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Lentigo maligna and lentigo maligna melanoma
512
Correspondence
Lentigo maligna and lentigo maligna melanoma To the Editor: We enjoyed reading the CME article on lentigo maligna and lentigo matigna melanoma by Cohen in the December 1995 issue of the Journal (1995;33:923-36). The article did, however, fail to mention dermatoscopy (skin surface microscopy, epiluminescence microscopy [ELM]) as a tool that is available for clinicians to help differentiate these potentially serious pigmented skin lesions from more banal pathology, such as seborrheic keratosis or lentigines. Dermatoscopy is an in vivo, noninvasive examination of skin lesions with the use of a hand-held microscope (Dermatoscope by Heine USA, Episcope by Welch Allyn), stereomicroscopes, or digital imaging computer systems and some type of oil/fluid immersion. The liquid applied to the lesion eliminates the reflection of light from the surface of the skin and subsurface colors, and structures in the epidermis, dermoepidermal junction, and papillary dermis become visible that cannot be seen with the naked eye, even with normal magnification typically used by clinicians. The major advantages of dermatoscopy are the differentiation of melanocytic from nonmelanocytic pigmented skin lesions, differentiation of benign from malignant skin lesions, minimization of unnecessary surgery, choice of appropriate surgical procedures, and patient reassurance. On the face, one can see with dermatoscopy skin appendages that appear as uniform white circles, often with hyperpigmented rims or borders. When the hyperpigmented borders touch each other, a networklike appearance is seen. This has been defined as the pseudopigment network. Normally, the pseudopigment network appears regular in terms of the color, thickness, and symmetry of the line segments and light areas. By definition, a rhomboid is a parallelogram with unequal sides and angles. The rhomboid pattern is formed when the monomorphous, uniform appearance of the pseudopigment network forms line segments that become thickened, irregular in size and shape, forming rhomboids with loss of symmetry within the lesion. The degree of changes that can be seen with the pseudopigment network vary with each lesion. At times, they can be subtle or pronounced. This pattern, when seen under the dermatoscope, is highly suggestive of lentigo maligna. In addition, if there are discrete structureless areas of hyperpigmentation, the possibility of dermal invasion and lentigo maligna melanoma should be considered. Although no formal studies have been performed on the sensitivity, specificity, and diagnostic accuracy of the rhomboid pattern, in our experience it is not only a helpful sign that a banal-appearing equivocally pig-
Journal of the American Academy of Dermatology September 1997
mented skin lesion might be of more importance, but this technique can be useful in localizing more specifically the best area for biopsy.
Robert H. Johr, MD Director, Pigmented Lesion Clinic University of Miami School of Medicine Wilhelm Stolz, MD Professor of Dermatology University of Regensburg Regensburg, Germany
REFERENCES 1. Wolff K, Binder M, Pehamberger H. A new approach to early detection of melanoma. Adv Dermato11994;9:45-57. 2. Schiffner R, Landthaler M, Shiffnes-Rohe J, Klughardt M, Stolz W. New skin surface microscopic features for differentiation between lentigo maligna, lentigo maligna melanoma and lentigo senilis, flat seborrheic keratosis on the face based on logistic regression. J Invest Dermatol 1995;105:511. 3. Stolz W, Brann-Falco O, Bilek P, Landthaler M, Cognetta A. Color atlas of dermatoscopy. Cambridge (MA): Blackwell Science; 1994.
Leishmaniasis: Recent advances in treatment To the Editor: We read with interest the review on leishmaniasis by Grevelink and Lerner published in the Journal (J Am Acad Dermatol 1996;34:257-72). Several exciting developments have taken place in antileishmanial therapy in the past decade. Unfortunately, in an otherwise excellent review, many of these advances appear to have escaped the authors' attention. It is mentioned that liposomes have not yet been evaluated in clinical trials. However, liposomal amphotericin ]3 has been used in visceral leishmaniasis (VL) in different countries, 1-5 with the first report appearing as early as 1991.1 Our experience 5 has endorsed the findings of other investigators. All these studies demonstrated excellent efficacy of liposomal amphotericin B. It is now clear that liposomal preparations hold the key to the treatment of leishmaniasis. The authors mention that WR 6026 is undergoing phase I clinical trials. In fact, the phase II trial of this drug was reported in 1994. 6 Another trial has been initiated by the U.S. army in Brazil (personal communication, J. D. ]3erman, September 1995). The review suggests that interferon gamma (IFNy) has been used in the treatment of VL in Brazil only. However, there are several reports of its use from other countries as well. 7-1° Our group used IFN-y
Correspondence
Lentigo maligna and lentigo maligna melanoma To the Editor: We enjoyed reading the CME article on lentigo maligna and lentigo matigna melanoma by Cohen in the December 1995 issue of the Journal (1995;33:923-36). The article did, however, fail to mention dermatoscopy (skin surface microscopy, epiluminescence microscopy [ELM]) as a tool that is available for clinicians to help differentiate these potentially serious pigmented skin lesions from more banal pathology, such as seborrheic keratosis or lentigines. Dermatoscopy is an in vivo, noninvasive examination of skin lesions with the use of a hand-held microscope (Dermatoscope by Heine USA, Episcope by Welch Allyn), stereomicroscopes, or digital imaging computer systems and some type of oil/fluid immersion. The liquid applied to the lesion eliminates the reflection of light from the surface of the skin and subsurface colors, and structures in the epidermis, dermoepidermal junction, and papillary dermis become visible that cannot be seen with the naked eye, even with normal magnification typically used by clinicians. The major advantages of dermatoscopy are the differentiation of melanocytic from nonmelanocytic pigmented skin lesions, differentiation of benign from malignant skin lesions, minimization of unnecessary surgery, choice of appropriate surgical procedures, and patient reassurance. On the face, one can see with dermatoscopy skin appendages that appear as uniform white circles, often with hyperpigmented rims or borders. When the hyperpigmented borders touch each other, a networklike appearance is seen. This has been defined as the pseudopigment network. Normally, the pseudopigment network appears regular in terms of the color, thickness, and symmetry of the line segments and light areas. By definition, a rhomboid is a parallelogram with unequal sides and angles. The rhomboid pattern is formed when the monomorphous, uniform appearance of the pseudopigment network forms line segments that become thickened, irregular in size and shape, forming rhomboids with loss of symmetry within the lesion. The degree of changes that can be seen with the pseudopigment network vary with each lesion. At times, they can be subtle or pronounced. This pattern, when seen under the dermatoscope, is highly suggestive of lentigo maligna. In addition, if there are discrete structureless areas of hyperpigmentation, the possibility of dermal invasion and lentigo maligna melanoma should be considered. Although no formal studies have been performed on the sensitivity, specificity, and diagnostic accuracy of the rhomboid pattern, in our experience it is not only a helpful sign that a banal-appearing equivocally pig-
Journal of the American Academy of Dermatology September 1997
mented skin lesion might be of more importance, but this technique can be useful in localizing more specifically the best area for biopsy.
Robert H. Johr, MD Director, Pigmented Lesion Clinic University of Miami School of Medicine Wilhelm Stolz, MD Professor of Dermatology University of Regensburg Regensburg, Germany
REFERENCES 1. Wolff K, Binder M, Pehamberger H. A new approach to early detection of melanoma. Adv Dermato11994;9:45-57. 2. Schiffner R, Landthaler M, Shiffnes-Rohe J, Klughardt M, Stolz W. New skin surface microscopic features for differentiation between lentigo maligna, lentigo maligna melanoma and lentigo senilis, flat seborrheic keratosis on the face based on logistic regression. J Invest Dermatol 1995;105:511. 3. Stolz W, Brann-Falco O, Bilek P, Landthaler M, Cognetta A. Color atlas of dermatoscopy. Cambridge (MA): Blackwell Science; 1994.
Leishmaniasis: Recent advances in treatment To the Editor: We read with interest the review on leishmaniasis by Grevelink and Lerner published in the Journal (J Am Acad Dermatol 1996;34:257-72). Several exciting developments have taken place in antileishmanial therapy in the past decade. Unfortunately, in an otherwise excellent review, many of these advances appear to have escaped the authors' attention. It is mentioned that liposomes have not yet been evaluated in clinical trials. However, liposomal amphotericin ]3 has been used in visceral leishmaniasis (VL) in different countries, 1-5 with the first report appearing as early as 1991.1 Our experience 5 has endorsed the findings of other investigators. All these studies demonstrated excellent efficacy of liposomal amphotericin B. It is now clear that liposomal preparations hold the key to the treatment of leishmaniasis. The authors mention that WR 6026 is undergoing phase I clinical trials. In fact, the phase II trial of this drug was reported in 1994. 6 Another trial has been initiated by the U.S. army in Brazil (personal communication, J. D. ]3erman, September 1995). The review suggests that interferon gamma (IFNy) has been used in the treatment of VL in Brazil only. However, there are several reports of its use from other countries as well. 7-1° Our group used IFN-y