Terri M. Campbell

Mobile teledermatology for skin tumour screening: Diagnostic accuracy of clinical and dermoscopic image tele-evaluation using cellular phones

Background  The ability to diagnose malignant skin tumours accurately and to distinguish them from benign lesions is vital in ensuring appropriate patient management. Little is known about the effects of mobile teledermatology services on diagnostic accuracy and their appropriateness for skin tumour surveillance.

Shiny white streaks: An additional dermoscopic finding in melanomas viewed using contact polarised dermoscopy

A point of contention within dermoscopy remains the ability to achieve an early diagnosis of melanoma through the differentiation between benign and malignant melanocytic lesions. In recent years, several studies have demonstrated the validity and reproducibility of various dermoscopic criteria that are directly associated with melanoma diagnosis, which have been subsequently defined as melanomaspecific criteria. In a recent study, an additional dermoscopic feature, shiny white streaks (SWS), was described in some melanomas examined under polarised light contact dermoscopy. Similar criteria have also been observed in other lesions, such as dermatofibromas, scars, basal cell carcinomas (included Pinkus’ fibroepithelioma variant) and pyogenic granulomas; however, to the best of our knowledge, SWS have not yet been described in naevi. The aim of the present study was to examine a large series of benign and malignant melanocytic lesions in order to determine the differences in frequency of SWS between the two.

State of the Art of Teledermatopathology

Teledermatopathology may involve real-time transmission of images from distant locations to consulting pathologists by the remote manipulation of a robotic microscope. Alternatively, the static store-and-forward option involves the single-file transmission of subjectively preselected and captured areas of microscopic images by a referring physician. The recent introduction of virtual slide systems (VSS) involves the digitization of whole slides at high resolution thus enabling the user to view any part of the specimen at any magnification. Such technology has surmounted previous restrictions caused by the size of preselected areas and specimen sampling for telepathology. In terms of client access, these VSS may be stored on a virtual slide server, made available on the Web for remote consultation by pathologists via an integrated virtual slide client network.Despite store-and-forward teledermatopathology being the most frequently used and less expensive approach to teledermatopathology, VSS represents the future in this discipline. The recent pilot studies suggest that the use of remote expert consultants in diagnostic dermatopathology can be integrated into daily routine, teleconsultation, and teleteaching. The new technology enables rapid and reproducible diagnoses, but despite its usability, VSS is not completely feasible for teledermatopathology of inflammatory skin diseases as the performance seems to be influenced by the availability of complete clinical data. Improvements in the diagnostic facility will no doubt follow from further development of the VSS, the slide processor, and of course training in the use of virtual microscope. Undoubtedly, as technology becomes even more sophisticated in the future, VSS will overcome the present drawbacks and find its place in all facets of teledermatopathology.

Dermatoscopy of genital warts

BACKGROUND Genital warts may mimic a variety of conditions, thus complicating their diagnosis and treatment. The recognition of early flat lesions presents a diagnostic challenge. OBJECTIVE We sought to describe the dermatoscopic features of genital warts, unveiling the possibility of their diagnosis by dermatoscopy. METHODS Dermatoscopic patterns of 61 genital warts from 48 consecutively enrolled male patients were identified with their frequencies being used as main outcome measures. RESULTS The lesions were examined dermatoscopically and further classified according to their dermatoscopic pattern. The most frequent finding was an unspecific pattern, which was found in 15/61 (24.6%) lesions; a fingerlike pattern was observed in 7 (11.5%), a mosaic pattern in 6 (9.8%), and a knoblike pattern in 3 (4.9%) cases. In almost half of the lesions, pattern combinations were seen, of which a fingerlike/knoblike pattern was the most common, observed in 11/61 (18.0%) cases. Among the vascular features, glomerular, hairpin/dotted, and glomerular/dotted vessels were the most frequent finding seen in 22 (36.0%), 15 (24.6%), and 10 (16.4%) of the 61 cases, respectively. In 10 (16.4%) lesions no vessels were detected. Hairpin vessels were more often seen in fingerlike (χ(2) = 39.31, P = .000) and glomerular/dotted vessels in knoblike/mosaic (χ(2) = 9.97, P = .008) pattern zones; vessels were frequently missing in unspecified (χ(2) = 8.54, P = .014) areas. LIMITATIONS Only male patients were examined. CONCLUSIONS There is a correlation between dermatoscopic patterns and vascular features reflecting the life stages of genital warts; dermatoscopy may be useful in the diagnosis of early-stage lesions.

Immunophenotype of skin lymphocytic infiltrate in patients co-infected with Mycobacterium leprae and human immunodeficiency virus: a scenario dependent on CD8+ and/or CD20+ cells

Background  Leprosy occurs rarely in human immunodeficiency virus (HIV)‐positive patients. In contrast to tuberculosis, there has been no report to date of an increase in HIV prevalence among patients with leprosy or of differences in leprosy’s clinical spectrum. While several studies describe the systemic immune response profile in patients co‐infected with HIV and leprosy, the local immune skin response has been evaluated in only a small number of case reports and limited series of patients.

Dermoscopic presentation of a 2-mm melanoma in situ

A 37-year-old woman first presented in 2003 with an irregularly bordered, slightly elevated, brown-black plaque on her left lower leg and a history of the mole changing over a period of 6 months. Upon excision, the diagnosis of melanoma in the setting of pre-existing naevus, Clark level III, Breslow thickness 0.9 mm, was made. Standard staging work-up disclosed no significant abnormalities. The patient was subsequently managed via 3-monthly clinical surveillance and at the second follow-up visit in April 2004, a new 2-mm light-brown, bluish macule was detected on the left thigh (Fig. 1a). Dermoscopic examination revealed asymmetry of colour and structure, uneven distribution of brownish and bluish irregular streaks and some bluishblack dots with elements of an atypical pigment network (Fig. 1b). The excisional biopsy of this lesion revealed the histopathological features of a melanoma in situ, namely nests of melanocytes with varied size and shape, confluent junctional nest of melanocytes (Fig. 2a) as well as increased numbers of atypical melanocytes at the dermo-epidermal junction and in the upper layers of the epidermis (Fig. 2b). Despite the ABCD rule, a significant proportion of melanomas do not fit the D criterion of 6 mm. In fact small melanomas have a reported frequency of 11.4–38.2% of all diagnosed melanomas. In view of a complete skin examination with dermoscopy requiring less than 3 min, we propose all lesions be routinely evaluated under dermoscopy, regardless of the size. Our present observation emphasizes the need for clinicians to be alert to the development of new lesions on individuals with a prior history of melanoma, particularly in the first 6–12 months post excision of the first melanoma. A recent study based in Queensland, Australia, found the risk of a second primary invasive melanoma to be 12.7/1000 person-years in the first 12 months, a figure much higher than that of the general population. Accordingly, we consider our case of an early diagnosis of a second primary

Unusual clinical and dermoscopic presentation of a wart

A 28-year-old man presented with a 2-month history of an asymptomatic lesion on his right lower leg (Fig. 1). Dermatological examination revealed a 6 ¥ 5-mm mildly erythematous, slightly papillomatous nodule with scaling and haemorrhagic crusts on the surface. Dermoscopically, a mosaic pattern with red dotted, looped and coiled vessels embedded in shiny white background colouration was seen (Fig. 2). The vascular features were mainly located in the centre of the ‘tiles’; although, in a small central area no vascular structures at all were noted. In addition, in the right upper pole a few irregular outlined dark-red to black areas reminiscent of haemorrhagic crusts were observed. Clinically and dermoscopically, the definitive diagnosis was not clear and most concerning was the possibility of this lesion representing an amelanotic nodular melanoma. Therefore, a deep shave biopsy with subsequent histopathological examination was performed. Histopathology revealed a typical exo-endophytic verruca vulgaris. The patient was reassured and no further treatment was required (Fig. 3). Published dermoscopic patterns of verruca vulgaris are limited, but have been described to consist of multiple densely packed papillae, containing a central red dot or loop in each, surrounded by a whitish halo reminiscent of frogspawn. Recently, Bae and colleagues described homogenous black to red dots and globules, and papilliform surfaces or interrupted skin lines as diagnostic features for viral warts. The mosaic pattern described in this case report is not dissimilar to the frogspawn appearance described above, and we note that the dermoscopic term ‘mosaic pattern’ was used by the same authors for verruca genitalis. In this case, dermoscopically the red dotted, looped and coiled vessels correspond histopathologically with apices of capillaries in the papillary dermis. Pinpoint / red dots and hairpin vessels can be found in keratinizing tumours, including seborrhoeic keratoses, warts, squamous cell carcinomas and, rarely, also in melanocytic tumours. However, the presence of white halos surrounding the vessels, as observed in the presently reported lesion, is suggestive of a keratinizing process. Comedolike openings and milialike cysts are two wellrecognised classic dermoscopic criteria for seborrhoeic keratoses, and the dermoscopic accuracy is improved with the additional dermoscopic features of fissures, hairpin blood vessels, sharp demarcation and moth-eaten borders. Apart from the sharp demarcation, all of the other typical features of seborrhoeic keratoses were not evident in this case. The lack of linear-irregular vessels and glomerular vessels reduced the likelihood of this lesion representing a squamous cell carcinoma. Hypopigmented and amelanotic melanoma are able to be distinguished dermoscopically from benign lesions to a certain extent . The presence of blue-white veil, scar-like and irregularly shaped depigmentation, irregular or multiple blue-gray dots, predominantly central vessels and red-blue colour were some of the key features not seen in this case. Dermoscopic findings in this case were only suggestive, but not conclusive, of verruca vulgaris, therefore a biopsy with subsequent histopathological examination was necessitated due to the concern surrounding the possibility of an amelanotic melanoma. One of the most predictive and distinguishing dermoscopic features of amelanotic melanoma is the presence of irregular polymorphic vessels. It is well recognised that vascular detail may vary according to operator compression; however, with the increased use of cross-polarized light contact and non-contact dermoscopy devices, in addition to increased magnification, the vessel detail will no longer be compromised, and more distinctive features will be attainable to improve its positive predictive values. Via clinicopathological correlation, the clinical and dermoscopic features of this case were supported by the underlying histopathology, which confirmed that it was in fact a wart, despite its unusual clinical and dermoscopic findings. Correspondence: Professor H Peter Soyer, Dermatology Research Centre, The University of Queensland, School of Medicine, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. Email: p.soyer@uq.edu.au Corinne Yoong, MB BS. Alessandro Di Stefani, MD. Rainer Hofmann-Wellenhof, MD. Terri Campbell, BBMedSc (Hons). H Peter Soyer, FACD. Submitted 22 March 2009; accepted 28 April 2009. Australasian Journal of Dermatology (2009) 50, 228–229 doi: 10.1111/j.1440-0960.2009.00548.x

Telemedicine in Skin Emergencies

Tele-dermatology has comparable diagnostic accuracy to face-to-face consultation. Skin emergencies need rapid turnaround. Tele-dermatology can reduce patient morbidity from skin emergencies. Tele-dermatology is cost effective in skin emergencies. Tele-dermatology is an under-utilised service, particularly for skin emergencies. The technical requirements for tele-dermatology may be limited to a digital camera and effective telecommunication. Most dermatological investigation and treatment can be carried out easily by medical practitioners and medical staff in A and E units.