Reflectance confocal microscopy and optical coherence tomography for the diagnosis of bullous pemphigoid and pemphigus

Introduction & Objectives: Bullous pemphigoid (BP) and pemphigus (P) are autoimmune diseases characterized by the presence of blisters on the skin and/or the mucous membranes. The diagnosis of these bullous diseases is based on a combination of criteria encompassing clinical features, histology, immunofluorescence and laboratory data. The aim of this study was to evaluate features of BP and P at reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) in order to provide a rapid non-invasive bed-side diagnosis. Secondary objective was to evaluate the detectability of clinically non-visible lesions. Material & Methods: This was an observational, retrospective, multicentre study (University of Modena, Italy and University of Saint-Etienne, France) in which patients with suspicious lesions for BP or P underwent clinical assessment, RCM, OCT, blood tests and skin biopsy for histological and direct immunofluorescence examinations. A total of 72 lesions in 24 patients (16 with PB and 8 with P) were evaluated. Apparently unaffected skin was examined in order to test sub-clinical lesion detectability in all patients. Data analysis was performed from January 2014 to December 2015. Results: RCM was able to detect sub-epidermal and intra-epidermal blisters respectively in 75% and 50% of the patients affected by BP and P. At OCT the exact blister level was identified in all BP and P cases’. Acantholytic cells were observed only at RCM in P (62.5%). Fibrin deposition inside the blisters was only found in PB, evidenced both at RCM and OCT. Subclinical bullae were revealed on clinically healthy skin at OCT in some cases of BP and P. Conclusions: RCM and/or OCT can assist the clinician in providing rapid information through a non-invasive procedure for a rapid diagnosis of BP and P. Combined use of RCM and OCT for a real-time examination of the skin lesions associates the higher resolution of RCM with the greater penetration depth in cross-sectional view of OCT, providing in vivo quasi-histologic information

Rôle de la microscopie confocale de réflectance et de tomographie par cohérence optique pour le diagnostic de la pemphigoïde bulleuse et du pemphigus

Introduction: La pemphigoïde bulleuse (PB) et le pemphigus vulgaire (PV) sont des maladies auto-immunes caractérisées par la présence de bulles cutanées et ou muqueuses. Le diagnostic de ces maladies bulleuses repose sur une combinaison de critères cliniques, histologiques, d’immunofluorescence et biologique. L’utilité de la microscopie confocale de réflectance de (MRC) et tomographie par cohérence optique (OCT) pour le diagnostic de BP et de PV a été rapporté dans un petit nombre de cas. Nous rapportons l’examen en MRC et l’examen OCT des caractéristiques de BP et PV. Matériel et méthodes: Il s’agissait d’une étude observationnelle multicentrique dans laquelle les patients présentant des lésions suspectes pour BP ou PV ont eu un examen clinique, en MRC (Vivascope 3000® Caliber) et OCT (Vivosight®, Mickelson) ; de plus étaient réalisés un examen histologique et une immunofluorescence directe et indirecte. Vingt-quatre patients (16 avec PB et 8 avec PV) étaient évalués. Trois zones étaient examinées pour chaque patient : 2 lésions et une zone de peau saine. Résultats: La RCM et l’OCT ont tous deux permis de visualiser un décollement sous-épidermique et bulles intra-épidermiques chez tous les patients atteints de BP et PV. L’OCT était la méthode la plus appropriée pour l’identification du niveau exact de la bulle, alors que la MRC permettait d’observer l’acantholyse de kératinocytes des bulles de PV. Des dépôts de fibrine et des septa à l’intérieur des bulles ne se trouvaient que dans les PB et non dans les PV aussi bien en OCT que MCIV. Discussion: Il est maintenant possible au clinicien de déterminer le type et le niveau de clivage d’une bulle et de différencier PB ou PV de manière non-invasive. Par ailleurs, il est possible d’examiner les bulles sans fixation ce qui permet de visualiser le cloisonnement par des septa de fibrine lors de la PB. Conclusion: La MCIV et l’OCT peuvent aider le clinicien dans le diagnostic de BP et PV au cours d’un examen rapide est simple à réaliser de manière non-invasive. De plus, ces techniques peuvent être utiles pour la sélection du site de biopsie

Handheld In Vivo Reflectance Confocal Microscopy for the Diagnosis of Eyelid Margin and Conjunctival Tumors

OBJECTIVE To assess the diagnostic accuracy of handheld in vivo reflectance confocal microscopy (IVCM) for the diagnosis of eyelid margin and conjunctival tumors. DESIGN A prospective observational study was conducted at University Hospital of Saint-Etienne from January 2, 2011, to December 31, 2016 (inclusion of patients until December 31, 2015, and follow-up until December 31, 2016). A total of 278 consecutive patients with eyelid margin or conjunctival lesions were included. Conjunctival lesions were diagnosed with a conventional clinical examination using a slitlamp and by handheld IVCM. Final diagnoses were established by histopathologic examination for 155 neoformations suspicious for being malignant through clinical and/or IVCM examination that were excised and on follow-up of 12 months or longer for the remaining 140 lesions. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, and positive and negative predictive values for malignant tumors of the conjunctiva and eyelid margin were calculated using clinical examination with slitlamp and handheld IVCM. RESULTS In the 278 patients (136 [48.9%] females; mean [SD] age, 59 [21] years), a total of 166 eyelid margin and 129 conjunctival lesions were included in the analysis. Of the 155 excised neoformations with a histopathologic diagnosis, IVCM showed higher sensitivity compared with clinical examination conducted with the slitlamp for malignant tumors of the eyelid margin (98%vs 92%) and conjunctiva (100% vs 88%). The specificity for malignant eyelid margin tumors was higher for IVCMthan for slitlamp examination (74%vs 46%), but slightly less for malignant conjunctival tumors (78%vs 88%). Analysis of all neoformations (155 excised and 140 in follow-up) confirmed these differences in the diagnostic accuracy of the clinical examination and IVCM. The presence of hyperreflective Langerhans cells mimicking malignant melanocytes was the main cause for misdiagnosis of malignant conjunctival tumors with IVCM. CONCLUSIONS AND RELEVANCE Handheld IVCM could be a useful tool for the identification of malignant conjunctival tumors. Further studies are required to confirm the usefulness of this device and identify possible features that can differentiate Langerhans cells from malignant melanocytes to prevent the misdiagnosis of melanoma using IVCM

Uso della microscopia laser confocale e della tomografia a coerenza ottica nella diagnosi del pemfigoide bolloso e del pemfigo

Il pemfigoide bolloso (PB) ed il pemfigo (P) sono malattie autoimmuni caratterizzate dalla formazione di bolle sulla pelle e/o sulle mucose. La diagnosi di queste patologie viene posta sulla base della valutazione clinica, dei dati di laboratorio, dell\u2019istologia, dell\u2019immunofluorescenza diretta ed indiretta. Nel nostro studio osservazionale multicentrico sono stati valutati con la microscopia laser confocale (RCM) e con la tomografia a coerenza ottica (OCT) di 16 pazienti con PB e di 8 con P sia la cute apparentemente sana che tre lesioni bollose. L\u2019OCT \ue8 risultato essere pi\uf9 preciso del RCM nella definizione della localizzazione delle bolle e nell\u2019identificazione delle lesioni subcliniche. Grazie al potere risolutivo maggiore, l\u2019RCM \ue8 in grado di visualizzare strutture a risoluzione quasi istologica e pertanto \ue8 risultato essere capace di valutare pi\uf9 parametri rispetto all\u2019OCT, dimostrando di essere un ottimo strumento nella diagnosi differenziale con altre patologie bollose come ad esempio quelle di natura virale

Reflectance confocal microscopy for cutaneous infections and infestations

Reflectance confocal microscopy (RCM) is a high-resolution emerging imaging technique that allows non-invasive diagnosis of several cutaneous disorders. A systematic review of the literature on the use of RCM for the study of infections and infestations has been performed to evaluate the current use of this technique and its possible future applications in this field. RCM is particularly suitable for the identification of Sarcoptes scabies, Demodex folliculorum, Ixodes, Dermatophytes and Candida species in the clinical practice and for the follow-up after treatment. The cytopathic effect of herpes simplex virus, varicella zoster virus and molluscipoxvirus is also detectable by this imaging technique even in a pre-vesicular stage. In addition, thanks to its non-invasiveness, RCM allows pathophysiological studies

Confocal Microscopy for Special Sites and Special Uses

This article describes the use of confocal microscopy for special sites and unconventional applications. These new applications have been made possible thanks to the introduction on the market of a hand-held camera. Special sites discussed include mucosa, nails, and palms and soles. Special uses discussed include infections and infestations; tumor mapping; understanding clinical, dermoscopic, and histology features; videos and ex vivo confocal microscopy