40THE VALUE OF DIGITAL DERMATOSCOPY IN THE DIAGNOSIS AND [630687]

40THE VALUE OF DIGITAL DERMATOSCOPY IN THE DIAGNOSIS AND
TREATMENT OF PRECANCEROUS SKIN LESIONS
ABSTRACT
We propose that through the presented study, to strengthen the value of the pre-excision digital dermatoscopy
by emphasizing its accuracy compared to the histopathological examination in the diagnosis and treatment
of precancerous lesions of the skin for which the histopathological examination of certainty can only be performed after post-excision.
Keywords: dermatoscopy, precancerous skin lesion, histopatological.
Introduction
As a non-invazive mainly used tehnique,
digital dermatoscopy had considerably improved
the accuracy of skin lesion diagnosis; this procedure enables the in vivo observation of the skin with the visualization of the morphological structures in the dermis and papilary dermis, which are not routinely discernible to the unaided eye.Dermatoscopy is a helpful diagnostic tool for the clinical examination of non-melanoma skin cancer and had a notable impact on early diagnosis of melanoma (1,2).
To rule out or confirm a given dermatoscopic
diagnosis, it involves the recognition of specific Podac Claudiu1, Bordeianu Ion2, Poalelungi Tudorel3, Iordache I.V.2, Bosnac Nida1, Abdulazis T.4,
Panculescu F.G.1
1 Emerg ency County Hospital “Sf. Apostol Andrei” Constanța
2 Faculty of Medicine, University ”Ovidius” of Constanța
3 P.h M.D. Dermatology and Vener eology, Constanța
4 P.h M.D. Plastic surger y, Constanța
structures, or their absence; this task can be
accomplished using a ‘bottom-up’ or ‘top-down’ ‘ strategy (3).
Essentially, dermatoscopy is a new
procedure of gross, histopathological examination of the skin performed by clinicians, since the structures and colors observed by dermatoscopy have specific correlations on histopathological examination, clinicians must learn the definition and histopathological correlation of dermatoscopic structures and colors (4).
The digital dermatoscope can see the entire
width of the lesion horizontally, the structure and the colors observed are generally limited in depth to the papillary dermis and do not allow Claudiu Podac
Str.Farului nr.34, Bl.A.L.5, Sc.A, Ap.4,
Constanța, Romania
email: [anonimizat]
phone: +[anonimizat] doi:10.2478/arsm-2018-0008ARS Medica Tomitana – 2018; 1(24): pag. 40 – 45
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41the assessment of the lesion at a cellular level,
however dermatoscopy has the capability to
sequentially monitor the lesions, which in turn
they can provide information about the lesion
biology and the growth dynamics (5,6).
History
The surface microscopy of the skin began
in 1663 when Kolhaus investigated the vessels
of the nail matrix with a microscope (7,8). The
application of immersion oil in light microscopy
was described in 1878 by Abbe, and his principle
was transferred by the german dermatologist
Unna in 1893 to skin surface microscopy.
Johann Saphier published in 1920 a series
of communications using a new diagnostic tool
similar to a binocular microscope with a built-in
light source and introduced for the first time the
term “dermatoscopy” (7,9).
Skin surface microscopy was further
developed in the United States by Goldman in
the 1950 which published a series of articles on
new devices on what he called “Dermoscopy”
(7,10).
The advantage of surface microscopy was
clearly established for the first time in 1971,
by Rona MacKie for improving the differential
diagnosis of benign from malignant lesions and
the preoperative diagnosis of pigmented skin
lesions (7,11).
In 1989 in Hamburg was held the first
Conference on Skin Microscopy, and in
2001 in Rome took place the Netmeeting of
Dermatoscopy which was the first international
meeting of this kind (7,12,13).
Dermatoscopy is today a routine technique,
and the digital video dermatoscopy is successfully
used in teledermoscopy, through which we can
send images from a cabinet to specialized centers
(second opinion).
Material and method
In order to confirm the clinical value
of digital dermatoscopy in the diagnosis and
treatment of precancerous lesions of the skin,
we conducted a prospective study on a group of
patients with precancerous skin tumors (where
the diagnosis was based on clinical signs) to which we checked the concordances between
the diagnosis of digital dermatoscopy and
histopathological diagnosis.
The study was spread over a period of 3
years, respectively 01.01.2014-31.12.2016,
being represented in cases of patients diagnosed
in ambulatory with precancerous conditions and
which have benefited of digital dermatoscopy ,
one day surgical treatment, histopathological
examination in paraffin and a small part of them
of immunohistochemical examination.
For the establishmentof the study group,
we have set criteria for inclusion / exclusion from
the start in order to be able to obtain scientifically
and technically conclusive results.
It should be noted that inclusion in the
group was not restrictive, accepting patients of
different sexes and ages with various associated
diseases, and exclusion criteria did not include
noncompliant patients (who did not show
post-operative checks in accordance with the
indications).
Postoperative controls were performed
every 3 months clinically and biannually from
dermatoscopic point of view for at least 1 year
after surgery.
Results
The group of patients included a total
of 29 cases, of both sexes, aged between 20-85
years, from rural and urban areas, with primary,
secondary and / or higher education studies.
Also, the classification of the lesions of the
patients included in the study regarding the type
of precancerous lesions is diverse such as actinic
keratosis, lentigo maligna, Recklinghausen
neurofibromatosis, Bowen disease.
Surgical excision was performed
according to current international standards at a
distance of 2-3 mm in the surface in healthy tissue
and deeply into fat and / or fascial planes. Closure
of the post-excision defect was performed by
direct suturing and / or free skin grafting (split-
thickness or full- thickness).
The statistical survey of the group showed
the following:
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42
55%
45%
MALE
FEMALE

Figure 1. Gender distribution of patients with precancerous lesions

The sex distribution of patients with precancerous lesions included in our study reveals a
majority of 55% for male gender and 45% for female gender. Figure 1. Gender distribution of patients with
precancerous lesions
The sex distribution of patients with
precancerous lesions included in our study
reveals a majority of 55% for male gender and
45% for female gender.

Figure 2. The repartition of patients with precancerous lesions over decades of age

The distribution of cases with precancerous skin lesions included in the study over decades of
age revealed a higher incidence of cases in the 6th decade to both sexes, followed by the 7th
decade with the mention that in the 4th and 9th decade the majority of cases were female cases,
and for the 5th, 7th and 8th decade there were predominant cases of males. Figure 2. The repartition of patients with precancerous
lesions over decades of age
The distribution of cases with precancerous
skin lesions included in the study over decades
of age revealed a higher incidence of cases in
the 6th decade to both sexes, followed by the 7th
decade with the mention that in the 4th and 9th
decade the majority of cases were female cases,
and for the 5th, 7th and 8th decade there were
predominant cases of males.

Figure 3. Distribution of patients with precancerou s lesions by age group depending on
gender Figure 3. Distribution of patients with precancerous
lesions by age group depending on gender
Presentation to a specialist and therapeutic
indication is relatively similar in both sexes by
age group. Presentation to a specialist and therapeutic indication is relatively similar in both sexes by age
group.
Figure 4. Distribution of patients with precancerous lesions according to their home
environment
It can be seen a net predominance of those from the rural area, representing 62% of the total
studied cases. Figure 4. Distribution of patients with precancerous
lesions according to their home environment
It can be seen a net predominance of those
from the rural area, representing 62% of the total
studied cases.
012345678910
RURAL URBAN10
68
5
MALE
FEMALE

Figure 5. Distribution of patients with precancerous lesions by area of origin and gender Figure 5. Distribution of patients with precancerous
lesions by area of origin and gender
The patients with precancerous lesions
included in the study, according to area of origin
related on the gender ,shows that men are more
affected in both rural and urban area.
The patients with precancerous lesions included in the study, according to area of origin related
on the gender ,shows that men are more affected in both rural and urban area.
CONFORMITY
97%NONCONFORMITY
3%

Figure 6. Conformity / Nonconformity – Dermatoscopic Exam → Histopathological Exam

We note that the overlap between dermatoscopic and histopathological results was 97%; The
result confirms the value of digital dermatoscopy proper diagnosis of precancerous skin lesions . Figure 6. Conformity / Nonconformity – Dermatoscopic
Exam → Histopathological Exam
We note that the overlap between
dermatoscopic and histopathological results was
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4397%;The result confirms the value of digital
dermatoscopy proper diagnosis of precancerous
skin lesions.

Figure 7. Distribution methods of closing the post -excision defect

Regarding the method of closing the post -excision defect, the most used was the direct suturing
technique with 72% , followed by split -thickness grafts with 21% respectively, by full -thickness
grafts with 7%.
Illustrative clinical cases.
CASE I.
Before surgery -19-09-2015

Figure 7. Distribution methods of closing the post-
excision defect
Regarding the method of closing the post-
excision defect, the most used was the direct
suturing technique with 72% , followed by split-
thickness grafts with 21% respectively, by full-
thickness grafts with 7%.
Illustrative clinical cases.
CASE I.
Before surgery-19-09-2015
Clinical appearance Dermatoscopic appearance
Dermatoscopic diagnosis: Lentigo
maligna (white-blue wave, asymmetric follicular
pigmentation, marginal rhomboid structures.
Differential diagnosis with:
1. Superficial malignant melanoma on
lentigo maligna;
2. Solar Lentigo.
Recommendations: Surgical excision with
side edges 0.5 cm
The result of the histopathological
examination was in conformity with the
examination of digital dermatoscopy (superficial melanoma on lentigo maligna).
The post-excision defect was covered by
auto-transplantation of full-thickness grafts.
Postoperatively (2 years) – 03-07-2017
Clinical appearance Dermatoscopic appearance
Status after surgery.No elements of local
recurrence.
CASE II.
Before surgery-04-08-2016
Clinical appearance Dermatoscopic appearance
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44Dermatoscopic diagnosis: In observation
pigmentary actinic keratosis (rosette sign +
diffuse pigmentation).
Differential diagnosis with: Lentigo
maligna;
Recommendations: For preventive
considerations, surgical excision with side edges
3-4 mm from the apparent margin and in depth to
the cartilaginous plane, with the direct closure of
the post-excisional defect.
The result of the histopathological
examination was in conformity with the digital
dermatoscopy exam.
Postoperatively (1 year) – 12-10-2017
Clinical appearance Dermatoscopic appearance
Status after surgery.No elements of local
recurrence.
Dscussion
The data obtained in this study come to
confirm the value of digital dermatoscopy in the
diagnosis, treatment and postoperative follow-up
of precancerous skin lesions .
From the literature that we have
studied, results conclusions and percentages
that practically overlap with ours, although the experience of the clinic in which the
study was conducted is modest in terms of the
implementation of digital dermatoscopy.
The value of digital dermatoscopy is
particularly useful in preoperative diagnosis, as
it removes the “surprises” that can occur after
a surgical excision performed only by clinical
criteria (the lateral and deep edges) and which
can often require re-excitement (completing the
excision), thus exposing the patient to undesirable
risks.
Cnclusions
Dermatoscopy is a valuable non-invasive
technique both in the diagnosis, treatment, and in
the proper tracking of precancerous skin lesions.
The value of digital dermatoscopy is
underlined by the 97% compliance of the in vivo
diagnosis by dermatoscopy with histopathological
diagnosis.
Digital dermatoscopy has become a
current examination today and we appreciate
that in the future it should become mandatory
(according to a diagnosis / treatment protocol) in
the treatment of pre-cancerous lesions.
In addition to surgical treatment,
we consider that non-surgical treatments
(cryotherapy, radiotherapy, laser therapy,
photodynamic therapy, topical drugs,
chemotherapy) in precancerous tumors of the
skin due to the in vivo histopathological diagnosis
by digital dermatoscopy will be required in the
future.
Acknowledgments:
Bordeianu I. – for guidance and experience
sharing.
Poalelungi T. – for cases and results of
dermatoscopy.
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