Dermoscopic features of actinic keratosis and follow up with dermoscopy: A pilot study

Basal Cell Carcinoma: Comprehensive Review with Emphasis on Scar Tissue Manifestation and Post-Vaccination Incidence

Basal cell carcinoma (BCC) arising within scar tissue is a rare but clinically significant phenomenon. This comprehensive review aims to provide a succinct overview of the current state of knowledge regarding the etiological factors, pathogenesis, clinical presentation, and management of BCC. This study constitutes a literature review pertaining to BCC, with a particular emphasis on BCC developing within scar tissue. It also provides a clinical case presentation of a patient who had developed BCC in a BCG post-vaccination scar and a review of analogous findings available in the existing literature. Despite the fact that an array of mechanisms play a role in injury-related BCC growth, the main mechanism remains ambiguous and yet to be elucidated. The review also includes a detailed description of the various therapeutic options available for BCC, ranging from surgical interventions to novel pharmacological treatments. By examining these intersections, the review seeks to elucidate the potential mechanisms, identify risk factors, and suggest considerations for clinical practice. The findings underscore the importance of vigilant dermatological assessment in patients with scar tissue and those recently vaccinated, aiming to improve early detection and optimize management strategies for BCC.

[Translated article] Dermoscopy of Squamous Cell Carcinoma: From Actinic Keratosis to Invasive Forms

When the dermoscopy of squamous cell carcinoma and its precursors we differentiate among keratin-related, vascular, and pigment-related criteria. Non-pigmented actinic keratoses are characterized by the "strawberry pattern". Pigmented actinic keratosis shows a significant dermatoscopic overlap with lentigo maligna, but the presence of pigmented scales, erythema, and prominent follicles favors its diagnosis. Bowen's disease is characterized by clustered glomerular vessels, white-yellowish scales, and brown or grey dots arranged in lines in its pigmented variant. Finally, dermoscopy allows us to detect invasive squamous cell carcinoma in its early stages and differentiate it from its precursors. Furthermore, its presentation may vary depending on the degree of differentiation, with keratin-associated criteria predominating in well-differentiated tumors, while an atypical vascular pattern will predominate in poorly differentiated tumors.

Vascular feature identification in actinic keratosis grades I-III using dynamic optical coherence tomography with automated, quantitative analysis

Clinical grading of actinic keratosis (AK) is based on skin surface features, while subclinical alterations are not taken into consideration. Dynamic optical coherence tomography (D-OCT) enables quantification of the skin´s vasculature, potentially helpful to improve the link between clinical and subclinical features. We aimed to compare microvascular characteristics across AK grades using D-OCT with automated vascular analysis. This explorative study examined AK and photodamaged skin (PD) on the face or scalp. AKs were clinically graded according to the Olsen Classification scheme before D-OCT assessment. Using an open-source software tool, the OCT angiographic analyzer (OCTAVA), we quantified vascular network features, including total and mean vessel length, mean vessel diameter, vessel area density (VAD), branchpoint density (BD), and mean tortuosity from enface maximum intensity projection images. Additionally, we performed subregional analyses on selected scans to overcome challenges associated with imaging through hyperkeratosis (each lesion group; n = 18). Our study included 45 patients with a total of 205 AKs; 93 grade I lesions, 65 grade II, 47 grade III and 89 areas with PD skin. We found that all AK grades were more extensively vascularized relative to PD, as shown by greater total vessel length and VAD (p ≤ 0.009). Moreover, AKs displayed a disorganized vascular network, with higher BD in AK I-II (p < 0.001), and mean tortuosity in AK II-III (p ≤ 0.001) than in PD. Vascularization also increased with AK grade, showing significantly greater total vessel length in AK III than AK I (p = 0.029). Microvascular quantification of AK unveiled subclinical, quantitative differences among AK grades I-III and PD skin. D-OCT-based microvascular assessment may serve as a supplement to clinical AK grading, potentially raising perspectives to improve management strategies.

A Systematic Review of Diagnoses with Rosettes Under Dermoscopy

INTRODUCTION

Rosettes are a cluster of shiny white dots in the shape of a four-leaf clover seen under polarized dermoscopic light. Historically, rosettes were primarily reported in actinic keratoses and squamous cell carcinoma. However, rosettes have also been reported in other conditions.

OBJECTIVES

The objective of this systematic review to elucidate the breadth of diagnoses exhibiting this unique dermoscopic phenomenon.

METHODS

A review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Literature searches were performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science, as well as a manual search of the reference lists of screened articles.

RESULTS

A total of 73 articles met the inclusion criteria. Out of these, 47 distinct diagnoses with rosette were identified. Among neoplastic conditions, keratinizing neoplasms had the highest number of articles reported (N = 19). Discoid lupus was the most commonly reported diagnosis within the inflammatory category (N = 6). Molluscum contagiosum was the predominant diagnosis among infectious entities (N = 3), while acroangiodermatitis was the sole diagnosis reported in the vascular category (N = 1).

CONCLUSIONS

These findings confirm rosettes are not specific to keratinocytic growths and are observed in a wide range of conditions. Knowledge of the breadth of conditions with rosettes may aid clinicians when developing a differential diagnosis of a growth or an eruption with rosettes under dermoscopy.

Efficacy and safety of microneedling, fractional CO2 laser, and cryotherapy combined with 5-aminolevulinic acid photodynamic therapy in the treatment of actinic keratosis: A multicenter prospective randomized controlled study

BACKGROUND

Photodynamic therapy (PDT) for actinic keratosis (AK) is limited by the depth of treatment. Microneedling or fractional CO2 laser can facilitate the penetration of photosensitizer, while cryotherapy can treat deeper tissues but is not suitable for field cancerization.

OBJECTIVE

To investigate the efficacy of microneedling, fractional CO2 laser, and cryotherapy in combination with PDT for AK.

METHODS

Patients with AK were randomized into 4 groups, including group A with microneedling + PDT, group B with fractional CO2 laser + PDT, group C with cryotherapy + PDT, and group D with PDT. After 12 weeks, the clinical, dermoscopic, and reflectance confocal microscopy (RCM) outcomes were assessed.

RESULTS

A total of 129 patients were included in this study, with 31, 30, 35, and 31 patients in each group, yielding clinical response rates of 90.3%, 93.3%, 97.1%, and 74.2%, respectively (P=0.026). The RCM response rates were 71.0%, 80.0%, 85.7%, and 54.8%, respectively (P=0.030). The dermoscopic response rates were 77.4%, 83.3%, 88.6%, and 60.0%, respectively (P=0.039). Group C showed the best efficacy in terms of clinical, dermoscopic, and RCM outcomes.

CONCLUSIONS

All three treatments improved the efficacy of PDT and were well tolerated, with cryotherapy + PDT showing the best efficacy.

Actinic Keratoses: A Prospective Pilot Study on a Novel Formulation of 4% 5-Fluorouracil Cream and a Review of Other Current Topical Treatment Options

BACKGROUND

Actinic keratosis (AK) is one of the most common skin diseases, with a low risk of progression into invasive squamous cell carcinoma. We aim to assess efficacy and safety of a novel formulation of 5-Fluorouracil (5-FU) 4% with once daily application for the treatment of multiple AKs.

METHODS

A pilot study was performed on 30 patients with a clinical and dermoscopic diagnosis of multiple AKs, enrolled between September 2021 and May 2022 at the Dermatology Departments of two Italian hospitals. Patients were treated with 5-FU 4% cream once daily for 30 consecutive days. The Actinic Keratosis Area and Severity Index (AKASI) was calculated before starting therapy, and at each follow-up, to assess objective clinical response.

RESULTS

The cohort analyzed included 14 (47%) males and 16 (53%) females (mean age: 71 ± 12 years). A significant decrease in AKASI score at both 6 and 12 weeks (p < 0.0001) was observed. Only three patients (10%) discontinued therapy, and 13 patients (43%) did not report any adverse reactions; no unexpected adverse events were observed.

CONCLUSIONS

In the setting of topical chemotherapy and immunotherapy, the new formulation of 5-FU 4% proved to be a highly effective treatment for AKs and field cancerization.

Efficacy evaluation and dermoscopy predictors of photodynamic therapy with different pretreatments in the treatment of actinic keratosis

OBJECTIVE

The aim of this study was to accurately evaluate the efficacy of photodynamic therapy (PDT) on actinic keratosis (AK) in the Asian population and its relationship with preconditioning and dermoscopy grading, and to determine whether some dermoscopic features of AK can independently predict the response to PDT to optimize the choice of clinical treatment.

MATERIALS AND METHODS

From January 2017 to January 2020, patients who were diagnosed as AK with only one lesion in our hospital were included in our study. PDT was performed after pretreatment with ablative fractional CO2 laser or cryotherapy. Logistic regression analysis was used to evaluate the characteristics of dermoscopy to determine the independent predictors of efficacy.

RESULTS

A total of 95 patients were enrolled in the study, and the final clinical evaluation was 92 cases (96.8%) as complete remission and 3 cases (3.2%) as partial remission/no response. Dermoscopy showed complete remission in 77 cases (81.1%) and partial remission/no response in 18 cases (18.9%). No significant difference was observed in the complete remission rate of dermoscopy grade 1 lesion after laser or cryotherapy pretreatment (p > 0.05), but for dermoscopy grade 2 and grade 3 lesions, the complete remission rate (dermoscopy evaluation) of the cryotherapy pretreatment group was higher than that of laser group (p < 0.05). The probability of complete remission with red pseudonetwork at the T0 time point increased by 3.8 times (odds ratio [OR] = 3.870,95%confidence interval [CI]:1.077-13.912, p = 0.048), while the probability of complete response for lesions with slight erosion at the baseline decreased by 85% (OR = 0.150,95%CI:0.033-0.671, p = 0.013).

CONCLUSION

For dermoscopy grade 2 and 3 lesions, PDT after pretreatment with cryotherapy is more effective. Dermoscopy pseudo-reticular structure and microscopic erosions were independent predictors of PDT efficacy. These findings may help clinicians to better select patients with AK for PDT.

Assessment of Basal Cell Carcinoma Using Dermoscopy and High Frequency Ultrasound Examination

Basal cell carcinoma (BCC) is the most common form of cutaneous neoplasia in humans, and dermoscopy may provide valuable information for histopathological classification of BCC, which allows for the choice of non-invasive topical or surgical therapy. Similarly, dermoscopy may allow for the identification of incipient forms of BCC that cannot be detected in clinical examination. The importance of early diagnosis using the dermoscopy of superficial BCC forms is proven by the fact that despite their indolent clinical appearance, they can be included in high-risk BCC forms due to the rate of postoperative recurrence. Nodular pigmentary forms of BCCs present ovoid gray-blue nests or multiple gray-blue dots/globules associated with arborized vessels, sometimes undetectable on clinical examination. The management of BCC depends on this, as pigmentary forms have been shown to have a poor response to photodynamic therapy. High frequency ultrasound examination (HFUS) aids in the diagnosis of BCC with hypoechoic tumour masses, as well as in estimating tumour size (thickness and diameter), presurgical margin delineation, and surgical planning. The examination is also useful for determining the invasion of adjacent structures and for studying local recurrences. The use of dermoscopy in combination with HFUS allows for optimisation of the management of the oncological patient.

The “Virtual Biopsy” of Cancerous Lesions in 3D: Non-Invasive Differentiation between Melanoma and Other Lesions Using Vibrational Optical Coherence Tomography

Early detection of skin cancer is of critical importance to provide five year survival rates that approach 99%. By 2050, one out of five Americans by age 70 will develop some form of skin cancer. This will result in a projected rate of 50 million skin biopsies per year given the current rate of escalation. In addition, the ability to differentiate between pigmented lesions and melanomas has proven a diagnostic challenge. While dermoscopy and visual analysis are useful in identifying many skin lesions, additional non-invasive techniques are needed to assist in the analysis of difficult to diagnose skin tumors. To augment dermoscopy data, we have developed 3D maps based on physical biomarker characteristics of benign and cancerous lesions using vibrational optical coherence tomography (VOCT). 3D images based on quantitative physical data involving changes in cellular and fibrous tissue stiffness along with changes in vascular quality are used to map and evaluate different types of cancers. 3D tumor maps constructed using quantitative VOCT data and OCT images have been used to characterize the differences between melanoma and other lesions. These characteristics can be used to plan the excision of difficult lesions where extensive surgery may be needed to remove the entire tumor in one step. In addition, it is now possible to use dermoscopy and VOCT to non-invasively differentiate between different cancerous lesion types using measurements of the resonant frequency of new cellular and vascular peaks. Quantitative VOCT information along with dermoscopic findings can be collected and analyzed remotely using artificial intelligence to improve cancerous tissue diagnosis.

Evaluation of relationship between antihypertensive drug usage and dermatoscopic features in patients with keratinizing skin cancer

Keratinizing skin cancers including actinic keratoses (AK), in situ squamous cell carcinoma/Bowen's disease/intraepidermal carcinoma (IEC), invasive cutaneous squamous cell carcinoma (cSCC) and keratoacanthoma share similar dermatoscopic features and also reveal different patterns that assist in their diagnosis. Recently epidemiological studies reveal the association between antihypertensive drugs and skin cancer risk, especially cSCC. This study aims to determine the dermatoscopic features of keratinizing skin cancer in patients using antihypertensive drug and compare with non-users. A total of 46 patients with 64 keratinizing skin cancer lesions were included in the study. The demographic, clinical characteristic of patients, the number, duration, localization and dermatoscopic features from each lesion were collected. First, we evaluated the dermatoscopic features according to the histopathologic diagnosis. Then, all patients were divided into two groups as users of antihypertensive drugs and non-users. The dermatoscopic features were compared in terms of antihypertensive drug usage and histopathologic diagnosis in antihypertensive drug users and non-users, separately. The users of anti-hypertensive drugs were 22 (47,8%) and non-users 24 (52,2%). Of the total 64 lesions including 47 AK, 5 IEC, 10 cSCC, and 2 keratoacanthoma were evaluated. White structureless area was found statistically significant in cSCC lesions of patients using antihypertensive drugs (P = .004). This finding in cSCC may be a clue for antihypertensive drug usage and these drugs may be a predisposan factor for dermal fibrosis. Regardless of histopathology, dermatoscopic features show no statistically difference between antihypertensive drug users and non-users (P > .05). Clearer results can be obtained by conducting more detailed and long-term studies.

Evaluation of dermatoscopic criteria for early detection of squamous cell carcinoma arising on an actinic keratosis

BACKGROUND

Advanced squamous cell carcinoma (SCC) can be discriminated easily from actinic keratosis (AK) based on clinical and dermatoscopic features. However, at the initial stage of dermal invasion, SCC might still be clinically flat and discrimination from AK remains challenging, even with the addition of dermatoscopy.

OBJECTIVE

The aim of this study was to investigate the clinical and dermatoscopic criteria that could suggest early invasion and serve as potent predictors to discriminate early SCC from AK.

METHODS

Clinical and dermatoscopic images of histopathologically diagnosed AKs and early SCCs were evaluated for the presence of predefined criteria by 3 independent investigators.

RESULTS

A total of 50 early SCCs and 45 AKs were included. The main positive dermatoscopic predictors of early SCC were dotted/glomerular vessels (odds ratio [OR] 3.83), hairpin vessels (OR 12.12), and white structureless areas (OR 3.58), whereas background erythema represented a negative SCC predictor (OR 0.22).

LIMITATIONS

The retrospective evaluation of images. Moreover, the differential diagnosis included in the study is restricted between AK and early SCC.

CONCLUSIONS

We identified potent predictors for the discrimination of AK and early SCC that may better guide management decisions in everyday clinical practice.

The role of dermoscopy in diagnostics of dermatological conditions of the eyelid, eyelashes, and conjunctiva - a literature review

The role of dermoscopy in dermatology is constantly evolving. Relatively little is known about its application in diagnosis of dermatological conditions of the eyelid, eyelashes, and conjunctiva. The aim of the study is to summarize the existing knowledge in this field.

Dermoscopy in China: current status and future prospective

OBJECTIVE

Dermoscopy is a useful technique for improving the diagnostic accuracy of various types of skin disorders. In China, dermoscopy has been widely accepted, and domestic researchers have made tremendous progress in the field of dermoscopy. The main purpose of this review is to summarize the current status of dermoscopy in China and identify its future directions.

DATA SOURCES

Articles included in this review were obtained by searching the following databases: Wanfang, China National Knowledge Infrastructure, PubMed, and the Web of Science. We focused on research published before 2019 with keywords including dermoscopy, dermoscopic, dermoscope and trichoscopy.

STUDY SELECTION

A total of 50 studies were selected. Of these studies, 20 studies were in Chinese and 30 in English, research samples of all the studies were collected from Chinese populations.

RESULTS

Since 2000, more than 380 articles about dermoscopy have been published in domestic or foreign journals. Dermoscopy can improve the diagnostic accuracy of neoplastic diseases, evaluating the therapeutic effect of treatment, and determining the treatment endpoint, and it can also assist in the differential diagnosis of inflammatory diseases and in the assessment of the severity of the disease. In addition, researches about the applications of dermoscopy during surgical treatment have been published. Training courses aiming to improve the diagnostic ability of dermatologists, either face-to-face or online, have been offered. The Chinese Skin Image Database, launched in 2017 as a work platform for dermatologists, has promoted the development of dermoscopy in China. Computer-aided diagnostic systems based on the Chinese population are ready for use. In the future, cooperation, resource sharing, talent development, image management, and computer-aided diagnosis will be important directions for the development of dermoscopy in China.

CONCLUSION

Dermoscopy has been widely used and developed in China, however, it still needs to address more challenges in the future.

Kératoses actiniques : diagnostic anatomoclinique

Actinic keratoses are epidermal preneoplastic lesions localised in photo-exposed areas. They are made of a keratosis of variable thickness overlying an erythematous area, that may be indurated. A field of cancerization is characterized by multiple actinic keratoses in a chronically sun exposed area, especially on the bald area of the scalp in aged males. In general, the diagnosis is made on clinical basis, but a biopsy is necessary in case of ulceration, induration, post-treatment recurrence or bleeding. Biopsy is also mandatory for atypical keratosis, especially the pigmented variants. Histopathology shows dysplasia of the epidermal basal layer, with irregular and hyperchromatic nuclei, parakeratosis and generally a dermal lymphocytic infiltrate. There are hypertrophic, atrophic, pigmented and lichenoid variants among the most common subtypes. The main clinicopathological issue is transformation of actinic keratosis into squamous cell carcinoma, defined by epidermal sheaths of atypical cells penetrating into the dermis. These cells are eosinophilic and show images of dyskeratosis or squamous whorls. Dermatoscopy (and other non invasive imaging techniques) might be useful to help decision making - when to perform a biopsy - and for differential diagnosis. © 2019 Elsevier Masson SAS. All rights reserved. Cet article fait partie du numéro supplément Kératoses actiniques : comprendre et traiter réalisé avec le soutien institutionnel de Galderma International.

Actinic keratoses: review of clinical, dermoscopic, and therapeutic aspects

Actinic keratoses are dysplastic proliferations of keratinocytes with potential for malignant transformation. Clinically, actinic keratoses present as macules, papules, or hyperkeratotic plaques with an erythematous background that occur on photoexposed areas. At initial stages, they may be better identified by palpation rather than by visual inspection. They may also be pigmented and show variable degrees of infiltration; when multiple they then constitute the so-called field cancerization. Their prevalence ranges from 11% to 60% in Caucasian individuals above 40 years. Ultraviolet radiation is the main factor involved in pathogenesis, but individual factors also play a role in the predisposing to lesions appearance. Diagnosis of lesions is based on clinical and dermoscopic examination, but in some situations histopathological analysis may be necessary. The risk of transformation into squamous cell carcinoma is the major concern regarding actinic keratoses. Therapeutic modalities for actinic keratoses include topical medications, and ablative and surgical methods; the best treatment option should always be individualized according to the patient.

Rosettes and other white shiny structures in polarized dermoscopy: histological correlate and optical explanation

BACKGROUND

Rosettes are a specific form of a white shiny structure seen with polarized dermoscopy. The precise morphological correlate and optical explication are not known.

OBJECTIVE

To estimate the frequency of rosettes in ex vivo dermoscopy and to find explication and morphologic correlate of this dermoscopic feature.

METHODS

A series of 6108 consecutive skin biopsies were examined with ex vivo dermoscopy and when rosettes were present serial transverse sections with polarization were examined.

RESULTS

In this series of 6108 consecutive skin biopsies, rosettes were found on ex vivo dermoscopy in 63 cases. When multiple we observed that they are always oriented at the same angle. Transverse sections with polarization of these lesions proved that smaller rosettes are mainly caused by polarizing horny material in adnexal openings, and larger rosettes by concentric perifollicular fibrosis.

CONCLUSIONS

Rosettes are an optical effect of crossed polarization by concentric fibrosis or horny material and hence are not lesion-specific.