In vivo abnormal keratinazation in Darier-White's disease as viewed by real-time confocal imaging

Dermoscopic and reflectance confocal microscopic presentation of Hailey-Hailey disease: A case series

BACKGROUND/PURPOSE

Hailey-Hailey disease is a rare inherited acantholytic skin disorder characterized by heterogeneous clinical presentation. Its differential diagnosis might be wide, including other genodermatoses, inflammatory, and infectious skin diseases. Although histopathology remains as diagnostic gold standard, noninvasive techniques such as dermoscopy and reflectance confocal microscopy may assist clinical examination. Herein, we aim to further characterize the dermoscopic and reflectance confocal microscopic presentation of Hailey-Hailey disease with histologic correlation.

METHODS

Eight patients with Hailey-Hailey disease were consecutively recruited. All patients were examined using dermoscopy and reflectance confocal microscopy.

RESULTS

In all cases, dermoscopy enabled the visualization of polymorphous vessels, including glomerular and linear-looped vessels, within a pink-whitish background. Reflectance confocal microscopy revealed wide suprabasilar partial acantholysis and clefting, crusts, dilated papillae with tortuous vessels, and inflammatory cells. Dyskeratosis, uplocated papillae, and adnexal sparing were also observed.

CONCLUSION

Although definite diagnosis was obtained by histopathology in all cases, dermoscopy and reflectance confocal microscopy allowed the identification of common features (even in cases with dissimilar clinical presentation) that may support an early diagnosis of Hailey-Hailey disease, and its differentiation from other more frequent skin disorders.

Grover's disease: dermoscopy, reflectance confocal microscopy and histopathological correlation

Grover’s disease is a benign condition of unknown origin characterized clinically by an erythematous papulovesicular eruption and histopathologically by intraepidermal clefting and four different patterns of acantholysis: Darier-like, pemphigus-like, spongiotic, and Hailey-Hailey-like. A case of a 54-year-old female affected by Grover’s disease and showing a Darier-like histopathological pattern is described. Polarized light dermoscopy (PLD) revealed the presence of polygonal, star-like shaped yellowish/brownish areas of various sizes surrounded by a thin whitish halo. Handheld reflectance confocal microscopy (RCM) showed the presence of intraepidermal dark spaces histopathologically corresponding to intraepidermal clefts, roundish, bright cells correlating to acantholytic keratinocytes, target-like cells with a dark center and a highly reflectant halo corresponding to dyskeratotic cells, and epidermal, polygonal, structureless areas reflecting hyperparakeratosis. In conclusion, the use of PLD and RCM combined with clinical presentation, personal/family history, and genetic evaluation may be useful for the non-invasive diagnosis of Darier-like Grover’s disease.

Concordance between in vivo reflectance confocal microscopy and optical histology of lymphomatoid papulosis

BACKGROUND

Lymphomatoid papulosis is a primary cutaneous CD30+ T-cell lymphoma clinically characterized by a benign, chronic, recurrent course with self-limited papulo-nodular skin lesion eruption. In vivo Reflectance Confocal Microscopy is a non-invasive technique for real-time imaging of the superficial layers of the skin down to the superficial dermis with cellular-level resolution close to conventional histopathology. RCM has been previously reported to be useful in the in vivo evaluation of inflammatory diseases, skin tumours and also cutaneous lymphomas. Only two articles have been published on cutaneous lymphomas and none detailing confocal features of LyP. The aim of this manuscript was to describe the confocal features of LyP and their histological correlation to evaluate the possible application of this non-invasive tool in this T-cell lymphoma subtype clinical management.

METHODS

Five patients with histological diagnosis of LyP were imaged with RCM, followed by a skin biopsy on a clinically selected lesion.

RESULTS

High grade of correspondence between RCM and histopathology of LyP was observed, disclosing the potential rule of RCM at least for biopsy site selection.

CONCLUSION

Future studies on RCM for LyP vs. other cutaneous T-cells lymphomas and inflammatory skin diseases are needed to assess specificity and sensibility of our preliminary data.

Reflectance confocal microscopy characteristics of eight cases of pustular eruptions and histopathological correlations

BACKGROUND

Reflectance confocal microscopy (RCM)'s interest has been well established for the non-invasive diagnosis of skin cancers, especially melanocytic, and in the differential diagnosis between benign and malignant cutaneous lesions. However, its diagnostic interest in inflammatory skin diseases still needs to be demonstrated. Our purpose was to evaluate the correlation between RCM and conventional histopathology in a series of pustular eruptions of different pathogeny.

METHODS

Reflectance confocal microscopy analysis was performed in eight consecutive unselected patients in whom the diagnoses of pustular psoriasis, bacterial sur-infection, herpes-type virus skin sur-infection, Sneddon-Wilkinson subcorneal putulosis and Hailey-Hailey disease have been made and images were compared to conventional histopathology.

RESULTS

Neutrophils within the epidermis exhibited never reported earlier specific features, with either a shiny granular sludge or polylobated particules with a bright granular content. Moreover, some specific etiologies could be identified, such as acantholysis and herpes-type virus-infected keratinocytes.

CONCLUSION

Our studies show a good correlation between RCM and conventional histopathology in pustular eruptions. Reflectance confocal microscopy may play an important role in the differential diagnosis of pustular eruptions; as most of the pathologic clues are epidermal, narrow thickness of the field of imaging, its main technical limitation, is indeed of lesser importance.

Clinicopathological features of a suspected case of hereditary benign intraepithelial dyskeratosis with bilateral corneas involved: a case report and mini review

PURPOSE

To report a suspected case of hereditary benign intraepithelial dyskeratosis (HBID) in China.

METHODS

Case report and review of the related literature.

RESULTS

A 43-year-old woman developed bilateral, elevated, white-to-grayish, gelatinous plaques on the perilimbal region and buccal mucosa. Her daughter had similar lesions on the buccal and pharyngeal mucosa. In vivo confocal microscopy demonstrated the loss of limbal palisades of Vogt in the patient's left eye. An incisional biopsy of her conjunctiva and buccal mucosa was performed, which indicated that the histopathological characteristics were quite similar to those of HBID. The patient underwent removal of the plaques and limbal allograft transplantation in the left eye. Postsurgery treatments included systemic cyclosporin A and topical artificial tears for both eyes. Ocular symptoms were alleviated, and no relapse was observed during the 1.5-year follow-up.

CONCLUSIONS

In a suspected case of HBID in China, limbal stem cell transplantation was effective.

Confocal microscopic features of scarring alopecia: preliminary report

BACKGROUND

Lichen planopilaris (LPP) and discoid lupus erythematosus (DLE) are the most common causes of lymphocytic primary cicatricial alopecia. The management of scarring alopecia can be difficult. The combination of clinical, dermoscopy and reflectance confocal microscopy (RCM), a noninvasive, high-resolution imaging technique, examinations have already been demonstrated to be useful for choosing the correct biopsy site in patients with inflammatory skin disease and obtaining microscopic diagnostic criteria.

OBJECTIVES

We evaluated the usefulness in practice of RCM for the identification of criteria for LPP and DLE involving the scalp and their management during therapeutic follow-up.

METHODS

Seven white patients with a previously established histological diagnosis of DLE (three) and LPP (four), were included in the study. RCM criteria for primary scarring alopecia were selected: epidermal disarray, spongiosis, exocytosis of inflammatory cells in the epidermis, interface dermatitis, peri- and intra-adnexal infiltration of inflammatory cells, dilated vessels in the dermis, dermal infiltration of inflammatory cells and melanophages and dermal sclerosis. All patients were followed up using RCM during the treatment. During follow-up the RCM evolution of the epidermal, junctional and dermal inflammation were evaluated.

RESULTS

A series of RCM features of scalp LPP and DLE were identified that show correlation with the histopathological evaluation. During the treatment follow-up of the cases RCM was shown to be sensitive for the identification of therapeutic response.

CONCLUSION

In our preliminary study the effective usefulness of RCM for the diagnosis of scarring alopecia and follow-up seemed to be evident. Moreover, RCM seems to be also promising for differential diagnosis between the different entities.

Corneal confocal microscopy in Darier disease

PURPOSE

We report ocular findings in a patient with Darier disease. In particular, we discuss the in vivo confocal images.

METHOD

A retrospective noninterventional case report.

RESULTS

Confocal microscopy revealed collections of intercellular material, separating the cells of the patient's basal corneal epithelium. Discrete foci of this material were scattered throughout the central corneal basal epithelium in both eyes. These deposits had a similar reflectance as corneal nerves, were 3-5-microm thick, and of note in places conformed to the cell borders.

CONCLUSIONS

The findings of abnormal intercellular collections at the basal epithelial layer of the cornea correlate with the previously reported histological findings. They are consistent with the abnormal keratocyte-to-keratocyte adhesions that are described both in the skin and cornea of Darier disease. The abnormalities we describe occurred in the absence of other ocular signs of Darier disease. These findings on confocal microscopy may help with the diagnosis and monitoring of disease progression.

Preliminary evaluation of in vivo reflectance confocal microscopy features of discoid lupus erythematosus

BACKGROUND

Discoid lupus erythematosus (DLE) can simulate other inflammatory diseases both clinically and histologically. In vivo reflectance confocal microscopy (RCM) is a noninvasive, reproducible imaging technique already reported to be useful in the evaluation of several inflammatory skin conditions such as contact dermatitis, psoriasis and Darier disease.

OBJECTIVES

The aims of our study were to define RCM features of DLE and to evaluate its feasibility in biopsy site selection.

METHODS

Discoid lesions were selected for RCM evaluation from 10 patients with an established diagnosis of DLE. Subsequently, a 4-mm punch biopsy of the same areas evaluated with RCM was rendered for histopathological examination.

RESULTS

A series of RCM features of DLE was identified and shown to correlate well with histopathological evaluation. Interface changes, as well as epidermal, dermal and adnexal inflammatory cell infiltration, were identified with RCM in a high percentage of the lesions. A limitation of RCM examination besides imaging depth was the inability to distinguish lymphocytes from other white blood cells.

CONCLUSIONS

The utility of RCM as a diagnostic tool for DLE awaits further evaluation, although it appears to be promising for biopsy site selection.

Large area confocal microscopy

Imaging large tissue areas with microscopic resolution in vivo may offer an alternative to random excisional biopsy. We present an approach for performing confocal imaging of large tissue surface areas using spectrally encoded confocal microscopy (SECM). We demonstrate a single-optical-fiber SECM apparatus, designed for imaging luminal organs, that is capable of imaging with a transverse resolution of 2.1 microm over a subsurface area of 16 cm2 in less than 1 min. Due to the unique probe configuration and scanning geometry, the speed and resolution of this new imaging technology are sufficient for comprehensively imaging large tissues areas at a microscopic scale in times that are appropriate for clinical use.

Molecular optical imaging of therapeutic targets of cancer

Recent progress in discerning the molecular events that accompany carcinogenesis has led to development of new cancer therapies directly targeted against the molecular changes of neoplasia. Molecular-targeted therapeutics have shown significant improvements in response rates and decreased toxicity as compared to conventional cytotoxic therapies which lack specificity for tumor cells. In order to fully explore the potential of molecular-targeted therapy, a new set of tools is required to dynamically and quantitatively image and monitor the heterogeneous molecular profiles of tumors in vivo. Currently, molecular markers can only be visualized in vitro using complex immunohistochemical staining protocols. In this chapter, we discuss emerging optical tools to image in vivo a molecular profile of risk-based hallmarks of cancer for selecting and monitoring therapy. We present the combination of optically active, targeted nanoparticles for molecular imaging with advances in minimally invasive optical imaging systems, which can be used to dynamically image both a molecular and phenotypic profile of risk and to monitor changes in this profile during therapy.

Clinical presentations of cutaneous melanoma

Cutaneous melanoma is responsible for the majority of skin cancer deaths. Early and accurate detection are the most important means to improve patient survival. This article reviews the common clinical presentations of head and neck cutaneous melanoma, and discusses lesions that might be clinically mistaken for melanoma.

In vivo assessment of melanocytic nests in nevi and melanomas by reflectance confocal microscopy

In vivo reflectance confocal microscopy is a novel technique for the noninvasive study and diagnosis of the skin. The aim of this study was to describe and characterize the cytological and architectural aspects of cell clusters in melanocytic lesions observed by confocal microscopy, and to correlate them with routine histopathology. A total of 55 melanocytic lesions comprising 20 melanomas, 25 acquired nevi and 10 Spitz nevi were studied by means of reflectance confocal microscopy, dermoscopy and routine histopathology. Three different types of cell clusters at confocal microscopy observation (dense, sparse cell and cerebriform clusters) were identified and correlated with histopathology. Dense clusters appeared characteristic for benign lesions, although present in 13 out of 20 melanomas. Sparse cell clusters were more frequently observable in melanomas, but also sporadically present in one Spitz nevus. Moreover, cerebriform clusters were exclusively observed in five out of 20 melanomas. Confocal microscopy allowed the in vivo characterization of aspects of melanocytic nests and their exact correlation with histopathology.

Topical activity of ascorbic acid: from in vitro optimization to in vivo efficacy

We present here a new cosmetic formula system containing 3% ascorbic acid based on an optimized oil-in-water (O/W) emulsion. This formulation demonstrated a good long-term stability of the active ingredient and also of the emulsion itself. It could be deduced from in vitro release studies that this O/W emulsion enabled a better release of the hydrophilic active agent than an alternative W/O emulsion. By measuring the ultraweak photon emission, which is a well-established parameter for the oxidative stress in the skin, the high in vivo antioxidant capacity of 3% ascorbic acid was demonstrated after 1 week of product application. This placebo-controlled study also proved that ascorbic acid in an O/W cream reduced oxidative stress in human skin significantly better than the derivative sodium ascorbyl-2-phosphate, a more stable vitamin C replacement commonly used in cosmetic formulations. With increasing age, the number of papillae in the epidermal-dermal junction zone in human skin are reduced. This implies a possible consequence of reduced mechanical resistance of the skin and impaired supply of the epidermis with nutrients. In a 1-month placebo-controlled study on 25 human volunteers, a significant increase in the number of dermal papillae after application of the 3% ascorbic acid cream was demonstrated, using a confocal laser scanning microscope. Fine lines and wrinkles are a characteristic sign of aged and especially photo-aged skin. Application of 3% ascorbic acid in a 12-week placebo-controlled usage study indicated a significant reduction of facial wrinkles. Altogether, 3% ascorbic acid in a cosmetic O/W emulsion has been shown to be appropriately stable and to enable a good release of the active agent in vitro as a precondition for a high efficacy in vivo. Application in vivo resulted in a significant reduction of oxidative stress in the skin, an improvement of the epidermal-dermal microstructure and a reduction of fine lines and wrinkles in aged skin. These results were received within a relatively short period of time of product application.

Time and depth resolved visualisation of the diffusion of a lipophilic dye into the hair follicle of fresh unfixed human scalp skin

Visualising the penetration pathway of a lipophilic model dye into the hair follicle of fresh unfixed human skin would facilitate optimisation of drug formulations for local delivery to the pilosebaceous unit. A block of fresh human scalp skin was mechanically fixed in a newly designed combination of cutting device/on-line diffusion cell, manual cross-sectioned perpendicular to the skin surface and sealed to create the donor and acceptor compartment. The donor phase consisted of a saturated solution of Bodipy FL C(5) in a citric acid buffer solution. Images were obtained on-line by confocal laser scanning microscopy (CLSM) every 30 min for 16 h. For each time point and each skin region relative intensity values were calculated. The on-line visualisation showed a fast diffusion of the label into the gap of the hair follicle followed by a fluorescent staining in the gap itself. The data strongly indicate that the fluorescence in the cuticle originates mainly from the dye of the gap and not from the surrounding epidermis. The on-line visualisation provides a new and excellent tool to monitor simultaneous changes in distribution profiles in the various skin layers including the hair follicle. This information can be used to determine penetration pathways in the skin.

Optical systems for in vivo molecular imaging of cancer

Progress toward a molecular characterization of cancer would have important clinical benefits; thus, there is an important need to image the molecular features of cancer in vivo. In this paper, we describe a comprehensive strategy to develop inexpensive, rugged and portable optical imaging systems for molecular imaging of cancer, which couples the development of optically active contrast agents with advances in functional genomics of cancer. We describe initial results obtained using optically active contrast agents to image the expression of three well known molecular signatures of neoplasia: including over expression of the epidermal growth factor receptor (EGFR), matrix metallo-proteases (MMPs), and oncoproteins associated with human papillomavirus (HPV) infection. At the same time, we are developing inexpensive, portable optical systems to image the morphologic and molecular signatures of neoplasia noninvasively in real time. These real-time, portable, inexpensive systems can provide tools to characterize the molecular features of cancer in vivo.

Noninvasive Imaging of Skin Tumors

In this article, the authors review different approaches to the diagnosis of skin tumors using noninvasive diagnostic tools, which are becoming increasingly reliable and, as a consequence, increasingly popular among physicians and patients. Especially in the realm of pigmented skin lesions, dermoscopy and sonography may add useful information to the clinical constellation, improving the diagnostic performance for early diagnosis of melanoma and for differentiating various melanocytic and nonmelanocytic pigmented lesions. More recently, confocal scanning laser microscopy was introduced as a novel technique that enables the in vivo study of the skin at a nearly histologic resolution, being of diagnostic value in various skin disorders, including basal cell carcinoma and pigmented skin lesions. These modalities have various other potential applications besides diagnosis, including lesion's selection for biopsy, determination of appropriate therapeutic modalities, verification of treatment efficacy, and decision of surgical margins. Finally, a hint to the use of cytodiagnosis for basal cell carcinoma is provided.

Topographic variations in normal skin, as viewed by in vivo reflectance confocal microscopy

Near-infrared confocal microscopy is a new tool that provides skin images in vivo, with high resolution and contrast at a specific depth. Regional variations in live human skin viewed by confocal microscope have not been studied so far. In vivo reflectance confocal microscopy was performed in 10 adults (eight males, two females) of various skin phototypes. Six topographic sites were studied in each subject: forehead, cheek, inner and outer forearm surfaces, lower back and leg. Epidermal thickness at suprapapillary epidermal plates and rete pegs was measured during real-time imaging and the number and diameter of epidermal keratinocytes in each epidermal cell layer as well as the characteristics of dermal papillae were defined from the grabbed images. Stratum corneum appeared brighter in sun-exposed than in sun-protected areas and particularly pronounced in heavily pigmented individuals. The epidermal thickness at rete pegs, but not the suprapapillary epidermal plate, was greater in sun-exposed areas than in sun-protected sites except forearm flexor surface. The en face numerical density of granular keratinocytes is greater on the face as compared with all other sites, whereas the surface density of spinous keratinocytes is greater on sun-protected sites. Additionally, the number of basal keratinocytes per millimeter length of dermoepidermal junction is greater in sun exposed areas. Interestingly, the dermal papillae shape varies and their sizes increase in circumference from sun-exposed to sun-protected sites, as observed at a specific depth below the stratum corneum. In summary, our results demonstrate that near infra-red reflectance confocal microscopy is a feasible tool for microscopic analysis of skin morphometry in vivo.