Fungal Infections

Dermoscopy is the non-invasive examination of the skin using skin surface microscopy. It is used to evaluate pigmented skin lesions and is a particularly useful tool for the early diagnosis of malignant melanoma. Dermoscopy has been shown to improve the diagnostic accuracy of melanoma by up to 49% if used by experts (Kittler et al. 2002). There is recent interest in using it to diagnose cutaneous fungal infections of many types, including tinea capitis, pityriasis versicolor, onychomycosis and many other unusual fungal diseases. For a recent review, see Erruchetti & Stinco (2016).

The gold standard technical equipment in this context is an epi-illuminescent stereo microscope, with an attached high-end digital camera and a computer station with typically, proprietary image storing software which can be connected to an electronic health record (e.g. the FotoFinder Dermoscope Studio). This type of total dermoscopy system however, is very expensive and not widely accessible. Technological advances have sought to improve on this set up, with specially designed portable devices now commercially available. Such devices include:

  • Optical lenses which can be attached to a digital camera, such as the Nevoscope (TransLite, LLC, Sugar Land, Texas, USA) and the DermLite Foto range (3Gen, LLC, Dana Point, CA). The DermaLite Foto Flash unit, attached to a Nikon Coolpix digital camera has been shown to improve diagnostic accuracy for pigmented lesions (Argenziano, 2008; Rosendahl, 2011), and also effectively image nailfold capillary abnormalities (Sontheimer, 2004).
  • Portable all in one devices, such as the NITID (DermaLumics, Madrid, Spain), combining 3 imaging modalities (clinical camera, Digital Dermatoscopy and an Optical Coherence Tomography system), allowing physicians to identify different skin structures, inflammatory lesions, vascularisation and the detection of malignant nodules, especially in non-melanoma skin cancer.
  • Compact hand-held devices with or without attachments for smart phones. Examples include the DermLite pocket range (3Gen, LLC, Dana Point, CA) the FotoFinder handyscope (FotoFinder Systems GmbH, Bad Birnbach, Germany), the HEINE iC1 (HEINE Optotechnik, GmbH & Co. KG, Herrsching, Germany), and the VEOS range (Canfield Scientific, Parsippany, NJ). Many of these options also come with an associated smartphone app, allowing the convenient capture and storage of dermatoscopic images.

This rise in availability of portable devices has allowed patients and primary care physicians access to dermatologists in medically underserved and remote communities. Known as teledermoscopy, devices attached to phones with cameras and internet capabilities make it possible to send digital images of skin lesions with relevant clinical information to a dermatologist for his/her opinion. In a recent study, the diagnostic accuracy of teledermoscopy was tested using the FotoFinder Handyscope, attached to an iPhone 4, running the iDoc24 app. Teledermoscopy was found to be comparable to a Face-to-Face dermatologist appointment (Borve et al. 2013).

References

Argenziano G, Mordente I, Ferrara G, Sgambato A, Annese P, Zalaudek I. Dermoscopic monitoring of melanocytic skin lesions: clinical outcome and patient compliance vary according to follow‐up protocols. Br JDermatol 2008;159:331-6.

Börve A, Terstappen K, Sandberg C, Paoli J. 2013. Mobile teledermoscopy—there’s an app for that! Dermatol Pract Concept 2013;3:41.

Errichetti, E., & Stinco, G. Dermoscopy in General Dermatology: A Practical Overview. Dermatology and Therapy 2016; 6(4); 471-507.

Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159–65.

Rosendahl,C, Tschandl P, Cameron A, Kittler H. 2011. Diagnostic accuracy of dermatoscopy for melanocytic and nonmelanocytic pigmented lesions. J Am Acad Dermatol 2011;64:1068-73.

Sontheimer RD,A portable digital microphotography unit for rapid documentation of periungual nailfold capillary changes in autoimmune connective tissue diseases.  J Rheumatol 2004;31:539-44.

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