Reflectance confocal microscopy can differentiate

1122 Correspondence
Table 1 Differential diagnoses of folliculitis
Infection or infestation
Fungi: Malassezia furfur, Candida albicans, atypical mycotic
infections (e.g. Rhodotorula mucilaginosa)
Viruses: herpes simplex, herpes zoster, molluscum
contagiosum, human papillomavirus
Bacteria: Staphyloccocus aureus, Pseudomonas aeruginosa, Gram-negative
infections, Streptococcus G
Mite: Demodex
Folliculitis due to medications with ⁄ without
immunosuppression
Epidermal growth factor receptor folliculitis
Steroid folliculitis
Other medications
Sterile folliculitis
Behc¸et disease
Pyoderma gangrenosum
Eosinophilic folliculitis of Ofuji
Others
Keratosis pilaris
Lichen ruber follicularis
Kyrle disease
Phrynoderma (vitamin A deficiency)
Haemorrhagic folliculitis (vitamin C deficiency)
Perforating folliculitis
Adjuvant temozolomide chemotherapy with radiation
significantly improves progression-free and overall survival in
patients with glioblastoma multiforme. Temozolomide, an oral
alkylating agent, is a derivative of dacarbazine and undergoes
rapid chemical conversion to the active compound monomethyl triazeno imidazole carboxamide. Temozolomide exhibits antineoplastic activity by interfering with DNA replication.5
However, patients treated with long-term corticosteroid therapy and chemotherapy are at increased risk of developing
opportunistic infections, especially when they additionally
develop lymphopenia commonly associated with temozolomide.6 They also may be susceptible to infections with cytomegalovirus, Cryptococcus neoformans and Salmonella species.7–9
Besides a brain abscess with Listeria monocytogenes, Pneumocystis jiroveci
pneumonia and cutaneous Kaposi sarcoma have been observed
in a patient undergoing treatment with temozolomide.10
In summary, this is the first case of R. mucilaginosa folliculitis,
probably facilitated by immunosuppression with temozolomide, in a rare syndrome, LFS. Rhodotorula mucilaginosa can be a
significant, recalcitrant pathogen in immunocompromised
patients and prompt antimycotic treatment should be initiated.
Acknowledgments
We are indebted to Arnoud Templeton, Haematology ⁄Oncology,
Cantonal Hospital of St Gallen, St Gallen, Switzerland, who
refered the patient to us and to Thomas Bruderer, Bacteriology ⁄Microbiology, Cantonal Hospital of St Gallen, St Gallen,
Switzerland, for assistance with the analysis of the microbiological culture.
*Department of Dermatology and Allergy Biederstein,
T. JAEGER*
Technische Universita¨t Mu¨nchen, 80802 Munich, Germany C . A N D R E S *
Dermatology ⁄Allergy, Cantonal Hospital of St Gallen,
J. RING*
9007 St Gallen, Switzerland
M.D. ANLIKER
E-mail: [email protected]
References
1 Tuon FF, Costa SF. Rhodotorula infection. A systematic review of 128
cases from literature. Rev Iberoam Micol 2008; 25:135–40.
2 Fung HB, Martyn CA, Shahidi A, Brown ST. Rhodotorula mucilaginosa
lymphadenitis in an HIV-infected patient. Int J Infect Dis 2009;
13:e27–9.
3 Perniola R, Faneschi ML, Manso E et al. Rhodotorula mucilaginosa outbreak in neonatal intensive care unit: microbiological features, clinical presentation, and analysis of related variables. Eur J Clin Microbiol
Infect Dis 2006; 25:193–6.
4 Birch JM. Li–Fraumeni syndrome. Eur J Cancer 1994; 30A:1935–41.
5 Koukourakis GV, Kouloulias V, Zacharias G et al. Temozolomide
with radiation therapy in high grade brain gliomas: pharmaceuticals considerations and efficacy; a review article. Molecules 2009;
14:1561–77.
6 Schwarzberg AB, Stover EH, Sengupta T et al. Selective lymphopenia
and opportunistic infections in neuroendocrine tumor patients
receiving temozolomide. Cancer Invest 2007; 25:249–55.
7 Meije Y, Lizasoain M, Garcı´a-Reyne A et al. Emergence of cytomegalovirus disease in patients receiving temozolomide: report of
two cases and literature review. Clin Infect Dis 2010; 50:e73–6.
8 Choi JD, Powers CJ, Vredenburgh JJ et al. Cryptococcal meningitis
in patients with glioma: a report of two cases. J Neurooncol 2008;
89:51–3.
9 Georgescu G, Isola IM, Youssef S et al. Disseminated salmonellosis in a patient treated with temozolomide. J Infect 2008; 57:
414–15.
10 Ganie`re V, Christen G, Bally F et al. Listeria brain abscess, Pneumocystis
pneumonia and Kaposi’s sarcoma after temozolomide. Nat Clin Pract
Oncol 2006; 3:339–43.
Funding sources: none.
Conflicts of interest: none declared.
Reﬂectance confocal microscopy can
differentiate dermoscopic white dots of the
scalp between sweat gland ducts or follicular
infundibulum
DOI: 10.1111/j.1365-2133.2011.10242.x
MADAM, White dots are dermoscopic features observed in dark
or sun-exposed scalp. They appear as rounded white structures, diffusely distributed, with slightly different diameters,
ranging from 9Æ3 to 16Æ5 lm.1 These structures were first
described in a dark-skinned patient with lichen planopilaris.
The authors correlated the white dots with fibrous tracts
replacing the hair follicles, due to a focal decrease in the
pigmentation in the rete ridges above the residual tracts.2
2011 The Authors
BJD 2011 British Association of Dermatologists 2011 164, pp1107–1124
Correspondence 1123
However, the routine use of dermoscopy for evaluation of
hair and scalp disorders indicates that white dots are actually a
common dermoscopic finding even in normal scalp.
Abraham et al.3 have recently shown that the white dots
(renamed pinpoint dots) corresponded to eccrine sweat duct
openings in several cases of scarring and nonscarring alopecia, as well as in the normal scalp. In a recent study we
showed that in vivo reflectance confocal microscopy (RCM)
technology allows evaluation of the upper follicle with a
consistent correlation with pathology. In particular, we were
able to demonstrate that the yellow dots observed in alopecia
areata correspond to dilated infundibula that may contain
hair remnants.4
Using RCM, we evaluated the white dot pattern of the sunexposed scalp of four men (age range 37–45 years) with
advanced male pattern alopecia. The patients were first submitted to scalp dermoscopy using a Vivacam (Lucid Technologies, Henrietta, NY, U.S.A.) connected to a confocal
microscope followed by RCM examination of the same area.
We employed a commercially available Vivascope 1500
RCM device connected to the Vivacam for clinical in vivo
imaging. This system includes a diode class 3A laser (European version) with a wavelength excitation maximum at
830 nm and power under 35 mW at tissue level. A
30 · 0Æ9 NA water-immersion objective lens was used. The
RCM device was attached to the skin using an adhesive ring to
reduce motion artefacts during examination. Immersion media
employed included water between the adhesive window and
the skin, and ultrasound gel between the adhesive window
and the objective lens. Details of this system have been
reported previously.5 Single images (0Æ5 · 0Æ5 mm) were
obtained from different skin levels for descriptive analysis.
Additionally, VivaBlock software was used to obtain
mosaics of 64 images (4 · 4 mm) at the level of the superficial epidermal layers, dermoepidermal junction and upper dermis. These mosaics were used for correlation with
dermoscopy in order to define the features, distribution,
dimension and density of adnexal structures and for evaluation
of white dots.
RCM showed the presence of diffuse adnexal structures characterized by the prevalence of empty adnexal lumina (Fig. 1b).
Correlation between RCM and dermoscopy (Fig. 1a) disclosed
that the white dots did not correspond to a specific anatomical
structure. In fact, on RCM examination white dots were seen to
correspond both to empty and ⁄or miniaturized hair follicles
and to sweat gland openings (Fig. 1b).
Confocal features of hair follicles were characterized by the
presence of keratotic material in the adnexal lumina and a
more prominent and thick epithelial wall in comparison with
eccrine glands (Fig. 2a). In some miniaturized hair follicles of
androgenetic alopecia, the presence of a subtle, small, short
hair shaft surrounded by keratotic material could be seen
(Fig. 2b). In contrast, sweat gland ducts were characterized
confocally by a thin epithelium and empty lumina (Fig. 2a).
Miniaturized hairs were seen on RCM as short, thin dark lines
coming from the follicle lumen (Fig. 1b).
2011 The Authors
BJD 2011 British Association of Dermatologists 2011 164, pp1107–1124
(a)
(b)
Fig 1. Dermoscopy of androgenetic alopecia, obtained using
Vivacam (a), vs. 4 · 4 mm VivaBlock mosaic reflectance confocal
microscopy (RCM) image taken at the level of the dermoepidermal
junction (b). Specifically, dermoscopy shows the presence of
numerous, diffuse white dots located in glabrous areas. On RCM, the
white dots are seen to correspond to different adnexal structures
ranging from empty and ⁄ or miniaturized hair follicles to gland ducts.
Hair follicles are generally characterized by the presence of keratotic
material in the lumina and a more prominent and thick epithelium
(yellow arrows). In contrast, gland ducts are characterized by a
thinner epithelium and empty lumina (white arrows). Miniaturized
hairs can be seen on dermoscopy as thin, short hairs in the middle
of white dots, and on RCM as short, little hair shafts from hair
follicles.
On scalp dermoscopy, the patients showed numerous white
dots (Fig. 1a). From dermoscopy it was not possible to establish
if the white dots were in a follicular or interfollicular distribution, except for a few dots containing extremely miniaturized
hairs. On RCM examination we were able to establish that the
white dots corresponded to different adnexal structures including sweat gland ducts and follicular infundibula, which were
empty or sometimes contained miniaturized hair shafts.
RCM is a noninvasive, infinitely repeatable technique for
real-time en-face microscopic imaging of the superficial layers
1124 Correspondence
(a)
(b)
structures, and thus they are not useful criteria to distinguish
cicatricial from noncicatricial alopecia.
IRCCS San Gallicano Dermatological Institute,
M . A R D I G O`
Rome, Italy
F. TORRES*
*Institute of Dermatology of Rio de Janeiro,
L.S. ABRAHAM§
St Alexandre Ferreira 206,
J . P I N˜ E I R O - M A C E I R A Lagoa, Rio de Janeiro 22470-220, Brazil
N. CAMELI
Department of Dermatology and Cutaneous Surgery,
E. BERARDESCA
Miller School of Medicine,
A. TOSTI
University of Miami,
Miami, FL, U.S.A.
Pathology Department,
Federal University of Rio de Janeiro,
Institute of Dermatology of Rio of Janeiro,
Rio de Janeiro, Brazil
§Institute of Dermatology Prof. Rubem David Azulay,
Rio de Janeiro, Brazil
Correspondence: Fernanda Torres.
E-mail: [email protected]
References
Fig 2. (a) Reflectance confocal microscopy (RCM) image of a hair
follicle (below) and a gland duct (above). Note the thicker epithelium
of the hair follicle and the empty lumen of the gland. (b) RCM image
taken at the level of the stratum spinosum showing a hair follicle with
miniaturized hair surrounded by keratotic material in the lumen.
of the skin down to the superficial reticular dermis, with
cellular-level resolution close to conventional histopathology.6 Contrast is provided by differences in the refractive
index due to molecules present in the cell’s cytoplasm and
organelles as well as the extracellular microstructures within
the tissue.7,8 RCM has been used for the evaluation of several inflammatory skin conditions, such as acute contact
dermatitis, discoid lupus erythematosus and psoriasis, and
has been correlated with conventional histology in several
instances.5–10
We considered that this technique may also play a role in
the diagnosis and management of hair and scalp disorders, as
it can appreciably differentiate skin structures. In our case
RCM was able to demonstrate that the white dots seen by dermoscopy could represent both follicular and sweat gland
1 Duque-Estrada B, Tamler C, Sodre´ CT et al. Dermoscopy patterns of
cicatricial alopecia resulting from discoid lupus erythematosus and
lichen planopilaris. An Bras Dermatol 2010; 85:179–83.
2 Kossard S, Zagarella S. Spotted cicatricial alopecia in dark skin.
A dermoscopic clue to fibrous tract. Australas J Dermatol 1993;
34:49–51.
3 Abraham LS, Pin˜eiro-Maceira J, Duque-Estrada B et al. Pinpoint
white dots in the scalp: dermoscopic and histopathologic correlation. J Am Acad Dermatol 2010; 63:721–2.
4 Ardigo` M, Tosti A, Cameli N et al. Reflectance confocal microscopy
of the yellow dots pattern in alopecia areata. Arch Dermatol 2011;
147:61–4.
5 Ardigo` M, Maliszewski I, Cota C et al. Preliminary evaluation of in
vivo reflectance confocal microscopy features of discoid lupus erythematosus. Br J Dermatol 2007; 156:1196–203.
6 Rajadhyaksha M. Confocal reflectance microscopy: diagnosis of skin
cancer without biopsy? In: Frontiers of Engineering. Washington, DC:
National Academies Press, 1999; 24–33.
7 Rajadhyaksha M, Grossman M, Esterowitz D et al. In vivo confocal
scanning laser microscopy of human skin: melanin provides strong
contrast. J Invest Dermatol 1995; 104:946–52.
8 Gonzalez S, Gonzalez E, White WM et al. Allergic contact dermatitis: correlation of in vivo confocal imaging to routine histology. J
Am Acad Dermatol 1999; 40:708–13.
9 Swindells K, Burnett N, Rius-Diaz F et al. Reflectance confocal
microscopy may differentiate acute allergic and irritant contact
dermatitis in vivo. J Am Acad Dermatol 2004; 50:220–8.
10 Astner S, Gonzalez E, Cheung A et al. Pilot study on the sensitivity
and specificity of in vivo reflectance confocal microscopy in the
diagnosis of allergic contact dermatitis. J Am Acad Dermatol 2005;
53:986–92.
Funding sources: none.
Conflicts of interest: none declared.
2011 The Authors
BJD 2011 British Association of Dermatologists 2011 164, pp1107–1124

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