Dermoscopy: Recognizing Top Five Common In- Office Diagnoses

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1 Dermoscopy: Recognizing Top Five Common In- Office Diagnoses Vu A. Ngo, DO Department of Family Medicine and Dermatology Choctaw Nation Health Services Authority

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3 Learning Objectives Introduction to dermoscopy Understanding polarized and nonpolarized 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 3-Point Checklist

4 Question 1 A. Pigmented Actinic Keratosis B. Seborrheic Keratosis C. Spitz Nevus D. Melanoma E. Pigmented Basal Cell Carcinoma

5 Question 2 A. Actinic Keratosis B. Pink Nevus C. Squamous Cell Carcinoma D. Amelanotic Melanoma E. Pigmented Basal Cell Carcinoma

6 Question 3 A. Pigmented Actinic Keratosis B. Seborrheic Keratosis C. Dysplastic Nevus D. Melanoma E. Pigmented Basal Cell Carcinoma

7 Dermoscope/Dermatoscope

8 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

9 Normal Skin Layers Stratum Corneum Epidermis Papillary Dermal Junction Dermis

10 Without Dermoscope Epidermis Dermis

11 Nonpolarized Dermoscopy Epidermis Dermis

12 Polarized Dermoscopy Epidermis Dermis

13 Polarized vs Non-polarized Dermoscopy Non-Polarized Superificial structures and colors Blue white orthokeratosis or regression Milia-like cyst Polarized Deep layer of epidermis and papillary dermis, and dermis Melanin, Red/Pink, Crysalis or white scar, vessels

14 Network Patterns

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16 Colors Yellow Black Epidermis Brown Dermis Blue Red

17 The 2-Step Algorithm Pigmented Skin Lesion Step 1 Melanocytic Non- Melanocytic

18 Step 1 - Criteria for a Melanocytic Lesion Pigment Network Negative Network Branched or Streaks Aggregated Globules

19 Step 1 - Criteria for a Melanocytic Lesion Angulated Lines Peripheral rim of globules Homogeneous Blue Pigmentation Parallel Pattern

20 The 2-Step Algorithm Skin Lesion Step 1 Melanocytic Non- Melanocytic Step 2 Nevus Melanoma

21 The 2-Step Algorithm Skin Lesion Step 1 Melanocytic Non-Melanocytic Step 2 Nevus Melanoma BENIGN 1. Dermatofibroma 2. Seborrheic Keratosis 3. Hemagioma MALIGNANT 1. Basal Cell Carcinoma 2. Squamous Cell Carcinoma

22 Case 1

23 Criteria for a Melanocytic Lesion Pigment Network Peripheral rim of globules Homogeneous Blue Pigmentation Parallel Pattern Angulated Lines Negative Network Branched or Streaks Aggregated Globules

24 The 2-Step Algorithm Skin Lesion Step 1 Non-Melanocytic BENIGN 1. Dermatofibroma 2. Seborrheic Keratosis 3. Hemagioma MALIGNANT 1. Basal Cell Carcinoma 2. Squamous Cell Carcinoma

25 Rough Surface Lesions

26 Smooth Surface Lesions

27 Diagram showing dermoscopic features of seborrheic keratosis [Marghoob]

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30 Pretest Question 1 A. Pigmented Actinic Keratosis B. Seborrheic Keratosis C. Spitz Nevus D. Melanoma E. Pigmented Basal Cell Carcinoma

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32 Case 2

33 Pretest Question 2 A. Actinic Keratosis B. Pink Nevus C. Squamous Cell Carcinoma D. Amelanotic Melanoma E. Pigmented Basal Cell Carcinoma

34 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

35 Nodular Basal Cell Carcinoma Most common type of facial BCC Shiny or pearly nodule with a smooth surface May have central depression or ulceration Blood vessels cross its surface

36 Superficial Basal Cell Carcinoma

37 Basal Cell Carcinomas Sensitivity (%) Specificity (%) Arborizing Telengiectasia Leaf-like Structures Large Blue-Gray Ovoid Nests Multiple Glue-Gray Globules Spoke-Wheel-Like Structures Ulceration Sensitivity and Specificity of Dermoscopic Structures for Pigmented Basal Cell Carcinoma (Menzies et al., 2000)

38 Large Blue-Gray Ovoid Nests Spoke-Wheel-Like Structures Multiple Glue-Gray Globules Ulceration Arborizing Telengiectasia Leaf-like Structures

39 Arborizing Telengiectasia Ulceration Large Blue-Gray Ovoid Nests

40 NonPigmented Basal Cell Carcinomas Arborizing Telangiectasia Shallow Erosions Shiny White Areas

41 Arborizing Telengiectasia Spoke-Wheel-Like Structures Large Blue-Gray Ovoid Nests Leaf-Like Structures

42 Case 3

43 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

44 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

45 Pink to Red Background Wavy vessels White circles surrounding yellow clod White to Yellow Scale

46 Rosette Sign

47 Actinic Keratosis vs Squamous Cell Carcinoma All Features of Actinic Keratosis PLUS - Polymorphous vessels - Linear or serpentine - Hairpin or Looped - Glomerular or Coiled - Dotted

48 Squamous Cell Carcinoma - Linear or serpentine Dotted Hairpin or Looped

49 Case 4

50

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52 Dermatofibroma

53 The 2-Step Algorithm Skin Lesion Step 1 Melanocytic Non-Melanocytic Step 2 Nevus Melanoma BENIGN 1. Dermatofibroma 2. Seborrheic Keratosis 3. Hemagioma MALIGNANT 1. Basal Cell Carcinoma 2. Squamous Cell Carcinoma

54 Hemangioma Benign proliferations of blood vessels

55 Lacunae in Hemangioma

56 The 2-Step Algorithm Skin Lesion Step 1 Melanocytic Non-Melanocytic Step 2 Nevus Melanoma BENIGN 1. Dermatofibroma 2. Seborrheic Keratosis 3. Hemagioma MALIGNANT 1. Basal Cell Carcinoma 2. Squamous Cell Carcinoma

57 The 2-Step Algorithm Step 1 Melanocytic How? Step 2 Nevus Melanoma Suspicious

58 Benign Patterns Pigment Network Central Hypopigmentation Central Hyperpigmentation Aggregated Globules Central Hypopigmentation Homogeneous Pigmentation

59 Melanoma Specific Structures Atypical Network Off-Centered Blotch Blue-White Veil Regression Structures Atypical Dots and Globules Negative Network Branched or Streaks Crystalline Structures

60 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

61 Asymmetry of color and/or structure Irregular pigment network Blue and/or white color

62 Asymmetry of color and/or structure Irregular pigment network Blue and/or white color

63 Melanoma in Situ Asymmetry of color and/or structure Irregular pigment network Blue and/or white color

64 Asymmetry of color and/or structure Irregular pigment network Blue and/or white color

65 Question 3 Atypical dots and globules Asymmetry of color and/or structure Irregular pigment network Blue and/or white color

66 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

67 References 1. Habif, T. Clinical Dermatology. A Color guide to Diagnosis and Therapy. Sixth Edition Kittler H, et al. Diagnostic accuracy of dermoscopy. Lancet Oncol. 2002;3(3) Marghoob, Atlas of Dermoscopy, 2 nd edition, Informa healthcare, 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: Johr, Robert, Dermoscopy: An Illustrated Self-Assessment Guide, McGraw-Hill Education, 2010

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