Paolo Broganelli

Psoriasis‐like dermoscopic pattern of clear cell acanthoma

Background Dermoscopy provides additional criteria for the diagnosis of skin lesions.

Total body skin examination for skin cancer screening in patients with focused symptoms

BACKGROUND The value of total body skin examination (TBSE) for skin cancer screening is controversial. OBJECTIVE We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE. METHODS In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE. RESULTS We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas. LIMITATIONS The impact of TBSE on skin cancer mortality was not evaluated. CONCLUSIONS TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.

Natural evolution of Spitz nevi.

Background: The natural evolution of melanocytic nevi is a complex, multifactorial process that can be studied by monitoring nevi on a long-term basis. Methods: To assess the evolution pathway of Spitz nevi, lesions with clinical and dermoscopic features suggestive of Spitz nevi were monitored and baseline and follow-up images compared. Results: Sixty-four patients (mean age 10.4 years) with lesions suggestive of Spitz nevi were included. Lesions were monitored for a mean follow-up period of 25 months. Upon side-by-side evaluation of baseline and follow-up images, 51 (79.7%) lesions showed an involution pattern and 13 (20.3%) lesions showed a growing or stable pattern. No significant differences were found between growing and involving lesions in terms of patient age and sex and the location and palpability of lesions. The great majority of growing lesions were pigmented or partially pigmented (92.3%), whereas 47.1% of lesions in involution were amelanotic (p = 0.005). Conclusion: In this series of lesions clinically and dermoscopically diagnosed as Spitz nevi, spontaneous involution seems to be the most common biologic behavior.

Sclerosing nevus with pseudomelanomatous features and regressing melanoma with nevoid features

To the Editor, Fabrizi et al. recently described 19 cases of sclerosing nevus with pseudomelanomatous features’ as a close simulator of regressing melanoma. These lesions are probably the result of minor, unnoticed traumas on pre-existing nevi and are histopathologically characterized by a trizonal pattern: (i) an atypical junctional proliferation associated with pagetoid spreading, (ii) significant areas of dermal sclerosis containing architecturally atypical melanocytic nests and (iii) residual nevus tissue (often with congenital-like features) around and deep into the cicatricial tissue. Fabrizi et al. also state that these lesions can be differentiated from regressing melanoma because lacking cytologic atypia, dermal mitoses, cell necrosis, tumoral melanosis and expansile dermal nodules of atypical melanocytes; moreover, since regressing melanoma is usually a melanoma de novo, the presence of a bland, putatively benign nevus cell component within a sclerosing lesion can be considered an additional feature pointing toward benignity. The study by Fabrizi et al. deserves great attention because, as already underlined by Weedon, routine practice not uncommonly faces with such worrisome lesions, which we currently call nevi with regression-like fibrosis’ (NRLF) – a simpler designation which maintains regression as an immunologic, melanoma-specific phenomenon. On the other hand, fibroplasia, neo-angiogenesis and subsequent flattening the dermoepidermal junction could also be a host response favoring melanoma cell invasion of the dermis; and with such a histogenetic model in mind, histopathologists could be forced to diagnose as melanoma a large proportion of melanocytic lesions showing dermal fibrosis. Following the report of Fabrizi et al., we collected a series of consecutive cases of melanocytic skin lesions characterized by a dermal component focally or entirely replaced by hypocellular fibrous tissue. Cases were excluded if previously submitted to surgical procedures or if showing at least one of the microscopic criteria suggested by Fabrizi et al. as favoring a diagnosis of regressing melanoma, namely cytologic atypia, dermal mitoses, cell necrosis, tumoral melanosis and expansile dermal nodules of atypical melanocytes. Thus, based on the criteria of Fabrizi et al., only cases showing microscopic features consistent with NRLF were expected to enter the study. Overall, of the 175 melanocytic lesions showing fibrous replacement of the dermal component, 90 cases (51.4%) fitted with the above-specified selection criteria (M:F 1⁄4 2.7:1; mean age: 38.3 years; median age: 39 years); along with previously reported data, most lesions were located on the back (65/90; 72.2%). No patent trauma was recorded by patients, with the exception of a case of nevus of the thorax removed after a motorbike accident (Fig. 1: note the trizonal pattern of NRLF associated with a foreign body reaction around metal particles). Histopathologically, despite the adoption of the criteria of Fabrizi et al. for NRLF, 27 cases (30%) were diagnosed as melanoma, none of which being thick (24 invasive lesions; Breslow thickness range: 0.21–0.90 mm; Breslow thickness .0.75 mm: three cases). Because of the definitional criteria of our study (see above), these morphologically malignant cases could be labeled as regressing melanoma with nevoid features (RMNF). The following criteria led to a morphologic diagnosis of malignancy: (i) irregular architecture of junctional nests: 16 cases; (ii) too many single melanocytes at the junction

Targetoid Hemosiderotic Nevus

Background: Simulators of malignant melanoma comprise a heterogenous group of melanocytic and nonmelanocytic lesions of the skin. Among frequent clinical mimickers of melanoma are injured melanocytic nevi. Any change in the clinical appearance of a pre-existing nevus should alert the clinician to exclude the possibility of malignant transformation in order to early identify a lesion at a stage when complete cure can still be achieved. Objective: The purpose of this study was to present the clinical, dermoscopic and histopathologic findings of a series of acquired melanocytic nevi which abruptly developed a pigmented peripheral halo, presumably following minor trauma. Methods: A series of 6 cases of acquired melanocytic nevi which suddenly developed a targetoid halo were included in the study. All lesions were evaluated by dermoscopy. Three cases were surgically removed at different stages of evolution and submitted to histopathologic examination. In all cases, follow-up was obtained. Results: All the lesions arose on trauma-prone skin sites of young women. The sudden development of an asymptomatic, targetoid halo on a long-lasting, acquired exophytic nevus was the main presentation. Whereas the central nevus persisted, the ecchymotic halo ultimately disappeared. Histopathologic examination disclosed changes of the traumatized nevus in the central part, whereas the ring showed hemorrhage and hemosiderin deposits. Increased numbers of small vessels with hobnail characteristics were associated features. Conclusions: Targetoid hemosiderotic nevus is a distinctive clinicopathologic variant of traumatized acquired melanocytic nevus which should be included in the list of clinical simulators of melanoma.

Clinical and dermoscopic features of atypical Spitz tumors: A multicenter, retrospective, case-control study

BACKGROUND Few studies have described the clinical and dermoscopic features of atypical Spitz tumors. OBJECTIVE We sought to describe the clinical and dermoscopic features of a series of atypical Spitz tumors as compared with those of conventional Spitz nevi. METHODS This was a multicenter, retrospective, case-control study, analyzing the clinical and dermoscopic characteristics of 55 atypical Spitz tumors and 110 Spitz nevi that were excised and diagnosed histopathologically. RESULTS The majority of atypical Spitz tumors presented clinically as a plaque or nodule, dermoscopically typified by a multicomponent or nonspecific pattern. A proportion of lesions (16.4%) exhibited the typical nonpigmented Spitzoid pattern of dotted vessels and white lines under dermoscopy. Nodularity, ulceration, linear vessels, polymorphic vessels, white lines, and blue-white veil were associated with atypical Spitz tumors by univariate analysis, but only nodularity and white lines remained significant after multivariate analysis. In contrast, a pigmented typical Spitzoid pattern was a potent predictor of Spitz nevi, associated with 6.5-fold increased probability. LIMITATIONS Differentiation from Spitzoid melanoma and other nonmelanocytic lesions was not investigated. CONCLUSION Atypical Spitz tumors are polymorphic melanocytic proliferations with a nodular clinical appearance. Dermoscopically they demonstrate a multicomponent and nonspecific pattern. A typical nonpigmented Spitzoid pattern on dermoscopy (with dotted vessels and white lines) does not exclude atypical Spitz tumors.

Sclerosing Nevus with Pseudomelanomatous Features (Nevus with Regression-Like Fibrosis): Clinical and Dermoscopic Features of a Recently Characterized Histopathologic Entity

Background: Sclerosing nevi with pseudomelanomatous features or, else, nevi with regression-like fibrosis (NRLF) are histopathologic simulators of regressing melanoma. Objective: We aimed at evaluating the clinical features in a series of NRLF. Methods: Dermoscopic images of NRLF were re-evaluated according to the amount of regression, the presence of white/blue areas and the 7-point checklist. Results: Forty-six lesions from 44 patients (M:F = 3.4:1; mean age: 42 years) were evaluated. Thirty-seven lesions were excised from the back, mostly from the scapular area. All the lesions were dermoscopically atypical, with large amounts of regression (>10% in 43 cases) and with coexistence of white and blue areas (41 cases). According to the 7-point checklist, 25 lesions were labeled as benign, probably because regression obscured other dermoscopic features of atypia. Conclusion: NRLF are mostly found in the convex area of the back. A better recognition of their clinicopathologic features can allow a more conservative management.

Intralesional cidofovir for the treatment of multiple and recalcitrant cutaneous viral warts

Cidofovir is a nucleoside analog of deoxycytidine with a strong activity against a broad spectrum of DNA viruses, including human papillomavirus. The first objective was to evaluate efficacy of cidofovir for the treatment of cutaneous viral warts, recalcitrant after conventional therapies or where the surgery approach is difficult for their location or extension. Second, the present authors propose to point out possible local and systemic side effects consequent to treatment. Two‐hundred eighty patients affected by recalcitrant cutaneous viral warts, were treated with intralesional cidofovir 15 mg/mL once a month. The present authors stated that candidates were those who had made before at least two other treatments reported in the guideline for management of cutaneous viral warts. In 276 cases, warts completely cleared: 158 of those have a follow‐up period longer than 12 months and 118 have a follow‐up of 6 months. On the average, 3,2 injections were enough to solve the problem. Local side effects consisted of pain and burning sensation during the injections; itching, erythema, and post‐inflammatory hyperpigmentation were observed. No cases of systemic side effects were noted. The treatment was well tolerated, and the warts were completely cleared without relapses. Intralesional cidofovir is emerging as an effective therapeutic alternative for warts that are unresponsive to conventional treatments.

Usefulness of Photodynamic Therapy as a Possible Therapeutic Alternative in the Treatment of Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common cancer in individuals with fair skin type (I–II) and steadily increasing in incidence (70% of skin malignancy). It is locally invasive but metastasis is usually very rare, with an estimated incidence of 0.0028%–0.55%. Conventional therapy is surgery, especially for the H region of the face and infiltrative lesions; in case of inoperable tumors, radiotherapy is a valid option. Recently, topical photodynamic therapy (PDT) has become an effective treatment in the management of superficial and small nodular BCC. PDT is a minimally invasive procedure that involves the administration of a photo-sensibilizing agent followed by irradiation at a pre-defined wavelength; this determines the creation of reactive oxygen species that specifically destroy target cells. The only major side effect is pain, reported by some patients during the irradiation. The high cure rate and excellent cosmetic outcome requires considering this possibility for the management of patients with both sporadic and hereditary BCC. In this article, an extensive review of the recent literature was made, in order to clarify the role of PDT as a possible alternative therapeutic option in the treatment of BCC.

Update on dermoscopy of Spitz/Reed naevi and management guidelines by the International Dermoscopy Society

Spitzoid lesions represent a challenging and controversial group of tumours, in terms of clinical recognition, biological behaviour and management strategies. Although Spitz naevi are considered benign tumours, their clinical and dermoscopic morphological overlap with spitzoid melanoma renders the management of spitzoid lesions particularly difficult. The controversy deepens because of the existence of tumours that cannot be safely histopathologically diagnosed as naevi or melanomas (atypical Spitz tumours). The dual objective of the present study was to provide an updated classification on dermoscopy of Spitz naevi, and management recommendations of spitzoid‐looking lesions based on a consensus among experts in the field. After a detailed search of the literature for eligible studies, a data synthesis was performed from 15 studies on dermoscopy of Spitz naevi. Dermoscopically, Spitz naevi are typified by three main patterns: starburst pattern (51%), a pattern of regularly distributed dotted vessels (19%) and globular pattern with reticular depigmentation (17%). A consensus‐based algorithm for the management of spitzoid lesions is proposed. According to it, dermoscopically asymmetric lesions with spitzoid features (both flat/raised and nodular) should be excised to rule out melanoma. Dermoscopically symmetric spitzoid nodules should also be excised or closely monitored, irrespective of age, to rule out atypical Spitz tumours. Dermoscopically symmetric, flat spitzoid lesions should be managed according to the age of the patient. Finally, the histopathological diagnosis of atypical Spitz tumour should warrant wide excision but not a sentinel lymph‐node biopsy.