Eccrine poroma: dermoscopical and confocal features of five cases

Background: Eccrine poroma (EP) is a rare benign adnexal tumor arising from the intraepidermal ductal portion of the sweat gland. It commonly occurs as a single, slowly growing, erythematous, skin-colored, cyanotic or pigmented papule, plaques or nodule. EP occurs usually at the acral sites, but it can develop in other cutaneous sites. It may occasionally mimic malignant tumors including basal cell carcinoma, squamous cell carcinoma and melanoma. Objective: The aim of this study was to describe dermoscopical and confocal features of EP. Methods: A retrospective analysis of the dermoscopical and confocal characteristics of EP was performed. All diagnosis were confirmed by histological examination. Results: A total of 5 cases of non-pigmented EP was analysed. Dermoscopic evaluation found in all lesions a polymorphous vascular pattern, including at least two type of vessels: hairpin (80%), linear (60%), leaf-like (60%), flower-like (40%) and glomerular (40%) vessels. A white-to-pink halo surrounding the vessels was found in 40% of the lesions. Multiple pink-white structureless areas were found in 4 out of 5 (80%) cases. Only in 2 cases irregular haemorrhagic and blue-white areas were also observed. Reflectance Confocal Microscopy (RCM) revealed the presence of well-demarcated hyporefractile tumor nests, dark holes corresponding to areas of ductal differentiation within the tumor and highly vascularized stroma in all 5 lesions. Conclusions: The great clinical variability of EP gives reason of the appellative of “big simulator”. Dermoscopy does not revealed univocal features except from “leaf-flower-like” vessels that have not been described in other types of skin tumors. This characteristic, when presents, may be considered an useful clue for the diagnosis. RCM examination of EP revealed features (hyporefractile tumor nests and dark holes) that relate with their histopathological findings. Dermoscopy and RCM improve the diagnostic accuracy and help for diagnosis, although they cannot replace histology that is still required

“Lambs” in wolves’ clothing: when basal cell carcinoma mimics melanoma, but it is detected by the use of reflectance confocal microscopy

Background Basal cell carcinoma (BCC) is the most frequent non-melanoma skin cancer. There are some cases in which clinical and dermoscopic examinations do not allow to formulate a unique diagnosis and in particular can be difficult the differential diagnosis with melanoma. Reflectance confocal microscopy (RCM) is a non-invasive technology, which allows an in vivo imaging of the skin with high resolution. Objectives We addressed our research to evaluate the reliability of the well-known RCM criteria for classic BCCs in a group of lesions with atypical dermoscopy presentation, possibly mimicking melanoma. Methods We retrospectively analyzed at RCM excised lesions presenting in dermoscopy ≥1 score at revisited 7-point checklist. The study population consisted of 177 cases showing no melanocytic RCM findings. Lesions were investigated for distinct non-melanocytic RCM features, while blinded from histopathology. Histopathology matching was performed before statistical analysis. Results Among the lesions classified at RCM with no-melanocytic characteristics, we recognized 34 cases, histopathological confirmed as BCCs (21 nodular BCCs and 13 superficial BCCs) and 143 cases classified as other lesions (DFs, SebKs, SCCs and others). The main features of nBCCs (with histopathological confirm) at RCM are peritumoral clefts (20/21 95,2%; p=0,037), peripheral palisading (19/21 90,5%; p=0,001), increased vascularization (20/21 95,2%; p=0,004). In sBCCs we found mild keratinocytic atypia (13/13 100%; p=<0,001), solar elastosis (12/13 92,3%; p=0,002), cords connected to epidermidis (9/13 69,2%; p=<0,001). Dendritic structures, nests of basaloid cells, inflammatory infiltrate can be seen in all tumors. Conclusions RCM classification proved high agreement with histopathology for BCCs with atypical dermoscopy presentations, allowing an early differential diagnosis and even identification of BCCs subtypes. RCM features in this group of lesions were similar to those described for typical cases of BCCs, and may drive clinicians decisions, helped them in the recognition of melanocytic and non melanocytic lesions, increasing the rate of accurate diagnoses and allowing better therapeutic management

A recalcitrant case of folliculitis decalvans: imaging and treatment options

Folliculitis decalvans (FD) is a rare form of scarring alopecia, presenting with tufted hairs, follicular papules or pustules. It is the most common of neutrophilic alopecia, often associated with pruritus and pain. Currently, the cause of FD is still unknown. Scalp colonization by staphylococcus aureus seems to induce a severe inflammatory reaction with consequent destruction of hair follicles. All patients with active FD should be treated because the disease destroys hair follicles and causes permanent hair loss. Multiple treatments exist, but often provide only transitory or modest improvement. For this reason FD can negatively affect patient’s quality of life. A 46-year-old man presented with 15-year history of FD characterized by recurrent purulent follicular lesion on occipital side of the scalp and consequent scarring alopecia. His medical history was unremarkable, but he was distressed by the appearance of the lesions and hair loss. He was treated with different therapies such as doxycycline, rifampicin and hydroxychloroquine with poor results. He underwent two sessions of photodynamic treatment with methyl aminolevulinate at 2-week interval. At first, he was achieved benefit, but after 2 months there was recurrence and further progression of the disease. Based on literature reports, we decided to treat with long-pulse ND:Yag laser. We started at 30 J/cm2 and then we improved dose until 80 J/cm2. A total of 7 treatments in an 8-12 weeks inter-treatment interval were performed with successfully outcome, without relapse for more than 18 months of follow up. We monitored scalp inflammation with reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) during patient’s treatment. Both technologies represent non-invasive diagnostic tool and their application on inflammatory skin diseases has increased in the last years. ND:Yag laser is useful therapy option in the treatment of recalcitrant FD. Our experience allowed us to monitor the evolution of inflammatory reaction, confirmed treatment’s efficacy over the clinical examination

Osservazioni dermoscopiche ed in microscopia laser confocale sul poroma eccrino: la nostra casistica

Il poroma eccrino è una neoplasia benigna che clinicamente può simulare molteplici lesioni cutanee sai benigne che maligne. Le immagini dermoscopiche ed in microscopia laser confocale di cinque poroma eccrini non pigmentati, istologicamente provati, sono stati esaminate da due valutatori indipendenti. Le caratteristiche dermoscopiche più frequentemente osservate sono state il pattern vascolare polimorfo (100% dei casi) e le aree prive di struttura rosa-biancastre (80% dei casi). L’esame alla microscopia laser confocale ha evidenziato nei cinque casi di poroma nidi iporiflettenti ben demarcati circondati da abbondante stroma, assenza di cellule con disposizione a palizzata e “dark holes” corrispondenti ad aree di differenziazione duttale. L’integrazione delle caratteristiche clinico-dermoscopiche con l’osservazione alla microscopia laser confocale risulta utile nella diagnosi differenziale del poroma eccrino con altri tumori cutanei e nella sua corretta gestione terapeutica, sebbene la diagnosi definitiva resta affidata all’esame istologico che rimane imprescindibile nei casi dubbi

“Agnelli” vestiti da lupi: quando il carcinoma basocellulare imita il melanoma, ma viene smascherato dalla microscopia laser confocale

Background. Nella pratica clinica, molto spesso, l’esame clinico-dermoscopico del carcinoma basocellulare (BCC) non è sufficiente per una diagnosi corretta e la diagnosi differenziale si pone con il melanoma. La microscopia laser confocale (RCM) è una metodica di diagnosi non invasiva che consente di ottenere immagini in vivo ad alta risoluzione. Obiettivi. Nel nostro studio abbiamo valutato l'affidabilità dei ben noti criteri RCM per i classici BCC in un gruppo di lesioni con presentazione clinica e dermoscopica atipica. Metodi. Abbiamo analizzato retrospettivamente alla RCM tutte le lesioni asportate dal 2010 al 2016 con positività per almeno uno dei criteri dermoscopici della 7-point check list revisitata. Risultati. Tra le lesioni esaminate sono stati identificati 34 casi, confermati istologicamente come BCC (21 nodulari, 13 superficiali) e 143 casi classificati come altre lesioni (DF, Sebk, SCC e altri). Conclusioni. Le caratteristiche in RCM dei BCC che mimano dermoscopicamente il melanoma erano le stesse descritte per i classici BCC. Il nostro studio sottolinea l'importante ausilio della microscopia laser confocale nel corretto inquadramento diagnostico di neoplasie con differente comportamento biologico e nella conseguente gestione terapeutica

Lesions mimicking melanoma at dermoscopy confirmed basal cell carcinoma: evaluation with reflectance confocal microscopy

Background Atypical basal cell carcinoma (BCC), characterized by equivocal dermoscopic features typical of malignant melanoma (MM), can be difficult to diagnose. Reflectance confocal microscopy (RCM) enables in vivo imaging at nearly histological resolution. Objectives To evaluate BCCs mimicking melanoma at dermoscopy according to well-known RCM criteria for typical BCCs, and identify discriminate RCM parameters for superficial (sBCCs) and nonsuperficial BCCs (nsBCCs). Material and Methods A retrospective analysis of consecutive patients, evaluated with RCM, selecting excised lesions classified at dermoscopy with ≥1 score from the revisited seven-point checklist, mimicking melanoma, registered between 2010 - 2016. Lesions without RCM melanocytic parameters, were investigated by operators blinded to histopathology diagnoses. Cluster analysis identified BCC sub-classifications. Results Of 178 atypical lesions, 34 lesions were diagnosed BCC with RCM, and diagnoses were confirmed with histopathology. Dermoscopic features observed atypical network (55.9%), and regressions structures (35.5%) associated with sBCCs, and atypical vascular pattern (58.8%) and irregular blotches (58.8%) with nsBCC. Hierarchical cluster analysis identified 2 clusters: cluster 1 (100% sBCCs) was characterized by the presence of cords connected to the epidermis (90%, p<0.001), tumor islands located in the epidermis (100%, p<0.001), smaller vascular diameter (100%, p<0.001) and solar elastosis (90%, p=0.017) and cluster 2 (nsBCCs 85%) by the dermic location of tumor islands (87.5%, p<0.001) with branch-like structures (70.8%, p= 0.007) and surrounding collagen (83.3%, p=0.012), peripheral palisading (83.3%, p=0.012), and coiled vascular morphology (79.2%, p<0.001) with larger vascular diameter (50%, p<0.001). Conclusions RCM is able to diagnose BCCs mimicking melanoma at dermoscopy and seems able to identify sBCCs and nsBCCs. Therefore, the use of RCM may assist in optimizing therapeutic management of these equivocal lesions

Lesions mimicking melanoma at dermoscopy confirmed basal cell carcinomas: evaluation with reflectance confocal microscopy

Background: Atypical basal cell carcinoma (BCC), characterized by equivocal dermoscopic features typical of malignant melanoma (MM), can be difficult to diagnose. Reflectance confocal microscopy (RCM) enables in vivo imaging at nearly histological resolution. Objectives: To evaluate BCCs mimicking melanoma at dermoscopy according to well-known RCM criteria for typical BCCs, and identify discriminate RCM parameters for superficial (sBCCs) and nonsuperficial BCCs (nsBCCs). Material and Methods: A retrospective analysis of consecutive patients, evaluated with RCM, selecting excised lesions classified at dermoscopy with ≥1 score from the revisited seven-point checklist, mimicking melanoma, registered between 2010 - 2016. Lesions without RCM melanocytic parameters, were investigated by operators blinded to histopathology diagnoses. Cluster analysis identified BCC sub-classifications. Results: Of 178 atypical lesions, 34 lesions were diagnosed BCC with RCM, and diagnoses were confirmed with histopathology. Dermoscopic features observed atypical network (55.9%), and regressions structures (35.5%) associated with sBCCs, and atypical vascular pattern (58.8%) and irregular blotches (58.8%) with nsBCC. Hierarchical cluster analysis identified 2 clusters: cluster 1 (100% sBCCs) was characterized by the presence of cords connected to the epidermis (90%, p<0.001), tumor islands located in the epidermis (100%, p<0.001), smaller vascular diameter (100%, p<0.001) and solar elastosis (90%, p=0.017) and cluster 2 (nsBCCs 85%) by the dermic location of tumor islands (87.5%, p<0.001) with branch-like structures (70.8%, p= 0.007) and surrounding collagen (83.3%, p=0.012), peripheral palisading (83.3%, p=0.012), and coiled vascular morphology (79.2%, p<0.001) with larger vascular diameter (50%, p<0.001). Conclusions: RCM is able to diagnose BCCs mimicking melanoma at dermoscopy and seems able to identify sBCCs and nsBCCs. Therefore, the use of RCM may assist in optimizing therapeutic management of these equivocal lesions

Osservazioni dermoscopiche ed in microscopia laser confocale sul poroma eccrino: la nostra casistica

Il poroma eccrino è una neoplasia benigna che clinicamente può simulare molteplici lesioni cutanee sai benigne che maligne. Le immagini dermoscopiche ed in microscopia laser confocale di cinque poroma eccrini non pigmentati, istologicamente provati, sono stati esaminate da due valutatori indipendenti. Le caratteristiche dermoscopiche più frequentemente osservate sono state il pattern vascolare polimorfo (100% dei casi) e le aree prive di struttura rosa-biancastre (80% dei casi). L’esame alla microscopia laser confocale ha evidenziato nei cinque casi di poroma nidi iporiflettenti ben demarcati circondati da abbondante stroma, assenza di cellule con disposizione a palizzata e “dark holes” corrispondenti ad aree di differenziazione duttale. L’integrazione delle caratteristiche clinico-dermoscopiche con l’osservazione alla microscopia laser confocale risulta utile nella diagnosi differenziale del poroma eccrino con altri tumori cutanei e nella sua corretta gestione terapeutica, sebbene la diagnosi definitiva resta affidata all’esame istologico che rimane imprescindibile nei casi dubbi

Eccrine poroma: dermoscopical and confocal features of five cases

Background: Eccrine poroma (EP) is a rare benign adnexal tumor arising from the intraepidermal ductal portion of the sweat gland. It commonly occurs as a single, slowly growing, erythematous, skin-colored, cyanotic or pigmented papule, plaques or nodule. EP occurs usually at the acral sites, but it can develop in other cutaneous sites. It may occasionally mimic malignant tumors including basal cell carcinoma, squamous cell carcinoma and melanoma. Objective: The aim of this study was to describe dermoscopical and confocal features of EP. Methods: A retrospective analysis of the dermoscopical and confocal characteristics of EP was performed. All diagnosis were confirmed by histological examination. Results: A total of 5 cases of non-pigmented EP was analysed. Dermoscopic evaluation found in all lesions a polymorphous vascular pattern, including at least two type of vessels: hairpin (80%), linear (60%), leaf-like (60%), flower-like (40%) and glomerular (40%) vessels. A white-to-pink halo surrounding the vessels was found in 40% of the lesions. Multiple pink-white structureless areas were found in 4 out of 5 (80%) cases. Only in 2 cases irregular haemorrhagic and blue-white areas were also observed. Reflectance Confocal Microscopy (RCM) revealed the presence of well-demarcated hyporefractile tumor nests, dark holes corresponding to areas of ductal differentiation within the tumor and highly vascularized stroma in all 5 lesions. Conclusions: The great clinical variability of EP gives reason of the appellative of “big simulator”. Dermoscopy does not revealed univocal features except from “leaf-flower-like” vessels that have not been described in other types of skin tumors. This characteristic, when presents, may be considered an useful clue for the diagnosis. RCM examination of EP revealed features (hyporefractile tumor nests and dark holes) that relate with their histopathological findings. Dermoscopy and RCM improve the diagnostic accuracy and help for diagnosis, although they cannot replace histology that is still required

Capecitabine-induced eruptive acral hyperpigmentation: Clinical and dermoscopic evaluation of two cases

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