Ultrasonography > Volume 42(3); 2023 > Article
Wortsman: Re: Expanding dermatologic ultrasonography applications: further insights for enhanced patient management
I read with great interest the recently published letter to the editor by Dr. Mese [1], and I agree that the applications of dermatologic ultrasound have grown exponentially during the last decade, as also mentioned in our article that was recently published in Ultrasonography [2].
As Dr. Mese pointed out, there are numerous applications in what is called "soft tissues ultrasonography" that can extend beyond dermatology. Although we were not able to fully address these applications in our article due to space restrictions; multiple publications and books have extensively discussed them [2-7].
I would like to make a few comments on the ultrasonographic descriptions presented by Dr. Mese [1]. One of them relates to the ultrasonographic appearance of lipomas, because this depends on the type of tissues mixed with the fat. If the lipoma is intermixed with fibrous tissue, it is called fibrolipoma, which usually appears as an oval, well-defined, hypoechoic, hypodermal structure that tends to follow the axis of the skin layers. If capillary vessels are present throughout the fat, it is called angiolipoma, which tends to manifest as a round or oval hyperechoic structure [5,7]. Posterior acoustic enhancement is not prominent in these structures compared to cystic lesions, and they usually do not generate a posterior acoustic enhancement artifact [8,9].
The ultrasonographic appearance of foreign bodies depends on their organic or inert nature; both of these usually present as linear hyperechoic structures, but inert foreign bodies such as metal or glass generate a posterior acoustic reverberation. Hypoechoic tissue in the periphery of a foreign body due to inflammation and granulomatous tissue is commonly seen [5,7].
One of the most prominent characteristics of warts is the fusiform shape, which accompanies their hypoechoic epidermal and dermal structure [4,5,7].
Regarding cutaneous psoriasis, epidermal thickening and undulation are frequently present, as well as dermal hypoechogenicity due to inflammation. In my experience and as far as I know, the literature contains no reports of dermal hyperechogenicity in psoriasis. Furthermore, dermal echogenicity is inverted under inflammation and frequently transitions from normal hyperechogenicity to a hypoechoic inflamed stage [5,7,10].
Last but not least, I would like to deeply thank Dr. Mese for bringing valuable information to the discussion.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

References

1. Mese I. Expanding dermatologic ultrasonography applications: further insights for enhanced patient management. Ultrasonography 2023;42:474–475.
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2. Wortsman X. Top applications of dermatologic ultrasonography that can modify management. Ultrasonography 2023;42:183–202.
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3. Almuhanna N, Wortsman X, Wohlmuth-Wieser I, Kinoshita-Ise M, Alhusayen R. Overview of ultrasound imaging applications in dermatology [formula: see text]. J Cutan Med Surg 2021;25:521–529.
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4. Wortsman X. Common applications of dermatologic sonography. J Ultrasound Med 2012;31:97–111.
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5. Wortsman X. Atlas of dermatologic ultrasound. New York: Springer, 2018.

6. Wortsman X. Top advances in dermatologic ultrasound. J Ultrasound Med 2023;42:521–545.
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7. Wortsman X. Textbook of dermatologic ultrasound. Cham: Springer, 2022.

8. Huang CC, Ko SF, Huang HY, Ng SH, Lee TY, Lee YW, et al. Epidermal cysts in the superficial soft tissue: sonographic features with an emphasis on the pseudotestis pattern. J Ultrasound Med 2011;30:11–17.

9. Yuan WH, Hsu HC, Lai YC, Chou YH, Li AF. Differences in sonographic features of ruptured and unruptured epidermal cysts. J Ultrasound Med 2012;31:265–272.
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10. Gutierrez M, Wortsman X, Filippucci E, De Angelis R, Filosa G, Grassi W. High-frequency sonography in the evaluation of psoriasis: nail and skin involvement. J Ultrasound Med 2009;28:1569–1574.

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