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Pigmented Vulvar Lesions. Dermatoscopy. Is It Advisable?

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"ISSVD - International Society for the Study of Vulvovaginal Disease " PIGMENTED VULVAR LESIONS. DERMATOSCOPY. IS IT ADVISABLE? Damian Ferrario MD. Dermatology Department. Italian Hospital of Buenos Aires Without Conflic Interest PIGMENTED VULVAR LESIONS • Pigmented skin lesions in the vulvar area include nevi, melanoma, melanotic macules (lentiginosis, melanosis), angiokeratomas, seborrheic keratosis, SeborrHeic keratosis AMNGT squamous cell carcinoma, basal cell carcinoma (BCC). • Atypical melanocytic nevi of the genital type (AMNGT) and vulvar melanomas usually affect postmenopausal women and the prognosis is poor. Melanosis Melanoma Pigmented lesions of the vulva are present in 20% of the women who Have Had gynecological examination. Even thougH vulvar pigmented lesions Has a benign prognosis, it causes concern to the patient and to the pHysician, owing to its melanoma-liKe presentation. Vulvar melanosis is the most frequent lesion among these pigmented disorders... but COLPOSCOPY You examine a 40-year-old patient and detect a nevus in the upper labia majora. According to Her, she Has it since childHood. She does not remember whether it grew or not. It is asymptomatic. WHAT IS YOUR BEHAVIOR? A. Do nothing and continue the examination. B. Urgently refer the patient to a dermatologist telling her it may be a melanoma. C. Performing radical You examine a 40-year-old patient and detect a nevus in the region of the labia surgery for suspected majora. According to Her, she Has it since childHood. He does not remember melanoma. whether He grew up. It is asymptomatic. D. Take a biopsy. A. Do nothing and continue the examination. B. Urgently refer the patient to a dermatologist telling her it may be a melanoma. C. Performing radical You examine a 40-year-old patient and detect a nevus in the region of the labia surgery for suspected majora. According to Her, she Has it since childHood. He does not remember melanoma. whether He grew up. It is asymptomatic. D. Take a biopsy. IS DERMATOSCOPY ADVISABLE IN THIS VULVAR LESION? You examine a 40-year-old patient and detect a nevus in the region of the labia majora. According to Her, she Has it since childHood. He does not remember whether He grew up. It is asymptomatic. COLPOSCOPY DERMATOSCOPY What diagnostic data does dermoscopy give me? • Also known as surface microscopy or epiluminescent microscopy. • Dermoscopy is a technique that allows the visualization of pigmented cutaneous lesions in vivo right to the starting edge of the reticular dermis. THe polarized ligHt do not require the use of fluid systems and not necessary contact the skin. • It generates a beam of light that falls on the skin surface at an angle of 20°. • Placing a fluid (gel) at the interface between the epidermis and the device’s glass slide, light reflection is eliminated, allowing the visualization of the dermoscopic features. Allows you to see the different layers of the skin superimposed on a single image. AtropHy Contact dermatitis Erosions, bleeding In genitals is recommended to place gel. These lesions may alter dermoscopy. WHO OWNS THE VULVAR LESIONS? DERMATOLOGIST? GYNECOLOGIST? VULVAR EXAMINATION - GYNECOLOGISTS • Gynecologists are not trained in differential diagnosis of melanocytic lesions (skin and mucosa). • The vulvar examination with colposcopy… you have a partial view. Areas may remain unobserved. VULVAR EXAMINATION - GYNECOLOGISTS • Gynecologists are not trained in differential diagnosis of melanocytic lesions (skin and mucosa). • The vulvar examination with colposcopy… you have a partial view. Areas may remain unobserved. • To examine the vulva, a magnifying head glass is recommended. Large areas of the vulva can be visualized and hands free. Palpable focal lesion is a strong finding Stretch the sKin of suspected melanoma VULVAR EXAMINATION - DERMATOLOGISTS PROBLEMS • In most cases dermatologists do not examine vulvar region properly well, because they hasn’t got a gynecological stretcher. • During dermatoscopy physicians should be in close proximity with the dermatoscope. Leaving the head between patient legs. • They can use only one hand to move the It is necessary an assistant. labial folds of the vulva. VULVAR EXAMINATION - PROBLEMS No-contact dermatoscopy • Polarized dermoscopes can be used to examine lesions without the need to directly contact the mucosal surface. Stretch the skin • But if contact dermatoscopy is used, it is Contact dermatoscopy very likely that the lens will become dirty. • Any transparent plastic shield (such as plastic food wrap) placed between the lesion and the glass plate of the dermoscope will prevent contamination of the scope. Labial minor folds VULVAR EXAMINATION - VIDEODERMASCOPE • It allow a dermoscope probe to be placed on the lesion (contact dermoscopy) while the image is projected on a monitor. • It allows visualizing the lesion and it can be documented in photography to be compared in the second consultation. VULVAR EXAMINATION - VIDEODERMASCOPE • It allow a dermoscope probe to be placed on the lesion (contact dermoscopy) while the image is projected on a monitor. • It allows visualizing the lesion and it can be documented in photography to be compared in the second consultation. • Dermoscopy attachments exist for cell phones that allow image capture and videodermoscopy with the screen of the cell phone acting as a monitor. Are the dermatoscopical patterns differed in the mucosal pigmented lesions? • Dermoscopy plays an potencial role in the diagnosis of suspicious large pigmented lesions or in thin lesions with a diameter less than 6 mm. • Identifying the different dermatoscopic patterns observed on vulvar pigmented lesions, alows to define the best site to perform the biopsy. DERMATOSCOPIC PATTERNS D Globular and paralell Cobblestone C (‘fingerprint-liKe’) A B A Polycircular Pararell B C D Melanosis on the labia minora showing a parallel pattern (uniform linear and curved structures) Common melanocytic nevus showing a structureless pattern Globular pattern Parallel pattern Ring-like pattern CobblestoneliKe Parallel pattern with pattern curved streaks Irregular vessels WHite veil THree or more colours Blue-whitish veil Multicomponent pattern Variables that were strongly related to melanoma THick reticular-liKe and projections Structureless (or Homogeneous) Blue-white veil, irregular black dots Irregular globular and areas of reticular depigmentation (cobblestone) DERMATOSCOPY AND VULVAR AREA • Dermoscopy is a complementary diagnostic method. • It may be helpful in the diagnosis and management of benign and malignant pigmented skin tumors. • It should be based on a good clinic - dermoscopic and histologic correlation. DERMATOSCOPY AND VULVAR AREA • Identifying the different dermatoscopic patterns observed on vulvar pigmented lesions, alows to define the best site to perform the biopsy • Any lesion suspected of being a melanoma should be confirmed by histopathology. • But…The most important message I want to leave today is… THE GREAT WALL OF VAGINA - JAMIE MC CARTNEY GYNECOLOGIST THE SECRET IS “TEAM WORK” DERMATOLOGIST PATHOLOGIST .
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