Acral Lentiginous Melanoma Developing during Long-standing Atypical Melanosis: Usefulness of Dermoscopy for Detection of Early Acral Melanoma

Clinical guidelines suggest that suspicious pigmented lesions of the plantar or palmar area require biopsy for early detection of acral melanoma. We present here a case of acral lentiginous melanoma in which various melanocytic atypia was observed at each biopsy site, including focal melanocytic proliferation. We suggest that this atypical melanosis is part of a contiguous phase of invasive tumor growth, which is known as the very early stage of melanoma in situ. In addition, noninvasive dermoscopy has been effective for the early discovery of hidden lesions of acral melanoma.     

Long-Term Survival Analysis and Clinical Follow-Up in Acral Lentiginous Malignant Melanoma Undergoing Sentinel Lymph Node Biopsy in Korean Patients

Background

In cutaneous malignant melanoma (MM) with clinically uninvolved regional lymph nodes, sentinel lymph node (SLN) status is the most powerful indicator of both overall survival (OS) and disease-free survival (DFS). However, no studies on the long-term survival and clinical follow-up of Korean patients with acral lentiginous MM (ALM) undergoing SLN biopsy (SLNB) have been published.

Objective

The purpose of this study was to investigate the clinical prognosis and long-term survival of Korean patients with ALM according to SLN status.

Methods

Thirty-four ALM patients undergoing SLNB were included in this study. We evaluated clinical and histopathological follow-up data such as the stage of disease, treatment, recurrence, and metastasis, and analyzed OS and DFS according to SLN status.

Results

The median follow-up time was 60.5 months (range 3~127 months). Positive SLNs were noted in 14 patients (41.2%). Patients with negative SLNs had better OS and DFS than those with positive SLNs (p<0.05). Increased Breslow thickness was associated with short OS and DFS (p<0.05), and female patients showed better DFS than male patients (p<0.05).

Conclusion

To our knowledge, this is the first study on the long-term survival and clinical follow-up of patients undergoing SLNB for ALM in Korea. Our findings show that SLN status is an important prognostic factor for predicting OS and DFS.     

Amelanotic Acral Melanoma Associated with KIT Mutation and Vitiligo

Amelanotic acral melanoma is rare and difficult to diagnose, both clinically and pathologically. KIT mutations are frequently found in acral melanomas and are considered a risk factor for poor prognosis. The presence of vitiligo in melanoma has been reported, and KIT is thought to be partly responsible for the dysfunction and loss of melanocytes observed in vitiligo. We report a case of amelanotic subungual melanoma with multiple metastases that was associated with KIT mutation and vitiligo. An 85-year-old man presented with a 3-year history of a tender erythematous ulcerated tumor on the left third fingertip and developed hypopigmented patches on the face and trunk. Histopathological examination of the ulcerative tumor showed aggregates of tumor cells that were pleomorphic epithelioid cells. Immunohistochemical staining of the tumor cells was positive for S100, HMB45, and c-Kit. Histopathological findings from the hypopigmented patch on the face were consistent with vitiligo. Mutation analysis showed a KIT mutation in exon 17 (Y823D). The patient had metastasis to the brain, liver, bone, and both lungs. The patient refused chemotherapy, and died 3 months after the first visit.     

A Case of Acral Melanocytic Hyperplasia: A Unique Pigmented Lesion Mimicking Acral Lentiginous Melanoma In situ

A mottled black pigmented patch on the sole of the foot is reported. Clinically, the lesion closely mimicked acral lentiginous melanoma in situ. However, the histologic findings revealed melanocytic hyperplasia with minimal cytologic atypia confined to the epidermis. Irregular pigmented patches in the acral region comprise a heterogenous group of lesions that range from benign melanocytic hyperplasia to acral lentiginous melanoma.     

Frequency of Trauma,Physical Stress,and Occupation in Acral Melanoma: Analysis of 313 Acral Melanoma Patients in Korea

BackgroundTraumatic events are thought to be a cause of acral melanoma. However, little is known about the role of mechanical trauma or physical stress in the development of acral melanoma.ObjectiveIn our study, we evaluated the frequency of trauma, physical stress, and occupation in patients with acral melanoma and aimed to identify any pathological correlates of these factors.MethodsWe conducted a retrospective study of 313 acral melanoma patients from Chonnam National University Hospital. We mapped melanoma-developed anatomical sites of acral areas and assessed patients'' history of trauma, physical stress, and occupation.ResultsAmong the 313 acral melanoma patients, many reported a traumatic event (84 of 313; 26.8%) or physical stress (91 of 313; 29.1%) before the melanoma developed. The most common anatomical sites in these patients were on the borders of the foot (136 of 313; 43.5%). Trauma was more commonly associated with the fingernails and toenails than other sites. The frequency of each type of physical stress depended on the site of the lesion. Farmer and fisherman were the most common occupations (130 of 313; 41.5%) of the acral melanoma patients.ConclusionOur results demonstrate that traumatic events, physical stress, and certain occupations are common in acral melanomas. Further studies are needed to establish whether these are risk factors for acral melanomas.     

Sensitivity and Usefulness of VE1 Immunohistochemical Staining in Acral Melanomas with BRAF Mutation

BackgroundAcral melanomas are known to have a low frequency of BRAF mutation, in contrary to higher KIT mutation. Recently, VE1 immunostaining was reported to have a good correlation with BRAF mutation status.ObjectiveWe aimed to evaluate the clinicopathological features of BRAF-mutated acral melanomas and validate the correlation of the VE1 immunohistochemical stains in those cases.MethodsThe clinical features (age, sex, anatomical site), and histopathological characteristics of 41 patients with acral melanoma were evaluated. We performed a next-generation sequencing to detect BRAF mutation status. We also determined the correlation of VE1 immunohistochemical staining with BRAF mutation status.ResultsAmong 19 acral melanomas with BRAF mutation, common histopathological subtype was acral lentiginous melanoma (8/19, 42%) and nodular melanoma (8/19, 42%) and superficial spreading melanoma (3/19, 16%) followed. VE1 immunostaining results were positive in all 15 cases with BRAF V600E mutation (sensitivity 100%), and negative in 4 cases of BRAF non-V600E mutation. However, VE1 immunostaining was negative in all 22 patients with BRAF wild-type.ConclusionVE1 immunostaining had a good correlation with BRAF V600E mutation status.     

The Clinical Significance of Tumor-Infiltrating Lymphocytes and Microscopic Satellites in Acral Melanoma in a Korean Population

Background

There are various histological prognostic parameters of cutaneous malignant melanoma, including tumor thickness and ulceration. Tumor-infiltrating lymphocytes (TIL) are among these parameters and can be further classified into three categories: ''absent'', ''non-brisk'' and ''brisk''. Brisk TIL usually indicates better clinical prognosis. Microscopic satellite (Ms) is defined as a nest of tumor cells that is greater than 0.05 mm in diameter and definitely separated from the main tumor. Even though the incidence of Ms varies according to Breslow thickness, the presence of Ms generally indicates poor prognosis.

Objective

Clinical significance of both TIL and Ms has been extensively studied in western populations but much less so in Asian countries, including Korea, where acral melanoma is the most common subtype.

Methods

We reviewed 90 patients with acral melanoma diagnosed at Kyungpook National University Hospital in Korea. Tissue specimens were examined using hematoxylin-eosin and HMB45 immunohistochemical staining. They were also evaluated by the presence and categorization of TIL (absent, non-brisk and brisk) and the presence of Ms. We further evaluated their impact on survival events (recurrence, distant metastasis and death).

Results

The number of survival events by TIL type was 22 in the absent category (22/64, 34.4%), 3 in the non-brisk category (3/25, 12.0%) and 0 in the brisk category. For Ms, survival events were present in 7 patients in Ms-present group (7/11, 63.6%) and 21 patients in Ms-absent group (21/79, 26.6%).

Conclusion

We suggest the possibility of TIL and Ms as prognostic indicators for acral melanoma in Korean population.     

Acral,Superficial Spreading Melanoma Arising on Melanocytic Nevus in a Pregnant Woman: A Case Report with Review

We are reporting a case of superficial spreading melanoma (SSM) on left palm of a 37-year-old pregnant housewife. She had a small acquired melanocytic nevus on her left palm since childhood, which changed its consistency and color in the last 4 months. Dermoscopy of the lesion indicated malignant changes. The lesion was managed surgically using split-thickness skin graft. The histopathology report was suggestive of SSM with positive HMB-45 cells. SSM is very rare on the acral site, and it is very difficult to differentiate it from acral lentiginous melanoma. The rarity of the site (acral nonchronic sun damage) with evolution during pregnancy and importance of management approach are reasons for publishing this case.     

Clinical Profile of Leprosy Patients: A Prospective Study

Introduction:

Early diagnosis and early adequate drug treatment is very important aspect to reduce the load in cases of leprosy. So, correct labeling of paucibacillary and multibacillary cases is a prerequisite for the adequate treatment. Confirmation of diagnosis is an important indication for histopathological examination in doubtful cases.

Objectives:

The present study was carried out to know the clinical profile of leprosy patients, concordance between clinical and histopathological diagnosis in cases of leprosy, and to assess the therapeutic efficacy of antileprosy therapy.

Study Design:

Two hundred and fifty clinically diagnosed leprosy patients attending skin outdoor patient department (OPD) were included in the study. Slit skin smear was performed in all the cases. In that case concordance between clinical and histology can be determined only in 30 cases. All the patients were treated with MDT (multidrug therapy) as per WHO guideline.

Results:

A total of 250 patients attended the clinic with male to female ratio of 1.7:1. The highest incidence was noted in 17-40 years of age group. In the clinical disease spectrum, 40% patients were in the borderline spectrum followed by tuberculoid leprosy (TT) (29.2%), lepromatous leprosy (LL) (26.8%), and 3.9% of indeterminate leprosy (IL). A total of 18% of patients were of primary neuritic leprosy. A total of 8.3% patients had definite history of contact in the family or neighborhood. Clinicopathological correlation was noted in 60% of patients with maximum disparity (52.9%) in the borderline group of patients. A total of 52.8% were MB (Multibacillary) and 47.2% were PB (Paucibacillary) cases. Morphological index became negative after 6 months in all patients. Mean fall of bacteriological index after 6 months was 0.19, while after 1 year, it was 1.05.

Conclusion:

Timely diagnosis and adequate treatment of cases with MDT is most effective. Histopathological examination is must in doubtful cases of leprosy.     

Distribution of Malassezia Species on the Scalp in Korean Seborrheic Dermatitis Patients

Background

Malassezia species play an important role in the pathogenesis of seborrheic dermatitis. In particular, M. restricta and M. globosa are considered to be the predominant organisms in seborrheic dermatitis of Western countries. However, species distribution of Malassezia in seborrheic dermatitis has not been clearly determined yet in Asia.

Objective

To identify the distribution of Malassezia species on the scalp of seborrheic dermatitis patients in Korea using 26S rDNA PCR-RFLP analysis.

Methods

A total of 40 seborrheic dermatitis patients and 100 normal healthy volunteers were included in this study. For the identification of Malassezia species, the scalp scales of the subjects were analyzed by 26S rDNA PCR-RFLP analysis.

Results

The most commonly identified Malassezia species were M. restricta in the seborrheic dermatitis patients, and M. globosa in the normal controls. In the seborrheic dermatitis group, M. restricta was identified in 47.5%, M. globosa in 27.5%, M. furfur in 7.5%, and M. sympodialis in 2.5% of patients. In the healthy control group, M. globosa was identified in 32.0%, M. restricta in 25.0%, M. furfur in 8.0%, M. obtusa in 6.0%, M. slooffiae in 6.0%, and M. sympodialis in 4.0% of subjects.

Conclusion

M. restricta is considered to be the most important Malassezia species in Korean seborrheic dermatitis patients.     

Role of In Vivo Reflectance Confocal Microscopy in Determining Stability in Vitiligo: A Preliminary Study

Background:

Vitiligo is an acquired pigmentary disorder. In vivo reflectance confocal microscopy (RCM) reproducible imaging technique has already been reported to be useful in the diagnosis of other skin diseases.

Objective:

To define RCM features of vitiligo on different clinical stages.

Materials and Methods:

A total of 125 patients with a clinical diagnosis of vitiligo were included in this study. After informed consent, lesional skins of those vitiligo patients were characterized by using RCM. Five patients with inflammatory cell infiltration observed at the edge of skin lesions and another 5 patients without inflammatory cell infiltration were selected. Biopsies were performed at same sites of the RCM examination areas for histological and immune-histological analysis.

Results:

In the active stage of vitiligo, the RCM examination revealed that the bright dermal papillary rings presented at the dermoepidermal junction level in normal skin lost their integrity or totally disappeared, border between vitiligo lesion and normal skin became unclear, and highly refractile cells that referred to infiltrated inflammatory cells could be seen within the papillary dermis at the edge of the lesions. In the stable stage of vitiligo, the RCM showed a complete loss of melanin in lesional skin and a clear border between lesional and normal skin.

Conclusion:

A simple clinical examination with RCM may reliably and efficiently allow evaluation of the stability status of vitiligo lesions.     

Clinicopathologic Manifestations of 36 Korean Patients with Acute Generalized Exanthematous Pustulosis: A Case Series and Review of the Literature

Background

Acute generalized exanthematous pustulosis (AGEP) is a rare and severe subtype of drug eruption, characterized by acute, extensive, non-follicular, sterile pustules on an erythematous background, accompanied by fever and leukocytosis.

Objective

The purpose of this study was to characterize AGEP in Korean patients in terms of clinical, laboratory, and pathologic findings.

Methods

Thirty-six patients (M:F=17:19) with AGEP were identified from an extensive review of medical records over a 15 year period. All patient cases were confirmed by biopsy and fulfilled the diagnostic criteria.

Results

The patient ages ranged from 4~80 years (37.6±19.4). The incubation period was 1~23 days. The duration of disease was 5~14 days. Neutrophilia (36/36), high CRP (14/36), and eosinophilia (30/36) were common laboratory findings. A history of drug administration existed in 23 of 36 patients; herbal medications, lacquers and radiocontrast media were the unique causative drugs. Spongioform subcorneal or intraepidermal pustules in the epidermis was observed in all patients. Thirty-six patients were subdivided into 2 groups: group A (n=23) was strongly associated with known agents; and group B (n=13) had no identified causative agents. There was no significant difference between the 2 groups.

Conclusion

Our results demonstrate the characteristic features of AGEP in Korean patients as follows: lower identification of causative agents; herbal medications, lacquers, and radiocontrast media were the main causative agents; and no significant differences existed between the 2 groups.     

Role of Depression,Anxiety and Stress in Patients with Oral Lichen Planus: A Pilot Study

Context:

Lichen planus is a psychosomatic disease. Higher frequency of psychiatric symptoms, poor quality of life, higher level of anxiety and neuroendocrine and immune dysregulations, all these factors, will enhance the exacerbation of the disease.

Aims:

The present study was to assess depression, anxiety and stress levels in patients with oral lichen planus.

Materials and Methods:

The psychometric evaluation using the Depression Anxiety Stress Scale (DASS)-42 questionnaire was carried out, by the same investigator on all members of group 1 (Oral Lichen Planus) and group 2 (Control). DASS-42 questionnaire consists of 42 symptoms divided into three subscales of 14 items: Depression scale, anxiety scale, and stress scale.

Statistical Analysis Used:

The Student t test was used to determine statistical difference for both the groups and to evaluate for significant relationships among variables.

Results:

Psychological assessment using DASS-42 reveals lichen planus patients showed higher frequency of psychiatric co morbidities like depression, anxiety and stress compared to control group.

Conclusions:

This study has provided evidence that the DASS-42 questionnaire is internally consistent and valid measures of depression, anxiety, and stress. Psychiatric evaluation can be considered for patients with oral lichen planus with routine treatment protocols are recommended. DASS-42 Questionnaire can also be used to determine the level of anxiety, stress and depression in diseases of the oral mucosa like recurrent apthous stomatitis, burning mouth syndrome and TMD disorders.     

Quality of Life and Psychological Morbidity in Vitiligo Patients: A Study in a Teaching Hospital from North-East India

Background:

Vitiligo is an acquired discoloration of skin and mucous membrane of great cosmetic importance affecting 1-4% of the world''s population. It causes disfiguration in all races, more so in dark-skinned people because of strong contrast. Men, women, and children with vitiligo face severe psychological and social disadvantage.

Aim:

To assess the impact of the disease on the quality of life of patients suffering from vitiligo, also to ascertain any psychological morbidity like depression associated with the disease and to compare the results with that of healthy control group.

Materials and Methods:

Dermatology Life Quality Index (DLQI) and Hamilton Depression Rating Scale (HAMD) are administered to 100 vitiligo patients presenting to the Dermatology OPD and 50 age- and sex-matched healthy controls. Results were analyzed and compared with that of control group. Findings are also correlated in relation to demographic and clinical profile of the disease. Statistical analysis is made to see the significance.

Results:

Vitiligo-affected patients had significantly elevated total DLQI scores (P < 0.001) compared to healthy controls. There is increase in parameters like itch, embarrassment, social and leisure activities in the patient cohort than the control group. Patients of vitiligo are also found to be more depressed (P < 0.001) than the controls.

Conclusion:

Quality of life (QOL) in patients affected with vitiligo declined more severely, and also there is increase in incidence of depression than in the control group. These changes are critical for the psychosocial life of the affected people.     

Clinical and Investigative Assessment of Patients with Positive Versus Negative Autologous Serum Skin Test: A Study of 80 South Indian Patients

Background:

Chronic urticaria (CU) is defined as urticaria persisting daily as or almost daily for more than 6 weeks and affecting 0.1% of the population. Mast cell degranulation and histamine release is of central importance in the pathogenesis of CU. About 40-50% of the patients with chronic idiopathic urticaria demonstrate an immediate wheal and flare response to intra-dermal injected autologous serum. This led to the concept of autoimmune urticaria.

Aims:

To determine the occurrence, clinical features, associated clinical conditions, comorbidities of autoimmune urticaria and to compare this with chronic spontaneous urticaria. This study aimed to find the frequency of autologous serum skin test (ASST) positive patients among patients with CU and to identify the clinical and laboratory parameters associated with positive ASST.

Materials and Methods:

Prospective correlation study was done on 80 chronic urticaria patients, more than 6 weeks duration, attending outpatient department of dermatology during a period of November 2007 to January 2010. Patients were subjected to ASST, complete blood count, urine routine examination, liver function tests, renal function tests, thyroid function tests, H. pylori antibody tests, C3 and C4 complement level estimation, antinuclear antibody, and urine analysis.

Results:

ASST was positive in 58.75% and negative in 41.25% of the patients, respectively. Out of 33 patients with history of angioedema, 9 (27.3%) patients were in ASST negative group and 24 were in positive group, this was statistically significant. Both groups showed no statistically significant difference for epidemiological details.

Conclusion:

ASST is considered a screening test for an autoimmune urticaria, which decreases the rate of diagnosis of “idiopathic” form of chronic urticaria. Patients with an autoimmune urticaria have more severe urticaria, more prolonged duration, more frequent attacks, and angioedema. Identification of autoimmune urticaria may permit the use of an immunotherapy in severe disease unresponsive to anti-histamine therapy.     

Dermoscopy to Detect Signs of Subclinical Nail Involvement in Chronic Plaque Psoriasis: A Study of 68 Patients

Background:

Onychopathies constitute one of the major challenges faced by a dermatologist in terms of its early detection and diagnosis. Utility of dermoscope as a tool for detection is increasing by the day and its use in onychopathies needs to be explored.

Aims:

To study the dermoscopic features of nails in patients of chronic plaque psoriasis.

Materials and Methods:

In a cross-sectional study, a total of 68 patients with chronic plaque psoriasis were recruited. Dermoscopy of nail plate was conducted and were compared with equal number of age and sex matched healthy volunteers.

Results:

Forty-six patients showed dermoscopic findings. Twenty-two patients did not show any dermoscopic findings. Coarse pits (18/46, P < 0.0001), onycholysis (10/46, P < 0.001), oil drop sign (2/46, P = 0.12) and splinter hemorrhages (5/46, P = 0.05) were seen. In addition certain findings of interest were stout, globose, dilated, pink- to red-colored nail bed vessels arranged longitudinally at the onychodermal band surrounded by a prominent halo (9/46, P = 0.01). In contrast, splinter hemorrhages appeared as streaks and were purple in color.

Conclusion:

In a psoriasis patient, dermoscope can be a useful tool to detect early nail involvement in psoriasis and aid in differentiating it from other disorders of nails.     

The Spectrum of Cutaneous Infection in Diabetic Patients with Hepatitis C Virus Infection: A Single-Center Study from Egypt

Context:

Hepatitis-C virus (HCV) infection and diabetes mellitus (DM) have a significant association with skin disorders. Aims: The aim of this study was to assess the impact of HCV infection on the pattern of cutaneous infections among diabetic patients. Methods and Material: A prospective study included diabetic patients who attended Al-Hussein University hospital, Cairo during the period from 2008 to 2010. Patients were examined for skin infections, and investigated for HCV infection.

Statistical Analysis Used:

SPSS (version 11.5).

Results:

The study included 163 patients (102 males and 61 females) with a mean age of 46.2 ± 4.83 years. Ninety five patients (58.3%) were HCV+ve (group A) while 68 patients (41.8%) were HCV-ve (group B). Skin infections in group A included fungal (48.4%), viral (26.3%), bacterial (22.1%) and parasitic (3.2%) while in group B, the spectrum included bacterial (41.2%), fungal (39.7%), viral (11.7%) and parasitic (7.4%). Onychomycosis was the commonest infection in group A (25.2%) compared with folliculitis in group B (19.1%). Cutaneous infections in HCV+ patients were more characterized by increased severity, aggressive course, resistance to treatment and rapid relapse.

Conclusions:

HCV infection has a significant impact in increasing and changing the spectrum of skin infections in diabetic patients. Severe and resistant infections in diabetics could be an important sign of HCV infection.     

A Clinicopathological Analysis of Primary Cutaneous Lymphomas: A 6-year Observational Study at a Tertiary Care Center of South India

Background:Little data are available concerning clinical and pathological patterns of cutaneous lymphomas in India.Aim:To analyze the clinical and histopathological characteristics of cutaneous lymphomas in Indian patientsResults:Among 35 cases, 33 (94.3%) were T-cell, and 2 (5.7%) were B-cell lymphomas. The mean age was 52.66, and the male to female ratio was 2.5:1. The most common types of T-cell lymphomas included mycosis fungoides (MF) (57.1%) followed by adult T-cell lymphoma/leukemia (ATL) (17.1%). Primary cutaneous peripheral T-cell lymphoma not otherwise specified was diagnosed in 17.1% and anaplastic large cell lymphoma in 2.9%. The morphological types of MF included polymorphic, poikilodermatous, folliculotropic, hypopigmented, hyperpigmented, mixed, and purpuric. Skin manifestations of ATL included ulcerated plaques and erythroderma. Epidermotropism was very marked in ATL (83.3%) than in MF (70%). Larger Pautrier''s microabscess was noted in ATL compared to smaller ones in MF. Markedly dense, diffuse infiltrate of atypical cells was noted in ATL in contrast to mild to moderate nodular or perivascular infiltrate in MF. ATL had an extremely poor prognosis.Limitations:Identification of DNA integration of HTLV-1 by Southern blot could not be analyzed, and the number of cases studied is limited.Conclusions:The study showed unique patterns of subtypes of cutaneous lymphomas in our country. Variations in the clinical pattern and histopathological analysis will help to differentiate T-cell lymphoma types which have prognostic implications.