Syril Keena T. Que

Through the looking glass: Basics and principles of reflectance confocal microscopy

Reflectance confocal microscopy (RCM) offers high-resolution, noninvasive skin imaging and can help avoid obtaining unnecessary biopsy specimens. It can also increase efficiency in the surgical setting by helping to delineate tumor margins. Diagnostic criteria and several RCM algorithms have been published for the differentiation of benign and malignant neoplasms. We provide an overview of the basic principles of RCM, characteristic RCM features of normal skin and cutaneous neoplasms, and the limitations and future directions of RCM.

Pigmentary disorders of the eyes and skin

Oculocutaneous albinism, Menkes syndrome, tuberous sclerosis, neurofibromatosis type 1, dyskeratosis congenita, lentiginosis profusa syndrome, incontinentia pigmenti, and Waardenburg syndrome all are genodermatoses that have well established gene mutations affecting multiple biological pathways, including melanin synthesis, copper transport, cellular proliferation, telomerase function, apoptosis, and melanocyte biology. Onchocerciasis results from a systemic inflammatory response to a nematode infection. Hypomelanosis of Ito is caused by chromosomal mosaicism, which underlies its phenotypic heterogeneity. Incomplete migration of melanocytes to the epidermis and other organs is the underlying feature of nevus of Ota. Vogt-Koyangi-Harada and vitiligo have an autoimmune etiology; the former is associated with considerable multiorgan involvement, while the latter is predominantly skin-limited.

Basics of Confocal Microscopy and the Complexity of Diagnosing Skin Tumors: New Imaging Tools in Clinical Practice, Diagnostic Workflows, Cost-Estimate, and New Trends

The use of reflectance confocal microscopy (RCM) and other noninvasive imaging devices can potentially streamline clinical care, leading to more precise and efficient management of skin cancer. This article explores the potential role of RCM in cutaneous oncology, as an adjunct to more established techniques of detecting and monitoring for skin cancer, such as dermoscopy and total body photography. Discussed are current barriers to the adoption of RCM, diagnostic workflows and standards of care in the United States and Europe, and medicolegal issues. The potential role of RCM and other similar technological innovations in the enhancement of dermatologic care is evaluated.

Application of Handheld Confocal Microscopy for Skin Cancer Diagnosis : Advantages and Limitations Compared with the Wide-Probe Confocal

The clinical diagnosis of tumors on the curved surfaces of the face, around the eyes, and on the mucosal surfaces can be difficult, while biopsies and excisions can have functional and aesthetic consequences. To avoid unnecessary surgery, clinicians have been aiming to attain accurate noninvasive diagnosis of lesions at these sites. However, acquisition of high-quality images with dermoscopy and with traditional wide-probe reflectance confocal microscopy (WP-RCM) have been hampered with technical difficulties. This article discusses the technical parameters of the handheld reflectance confocal microscope and discusses its advantages and limitations compared with the WP-RCM.

Laser treatment of periocular skin conditions

Advances in laser technology in recent decades have increased the options for the treatment of dermatologic conditions of the eye and eyelid. Benign tumors can be laser-ablated with relative ease, and vascular and melanocytic lesions can be precisely targeted with modern lasers. In this contribution, we review treatment of periocular pigmented lesions, including melanocytic nevi and nevus of Ota; vascular lesions including telangiectasias, port wine stains, and infantile hemangiomas; hair removal; eyeliner tattoo removal; laser ablation of common benign periocular tumors, such as syringomas, xanthelasma, milia, and seborrheic keratoses; and laser resurfacing. The recent advent of fractionated laser technology has resulted in dramatically decreased healing times for periocular skin resurfacing and fewer adverse effects. Fractionated laser resurfacing has now nearly supplanted traditional full-field laser resurfacing, and safe treatment of rhytides on the thin skin of the eyelids is possible. Proper eye protection is, of course, essential when using lasers near the eye. Patient preparation, safety precautions, and risks--intraocular and extraocular--are discussed herein. As laser technology continues to advance, we are sure to see improvements in current treatments, as well as development of new applications of cutaneous lasers.

Trachyonychia, Cutis Laxa, and Easy Bruising of the Skin

A man in his 60s presented with a 1-year history of dystrophic nails, doughy palms, and redundant skin on each side of the gluteal cleft. He also reported easy bruising with minor trauma. Physical examination showed trachyonychia (rough accentuated linear ridges) on 8 fingernails (Figure, A), thin and brittle toenails, diffuse nonscarring alopecia, and multiple purpuric patches on the forehead, scalp, chest, and arms. He had substantial laxity of the skin on finger pads (Figure, A), and both sides of the gluteal cleft revealed soft, nontender, rugated, skin-colored linear kissing plaques with no vesicles, bullae, ulcers, or erosions present. Quiz at jamadermatology.com A

A pink papule on the back of an 82-year-old man: an example of the buttonhole sign on reflectance confocal microscopy

An 82-year-old man with Fitzpatrick skin type III presented for the evaluation of a lesion on the left upper back. A scaly pink papule was observed (Figure 1). The differential diagnosis included squamous cell carcinoma (SCC), actinic keratosis, basal cell carcinoma, and amelanotic melanoma. On dermoscopy, multiple coiled blood vessels (also termed glo-merular vessels) were scattered across the papule (Figure 2) [1].

Acne: Kids are not just little people

Acne vulgaris is a common inflammatory disease of the pilosebaceous follicles that affects patients of all ages, from neonates to adults. We have compared and contrasted the clinical presentation of acne in neonates, infants, children, teenagers, and young adults and review the scenarios in which further systemic endocrine or hormonal tests are indicated. We also discuss age-dependent treatment considerations, including appropriate oral antimicrobial regimens and the proper dosing of isotretinoin in young children versus teenagers and adults.

Infiltrated papules on the trunk and headaches: A case of actinic granuloma and a review of the literature

Actinic granuloma is a rare granulomatous reaction that is more commonly seen in females and thought to occur as an autoimmune response to actinic damage of elastic tissue. We discuss a case of a patient with actinic granuloma presenting with concomitant temporal arteritis. Our case and review of the literature emphasize the association between actinic granuloma and temporal arteritis, a serious inflammatory condition that could lead to blindness if misdiagnosed.