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Reflectance confocal microscopy for better management of cutaneous pink lesions

Insights into the usefulness of new techniques for noninvasive diagnosis of skin lesions in daily practice are always welcome and this is even more valid in the case of solitary cutaneous ‘pink lesions’, which represent one of the most intriguing and challenging diagnostic dilemmas in dermatology. Although dermoscopy is useful in the differentiation of pink skin lesions, in specific cases it lacks distinctive diagnostic criteria even in experienced hands. Obviously missing the diagnosis of an amelanotic melanoma is the elephant in the room and pitfalls in the clinical and dermoscopic diagnosis of pink lesions are legendary. Reflectance confocal microscopy (RCM) is a relatively new noninvasive technique demonstrated to increase specificity in the diagnosis of skin cancer. Due to its high lateral resolution and quasi-histology image quality, RCM opens up a new dimension in the presurgical interpretation of pink lesions. In this issue of the BJD, Caterina Longo and colleagues describe, in a meticulous and rigorous review, the RCM features for the differential diagnosis of solitary pink lesions. The authors detail the advantages of the use of RCM in fast, real-time identification of the melanocytic, epithelial or vascular differentiation of a given lesion. However, they also describe how the absence of pigment decreases the quality of confocal imaging, with diagnostic features becoming subtle and difficult to detect. In this context, we cannot emphasize enough the relevance of formal training in RCM in order to minimize human error in diagnosis, which is well known in conventional pathology and will certainly also occur with RCM. Because diagnostic RCM has come into use only recently, this aspect has not been widely published. In addition, there are a few inherent reasons making diagnostic confocal clues difficult to detect, including acanthosis, ulceration and hyperkeratosis characterizing some pink lesions, such as seborrhoeic keratoses, basal cell carcinomas or Spitz naevi, as well as some inflammatory skin conditions. These issues can be addressed by preselection of the lesions or pretreatment with keratolytic ointments; however, they remain a drawback to the wider implementation of RCM. Inflammatory skin diseases, although not normally presenting as single lesions, must be kept in consideration in the differential diagnosis with pink neoplastic tumours. A typical example for this differential diagnostic predicament is a solitary psoriasis lesion vs. Bowen disease on the lower leg. While assessment of inflammatory skin diseases with RCM is an increasing topic of interest, well-designed clinical studies are still necessary to create adequate guidelines and protocols for further implementation of RCM in clinical practice. Despite the limitations of both RCM and dermoscopy, their synergistic use will increase the diagnostic accuracy of solitary pink lesions with better identification of malignant neoplasms and ultimately will improve patient experience and reduce skin cancer morbidity and, hopefully, mortality. In conclusion, from a purely selfish dermatologists’ perspective, embracing new imaging technologies for diagnosing and managing neoplastic and inflammatory skin diseases is necessary in order to be at the forefront of the exciting technology revolution in medicine in the 21st century. In this spirit we commend Caterina Longo and colleagues for their insightful review.