Valda N. Kaye

Accuracy of teledermatology for pigmented neoplasms

BACKGROUND Accurate diagnosis and management of pigmented lesions is critical because of the morbidity and mortality associated with melanoma. OBJECTIVE We sought to compare accuracy of store-and-forward teledermatology for pigmented neoplasms with standard, in-person clinic dermatology. METHODS We conducted a repeated measures equivalence trial involving veterans with pigmented skin neoplasms. Each lesion was evaluated by a clinic dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and a management plan. The primary outcome was aggregated diagnostic accuracy (match of any chosen diagnosis with histopathology). We also compared the severity of inappropriately managed lesions and, for teledermatology, evaluated the incremental change in accuracy when polarized light dermatoscopy or contact immersion dermatoscopy images were viewed. RESULTS We enrolled 542 patients with pigmented lesions, most were male (96%) and Caucasian (97%). The aggregated diagnostic accuracy rates for teledermatology (macro images, polarized light dermatoscopy, and contact immersion dermatoscopy) were not equivalent (95% confidence interval for difference within +/-10%) and were inferior (95% confidence interval lower bound <10%) to clinic dermatology. In general, the addition of dermatoscopic images did not significantly change teledermatology diagnostic accuracy rates. In contrast to diagnostic accuracy, rates of appropriate management plans for teledermatology were superior and/or equivalent to clinic dermatology (all image types: all lesions, and benign lesions). However, for the subgroup of malignant lesions (n = 124), the rate of appropriate management was significantly worse for teledermatology than for clinic dermatology (all image types). Up to 7 of 36 index melanomas would have been mismanaged via teledermatology. LIMITATIONS Nondiverse study population and relatively small number of melanomas were limitations. CONCLUSIONS In general, the diagnostic accuracy of teledermatology was inferior whereas management was equivalent to clinic dermatology. However, for the important subgroup of malignant pigmented lesions, both diagnostic and management accuracy of teledermatology was generally inferior to clinic dermatology and up to 7 of 36 index melanomas would have been mismanaged via teledermatology. Teledermatology and teledermatoscopy should be used with caution for patients with suspected malignant pigmented lesions.

Sweat gland carcinoma ex eccrine spiradenoma

We herein report two cases of sweat gland carcinoma that arose in association with eccrine spiradenoma. These lesions presented as enlarging masses that previously had been stable for many years. One produced widespread metastasis and death 5 months after diagnosis. Immuno histochemical studies demonstrated an antigenic relationship between the benign and malignant components of sweat gland carcinoma ex eccrine spiradenoma, but ultra-structural analyses showed a paucity of specialized differentiation. This neoplasm appears to display a range of microscopic appearances and has proven fatal in 20% of reported cases.

Unilateral linear lichenoid eruption after bone marrow transplantation: An unmasking of tolerance to an abnormal keratinocyte clone?

Chronic cutaneous graft-versus-host disease may appear clinically as a lichenoid eruption. We describe a 26-year-old man who developed a unilateral linear lichenoid eruption 7 months after allogeneic bone marrow transplantation. We believe this represents an unusual form of localized, chronic graft-versus-host disease. The possible relationship to viral infection or cellular mosaicism and the clinical, histologic, and immunologic similarities to idiopathic lichen planus are discussed.

Carcinoma in situ of penis Is distinction betweem erythroplasia of Queyrat and Bowen's disease relevant?

Because of the confusion and controversy that exists in terminology, we attempted to determine whether or not there were any differences in histomorphology or behavior between erythroplasia of Queyrat and Bowens disease

Original articleAccuracy of teledermatology for nonpigmented neoplasms

BACKGROUND Studies of teledermatology utilizing the standard reference of histopathology are lacking. OBJECTIVE To compare accuracy of store-and-forward teledermatology for non-pigmented neoplasms with in-person dermatology. METHODS This study was a repeated-measures equivalence trial involving veterans with non-pigmented skin neoplasms. Each lesion was evaluated by an in-person dermatologist and a teledermatologist; both generated a primary diagnosis, up to two differential diagnoses, and management plan. The primary outcome was aggregated diagnostic accuracy (percent correct matches of any chosen diagnosis with histopathology). Secondary outcomes included management plan accuracy (percent correct matches with expert panel management plan). Additional analyses included evaluation of the incremental effect of using polarized light dermatoscopy in addition to standard macro images, and evaluating benign and malignant lesion subgroups separately. RESULTS Most of the 728 participants were male (97.8%) and Caucasian (98.9%). The aggregated diagnostic accuracy (primary outcome) of teledermatology (macro images) was not equivalent (95% confidence interval [CI] for difference within +/-10%) and was inferior (95% CI lower bound <10%) to in-person dermatology for all lesions and the subgroups of benign and malignant lesions. However, management plan accuracy was equivalent. Teledermatology aggregated diagnostic accuracy using polarized light dermatoscopy was significantly better than for macro images alone (P = .0017). The addition of polarized light dermatoscopy showed the same pattern for malignant lesions, but not for benign lesions. Most interestingly, for malignant lesions, the addition of polarized light dermatoscopy yielded equivalent aggregated diagnostic accuracy rates. LIMITATIONS Non-diverse study population. CONCLUSIONS Using macro images, the diagnostic accuracy of teledermatology was inferior to in-person dermatology, but accuracy of management plans was equivalent. The addition of polarized light dermatoscopy yielded significantly better aggregated diagnostic accuracy, but management plan accuracy was not significantly improved. For the important subgroup of malignant lesions, the addition of polarized light dermatoscopy yielded equivalent diagnostic accuracy between teledermatologists and clinic dermatologists.

Cryptococcal cellulitis in congenital lymphedema.

A 27‐year‐old woman with intestinal lymphangiectasia and congenital lymphedema developed cryptococ‐cal cellulitis as a result of her underlying depressed cell‐mediated immune responsiveness. Prompt therapy with amphotericin B and 5‐fluorocytosine resulted in an excellent outcome. The authors believe that the increasing population of patients with depression of cellmediated immune response will lead to an increase in the frequency with which cryptococcal cellulitis is seen and emphasize that proper evaluation of a patient with presumptive cellulitis includes consideration of fungal, as well as bacterial, etiology.

Experimental Rationale for Treatment of High-Risk Human Melanoma with Zinc Chloride Fixative Paste: Increased Resistance to Tumor Challenge in Murine Melanoma Model

BACKGROUND. Fixed‐tissue micrographic surgery (Mohs) of melanoma has been shown by retrospective analysis to improve 5‐year survival. OBJECTIVES. To determine whether zinc chloride fixative paste acts as an immune adjuvant to increase host resistance to melanoma. METHODS. We performed a murine study using the poorly im‐munogenic B16 melanoma of C57Bl/6J mice, and the more im‐munogenic K1735p melanoma of C3H/HeN mice. Tumors were treated with zinc chloride paste and excised 24 hours later (Group 1), or simply excised (Group 2). Mice were challenged 7 days later with injection of melanoma cells at a distant site, and tumor growth in this second site was followed. RESULTS. K1735p melanomas developed at the challenge site in 69% of mice treated with excision versus 32% of mice treated with zinc chloride fixation (P < 0.025). Development of B16 melanoma was not altered by zinc chloride fixation. CONCLUSION. Zinc chloride fixation of the more immunogenic K1735p melanoma increased resistance to subsequent tumor challenge, suggesting that zinc chloride fixative paste acts as an immune adjuvant.

Plaque-type syringoma: two cases misdiagnosed as microcystic adnexal carcinoma.

Background:  Plaque‐type syringoma is a rare variant of syringoma. This benign neoplasm may be easily misdiagnosed as microcystic adnexal carcinoma (MAC), potentially resulting in unnecessary surgery with disfiguring consequences.

Melanoma Tumor Seeding After Punch Biopsy

A 65-year-old man presented with an asymptomatic pigmented lesion of unknown duration located on the left mid back. Clinical examination revealed a 1.59 1.2-cm well-circumscribed, asymmetric, nonulcerated brown plaque with variegated coloration (Figure 1). A blue– white veil, irregular pigment globules, and regression structures were visualized using dermoscopy. Because of clinical suspicion of malignant melanoma, three scouting 4-mm punch biopsies were performed within the lesion. Two of three specimens showed invasive nodular melanoma with a Breslow depth of 0.71 mm. Fourteen days later, the tumor was excised down to the fascia with 1-cm lateral margins. Histologic examination of this excision revealed a tumor with a Breslow depth of 1.8 mm, but neoplastic melanocytes were also identified extending down the fibroinflammatory reaction from a previous punch biopsy tract into the subcutaneous fat with a Breslow depth of 9.0 mm (Figure 2). All margins were clear of tumor. Positron emission tomography–computed tomography (PET-CT) was negative for metastasis. Surgical oncology performed a wide excision and sentinel lymph node sampling. No residual tumor was present in the wide excision, and the sentinel lymph node biopsy was negative for metastatic disease. The patient declined further nodal basin dissection. Oncology ultimately opted not to “upstage” the patient based on biopsy seeding and maintained tumor classification as T2a. The patient declined adjuvant therapy. Six months later, there was no Figure 1. 1.59 1.2-cm plaque on left mid back.

Tinea versicolor with interface dermatitis

To the Editor, Tinea versicolor (TV) is a common fungal infection caused by normal skin saprophytes, Malassezia species. TV has a spectrum of clinical presentations: (i) numerous, well-circumscribed, scaly, hyperor hypopigmented macules and patches on the trunk and chest, which is the most common presentation; (ii) inverse TV, seen more often in immunocompromised hosts and (iii) follicular papules and pustules, which is known as pityrosporum folliculitis. We report an atypical and likely under-recognized presentation of TV with a novel histopathological finding of interface dermatitis. A 77-year-old male was evaluated for an asymptomatic eruption on the right upper abdomen, present for over 6 months. Physical examination revealed multiple firm, 2–3 mm, monomorphic, redbrown, inflammatory papules, some of which exhibited a fine white scale (Fig. 1). No pustules were present. A punch biopsy showed a slightly acanthotic epidermis with a mild superficial perivascular lymphocytic infiltrate. Fungal hyphae and spores were identified within the stratum corneum. Interestingly, an interface lymphocytic infiltrate was observed in the superficial dermis underlying the fungal elements (Fig. 2A,B). The diagnosis of TV was thus made. The patient had complete resolution of these papules after treatment with ketoconazole cream twice daily for 4 weeks, leaving normal pigmented skin. The histological changes associated with TV are slight hyperkeratosis and acanthosis with a minimal superficial perivascular lymphocytic infiltrate. Round spores of 2–8 mm in size admixed with 2– 3 mm short, thick hyphae are identifiable in the basket-weave stratum corneum. The inflammatory infiltrate consisting of mononuclear cells is usually sparse; it can be so subtle that the biopsy may resemble normal skin. Because the organisms are Fig. 1. Multiple red-brown papules with a minimal scale.