Value Of Reflectance Confocal Microscopy Research Articles

Reflectance confocal microscopy for the early diagnosis of herpes zoster.

For herpes zoster (HZ) infection, early diagnosis and treatment are important in order to shorten the course of the disease and reduce sequelae, however, there is a lack of non-invasive diagnostic methods. Reflectance confocal microscopy (RCM) is a non-invasive technique often used to diagnose dyspigmented dermatosis, skin tumours, human papillomavirus infectious dermatosis, etc. To evaluate the clinical value of RCM for the early diagnosis of HZ. We collected RCM images from 30 HZ patients with typical vesicles in order to analyse their features. We then utilized RCM to analyse early lesions of another 12 HZ patients, who presented with localized erythema or papules, but not typical vesicles. In addition, we recruited one patient with HZ and observed the lesions over 14 days also using RCM. RCM images showed that the typical lesions of HZ mainly involved oedema of the spinous layer, intraepidermal blister formation, ballooning multinucleated giant (BMG) cells, and dermal papillary oedema. Among them, BMG cells were of specific diagnostic value. Early lesions of HZ patients without typical vesicles showed BMG cells under RCM. A few BMG cells were observed during the early stage of HZ. However, the number of BMG cells increased significantly as typical clustered blisters gradually appeared in the lesions. With the regression of the lesions, the number of BMG cells decreased gradually. RCM, with the advantages of being non-invasive, rapid, and convenient, has an important role in monitoring the evolution of HZ.

Concordance between reflectance confocal microscopy and histopathology for the diagnosis of acral lentiginous melanoma.

Acral lentiginous melanoma (ALM) is a highly malignant and invasive type of melanoma with unique locations of onset. Its incidence is increasing and early diagnosis is challenging. Reflectance confocal microscopy (RCM) is a non-invasive technique that provides an accurate image of tissue pathology. There are few reports on the use of RCM for the assessment of ALM. In this retrospective study, data from 31 patients with a clinical diagnosis of ALM were collected. RCM image features were compared with histopathological findings to determine the concordance between the two methods. The sensitivity, specificity, positive predictive value, and negative predictive value of RCM for the diagnosis of ALM were evaluated. RCM and histopathology findings were concordant in 29 of 31 patients (93.5%). There were no false-negative results, although there were two false positives in RCM diagnosis. The sensitivity of RCM for diagnosing ALM was 100%, specificity was 50%, positive predictive value was 93.1%, and negative predictive value was 100%. RCM showed substantial concordance with histopathology in the diagnosis of ALM. It is a reliable and valuable non-invasive diagnostic tool that holds promise for the early diagnosis of ALM.

In vivo evaluation of vulvar lichen sclerosus with reflectance confocal microscopy and therapeutic monitoring in children.

Vulvar lichen sclerosus (VLS) in girls presents with itching, dysuria, and constipation and may result in the loss of vulvar architecture. In patients with an ambiguous clinical presentation, reflectance confocal microscopy (RCM) could be a helpful noninvasive diagnostic tool. The aim of this study was to describe the RCM characteristics of VLS and explore the clinical application value of RCM in therapeutic monitoring. Sixteen patients with VLS were included in the study. All patients were periodically evaluated clinically with RCM, and different treatment regimens were given based on the patient's clinical appearances and RCM features. Some major key diagnostic features of VLS can be observed by RCM, including round to oval cyst-like structures with medium-to-low-refractive keratinoid substances (75%), thinning of the epidermal thickness (100%), destruction of the ring-like structures around dermal papillae (100%), disorderly distributed coarse medium-refractive fibrous material (100%),polygonal, plump, high-refractive cellular structures and linear low-refractive canalicular structures (100%). All of these characteristics had a high correspondence with histopathological features. The clinical manifestations improved after individualized treatment regimens based on the clinical appearances and RCM features. RCM allows the visualization of major key diagnostic features of VLS and represents a valid option for objective therapeutic monitoring.

In vivo evaluation of facial papule dermatoses with reflectance confocal microscopy in children.

Molluscum contagiosum (MC), milia, keratosis pilaris (KP), verruca plana (VP), seborrheic keratosis (SK), and juvenile xanthogranuloma (JXG) are common papule dermatoses on the face of children that have a similar appearance. In vivo evaluation of facial papule dermatoses with reflectance confocal microscopy (RCM) is helpful in the diagnosis of these ambiguous lesions in children. The purpose of this study was to clarify the RCM characteristics of MC, milia, KP, VP, SK, and JXG and explore the clinical application value of RCM for these common facial papule dermatoses. We recruited 113 patients referred for unequivocal facial papule dermatosis, including 21 patients with MC, 17 patients with milia, 19 patients with KP, 36 patients with VP, 8 patients with SK, and 12 patients with JXG. We evaluated the characteristics and distinguishing features of the six kinds of facial papule dermatoses using RCM. The main RCM features of the six dermatoses included a well-demarcated border of the lesion area. MC, milia and KP all manifested cyst-like structures, and their distinguishing features were the location of the cystic structures and the refractive index of the contents. Although VP, SK, and JXG did not have obvious cystoid structures, VP was typically characterized by uniformly distributed petal-like structures with a medium-to-high refractive index in the epidermis. With regard to SK, the characteristic features were an obviously thickened epidermis and cobblestone-like structures. JXG was mainly characterized by multiple large round and ovoid cells with a foamy cytoplasm, and discoid-shaped multinucleated large cells were diffusely distributed in the dermis. RCM allows the real-time visualization of major key diagnostic and distinguishing features of common facial papule dermatoses in children, including MC, milia, KP, VP, SK, and JXG.

The Value of In Vivo Reflectance Confocal Microscopy as an Assessment Tool in Chemotherapy-Induced Peripheral Neuropathy: A Pilot Study.

BackgroundThere is a lack of standardized objective and reliable assessment tools for chemotherapy-induced peripheral neuropathy (CIPN). In vivo reflectance confocal microscopy (RCM) imaging offers a non-invasive method to identify peripheral neuropathy markers, namely Meissner’s corpuscles (MC). This study investigated the feasibility and value of RCM in CIPN.Patients and MethodsReflectance confocal microscopy was performed on the fingertip to evaluate MC density in 45 healthy controls and 9 patients with cancer (prior, during, and post-chemotherapy). Quantification was completed by 2 reviewers (one blinded), with maximum MC count/3 × 3 mm image reported. Quantitative Sensory Testing (QST; thermal and mechanical detection thresholds), Grooved pegboard test, and patient-reported outcomes measures (PROMS) were conducted for comparison.ResultsIn controls (25 females, 20 males; 24-81 years), females exhibited greater mean MC density compared with males (49.9 ± 7.1 vs 30.9 ± 4.2 MC/3 × 3 mm; P = .03). Differences existed across age by decade (P < .0001). Meissner’s corpuscle density was correlated with mechanical detection (ρ = −0.51), warm detection (ρ = −0.47), cold pain (ρ = 0.49) thresholds (P < .01); and completion time on the Grooved pegboard test in both hands (P ≤ .02). At baseline, patients had reduced MC density vs age and gender-matched controls (P = .03). Longitudinal assessment of MC density revealed significant relationships with QST and PROMS. Inter-rater reliability of MC count showed an intraclass correlation of 0.96 (P < .0001).ConclusionsThe findings support the clinical utility of RCM in CIPN as it provides meaningful markers of sensory nerve dysfunction. Novel, prospective assessment demonstrated the ability to detect subclinical deficits in patients at risk of CIPN and potential to monitor neuropathy progression.

Evaluation of in vivo reflectance confocal microscopy in the diagnosis of extramammary Paget's disease.

Extramammary Paget's disease (EMPD) is a rare cutaneous malignancy that most commonly affects the apocrine glands of older men and women. Because it is associated with other cancers, early diagnosis and evaluation are needed. This study is to evaluate the value of reflectance confocal microscopy (RCM) in diagnosing EMPD. A total of 73 patients with clinically suspicious diagnosis of EMPD were enrolled in this study, and the RCM device imaged their lesions. Moreover, 67 patients underwent skin biopsies to confirm the diagnosis. We retrospectively analyzed the results of RCM and histological diagnosis and then evaluated the RCM value of biopsy-confirmed lesions. Based on the RCM image analysis, 54 of 73 (74.0%) patients were diagnosed with EMPD. Of all 67 biopsied lesions, 52 (77.6%) were EMPD. Then, we analyzed the RCM characteristics of 52 cases of biopsy-confirmed EMPD, compared their RCM image characteristics of three different lesions of EMPD, and further concluded the key points of EMPD under RCM microscopy based on the 52 EMPD cases. Finally, we focused on the differential diagnosis of EMPD from other skin diseases. RCM showed great diagnostic value in diagnosing EMPD.

The diagnostic value of in vivo reflectance confocal microscopy in actinic keratosis.

Actinic keratosis (AK) is a pre-neoplastic skin damage caused by sun exposure with a risk of transforming squamous cell carcinoma (SCC) ranging from 0.1%-20%, while it should be differentiated with many diseases such as seborrheic keratosis (SK), discoid lupus erythematosus (DLE), Bowen's disease, and basal cell carcinoma(BCC) et al. Reflectance confocal microscopy (RCM) as a non-invasive method is showing an increasing diagnostic accuracy. Currently, there are a few studies that summarized the characteristics of AK with RCM. The study aimed to find the diagnostic value of diagnosing actinic keratosis by reflectance confocal microscopy. A total of 92 patients with clinical suspicious diagnosis of actinic keratosis were enrolled in this study, and RCM device imaged their lesions. Fifty-three of these patients underwent skin biopsies to confirm the diagnosis. We retrospectively analyzed the results of RCM and histological diagnosis and then summarized the RCM characteristics of biopsy-confirmed lesions. Based on RCM images, 76 of 92 (82.6%) patients were diagnosed with AK, 9 of 92 (9.8%) patients could not be diagnosed by the dermatologist according to RCM. Of all 53 biopsied lesions, 42 (79.2%) were AK, 1 was seborrheic keratosis, 3 were basal cell carcinoma, three were discoid lupus erythematosus, 1 was Bowen's disease, and three were squamous cell carcinoma. The value of RCM in the diagnosis and differential diagnosis of AK is good and worthy of clinical application.

Value of reflectance confocal microscopy for the monitoring of rosacea during treatment with topical ivermectin

Background Reflectance confocal microscopy (RCM) enables noninvasive Demodex mite detection in rosacea. Objective scoring of rosacea severity is currently lacking. Objectives To determine the value of RCM for monitoring Demodex, inflammation and vascular parameters in rosacea during treatment. Methods In 20 rosacea patients, clinical and RCM examination were performed before, during, and 12 weeks after a 16-week treatment course with topical ivermectin. Using RCM, number of mites and inflammatory cells, epidermal thickness, and vascular density and diameter were measured. RCM features were correlated with clinical assessment. Results Treatment resulted in clinical reduction of inflammatory lesions. Mites were detected in 80% of patients at baseline, 30% at week 16, and 63% at week 28. The number of mites reduced significantly during treatment, but no changes in inflammatory cells, epidermal thickness or vascular parameters were observed. Correlation between number of inflammatory lesions and mites was low. None of the RCM variables were significant predictors for clinical success. Conclusions RCM enables anti-inflammatory effect monitoring of topical ivermectin by determining mite presence. Quantifying exact mite number, and inflammatory and vascular characteristics is challenging due to device limitations. In its current form, RCM seems of limited value for noninvasive follow-up of rosacea in clinical practice.

A Systematic Review and Meta-Analysis of the Accuracy of in VivoReflectance Confocal Microscopy for the Diagnosis of Primary Basal Cell Carcinoma.

Basal cell carcinoma (BCC) is the most common cancer worldwide and its incidence is constantly rising. Early diagnosis and treatment can significantly reduce patient morbidity and healthcare costs. The value of reflectance confocal microscopy (RCM) in non-melanoma skin cancer diagnosis is still under debate. This systematic review and meta-analysis were conducted to assess the diagnostic accuracy of RCM in primary BCC. PubMed, Google Scholar, Scopus, and Web of Science databases were searched up to July 05, 2019, to collect articles concerning primary BCC diagnosis through RCM. The studies’ methodological quality was assessed by the QUADAS-2 tool. The meta-analysis was conducted using Stata 13.0, RevMan 5.0, and MetaDisc 1.4 software. We included 15 studies totaling a number of 4163 lesions. The pooled sensitivity and specificity were 0.92 (95% CI, 0.87–0.95; I2 = 85.27%) and 0.93 (95% CI, 0.85–0.97; I2 = 94.61%), the pooled positive and negative likelihood ratios were 13.51 (95% CI, 5.8–31.37; I2 = 91.01%) and 0.08 (95% CI, 0.05–0.14; I2 = 84.83%), and the pooled diagnostic odds ratio was 160.31 (95% CI, 64.73–397.02; I2 = 71%). Despite the heterogeneity and risk of bias, this study demonstrates that RCM, through its high sensitivity and specificity, may have a significant clinical impact on the diagnosis of primary BCC.

Reflectance confocal microscopy features of irritant cutaneous reactions to sodium lauryl sulphate in healthy adults

Objective To investigate reflectance confocal microscopy (RCM) features of irritant cutaneous reactions to sodium lauryl sulphate (SLS) in healthy persons aged from 18 to 60 years, to analyze effects of age and gender on cutaneous reactions, and to estimate the value of RCM in objective evaluation of cutaneous reactions. Methods An occlusive patch test was performed on the back of 120 healthy testees with 0.1% and 0.5% SLS solution (0.1% and 0.5% SLS groups) and distilled water (negative control group) for 48 hours. At different time points after the patch removal, clinical evaluation and RCM were performed. Results RCM imaging in the 0.1% and 0.5% SLS groups showed parakeratosis, indistinct structure of the stratum corneum, spongiosis and infiltration of inflammatory cells in the epidermis, and telangiectasia in the papillary dermis. The incidence of RCM features reached the peak until 24 hours after the removal of 0.1% and 0.5% SLS patches, and the incidence of telangiectasia in the dermis was up to 66.7% and 95.0% in the 0.1% and 0.5% SLS groups respectively. At 24 hours after the removal of 0.5% SLS patch, the incidence of spongiosis was significantly lower in the males than in the females (68.9%[42/61] vs. 84.7%[50/59], χ2=4.24, P 0.05) . Clinical evaluation showed that after the removal of 0.1% and 0.5% SLS patches, no significant difference in the incidence of irritant cutaneous reactions was observed between the males and the females or between the testees aged 18-40 years and those aged 41-60 years (all P > 0.05) . There were good correlations between the clinical evaluation results and RCM features. At 24 hours after the removal of 0.1% SLS patch, the correlation coefficient between spongiosis and clinical evaluation results was up to 0.77, so was that between telangiectasia in the dermis and clinical evaluation results (both P < 0.001) . However, at 0.5 hour after the removal of SLS patches, clinical evaluation showed that the positive reaction rates were 2.5% (3/120) and 12.5% (15/120) in the 0.1% and 0.5% SLS groups respectively. In the meantime, there were 17.5% (21/120) and 51.7% (62/120) of testees manifesting more than 2 RCM features in the 0.1% and 0.5% SLS groups respectively, which were more similar to the clinical evaluation results at 24 hours after the removal of SLS patches (34.2%[41/120] and 85.0%[102/120] in the 0.1% and 0.5% SLS groups respectively) compared with the clinical evaluation results at 0.5 hour after the removal of SLS patches. Conclusions Neither gender nor age affects irritant cutaneous reactions to 0.1% and 0.5% SLS. Compared with clinical evaluation, RCM can evaluate cutaneous reactions more objectively and accurately in the early stage of irritant reactions. Key words: Dermatitis, irritant; Sodium dodecyl sulfate; Age factors; Sex factors; Microscopy, confocal

Diagnostic accuracy of confocal microscopy imaging vs. punch biopsy for diagnosing and subtyping basal cell carcinoma.

Background In vivo reflectance confocal microscopy (RCM) is a promising non‐invasive skin imaging technique that could facilitate early diagnosis of basal cell carcinoma (BCC) instead of routine punch biopsies. However, the clinical value and utility of RCM vs. a punch biopsy in diagnosing and subtyping BCC is unknown.ObjectiveTo assess diagnostic accuracy of RCM vs. punch biopsy for diagnosing and subtyping clinically suspected primary BCC.MethodsA prospective, consecutive cohort of 100 patients with clinically suspected BCC were included at two tertiary hospitals in Amsterdam, the Netherlands, between 3 February 2015 and 2 October 2015. Patients were randomized between two test‐treatment pathways: diagnosing and subtyping using RCM imaging followed by direct surgical excision (RCM one‐stop‐shop) or planned excision based upon the histological diagnosis and subtype of punch biopsy (standard care). The primary outcome was the agreement between the index tests (RCM vs. punch biopsy) and reference standard (excision specimen) in correctly diagnosing BCC. The secondary outcome was the agreement between the index tests and reference standard in correctly identifying the most aggressive BCC subtypes.ResultsSensitivity to detect BCC was similar for RCM and punch biopsy (100% vs. 93.94%), but a punch biopsy was more specific than RCM (79% vs. 38%). RCM expert evaluation for diagnosing BCC had a sensitivity of 100% and a specificity of 75%. The agreement between RCM and excision specimen in identifying the most aggressive BCC subtype ranged from 50% to 85% vs. 77% by a punch biopsy.ConclusionReflectance confocal microscopy and punch biopsy have comparable diagnostic accuracy to diagnose and subtype BCC depending on RCM experience. Although experienced RCM users could accurately diagnose BCC at a distance, we found an important difference in subtyping BCC. Future RCM studies need to focus on diagnostic accuracy, reliability and specific criteria to improve BCC subtype differentiation.

The value of reflectance confocal microscopy in diagnosis of flat pigmented facial lesions: a prospective study.

Flat pigmented facial lesions are difficult to diagnose even with dermatoscopy. It is controversial how additional information obtained by in vivo reflectance confocal microscopy (RCM) impacts the diagnosis and management. To examine what in vivo reflectance confocal microscopy of flat pigmented facial lesions adds to clinical examination using dermatoscopy including digital dermatoscopic monitoring. We prospectively collected 70 cases of flat pigmented facial lesions and recorded diagnoses and management decisions by experts based on direct clinical examination aided by dermatoscopy including digital dermatoscopic monitoring and by remote experts who reviewed the corresponding confocal images. The expert confocal readers were blinded to the clinical and dermatoscopic appearance of the lesion. The sensitivity of dermatoscopy plus digital dermatoscopic monitoring was 95.0% (95% CI 75.13% to 99.87%) and the specificity was 84.0% (95% CI 70.89% to 92.83%). The sensitivity of RCM was 95.0% (95% CI 75.13% to 99.87%) and the specificity was 82.0% (95% CI 68.56% to 91.42%). Although most flat pigmented facial lesions can be managed by clinical examination and dermatoscopy alone, confocal microscopy is a useful adjunct in selected lesions. If RCM is not correlated with clinical and dermatoscopic information, there is risk of overdiagnosis of actinic keratosis, however.

Combined in vivo reflectance confocal microscopy and digital dermoscopy for follow up of patients at high risk of malignant melanoma: A prospective case series study.

Digital dermoscopy (DD) follow up is a useful strategy for monitoring patients at high risk of melanoma. Reflectance confocal microscopy (RCM) is a valuable second-level examination after dermoscopy for the evaluation of difficult to diagnose lesions. The aim of this study was to assess the value of RCM in routine DD monitoring of patients at high risk of melanoma. In this prospective study, performed over 22 months, changing melanocytic lesions were detected by DD and excised. RCM imaging was performed before surgical excision of all the lesions, and histopathology used as the gold standard diagnostic test. Eighty-seven lesions, including 11 thin melanomas, were studied. Dermoscopic evaluation at follow up revealed a significant association between melanoma and asymmetry in two axes (P = 0.035). Enlargement and other changes in structure or color did not significantly differ between nevi and melanomas. Widespread pagetoid cells, non-edged papillae, irregular and dishomogeneous junctional clusters, and sheet-like structures were significantly associated with malignancy (P < 0.001). RCM allowed accurate diagnosis of melanoma in 10 of 11 cases (90.9%). The remaining case was classified as a dysplastic nevus. Forty-six lesions (52.8%) in which RCM revealed no atypia were deemed unnecessarily removed. This study was limited by sample size. In conclusion, combined DD and RCM facilitates the recognition of thin malignant melanomas and reduces unnecessary excisions.

The reflectance confocal microscopy in diagnosis of recurrent basal cell carcinoma

Background: Reflectance confocal microscopy (RCM) is very valuable, non-invasive diagnostic tool in the diagnosis of basal cell carcinoma (BCC). Objective: We aimed to demonstrate the positive predictive value (PPV), negative predictive value, sensitivity and specificity of RCM and dermoscopic features in recurrent BCC. Methods: The 152 entire lesion sites in 128 patients with BCC were evaluated by clinical examination, dermoscopy and RCM imaging techniques. Biopsy was performed from 46 lesions if there was at least one of the clinical findings or at least one of the diagnostic criteria of BCC with dermoscopy or RCM examination. Histopathological examination was considered as a gold standard for the diagnosis of recurrence BCC. Results: Recurrence was observed in 29 cases (63%). In the dermoscopic examination, arborizing telangiectasia and blue-grey globules were found to be statistically significantly correlated with BCC recurrence (p < 0.05). The specificity and PPV of nucleated corneocytes in the stratum corneum and polarisation of elongated nuclei in the epidermis was 100%. PPV of streaming of aggregated tumour cells and variable refractile stroma was 92% with RCM examination. Conclusion: RCM is a diagnostic tool with a high PPV, sensitivity and specificity for the diagnosis of recurrence of BCC lesions.

Vascular patterns of nonpigmented tumoral skin lesions: confocal perspectives.

The characteristic vascular patterns of nonpigmented skin tumors have been established by dermoscopy. Recently, in vivo reflectance confocal microscopy (RCM) has become an established method for the noninvasive examination of skin tumors. Determination of the value of RCM on the vascularity of nonpigmented skin tumors. One hundred and twenty two tumoral lesions have been evaluated by RCM in terms of their vascular structures. They were classified in five groups as basal cell carcinoma (BCC), seborrheic keratosis (SK), squamous cell carcinoma (SCC)/keratoacanthoma, actinic keratosis (AK)/Bowen disease and others. Vascular morphologies were investigated as curved linear, straight linear, branching, tubular/canalicular, round and polymorphic vessels in six types. Relatively, small number of patients with some tumor subgroups is limitation. Larger prospective studies are required before firm conclusions can be drawn. Excellent compliance was obtained in interobserver analysis. Branching vessels had a high predictive value for basal cell carcinoma (BCC) with RCM (P<0.001). Also vascular polymorphism was more frequently (69.4%) seen in malignant nonpigmented tumors (P<0.05) than benign nonpigmented tumors (30.6%). Furthermore, vessels with opposite flows had high predictive value for malignant tumors (P<0.05) compared with benign tumors. Vascular properties can be evaluated in the diagnosis of nonpigmented tumoral skin lesions via RCM.

Basal cell carcinoma with spontaneous regression: Added value of reflectance confocal microscopy when the dermoscopic diagnosis is uncertain

Basal cell carcinoma with spontaneous regression: Added value of reflectance confocal microscopy when the dermoscopic diagnosis is uncertain

Large congenital nevus spilus—improved follow-up through the use of in vivo reflectance confocal microscopy

Background:Nevus spilus (NS) is a potential precursor of melanoma; the vast majority of cases reported in the literature were histologically classified as superficial spreading melanoma.Objective:To demonstrate the diagnostic value of reflectance confocal microscopy (RCM) in this subtype of congenital nevi.Methods:We report a case of a large congenital NS with equivocal clinical and dermoscopic findings in which RCM was applied for diagnosis and follow-up.Results:There was a good correlation of RCM with histopathology and a lack of dynamic changes during follow-up.Conclusion:Our observations indicate that RCM, as a non-invasive tool, can be useful for diagnosis and follow-up of clinically and dermoscopically equivocal NS.

Reflectance confocal microscopy: a useful and non-invasive tool in the in vivo differentiation of benign pigmented skin lesions from malignant melanoma. Report of a case

The diagnosis of seborrheic keratoses (SK) undergoing regression can be challenging clinically and dermoscopically. We report a case of a SK with a history of change and equivocal dermoscopic features, thereby showing confocal features suggestive of solar lentigo/early SK. The present case emphasizes the potential value of reflectance confocal microscopy (RCM) in the differentiation of malignant from benign pigmented skin lesions.

Reflectance confocal microscopy in the diagnosis of partially and completely amelanotic melanoma: report on seven cases

The clinical diagnosis of amelanotic melanoma is often challenging, because the classical clinical and dermoscopic features of pigmented melanoma are usually missing. The reflectance confocal microscopy (RCM) offers an additional possibility of an in vivo diagnosis of both pigmented and amelanotic melanoma lesions. To test the value of RCM in vivo in the preoperative prediction of melanoma lesions lacking significant pigment and to compare the results with the evaluation by dermoscopy and histopathology. We examined seven patients with the clinically uncertain differential diagnosis of partially or completely amelanotic melanoma by RCM and dermoscopy prior to surgical excision of the lesions according to the previously suggested dermoscopy algorithm and RCM score for melanoma. The following RCM features were evaluated: major criteria scored +2 (non-edged papillae, cytological atypia at the dermo-epidermal junction) and minor criteria +1 (roundish pagetoid cells, widespread pagetoid infiltration, nucleated cells within dermal papillae, cerebriform cell clusters). The dermoscopic evaluation included the following criteria: polymorphous vessels, dotted and linear irregular vessels, hairpin vessels, pink-erythematous colour, milky red areas, irregularly shaped depigmentation, blue-grey dots and subtle pigmentation. The preoperative in vivo RCM analysis revealed common features of melanoma also found in pigmented melanoma lesions. All lesions showed a score above three in the applied RCM algorithm which was proposed earlier as the threshold for malignancy. In dermoscopy, five of seven lesions showed characteristic vascular changes. In vivo RCM is a valuable tool in the preoperative diagnosis of partially and completely amelanotic tumours suspicious for melanoma in addition to dermoscopic evaluation.

Confocal features of equivocal facial lesions on severely sun-damaged skin: Four case studies with dermatoscopic, confocal, and histopathologic correlation

Facial skin has a distinct histologic architecture and reveals specific dermatoscopic features. Diagnosis of lentigo maligna on the face is often challenging because of the overlap of clinical and morphologic features with other lesions. We aim to show the value of reflectance confocal microscopy (RCM) as a noninvasive diagnostic tool for facial lesions and to increase knowledge of RCM morphologic features among the scientific community. We describe a series of 4 facial lesions on severely sun-damaged skin that was evaluated via RCM immediately after face-to-face examination, followed by shave biopsy for histopathological analysis. Lesions included a lentigo maligna, a pigmented seborrheic keratosis, pigmented basal cell carcinoma, and a pigmented actinic keratosis. In the presented cases, RCM enabled an accurate diagnosis. The study describes morphologic features on selected cases, but does not test accuracy of RCM criteria. RCM is a useful adjuvant for the accurate and precise diagnosis of equivocal facial lesions.