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Background Multiple studies have reported on dermoscopic structures in basal cell carcinoma (BCC) and its subtypes, with varying results. Objective To systematically review the prevalence of dermoscopic structures in BCC and its subtypes. Methods Databases and reference lists were searched for relevant trials according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were assessed for the relative proportion of BCC dermoscopic features. Random-effects models were used to estimate summary effect sizes. Results Included were 31 studies consisting of 5950 BCCs. The most common dermoscopic features seen in BCC were arborizing vessels (59%), shiny white structures (49%), and large blue-grey ovoid nests (34%). Arborizing vessels, ulceration, and blue-grey ovoid nests and globules were most common in nodular BCC; short-fine telangiectasia, multiple small erosions, and leaf-like, spoke wheel and concentric structures in superficial BCC; porcelain white areas and arborizing vessels in morpheaform BCC; and arborizing vessels and ulceration in infiltrative BCC. Limitations Studies had significant heterogeneity. Studies reporting BCC histopathologic subtypes did not provide clinical data on pigmentation of lesions. Conclusion In addition to arborizing vessels, shiny white structures are a common feature of BCC. A constellation of dermoscopic features may aid in differentiating between BCC histopathologic subtypes.

Trichoblastoma (TB) is an uncommon benign follicular tumour for which clinical data is limited since most reports originate from pathology studies.To describe the clinical aspects of TB.This is an ancillary study of a prospective multicentre cohort of 2710 clinically suspected basal cell carcinoma (BCC), including 935 nodular BCCs. Sixty-two cases were TB: they were analysed and compared to 935 nodular BCCs.TB mostly occurred in females (61% vs. 43% for BCC, P0.01) of mean age 63 years. They were located on the head and neck, mainly on the nose and forehead, in 87% of cases. The mean size was 8.1mm, 77% were10mm (55% of BCCs, P0.001), 8% were ulcerated (vs. 21% of BCCs, P0.02), and 47% persisted for more than 1 year (34% of BCCs, P0.05). Most cases had a clinical presentation similar to nodular BCC, except for 5 small, flat, white papules and 1 anfractuous plaque.Cases originated from a series of tumours clinically suspected as BCCs.Some 2.6% of tumours clinically diagnosed as BCC are in fact TB. TB occurs on the head, are more frequent in women, and are smaller and of longer duration than BCC. In most cases, clinical diagnosis on clinical grounds is difficult.

Purpose: Nodular basal cell carcinoma (nBCC) is mostly treated with surgical excision. Interest in minimally invasive treatment of these low-risk tumors is increasing. We assessed the effectiveness of nBCC treatment with curettage and imiquimod cream compared with surgical excision.Methods: Patients with nBCC included in this randomized, controlled noninferiority trial were randomly assigned to either a curettage and imiquimod cream group or a surgical excision group. The primary endpoint was the proportion of patients free from treatment failure 1 year after the end of treatment. A prespecified noninferiority margin of 8% was used. A modified intention-to-treat and a per-protocol analysis was performed (ClinicalTrials.gov identifier NCT02242929).Results: One hundred forty-five patients were randomized: 73 to the curettage and imiquimod cream group and 72 to the surgical excision group. The proportion of patients free of recurrence after 12 months was 86.3% (63/73) for the curettage and imiquimod group and 100% (72/72) for the surgical excision group. The difference in efficacy was -13.7% (95% confidence interval -21.6% to -5.8%; 1-sided P =.0004) favoring surgical excision.Conclusion: Noninferiority of curettage and imiquimod cream cannot be concluded. Given the still high efficacy of curettage and imiquimod cream and the indolent growth pattern of nBCC, curettage and imiquimod could still be a valuable treatment option with the possibility to prevent overuse of excisions. However, it cannot replace surgical excision.

Trichoblastoma is a benign cutaneous neoplasm that is clinically and histologically similar to basal cell carcinoma. We report the dermoscopic features seen in 2 cases of facial trichoblastoma. One case presented with very short, delicate, scarcely branching telangiectases against a pearly white background. In the second case, the veins were also short and scarcely branching, but they were arranged in a crown pattern, with white striae and milia-like cysts. Although dermoscopic evidence of fine, scarcely branching telangiectases is not specific to a diagnosis of trichoblastoma, these features may be useful for differentiating this neoplasm from nodular basal cell carcinoma.

BACKGROUND: The management of basal cell carcinoma (BCC) depends, among other factors, on its histopathologic subtype. Although dermoscopic criteria of BCC have been investigated, the possible role of dermoscopy in predicting the tumor subtype remains unclear. OBJECTIVES: We sought to assess the diagnostic accuracy of dermoscopic criteria for differentiating superficial BCC (sBCC) from other BCC subtypes. METHODS: Dermoscopic images of histopathologically confirmed BCCs were retrospectively evaluated for the presence of predefined criteria. Univariate and adjusted odds ratios were calculated. Discriminant functions were used to plot receiver operating characteristic curves. RESULTS: In all, 77 sBCCs and 258 non-sBCCs were included. Maple leaf-like areas, short fine superficial telangiectasia, multiple small erosions, and shiny white-red structureless areas were potent predictors of sBCC, each making its diagnosis over 5-fold more likely. Conversely, the presence of arborizing vessels, blue-gray ovoid nests, and ulceration gave 11-fold, 15-fold, and 3-fold increased possibility for the diagnosis of non-sBCCs, respectively. Based on the results of the multivariate analysis, we propose a diagnostic algorithm that can predict the diagnosis of sBCC with a sensitivity of 81.9% and a specificity of 81.8%. LIMITATIONS: The retrospective design and the inclusion of only Caucasian patients are limitations. CONCLUSION: Dermoscopy is reliable in differentiating sBCC from other BCC subtypes.

In this edition of PDPDT, three papers describe current practice in the delivery of topical phodosage and preparation protocols, as well as a variety of approaches to minimise side effects, comtodynamic therapy (PDT) in non-melanoma skin cancer (NMSC) [1—3]. PDT has moved from being a research therapy with limited availability to a standard modality for NMSC in many dermatology departments. The evidence base for the use of PDT was assessed by the British Photodermatology Group in 2000 with a recent review of its use in NMSC by Szeimies and co-workers [4,5]. The FDA approved the use of topical PDT in actinic keratosis (AK) in 1999 using the Levulan formulation of 5-aminolaevulinic acid (5-ALA) (DUSA Pharmaceuticals, Wilmington, MA, USA), but there remain no other approvals of this formulation to date. Subsequent approval of the methyl ester of 5-ALA (Galderma, Paris, France and PhotoCure AS, Oslo, Norway) in most European countries, Australia and across Scandinavia, for actinic keratoses, superficial and nodular basal cell carcinoma (BCC), and recently also for Bowen’s disease (squamous cell carcinoma in situ), has permitted the much wider bine now with several skin cancer applications, to risk sub-optimal therapy due to failure to use protocols most appropriate for the cream and light used in that given indication. Recently we have seen the increase in off-label use of PDT in certain non-cancer dermatological indications, where individual treatments may be less intense, but where multiple visits are typically required. This edition of PDPDT also carries an updated assessment of the potential of topical PDT in non-cancer indications [6]. Ibbotson [1] reports on specific issues concerning the delivery of topical PDT in superficial BCC, arguably one of the strongest indications for PDT, where the alternative of extensive surgery may now be avoided. The Dundee team recommend that BCC with a histological thickness not exceeding 2mm and of superficial subtype are most appropriate for the ALA-PDT described. Multiple methods of lesion preparation are described in the literature on topuse of topical PDT. The current focus of PDPDT, on how we should best deliver PDT, is therefore timely as many ical PDT [4] and the team advise the application of vaseline to the tumour for 3 days prior treatment to loosen surface crust. There has been no specific s a e a p r t

Summary Background Pain is a major side effect of topical photodynamic therapy (PDT), a relatively new and non-invasive treatment for particular types of basal cell carcinoma (BCC). In this study, we sought to characterise in more detail the quality and intensity of pain associated with PDT. Furthermore, we studied if gender, tumour size and localization as well as different light sources with comparable wavelengths had an influence on the pain. Methods A total of 64 nodular BCCs in 55 patients, of which 48 BCCs underwent preceding debulking, were treated with 5-aminolevulinic acid (ALA-PDT). Two metal halogen light sources were randomly used. Pain assessment was performed using a visual analogue scale (VAS). Results All patients experienced pain during illumination and 41.8% after illumination. The mean pain intensity was 3.88 with most patients experiencing burning (82.5%) or stinging (36.8%) sensations. Illumination with the Medeikonos ® light source was experienced less painful than the Waldmann ® lamp (4.64 versus 3.40; p = 0.027). Gender as well as tumour localization and size did not alter the pain scores. Likewise, no differences were observed between patients who underwent debulking and those who did not. Conclusions Treatment of single BCCs with ALA-PDT rarely results in unbearable pain. However, the degree of pain can vary depending on the light source used. Further studies are needed to unravel the pathomechanisms underlying the development of pain in PDT in order to develop adequate solutions for this undesirable side effect.

Purpose To evaluate the efficacy and safety of topical imiquimod 5% cream for the treatment of eyelid basal cell carcinoma. Design Two interventional case reports. Methods Imiquimod 5% cream was applied topically once daily, 3 days a week for 8 to 12 weeks, in two patients affected by eyelid nodular basal cell carcinoma. Patients were followed up clinically with slit-lamp examination for evidence of tumor disappearance or recurrence, and local and systemic side effects. Results Complete clinical response was obtained in both patients. No severe local side effects were observed. Patients did not show any local recurrence after 1 year. Conclusions Topical imiquimod 5% cream seems to be a useful treatment for eyelid nodular basal cell carcinoma in selected cases, but further long-term studies are needed to assess the efficacy and safety of this approach.

s / Photodiagnosis and Photodynamic Therapy 12 (2015) 325–375 375 (19%/n=5). The area of the lesions ranged from 3 to 48 cm2, with a mean of 14.7cm2. A total responsewas observed in 69% of the cases (18). In the eight remained lesions (30%) was observed a reduction of at least 50% of the area. This study shows an important contribution of PDT treatment in large area lesions, avoiding surgery for big reconstructions flaps or grafts in old patients with comorbidities. http://dx.doi.org/10.1016/j.pdpdt.2015.07.194 Longterm follow-up of nodular basal cell carcinoma after Photodynamic Therapy Ana Gabriela Salvio1, Elisangela Ramos de Oliveira1, Dora Patricia Ramirez2, Natalia Mayumi Inada2, Cristina Kurachi2, Vanderlei Salvador Bagnato2 1 Skin Department of Amaral Carvalho Hospital, Brazil 2 Sao Carlos Institute of Physics University of Sao Paulo, Brazil Studies about the long-term follow-up of nodular basal cell carcinoma (nBCC) underwent through photodynamic therapy is few reported. This clinical research describes a total of 56 cases of nBCC less than 1 cm diagnosed and treated during 2010 and 2011 at Amaral CarvalhoHospitalwith Photodynamic Therapy (PDT) (topic 15%MAL-PDT, illuminated at 630 nmwith a total delivered energy of 100 J/cm2). Most of the nBCC were located at head and neck area (57%/n=32) followed by trunk (30%/n=17) and upper limbs (13%/n=7). During a total time follow up of 53 months (with a median follow up of 30,8 months (0 to 53 months), the recurrence was observed in only 5% of the patients and it occurred in the first 14 months of follow up. For this group it can be considered a free disease follow up of 93.7%. It can be concluded that PDT for nodular BCC is safe treatment with low rates of late recurrence. http://dx.doi.org/10.1016/j.pdpdt.2015.07.195 Reduction in surgical procedures in patients with Gorlin syndrome when management associated with Topical Photodynamic therapy: report of two cases Ana Gabriela Salvio1, Dora Patricia Ramirez2, Elisangela Ramos de Oliveira1, Natalia Mayumi Inada2, Cristina Kurachi2, Vanderlei Salvador Bagnato2 1 Skin Department of Amaral Carvalho Hospital, Brazil 2 Sao Carlos Institute of Physics University of Sao

s / Photodiagnosis and Photodynamic Therapy 12 (2015) 325–375 375 (19%/n=5). The area of the lesions ranged from 3 to 48 cm2, with a mean of 14.7cm2. A total responsewas observed in 69% of the cases (18). In the eight remained lesions (30%) was observed a reduction of at least 50% of the area. This study shows an important contribution of PDT treatment in large area lesions, avoiding surgery for big reconstructions flaps or grafts in old patients with comorbidities. http://dx.doi.org/10.1016/j.pdpdt.2015.07.194 Longterm follow-up of nodular basal cell carcinoma after Photodynamic Therapy Ana Gabriela Salvio1, Elisangela Ramos de Oliveira1, Dora Patricia Ramirez2, Natalia Mayumi Inada2, Cristina Kurachi2, Vanderlei Salvador Bagnato2 1 Skin Department of Amaral Carvalho Hospital, Brazil 2 Sao Carlos Institute of Physics University of Sao Paulo, Brazil Studies about the long-term follow-up of nodular basal cell carcinoma (nBCC) underwent through photodynamic therapy is few reported. This clinical research describes a total of 56 cases of nBCC less than 1 cm diagnosed and treated during 2010 and 2011 at Amaral CarvalhoHospitalwith Photodynamic Therapy (PDT) (topic 15%MAL-PDT, illuminated at 630 nmwith a total delivered energy of 100 J/cm2). Most of the nBCC were located at head and neck area (57%/n=32) followed by trunk (30%/n=17) and upper limbs (13%/n=7). During a total time follow up of 53 months (with a median follow up of 30,8 months (0 to 53 months), the recurrence was observed in only 5% of the patients and it occurred in the first 14 months of follow up. For this group it can be considered a free disease follow up of 93.7%. It can be concluded that PDT for nodular BCC is safe treatment with low rates of late recurrence. http://dx.doi.org/10.1016/j.pdpdt.2015.07.195 Reduction in surgical procedures in patients with Gorlin syndrome when management associated with Topical Photodynamic therapy: report of two cases Ana Gabriela Salvio1, Dora Patricia Ramirez2, Elisangela Ramos de Oliveira1, Natalia Mayumi Inada2, Cristina Kurachi2, Vanderlei Salvador Bagnato2 1 Skin Department of Amaral Carvalho Hospital, Brazil 2 Sao Carlos Institute of Physics University of Sao

There aremany studies to achieve the ideal irradiance anddelivered energy during the photodynamic therapy for nodular basal cell carcinoma (BCCn). The aim of this study was a comparison of two different clinical protocols: it was selected 200 patients with BCCn less than 1 cm of diameter. A cream containing 15% MAL (methyl aminolevulinate, PDTPharma, Brazil)was applied and after three hours the lesions were illuminated using the device LINCE® (MMOptics, Sao Carlos-SP, Brazil) developed by a Brazilian project with financial support of the Brazilian Development Bank (BNDES). A hundred lesions received the PDT treatment with an irradiance of 100 mW/cm2 for 17 minutes, (100 J/cm2). The other 100 BCC lesions received an irradiance of 125mW/cm2 for 20minutes, (150 J/cm2). Another treatment session was performed after one week. After 30 days, the lesions were evaluated and taken for a biopsy. The 30rd day biopsy showed 77% and 88% of complete response for the 100 J/cm2 and 150 J/cm2, respectively. The comparison of these two clinical protocols shows that the better response leads to the use of 150 J/cm2 delivered energy for BCCn treatment.

s / Photodiagnosis and Photodynamic Therapy 12 (2015) 325–375 375 (19%/n=5). The area of the lesions ranged from 3 to 48 cm2, with a mean of 14.7cm2. A total responsewas observed in 69% of the cases (18). In the eight remained lesions (30%) was observed a reduction of at least 50% of the area. This study shows an important contribution of PDT treatment in large area lesions, avoiding surgery for big reconstructions flaps or grafts in old patients with comorbidities. http://dx.doi.org/10.1016/j.pdpdt.2015.07.194 Longterm follow-up of nodular basal cell carcinoma after Photodynamic Therapy Ana Gabriela Salvio1, Elisangela Ramos de Oliveira1, Dora Patricia Ramirez2, Natalia Mayumi Inada2, Cristina Kurachi2, Vanderlei Salvador Bagnato2 1 Skin Department of Amaral Carvalho Hospital, Brazil 2 Sao Carlos Institute of Physics University of Sao Paulo, Brazil Studies about the long-term follow-up of nodular basal cell carcinoma (nBCC) underwent through photodynamic therapy is few reported. This clinical research describes a total of 56 cases of nBCC less than 1 cm diagnosed and treated during 2010 and 2011 at Amaral CarvalhoHospitalwith Photodynamic Therapy (PDT) (topic 15%MAL-PDT, illuminated at 630 nmwith a total delivered energy of 100 J/cm2). Most of the nBCC were located at head and neck area (57%/n=32) followed by trunk (30%/n=17) and upper limbs (13%/n=7). During a total time follow up of 53 months (with a median follow up of 30,8 months (0 to 53 months), the recurrence was observed in only 5% of the patients and it occurred in the first 14 months of follow up. For this group it can be considered a free disease follow up of 93.7%. It can be concluded that PDT for nodular BCC is safe treatment with low rates of late recurrence. http://dx.doi.org/10.1016/j.pdpdt.2015.07.195 Reduction in surgical procedures in patients with Gorlin syndrome when management associated with Topical Photodynamic therapy: report of two cases Ana Gabriela Salvio1, Dora Patricia Ramirez2, Elisangela Ramos de Oliveira1, Natalia Mayumi Inada2, Cristina Kurachi2, Vanderlei Salvador Bagnato2 1 Skin Department of Amaral Carvalho Hospital, Brazil 2 Sao Carlos Institute of Physics University of Sao

There aremany studies to achieve the ideal irradiance anddelivered energy during the photodynamic therapy for nodular basal cell carcinoma (BCCn). The aim of this study was a comparison of two different clinical protocols: it was selected 200 patients with BCCn less than 1 cm of diameter. A cream containing 15% MAL (methyl aminolevulinate, PDTPharma, Brazil)was applied and after three hours the lesions were illuminated using the device LINCE® (MMOptics, Sao Carlos-SP, Brazil) developed by a Brazilian project with financial support of the Brazilian Development Bank (BNDES). A hundred lesions received the PDT treatment with an irradiance of 100 mW/cm2 for 17 minutes, (100 J/cm2). The other 100 BCC lesions received an irradiance of 125mW/cm2 for 20minutes, (150 J/cm2). Another treatment session was performed after one week. After 30 days, the lesions were evaluated and taken for a biopsy. The 30rd day biopsy showed 77% and 88% of complete response for the 100 J/cm2 and 150 J/cm2, respectively. The comparison of these two clinical protocols shows that the better response leads to the use of 150 J/cm2 delivered energy for BCCn treatment.

Many studies in literature try to define the best photosensitizer used in photodynamic therapy (PDT) for the treatment of basal cell carcinoma (BCC). In this study it was selected 378 patients with nodular BCC and divided in two groups. The first group (n=189) had their lesions curetted and treated with 20% MAL (methyl aminolevulinate, PDTPharma, Brazil), and the other with 20% ALA (aminolevulinic acid, PDTPharma, Brazil). All the lesions were illuminated using the device LINCE® (MMOptics, Sao Carlos-SP, Brazil) and received an irradiance of 125 mW/cm2 for 20 minutes, (150 J/cm2). After treatment they had a 6 month follow up. The group treated with MAL PDT had a complete response of 86%, and the ALA PDT had 90%. The 6 months follow up showed 1% recurrence for the ALA group and 2% for the MAL group. The difference has no statistical significance. According to these data, there is no difference in cure rates when using ALA nor MAL PDT for nodular basal cell carcinoma treatment.

There aremany studies to achieve the ideal irradiance anddelivered energy during the photodynamic therapy for nodular basal cell carcinoma (BCCn). The aim of this study was a comparison of two different clinical protocols: it was selected 200 patients with BCCn less than 1 cm of diameter. A cream containing 15% MAL (methyl aminolevulinate, PDTPharma, Brazil)was applied and after three hours the lesions were illuminated using the device LINCE® (MMOptics, Sao Carlos-SP, Brazil) developed by a Brazilian project with financial support of the Brazilian Development Bank (BNDES). A hundred lesions received the PDT treatment with an irradiance of 100 mW/cm2 for 17 minutes, (100 J/cm2). The other 100 BCC lesions received an irradiance of 125mW/cm2 for 20minutes, (150 J/cm2). Another treatment session was performed after one week. After 30 days, the lesions were evaluated and taken for a biopsy. The 30rd day biopsy showed 77% and 88% of complete response for the 100 J/cm2 and 150 J/cm2, respectively. The comparison of these two clinical protocols shows that the better response leads to the use of 150 J/cm2 delivered energy for BCCn treatment.