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Synergism between narrowband ultraviolet B phototherapy and etanercept for the treatment of plaque‐type psoriasis

The implementation of a new morphological technique in dermatology always takes a bit of time, as we have learned from dermoscopy (dermatoscopy) in the past two decades. Now, it seems that reflectance confocal microscopy (RCM) for skin diseases (cutaneous confocal microscopy or in vivo confocal microscopy of the skin) is coming of age as witnessed by a growing number of publications including two textbooks. Probably more relevant is the increasing use of the ‘confocal microscope’ for the diagnosis of equivocal skin neoplasms by dermatologists at the ‘coalface’ in public and private settings all over the world. In this edition of the BJD, Caterina Longo and colleagues from Modena, Italy, present a study of 140 nodular skin lesions in order to address the widely perceived belief that RCM does not allow an accurate interpretation of these nodular lesions. Their task is comparable to a dermatopathology study of nodular lesions when only shave biopsies with a standard depth of 150 lm are available. Remarkably, the authors found that 121 out of 140 (86%) nodular lesions had been correctly diagnosed as compared against histopathology, which served as the practical reference standard. And most relevant, the diagnosis of nodular melanoma was achieved with a 96 5% sensitivity and 94 1% specificity (area under the curve 0 970; 95% confidence interval 0 924–1 015; P < 0 001). Without being too critical we address two points. Firstly, not every nodule is assessable. Only nodules located in the superficial dermis (and the authors very carefully just selected those) can be meaningfully assessed by RCM. The deeper-seated nodules in the deep dermis and/or subcutis can be assessed neither by RCM nor with shave biopsies followed by conventional dermatopathology. Neurofibroma, leiomyoma and lipoma are examples of benign cutaneous/subcutaneous nodules, and dermatofibrosarcoma protuberans, leiomyosarcoma and solitary B-cell lymphomas are archetypes of rarer cutaneous/subcutaneous malignant nodules falling into this category. Secondly, the quest for prospective multicentre studies in RCM – there is a need for prospective studies in general focused on RCM if this exciting technique is to stand the test of time; the authors of course have addressed this point. The fast-paced technical evolution in the field of biophotonics will lead to more powerful and user-friendly confocal microscopy devices, which will become more affordable. Moreover, RCM is well suited for automated image analysis leading to computer-aided diagnosis of RCM images, which can be used for an expert second opinion as well as for training purposes. RCM will become a linchpin in the morphological evaluation of neoplastic skin diseases including nodular lesions that are located in the superficial dermis.