Slow‐growing melanoma: a dermoscopy follow‐up study

Background Recent evidence suggests that melanoma is a family of different tumours with varying abilities to grow and metastasize. Trends in melanoma epidemiology show a strong increase in the incidence of thin melanoma, with no corresponding increase in mortality or incidence of thick melanoma. We initially evaluated five cases and found that none had baseline features suggestive of melanoma; excision was performed based on slight changes visible only in side‐by‐side comparisons of dermoscopic images. Objectives To assess the clinico‐dermoscopic features and the growth patterns of melanomas that were excised after a follow‐up of 1 year or more due to their inconspicuous features at the baseline consultation. Methods In a multicentre, retrospective study of histopathologically confirmed melanomas excised after follow‐up, we analysed dermoscopic images obtained at the initial consultation and compared them with images obtained at the last follow‐up consultation. Images were analysed and graded using standard algorithms and scored for changes in size, symmetrical or asymmetrical structural change, and development of new melanoma‐specific criteria. An overall score reflecting the amount of change was calculated for each lesion. Results Our series consisted of 103 melanomas. After a median follow‐up of 20 months, most lesions were still in situ or early invasive (median Breslow thickness of 0·48 mm), with only three lesions showing tumour thickness of 1 mm or more. The most frequent baseline characteristics were asymmetrical pigmentation (78·6% of lesions), reticular overall pattern (62·1%), and regression features (35·9%). Most melanomas (58·3%) showed minor to moderate changes over time, with < 2 mm size increase, with asymmetrical structural change, and without development of new melanoma‐specific criteria. Major changes were visible only after a mean follow‐up of 33 months. Conclusions This study provides evidence for the existence of a subgroup of slow‐growing melanomas, which may explain the increase in the incidence of thin melanoma, despite stable rates of thick melanoma and melanoma‐associated mortality.     

Impact of digital dermoscopy analysis on the decision to follow up or to excise a pigmented skin lesion: a multicentre study

Background: The quality of early malignant melanoma (MM) diagnosis is dependent on the experience of dermatologists, tools like dermoscopy and histopathology, and awareness and education of the studied population. Does a higher rate of excision of pigmented skin lesions (PSL) increase the rate of detected melanomas? Material and Methods: The DB‐MIPS objective tool, able to evaluate mathematical defined variables, has been used to verify the variability of measurements among PSL stored by five different centres located in Italy, Switzerland, and Germany. Results: The objective analysis showed low differences in terms of moles' features among the different groups, arguing for robustness of the dermatological patient's PSL inspection. Differences in terms of false positives and predictive positive values have been detected. The tendency to follow up a lesion was proportional to the percentage of thin MM (<0.75 mm tumour thickness), while the interventism was proportional to the percentage of dysplastic moles. Similar percentage of thin melanoma has been observed in all the centres, indicating a standardization in early diagnosing among experienced dermatologists. The main difference among the centres was their mode of action, i.e. to follow up or remove suspicious PSL. Conclusion: Interventism depends neither on the geographic site nor on the features of the observed moles. Higher removal rates do not correspond to higher MM detections: this means that an in‐depth knowledge of melanoma patterns is required and follow‐up of suspicious moles is highly suggested.     

Clinical course of guttate psoriasis: Long‐term follow‐up study

Guttate psoriasis, known to have a better prognosis than other types of psoriasis, shows rapid involution and longer remission, but its clinical course has barely been studied. The aim of this study was to determine the clinical course and to compare the clinical and laboratory features of guttate psoriasis. This is a retrospective study of 26 patients with guttate psoriasis. The patients were divided into two groups; the good one with complete remission and long remission for at least 1 year (group A) and the poor one with incomplete remission and progression into chronic plaque psoriasis (group B). Among 36 patients, 22 patients (61.1%) were group A and 14 patients (38.9%) were group B. In group A, most of the skin lesions disappeared within 8 months. In group B, two patients without proper treatment progressed to plaque psoriasis. The onset age was younger and more frequent upper respiratory infection and high anti‐streptolysin O (ASO) titer were found in group A, but family history of psoriasis was more common in group B. Patients had two distingushable clinical courses: rapid involuting course with long‐term remission and chronic course without remission. There was a tendency toward younger age of onset with elevated ASO titer in patients with rapid involuting course.     

Cost‐effectiveness of reduced follow‐up in malignant melanoma

Background: Considerable variability exists in the extent and frequency of follow‐ up examinations for melanoma patients between different countries, generating significantly different total costs and uncertain clinical benefits. Patients and Methods: We have analyzed the follow‐up of melanoma patients under clinical and economic aspects based on the latest recommendations of the American Joint Committee on Cancer (AJCC) and the German Dermatologic Society (DDG) in the Düsseldorf cohort of 526 patients (stage IIII) during a 5‐year follow‐up period. Outcome measures were frequency of metastasis detection, most effective detection method, costs per detected metastasis and cost per quality‐adjusted life year. Results: Structured follow‐up detected 17 recurrences in stages I‐III. Physical examination and lymph node ultrasound were the only cost‐effective methods at all stages, while laboratory studies were generally not cost‐effective. The implementation of a reduced, yet medically adequate follow‐up reducing chest X‐rays, abdominal ultrasound examinations and eliminating blood tests in early stages yielded savings of more than 100,000 € (120,000 $) annually at a tertiary care university hospital. Conclusion: The implementation of a reduced follow‐up for melanoma patients seems not only medically justified but also economically required without adversely affecting patient outcome.     

Multiple primary melanoma: the impact of atypical naevi and follow up

Background Patients with melanoma are especially encouraged to have regular follow‐up visits with their dermatologist and to perform total‐body skin examination on a routine basis to identify new pigmented lesions or detect significant changes in existing naevi. Objectives To identify main risk factors (sex, age, number of common and atypical naevi, family history, phototype) associated with multiple primary melanomas (MPM) and to investigate the association between regular follow up and tumour thickness of a second primary melanoma. Methods We performed a retrospective analysis of patients with MPM in order to evaluate risk factors for developing a second primary melanoma. Medical records of patients with melanoma who developed a second primary melanoma were selected from a database of all patients with histopathologically confirmed melanoma treated at the dermatology clinic of the University of Florence, Italy, from 2000 to 2004. Medical data culled from the patient records were as follows: medical history, number of typical naevi, presence of atypical naevi, Breslow thickness, Clark level and histotype of the melanomas, site of the melanomas and patient adherence to 6‐month follow‐up examinations. Results The presence of atypical naevi was associated with a higher risk of developing MPM (adjusted odds ratio 3·28, 95% confidence interval 1·35–7·44). Moreover, in the subjects who did not attend follow up, we noted that the thickness of the second melanoma was significantly higher, with a mean thickness of 1·22 mm, in comparison with patients with a careful adherence to follow up in whom the mean thickness was 0·36 mm (P = 0·0189). Conclusions For the first time, the validity of this clinical approach has been supported by real comparison of thickness levels of second melanoma in patients with or without periodical follow up. Results obtained from this analysis show that follow up is an effective method for early detection of melanoma.     

Histological features and outcome of inverted type‐A melanocytic nevi

The presence of enlarged epithelioid/spindled nests located deep in the reticular dermis of a biphasic melanocytic neoplasm can mimic melanoma arising in a pre‐existing nevus, causing over‐interpretation of malignancy. We aimed to define the clinicopathologic significance of epithelioid/spindled nests in melanocytic nevi. Retrospectively using clinical and histologic information, we characterized 121 patients with a single lesion showing epithelioid/spindled melanocytes in the reticular dermis or subcutaneous fat, surrounded by melanophages, sometimes blending in with the adnexa. The majority of nevi occurred in women in the ages of 10 to 39 years, where the most frequent presentation was a changing mole. While 78% of the lesions displayed an anatomic (Clark’s) level of IV‐V, there was no ulceration, significant regression or inflammation. Up to 2 mitoses were found in only 12% of the cases, not correlating with the severity of cytological atypia. No recurrence or metastasis occurred during 45.5 months (mean) of clinical follow up in 26 patients. Notwithstanding the deep dermal extension, these findings suggest a benign histopathology and clinical outcome. Having compared the overlapping histopathology and clinical features between deep penetrating/clonal nevus and combined nevus, we posit that “inverted type‐A nevus” might be considered a variant of the two.     

In vivo reflectance confocal microscopy assessment of the therapeutic follow‐up of cutaneous T‐cell lymphomas causing scalp alopecia

Cutaneous T‐cell lymphomas involving the scalp and determining scarring alopecias are difficult to be followed up during treatment because of the peculiar anatomical site of onset. In vivo reflectance confocal microscopy has already been reported to be useful for cutaneous T‐cell lymphoma evaluation and for therapeutic follow‐up in inflammatory skin conditions. We describe a case of a 26‐year‐old man affected by cutaneous T‐cell lymphoma affecting the scalp in which reflectance confocal microscopy demonstrated to be useful for in vivo evaluation of the therapeutic response to topical and systemic treatment.     

Late recurrence (10 years or more) of malignant melanoma in south‐east Germany (Saxony) A single‐centre analysis of 1881 patients with a follow‐up of 10 years or more

Background Late recurrent melanoma (MM) is rare. Objective In the present study, we analysed the frequency of late recurrent MM in south‐eastern Germany. Patients and methods In our centre, 2314 MM patients were documented (1972–2001). A total of 1881 patients in stage I or II (AJCC) with a follow‐up of ≥10 years were selected and screened for late recurrence (≥10 years after diagnosis). Results Twenty patients were identified (1.1%), 13 women and 7 men, median age 44 years (age range 30–74 years). Nineteen suffered from cutaneous MM and one had a uveal MM (excluded from further analysis). The primary cutaneous MM occurred on the trunk (6), on the upper limb/shoulder (4), or on the lower limb (9). MM type was superficial spreading (13), nodular (2), acrolentiginous (1), lentigo maligna‐type (1) or unclassified (2). Tumour thickness varied from 0.33 mm to 9.5 mm (median 2.0 mm). Ulceration was seen in four, and spontaneous regression in two MM patients. Invasiveness into blood or lymphatic vessels occurred in seven MM patients. The largest period from primary diagnosis to recurrence was 25.1 years with a median of 13.9 years. Metastatic spread was loco‐regional (12 patients) or distant (7). Four patients were survivors and three of these had in‐transit metastases only. Overall survival was 14.7 ± 6.6 years. Statistical analysis could not identify factors significantly associated with late recurrence. Conclusions Late recurrence is a clinical sign of melanoma dormancy. We conclude that late recurrences argue for a lifelong follow‐up of melanoma patients.     

Nickel on the Swedish market: follow‐up 10 years after entry into force of the EU Nickel Directive

Background. The EU Nickel Directive, aimed at primary and secondary prevention of nickel allergy by limitation of nickel release from certain items, came fully into force in July 2001. Objectives. To assess the prevalence on the market of items with nickel release and to compare the outcome with previous studies performed in Sweden in 1999 and 2002–2003. Materials and Methods. Nickel release from 659 items covered by the EU Nickel Directive was assessed with the dimethylglyoxime (DMG) test. Special attention, as compared with the previous surveys, was given to cheap jewellery in street markets and sewing materials in haberdashery shops. Results. Nickel release was shown for 9% of the tested items, all of which were intended for direct and prolonged contact with the skin. A high proportion of items bought at haberdashery shops and street markets, 34% and 61%, respectively, showed nickel release. Conclusions. The Swedish market for products intended for direct and prolonged contact with the skin has largely adapted to the Nickel Directive. It is suggested that authorities should monitor the market regularly and give attention to areas where compliance with the requirements is poor, for protection of public health.     

Clinical and radiological outcomes of infantile hemangioma treated with oral propranolol: A long‐term follow‐up study

Infantile hemangiomas (IH) undergo rapid growth during early infancy followed by gradual involution. After involution, a part of IH remain as residual lesions. Since 2008, oral propranolol has been widely used in the treatment of IH. However, long‐term outcome of IH treated with propranolol remains unknown. This study aimed to investigate the sequelae of IH treated with propranolol. In this study, propranolol was given at a dose of 2 mg/kg per day at the age of 3.8 ± 2.5 months and follow‐up visits were arranged to continue at least through the age of 4 years. Types of sequela were recorded and classified as four degrees (“none”, “minimal”, “significant” and “severe” at last visit), then subsequent therapy was evaluated with the help of magnetic resonance imaging (MRI). A total of 73 patients with complete follow up were enrolled in the study. The most common types of sequela were telangiectasia, fibrofatty tissue and erythema. Significant and severe sequelae were observed in 72.4% of treated IH; superficial IH led to more but not significantly significant and severe sequelae than mixed IH (P > 0.05). Despite propranolol treatment, surgery was still needed in 37.5% of IH at a mean age of 70.3 months, and for the main reason of surgery, fibrofatty or hemangioma residua, MRI was useful for us to choose an appropriate surgical procedure.     

Delay in medical attention to hand eczema: a follow‐up study

Background Hand eczema often runs a chronic course but early medical intervention may be assumed to improve the prognosis. Objectives To follow patients with hand eczema for 6 months after seeing a dermatologist to investigate if delay in medical attention would impair the prognosis. Methods Study participants were 333 patients with hand eczema from nine dermatological clinics in Denmark. Severity of hand eczema was assessed by the patients at baseline and at the 6‐month follow up using a self‐administered photographic guide. Additional information was obtained by self‐administered questionnaires. Results Median patient delay (defined as the period from onset of symptoms until seeing a general practitioner) was 3 months [interquartile range (IQR) 1·5–8·0]. The median healthcare delay (defined as the period from the first visit to a general practitioner until seeing a dermatologist) was 3 months (IQR 1–8). In a logistic regression model, the odds ratio of a poor prognosis increased by a factor of 1·11 [95% confidence interval (CI) 1·02–1·21] per month of patient delay and by 1·05 (95% CI 1·00–1·10) per month of healthcare delay. Conclusions A poorer prognosis of hand eczema was associated with longer delay before medical attention.     

Divided or kissing nevus of the penis: A new case with dermoscopic findings

We report on a child with a divided or kissing nevus of the penis with benign symmetric globular pattern on dermoscopic examination that evolved into a globular‐reticular pattern after 1 year of follow‐up. Divided nevus of the penis is exceedingly rare, with only four cases with dermoscopic findings reported to date. Dermoscopy seems to be useful when deciding on the most appropriate management of these cases.     

Clinical follow‐up study of adult‐onset Still’s disease

Eighteen patients with adult‐onset Still’s disease have been followed up for 3–22 years in our department. Initial manifestations were fever with skin rash in 14 patients, fever, skin rash and sore throat in two, skin rash in one and arthralgia in one. During the follow‐up period, typical skin rash was seen in all patients, of them five patients (29%) revealed atypical skin rash simultaneously. Atypical rash included persistent erythema with pigmentation in two, persistent plaques and papules with linear erythema in two and edema of the eyelids mimicking dermatomyositis in one. Persistent papules and plaques revealed histologically characteristic features, such as dyskeratotic keratinocyte and liquefaction degeneration as well as a sparse superficial dermal infiltrate containing scattered neutrophils. In patients of chronic articular type and polycyclic systemic type, atypical skin rash, lymphadenopathy and hyperferritinemia were noted to be significantly higher than those of monocyclic type. These factors might be prognostic factors of adult‐onset Still’s disease in our study.     

A dual concept of nevogenesis:Theoretical considerations based on dermoscopic features of melanocytic nevi

The dermoscopic features of melanocytic nevi in children are clearly different from those in adults. While nevi in children show almost exclusively globular patterns, those in adults usually exhibit reticular patterns. These remarkable differences could be explained by a dual concept of nevogenesis, based on current clinico‐epidemiologic, dermoscopic, histopathologic and genetic data.     

Proliferative activity in melanocytic nevi from patients grouped by age with clinical follow‐up

Any mitotic activity in a melanocytic nevus is a source of concern about the biologic potential of that lesion, especially in an adult. Previously diagnosed benign melanocytic nevi in individuals from six different age groups were re‐examined; mitotic figures were counted in routine hematoxylin and eosin‐stained sections; Ki‐67 nuclear positivity was assessed by immunohistochemistry. Mitoses were seen in 0–14.3% of nevi in all groups of patients >1 year of age; 55.6% (5/9 cases) of nevi in patients <1‐year old had mitoses identified histologically. Ki‐67‐positive melanocytes were seen in all cases of those lesions in infants (less than 1‐year old) and only in a minority of lesions from the other age groups. The maximum and mean numbers of Ki‐67‐positive melanocytes per square millimeter were highest in patients <1‐year old (16.7 and 5.6, respectively), and decreased in all other groups. Follow‐up data were available in the majority of the patients. There were no examples of malignant melanoma in the various age groups. We conclude that proliferative activity in benign melanocytic nevi decreases with age, however, proliferative activity can be seen at any age and its significance must be judged in the context of other histopathologic features.     

Genomic analysis of a case of agminated Spitz nevi and congenital‐pattern nevi arising in extensive nevus spilus

Nevus spilus is a melanocytic neoplasm characterized by a tan macular background punctuated by multiple hyperpigmented macules or papules that represent various types of nevi. These include junctional and compound nevi, Spitz nevi, and rarely blue nevi. We report a unique case of widespread, multiple nevi spili giving rise to agminated Spitz nevi and congenital‐pattern compound nevi. We performed genetic analysis to further characterize the mutational profile of this rare entity.