedones (blackheads), papules, pustules, cysts (nodules) and scars. For a validated assessment, the different morphologies need to be counted independently, a method that is far too time consuming considering the limited time available for a consultation. However, it is practical to record and analyze images since dermatologists can validate the severity of acne within seconds after uploading an image. This paper covers the processes of region-ofinterest determination using entropy-based filtering and thresholding as well acne lesion feature extraction. Feature extraction methods using discrete wavelet frames and gray-level co-occurence matrix were presented and their effectiveness in separating the six major acne lesion classes were discussed. Several classifiers were used to test the extracted features. Correct classification accuracy as high as 85.5% was achieved using the binary classification tree with fourteen principle components used as descriptors. Further studies are underway to further improve the algorithm performance and validate it on a larger database.