Onychoscopy of non-infectious nail abnormalities in patients after allogeneic haematopoietic stem cell transplantation

What Do the Lips Say in Chronic Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation? A Case Series

Introduction

Chronic graft-versus-host disease (cGvHD) affects around half of allogeneic hematopoietic stem cell transplantation (alloHSCT) recipients, with frequent involvement of the oral mucosa and lip vermillion, that clinically may resemble other autoimmune and inflammatory conditions. Our objectives were to define the dermoscopic patterns of lip vermilion in patients suffering from cGvHD and to compare the presentation with previously published dermoscopic presentations of other disease entities presenting on the lip vermillion.

Methods

A group of 16 patients diagnosed with cGvHD was assessed clinically and dermoscopically. The dermoscopic descriptions were made according to recent consensus on terminology of non-neoplastic disorders.

Results

Dermoscopy of vermillion frequently revealed dotted vessels that were found in all patients, while linear vessels without bends or branches were seen in 10 of them (62.5%). Peripheral scale, mainly in white color (13/16, 81.2%) was often present. Most striking features were parallel and perpendicular white lines, found in all patients. Other structures included brown dots and blood spots that were present in 10 patients (62.5%). Four patients (25.0%) had blurred vermillion border and in 8 (50.0%) linear fissures or ulceration were found. Typical Wickham striae were found in 3 (18.8%) patients.

Conclusions

The dermoscopic features observed in cGvHD affecting lip vermillion warrant differentiation with inflammatory (lichen planus), autoimmune (lichen sclerosus, discoid lupus erythematosus), precancerous (actinic keratosis, leukoplakia), and neoplastic diseases (squamous cell carcinoma), among others. Dermoscopy of lip vermillion might be an additional tool to visualize diagnostic mucoscopic features of cGvHD (lichen planus-like, lichen sclerosus-like lesions).

Dermoscopy of Cutaneous Graft-Versus-Host-Disease in Patients After Allogeneic Hematopoietic Stem Cell Transplantation

Introduction

Progress in the transplant procedure has resulted in a higher proportion of patients with long-term survival after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Cutaneous graft-versus-host disease (GvHD) occurs often among patients who have undergone allo-HSCT. Routine diagnosis of skin and mucosal lesions is based primarily on clinical evaluation and histopathologic confirmation of skin biopsies. However, biopsy is an invasive method and histopathologic analysis is time-consuming, often accompanied by a lack of clinical correlation. There is therefore an urgent need for non-invasive, reproducible in vivo imaging methods that could be used in patients with cutaneous GvHD—both in the setting of initial diagnosis and during follow-up.The aim of the study reported here was to determine the role of dermoscopic monitoring of skin lesions in allo-HSCT recipients with consecutive histopathologic support as a non-invasive, alternative method to diagnose GvHD.

Methods

Twenty patients were examined by dermoscopy upon the manifestation of skin changes in the course of GvHD. Consecutive skin biopsies for histopathologic analysis were obtained from the suspected skin locations determined during dermoscopy.

Results

Graft-versus-host disease was confirmed by histopathology in 19 of the 20 allo-HSCT recipients. Four patients developed symptoms of acute cutaneous GvHD (grade 1, n = 2; grade 2, n = 1; grade 3, n = 1), and 15 patients developed chronic cutaneous GvHD. The most frequent dermoscopic signs (irrespective of whether GvHD was chronic or acute) were vessels and scaling (both n = 14, 73.7%). Hyperpigmentation and white patchy areas were present in eight patients (42.1%). Fair to moderate levels of agreement were found between presence of melanophages in the skin sample and dermoscopic granularity (Cohen’s Kappa [κ] = 0.39), scaling (κ = − 0.3) and vessels (κ = − 0.42). The finding of white patchy areas was inversely associated with lymphocytic infiltration (κ = − 0.55).

Conclusion

The results of this study suggest that dermoscopy may be a useful tool for diagnosing cutaneous GvHD in allo-HSCT recipients. Combining the clinical picture with dermoscopic features may bring us closer to a faster and easier diagnosis of GvHD.