Dermoscopy: Vu A. Ngo, DO Department of Family Recognizing Top Five Common In‐ Medicine and Dermatology Choctaw Nation Health Office Diagnoses Services Authority
1 • Introduction to dermoscopy • Understanding polarized and non‐ polarized dermoscopy • Learn the 2‐Step Algorithm • Recognize several basic patterns of common lesions • Basal Cell Carcinoma, • Squamous Cell Carcinoma, • Dermatofibroma, • Seborrheic Keratosis, and • Hemangioma • Common Mole vs Melanoma features Learning Objectives • 3‐Point Checklist
Question 1
A. Pigmented Actinic Keratosis B. Seborrheic Keratosis C. Spitz Nevus D. Melanoma E. Pigmented Basal Cell Carcinoma
2 Question 2
A. Actinic Keratosis B. Pink Nevus C. Squamous Cell Carcinoma D. Amelanotic Melanoma E. Pigmented Basal Cell Carcinoma
http://www.ijdvl.com/viewimage.asp?img=ijdvl_2011_77_1_16_74966_f7.jpg
Question 3
A. Pigmented Actinic Keratosis B. Seborrheic Keratosis C. Dysplastic Nevus D. Melanoma E. Pigmented Basal Cell Carcinoma
3 Dermoscope/Dermatoscope
Introduction to Dermoscopy
• Dermoscope • Magnification x10 • Clarity • Visualization of subsurface skin structures • Epidermis • Dermoepidermal Junction • Papillary Dermis • Benefits of Dermoscopy • Increase accuracy, sensitivity, and specificity for skin cancer* • Sensitivity to diagnose melanoma is 85% vs 60‐80% (without) • Early Detection • Reduce unnecessary skin biopsy and excision
*Johr, Robert, Dermoscopy: An Illustrated Self‐Assessment Guide, McGraw‐Hill Education, 2010
4 Normal Skin Layers
Stratum Corneum
Epidermis
Papillary Dermal Junction
Dermis
http://slideplayer.com/slide/3878772/13/images/6/Histology+review+(no+labels)%E2%80%8F.jpg
Without Dermoscope
Epidermis
Dermis
5 Nonpolarized Dermoscopy
Epidermis
Dermis
http://cdn.shopify.com/s/files/1/0253/1565/files/PigmentBoost_f7624ebc‐44d0‐49a8‐b67d‐f9d66e16451b.jpg?13384542420101064838
Polarized Dermoscopy
Epidermis
Dermis
http://cdn.shopify.com/s/files/1/0253/1565/files/PigmentBoost_f7624ebc‐44d0‐49a8‐b67d‐f9d66e16451b.jpg?13384542420101064838
6 Polarized vs Non‐polarized Dermoscopy Non‐Polarized Polarized • Superificial structures and colors • Deep layer of epidermis and papillary • Blue white –orthokeratosis or dermis, and dermis regression • Melanin, Red/Pink, Crysalis or white • Milia‐like cyst scar, vessels
Network Patterns
7 Colors
Yellow
Black
Epidermis
Brown
Dermis Blue
Red
8 The 2‐Step Algorithm
Pigmented Skin Lesion
Non‐ Step 1 Melanocytic Melanocytic
Step 1 ‐ Criteria for a Melanocytic Lesion
Pigment Negative Branched Aggregated Network Network or Streaks Globules
9 Step 1 ‐ Criteria for a Melanocytic Lesion
Peripheral Homogeneous Angulated rim of Parallel Blue Pigmentation Lines globules Pattern
The 2‐Step Algorithm
Skin Lesion
Non‐ Step 1 Melanocytic Melanocytic
Step 2 Nevus Melanoma
10 The 2‐Step Algorithm
Skin Lesion
Step 1 Melanocytic Non‐Melanocytic
BENIGN MALIGNANT 1. Dermatofibroma 1. Basal Cell Carcinoma 2. Seborrheic Keratosis 2. Squamous Cell 3. Hemagioma Carcinoma Step 2 Nevus Melanoma
Case 1
11 Criteria for a Melanocytic Lesion
Pigment Peripheral rim of Homogeneous Parallel Network globules Blue Pigmentation Pattern
Angulated Negative Branched Aggregated Lines Network or Streaks Globules
The 2‐Step Algorithm
Skin Lesion
Step 1 Non‐Melanocytic
BENIGN MALIGNANT 1. Dermatofibroma 1. Basal Cell Carcinoma 2. Seborrheic Keratosis 2. Squamous Cell 3. Hemagioma Carcinoma
12 Rough Surface Lesions
https://coursewareobjects.elsevier.com/objects/elr/ExpertConsult/Habif/dermatology6e/IC/
Smooth Surface Lesions
https://coursewareobjects.elsevier.com/objects/elr/ExpertConsult/Habif/dermatology6e/IC/
13 Diagram showing dermoscopic features of seborrheic keratosis [Marghoob]
14 Pretest – Question 1
A. Pigmented Actinic Keratosis B. Seborrheic Keratosis C. Spitz Nevus D. Melanoma E. Pigmented Basal Cell Carcinoma
15 Case 2
http://www.ijdvl.com/viewimage.asp?img=ijdvl_2011_77_1_16_74966_f7.jpg
16 Pretest – Question 2
A. Actinic Keratosis B. Pink Nevus C. Squamous Cell Carcinoma D. Amelanotic Melanoma E. Pigmented Basal Cell Carcinoma
http://www.ijdvl.com/viewimage.asp?img=ijdvl_2011_77_1_16_74966_f7.jpg
Basal Cell Carcinoma
‐ Most Common malignant cutaneous neoplasm found in humans ‐ 85% appear on the head and neck region ‐ 25% ‐ 30% occur on the nose alone (most common site) ‐ Main Risk Factor is ultraviolet light exposure UVB>UVA ‐ Slow Growing ‐ Spontaneous Bleeding or Ulceration ‐ Arise from basal keratinocytes of the epidermis and adnexal structure. ‐ Five types ‐ Nodular, superficial, micronodular, infiltrative, morpheaform
17 Nodular Basal Cell Carcinoma
•Most common type of facial BCC •May have central depression or ulceration •Shiny or pearly nodule with a smooth surface •Blood vessels cross its surface
Superficial Basal Cell Carcinoma
18 Basal Cell Carcinomas
Sensitivity Specificity (%) (%) Arborizing Telengiectasia 52 77|92
Leaf‐like Structures 17 100|100
Large Blue‐Gray Ovoid Nests 55 97|99
Multiple Glue‐Gray Globules 27 87|97
Spoke‐Wheel‐Like Structures 10 100|100
Ulceration 27 87|97
Sensitivity and Specificity of Dermoscopic Structures for Pigmented Basal Cell Carcinoma (Menzies et al., 2000)
Large Blue‐Gray Ovoid Nests
Spoke‐Wheel‐Like Structures Multiple Glue‐Gray Globules
Ulceration Arborizing Telengiectasia Leaf‐like Structures
19 Arborizing Telengiectasia
Ulceration
Large Blue‐Gray Ovoid Nests
NonPigmented Basal Cell Carcinomas
Arborizing Telangiectasia Shallow Erosions Shiny White Areas
20 Arborizing Telengiectasia
Spoke‐Wheel‐Like Structures
Leaf‐Like Structures Large Blue‐Gray Ovoid Nests http://www.ijdvl.com/viewimage.asp?img=ijdvl_2011_77_1_16_74966_f7.jpg
Case 3
https://www.dermnetnz.org/topics/actinic‐keratosis‐scalp‐images
21 Actinic Keratosis
• Actinic Keratosis, Bowen’s Disease, Keratoacanthoma, Squamous Cell Carcinoma • Majority are nonpigmented. • Dermoscopic diagnosis is based mainly on the assessment of vascular pattern • Nonspecific features • Erythema, scale, erosion, or keratin. • Nonpigmented Actinic Keratosis –More common • Pigmented Actinic Keratosis –Less common
https://coursewareobjects.elsevier.com/objects/elr/ExpertConsult/Habif/dermatology6e/IC/jpg/Chapter21/021013g.jpg
Nonpigmented Actinic Keratosis
FIVE FEATURES 1. Pink to Red Background 2. White to Yellow Scale 3. White circles surrounding yellow clod ‐ Hair follicle filled with keratotic plug, ‐ Surround by white halo ‐ “Strawberry Pattern” 4. Wavy vessel surrounding the hair follicles 5. Rosette’s sign
22 Pink to Red Background
Wavy vessels
White circles surrounding yellow clod
White to Yellow Scale
http://bp0.blogger.com/_dkQl_rw5Svc/SEJTknsaezI/AAAAAAAAHks/gKm2X9CchnY/s1600/A1.jpg
Rosette Sign
https://www.medicaljournals.se/acta/content/html/10.2340/00015555‐2720 https://jamanetwork.com/data/Journals/DERM/5207/dsk80011f2.png
23 Actinic Keratosis vs Squamous Cell Carcinoma
All Features of Actinic Keratosis PLUS ‐ Polymorphous vessels ‐ Linear or serpentine ‐ Hairpin or Looped ‐ Glomerular or Coiled ‐ Dotted
Squamous Cell Carcinoma
‐ Linear or serpentine
Dotted
Hairpin or Looped https://www.dermnetnz.org/assets/Uploads/lesions/scc‐in‐situ/_resampled/FitWzY0MCw0ODBd/2917.jpg https://www.dermnetnz.org/assets/Uploads/lesions/scc‐in‐situ/_resampled/FitWzY0MCw0ODBd/2954.jpg
24 Case 4
25 Dermatofibroma
26 The 2‐Step Algorithm
Skin Lesion
Step 1 Melanocytic Non‐Melanocytic
BENIGN MALIGNANT 1. Dermatofibroma 1. Basal Cell Carcinoma 2. Seborrheic Keratosis 2. Squamous Cell 3. Hemagioma Carcinoma Step 2 Nevus Melanoma
Hemangioma
• Benign proliferations of blood vessels
27 Lacunae in Hemangioma
The 2‐Step Algorithm
Skin Lesion
Step 1 Melanocytic Non‐Melanocytic
BENIGN MALIGNANT 1. Dermatofibroma 1. Basal Cell Carcinoma 2. Seborrheic Keratosis 2. Squamous Cell 3. Hemagioma Carcinoma Step 2 Nevus Melanoma
28 The 2‐Step Algorithm
Step 1 Melanocytic How?
Step 2 Nevus Melanoma
Suspicious
Benign Patterns
Pigment Central Central Network Hypopigmentation Hyperpigmentation
Aggregated Central Homogeneous Globules Hypopigmentation Pigmentation
29 Melanoma Specific Structures
Atypical Off‐Centered Blue‐White Regression Network Blotch Veil Structures
Atypical Dots Negative Branched Crystalline and Globules Network or Streaks Structures
Pattern Analysis
• The ABCD rule of dermoscopy • The 11‐point checklist • The 7‐point checklist • The 3‐point checklist • Asymmetry of color and/or structure • Irregular pigment network • Blue and/or white color • 2 out 3 => Biopsy • 3 out 3 => Excise
30 Asymmetry of color and/or structure
Irregular pigment network
Blue and/or white color
Asymmetry of color and/or structure
Irregular pigment network
Blue and/or white color
31 Melanoma in Situ
Asymmetry of color and/or structure
Irregular pigment network
Blue and/or white color
Asymmetry of color and/or structure
Irregular pigment network
Blue and/or white color
32 Question 3
Asymmetry of color and/or Atypical dots and globules structure
Irregular pigment network
Blue and/or white color
Summary
• Polarized Light vs Nonpolarized Dermoscopy provide complimentary information. • Learn the 2‐Step Algorithm: Melanocytic and Non‐melanocytic lesions • Recognize several basic patterns of common lesions • Basal Cell Carcinoma, • Actinic keratosis => Squamous Cell Carcinoma, • Dermatofibroma, • Seborrheic Keratosis, and • Hemangioma • Common Mole Features and Common Melanoma features • Practice 3‐Point Checklist
33 References
1. Habif, T. Clinical Dermatology. A Color guide to Diagnosis and Therapy. Sixth Edition.2016 2. Kittler H, et al. Diagnostic accuracy of dermoscopy. Lancet Oncol. 2002;3(3) 159‐165 3. Marghoob, Atlas of Dermoscopy, 2nd edition, Informa healthcare, 2012 4. Malvehy, Dermoscopy, Confocal Microscopy and other Non‐invasive Tools for the Diagnosis of Non‐Melanoma 5. Skin Cancers and Other Skin Conditions, Acta Derm Venereol 2017; Suppl 218: 22–30. 6. Johr, Robert, Dermoscopy: An Illustrated Self‐Assessment Guide, McGraw‐Hill Education, 2010
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