Utility of the Wood's light: five cases from a pigmented lesion clinic

Comparison of the efficacy of carboxytherapy versus fractional CO2 laser therapy for the treatment of periorbital dark circles: A randomized clinical trial

BACKGROUND

Periorbital dark circles (PDC) is one of the most common cosmetic issues in today's society. Only moderate degree of improvement has been achieved by various available treatment options. The present study aimed to compare the clinical efficacy of carboxytherapy and fractional CO₂ laser therapy in the management of PDC.

METHODS

In this split face study, 30 patients with bilateral PDC aged between 23 and 52 years were recruited who underwent carboxytherapy (n = 30) on PDC of one side of the face and fractional CO₂ laser therapy (n = 30) on the PDC of other side. The entire treatment comprised of four sessions of each therapy with an interval of 2 weeks each time. The assessment was based on both subjective methods (patients' satisfaction and physician's judgment) and objective method (based on digital standard photographs). The degree of improvement from the patient's point of view (patient satisfaction) and physician's point of view (physician satisfaction) was assessed in different therapy sessions in comparison with the improvement after first session.

RESULTS

The study included 30 patients with mean age of 38.22 ± 8.3 years. The mean disease duration was 45 ± 12.3 months. After the second therapy session, patients' satisfaction was remarkably better in the fractional CO₂ laser therapy group than the carboxytherapy group, over the time. According to the physician satisfaction, the improvement rate was higher after the second and sixth weeks in the fractional CO₂ laser therapy group than the carboxytherapy group; whereas in other sessions, there were no statistically significant differences. There were no significant side effects observed in either group post-treatment each time.

CONCLUSION

Fractional CO₂ laser therapy is a better option to treat PDC than carboxytherapy. Also, mild side effects (including erythema, pain, and discomfort) were reported in both groups; with no significant difference between the groups.

Novel strategy for applying hierarchical density-based spatial clustering of applications with noise towards spectroscopic analysis and detection of melanocytic lesions

Advancements in dermoscopy techniques have elucidated identifiable characteristics of melanoma which revolve around the asymmetrical constitution of melanocytic lesions consequent of unfettered proliferative growth as a malignant lesion. This study explores the applications of hierarchical density-based spatial clustering of applications with noise (HDBSCAN) in terms of the direct diagnostic implications of applying agglomerative clustering in the spectroscopic analysis of malignant melanocytic lesions and benign dermatologic spots. 100 images of benign (n = 50) and malignant moles (n = 50) were sampled from the International Skin Imaging Collaboration Archive and processed through two separate Python algorithms. The first of which deconvolutes the three-digit tupled integer identifiers of pixel color in image composition into three separate matrices corresponding to the red, green and blue color channel. Statistical characterization of integer variance was utilized to determine the optimal channel for comparative analysis between malignant and benign image groups. The second applies HDBSCAN to the matrices, identifying agglomerative clustering in the dataset. The results indicate the potential diagnostic applications of HDBSCAN analysis in fast-processing dermoscopy, as optimization of clustering parameters according to a binary search strategy produced an accuracy of 85% in the classification of malignant and benign melanocytic lesions.

Tools of dermatology: A historical perspective

Dermatology is one of the few visual specialties; much can be seen with the naked eye, yet many tools and devices can facilitate the diagnosis of cutaneous maladies. There has been significant progress in diagnostic techniques in recent decades with the advent of artificial intelligence and teledermatology. Such advancements reflect principles of long-standing aids, whereas others embody novel techniques and concepts. These bedside tools range from simple magnifiers and binocular loupes to reflectance confocal microscopes and ultrasounds. The cornerstone diagnostic techniques, including the potassium hydroxide examination and the Tzanck smear, remain highly useful. Although visual examination often permits an accurate diagnosis of a skin disease, the clinician is now even further equipped. Just as the microscope did 4 centuries ago, newer advances will continue to revolutionize the practice of medicine.

Diagnosis and Management of Lentigo Maligna: Clinical Presentation and Comprehensive Review

Lentigo maligna (LM), also known as Hutchinson's melanotic freckle, is a form of in situ melanoma characterized by the proliferation of atypical melanocytes along the basal epidermis in sun-damaged skin. If left untreated, LM will progress to lentigo maligna melanoma (LMM), a form of invasive melanoma with the same prognosis as other forms of invasive melanoma. LM is more common in the elderly, with a peak occurrence between the ages of 65 and 80 years. LM, however, is rarely present on the trunk and extremities. The diagnosis of LM, confirmed by histopathological and biopsy examination, is based on clinical and dermoscopic features. It typically begins as a tan-brown macule or patch, but it can progress to a variegated pigmentation with dark black color or even amelanotic characteristics. The risk factors involved in the LM development include a history of sunburns, lighter skin types, advanced age, history of nonmelanoma skin cancers, and tendency to form solar lentigines. This article explains the clinical presentation of LM, also reviews the available information on the diagnosis and management of LM, and discusses the potential of such information in facilitating the future prospective.

Periorbital Discolouration Diagnosis and Treatment: Evidence-Based Review

Infraorbital dark circles are a significant esthetic concern with few publications however offering evidence-based recommendations for their classification and consequent management. A literature review has been undertaken to classify dark circles based on etiology: shadowing, vascular, idiopathic hyperpigmentation, post-inflammatory hyperpigmentation, constitutional and offer an analysis of current treatment modalities and their effectiveness in managing specific types of infraorbital circles. This review aims to provide a detailed account of dark circle etiology, assessment and management.

Lentigo Maligna: Clinical Presentation and Appropriate Management

Lentigo maligna (LM) is a type of melanoma in situ that has distinctive characteristics regarding epidemiology, risk factors and clinical features. In addition, LM has a potential to progress to an invasive tumor with potentially aggressive behavior: lentigo maligna melanoma (LMM). Overall, LM has a very good prognosis, whereas LMM has the same prognosis as other invasive melanomas with similar Breslow thickness. LM/LMM represents a challenging entity not only regarding the diagnosis but also regarding the management. Diagnostic criteria are not well established, and there is an overlap of clinical, dermoscopic and pathological features with other benign pigmented skin lesions such as lentigines, pigmented actinic keratoses or macular seborrheic keratoses. LM/LMM's common appearance within photodamaged skin makes lesion border identification difficult. Wide excisions are often required, but since LM/LMM typically appears on cosmetically sensitive areas such as the face, sometimes large excisions are not possible nor desirable. In this sense, specialized approaches have been developed such as margin-controlled surgery or image-guided treatment using reflectance confocal microscopy. Other treatments for LM such as cryosurgery, imiquimod, radiotherapy or photodynamic therapy have been proposed, although recurrence/persistence is common. The current manuscript reviews extensively the published data regarding the diagnosis, treatment and management of both complex entities LM and LMM.

Clinical size is a poor predictor of invasion in melanoma of the lentigo maligna type

BACKGROUND

There are no well-defined clinical factors to predict the risk of occult invasion in melanoma of the lentigo maligna type (LM) before complete histopathologic analysis.

OBJECTIVE

To evaluate whether clinical size was a predictor of invasion in LM and subclinical extension.

METHODS

Consecutive cases of LM were recorded in a prospectively maintained database from 2006 to 2019. Patient and tumor data were recorded during initial evaluation. The LM clinical area was calculated in square millimeters (length × width). All patients were treated with staged excision.

RESULTS

We included 600 patients. The mean age was 65.9 years (standard deviation, 12.3; range, 27-95 years); 62.8% (n = 377) were men. The mean LM clinical area was 128.32 mm² for in situ lesions versus 200.14 mm for invasive lesions (P = .1). Based on quantile regression, the median margin required for complete removal increased with LM clinical area.

LIMITATIONS

The study was performed in a tertiary cancer center with possible referral bias and more complex cases.

CONCLUSIONS

LM can present with variable clinical size, which may correlate with subclinical extension; however, the presence of invasion is not well estimated by LM clinical area.

Comparing the effectiveness of fractional CO2 laser and the combination therapy with micro-needling and topical 10% trichloroacetic acid to remove infra-orbital dark circles in Tehran women

BACKGROUND

Infra orbital dark circles are now recognized as being a cosmetic problem that should be considered in treatment issue. The present study aimed to assess and compare the clinical efficiency of the combination of micro-needling and 10% trichloroacetic acid (TCA) cream as well as carbon dioxide laser in the management of infra-orbital dark circles.

METHODS

This randomized clinical trial was performed on women aged 28-62 years who complained of infra-orbital dark circles. The patients were randomly assigned to be treated with micro-needling combined with 10% TCA cream topically or CO₂ laser. The treatment period in each group included three sessions with an interval of one month between sessions. The assessment was based on both subjective and objective methods.

RESULTS

the mean of ΔE (the difference in the intensity of darkening at infra-orbital points and other points of the face) was significantly higher in the laser group than in the other group in all sessions. The patients who were treated with laser were found to have a higher level of satisfaction in the fifth visit when compared to those who received the other treatment method.

CONCLUSION

Regarding clinical effectiveness and the patients' compliance, fractional CO₂ laser was more preferred in the combination therapy with micro-needling and topical TCA for removing infra-orbital dark circles.

Acquired disorders with depigmentation: A systematic approach to vitiliginoid conditions

Acquired disorders with depigmentation are commonly encountered by dermatologists and present with a wide differential diagnosis. Vitiligo, the most common disorder of acquired depigmentation, is characterized by well-defined depigmented macules and patches. Other conditions, such as chemical leukoderma, can present with similar findings, and are often easily mistaken for vitiligo. Key clinical features can help differentiate between acquired disorders of depigmentation. The first article in this continuing medical education series focuses on conditions with a vitiligo-like phenotype. Early recognition and adequate treatment of these conditions is critical in providing appropriate prognostication and treatment.

Atypical Melanocytic Proliferations: A Review of the Literature

BACKGROUND

Ambiguous histopathologic diagnoses represent a challenge for clinicians because of a lack of definitive diagnosis and related uncertainty about management.

OBJECTIVE

To review the literature on atypical melanocytic proliferations and detail synonymous terms, epidemiology, diagnostic work-up, histopathology, treatment, and prognosis.

METHODS

Databases from PubMed and Web of Science were searched for articles related to atypical melanocytic proliferations.

RESULTS

Intraepidermal melanocytic proliferations with features worrisome for possible melanoma in situ (MIS) are generally excised as for MIS. Reported rates of upstaging of such cases to invasive melanoma on review of the excision are very low. Because invasion, lymph node spread, and metastasis can occur in atypical melanocytic lesions with a thick intradermal component, these are often treated as for malignant melanoma.

CONCLUSION

Because the diagnosis dictates treatment, it is incumbent to establish a diagnosis as definitive as possible, obtaining second or third opinions and using ancillary studies when appropriate. When the diagnosis remains uncertain, it is difficult to provide guidelines for treatment. Clinical care decisions for patients with an uncertain diagnosis are best done on a case-by-case basis weighing probabilities of adverse outcomes against potential benefits and risks from various treatment options.

Guidelines of the Brazilian Dermatology Society for diagnosis, treatment and follow up of primary cutaneous melanoma--Part I

The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In the first part, the following clinical questions were answered: 1) The use of dermoscopy for diagnosis of primary cutaneous melanoma brings benefits for patients when compared with clinical examination? 2) Does dermoscopy favor diagnosis of nail apparatus melanoma? 3) Is there a prognostic difference when incisional or excisional biopsies are used? 4) Does revision by a pathologist trained in melanoma contribute to diagnosis and treatment of primary cutaneous melanoma? What margins should be used to treat lentigo maligna melanoma and melanoma in situ?

Utility of Wood's light in margin determination of melanoma in situ after excisional biopsy

BACKGROUND

Margin evaluation of melanoma in situ (MIS) is difficult because of its ill-defined clinical borders. Wood's light examination is commonly used to help delineate MIS margin before excision.

OBJECTIVE

To prospectively study the accuracy of preoperative Wood's light examination for margin assessment of MIS.

MATERIALS AND METHODS

The authors evaluated 60 patients before excision of MIS under white light and Wood's light. Staged excision was performed using the square procedure technique. After achieving clear margins, they compared final wound size with expected wound size if surgical margins had been based on Wood's light examination.

RESULTS

Seven patients (11.7%) had Wood's light enhancement beyond the visible margin of the biopsy site. In all 7, increased wounding would have occurred if the surgical margins had been based on Wood's light examination. In 1 of the 7, use of the Wood's light examination would have reduced the surgical stages needed by 1 stage but would have increased the wound size by 83.3%.

CONCLUSION

Wood's light examination has limited utility if complete excisional biopsy of MIS is performed before treatment. In this study, surgical margin based on the Wood's light examination would have resulted in an increased average wound size and would not have reduced the number of stages needed when performing the square procedure.

Diagnosis and management of lentigo maligna: a review

Lentigo maligna is a melanocytic neoplasm occurring on sun-exposed skin, usually on the head and neck, of middle-aged and elderly patients. It is thought to represent the in situ phase of lentigo maligna melanoma. The ill-defined nature and potentially large size of lesions can pose significant diagnostic and treatment challenges. The goal of therapy is to cure the lesions in order to prevent development of invasive disease, and surgical excision is the treatment of choice to achieve clear histological margins. Nonsurgical treatment modalities have been reported; however, evidence is lacking to support their use. Age, general health, and comorbidities need to be taken into account when deciding the right treatment modality for each individual patient.

Lentigo maligna: review of salient characteristics and management

Lentigo maligna is a melanocytic neoplasm, often regarded as 'melanoma in situ,' which may progress to lentigo maligna melanoma. Lentigo maligna clinically presents as a pigmented, asymmetric macule that originates on the head and neck and spreads slowly. The preferred method for diagnosing lentigo maligna is excisional biopsy. Histology shows proliferation of atypical melanocytes at the epidermal-dermal junction in small nests or single cells. The differential diagnosis includes solar lentigo, seborrheic keratosis, lichen planus-like keratosis, pigmented actinic keratosis, and melanocytic nevus. Stains used in diagnosis include hematoxylin and eosin, HMB-45, MART-1/Melan-A, Mel-5, and S-100. Surgical excision is the preferred treatment for lentigo maligna. Second-line techniques include medical (topical imiquimod) and destructive therapy.

Assessment methods for the evaluation of vitiligo

There is no standardized method for assessing vitiligo. In this article, we review the literature from 1981 to 2011 on different vitiligo assessment methods. We aim to classify the techniques available for vitiligo assessment as subjective, semi-objective or objective; microscopic or macroscopic; and as based on morphometry or colorimetry. Macroscopic morphological measurements include visual assessment, photography in natural or ultraviolet light, photography with computerized image analysis and tristimulus colorimetry or spectrophotometry. Non-invasive micromorphological methods include confocal laser microscopy (CLM). Subjective methods include clinical evaluation by a dermatologist and a vitiligo disease activity score. Semi-objective methods include the Vitiligo Area Scoring Index (VASI) and point-counting methods. Objective methods include software-based image analysis, tristimulus colorimetry, spectrophotometry and CLM. Morphometry is the measurement of the vitiliginous surface area, whereas colorimetry quantitatively analyses skin colour changes caused by erythema or pigment. Most methods involve morphometry, except for the chromameter method, which assesses colorimetry. Some image analysis software programs can assess both morphometry and colorimetry. The details of these programs (Corel Draw, Image Pro Plus, AutoCad and Photoshop) are discussed in the review. Reflectance confocal microscopy provides real-time images and has great potential for the non-invasive assessment of pigmentary lesions. In conclusion, there is no single best method for assessing vitiligo. This review revealed that VASI, the rule of nine and Wood's lamp are likely to be the best techniques available for assessing the degree of pigmentary lesions and measuring the extent and progression of vitiligo in the clinic and in clinical trials.

Grenz ray treatment of lentigo maligna and early lentigo maligna melanoma

BACKGROUND

Lentigo maligna (LM) is the in situ phase of lentigo maligna melanoma (LMM). A wide variety of modalities has been used to manage LM, including conventional surgery, staged excision, Mohs micrographic surgery, cryotherapy, radiotherapy, laser therapy, and, recently, imiquimod.

OBJECTIVES

Soft x-radiation is an accepted treatment for LM/LMM. The aim of the present study was to evaluate the efficacy and safety of ultra-soft x-ray/grenz-ray (GR) treatment in patients with LM and early LMM.

METHODS

Five hundred ninety-three patients were treated with GR (primary therapy, n = 350; partial excision followed by GR, n = 71; radical excision followed by GR as recurrence-prophylactic treatment, n = 172) at the Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden between 1990 and 2009. The treatment was given twice a week over 3 consecutive weeks in total doses of 100 to 160 Gy. Dosage depended on the stage of LM and the depth of periadnexal atypical melanocytic extension in histologically examined materials before treatment. Four hundred twenty-five patients have been followed up for at least 2 years; of these, 241 for 5 years.

RESULTS

Overall, 520 of 593 patients (88%) showed complete clearance after one fractionated treatment. Residual lesions were seen in 15 patients, and 58 relapsed, 53 of whom (72%) within 2 years.

LIMITATION

Woods light examination was not used in the clinical diagnosis of lentigo maligna.

CONCLUSIONS

GR is an efficient and safe treatment in LM and early LMM when administered according to the recommendations presented herein. Moreover, GR offers an excellent cosmetic result.

A novel approach to identify non-palpable breast lesions combining fluorescent liposomes and magnetic resonance-guided high intensity focused ultrasound-triggered release

The combination of fluorescein-containing liposomes (FCL) and magnetic resonance-guided high intensity focused ultrasound (MR-HIFU)-triggered release is a promising approach for lesion demarcation and more efficient removal of non-palpable breast lesions. Exposure of FCL to ablation temperatures (60 °C) using MR-HIFU would result in palpable, stained tumors, which are more easy to identify during surgical resection. In this study, proof-of-concept concerning fluorescent FCL for MR-HIFU-triggered release and tumor demarcation of non-palpable breast lesions is presented. Ex vivo experiments in human blood and porcine muscle tissue showed increased label release from the liposomes, clear fluorescence enhancement and diffusion of the released compound after heating to 60 °C. Next, fluorescein release of FCL was observed after MR-HIFU-mediated mild hyperthermia (42 °C) and ablation temperature (60 °C) for a short period (30s), which is in line with the clinically relevant MR-HIFU treatment parameters. These results indicate the potential of the FCL as a tool to improve tumor demarcation in patients by MR-HIFU-triggered release. Therefore, this method may offer a new tool for efficient surgical resection of non-palpable breast tumor lesions by enabling proper discrimination between tumor tissue and adjacent healthy tissue.

Infraorbital dark circles: definition, causes, and treatment options

BACKGROUND

Infraorbital dark circles refer to the conditions that present with darkness of the infraorbital eyelids. Although it is not a medical concern, it can be a cosmetic concern for a large number of individuals. Moreover, clear definition and possible causes have not been elucidated.

OBJECTIVE

To review the possible causes and treatment options for infraorbital dark circles.

METHODS

The article is based on a review of the medical literature and the author's clinical experience in treating infraorbital dark circles.

CONCLUSION

Possible causative factors of infraorbital dark circles include excessive pigmentation, thin and translucent lower eyelid skin overlying the orbicularis oculi muscle, and shadowing due to skin laxity and tear trough, but because multiple factors cause infraorbital dark circles in the majority of patients, it is essential to identify the cause and choose the appropriate treatment according to the cause.

Lentigo maligna

Lentigo maligna (LM), a melanoma in situ, is a fairly common melanocytic lesion that usually develops on the chronically sun-exposed skin of the head and neck of Caucasians. It occurs mostly in people older than 40 years, with an incidence rate that increases with age and peaks in the seventh and eighth decades of life. Its diagnosis and treatment remain challenging. In this article, we review the history, epidemiology, clinical presentation, histology, and treatment of LM.

Fluorescent image analysis for evaluating the condition of facial sebaceous follicles

BACKGROUND/PURPOSE

Conventional methods, such as 'Sebutape' and 'Sebumeter,' can provide quantitative information on sebum excretion but cannot reflect the condition of sebaceous follicles that can be indirectly evaluated with fluorescent colors of sebum. The images of sebum excretion can be obtained with an ultraviolet-A light that is generally called 'Wood's Lamp.' In this study, we describe fluorescent image analysis methods for the detection of sebum and the color segmentation of sebum to evaluate the condition of sebaceous follicles.

METHODS/RESULTS

For subject-dependent automatic image analysis, we extracted calibrated image analysis methods that were optimized for digital fluorescent images acquired from our imaging system. The calibrated subjective threshold values for sebum detection were determined by statistically analyzing the number of sebum detected by the automatic threshold value method and the subjective threshold value method (R=0.947, the number of volunteers: 29). In fluorescent color analysis of sebum, the calibrated reference color markers for the red and white colors were extracted with a coefficient of variance of <10%.

CONCLUSION

We are confident that such calibrated image analysis methods in combination with our imaging system can provide useful quantitative diagnostic information for sebum-related skin pathologies.

[Melanoma in invisible naevus spilus]

BACKGROUND

Diagnosis of naevus lesions may be complex where they contain little or no pigmentation. Naevus spilus (or naevus on naevus) is, generally, readily identified by the difference in pigmentation between overlying and underlying naevi and healthy skin. Malignant transformation of naevus spilus is rare. We report two cases of melanoma in which surgical procedures revealed underlying melanocyte lesions, diagnosed at histology but undetectable on clinical examination.

PATIENTS AND METHODS

Two patients were operated for melanoma in which surgery, at a site remote from the melanoma, suggested incomplete relapse despite the fact that previous clinical examination had indicated healthy skin. A diagnosis was made of melanoma in invisible naevus spilus.

DISCUSSION

Diagnosis of melanoma in invisible naevus spilus may be suspected where several naevi are found together in a specific area. The main problem is the therapeutic stance to be adopted since complete excision of the underlying naevi is difficult in practice. Wood's light examination may be helpful.

Origin, clinical presentation, and diagnosis of hypomelanotic skin disorders

Hypomelanotic skin disorders are cutaneous pigmentary disorders characterized by a reduced melanin content in the skin that results in a lightening of the skin. Establishing the correct diagnosis for hypomelanotic skin disorders requires a good history, a detailed physical examination, the use of special lighting techniques, such as Wood's light, and sometimes a biopsy of the abnormally pigmented skin and the normally pigmented skin. This article focuses on the origin, clinical presentation, and diagnosis of acquired hypomelanotic skin disorders. An algorithm for the diagnostic approach to these hypomelanoses is given.

Multimodal in vivo optical imaging, including confocal microscopy, facilitates presurgical margin mapping for clinically complex lentigo maligna melanoma

Knowledge of the accurate margins of a lentigo maligna melanoma (LMM) is crucial in the presurgical evaluation of the patient. Towards this end clinicians have utilized the Wood's lamp and dermoscopy to help delineate the borders of the LMM. However, many LMMs arise on photodamaged skin, making it difficult to determine the border of the LMM and separate it from the background lentiginous skin. We present a case of a patient with a recurrent LMM on the scalp that developed in a background of photodamage with diffuse melanocytic atypia and lentigines, making it virtually impossible to determine the precise margins of the LMM by clinical, Wood's lamp or dermoscopic examination. To avoid subjecting the patient to multiple staged excisions we attempted to determine the margins of the LMM by utilizing in vivo confocal laser scanning reflectance microscopy. Using this, it was apparent that there were increased numbers of atypical/dendritic intraepidermal melanocytes in all layers of the epidermis within the LMM. In contrast, skin not involved with the LMM, as viewed under confocal laser examination, had normal honeycomb architecture and no abnormal melanocytes. The confocally determined border was further confirmed by obtaining multiple punch biopsies that were evaluated by haematoxylin and eosin histology and immunohistochemistry. Based on this information, the presurgical margins were marked and the tumour excised accordingly. The excised tissue was examined with multiple-step sections and the margins were determined to be clear. There has been no evidence of tumour recurrence after 1 year. In conclusion, this case illustrates that confocal reflectance microscopy, in conjunction with other in vivo optical instruments, can be utilized to enhance the accuracy for the presurgical margin mapping of LMM.