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Notes: The optimal use of topical corticosteroids (TC) in the treatment of inflammatory disorders of the skin is related to a number of factors concerning the drug on the one hand (potency, pharmacological properties, formulation), and the patient on the other hand (type and phase of the disease, characteristics of the lesion, site to be treated, age and general conditions). The careful balance between drug and disease/patient allows the establishment of a simple series of gold standard guidelines for TC treatment.

Notes: Skin biopsies from seven patients with mycosis fungoides in various clinical stages (patches, plaques, nodules) were studied immunohistochemically and ultrastructurally, with the aim of investigating and quantifying the distribution of Langerhans cells and their relationships to mycosis cells. Our findings have revealed that in patches and plaques both Langerhans cells and mycosis cells were numerous in the epidermis. Notwithstanding this, in all the specimens examined, only one Langerhans cell forming close contact with a mycosis cell was detected. In the nodules, Langerhans cells and mycosis cells were sparse in the epidermis and no contacts were seen between them. Moreover, in all the patients studied, only a single Langerhans cell was found in the dermal infiltrate without any closely related mycosis cells. Conversely, numerous interdigitating cells have been found in the dermis of patches and plaques, often lightly adhering to mycosis cells. In the nodule, a few scattered interdigitating cells were seen, but often these had close contacts with neoplastic lymphoid cells. These findings indicate that close apposition between Langerhans cells and mycosis cells, which led previous authors to hypothesize a persistent stimulatory action of Langerhans cells on T lymphocytes, eventually leading to the malignant transformation of the latter, is unusual in mycosis fungoides. Therefore, if such a pathogenic role may be attributed to accessory cells in mycosis fungoides it is more probably exerted by dermal interdigitating cells and not by Langerhans cells, as previously proposed.

Notes: Background The early diagnosis of melanoma is based on the collaboration between dermatologists and family doctors, who filter subjects to be referred to a pigmented lesion clinic (PLC). Following growing media coverage, there is increasing concern in the general population about the risk of the ‘changing mole’, resulting in a progressively increased workload in PLCs. Aim and methods We investigated the causes of referral to a PLC in a series of 193 attendees seen consecutively at the PLC of the University of Florence. Because the number of naevi is the major risk factor for melanoma in Mediterranean populations, the concordance between self-counting of naevi and the clinical evaluation of a PLC dermatologist in order to classify high-risk individuals was also investigated. Results Detection of a clinically suspicious lesion at dermatological examination occurred in 13 of 193 subjects referred by general practitioners (6·7%), with three melanomas confirmed histologically (overall detection rate: three of 193, 1·6%). The positive predictive value of the ‘presence of a suspicious lesion’, the cause of referral in 39·9% of subjects, was 9·1% when based on the gold standard criterion represented by the clinical detection of a suspicious lesion by the dermatologist and 3·8% based on the histological diagnosis of melanoma; the negative predictive value was 94·8% (100% when based on the histological diagnosis of melanoma), suggesting that the clinical detection of a suspicious lesion in subjects with different causes of referral (such as risk factors for melanoma, or the need to be reassured about moles) is unlikely. There was poor agreement between self-evaluation based on the presence of multiple naevi and the dermatological examination (gold standard) for both common and atypical naevi. The highest concordance (κ = 0·32, 95% confidence interval 0·20–0·43) was associated with a dichotomized count of naevi as up to 50 or more than 50 naevi. Conclusions In order to reduce the PLC workload, the filtering role of the family doctor needs to be improved, so that only subjects with a specific suspicious lesion are referred to the PLC. The self-assessment of melanoma risk based on the presence of multiple naevi was not reliable.

Notes: Background  Because of the many limitations of studies based on the diagnostic setting of excised lesions, the impact of dermoscopy (epiluminescence microscopy, dermatoscopy) in melanoma screening during practice remains to be established.Objectives  We assumed that effects of the use of dermoscopy on some indicators of diagnostic performance in melanoma screening should be traceable retrospectively; therefore, we analysed the impact of routine dermoscopy use on the malignant/benign ratio in excised melanocytic lesions.Methods  Preoperative and histological diagnosis of 3053 melanocytic lesions [319 melanomas (10·4%)] consecutively diagnosed and excised at the Department of Dermatology, University of Florence in the period 1997–2001 inclusive were retrieved. Six dermatologists who selected the lesions to excise and who performed preoperative diagnosis were divided into two groups according to their use of dermoscopy in routine activity (n = 2 dermoscopy users and n = 4 nonusers). The study period was divided into a predermoscopy period (1997), a shift phase (1998) and a dermoscopy period (1999–2001).Results  During the study period, the malignant/benign ratio improved in dermoscopy users only (from 1 : 18 to 1 : 4·3, P = 0·037). No significant difference was found for nonusers (from 1 : 11·8 to 1 : 14·4). Dermoscopy users were more likely to have a melanoma diagnosed within a series of excised lesions than nonusers, even taking into account potential confounders such as sex, age and study period by means of multivariate analysis (odds ratio 1·55, 95% confidence interval 1·17–2·01). The percentage of ‘problem’ naevi (naevi with architectural disorder with or without cytological atypia and Spitz or Reed naevi) over the total number of excised lesions was higher in dermoscopy users than in nonusers (year 2001, 51·6% vs. 40·9%, P = 0·014). Similar findings were obtained after exclusion from the data set of lesions excised for cosmetic reasons.Conclusions  The adoption of dermoscopy in routine melanoma screening is followed by an improvement of the malignant/benign ratio in excised lesions, suggesting a more appropriate selection of pigmented lesions referred to surgery. Because of the possible limitations of a retrospective study design, future confirmation of this finding by means of a prospective, randomized study is advisable. The introduction of dermoscopy in routine practice may have major implications in large-scale melanoma screening with cost savings and a reduction of the dermosurgery workload.

Notes: The phenotypic profile of atypical cells from a patient with cutaneous multilobated T-cell lymphoma was investigated using a multiparameter approach including evaluation of membrane markers, cytochemistry, and functional activity. Retroviral sequence restriction analysis was also used to investigate the presence of human T-cell leukaemia/lymphoma virus type I (HTLV-I) in atypical cells infiltrating the skin and in otherwise normal peripheral blood lymphocytes. The atypical cells appeared to belong to the T-lineage demonstrating OKT11 positivity, E-rosette formation, tartrte-sensitive acid phosphatase and β-glucuronidase activity, and consistent negativity for cytoplasmic and/or surface monoclonal immunoglobulins. However, they failed to stain for other T-lymphocyte-associated antigens, such as those defined by OKT3, OKT4, OKT6, OKT8, OKT9, OKT10, Leu-2a and Leu-3a monoclonal antibodies, and did not express a definite α-naphthyl-acetate esterase pattern. Additional studies including phagocytosis tests and a series of monoclonal antibodies against phagocytic and natural killer cell associated antigens were all negative. No HTLV-I related sequences were found in either the cells infiltrating the skin or in circulating lymphocytes. To our knowlege, in previously reported cases of cutaneous multilobated cell lymphoma a clear T-lymphocyte phenotypic profile was demonstrated. Our present data indicate that this is not always necessarily the case. The peculair phenotype we found might represent a transitional state between different T-cell subsets or an as yet unrecognized phenotype of a neoplastic T-lymphocyte which lacks a normal counterpart.

Notes: In this study the clinico-pathological and immunohistological features, the methods of treatment and follow-up data of 11 patients with follicular centre-cell (B-cell) lymphoma primarily presenting in the skin are reported. All the patients had nodular, tumorous and/or papulonodular skin lesions on the trunk. In nine patients the disease was confined to a circumscribed area of the back. Small papulonodular or plaque-like lesions, as well as large nodules or tumours, were biopsied in six of 11 patients. No clear-cut correlation between the age and clinical morphology of the lesions and their histological growth pattern was found. Interestingly, however, a different immuno-architectural pattern was observed in large, late lesions compared to small, early lesions. Initial treatment consisted of orthovolt radiotherapy (in two patients associated with surgical excision), resulting in complete remission in all patients. Only one patient developed extracutaneous disease, which was limited to a single drainage lymph node appearing simultaneously with a cutaneous relapse. Five other patients had recurrent disease in the skin close to the initial site. The median disease-free period was 15·5 months. On relapse, radiotherapy alone or in combination with short courses of chemotherapy was performed. This resulted in a second complete remission. All the patients are still alive and in complete remission, with a median survival of 37 months. These results confirm the favourable prognosis of patients affected with primary cutaneous follicular centre-cell lymphoma limited to the trunk. Orthovolt radiotherapy proved to be the most suitable treatment for both initial lesions and relapses limited to the skin.

Notes: Background Epiluminescence microscopy (ELM) (dermoscopy, dermatoscopy) is a technique for non-invasive diagnosis of pigmented skin lesions that improves the diagnostic performance of dermatologists. Little is known about the possible influence of associated clinical features on the reliability of dermoscopic diagnosis during in vivo examination.Objective To compare diagnostic performance of in vivo dermoscopy (combined clinical and dermoscopic examination) with that of dermoscopy performed on photographic slides (pure dermoscopy).Design This case series comprised 256 pigmented skin lesions consecutively identified as suspicious or equivocal during examination in a general dermatological clinic. Clinical examination and in vivo dermoscopy were performed before excision by two trained dermatologists. The same observers carried out dermoscopy on photographic slides at a later time, and these three diagnostic classifications were reviewed together with the histological findings for the individual lesions. This was carried out in a university hospital.Results In vivo dermoscopy performed better than dermoscopy on photographic slides for classification of pigmented skin lesions compared with histological diagnosis, and both performed better than general clinical diagnosis. In vivo dermoscopic diagnosis of melanoma showed 98.1% sensitivity, 95.5% specificity and 96.1% diagnostic accuracy while dermoscopic diagnosis of melanoma on photographic slides was less reliable with 81.5% sensitivity, 86.7% specificity and 85.2% diagnostic accuracy. In particular, diagnosis of melanoma based on photographic slides led to nine false negative cases (three in situ , six invasive; thickness ranges 0.2–1.5 mm).Conclusions In vivo dermoscopy, i.e. combined clinical and dermoscopic examination, is more reliable than dermoscopy on photographic slides. In clinical practice, therefore, in vivo dermoscopy cannot be considered independent from associated clinical characteristics of the lesions, which help the trained observer to reach a more precise classification. This may have implications on the reliability of ELM diagnosis made by an observer not fully trained in the clinical diagnosis of pigmented skin lesions or by a remote observer during digital ELM teleconsultation.