Roman Schiffner

Dermatoscopy for facial pigmented skin lesions.

On the face, the important differential diagnosis of pigmented skin lesion is between lentigo maligna, lentigo maligna melanoma, and flat seborrheic keratosis or lentigo seniles (synonymous with flat seborrheic keratosis in our terminology). In this article, we have summarized our experience in this field. Numerous examples for the criteria mentioned are given in the second edition of the Color Atlas of Dermatoscopy.1 Table 1 and Figure 1 are also adopted from that atlas with permission. A conventional pigment network is rarely found on adult facial skin. The rete ridges are flat to absent, so they produce no pigmented pattern. Instead, a pseudonetwork with a broad mesh and holes is created by the numerous pigment-free terminal and vellus hair follicles, as well as the openings of sweat glands. This pseudonetwork is location dependent and therefore present in both melanocytic lesions and nonmelanocytic lesions, such as seborrheic keratoses, on the face. On the face, therefore, the pseudonetwork does not distinguish between melanocytic and nonmelanocytic lesions, making it necessary to employ appropriate primary criteria.2–4 We compared the dermatoscopic features of lentigo maligna and lentigo senilis on the face by using logistic regression analysis.5 In this analysis, horn pseudocysts, yellow opaque areas, and fingerprint-like structures were most suggestive of lentigo senilis. In equivocal lesions, the presence of a moth-eaten border and the jelly sign can indicate lentigo senilis. A biopsy or close observation is necessary if asymmetric pigmented follicles occur. The pigmented rete ridges can produce grouped circular structures resembling grape clusters; these, along with horn pseudocysts, also indicate lentigo senilis. Sometimes at the periphery of seborrheic keratosis, streaklike areas are identified, which look very similar to branched streaks of a melanocytic lesion. The differential diagnosis is then extremely difficult. In thicker lesions, pseudofollicular openings and broad, blue-gray areas can occur. In our same analysis, features favoring lentigo maligna were dark, rhomboidal structures, slate-gray dots and globules, and asymmetric, pigmented, follicular openings forming an annulargranular pattern (Cognetta sign). In lentigo maligna and lentigo maligna melanoma, the hypopigmented follicular openings are frequently surrounded by a rim of hyperpigmentation. When the follicles lie close together, a second pseudonetwork appears, which, in contrast to the location-dependent pseudonetwork that has broad mesh and holes, is characterized by a thin mesh and holes. Both of these networklike structures are seen only with a dermatoscope and are pseudonetworks because they are not due to pigmentation of rete ridges, but rather the openings of skin appendages superimposed on pigmented facial skin in one instance and the close association of hair follicles in the other. In both pseudonetworks, the central holes often exhibit hair follicles. These should not be confused with horny pseudocysts or pseudofollicular openings, which could lead to the misdiagnosis of seborrheic keratosis. On the other hand, in some initial From the Department of Dermatology, University of Regensburg, Regensburg, Germany, and Traubingerstr. 45a, 82327 Tutzing, Germany. Address correspondence to Wilhelm Stolz, MD, Oberarzt Dermatologische Klinik der Universitat Regensburg, Franz-Josef-Strau -Allee 11 D-93042, Regensburg, Germany. E-mail address: wilhelm.stolz@klinik.uni-regensburg.de Table 1: Diagnostic criteria for lentigo maligna (LM) and lentigo maligna melanoma (LMM) on the face

Improvement of monitoring of melanocytic skin lesions with the use of a computerized acquisition and surveillance unit with a skin surface microscopic television camera

BACKGROUND Photographic documentation of melanocytic skin lesions is important. Storage and retrieval of slides, however, take much time and space. OBJECTIVE Our purpose was to develop and clinically test a computerized acquisition and surveillance (CAS) unit with a television camera for monitoring including measurements of lesional areas. METHODS A CAS unit connected with a skin surface microscopic television camera was used for monitoring of melanocytic nevi (MN). The lesional area and the skin surface microscopic appearance (SMA) were analyzed after 10 to 21 months in 54 of 1355 MN. RESULTS In 19 MN (35.2%), changes were found. In eight cases, changes in size of more or less than 15% were detected; in five cases only the SMA changed. In six cases both characteristics changed. CONCLUSION In approximately 25% of MN, changes were only detectable in the SMA but not with area measurements. This favors the use of systems such as CAS because only they allow a time-saving comparison of actual and previous images.

Evaluation of different image acquisition techniques for a computer vision system in the diagnosis of malignant melanoma

BACKGROUND Digital image analysis was found to be a useful technique for improved accuracy of preoperative diagnosis of melanocytic lesions. In previous studies digitized color slides were used as input for digital image analysis. New technologies and smaller video cameras made it possible to develop a camera system that allows the digitization of skin lesions directly from the patient. OBJECTIVE We investigated whether conventional color slides or directly digitized images should be used for a reliable recognition of malignant melanoma. METHODS Computer features describing characteristics of the lesions were computed for 404 digitized color slides and for 309 directly acquired lesions. Statistical analysis and classifier construction was performed by the commercial statistical classification program CART. RESULTS With the data set derived either from the color slides or from the directly digitized lesions a sensitivity of about 90% for the recognition of malignant melanoma could be obtained. CONCLUSION Both image acquisition techniques allow a reliable detection of malignant melanoma and both are appropriate as input for an image analysis system regarding its efficiency as a diagnostic tool. However, none of the classifiers can be applied with reasonable significance to both techniques.

Willingness to pay and time trade‐off: sensitive to changes of quality of life in psoriasis patients?

Summary Background Willingness to pay (WTP) and time trade‐off (TTO) have been used successfully as quality of life (QOL) measurements in dermatology. However, until now there have been no studies available individually comparing these measures pre‐ and post‐treatment.

Treatment of atopic dermatitis and impact on quality of life: a review with emphasis on topical non-corticosteroids.

Atopic dermatitis (AD) is a chronic skin disease with increasing prevalence and rising costs. Stigmatisation and pruritus are only some aspects of potential quality-of-life (QOL) impairments. AD is not curable and repeated treatments are often necessary. At present, treatment with topically-applied corticosteroids is state-of-the-art for mild to moderate flare-ups. However, many patients are worried about the use of corticosteroids due to the widespread fear of adverse effects.In this review the present literature is analysed concerning impact on quality of life for topically-applicable alternatives to the state-of-the-art treatment. For comparison reasons, data from other treatment modalities are additionally given. Characteristics of studies were analysed using ‘general’ (year and mode of publication, type and aim of study, number of patients, and clinical measurement) and ‘QOL specific’ criteria (type and number of QOL measurements including relevance for study aim and age group, validation in used language, sensitivity to change, and improvement at end of study).QOL data are published only in the minority of studies evaluating treatment efficacy and do not cover the variety of possible therapies. Data are available for tacrolimus, pimecrolimus, UVA/UVB combination and UVB narrowband (topical non-corticosteroidal treatments), as well as for topical corticosteroids, cyclosporin, and inpatient treatment. All studies provided a marked improvement in quality of life after therapy. One study assessed quality of life after a treatment-free follow-up period obtaining a clear increase in impact on quality of life. Since studies used different QOL measurements and vary in inclusion criteria, treatment schedules and presentation of results, a comparison of QOL improvement is not recommended. A single randomised study compared topically applied non-corticosteroidal treatment (UVA/UVB combination) with another treatment modality (cyclosporin) and found no difference in QOL improvement.At present, there is a clear lack of controlled randomised studies evaluating different active treatment modalities and their impact on quality of life. Consensus meetings are desirable to formulate guidelines for the selection and correct use of QOL measurements. Patients’ fear of side effects (e.g. concerning corticosteroids) should be integrated in QOL questionnaires for evaluation of possible compliance problems and real costs. Since relapse after treatment is frequent in AD, QOL measurements should also be performed after a treatment-free follow-up period. At present, we can not answer the question ‘which treatment best improves quality of life in AD?’.

Willingness to pay and time trade‐off: useful utility indicators for the assessment of quality of life and patient satisfaction in patients with port wine stains

Summary Background For cost utility analyses in health economic research it is necessary to assess quality of life for content validation. Previously, both quality of life questionnaires and utility indicators such as willingness to pay and time trade‐off have been used successfully in patients with chronic skin diseases, such as psoriasis vulgaris or atopic eczema.

Differences in efficacy between intention-to-treat and per-protocol analyses for patients with psoriasis vulgaris and atopic dermatitis: clinical and pharmacoeconomic implications

Background Pharmacoeconomic outcome research is based on three criteria: (i) evaluation of objective therapeutic effects; (ii) quality of life; and (iii) treatment costs. Evaluation of therapeutic effect is mainly based on the results of clinical trials using objective clinical measures, e.g.: Psoriasis Area and Severity Index (PASI) (score for psoriasis vulgaris) and the Severity Scoring of Atopic Dermatitis (SCORAD) (score for atopic dermatitis). In most studies, only results for a treatment‐optimized subpopulation (patients treated according to the protocol) are presented in publications. The relevance of such data for daily routine therapy is doubtful.

Teledermatology - the requirements of dermatologists in private practice

Eighty-four dermatologists in private practice in Bavaria were surveyed by postal questionnaire. Of the 45 who responded (a 54% response rate), 96% used a computer in their private practice. Fifty-seven per cent of respondents owned systems with Pentium processors, while 23% were still using 386 or 486 processors. Most of them used the Windows 95, UNIX or Apple operating system. Of the respondents who had a modem, 74% used ISDN. There were few modems connected to the ordinary telephone network. Of all respondents, 56% used email regularly. Several possible teledermatology applications were proposed in the survey (i.e. teleconsultation, on-line off-line videoconferencing, email attachments). Fifty-six per cent of respondents said that they would perform teleconsultations with dermatology clinics, 40% preferred a teleconsultation via telephone and computer, and 42% sending files via email. The survey demonstrated that a high proportion of dermatologists in private practice would use a teledermatology service.

Prognostic significance of DNA cytometry in comparison with histologic measurements in malignant melanomas.

In the present study we evaluated the prognostic impact of both DNA cytometry and quantitative histology in patients with malignant melanoma (MM). In contrast to previous investigations on sections, rapid image analysis (IA) of imprint specimens was performed to measure DNA cytometric features; 34 cases of stage I MM with low (< 1.5 mm, n = 20) and higher tumor thickness (TTH) (> 1.5 mm, n = 14) were analyzed. We found significant correlations between cytometric features and TTH, which is accepted as the most important prognostic criterion in MM. Higher TTH was closely correlated with the rate of markedly aneuploid nuclei, which is indicated by the 5c exceeding rate (5cER; r, 0.89; p < 0.001). The gain of chromatin in thicker tumors was accompanied by higher mean nuclear area (MAREA; r, 0.60; p < 0.001) and mean DNA content (MDNA; r, 0.58; p < 0.001). Additional evidence for prognostic significance of cytometry was obtained by preliminary survival analysis of 16 cases (four patients died within 2 1/2 years and 12 patients survived for at least 4 1/2 years). Applying multivariate stepwise discriminant analysis, a combination of TTH, level of invasion (LEV), 2c deviation index (2cDI), and modified standard deviation of the DNA values (SDNAM) proved to be most effective. One hundred percent of the cases were correctly classified as survivors or nonsurvivors. TTH and the 5cER were found to be the best univariate criteria for prognosis. In the U test according to Mann and Whitney, a significant discrimination of survivors and nonsurvivors was possible using either TTH or the 5cER, respectively (p < 0.02). Thus, we would like to conclude that IA of imprint specimens can be recommended as a rapid and simple additional method for grading.

Charakterisierung der Farbeigenschaften melanozytärer Hautveränderungen zur Unterstützung der Früherkennung des malignen Melanoms

Beste Chancen zur Heilung des malignen Melanoms bestehen bei fruhzeitiger Erkennung. Die morphologische Vielfalt, auch gutartiger melanozytarer Hautveranderungen, erschwert die Diagnose. Hilfe verspricht die Dermatoskopie und die dazugehorige dermatoskopische ABCD-Regel, die die Merkmale Asymmetrie, Berandung, Farbvielfalt und Differentialstrukturen semiquantitativ bewertet. Durch Einsatz digitaler Bildverarbeitung sollen diese Kriterien quantitativ, objektiviert, reproduzierbar und nachvollziehbar zur Unterstutzung des Dermatologen bewertet werden. In diesem Beitrag wird die Quantifizierung der Farbeigenschaften detailliert beschrieben. Diese lassen sich durch die Farbvielfalt, die Farbhomogenitat innerhalb der Lasion und die farbliche Symmetrie bezuglich der Lasionsachsen beschreiben.