Tropical medicine rounds
Clinical and dermoscopic evaluation of cutaneous leishmaniasis Erhan Ayhan1, MD, Derya Ucmak2, MD, Sule Nergiz Baykara2, MD, Zeynep Meltem Akkurt2, MD, and Mustafa Arica2, MD
1 Department of Dermatology, Tokat Zile State Hospital, Tokat, Turkey, and 2 Department of Dermatology, Dicle University School of Medicine, Diyarbakır, Turkey
Abstract Background Dermoscopy is a method to aid in the visualization of the epidermis and dermis. In recent years, the use of dermoscopy in the diagnosis of non-melanocytic lesions such as those of leishmania cutis has increased. Objectives This study was intended to establish whether dermoscopic investigation has
Correspondence Erhan Ayhan, MD Department of Dermatology Tokat Zile State Hospital €cßlu € Sokak Tokat Bahc¸elievler Mahallesi Gu No: 2, Zile/Tokat, 60400, Turkey E-mail: [email protected] Funding: None. Conflicts of interest: None.
any diagnostic value in cutaneous leishmaniasis (CL). Methods Fifty-five patients diagnosed with CL at the Department of Dermatology, Faculty of Medicine, Dicle University, between February and October 2012, were included in the study. Collectively, the patients exhibited a total of 127 lesions. Results The mean standard deviation age of the patients was 25.7 21.3 years (range: 4–86 years). Twenty-three (41.8%) patients were male, and 32 (58.2%) were female. In dermoscopy, teardrop-like structures were observed in 42.5% of the lesions. Vascular structures were detected in 115 (90.6%) lesions; no vascular structures were observed in 12 (9.4%) lesions. Branching, linear, comma-like, and polymorphic vessels were seen more commonly in lesions on the face; pin-point and hairpin-like vessels were seen more commonly in lesions on the upper extremities. Conclusions When the findings obtained in this study were evaluated along with those reported in the literature, it became apparent that follicular plugs, also called “teardrop-like structures”, seen on the face and neck may be a dermoscopic feature specific to CL. As hairpin-like vessels seen in an asymmetric radial arrangement were often observed on parts of the body other than the face, further dermoscopic studies comparing the lesions of CL with other ulcerating lesions are necessary.
Introduction Leishmaniasis is an infection caused by Leishmania protozoa, which is usually transmitted by the bite of various species of phlebotomine sandfly. In clinical terms, leishmaniasis is divided into three types: cutaneous, mucocutaneous, and visceral. Interactions that occur among the parasite, host, vector, and environment play prominent roles in the epidemiology and clinical spectrum of the disease.1 Cutaneous leishmaniasis (CL) is a skin disease caused by parasites belonging to the genus Leishmania, which creates longstanding nodulo-ulcerative sores in the skin during its course and heals, leaving atrophic scars.2 Various methods can be used to diagnose CL, such as skin smears, screening, biopsy, culture, and polymerase chain reaction. Dermoscopy is a diagnostic technique that facilitates the examination of the epidermis and superficial dermis.3 It is usually applied in the diagnosis of melanocytic skin ª 2014 The International Society of Dermatology
lesions but has recently been used for the diagnosis of non-melanocytic skin lesions. However, only a limited number of studies have explored the use of this technique in CL, a non-melanocytic infection.4,5 The present study aimed to find out whether dermoscopy is a valuable technique in the diagnosis of CL. Materials and methods A total of 127 lesions in 55 patients with an age range of 4–86 years, who were admitted to the Dermatology Clinic at Dicle University Faculty of Medicine between February and October 2012 and diagnosed with CL, were included in this study. All lesions diagnosed according to a smear obtained from the lesion were included in the series. This study consisted of three phases: (i) locating the leishmania lesion in the patient and dermoscopically examining it; (ii) obtaining images of the lesion; and (iii) evaluating the results.
193 International Journal of Dermatology 2015, 54, 193–201
194
Tropical medicine rounds
Ayhan et al.
Evaluation of cutaneous leishmaniasis
Demographic data and the clinical features of patients and dermoscopic features of lesions were noted in all study
Table 1 Anatomic lesions (n = 127)
locations
of
cutaneous
leishmaniasis
participants. According to their morphological features, blood vessels were classified as follows: polymorphic vessels; arborizing vessels; hairpin-like vessels; linear vessels; dotted vessels; comma-like vessels; corkscrew-like vessels; glomerular vessels; crown vessels; and vessels of a strawberry pattern. According to their vascular arrangements, vascular structures that detected during dermoscopic examination were categorized as: regular (homogeneous); irregular (non-homogeneous); irregular arborizing; reticular; string-like; clustered; and radial. In this study, a radial arrangement was further classified as either symmetric or asymmetric. As vessels exist only in a particular part of the lesion, we found it appropriate to add an asymmetric radial pattern to our list of classifications. The lesions included in this study were evaluated individually. Both macroscopic and dermoscopic features were examined using a digital dermoscope (Fotofinder Dermoscope II Imaging System; TeachScreen Software GmbH, Bad Birnbach, Germany; original magnification: 920). All data were noted. An average of five dermoscopic images was taken of each lesion. As images were taken, 60% alcohol (ethanol) was used to
Location
Lesions, n (%)
Face Forehead Periorbital region Nose Cheek Perioral region Chin Ear Neck Anterior side Posterior side Lateral side Upper extremities Arm Forearm Hand Lower extremities Thigh Leg Foot Trunk Total
60 2 8 13 23 5 8 1 8 3 2 3 50 5 34 11 8 2 5 1 1 127
(47.2) (3.3) (13.3) (21.7) (38.3) (8.3) (13.3) (0.8) (6.3) (37.5) (25.0) (37.5) (39.4) (10.0) (68.0) (22.0) (6.3) (25.0) (62.5) (12.5) (0.8)
smooth the skin surface in order to help light penetrate more deeply into the skin and to reduce reflections and ultimately improve image quality. Pressure was reduced in order to avoid
Table 2 Dermoscopic structures in cutaneous leishmaniasis
the loss of dermoscopic images of vascular structures during imaging. Dermoscopic patterns were evaluated after all relevant
Dermoscopic structures
n (%)
Erythema Crust Erosion/ulceration Teardrop-like structures Scar Millium Orange areas Hyperkeratosis White-starburst pattern Pustules Vascular formation Polymorphic vessels Hairpin-like vessels Arborizing vessels Linear vessels Dotted vessels Comma-like vessels Corkscrew-like vessels Glomerular-like vessels Crown-like vessels Strawberry pattern
127 89 56 54 22 20 20 19 11 9 115 51 50 49 33 31 25 4 4 2 2
data in each patient had been recorded. All patient data were evaluated using SPSS Statistics for Windows Version 17.0 (SPSS, Inc., Chicago, IL, USA). Data were analyzed by independent-samples t-tests and one-way analysis of variance (ANOVA). A P-value of
Clinical and dermoscopic evaluation of cutaneous leishmaniasis Erhan Ayhan1, MD, Derya Ucmak2, MD, Sule Nergiz Baykara2, MD, Zeynep Meltem Akkurt2, MD, and Mustafa Arica2, MD
1 Department of Dermatology, Tokat Zile State Hospital, Tokat, Turkey, and 2 Department of Dermatology, Dicle University School of Medicine, Diyarbakır, Turkey
Abstract Background Dermoscopy is a method to aid in the visualization of the epidermis and dermis. In recent years, the use of dermoscopy in the diagnosis of non-melanocytic lesions such as those of leishmania cutis has increased. Objectives This study was intended to establish whether dermoscopic investigation has
Correspondence Erhan Ayhan, MD Department of Dermatology Tokat Zile State Hospital €cßlu € Sokak Tokat Bahc¸elievler Mahallesi Gu No: 2, Zile/Tokat, 60400, Turkey E-mail: [email protected] Funding: None. Conflicts of interest: None.
any diagnostic value in cutaneous leishmaniasis (CL). Methods Fifty-five patients diagnosed with CL at the Department of Dermatology, Faculty of Medicine, Dicle University, between February and October 2012, were included in the study. Collectively, the patients exhibited a total of 127 lesions. Results The mean standard deviation age of the patients was 25.7 21.3 years (range: 4–86 years). Twenty-three (41.8%) patients were male, and 32 (58.2%) were female. In dermoscopy, teardrop-like structures were observed in 42.5% of the lesions. Vascular structures were detected in 115 (90.6%) lesions; no vascular structures were observed in 12 (9.4%) lesions. Branching, linear, comma-like, and polymorphic vessels were seen more commonly in lesions on the face; pin-point and hairpin-like vessels were seen more commonly in lesions on the upper extremities. Conclusions When the findings obtained in this study were evaluated along with those reported in the literature, it became apparent that follicular plugs, also called “teardrop-like structures”, seen on the face and neck may be a dermoscopic feature specific to CL. As hairpin-like vessels seen in an asymmetric radial arrangement were often observed on parts of the body other than the face, further dermoscopic studies comparing the lesions of CL with other ulcerating lesions are necessary.
Introduction Leishmaniasis is an infection caused by Leishmania protozoa, which is usually transmitted by the bite of various species of phlebotomine sandfly. In clinical terms, leishmaniasis is divided into three types: cutaneous, mucocutaneous, and visceral. Interactions that occur among the parasite, host, vector, and environment play prominent roles in the epidemiology and clinical spectrum of the disease.1 Cutaneous leishmaniasis (CL) is a skin disease caused by parasites belonging to the genus Leishmania, which creates longstanding nodulo-ulcerative sores in the skin during its course and heals, leaving atrophic scars.2 Various methods can be used to diagnose CL, such as skin smears, screening, biopsy, culture, and polymerase chain reaction. Dermoscopy is a diagnostic technique that facilitates the examination of the epidermis and superficial dermis.3 It is usually applied in the diagnosis of melanocytic skin ª 2014 The International Society of Dermatology
lesions but has recently been used for the diagnosis of non-melanocytic skin lesions. However, only a limited number of studies have explored the use of this technique in CL, a non-melanocytic infection.4,5 The present study aimed to find out whether dermoscopy is a valuable technique in the diagnosis of CL. Materials and methods A total of 127 lesions in 55 patients with an age range of 4–86 years, who were admitted to the Dermatology Clinic at Dicle University Faculty of Medicine between February and October 2012 and diagnosed with CL, were included in this study. All lesions diagnosed according to a smear obtained from the lesion were included in the series. This study consisted of three phases: (i) locating the leishmania lesion in the patient and dermoscopically examining it; (ii) obtaining images of the lesion; and (iii) evaluating the results.
193 International Journal of Dermatology 2015, 54, 193–201
194
Tropical medicine rounds
Ayhan et al.
Evaluation of cutaneous leishmaniasis
Demographic data and the clinical features of patients and dermoscopic features of lesions were noted in all study
Table 1 Anatomic lesions (n = 127)
locations
of
cutaneous
leishmaniasis
participants. According to their morphological features, blood vessels were classified as follows: polymorphic vessels; arborizing vessels; hairpin-like vessels; linear vessels; dotted vessels; comma-like vessels; corkscrew-like vessels; glomerular vessels; crown vessels; and vessels of a strawberry pattern. According to their vascular arrangements, vascular structures that detected during dermoscopic examination were categorized as: regular (homogeneous); irregular (non-homogeneous); irregular arborizing; reticular; string-like; clustered; and radial. In this study, a radial arrangement was further classified as either symmetric or asymmetric. As vessels exist only in a particular part of the lesion, we found it appropriate to add an asymmetric radial pattern to our list of classifications. The lesions included in this study were evaluated individually. Both macroscopic and dermoscopic features were examined using a digital dermoscope (Fotofinder Dermoscope II Imaging System; TeachScreen Software GmbH, Bad Birnbach, Germany; original magnification: 920). All data were noted. An average of five dermoscopic images was taken of each lesion. As images were taken, 60% alcohol (ethanol) was used to
Location
Lesions, n (%)
Face Forehead Periorbital region Nose Cheek Perioral region Chin Ear Neck Anterior side Posterior side Lateral side Upper extremities Arm Forearm Hand Lower extremities Thigh Leg Foot Trunk Total
60 2 8 13 23 5 8 1 8 3 2 3 50 5 34 11 8 2 5 1 1 127
(47.2) (3.3) (13.3) (21.7) (38.3) (8.3) (13.3) (0.8) (6.3) (37.5) (25.0) (37.5) (39.4) (10.0) (68.0) (22.0) (6.3) (25.0) (62.5) (12.5) (0.8)
smooth the skin surface in order to help light penetrate more deeply into the skin and to reduce reflections and ultimately improve image quality. Pressure was reduced in order to avoid
Table 2 Dermoscopic structures in cutaneous leishmaniasis
the loss of dermoscopic images of vascular structures during imaging. Dermoscopic patterns were evaluated after all relevant
Dermoscopic structures
n (%)
Erythema Crust Erosion/ulceration Teardrop-like structures Scar Millium Orange areas Hyperkeratosis White-starburst pattern Pustules Vascular formation Polymorphic vessels Hairpin-like vessels Arborizing vessels Linear vessels Dotted vessels Comma-like vessels Corkscrew-like vessels Glomerular-like vessels Crown-like vessels Strawberry pattern
127 89 56 54 22 20 20 19 11 9 115 51 50 49 33 31 25 4 4 2 2
data in each patient had been recorded. All patient data were evaluated using SPSS Statistics for Windows Version 17.0 (SPSS, Inc., Chicago, IL, USA). Data were analyzed by independent-samples t-tests and one-way analysis of variance (ANOVA). A P-value of
