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CORRESPONDENCE |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 819-820 |
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| Dermoscopy as a diagnostic and monitoring tool for recurrent extramammary Paget's disease |
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Wei-Cheng Fang1, Pei-Chien Chou2, Li-Wen Chiu1, Chiao-Li Ke3, Shih-Tsung Cheng4
1 From the Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
2 Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
3 Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Psychiatry, Kaohsiung Municipal Hsiao-Kang Hospital, Medical University, Kaohsiung, Taiwan
4 From the Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Dermatology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Shih-Tsung Cheng
Department of Dermatology, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Dermatology, College of Medicine, Kaohsiung Medical University, Kaohsiung
Taiwan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_771_22
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How to cite this article:
Fang WC, Chou PC, Chiu LW, Ke CL, Cheng ST. Dermoscopy as a diagnostic and monitoring tool for recurrent extramammary Paget's disease. Indian J Dermatol 2022;67:819-20 |
How to cite this URL:
Fang WC, Chou PC, Chiu LW, Ke CL, Cheng ST. Dermoscopy as a diagnostic and monitoring tool for recurrent extramammary Paget's disease. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 29];67:819-20. Available from: https://www.e-ijd.org/text.asp?2022/67/6/819/370347 |
Sir,
Extramammary Paget's disease (EMPD) is a rare skin cancer occurring in areas with abundant apocrine glands.[1] It generally presents as an erythematous, eczematous, or ulcerative rash with associated pruritus and pain. Treatment is difficult, as EMPD has a high recurrence rate[2] despite therapies including Mohs surgery, wide excision, topical imiquimod, and photodynamic therapy (PDT). Therefore, early detection of recurrence followed by appropriate treatment is crucial for a better prognosis. We hereby report the use of dermoscopy to monitor the recurrence of EMPD in four patients at our hospital.
A total of four histopathologically confirmed EMPD patients were identified at our institute. Demographic data, clinical, and dermoscopic images were acquired under informed consent. EMPD lesions occurred at the axilla in patient 1 and at the genital area in patients 2 to 4. Three patients received wide excision with clear surgical margins and patient 4 completed treatment with PDT and subsequent topical imiquimod [Table 1]. All patients were followed up at our hospital regularly with a mean duration of 2.5 years. Thorough clinical and dermoscopic surveys were done at each visit. Unfortunately, new asymptomatic red patches appeared at previous EMPD sites for all four patients [Figure 1]a and [Figure 1]b. Dermoscopic examination showed milky-red areas for all patients [red asterisk, [Figure 1]c and [Figure 1]d, whereas white structureless areas [white asterisk, [Figure 1]d] and polymorphous vascular patterns [black arrows, [Figure 1]d] were observed in patients 2 to 4. Glomerular vessel patterns were only noted at the scrotal lesions [red arrows, [Figure 1]d]. Each patient then received skin biopsy under dermoscopic guidance, which confirmed recurrent EMPD. Topical imiquimod was given to all patients and the erythematous patches faded. | Table 1: Baseline data of patients and details of previous treatment and dermoscopic findings
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 | Figure 1: (a) A 1.5*1 cm red, tender patch (gray arrowhead) over the surgical scar on the left axilla of patient 1. (b) A 1.5*1.2 cm red patch (gray arrowhead) appeared over the postinflammatory hypopigmented area due to imiquimod treatment on the left penile base and scrotum of patient 4. (c) Dermoscopic examination of the left axilla of patient 1 showed a milky-red area (red asterisk) and pigmented structures (arrowhead). (d) Dermoscopic examination of the left penile base of patient 4 showed polymorphous vessels (black arrows) with glomerular vessels (red arrows), white structureless area (white asterisk), and a milky-red area (red asterisk). (e) and (f) Histopathologic examination revealed large pale vacuolated atypical cells (pagetoid cells) along the dermo-epidermal junction in both 1e (axilla, patient 1, HE 100X) and 1f (scrotum, Patient 4, HE 100X). However, dilated tortuous vessels in the superficial dermis (between arrows) were present only in 1f
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Dermoscopy has been used to monitor treatment outcomes and post-treatment follow-up in skin cancers such as Bowen's disease, basal cell carcinoma, and squamous cell carcinoma.[3],[4] Sampling bias from incisional biopsies could be prevented, as the entire skin lesion could be examined. Therefore, dermoscopy is a useful tool to assess and detect highly recurrent tumors such as EMPD, thus improving the clinical prognosis of the patient. Reported dermoscopic features of EMPD include milky-red areas, white structureless areas, polymorphous vascular patterns and glomerular vessel patterns, surface scales, ulcers, shiny white lines, and pigmentary structures.[5] In our study, similar dermoscopic findings could be seen in recurrent EMPD. Notably, vascular patterns were present at the scrotum but not at the axilla. Scrotal polymorphous and glomerular vessel patterns corresponded to the dilated and tortuous vessels in the superficial dermis [Figure 1]f, which may reflect tumor-related neoangiogenesis. In the axilla lesion, however, no vascular patterns were detected under dermoscopy. Correlating dermatopathological findings also showed the absence of dilated vessels in the superficial dermis [Figure 1]e. We speculated that the papillomatous epidermis and thicker dermis of the axilla may mask the vascular elements under dermoscopy.
In conclusion, dermoscopy is a useful tool for monitoring treatment outcome and detecting recurrent EMPD. Primary and recurrent EMPD have similar dermoscopic features; thus, the re-emergence of milky-red areas may forebode the relapse of EMPD.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Kanitakis J. Mammary and extramammary Paget's disease. J Eur Acad Dermatol Venereol 2007;21:581-90.  |
| 2. | O'Connor EA, Hettinger PC, Neuburg M, Dzwierzynski WW. Extramammary Paget's disease: A novel approach to treatment using a modification of peripheral Mohs micrographic surgery. Ann Plast Surg 2012;68:616-20. |
| 3. | Fargnoli MC, Kostaki D, Piccioni A, Micantonio T, Peris K. Dermoscopy in the diagnosis and management of non-melanoma skin cancers. Eur J Dermatol 2012;22:456-63. |
| 4. | Lallas A, Argenziano G, Zendri E, Moscarella E, Longo C, Grenzi L, et al. Update on non-melanoma skin cancer and the value of dermoscopy in its diagnosis and treatment monitoring. Expert Rev Anticancer Ther 2013;13:541-58. |
| 5. | Mun JH, Park SM, Kim GW, Song M, Kim HS, Ko HC, et al. Clinical and dermoscopic characteristics of extramammary Paget disease: A study of 35 cases. Br J Dermatol 2016;174:1104-7. |
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