皮肤镜对常见色素减退性疾病的临床图像特征分析技术的建立

目的:建立皮肤镜对白癜风、白色糠疹、无色素痣、炎症后色素减少症、进行性斑状色素减少症、老年性白斑和贫血痣的临床图像特征分析技术。方法:分别观察1439例色素减退性疾病患者的皮损,用皮肤镜观察肉眼不可见的细微结构,如背景颜色、血管形态、边界情况、毛发及毛囊是否异常等。应用卡方检验和Fisher精确检验方法进行统计学分析。结果:瓷白色、花斑色和浅白色背景色度分别为白癜风稳定期、无色素痣和进行性斑状色素减少症的较特异性皮肤镜图像特征。灰白色糠状鳞屑是白色糠疹的特异性皮肤镜图像特征,可区别于其他疾病。进展期白癜风特征为乳白色背景,边界模糊,毛囊周围色素残留,周边点状、不规则状色素减退斑,斑片状色素残留。稳定期白癜风特征为瓷白色背景,边界清晰,毛囊周围色素残留,皮损周围色素加深。恢复期白癜风特征为边界清晰,毛囊周围色素残留,皮损周围色素加深,易见色素岛。白色糠疹特征为淡黄白色背景,表面细小或片状灰白色糠状鳞屑,边界模糊。无色素痣:花斑样背景,边界模糊,斑片状色素残留。炎症后色素减少症特征为黄白色背景,边界模糊。进行性斑片状色素减少症特征为浅白色背景,边界模糊。老年性白斑特征为乳白色背景,边界清晰。贫血痣特征为黄白色背景,边界模糊,摩擦后周边呈现网格状血管分布。结论:皮肤镜临床图像特征分析技术可作为诊断和鉴别诊断白癜风、白色糠疹、无色素痣、炎症后色素减少症、进行性斑状色素减少症、老年性白斑和贫血痣的一种辅助方法。     

皮肤共聚焦激光扫描显微镜在儿童色素减退性疾病诊断中的应用

目的 探讨儿童常见色素减退性疾病皮肤共聚焦激光扫描显微镜(CLSM)图像的基本特征.方法 分别观察1 915例色素减退性疾病(包括白癜风、特发性滴状色素减少症、无色素痣、线状苔藓、白色糠疹及炎症后色素减退)患者的皮损,用CLSM观察皮损处、交界处及白斑周边正常皮肤的各层镜下特征.应用卡方检验和Fisher精确检验进行统计学分析.结果 1级和2级色素减少占总病例数的51.4％(984/1 915)和35.7％(684/1 915),白癜风3级色素减少的比例为77.9％(141/181),明显高于其他疾病(0～ 10.3％);815例角质层轻度角化过度,1 060例棘层灶性水肿,79例基底细胞环出现改变,1 133例真皮浅层可见稀疏炎症细胞或树枝状细胞.6种色素减退性皮肤病CLSM扫描图像色素减少程度及各层CLSM图像变化均有统计学差异(P＜0.05).CLSM特征:特发性滴状色素减少症可见色素环完全缺失;线状苔藓、白色糠疹、炎症后色素减退可见非特异性炎症改变,线状苔藓可见点灶状基底细胞液化变性;无色素痣仅为色素减少及折光变弱,白癜风白斑区色素完全缺失,且皮肤色素环缺乏完整性.结论 白癜风、特发性滴状色素减少症、无色素痣、线状苔藓、白色糠疹及炎症后色素减退皮损CLSM图像有差异,可以作为鉴别诊断的依据之一.     

儿童色素减退型扁平疣的皮肤镜和反射性共聚焦显微镜图像特征分析

目的:探讨儿童色素减退型扁平疣的反射性共聚焦显微镜(RCM)和皮肤镜影像学特征,为明确诊断、鉴别儿童其他色素减退性疾病提供有力依据。方法:应用RCM和皮肤镜检查12例临床拟诊为色素减退型扁平疣的患儿皮损,分析色素减退型扁平疣的皮肤影像特征。结果:色素减退型扁平疣皮肤影像学表现与经典型有较高一致性,其RCM图像特征:皮损区颗粒层及棘层上部可见多量体积较大细胞不规则分布,部分区域可见玫瑰花环样结构,较大细胞直径0.021～0.035 mm,玫瑰花环直径0.08～0.24 mm,基底层色素减少,真皮浅层毛细血管明显扩张,可见稀疏炎性细胞浸润。皮肤镜:粉白色背景下白色丘疹,可见点状血管结构。结论:RCM和皮肤镜检查为无创诊断儿童色素减退型扁平疣提供有力的皮肤影像依据,对减少误诊、鉴别儿童其他色素减退性疾病有较高的临床应用价值。     

色素异常性皮肤淀粉样变

报告3例色素异常性皮肤淀粉样变.3例患者临床表现为四肢和(或)躯干、面部弥漫色素沉着伴色素减退斑,毛细血管扩张及表皮萎缩不明显,一般手足未累及.自觉症状不明显.本病易被误诊为白癜风、血管萎缩性皮肤异色病等,组织病理诊断及特殊染色有助于鉴别.对其中1例使用共聚焦激光扫描显微镜观察皮损,在真皮乳头处可观察到折光较强的物质沉积,伴有部分真皮乳头毛细血管扩张,皮损基底层有黑素帽增多的现象.     

皮肤镜表现为玫瑰花瓣征的进展期白癜风1例

报告1例皮肤镜表现为玫瑰花瓣征的进展期白癜风。患者男,58岁,手背、阴囊及腹股沟白色斑片3个月。皮肤科检查：双侧手背、阴囊及腹股沟泛发性大小不一的近圆形或形状不规则的色素减退斑或瓷白色斑片,边缘模糊或清楚。皮肤镜检查：手背白斑可见亮白色玫瑰花瓣征,阴囊部位毛囊周围色素减退。皮损充分发展后,手背部位的玫瑰花瓣征消失。诊断：寻常型白癜风(进展期、散发型)。     

几种色素减退性疾病的研究进展

色素减退性疾病是皮肤科常见的疾病,严重影响美观.白癜风、无色素痣和进行性斑状色素减少症等色素减退性疾病的发病机制、组织病理和治疗不尽相同,但均以色素脱火斑为主要特征,临床鉴别有时较为困难.概述这几种色素减退性疾病的发病机制、临床表现、组织病理及治疗等方面的最近研究进展,以提高对色素减退性疾病的认识,帮助临床诊断与治疗.     

恶性黑素瘤伴有白癜风样色素减退斑

报告1例恶性黑素瘤伴有白癜风样色素减退斑.患者男,58岁.双手、足色素脱色斑1年余,右足跟肿块伴疼痛6个月.皮肤科检查:两足底及足内侧见境界清楚的大块色素减退斑,双手指末节侧缘见淡白色色素减退斑,边缘模糊不清,Wood灯下色素脱色斑区呈亮白色荧光.右足跟有一3 cm × 2.5 cm × 1 cm半圆形暗红色肿块,表面糜烂、渗出.皮损组织病理检查示表皮下瘤细胞呈片、块状分布,细胞核大小不一,深染,异形明显,局部向肌组织内浸润.免疫组化染色示S-100蛋白(+)、HMB45E(+)、波形蛋白(+)、Ki-67(+)>50%.诊断为恶性黑素瘤伴有白癜风样色素减退斑.     

无色素性色素失禁症并发白癜风

报告1例无色素性色素失禁症并发白癜风.患儿女,lO岁.出生后1年面部、躯干及左下肢出现色素减退斑.皮肤科检查:面部、躯干、左下肢见特殊形状的色素减退斑,部分色素减退斑呈旋涡状或泼墨状;左下肢及右胸部各有1枚钱币大界限清楚的色素减退斑.腰部皮损组织病理检查:表皮基底层见较多色素颗粒及个别黑素细胞,真皮未见明显炎性细胞浸润.     

儿童色素减退性蕈样肉芽肿在皮肤镜及反射式共聚焦显微镜下的特征

目的 探讨临床表现为色素减退的儿童蕈样肉芽肿在皮肤镜及反射式共聚焦显微镜（RCM）下的特征,分析皮肤镜联合RCM与组织病理诊断色素减退性蕈样肉芽肿的一致性。方法 2014年11月至2015年10月皮肤科门诊收集皮肤镜及RCM下疑似色素减退性蕈样肉芽肿患者15例,获取并分析影像资料。所有患者均经组织病理、免疫组化及相关检查。结果 皮肤镜联合RCM诊断疑似色素减退性蕈样肉芽肿15例,其中13例经病理证实为色素减退性蕈样肉芽肿。色素减退性蕈样肉芽肿皮肤镜下特征表现为皮纹明显,可见白色糠秕状鳞屑;色素减退呈网格状、斑马样或波点状模式;血管呈点状、短细线状、精子样或星状模式。RCM特征为表皮各层及真表皮交界处较多高折光细胞,部分可见Pautrier微脓疡,基底层色素环折光减弱,色素环外较多高折光细胞分布。结论 色素减退性蕈样肉芽肿在皮肤镜和RCM下有特征性表现,可作为儿童色素减退性蕈样肉芽肿早期筛查及辅助诊断的方法。     

儿童色素减退型线状苔藓反射式共聚焦显微镜图像特征分析

目的 分析儿童色素减退型线状苔藓皮肤反射式共聚焦显微镜(RCM)影像学特征.方法 RCM检查11例临床诊断为色素减退型线状苔藓的患儿皮损及皮损附近正常皮肤,再与该处皮损组织病理学检查进行对比.结果 色素减退型线状苔藓皮损组织病理学检查显示,表皮细胞间或细胞内轻度水肿,伴不同程度棘层增厚,基底细胞灶性液化变性,真皮浅层血管周围较多淋巴细胞及少数噬黑素细胞浸润.RCM水平扫描皮损显示,多灶性基底细胞液化变性,导致表真皮界面模糊,色素环不完整或不清晰,真皮乳头及真皮浅层较多高折光的噬黑素细胞及中、低折光的炎症细胞浸润.结论 RCM影像学特征可为儿童色素减退型线状苔藓的诊断及鉴别诊断提供有力依据.     

Dermoscopy in vitiligo: diagnosis and beyond

Background

Vitiligo is essentially a clinical diagnosis, and dermoscopy may aid in noninvasive confirmation of diagnosis by excluding other clinically simulating hypopigmentary conditions. More importantly, dermoscopy is rapidly gaining ground as an important adjunct tool to evaluate disease activity.

Aim

To study the dermoscopic features of vitiligo and ascertain their correlation with disease activity.

Methods

Retrospective analysis of dermoscopy of 60 cases suffering from vitiligo was undertaken. Dermoscopy was performed using Dermlite II hybrid m dermatoscope at 10× magnification in polarized mode, and photographs were captured by Apple iphone 6. Variables assessed in the dermoscopic evaluation included perifollicular changes, perilesional changes, altered pigmentary network, and presence of specific features such as the starburst appearance, comet tail appearance, leukotrichia, telangiectasia, and any new findings.

Results

Sixty patients with stable, progressive, or repigmenting vitiligo were retrospectively studied. While perifollicular depigmentation (PFD) was predictive of stable vitiligo, perifollicular pigmentation (PFP) was characteristic of active disease. Starburst appearance, altered pigment network, and comet tail appearance, were also noted, and these were typical of progressive vitiligo. A new dermoscopic feature, the ‘tapioca sago’ appearance (sabudana), was observed in the skin adjacent to the vitiligo lesion only in patients with progressive vitiligo .

Conclusion

Dermoscopy is useful in assessing the stage of evolution and the status of disease activity in vitiligo. The most useful dermoscopic clues are observed in the perifollicular region, since progressive lesions display perifollicular pigmentation and stable/remitting lesions display perifolliclar depigmentation.     

Application of a pigment measuring device – Mexameter®– for the differential diagnosis of vitiligo and nevus depigmentosus

Background/purpose: Vitiligo and nevus depigmentosus (ND) present similar hypopigmented macules with significantly different prognoses. Although the distinction between the two diseases is important, differential diagnosis relies on medical history and physical examination, which is far from decisive in some cases. The Mexameter^® is an objective skin color-measuring device, and has been reported to provide a reproducible and sensitive means of quantifying small skin color differences. In this study, we investigated the usefulness of a Mexameter^® for discriminating these diseases.
Methods: A selection of 202 hypopigmented skin lesions (182 from vitiligo and 20 from ND) were the objects of this study. Using a Mexameter, MIs were obtained from lesions and symmetrically located control skin. RMIs, ratios of the MIs of lesional skins to control skins, were calculated.
Results: The mean MIs and RMIs were significantly different for vitiligo and ND. The mean RMI of ND lesions was 74±13, which was significantly higher than that of vitiligo lesions (50±24). No ND lesion had an RMI of <50%.
Conclusion: This study shows that the Mexameter^®, an objective pigment-measuring device, can be used to achieve a more accurate diagnosis of hypopigmentary disorders, and that the relative melanin index (RMI), which represents the relative pigment levels, might be a more effective parameter than the melanin index (MI) itself for comparing pigmentation differences.     

几种色素减退性皮肤病的共聚焦激光扫描显微镜图像特点

目的 观察白癜风、无色素痣、进行性斑状色素减少症、贫血痣的活体共聚焦激光扫描显微镜（CLSM）特征。方法 用CLSM观察同一层面（基底层真表皮交界处）皮损处、交界处及白斑周边正常皮肤的镜下特征。结果 进展期白癜风白斑区部分区域色素完全缺失,部分区域可见残存色素环,残存之色素环结构欠完整且色素含量降低;交界处界限模糊;白斑周边正常皮肤可见部分色素环失去完整性。稳定期白癜风白斑处色素完全消失;交界处界限清晰;白斑周边正常皮肤色素环完整,折光明亮;恢复期可见到树突状、折光明亮的黑素细胞。无色素痣和进行性斑状色素减少症的CLSM表现相似：白斑处色素环结构完整,色素含量降低,折光减弱。贫血痣白斑处色素环结构和色素含量与周边正常皮肤无明显差异。结论 结合临床表现,CLSM可以作为鉴别诊断白癜风、无色素痣、进行性斑状色素减少症、贫血痣的一种辅助方法。     

Patterns of repigmentation in two cases of hypopigmented type of vitiligo

It has been observed that depigmentation in vitiligo passes through two stages; patches of light brown hypopigmentation which gradually changes into milky white patches. In this work, we studied two cases of hypopigmented vitiligo regarding the melanocytes and keratinocytes' changes before and after 7 months of psoralen plus ultraviolet A (PUVA) therapy. Skin biopsies were taken from the vitiliginous lesions before and after 7 months of PUVA therapy and were examined using haematoxylin and eosin and Masson Fontana stains, l -3,4-dihydroxyphenylalanine reaction, immuno-histochemical stains and ultrastructural examination. In the pretreated patients, the melanocytes present were inactive and degenerative changes were detected in both melanocytes and keratinocytes. After PUVA therapy, obvious histopathological improvement was detected. Clinically, the initial response to PUVA therapy was increased hypopigmentation indicating that degenerated cells in the vitiliginous patches might have continued the process of degeneration and did not recover. Meanwhile, the perifollicular and marginal pigmentation suggested that pigmentation occurred from those areas and not from activation of already degenerated melanocytes.     

In vivo reflectance confocal microscopy for the differential diagnosis between vitiligo and nevus depigmentosus

Background Nevus depigmentosus (ND) is frequently confused with vitiligo. Differential diagnosis can be difficult. In vivo reflectance confocal microscopy (RCM) is a noninvasive technique for real‐time en face imaging of the superficial layers of the skin down to the superficial dermis with cellular level resolution close to conventional histopathology. In this study, we tried to use this new technology to study the features of the distribution of pigment cells of these two hypopigmentation disorders and then concluded the differential features. Methods Sixty vitiligo patients and 62 ND patients were enrolled in the study. Three points in each patient (lesional, margin of the lesions and adjacent non‐ lesional points) were examined with RCM. The gray value of image was quantified using software, and we calculated the relative gray value. Results The RCM image feature was different between vitiligo and ND patients. The differential diagnosis was made based on the following four RCM features: complete absence of pigment cells; the distribution of pigment cells; the margins; and the relative gray value. Conclusion RCM can be used as an auxiliary diagnostic tool for the differential diagnosis between vitiligo and ND.     

白癜风皮损组织中黑素细胞谱系特异性标记基因检测

目的针尖皮肤切削术结合逆转录聚合酶链式反应（RT—PCR）技术检9n,4白癜风皮损组织中黑素细胞谱系特异性标记基因的表达,旨在预测治疗后白癜风皮损出现毛囊复色的可能性。方法选取6例就诊于武汉大学人民医院皮肤科静止期白癜风患者和4例健康志愿者,用针尖皮肤切削术对受试者白斑的中心、近边缘和周边“正常皮肤”处活检,抽提组织总RNA,用RT—PCR技术测定标本中多巴色素异构酶（Dct）,酪氨酸酶（Tyr）和管家基因β-肌动蛋白（ACTB）mRNA的表达。结果（1）用针尖皮肤切削术获取不同大小（3mg和7mg）的组织标本并与负压吸疱法采集的表皮片进行比较,结果显示针头切削术获取7mg组织,经研磨异硫氰酸胍-苯flff（Triz01）法抽提总RNA,能在正常皮肤组织中检测到3种基因表达。同时对10例针尖皮肤切削术后的局部伤口愈合进行了追踪随访,1个月后10例均正常愈合,未见瘢痕形成。（2）白癜风皮损黑素细胞谱系特异性标记基因检测：皮损中心区检测出3种模式,即Dct＋Tvr-ACTB＋,Dct—Tyr-ACTB＋和Dct＋Tyr＋ACTB＋。对1例检测结果“Dct＋Tyr-ACTB＋”的患者施以308nm准分子光照射2次,皮损即出现毛囊复色。结论针尖皮肤切削术结合RT—PCR技术检测白癜风皮损组织中黑素细胞谱系标记基因表达,是一种有价值的预测白癜风皮损可能出现毛囊复色的微创准确方法。     

alpha-Tocopherol in the combined treatment of vitiligo

Photochemotherapy was combined with alpha-tocopherol in the treatment of 56 patients with vitiligo in order to shorten the treatment. alpha-tocopherol was used as antioxidant to reduce skin erythema and build up single UV doses. Due to 1.5-2-fold increase of UV exposure follicular mechanisms stimulation was enhanced in vitiligo foci, perifollicular pigmentation was achieved approximately 2 times sooner, and the length of treatment necessary to achieve manifest repigmentation (i.e. more than 50% of the maculae surface) was reduced twofold.     

Clinical study of repigmentation patterns with different treatment modalities and their correlation with speed and stability of repigmentation in 352 vitiliginous patches

Because the etiopathogenesis of depigmentation in vitiligo is still obscure, the source of pigmentation in the repigmentating lesion and its stability is also not fully known. Several authors have shown on histopathology and electron microscopy predominantly a perifollicular spread of pigment. The aim of this study was to clinically assess the types of repigmentation patterns obtained with different treatment modalities and their correlation with speed and stability of repigmentation. A total of 125 patients with vitiligo on treatment with psoralens (topical and systemic psoralen-UVA [PUVA]), steroids (both topical and systemic), and topical calcipotriol, alone or in combination were enrolled. Representative lesions of vitiligo excluding mucosal sites were selected in each patient and photographed at baseline. Repigmentation was assessed and labeled as marginal, perifollicular, diffuse, or combined. The preselected patches were evaluated at 3 months to assess the speed of repigmentation. Retention of pigment (stability) was noted at 6 months, after the stoppage of active treatment. Of the 352 vitiligo patches selected, 194 (55%) showed predominant perifollicular repigmentation, of which a majority (127; 65.5%) were on systemic PUVA and 35 (18%) were on topical PUVA. Diffuse pigmentation was observed in 98 patches (27.8%) of which 66 (67.3%) were on topical steroids. Marginal repigmentation was seen in 15, of which the majority (80%) were on systemic PUVA and topical calcipotriol. Of the 28 total lesions showing marked repigmentation at 3 months, 22 lesions pigmented in a diffuse manner, 2 in a perifollicular pattern, and 4 showed a combined type of repigmentation. On follow-up, marginal repigmentation was the most stable (93.3%), followed by perifollicular (91.7%) and combined type (84.4%). Diffuse repigmentation was the least stable (78.5%). Psoralens predominantly exhibit a perifollicular pattern of repigmentation and steroids (topical/systemic), a diffuse type. The speed of repigmentation is much faster when initial repigmentation is of the diffuse type as compared with follicular repigmentation. The marginal and perifollicular repigmentation is more stable than the diffuse type of repigmentation.     

Chemical peeling with phenol : For the treatment of stable vitiligo and alopecia areata

Chemical peeling with 88% phenol was carried out on 142 sites of stable vitiligo (hairy-126, non hairy-16) and on 69 sites of alopecia areata (AA). After cleansing and defatting, phenol was applied on affected areas till a uniform frost appeared. On healing, all the lesions of vitiligo showed perifollicular pigmentation in hairy areas and perilesional repigmentation in non hairy areas. These were further treated with PUVA/PUVASOL. After the healing, 82.5% of hairy sites and 81.3% of non hairy sites showed repigmentation. In cases of AA, patients developed vellus hair. In AA, 72.5% had good regrowth and 27.5% had poor response. Side effects seen were hypopigmentation (58 AA), hyperpigmentation (11 AA), persistent erythema (42 vitiligo, 28 AA), demarcation lines (4 AA), secondary bacterial infection (2 vitiligo, 5 AA) and superficial scarring (2 vitiligo, 7 AA). The wounding action of phenol is useful to repigment the vitiligo patches and for induction of regrwoth of hair in alopecia areata.     

In vivo reflectance confocal microscopy imaging of vitiligo,nevus depigmentosus and nevus anemicus

Background/purpose: Hypopigmentary skin disorders such as vitiligo, nevus depigmentosus and nevus anemicus are common diseases in clinic. The lesions of these diseases could be similar to some extent, although each of them has its own characteristic clinical appearance and histological features. Clinically, the atypical lesions are often difficult to be differentiated. In vivo reflectance confocal microscopy (RCM) is a non‐invasive, repetitive imaging tool that provides real‐time images at a nearly cellular histological resolution. Our aim was to investigate the RCM features of vitiligo, nevus depigmentosus and nevus anemicus. Subjects and Methods: A total of 135 patients with a clinical diagnosis of the aforementioned diseases were included in this study. The RCM images from depigmented skin, border of the white macules, adjacent normal‐appearing skin and distant normal skin for all patients at the dermo‐epidermal junction (DEJ) level were investigated. Results: In the active phase of vitiligo (AVP), the RCM demonstrated a complete loss of melanin in lesional skin in eight (53; 15.1%) patients. In 45 patients (53; 84.9%) of the AVP, part of the bright dermal papillary rings normally seen at the DEJ level disappeared or part of the rings lost their integrity and the content of melanin decreased obviously. In 20 patients (53; 37.7%) of the AVP, highly refractile inflammatory cells could be seen within the papillary dermis in the lesional and adjacent normal‐appearing skin, which may indicate the lesion progresses. In addition, part of the dermal papillary rings showed lack of integrity or their brightness decreased in adjacent normal‐appearing skin in all the patients of the AVP. It is important to know that the RCM demonstrated an ill‐defined border. In the stable phase of vitiligo (SPV), the RCM demonstrates a complete loss of melanin in lesional skin and a clear border in 31 (41; 75.6%) patients; the content of melanin and dermal papillary rings in adjacent normal‐appearing skin show no changes. In 10 (41; 24.4%) patients, the dendritic and highly refractile melanocytes arose in the recovery phase of vitiligo, which may indicate the repigmentation of vitiligo. There are three kinds of repigmentation patterns under RCM: marginal, perifollicular and diffuse. Distant normal skin showed no difference from controls in both the active and the SPV. In all the patients with nevus depigmentosus, the content of melanin decreases obviously but the dermal papillary rings are intact. The dermal papillary rings show no differences between lesional skin and adjacent normal‐appearing skin of nevus anemicus. Conclusion: Considering our results, RCM may be useful to non‐invasively discriminate vitiligo, nevus depigmentosus and nevus anemicus in vivo.