Long-term pubic dermatitis diagnosed as white piedra

The case of a 58-year-old man with a pruritic rash involving the pubic area that had been undiagnosed for 30 years is presented. At least 15 different primary care physicians and dermatologists evaluated the patient during this time period. Multiple treatments were unsuccessful and a definitive diagnosis was not rendered. Wood lamp evaluation of the pubic area revealed hair shaft concretions that were confirmed on histologic evaluation to be white piedra (WP). The patient was successfully treated with topical ketoconazole and the eruption completely resolved. Our case raises awareness of the use of Wood lamp and dermoscopy to evaluate for parasitic infections of the pubic hair shafts when nonspecific dermatitis presents in this area.

e-Derma - a Novel Wireless Dermatoscopy System

Cutaneous Melanoma (CM) is a malignant tumour, and is one of the most rapidly growing cancers. Discovering a melanoma in the early stages of the disease is extremely difficult and, as such, only an invasive disease stage can be identified easily with the naked eye. Dermatoscopy is a diagnostic method intended to maximise early detection of CM performed by the dermatoscopy system. To address the limitations of existing systems a novel, wireless digital dermatoscopy system is presented for providing high-resolution images. It integrates a wire-free camera operation and offers a safe transfer of captured images to the computer. The working process of available dermatoscopy systems was studied, which are the most commonly used in everyday dermatology practice. Some findings, like operability, image quality, scalability, user-friendliness, and safeness, were used for the development of an e-Derma dermatoscopy system. An assessment method was performed by a group of dermatoscopy trained dermatologists to evaluate the quality of the testing images. Finally, a laboratory evaluation of images in regard to different parameters like sharpness, colour representation and illumination was performed with the side-by-side comparison of images of available dermatoscopy systems. e-Derma is a novel dermatoscopy system, which eliminates some limitations of existing systems and provides high-quality images. A novel low-budget highly capable dermatoscopy system is presented. The integrated wireless image transfer technology eliminates the movement limitations of a therapist. The image resolution is not limited by the integrated camera; it is easily upgradable with a wide range of on market alternative or improved camera models.

Differential Diagnosis of Seborrheic Keratosis: Clinical and Dermoscopic Features

<p>Seborrheic keratosis (SK) is a benign epidermal keratinocytic tumor that is extremely common, particularly in individuals over the age of 50. Most individuals with SK will have more than one lesion and the presence of over 10 lesions in the same person is not uncommon. Although the clinical morphology of most SK with their stuck-on, symmetric, keratotic, and waxy appearance makes them easy to identify, many manifest a morphology resembling melanoma or squamous cell carcinoma. One can argue that such cases will ultimately not prove to be problematic since a simple biopsy will easily reveal their benign nature and eliminate any concerns. However, the cost and morbidity associated with the biopsy of benign lesions should not be underestimated. Methods to improve our in vivo ability to correctly identify SK will prove beneficial not only to the health care system in general but to the individual patient specifically. The issue of greater concern resides with skin cancers that mimic SK or when skin cancers arise in association with SK. Needless to say, in vivo methods to help identify malignancy and differentiate them from benign lesions would be welcomed by all. Fortunately, we do now have in vivo imaging methods such as dermoscopy that can improve the clinician's diagnostic accuracy. In this article, we summarize the current knowledge regarding the clinical and dermoscopic features of SK, and provide clues to aid in their diagnosis.</p> <p><em>J Drugs Dermatol. 2017;16(9):835-842.</em></p>.

Non-invasive tools for the diagnosis of cutaneous melanoma

BACKGROUND

While the excisional biopsy and histological examination of suspicious lesions remains the current gold standard for diagnosing cutaneous melanoma (CM), there is a demand for more objective and non-invasive examination methods that may support clinicians in their decision when to biopsy or not.

METHODS

This review is based on publications and guidelines retrieved by a selective search in PubMed and MEDLINE and focused on non-invasive diagnostic strategies for detecting melanoma.

RESULTS

Ten different non-invasive techniques were compared with regard to applicability, status of development, and resources necessary for introduction into clinical routine (dermoscopy, sequential digital dermoscopy, total body photography, computer-aided multispectral digital analysis, electrical impedance spectroscopy, Raman spectroscopy, reflectance confocal microscopy, multiphoton tomography, stepwise two-photon-laser spectroscopy, quantitative dynamic infrared imaging). In an effort to create a classification based on our analyses, we suggest to differentiate i) tools for screening of patients in daily clinical routine, ii) tools for examination of a restricted number of preselected lesions that produce an automated diagnostic score, iii) tools for examination of a restricted number of preselected lesions at specialized centers requiring extensive training, iv) devices at an experimental stage of development.

CONCLUSION

None of the discussed examination techniques is able to provide a definite and final diagnosis or to completely replace the histopathological examination. Up to date, the need for fully automated devices offering a complete skin cancer screening has not been satisfied.

Black Hairy Tongue: Predisposing Factors, Diagnosis, and Treatment

Black hairy tongue (BHT) is a benign condition commonly found among people who smoke, have poor oral hygiene, are immunocompromised, or have a medical condition limiting their ability to practice good oral hygiene. Though this condition is harmless, patients need to be educated on etiology as many common medications are associated with this condition. Patients being placed on certain antibiotics or antipsychotics should be educated on the importance of good oral hygiene or cessation of habits that promote BHT. Similarly, those with medical conditions increasing the risk for the development of BHT should schedule routine visits with their dentist or dental hygienist. Prognosis is good, and treatment consists of gentle brushing of the tongue, but many anecdotal reports exist demonstrating the use of medications or other products to treat this condition. This review addresses the epidemiology, clinical presentation, pathophysiology, etiology, histology, differential diagnosis, and treatment of BHT and lists all of the medications reported to cause this condition.

Videodermoscopy as a novel tool for dermatologic education

Dermoscopy is used as an adjunct to clinical examination in the diagnosis of skin lesions, including melanoma. Videodermoscopy, which allows for the concurrent examination of dermoscopic features at high magnification by instructors and trainees, may serve as a useful educational tool during bedside instruction. This article presents images of common cutaneous lesions taken with a standard optical dermatoscope and a videodermatoscope to highlight the potential educational advantages conferred by videodermoscopy.

A deep bag-of-features model for the classification of melanomas in dermoscopy images

Deep learning and unsupervised feature learning have received great attention in past years for their ability to transform input data into high level representations using machine learning techniques. Such interest has been growing steadily in the field of medical image diagnosis, particularly in melanoma classification. In this paper, a novel application of deep learning (stacked sparse auto-encoders) is presented for skin lesion classification task. The stacked sparse auto-encoder discovers latent information features in input images (pixel intensities). These high-level features are subsequently fed into a classifier for classifying dermoscopy images. In addition, we proposed a new deep neural network architecture based on bag-of-features (BoF) model, which learns high-level image representation and maps images into BoF space. Then, we examine how using this deep representation of BoF, compared with pixel intensities of images, can improve the classification accuracy. The proposed method is evaluated on a test set of 244 skin images. To test the performance of the proposed method, the area under the receiver operating characteristics curve (AUC) is utilized. The proposed method is found to achieve 95% accuracy.

Clinical and dermoscopic features of truly amelanotic plantar melanoma

Currently, there are no specific clinical and dermoscopic features for diagnosing truly amelanotic plantar melanoma (TAPM). The present study aimed to investigate the dermoscopic features of all clinical variants of TAMPS and to evaluate their histopathological correlations. A retrospective analysis of prospectively collected data was carried out during a 10-year period (2003-2013). We analyzed the clinical data of 1321 patients, who had received a histological diagnosis of melanoma at the Melanoma Unit of the University of Florence. We selected the clinical and dermoscopic images of TAPMs and analyzed the presence of dermoscopic parameters. Incorrect preoperative diagnoses were analyzed to highlight peculiar dermoscopic features of pinkish plantar melanomas, the clinical diagnosis of which is extremely challenging for the dermatologist. Of all 1321 patients, 29 (24%) had TAPMs. Importantly, only 20.7% of patients with TAPMs had a correct preoperative diagnosis of suspicious melanocytic lesion. On the basis of the initial misdiagnosis, TAPMs were categorized as eczema-like, verruca-like, angioma-like lesions. Dermoscopically, all TAPMs showed the presence of a well-defined 'erythematous homogeneous area' with an atypical polymorphous vascular pattern with dotted, globular, and glomerular vessels. Our study highlights a crucial dermoscopic feature of TAPMs, the 'erythematous homogeneous area' that is characteristic of the plantar region, and, to our knowledge and experience, has not been described in nonacral amelanotic melanomas.

Melanoma Classification on Dermoscopy Images Using a Neural Network Ensemble Model

We develop a novel method for classifying melanocytic tumors as benign or malignant by the analysis of digital dermoscopy images. The algorithm follows three steps: first, lesions are extracted using a self-generating neural network (SGNN); second, features descriptive of tumor color, texture and border are extracted; and third, lesion objects are classified using a classifier based on a neural network ensemble model. In clinical situations, lesions occur that are too large to be entirely contained within the dermoscopy image. To deal with this difficult presentation, new border features are proposed, which are able to effectively characterize border irregularities on both complete lesions and incomplete lesions. In our model, a network ensemble classifier is designed that combines back propagation (BP) neural networks with fuzzy neural networks to achieve improved performance. Experiments are carried out on two diverse dermoscopy databases that include images of both the xanthous and caucasian races. The results show that classification accuracy is greatly enhanced by the use of the new border features and the proposed classifier model.

[Examination procedure and description of skin lesions]

The dermatologic examination follows a clear structure. After a short history is taken, the whole skin is inspected. The description, which is ideally provided in writing, forces one to look at the skin more closely. The description should include an accurate description of the location, the distribution, the form, and the type of lesion. The article contains tables with internationally approved definitions to describe skin changes. The analysis of these findings allows one to deduce pathophysiologic mechanisms occurring in the skin and to deduce hypotheses, i. e., suspected and differential diagnoses. These are confirmed or excluded by further diagnostic measures. The expert comes to a diagnosis very quickly by a pattern-recognition process, whereby novices must still develop this kind of thinking. Experts can minimize cognitive bias by reflective analytical reasoning and reorganization of knowledge.

Dermoscopy of keratinocyte skin cancer

Keratinocyte skin cancer (KSC) refers to a broad class of tumors with a regrettably rising incidence worldwide. The term KSC stands for different stages of skin cancer including actinic keratosis (AK), Bowen's Disease (BD) and invasive squamous cell carcinoma (SCC). These tumors tend to grow slow, are unlikely to result in distant metastatic disease and death but they frequently destroy underlying tissues and should therefore be removed at the earliest possible stage. The fact that the cure rate is very high when KSC is detected in early stages emphasizes once more the applicability of dermoscopy as an integrative part of the clinical examination of skin tumors. In the first part of this review article, we summarize key points of the dermoscopic diagnosis of KSC including different stages of AK, BD and SCC. In the second part we want to focus on the progression model of KSC and the role of dermoscopy in the management of keratinocyte skin cancer.

Dermoscopic criteria and basal cell carcinoma

Basal cell carcinoma (BCC) is nowadays the most frequent skin cancer in the fair-skinned population. Clinical suspicion for BCC diagnosis can be easy in advance cases, but it sometimes sets a real challenge wherein dermoscopy has proven to be a useful tool. Dermoscopy is a non-invasive diagnostic technique that improves the clinical diagnosis of pigmented and non-pigmented BCC representing a link between macroscopic clinical dermatology and microscopic dermatopathology. The dermoscopy of basal cell carcinoma is currently very well-known, as well as the clinical and histopathological features of BCC subtypes. Recently some flowcharts and algorithms for the most common subtypes of BCC have been proposed. We review the latest literature on the topic to describe the most frequent dermoscopy patterns for each subtype.

Dermoscopic Findings in Patients with Pigmented Purpuric Dermatoses

Pigmented purpuric dermatoses (PPD) are a group of chronic and relapsing cutaneous disorders characterized by a distinct purpuric rash. The diagnosis is made with clinical and histopathological findings. Dermoscopy has rarely been used in the diagnosis of PPD. The aim of our study is to describe the dermoscopic findings in patients with PPD. Eighteen patients who were clinically and histopathologically diagnosed with PPD were studied prospectively. The type and duration of PPD, associated diseases, and medication history of the patients were noted. Dermoscopic examination was performed in all of the patients. Four of the patients were women and 14 of them were men. 16 (88.8%) of them had Shamberg's disease, 1 of them had lichen aureus, and 1 had purpura annularis telangiectoides. Dermoscopic examination revealed multiple irregular red dots, globules and/or patches and brown-coppery coloration on the background in all of the patients, a network of interconnected brown lines in 8, linear vessels in 9, brown dots in 3, grey dots in 3, twisted red loops in 5, comma-like vessels in 2, and red lacunae in 1 patient. The dermoscopic examination of PPD might improve the accuracy of clinical diagnosis.

Separating melanin from hemodynamics in nevi using multimode hyperspectral dermoscopy and spatial frequency domain spectroscopy

Changes in the pattern and distribution of both melanocytes (pigment producing) and vasculature (hemoglobin containing) are important in distinguishing melanocytic proliferations. The ability to accurately measure melanin distribution at different depths and to distinguish it from hemoglobin is clearly important when assessing pigmented lesions (benign versus malignant). We have developed a multimode hyperspectral dermoscope (SkinSpect™) able to more accurately image both melanin and hemoglobin distribution in skin. SkinSpect uses both hyperspectral and polarization-sensitive measurements. SkinSpect’s higher accuracy has been obtained by correcting for the effect of melanin absorption on hemoglobin absorption in measurements of melanocytic nevi. In vivo human skin pigmented nevi (N=20) were evaluated with the SkinSpect, and measured melanin and hemoglobin concentrations were compared with spatial frequency domain spectroscopy (SFDS) measurements. We confirm that both systems show low correlation of hemoglobin concentrations with regions containing different melanin concentrations (R=0.13 for SFDS, R=0.07 for SkinSpect).

Pigmented lesions of the nail bed - Clinical assessment and biopsy

BACKGROUND

Subungual melanoma is an uncommon type of melanoma that can be difficult to diagnose. Patients often present with advanced primary lesions and have an associated increased risk of nodal disease. Delays in diagnosis are believed to contribute to poor patient outcomes.

OBJECTIVE

The objective of this article is to offer an approach to assessing and managing patients who present with subungual pigmented lesions. We describe the anatomy of the nail bed to offer a rationale for our technique of nail bed biopsy, and warn of the potential to cause permanent nail dystrophy through other approaches.

DISCUSSION

Many clinicians have limited experience in assessing lesions of the nail apparatus.Subungual pigmentation has extremely broad differential diagnoses, which include a variety of benign pathologies. A systematic approach to assessment, and early referral of patients with suspicious lesions to a specialist unit, has the potential to improve patient outcomes.

Dermoscopy: a useful tool for assisting the diagnosis of Pseudomonas folliculitis

This report describes the usefulness of dermoscopy as a supportive diagnostic tool in a pseudomonas folliculitis case.

Dermoscopy as an adjuvant tool for the diagnosis and management of basal cell carcinoma

The list of dermoscopic criteria associated with basal cell carcinoma (BCC) have been several times updated and renewed. Up to date, dermoscopy has been shown to increase diagnostic and therapeutic accuracy, since provides valuable information about histopathologic subtype, a more accurate assessment of the true extension of tumor, the presence of pigmentation not visible to the naked eye and the treatment choice for BCC. In the current review, we provide an update of the traditional and latest knowledges on the value of dermatoscopy for the diagnosis and management of BCC.

Association Between Confocal Morphologic Classification and Clinical Phenotypes of Multiple Primary and Familial Melanomas

Importance

The improved knowledge of clinical, morphologic, and epidemiologic heterogeneity of melanoma in the context of multiple primary and familial melanomas may improve prevention, diagnosis, and prognosis of melanoma.

Objective

To characterize reflectance confocal microscopy (RCM) morphologic patterns of melanomas in multiple primary and familial melanomas.

Design, Setting, and Participants

In this cross-sectional, retrospective study, patients in a hospital-based referral center were recruited from March 1, 2010, through August 31, 2013; data analysis was conducted from September 1, 2013, through May 31, 2014. Consecutive primary melanomas, documented by dermoscopic and confocal examination, from multiple primary and familial melanomas with known CDKN2A mutational status were studied.

Main Outcomes and Measures

Epidemiologic, genetic, dermoscopic, and histologic data were evaluated according to an RCM morphologic classification: dendritic cell, round cell, dermal nest, combined, and nonclassifiable types.

Results

Fifty-seven melanomas from 50 patients (28 women [56%] and 49 white patients [98%]) were included: 23 dendritic cell (40%), 21 round cell (37%), 2 dermal nests (4%), 2 combined (4%), and 9 nonclassifiable (16%). The median (SD) age of the participants was 53.0 (16.9) years (interquartile range, 41.8-71.2 years), and the median (SD) age at the first melanoma was 46.0 (17.1) years (interquartile range, 35.8-61.5 years). Dendritic cell melanoma was characterized by older age at diagnosis, phototypes 2 and 3, more intense solar exposure, and moderate to severe solar lentigines; it was the most prevalent confocal type in facial lesions and was associated with the lentigo maligna histologic subtype. Round cell melanomas were identified more often in the familial context and in individuals with phototype 1 skin types; RCM features, such as junctional thickening, dense dermal nests, and nucleated cells within papillary dermis, were more frequently found in this subtype. Dermal nest and combined melanoma were associated with the absence of pigmented network on dermoscopy and thicker tumors on histologic analysis. Nonclassifiable type was associated, by RCM, with the absence of pagetoid cells on confocal examination and lower frequency of marked atypia on melanocytes in the basal cell layer; it presented with lower ABCD Total Dermoscopy Scores and RCM scores compared with the other types. CDKN2A mutation carriers may develop any RCM type of melanoma.

Conclusions and Relevance

Different routes to develop melanoma can be identified according to RCM morphologic classification, with dendritic cell melanomas being associated with chronic sun damage and round cell melanoma with early age at onset and phototype 1 in the context of multiple primary and familial melanomas. The morphologic expression of melanomas via dermoscopy and confocal examination varies according to differences in tumor stage and biological behavior.

Improving Diagnostic Accuracy of Dermoscopically Equivocal Pink Cutaneous Lesions with Reflectance Confocal Microscopy in Telemedicine Settings: Double Reader Concordance Evaluation of 316 Cases

BACKGROUND

Solitary pink lesions in differential diagnosis with hypopigmented/amelanotic melanoma present a diagnostic challenge in daily practice and are regularly referred for second expert opinion. Reflectance confocal microscopy (RCM) has been shown to improve diagnostic accuracy of dermoscopically equivocal pink lesions. No studies have been performed to evaluate the effect of adding a second expert reader and automatic removal of lesions with discordant management recommendations and its potential effect on diagnostic sensitivity and final management of these lesions in retrospective or telemedicine settings.

OBJECTIVE

To improve diagnostic accuracy and reduce potential mismanagement of dermoscopically equivocal pink cutaneous lesions by implementing double reader concordance evaluation of RCM images.

METHODS

316 dermoscopically equivocal pink lesions with dermoscopy-RCM image sets were evaluated retrospectively. Accuracy of three readers was evaluated by single reader evaluation of dermoscopy only and dermoscopy-RCM image sets and finally by double reader evaluation of dermoscopy-RCM image sets. Lesions with discordant diagnosis between two readers were automatically recommended for excision.

RESULTS

Dermoscopy only evaluation resulted in an overall sensitivity of 95.9% and specificity of 33.6%, with 1 of 12 amelanotic melanomas mismanaged. Dermoscopy-RCM image set single reader evaluation resulted in an overall sensitivity of 93.9% and overall specificity of 54.2%, with 1 of 12 melanomas mismanaged. Dermoscopy-RCM image set double reader concordance evaluation resulted in an overall sensitivity of 98.3% and specificity of 42.7%, with no amelanotic melanoma mismanagement.

CONCLUSION

Evaluation of dermoscopy-RCM image sets of equivocal pink lesions by a single reader in telemedicine settings is limited by the potential for misdiagnosis of dangerous malignant lesions. Double reader concordance evaluation with automatic referral of lesions for removal in the case of discordant diagnosis improves the diagnostic sensitivity in this subset of lesions and reduce potential misdiagnosis in settings where a second expert opinion may be employed.