Line-field confocal optical coherence tomography of psoriasis, eczema and lichen planus: a case series with histopathological correlation

BACKGROUND

Line-field confocal optical coherence tomography (LC-OCT) is a novel, non-invasive technique that provides in vivo, high-resolution images in both vertical and horizontal sections.

OBJECTIVES

The aim of the study was to evaluate LC-OCT imaging in some inflammatory disorders and to correlate the resulting features with histopathology.

METHODS

The retrospective study included patients with histopathological confirmed diagnosis of plaque psoriasis, atopic eczema and lichen planus, who were imaged with LC-OCT before the biopsy. LC-OCT was performed with the commercially available LC-OCT device.

RESULTS

A total of 15 adult patients with histopathologically proven plaque psoriasis (N: 5), atopic eczema (N: 5) and lichen planus (N: 5) were included. In all cases, LC-OCT allowed the in vivo recognition of the main microscopic features of the examined inflammatory skin disease, with a strong correlation with histopathology.

CONCLUSIONS

Although future studies on larger series of patients are necessary, LC-OCT, based on these preliminary findings, may represent a promising tool in inflammatory skin disorders with potential applications including enhanced diagnosis, biopsy guidance, follow-up and treatment monitoring.

Clinical and trichoscopic aspects of scalp psoriasis: commentary to 'Clinical and trichoscopic features in various forms of scalp psoriasis' by F. Bruni et al

Linked article: F. Bruni et al. J Eur Acad Dermatol Venereol 2021; 35: 1830–1837. https://doi.org/10.1111/jdv.17354

The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies

BACKGROUND

Scabies is a common parasitic skin condition that causes considerable morbidity globally. Clinical and epidemiological research for scabies has been limited by a lack of standardization of diagnostic methods.

OBJECTIVES

To develop consensus criteria for the diagnosis of common scabies that could be implemented in a variety of settings.

METHODS

Consensus diagnostic criteria were developed through a Delphi study with international experts. Detailed recommendations were collected from the expert panel to define the criteria features and guide their implementation. These comments were then combined with a comprehensive review of the available literature and the opinion of an expanded group of international experts to develop detailed, evidence-based definitions and diagnostic methods.

RESULTS

The 2020 International Alliance for the Control of Scabies (IACS) Consensus Criteria for the Diagnosis of Scabies include three levels of diagnostic certainty and eight subcategories. Confirmed scabies (level A) requires direct visualization of the mite or its products. Clinical scabies (level B) and suspected scabies (level C) rely on clinical assessment of signs and symptoms. Evidence-based, consensus methods for microscopy, visualization and clinical symptoms and signs were developed, along with a media library.

CONCLUSIONS

The 2020 IACS Criteria represent a pragmatic yet robust set of diagnostic features and methods. The criteria may be implemented in a range of research, public health and clinical settings by selecting the appropriate diagnostic levels and subcategories. These criteria may provide greater consistency and standardization for scabies diagnosis. Validation studies, development of training materials and development of survey methods are now required. What is already known about this topic? The diagnosis of scabies is limited by the lack of accurate, objective tests. Microscopy of skin scrapings can confirm the diagnosis, but it is insensitive, invasive and often impractical. Diagnosis usually relies on clinical assessment, although visualization using dermoscopy is becoming increasingly common. These diagnostic methods have not been standardized, hampering the interpretation of findings from clinical research and epidemiological surveys, and the development of scabies control strategies. What does this study add? International consensus diagnostic criteria for common scabies were developed through a Delphi study with global experts. The 2020 International Alliance for the Control of Scabies (IACS) Criteria categorize diagnosis at three levels of diagnostic certainty (confirmed, clinical and suspected scabies) and eight subcategories, and can be adapted to a range of research and public health settings. Detailed definitions and figures are included to aid training and implementation. The 2020 IACS Criteria may facilitate the standardization of scabies diagnosis.

Dermoscopy of genital diseases: a review

The male and female external genital regions are anatomical areas in which various types of skin disorders may occur. Although most of these conditions can be diagnosed by means of clinical examination and an accurate medical history, in most cases further investigations with time-consuming and/or invasive procedures are needed in order to reach the correct diagnosis. Dermoscopy, as a modern non-invasive tool, is able to better diagnose pigmented and non-pigmented skin tumours along with various inflammatory and infectious skin and appendage disorders. The aim of this paper was to provide a review of the use of dermoscopy in genital disorders based on published data and to include personal experience gained from real life, focusing on any possible gender difference and whether disease mucosal/semimucosal dermoscopy features may differ from those observed on the skin. In conclusion, genital dermoscopy should always be considered during clinical inspection in order to enhance the diagnosis or to rule out those conditions that may look similar but that show a different dermoscopy pattern, thus narrowing down the differential diagnoses and avoiding unnecessary invasive investigations.

Standardization of dermoscopic terminology and basic dermoscopic parameters to evaluate in general dermatology (non-neoplastic dermatoses): an expert consensus on behalf of the International Dermoscopy Society

BACKGROUND

Over the last few years, several articles on dermoscopy of non-neoplastic dermatoses have been published, yet there is poor consistency in the terminology among different studies.

OBJECTIVES

We aimed to standardize the dermoscopic terminology and identify basic parameters to evaluate in non-neoplastic dermatoses through an expert consensus.

METHODS

The modified Delphi method was followed, with two phases: (i) identification of a list of possible items based on a systematic literature review and (ii) selection of parameters by a panel of experts through a three-step iterative procedure (blinded e-mail interaction in rounds 1 and 3 and a face-to-face meeting in round 2). Initial panellists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses.

RESULTS

Twenty-four international experts took part in all rounds of the consensus and 13 further international participants were also involved in round 2. Five standardized basic parameters were identified: (i) vessels (including morphology and distribution); (ii) scales (including colour and distribution); (iii) follicular findings; (iv) 'other structures' (including colour and morphology); and (v) 'specific clues'. For each of them, possible variables were selected, with a total of 31 different subitems reaching agreement at the end of the consensus (all of the 29 proposed initially plus two more added in the course of the consensus procedure).

CONCLUSIONS

This expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This tool, if adopted by clinicians and researchers in this field, is likely to enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology. What's already known about this topic? Over the last few years, several papers have been published attempting to describe the dermoscopic features of non-neoplastic dermatoses, yet there is poor consistency in the terminology among different studies. What does this study add? The present expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This consensus should enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology.

Sex-related differences of clinical features in hidradenitis suppurativa: analysis of an Italian-based cohort

The clinical characteristics associated with hidradenitis suppurativa (HS) severity are poorly understood. In this study, 124 patients with HS from 6 Italian dermatology centres participated in this study. Disease severity was assessed using the Hidradenitis Suppurativa Physician's Global Assessment score (HS-PGA) and Hurley score. The impact of clinical characteristics on disease severity was assessed by logistic regression. Clinical characteristics were similar between men (n = 53) and women (n = 71). Disease severity was also similar; 75% of the patients had Hurley stage II or III disease, and > 60% had moderate, severe or very severe HS as judged by HS-PGA. Lesions were more frequent in the gluteal region in men (32.3% in men vs. 8.7% in women, P < 0.001) and more frequent on the breast in women (16.3% in women vs. 4.6% in men, P = 0.02). Obesity was associated with increased disease severity as measured by HS-PGA (OR: 3.28, 95% CI 1.55-6.95, P < 0.01) and Hurley classification (OR: 3.22, 95% CI 1.34-7.31, P < 0.01). Although severity of HS is similar between the sexes, the localization of lesions is different.

Reflectance confocal microscopy in the diagnosis of vesicobullous disorders: case series with pathologic and cytologic correlation and literature review

BACKGROUND

Vesicobullous disorders are characterized by intraepidermal or subepidermal blistering resulting from different pathogenetic mechanisms. The diagnosis is generally based on clinical examination and semi-invasive/invasive procedures such as cytology and histopathology. In vivo reflectance confocal microscopy (RCM) is a non-invasive technique for real-time, en face imaging of the epidermis and upper dermis with high resolution close to conventional histopathology.

PURPOSE

To evaluate RCM features of different vesicobullous diseases and correlate with cytologic and histopathologic examination.

METHODS

Ten patients (6M/4F, age range: 9-81 years) affected by blistering diseases, such as herpes simplex, herpes zoster, Kaposi's varicelliform eruption, pemphigus vulgaris, Hailey-Hailey disease, bullous pemphigoid, and porphyria cutanea tarda were evaluated using a handheld RCM device.

RESULTS

In our study, a clear correlation between RCM and Tzanck's test and/or histopathology was observed. RCM allowed in all cases an easy identification of the blister spaces and of the split levels, and in some cases specific features were detected, such as giant keratinocytes in herpes infections and acantholytic cells in pemphigus vulgaris and Hailey-Hailey disease.

CONCLUSION

Reflectance confocal microscopy may support the clinical diagnosis of vesicobullous disorders and indicate to the physician the appropriate patient management and/or the need for further investigation.

Efficacy and tolerability of nitric-zinc complex in the treatment of external genital warts and "difficult-to-treat" warts: a "proof of concept", prospective, multicentre, open study

AIM

Treatment of plantar and periungueal warts (so called "difficult-to-treat" warts, DTW) and external genital warts (EGW) remains unsatisfactory. Medical or invasive procedures are partially effective and/or painful. Furthermore recurrences rates after treatments are still a relevant problem for all the available therapies. Nitric-zinc complex is a solution for topical application containing nitric acid, zinc, copper and organic acids able to induce a caustic effect of the wart trough mummification and proteins denaturation/coagulation action. Nitric-zinc complex has been shown to be an effective and well tolerated treatment of common warts.

METHODS

We evaluated in a prospective open label 4-centre trial, the efficacy and local tolerability of nitric-zinc complex in the treatment of EGW and DTW. A total of 37 immunocompetent subjects (20 men and 17 women; mean age: 45 years) with single or multiple lesions, were enrolled, after their informed consent. A total of 30 subjects had EGW, 2 subjects had plantar warts, 2 warts of the hand and 3 periungueal lesions. Nitric-zinc aqueous solution was applied topically using a 30 mL capillary tube over the lesions until a whitening/yellowish reaction appeared. A second (or more, if needed) application was performed at two-week interval until a complete clinical cure rate was observed. Primary outcome of the study was the clinical evaluation with picture documentation of the evolution of lesions classified as total cure, partial disappearance or no effect. Topical tolerability was evaluated through patient's reported adverse events.

RESULTS

All subjects completed the study. A complete cure of lesions was observed in 31 subjects (90%) after one and up to four applications. Three patients with EGW (8%) showed a partial disappearance of lesions and one (2%) subject was no responder to four nitric-zinc complex applications. The product was well tolerated. No serious adverse events were observed or recorded.

CONCLUSION

Nitric-zinc complex topical solution has shown to be an effective and well tolerated treatment of EGW and "difficult-to-treat" warts with a 90% of subjects with a total cure after one or up to four applications. A total or partial response was observed in 99% of the subjects. Nitric-zinc complex could be considered an easy-to-use effective treatment strategy of "difficult-to-treat" warts and external genital warts. Additional studies comparing nitric-zinc complex to other strategies are warranted.

Clinical, ultrasound, and videodermatoscopy monitoring of psoriatic patients following biological treatment

BACKGROUND AND PURPOSE

Effective non-invasive techniques to monitor plaque psoriasis progression and treatment are desirable. The aim of the study was to evaluate changes in vascular pattern using videodermatoscopy (VD) and in skin thickness by ultrasound (US), along with clinical observation, during treatment with biologicals.

METHODS

Forty-two patients with moderate-to-severe plaque psoriasis treated with adalimumab, etanercept, or ustekinumab were evaluated. Following the identification of a 'target' plaque at baseline, lesion changes were monitored at 15, 30 and 60 days by clinical observation using a Target Lesion Score (TLS), and by VD and US.

RESULTS

After 60 days, a significant improvement in all three parameters was observed. In adalimumab-treated patients mean values of TLS, VD, and US were reduced by 83.9%, 73.5%, and 90%, respectively; in etanercept-treated patients by 67.9%, 49.7%, and 79.3%; in ustekinumab-treated patients by 80.9%, 66.4%, and 80.1%. Skin thickness was the first parameter to improve. Vascular improvement was slower compared to clinical and US responses.

CONCLUSION

VD and US may be useful to monitor psoriasis treatment. Further investigations are warranted to assess if the persistence of an altered vascular pattern despite clinical and US normalization, as observed in 22% of patients, may influence disease progression and/or correlate with rate and severity degree of relapse.

Dermatoscopy in inflammatory and infectious skin disorders

Dermatoscopy is a non-invasive technique that allows a rapid and magnified in vivo observation of the skin surface. By definition, it is performed with handheld devices (dermatoscopes) allowing X10 magnification. More expensive, computer-assisted digital systems (videodermatoscopes) may be equipped with lenses that ensure magnifications up to X1000; in this case the term videodermatoscopy is generally used. Dermatoscopy is mainly utilized for the evaluation of pigmented skin lesions, and has increasing applications in dermatology. In this paper the use of dermatoscopy in a variety of inflammatory (psoriasis, lichen planus, pityriasis lichenoides, rosacea, lichen sclerosus, Darier's disease, pigmented purpuric dermatoses) and infectious (human papillomaviruses infections, molluscum contagiosum, tinea capitis, tinea nigra, scabies, head and pubic lice, tungiasis, cutaneous leishmaniasis and cutaneous larva migrans) cutaneous disorders will be analyzed. In these conditions, dermatoscopy may assist the clinical diagnosis, reducing the need of semi-invasive or invasive procedures such as skin scrapings and/or biopsy. Depending on the disease, the choice to use low or high magnifications may be crucial. Dermatoscopy may also be useful for prognostic evaluation and monitoring of response to treatment, representing an important and relatively simple aid in daily clinical practice.

Combined Clinical, Capillaroscopic and Ultrasound Evaluation during Treatment of Plaque Psoriasis with Oral Cyclosporine

Imaging techniques have only recently been utilized in combination with clinical observation to objectively quantify psoriasis severity and evaluate therapeutic response. This study evaluated the sensitivity of videodermatoscopy (VD) and ultrasound (US) imaging to assess the therapeutic effect of cyclosporine (Cs) in patients with moderate-to-severe psoriasis. Twenty patients with moderate-to-severe psoriasis were divided into two groups (A and B) based on PASI score. Group A (PASI >16) was treated with 5 mg/Kg/day Cs for 4 weeks and another 4 weeks with 3 mg/Kg/day Cs. Group B (PASI 1016) received 3 mg/Kg/day Cs for 8 weeks. A “target” plaque was selected for each subject and evaluated using a Target Lesion Score (TLS) for erythema, scaling and degree of infiltration, in addition to VD and US at baseline, 2, 4 and 8 weeks. At the end of the study, improvement rate was quicker in group A vs group B after 8 weeks of Cs therapy. All three parameters (TLS, VD and US) strongly correlated with one another. Skin thickness was the first parameter that improved, followed by TLS. In contrast, improvement in VD was delayed. Normalization rate of vascular pattern (assessed by VD) was low in both groups but higher in group A vs group B (46% vs 22%), despite virtually complete normalization by clinical and US assessment. In conclusion, while both TLS and US can be utilized in the evaluation of therapeutic efficacy in patients with plaque psoriasis, VD can provide information on vascular response to treatment, which may likely affect the duration of therapy and the relapse rates.

Two pediatric cases of pyogenic granuloma treated with imiquimod 5% cream: combined clinical and dermatoscopic evaluation and review of the literature

Pyogenic granuloma (PG), also referred to as lobular capillary hemangioma, is a common, benign vascular proliferation of skin and/or mucous membranes, occurring most frequently in children and young people. First line therapy of PG consists of surgical excision. Alternative treatments such as curettage, cauterization, laser therapy and cryotherapy may require multiple sessions, pose unwanted complications and have the highest rate of recurrence. Imiquimod (IQ) 5% cream is a synthetic imidazoquinolin heterocyclic amine that enhances, through cytokine induction, both the innate and acquired immune pathways, resulting in immunomodulating, antiviral and antitumor effects; it is currently used in adults in the treatment of various skin disorders. Definitive data on its efficacy and safety on pediatric age groups are not established, but there are different case reports about its use in the treatment of molluscum contagiosum, ano-genital warts, haemangiomas and, recently, PG with 12 cases reported in literature. We report our experience on the use of topical IQ 5% cream in two cases of PG occurring in pediatric patients, with complete resolution of clinical and dermatoscopic features.

Videodermatoscopy enhances the ability to monitor efficacy of scabies treatment and allows optimal timing of drug application

BACKGROUND

Videodermatoscopy (VD) is a noninvasive diagnostic tool that has recently been advanced as an alternative technique for the diagnosis of scabies, based on studies showing its ability to detect mites in vivo with results comparable to those obtained by traditional skin scraping.

OBJECTIVE

In this study we evaluated a group of patients undergoing topical treatment with a thermosensible foam containing 0.165% pyrethrins and 1.65% piperonyl butoxide to determine whether VD would enhance monitoring of the clinical response to treatment and indicate the optimal timing of drug application.

MATERIALS AND METHODS

Twenty patients (12 M, 8 F; age 1-65 years) affected by scabies (diagnosis confirmed by VD), and who were treatment naïve, were included in the study. The foam was applied to the entire body once a day at bedtime for two consecutive days. To detect treatment response, VD evaluation of two targeted skin sites for each patient was performed at baseline and at 12, 24, 36 and 48 h. A video microscope system equipped with a zoom lens that allowed skin observation with incident light at magnifications ranging from x 20 to x 600 was used.

RESULTS

In all patients, VD showed active mite migration within burrows at 12 h. At 24 h, there was no evidence of active mite migration, and a majority of patients reported that itching had subsided. At 48 h, the mites were no longer visible in appreciable amounts by VD, and an amorphous material, probably resulting from mite decomposition, was detectable at one end of an empty burrow in the majority of patients. Skin scraping at 48 h, followed by standard microscopic observation, also showed only mite remnants in all patients. None of the 20 patients showed signs of infestation by VD at targeted skin sites at a 2-week post baseline follow-up visit.

CONCLUSIONS

VD enhances the monitoring of clinical response to treatment and allows optimal timing of drug application. This may be particularly important in minimizing risk of overtreatment, reducing the potential for side-effects, and enhancing patient compliance.

The use of imiquimod 5% cream for the treatment of basal cell carcinoma as observed in Gorlin's syndrome

Gorlin's syndrome (naevoid basal cell carcinoma) is an autosomal dominant tumour-predisposition syndrome. It typically consists of multiple basal cell carcinomas (BCCs) of the skin, odontogenic keratocysts of the jaw, various skeletal abnormalities and lamellar falx calcifications. Four patients with multiple facial and trunk BCCs (superficial and nodular) consistent with Gorlin's syndrome are reported. Imiquimod 5% cream was topically applied to the lesions 3-5 times a week for 8-14 weeks. Two of the patients suffered mild to severe erythema and developed superficial erosions but did not discontinue treatment. Imiquimod 5% cream successfully treated 13 out of 17 BCCs in these patients with Gorlin's syndrome, with no patient suffering a relapse at the follow-up visit.

Topical imiquimod treatment of superficial and nodular basal cell carcinomas in patients affected by basal cell nevus syndrome: a preliminary report

BACKGROUND

Imiquimod 5% cream has been shown to be effective in the treatment of superficial basal cell carcinomas (sBCCs).

OBJECTIVE

To evaluate the efficacy, safety and compliance of imiquimod 5% cream for the treatment of sBCCs and nodular BCCs (nBCCs) in patients affected by basal cell nevus syndrome.

PATIENTS/METHODS

Three patients (two male, one female) were enrolled in the study. Nine tumors (five sBCCs and four nBCCs), all ranging in size from 0.5 cm to 1 cm, were treated. Treatment consisted for sBCCs of three weekly applications and for nBCCs of five weekly applications for 8 weeks. Histological examination was performed at the beginning and at the end of the study. For small tumors, similar-appearing lesions were removed for baseline histological confirmation. Follow-up was performed at 1-week intervals in order to carefully detect any change.

RESULTS

Three sBCCs cleared clinically after 4 weeks of treatment and two nBCCs after 8 weeks. The remaining four lesions showed excellent clinical responses with evident (>50%) size reduction at 6 weeks, but no further improvement. Histological examination with multiple-step sections confirmed complete clearing for those lesions showing clinical resolution, except for one nBCC that showed scant tumor remnants. Local adverse effects (itching, erythema and bleeding) were mild and did not prompt discontinuation of treatment. No systemic side effects were noted.

CONCLUSIONS

Imiquimod 5% cream is an effective therapeutic option for both sBCC and nBCC in patients with basal cell nevus syndrome. The treatment was very well received by all patients engaged in the study, who stated their appreciation for a topical treatment rather than multiple surgical excisions. A higher number of applications and longer treatment periods are required for nBCCs.

High-magnification videodermatoscopy: a new noninvasive diagnostic tool for scabies in children

A study of 100 children suspected of having scabies was carried out using high-magnification (HM) videodermatoscopy as the only diagnostic tool. HM videodermatoscopy reaches magnifications of up to 600x and allows a detailed inspection of the skin. Rapid and clear identification of mites, migration burrows, eggs, and feces was obtained in 62 of 100 patients. None of the 38 patients with negative findings showed any sign of infestation 2 weeks later. HM videodermatoscopy is rapid, effective, and sensitive, especially in those cases with nonspecific clinical features, and allows clear detection of diagnostic details usually not appreciable at lower magnifications. It has high specificity, with no chance of false-positive results, and being noninvasive, it eliminates the risk of accidental infections. Finally, the most important advantage in children is its high compliance rate, as it does not cause pain or physical or psychological discomfort. It may be used for primary diagnosis as well as for posttherapeutic follow-up and for screening of family members, thus reducing the risk of persistence and diffusion of the infestation.