Dermal-epidermal Junction Research Articles

Standardized Computer-Assisted Analysis of 5-hmC Immunoreactivity in Dysplastic Nevi and Superficial Spreading Melanomas.

5-Hydroxymethylcytosine (5-hmC) is an important intermediate of DNA demethylation. Hypomethylation of DNA is frequent in cancer, resulting in deregulation of 5-hmC levels in melanoma. However, the interpretation of the intensity and distribution of 5-hmC immunoreactivity is not very standardized, which makes its interpretation difficult. In this study, 5-hmC-stained histological slides of superficial spreading melanomas (SSM) and dysplastic compound nevi (DN) were digitized and analyzed using the digital pathology and image platform QuPath. Receiver operating characteristic/area under the curve (ROCAUC) and t-tests were performed. A p-value of <0.05 was used for statistical significance, and a ROCAUC score of >0.8 was considered a "good" result. In total, 92 5-hmC-stained specimens were analyzed, including 42 SSM (45.7%) and 50 DN (54.3%). The mean of 5-hmC-positive cells/mm2 for the epidermis and dermo-epidermal junction and the entire lesion differed significantly between DN and SSM (p = 0.002 and p = 0.006, respectively) and showed a trend towards higher immunoreactivity in the dermal component (p = 0.069). The ROCAUC of 5-hmC-positive cells of the epidermis and dermo-epidermal junction was 0.79, for the dermis 0.74, and for the entire lesion 0.76. These results show that the assessment of the epidermal with junctional expression of 5-hmC is slightly superior to dermal immunoreactivity in distinguishing between DN and SSM.

Comparison of Two Human Skin Cell Isolation Protocols and Their Influence on Keratinocyte and Fibroblast Culture.

For the development of advanced therapies, the use of primary cells instead of cell lines is preferred. The manufacture of human tissue-engineered skin substitutes requires efficient isolation and culture protocols allowing a massive expansion of the cells in culture from an initial specimen of a minimal size. This study compared two skin cell isolation protocols, routinely applied in two clinical laboratories. Epithelial (keratinocytes) and dermal (fibroblasts) cells were isolated and cultured from three human skin biopsies (N = 3). The two-step digestion protocol (LOEX-Protocol) firstly used thermolysin to enzymatically disrupt the dermal-epidermal junction while, for the one-step digestion protocol (UPCIT-Protocol), mechanical detachment with scissors was applied. Then, the epidermal and dermal layers were digested, respectively, to achieve cell isolation. The cell size, viability, yield and growth were analyzed over five passages (P). The colony-forming efficiency (CFE) and Keratin 19 (K19) expression of epithelial cells were also assessed after P0 and P1. Regarding the dermal cells, no significant differences were observed in the tested parameters of isolation and culture. However, for the epithelial cells, viability was higher (93% vs. 85%) and the number of cells extracted per cm2 of skin was 3.4 times higher using the LOEX-Protocol compared to the UPCIT-Protocol. No significant difference was observed for any parameter once the keratinocytes were cultured from P1 to P4. The CFE and K19 expression decreased from P0 to P1 in both protocols, probably due to the culture process. This study shows that both protocols enable the efficient isolation of skin dermal and epithelial cells and subsequent culture to produce grafts destined for the treatment of patients.

Development of a tissue-engineered skin model with epidermal, dermal and hypodermal components

Tissue-engineered models of skin have evolved over the past 50 years, have successfully been translated to clinical use and continue to be improved using new technologies. However, very few of these constructs incorporate a hypodermal component. The hypodermis is critical to skin homeostasis, skin function and many skin diseases, but our understanding of the hypodermis is limited in comparison to our knowledge of the epidermis and dermis, in part due to a lack of suitable in vitro models.The purpose of this study was to develop and characterise a tissue-engineered model of skin consisting of epidermal, dermal and hypodermal layers, namely a trilayer skin model. Models were produced by culturing human keratinocytes and fibroblasts on decellularised human dermis in combination with explanted human adipose tissue.Bilayer models of skin, comprising of an epidermis and dermis, had a thicker epidermal component compared to trilayer models but exhibited similar cytokeratin expression patterns (AE1/AE3 and cytokeratin 14). Addition of adipose tissue improved the appearance of the dermal-epidermal junction, increased the number of rete ridge-like features and cells maintained similar levels of proliferation (Ki-67) compared to native tissues over 28 days in culture.This technique enabled us to create a physiologically relevant model of human skin with representative morphology across the hypodermis, dermis and epidermis. This model maintained native extracellular matrix architecture, contained a heterogeneous population of cells and has the potential to be applied to a range of different applications where research questions require the inclusion of a hypodermis.

Artificial intelligence-based PRO score assessment in actinic keratoses from LC-OCT imaging using Convolutional Neural Networks.

The histological PRO score (I-III) helps to assess the malignant potential of actinic keratoses (AK) by grading the dermal-epidermal junction (DEJ) undulation. Line-field confocal optical coherence tomography (LC-OCT) provides non-invasive real-time PRO score quantification. From LC-OCT imaging data, training of an artificial intelligence (AI), using Convolutional Neural Networks (CNNs) for automated PRO score quantification of AK in vivo may be achieved. CNNs were trained to segment LC-OCT images of healthy skin and AK. PRO score models were developed in accordance with the histopathological gold standard and trained on a subset of 237 LC-OCT AK images and tested on 76 images, comparing AI-computed PRO score to the imaging experts' visual consensus. Significant agreement was found in 57/76 (75%) cases. AI-automated grading correlated best with the visual score for PROII (84.8%) vs. PROIII (69.2%) vs. PROI (66.6%). Misinterpretation occurred in 25% of the cases mostly due to shadowing of the DEJ and disruptive features such as hair follicles. The findings suggest that CNNs are helpful for automated PRO score quantification in LC-OCT images. This may provide the clinician with a feasible tool for PRO score assessment in the follow-up of AK.

Innovation in Actinic Keratosis Assessment: Artificial Intelligence-Based Approach to LC-OCT PRO Score Evaluation.

Actinic keratosis (AK) is a common skin cancer in situ that can progress to invasive SCC. Line-field confocal optical coherence tomography (LC-OCT) has emerged as a non-invasive imaging technique that can aid in diagnosis. Recently, machine-learning algorithms have been developed that can automatically assess the PRO score of AKs based on the dermo-epidermal junction's (DEJ's) protrusion on LC-OCT images. A dataset of 19.898 LC-OCT images from 80 histologically confirmed AK lesions was used to test the performance of a previous validated artificial intelligence (AI)-based LC-OCT assessment algorithm. AI-based PRO score assessment was compared to the imaging experts' visual score. Additionally, undulation of the DEJ, the number of protrusions detected within the image, and the maximum depth of the protrusions were computed. Our results show that AI-automated PRO grading is highly comparable to the visual score, with an agreement of 71.3% for the lesions evaluated. Furthermore, this AI-based assessment was significantly faster than the regular visual PRO score assessment. The results confirm our previous findings of the pilot study in a larger cohort that the AI-based grading of LC-OCT images is a reliable and fast tool to optimize the efficiency of visual PRO score grading. This technology has the potential to improve the accuracy and speed of AK diagnosis and may lead to better clinical outcomes for patients.

Idiopathic Lichenoid and Granulomatous Vulvitis: A Distinct Clinicopathological Entity.

The combination of lichenoid and granulomatous inflammation is uncommon in vulval biopsies. We present a series of 5 patients with lichenoid and granulomatous vulvitis, presenting with clinical changes resembling lichen sclerosus. Despite detailed clinicopathological investigation and follow-up, there was no apparent association with an underlying recognized cause. All 5 cases occurred in postmenopausal women and displayed a distinctive histological pattern of superficial band-like inflammation with granulomas "anchored" to the dermoepidermal junction. There was no evidence of deeper granulomatous inflammation. Despite repeated biopsies over 2 years in 2 patients, neither developed typical histological features of lichen sclerosus. We postulate that idiopathic lichenoid and granulomatous vulvitis may represent a distinct clinicopathologically defined vulvar dermatosis.

Metronidazole-induced linear immunoglobulin A disease in a patient suffering from ulcerative colitis: a case report and focused review of the literature

Linear immunoglobulin (Ig) A disease (LAD) is a rare autoimmune blistering dermatosis caused by linear deposition of IgA1 along the dermoepidermal junction of skin and mucosae. It can affect both children and adults. Although idiopathic in most cases, it can also be associated with infections, malignancies, or drug administration. Among medications, antibiotics are most commonly responsible, particularly vancomycin. We report the case of a 51-year-old female patient who developed mucocutaneous LAD after oral metronidazole administration, which was confirmed by histopathological examination and direct immunofluorescence of one of the bullous lesions. Lesions rapidly cleared after metronidazole discontinuation and a short course of oral methylprednisolone and dapsone. To our knowledge, this is the third reported case of metronidazole-induced LAD, and the first in which metronidazole was not administered in combination with other antibiotics such as ceftriaxone.

Line-field confocal optical coherence tomography coupled with artificial intelligence algorithms to identify quantitative biomarkers of facial skin ageing

Quantitative biomarkers of facial skin ageing were studied from one hundred healthy Caucasian female volunteers, aged 20–70 years, using in vivo 3D Line-field Confocal Optical Coherence Tomography (LC-OCT) imaging coupled with Artificial Intelligence (AI)-based quantification algorithms. Layer metrics, i.e. stratum corneum thickness (SC), viable epidermal thickness and Dermal–Epidermal Junction (DEJ) undulation, as well as cellular metrics were measured for the temple, cheekbone and mandible. For all three investigated facial areas, minimal age-related variations were observed in the thickness of the SC and viable epidermis layers. A flatter and more homogeneous epidermis (decrease in the standard deviation of the number of layers means), a less dense cellular network with fewer cells per layer (decrease in cell surface density), and larger and more heterogeneous nuclei within each layer (increase in nuclei volume and their standard deviation) were found with significant variations with age. The higher atypia scores further reflected the heterogeneity of nuclei throughout the viable epidermis. The 3D visualisation of fine structures in the skin at the micrometric resolution and the 1200 µm × 500 µm field of view achieved with LC-OCT imaging enabled to compute relevant quantitative biomarkers for a better understanding of skin biology and the ageing process in vivo.

P18 Epidermolysis bullosa acquisita in children: report of three cases

Abstract Epidermolysis bullosa acquisita (EBA) is an acquired, subepidermal blistering skin disease characterized by autoantibodies against type VII collagen, which links the epidermis to the dermis at the dermo-epidermal junction. Clinically, patients have skin fragility and blisters over trauma-prone sites, scarring, milia and onychodystrophy. The diagnosis can be challenging as it shares clinical and histopathological features with other immunobullous diseases. Although exceptionally rare in children, we report three paediatric patients with EBA and variable disease severity. The main clinical features were blisters (n = 3), milia (n = 3), scarring (n = 2), oral erosions (n = 2) and onychodystrophy (n = 1). Histological findings were nonspecific, showing a subepidermal blister with various inflammatory infiltrates. On direct immunofluorescence a bright deposit of IgG was seen, and the antibodies adhered to the dermal side of the salt-split in two cases. ELISA analysis confirmed circulating autoantibodies against type VII collagen in one patient. All received a course of oral corticosteroids alongside steroid-sparing agents such as dapsone, azathioprine and rituximab depending on clinical response and shared favourable prognosis. Early use of topical steroids can help but high-dose oral corticosteroids are often required as well as steroid-sparing agents such as dapsone, methotrexate, azathioprine, ciclosporin, mycophenolate mofetil, cyclophosphamide and rituximab. In our experience, although the treatment approaches have been different, all the patients had favourable outcomes.

P08 Linear IgA bullous dermatosis: treatment challenge

Abstract Linear IgA bullous dermatosis (LABD) is a rare idiopathic or drug-induced autoimmune blistering disease characterized by widespread annular blisters caused by IgA autoantibodies directed against different antigens of the basement membrane zone (BMZ) of the skin and mucosae. Linear deposits of IgA at the dermoepidermal junction are a dominant diagnostic feature. Dapsone is the most commonly used systemic treatment with complete remission achieved in most patients. A 15-month-old boy presented with widespread annular blisters, erosions and haemorrhagic crusts on the face, scalp, torso, extremities and genital skin. An episode of acute bronchitis preceded the skin lesions. The patient was otherwise healthy. A skin biopsy of a lesion showed subepidermal blistering with neutrophils and eosinophils in the superficial dermis. Direct immunofluorescence revealed linear IgA and discrete linear IgG deposits along the BMZ. Treatment with oral prednisone 1–2 mg kg–1 daily and dapsone 1–2 mg kg–1 daily resulted in modest control of LABD and prompted introducing concomitant medications in the following sequence, IVIG, methotrexate 10 mg weekly for 6 months, and ciclosporin 5 mg kg–1 daily over 4 months, all with moderate disease control. Prednisone was stopped after 2 years and the LABD cleared with dapsone 2 mg kg–1 daily. The attempt of tapering the dapsone resulted in a flare. The treatment of LABD is based on case reports and varies with the degree of involvement and identification of inciting factors. The severe, treatment-resistant LABD in our patient, managed by the multidisciplinary team and shared care with the parents, resulted in a good and safe treatment outcome.

Epidermolysis bullosa: a tale of two sisters

Epidermolysis bullosa (EB) is a clinically and genetically heterogenous, inherited, mechanobullous disorder characterised by spontaneous or trauma induced blisters over skin and mucous membranes. Four major forms are: EB Simplex, EB Junctional, EB dystrophic and mixed. A 11-year-old and a 9 year old female child, both sisters, accompanied by their father, presented to dermatology OPD, with chief complaints of multiple raw areas over elbows and knees since infancy. There was history of fluid filled lesions which were induced by trauma or friction during handling or while playing. These lesions ruptured on their own or on trauma to form raw areas with crusting which further healed with scarring and small white raised lesions. Also, he gave history of loss of nails following blistering on toes in infancy. No associated systemic complaints were noted. On examination, both of them presented with multiple erosions and ulcers with oozing of blood, few bullae and crusted lesions over elbows, knees and feet. There were multiple atrophic scars and skin coloured to whitish papules [milia] over feet, ankles, elbows and knees. There were loss of nails of toes of both feet. On biopsy, histopathological examination revealed bullae at dermoepidermal junction. Diagnosis of EB junctional was made. EB is a rare inherited disorder. Its management includes prevention and healing of blisters and infection. Psychological support to patients and their families is of prime importance.

Pemphigoid diseases in older adults

Pemphigoid diseases are agroup of bullous autoimmune diseases characterized by autoantibodies against structural proteins of the dermal-epidermal junction. With asteadily growing aging population, pemphigoid diseases are emerging as asignificant medical challenge, because they occur primarily in older individuals. The by far most common disease is bullous pemphigoid, which is clinically characterized by tense blisters, erosions, erythema or urticarial plaques, while severe pruritus is the leading subjective symptom. Mucous membrane pemphigoid predominantly affects surface-close mucous membranes with painful erosions and blisters as well as frequently scarring usually in the mouth, nose, and eyes. Anti-p200 pemphigoid clinically resembles bullous pemphigoid but is much less common. Diagnosis of these diseases involves the combination of clinical evaluation, lesional histopathology, direct immunofluorescence microscopy of aperilesional biopsy and serology. Topical and systemic corticosteroids are the mainstay of pemphigoid diseases treatment. Depending on the severity of the disease, various potentially corticosteroid-sparing therapies, such as dapsone, doxycycline, methotrexate, azathioprine and mycophenolate may be used. In severe courses, treatment with rituximab, cyclophosphamide, intravenous immunoglobulins or immunoadsorption are second- or third-line treatment options. Patients are best managed in centers experience with the management of pemphigoid diseases. Updated national and international guidelines for the diagnosis and treatment of bullous pemphigoid and mucous membrane pemphigoid have recently been published.

Neonatal lupus erythematosus: Expanded summary

Neonatal Lupus Erythematosus (ENL) is a rare autoimmune disease in which immunoglobulin G is transported across the placenta into the fetal circulation. It affects both males and females. The most common clinical manifestations have been found to be skin changes, hematologic changes, hepatobiliary changes and cardiac involvement such as atrioventricular block. However, some of these symptoms tend to disappear naturally after a few months. The diagnosis can be made by biopsy, which will show histopathological mechanisms similar to those of discoid lupus and direct immunofluorescence will show the presence of IgG at the dermal-epidermal junction. The aim of this article was to improve knowledge through an integrative literature review, which used a synthesis of results obtained through research already published in order to make argumentation of the results found. It was found that the use of sunscreen, healthy habits and lifestyle and palliative treatment when applied properly, can control and even make the symptoms of this disease disappear.

Accuracy of serration pattern analysis by direct immunofluorescence in subepidermal autoimmune blistering diseases.

Background Direct immunofluorescence (DIF) is essential for the diagnosis of sub-epidermal immunobullous diseases (SIBD). Bullous pemphigoid (BP), a sub-epidermal immunobullous disease, shows linear IgG and C3 deposition along the dermo-epidermal junction by DIF. However, similar histological and DIF findings are also seen in epidermolysis bullosa acquisita (EBA). High-power examination of antibody deposition by DIF in a "u" or "n" serrated pattern can help differentiate these two entities. Aims/Objectives The aim of this study was to determine the diagnostic accuracy of serration patterns in IgG-mediated sub-epidermal immunobullous disease. Methods All cases of IgG-mediated sub-epidermal immunobullous disease diagnosed over the past 2 years and 9 months period and confirmed serologically, were included. Examination of the serration pattern in DIF was assessed on oil emersion. Salt split skin indirect immunofluorescence (SSS IIF), BP180 enzyme-linked immunosorbent assay (ELISA), profile ELISA and BIOCHIP mosaic were performed, wherever available. Results This study included 74 cases of bullous pemphigoid, eight cases of mucus membrane pemphigoid (MMP) and one case of epidermolysis bullosa acquisita. The characteristic zigzag "n" pattern was visualised in 66 out of 82 cases (80.5%) of the pemphigoid group (BP + MMP); the single epidermolysis bullosa acquisita case showed the "u" serrated pattern. No statistical correlation was seen between serration pattern and BP180 positivity by ELISA (P = 0.05). Limitations The study is limited by the single case of epidermolysis bullosa acquisita (which could be due to rarity of this disease in north Indian population due to genetic variation), lack of detailed serological investigations and immunoblot in all cases. Conclusion Serration pattern analysis is an easy-to-interpret and highly useful technique for characterisation of sub-epidermal immunobullous diseases.

Human Skin Drug Metabolism: Relationships between Methyl Salicylate Metabolism and Esterase Activities in IVPT Skin Membranes.

The presence of esterase enzymes in human skin and their role in drug metabolism has been reported, but their distribution in the various skin layers and the relative contributions of those layers to metabolism is poorly defined. To gain further insight into esterase distribution, we performed in vitro skin permeation of a commercial 28.3% methyl salicylate (MeSA) cream (Metsal™) in Franz diffusion cells, using a range of human skin membranes, all from the same donor. The membranes were viable epidermis separated by a dispase II enzymatic method, heat separated epidermis, dermatomed skin, and dermis separated by a dispase II enzymatic method. Methyl salicylate and its metabolite, salicylic acid (SA), were measured by high-performance liquid chromatography. Alpha naphthyl acetate and Hematoxylin and Eosin staining provided qualitative estimations of esterase distribution in these membranes. The permeation of methyl salicylate after 24 h was similar across all membranes. Salicylic acid formation and permeation were found to be similar in dermatomed skin and dermis, suggesting dermal esterase activity. These results were supported by the staining studies, which showed strong esterase activity in the dermal-epidermal junction region of the dermis. In contrast with high staining of esterase activity in the stratum corneum and viable epidermis, minimal stained and functional esterase activity was found in heat-separated and dispase II-prepared epidermal membranes. The results are consistent with dispase II digesting hemidesmosomes, penetrating the epidermis, and affecting epidermal esterases but not those in the dermis. Accordingly, whilst the resulting dispase II-generated dermal membranes may be used for in vitro permeation tests (IVPT) involving esterase-based metabolic studies, the dispase II-generated epidermal membranes are not suitable for this purpose.

Full-thickness skin rejuvenation by a novel dual-length microneedle radiofrequency device: A proof-of-concept study using human skin.

A novel dual-length microneedle radiofrequency (DLMR) device has been developed to achieve full-thickness skin rejuvenation by stimulating the papillary and reticular dermis simultaneously. This device's dual-level targeting concept need to be validated on human skin, although its clinical efficacy has been demonstrated in a previous study. This study evaluated the dual-depth targeting capability and the ability to induce rejuvenation in each layer of vertical skin anatomy, that is, the epidermis, papillary dermis, and reticular dermis, using full-thickness human facial skin samples. Human facial skin samples were obtained from 13 Asian patients who had facelift surgery. To validate the dual-depth targeting concept, DMLR-treated skin samples were analyzed using a digital microscope, thermal imaging, and hematoloxylin and eosin (H&E) staining immediately after DLMR application. On samples stained with H&E, Masson's tricrome, and Verhoeff-Van Gieson, histological observation and morphometric analysis were performed. Total collagen assay (TCA) and quantitative real-time polymerase chain reaction (qPCR) were used to assess changes in total collagen content and mRNA expression levels of collagen types I/III and vimentin, respectively. The DLMR device successfully induced thermal stimulation in the papillary and reticular dermis. The thickness, stacks, and dermal-epidermal junction convolution of the epidermis treated with DLMR were significantly increased. Collagen bundles in the dermis treated with DLMR exhibited a notable increase in thickness, density, and horizontal alignment. Dermal collagen levels were significantly higher in the morphometric and TCA data, as well as in the qPCR data for dermal matrix proteins. Our DLMR device independently and precisely targeted the papillary and reticular dermis, and it appears to be an effective modality for implementing full-thickness rejuvenation.

Is reflectance confocal microscopy useful in the differential diagnosis of extra facial lentigo maligna? A retrospective multicentric case-control study.

Extra facial lentigo maligna (EF-LM) arises outside the head and neck area. EF-LM presents the classic histological features of lentigo maligna. The dermoscopic aspects of EF-LM have been poorly studied. The primary aims of our study were to analyse and describe the clinical, dermoscopic and confocal microscopy features of a series of histologically confirmed EF-LM. We conducted a retrospective and multicentric study. From our database, we selected 48 cases of thin melanomas on photodamaged skin with histological features of EF-LM of which clinical, dermoscopic and confocal microscopy images were available, and a control group of 45 lesions, that can be subjected to differential diagnosis such as solar lentigo, lichenoid keratosis, seborrheic keratosis and melanocytic nevi, of which dermoscopic and confocal microscope images were available. Extra facial lentigo maligna had a higher prevalence of lentigo-like pigment patterns, angulated lines and zigzag structures. At confocal microscopy, LM-EF cases showed a higher prevalence of pagetoid spreading, round cells, dendritic cells in the epidermis, atypical cells at the dermo-epidermal junction, dendritic cells at the junction, meshwork pattern and elastosis. Our study shows that reflectance confocal microscopy (RCM) has a sensitivity of 90% and a specificity of 97% for the differential diagnosis of this type of melanoma. Extra facial lentigo maligna does not have the classic dermoscopic features of superficial spreading melanoma, the most observed dermoscopic criteria are angulated lines and lentigo-like pigment patterns without lentigo-like border. RCM can be a valuable imaging tool for the evaluation of all those suspicion skin lesions at dermoscopy highlighting cellular atypia suggestive for melanoma.

Non-invasive imaging of pathological scars using a portable handheld two-photon microscope.

Pathological scars are a disorder that can lead to various cosmetic, psychological, and functional problems, and no effective assessment methods are currently available. Assessment and treatment of pathological scars are based on cutaneous manifestations. A two-photon microscope (TPM) with the potential for real-time non-invasive assessment may help determine the under-surface pathophysiological conditions in vivo . This study used a portable handheld TPM to image epidermal cells and dermal collagen structures in pathological scars and normal skin in vivo to evaluate the effectiveness of treatment in scar patients. Fifteen patients with pathological scars and three healthy controls were recruited. Imaging was performed using a portable handheld TPM. Five indexes were extracted from two dimensional (2D) and three dimensional (3D) perspectives, including collagen depth, dermo-epidermal junction (DEJ) contour ratio, thickness, orientation, and occupation (proportion of collagen fibers in the field of view) of collagen. Two depth-dependent indexes were computed through the 3D second harmonic generation image and three morphology-related indexes from the 2D images. We assessed index differences between scar and normal skin and changes before and after treatment. Pathological scars and normal skin differed markedly regarding the epidermal morphological structure and the spectral characteristics of collagen fibers. Five indexes were employed to distinguish between normal skin and scar tissue. Statistically significant differences were found in average depth ( t = 9.917, P <0.001), thickness ( t = 4.037, P <0.001), occupation ( t = 2.169, P <0.050), orientation of collagen ( t = 3.669, P <0.001), and the DEJ contour ratio ( t = 5.105, P <0.001). Use of portable handheld TPM can distinguish collagen from skin tissues; thus, it is more suitable for scar imaging than reflectance confocal microscopy. Thus, a TPM may be an auxiliary tool for scar treatment selection and assessing treatment efficacy.

Epidermolysis Bullosa-A Kindler Syndrome Case Report and Short Literature Review.

Epidermolysis bullosa (EB) represents a group of rare disorders, genetically determined, characterized by skin fragility, blister formation and erosions due to minimal trauma. Depending on the ultrastructural level of skin cleavage, above or below the basement membrane, epidermolysis bullosa can be classified into four major types: simplex, junctional, dystrophic and Kindler Syndrome. In the junctional form of EB, the cleavage level is at the dermo-epidermal junction and the targeted proteins are laminin, type XVII collagen and integrins. The dystrophic form of EB is characterized by cleavage in the dermal layer, collagen VII being the targeted protein. In Kindler EB, multiple levels of cleavage have been described. The mutated gene is FERMT1. Another classification of this disease refers to phenotypic aspects such as extracutaneous lesions, severity, and distribution. The management of epidermolysis bullosa includes supportive wound treatments as well as nutritional support. We present a case of epidermolysis bullosa presented at birth, in a newborn with no family history of bullous skin conditions. The clinical presentation revealed extensive denuded areas and significant skin fragility as well as mucous and nail involvement. Prenatal diagnosis is very hard to achieve due to increased genetic heterogeneity of the disease. The short-term results were good. The importance of prenatal testing and possibilities of diagnosis are reviewed in this article. EB is a devastating disease. The presented case had a favorable evolution, with good short-term results. Significant morbidity can result from secondary infections of blisters and complications of the extracutaneous manifestations.

Lentigo maligna and lentigo maligna melanoma in-vivo differentiation with dermoscopy and reflectance confocal microscopy: a retrospective, multi-center study.

Dermoscopic predictors of lentigo maligna (LM) and lentigo maligna melanoma (LMM) have been recently reported, but these have not been reported in reflectance confocal microscopy (RCM). (i) To validate dermoscopic predictors for LM/LMM, (ii) to identify RCM patterns in LM and LMM and (iii) correlations between dermoscopic and RCM features in LM and LMM. A retrospective, multicenter study of consecutive lesions with histologically proven LM or LMM subtypes of the head and face, with complete sets of dermoscopic and RCM images. A total of 180 lesions were included (n=40 LMM). Previously reported differential dermoscopic features for LM subtypes were confirmed. Other features significantly associated with LMM diagnosis included irregular hyperpigmented areas, shiny white streaks, atypical vessels, and light brown color at dermoscopy and medusa head-like structures, dermal nests and nucleated cells within the papillae at RCM (p<0.05). Correlations among LM lesions between dermoscopic and RCM features included brown to-gray dots and atypical cells (epidermis), grey color and inflammation and obliterated follicles and medusa head-like structures. Among LMM lesions, significant correlations included obliterated follicles with folliculotropism, both irregular hyperpigmented areas and irregular blotches with widespread atypical cell distribution (epidermis), dermal nests and nucleated cells within the papillae (dermis). Irregular blotches were also associated with medusa head-like structures (dermal epidermal junction [DEJ]). Dermoscopic and RCM features can assist in the in-vivo identification of LM histopathological subtypes and many are correlated. RCM 3-dimensional analysis of skin layers allows the identification of invasive components in the DEJ and dermis.