10/3/2018. Dermoscopy: Looking beneath the surface of the skin. Dermoscopy for Family Medicine 10/11/2018

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1 Dermoscopy for Family Medicine 10/11/2018 Jane M. Grant-Kels, MD, FAAD Founding Chair Emeritus, Dept of Dermatology Professor of Dermatology, Pathology & Pediatrics Director of the Cut Oncology Ctr & Melanoma Program UCONN Health Conflicts of Interest: NONE Thanks to Cliff Rosendahl MBBS PhD Associate Professor The University of Queensland Australia for sharing cases & devising a simple technique for Dermoscopy Family Physician Queensland, Australia Lecturer, School of Medicine, The University of Queensland, Brisbane, Australia Dermoscopy: Looking beneath the surface of the skin = Clinical Exam Addition of 70% alcohol Most of light does not penetrate stratum corneum. Only structures on the superficial skin surface are visualized. Structures deep in the skin are not seen. 1

2 Light reaches melanocytes along the rete ridges. Application of the non-polarized dermatoscope oil light Glass plate Globules Light reaches the nests of melanocytes. Networks Vessels Light reaches the vessels. Clinical Image Dermoscopy Image Why Dermoscopy? We want to bx MMs, BCCs, SCCs We do not want to bx Aks We do not want to bx DN To find one melanoma you have to excise 200,000 nevi Dermoscopy improves the Benign/Malignant ratio from 14:1 to 5:1 Tsao H, Bevona C, Goggins W, Quinn T. The transformation rate of moles (melanocytic nevi) into cutaneous melanoma: a population-based estimate. Arch Dermatol Mar;139(3): Dermatopathology Report Diagnosis: Seborrheic Keratosis Note: There is no evidence of a malignancy. Margins are clear. 2

3 Dermoscopy Uses Pattern Analysis The chaos factor Natural laws favor symmetry Pattern + Colors + Clues = Dx Pattern + Colors + Clues = Dx A pattern is made up of multiple repetitions of a basic structure It should cover a significant area (at least 25-30%) There are 5 basic structures Lines Pseudopods Circles Clods Dots 3

4 Lines Reticular Pseudopods Circles Clods Branched Parallel Radial Structures seen in Dermoscopy Dots Curved Black Brown Pattern + Colors + Clues = Dx Understanding colors in Dermatoscopy The Tyndall Effect Gray Blue Pattern + Colours + Clues = Dx Clues to a specific diagnosis Chaos & Clues Pattern + Colors + Clues(8) = Malignancy Clues to malignancy ( Chaos & Clues ) Chaos + Clues(8) = Malignancy (Asymmetry of structure or color) 4

5 CONCLUSIONS: Chaos & Clues Marghoob A, Korsenko A, Changchien L, Scope A, Braun R, Rabinovitz H.The Beauty and the Beast Sign in Dermoscopy. DermatolSurg 2007;33: CHAOS = Asymmetry of structure or color Sensitivity % Specificity % Chaos No chaos Judge on pattern and color, not on outline Symmetry/ Asymmetry Asymmetry: the distribution of colors and structures on either side of the axis whereby there is no mirror image. concentric = no chaos Be suspicious of combinations of more than one pattern or color 5

6 Benign lesions tend to have biaxial or monaxial symmetry. Malignant lesions tend to have biaxial asymmetry Biaxial Symmetry Monaxial Symmetry Biaxial Asymmetry Symmetry of SHAPE (but asymmetry of pattern) Symmetry / Asymmetry Symmetry of PATTERN (but asymmetry of shape) Symmetry/ Asymmetry Symmetry: the distribution of colors & structures on either side of the axis to produce a mirror image. It does not refer to the shape of the lesion! Clinically = symmetric lesion; dermoscopically = asymmetric Clinically = asymmetric lesion; dermoscopically = symmetric Examples -Symmetry in pattern -No symmetry of shape (asymmetric shape) -Dermoscopy = symmetric lesion! -No symmetry in pattern (asymmetric pattern) -Symmetry of shape -Dermoscopy = asymmetric lesion! 6

7 Black Brown Gray Blue Red White Yellow Colors Benign lesions generally have 3 or less colors. The most common colors being light brown, dark brown, and black. Malignant lesions generally have more than 3 colors. Types of Dermatoscopes 2 types are available: 1. Non-polarized light (NPD) a. contact with skin b. liquid immersion: 70% alcohol is recommended (hygienic, fewer air bubbles) 2. Polarized light (PD) a. contact polarized dermoscopoy (CPD) b. non-contact polarized dermoscopy (NCP) Utilizes 2 filters to cancel out any light REFLECTED off the surface of the stratum corneum (& superficial light) Thus, with PD you are able to see deeper structures, however, superficial epidermal structures can sometimes be seen with less clarity NPD & PD use2 diff mechanisms & compliment each other Non-polarized Dermoscopy Contact with skin Liquid immersion needed Most images seen in atlases & lectures w/ this type of dermatoscope Best for superficial strucutures as ridges, fissures, milia-like cysts, comedo-like openings, gray dots/granules, blue white veil Polarized Dermoscopy Contact & non-contact available No liquid immersion fluid Newer devices Best for deeper structures as white shiny structures & vascular structures Seborrheic keratoses Milia-like cysts are more prominent with non-polarized dermoscopy Ridges and fissures are more prominent with non-polarized dermoscopy Seborrheic keratoses 7

8 Comedo-like openings are more prominent with nonpolarized dermoscopy Regression structures Gray dots/granules or peppering better seen w/contact NPD Regression Melanophages structures: and Gray fibrosis dots/granules in the papillary also known dermis as peppering Important feature of melanoma on sun damaged skin. Seborrheic keratoses Regression structures (gray dots/granules) are more prominent with non-polarized dermoscopy Regression structures (gray dots/granules) are more prominent with non-polarized dermoscopy Melanoma Melanoma Blue white veil Seen better with CNP Blue Compact white orthokeratosis veil : Diffuse blue with Epidermal a superimposed hyperplasia white hazy appearance Blue white veil Blue white veil is better seen with non-polarized dermoscopy Important feature seen in thick melanomas Atypical melanocytes in the epidermis, papillary, & reticular dermis Melanoma 8

9 Blue white veil is better seen with non-polarized dermoscopy Blue white veil is better seen with non-polarized dermoscopy Melanoma Melanoma Blue white veil is better seen with non-polarized dermoscopy Crystalline structures = White Shiny Structures Shiny, bright white, orthogonal linear streaks seen only with polarized dermoscopy Due to increased amount of collagen in the stroma Melanoma Marghoob AA, Cowell L, Kopf AW et al. Observation of chrisalis structures with polarized dermoscopy. Arch. Dermatol 2009;145, 618 Crystalline structures: White reflective structures in the form of lines thin or thick, round oval structures both small and large, and in Thickened the shape collagen of rosettes. Crystalline structures are better seen with polarized dermoscopy Crystalline or White Shiny structures Important feature seen in melanomas Fibrous septa Melanoma 9

10 Crystalline structures are better seen with polarized dermoscopy Crystalline structures are better seen with polarized dermoscopy Melanoma Melanoma Small round structures Round oval structures surrounded by thickened collagen Crystalline or White Shiny structures often have different patterns seen with different neoplasms Large round structures SCC Fibrotic collagen Rosettes BCC Vascular structures Serpentine branched vessels: Vessels with a snake like configuration also called arborizing vessels Vessels and red areas (secondary to vascular changes) are better seen with polarized dermoscopy Vessels & red areas (2 0 to Vascular changes) better seen with PD. Vascular features of non Pigmented neoplasms are often only clue to dx BCC Dilated and tortuous linear blood vessels Melanoma 10

11 Vessels and red areas (secondary to vascular changes) are better seen with polarized dermoscopy Vessels and red areas (secondary to vascular changes) are better seen with polarized dermoscopy Melanoma Melanoma Vessels and red areas (secondary to vascular changes) are better seen with polarized dermoscopy Vessels and red areas (secondary to vascular changes) are better seen with polarized dermoscopy BCC BCC Vessels and red areas (secondary to vascular changes) are better seen with polarized dermoscopy Vessels and red areas (secondary to vascular changes) are better seen with polarized dermoscopy BCC SCC in situ 11

12 Hybrid Scopes Toggling to PD unveils crystalline or shiny white structures Melanoma 0.9 mm Toggling between PD and NPD highlight specific structures because of difference in depth of imaging NPD Arch Dermatol 2011;14:520 PD 2-step process Step 1: Is it melanocytic? Step 2: Is it a melanoma? CHAOS In a Blink! SCAN for CHAOS If in doubt assume chaos and assess for clues CHAOS 4 lesions on one patient 12

13 In contrast to scanning for CHAOS the search for CLUES involves thoughtful examination GET BLACK LOLLIPOPS Grey or blue structures Eccentric structureless area Thick lines reticular Black dots or clods peripheral Lines radial or pseudopods, segmental Lines white Lines parallel ridges (palms or soles) or chaotic Polymorphous vessels Polygons 1. Grey or blue structures Blue or Blue-Gray Ovoid Nests Confluent or near confluent pigmented ovoid or elongated areas Larger than globules 13

14 2. Eccentric structureless area Negative pigmented network 17 yo w/ DN w/ back pigmented lesion w/ Bolognia sign Eccentric dark blue structureless area 3. Thick lines reticular or branched Pigmented Network = Typical Reticular Pattern Grid-like structure Pigmented network lines and hypopigmented holes 14

15 Lines correspond to melanin in the melanocytes or keratinocytes in the epidermal rete ridges. Holes correspond to projections of the dermal papilla. melanocytes From Scott Menzies atlas Junctional melanocytic nevus Atypical Reticular Pattern / Network Thick lines reticular or branched 44 yo man w/ FH of melanoma. Pigmented lesion on left upper arm 4. Black dots or clods, peripheral Atypical network 15

16 5. Lines radial or pseudopods, segmental Can you see any transition from nevus to melanoma? 6. White lines 16

17 Non-polarized Polarized Inverse or Negative Network 7. Polymorphous vessels If white lines not shiny with PD & in a reticular pattern due to nests of melanocytes with intervening normal skin. 8. Lines parallel, ridges (acral) or chaotic (nails) 17

18 Lines parallel, ridges (acral) or chaotic (nails) Lines parallel on nails, varying in width interval and color 18

19 Polygons= Rhomdoidal Structures Geometric polygonal shape complete or incomplete, bounded by straight lines, or by straight pigment interface, angles & larger than holes caused by individual follicles & holes bounded by reticular lines Excluding seborrhoeic keratoses 19

20 Exceptions TADA Benign Skin Growths Card Created by: EV Seiverling, A Khalsa C Muraika, HT Ahrns Rogers T, Marino ML, Dusza SW, Bajaj S, Usatine RP, Marchetti MA, Marghoob AA. A Clinical Aid for Detecting Skin Ca: The Triage Amalgamated Dermoscopic Algorithm (TADA).J Am Board Fam Med. 2016;29(6): Hemangiomas = collections of blood vessels Red/blue/purple lacuane (lakes) of blood separated by white septae Characterized by well-demarcated round or oval structures (lacunae): red blue-red blue-black maroon Thrombosed: homogeneous, confluent dark bluish-black pigment. 20

21 Hemangioma Lacunae (Red oval Hemangioma structures) Lacunae (Red oval structures) Lacunae (Red oval structures) Lacunae (Red oval structures) Oval structures (lacunae) Dermatofibroma Central scar-like white area, ring-like brown globules, vessels/pink blush in center Pigmented Network (network-like structures) (71%) Globules Ring-like Globules Crystalline (Chrysalis) Central White Patch (57%) Vessels & Erythema (49%) Pigmented network (network-like structures) Central white patch Hyperpigmentation of basal layer Dense collagen bundles 21

22 Vessels and erythema Globule-like structures (Ring-like globules) Increased vascularity Elongated & broadened rete ridges. The pigmented rete envelope the papillae producing the ring like globules Central scar-like white patch Central scar-like white patch Central scar-like white patch Peripheral fine network Central scar-like white patch Peripheral fine network Central scar-like white patch Peripheral fine network Peripheral fine network Peripheral fine network Seborrheic Keratosis Epidermal features of a seborrheic keratosis are more prominent with contact non-polarization Stars in the sky Milia-like cysts Milia-like cysts Milia-like cysts Comedo-like openings (Crypts) Ridges (Gyri) Fissures (Sulci) Sharply demarcated border w/ moth-eaten appearance Fingerprint-like; hairpin vessels when inflamed 22

23 Seborrheic Keratosis Milia-like Cysts Milia-like cysts Keratin filled cyst Keratin filled cyst Sharply demarcated border with moth-eaten appearance Comedo-like openings: Irregularly shaped epidermal craters = Keratin-filled plugs Sharply demarcated border with moth-eaten appearance Comedo-like openings Keratin filled plug Comedo-like Openings Cerebriform Ridges and Fissures Pattern Comedo-like Openings Gyri /Ridges: Smooth raised portion of the lesion surface Sulci/Fissure: Linear epidermal depressions or clefts filled with keratin 23

24 Ridge: Papillomatous Raised projected portion of of a seborrheic seborrrheic keratosis Fissure: Depressed portion filled with keratin Ridge Fissure Ridge Fissures Ridge Smooth, raised portion of the lesion s surface Fissures Brown lines in between finger-like ridges or gyri. Ridges (gyri) Finger like projection (ridges) Milia-like cysts are more prominent with non-polarized dermoscopy Seborrheic keratoses 24

25 SEB KERS: Milia-like cysts; Comedo-like openings; Ridges & Fissures, Sharply demarcated border w/ moth-eaten appearance Fingerprint-like; hairpin vessels when inflamed Milia-like cysts Fingerprint-Like Comedo-like openings Fine lines slightly curved Scalloped borders Hairpin Vessels Triage Amalgamated Dermoscopy Algorithm (TADA) Starburst: knob-like projections or streaks at the edge of a growth 1. Blue-Black/Gray Color: ie. ovoid nests, peppering, veil 2. Shiny White Structures 3. Negative Network: hypopigmented serpiginous lines 4. Ulcer/Erosion: raw or non-healing, +/- crust 5. Vessels: ie. arborizing, polymorphous, dotted Negative Pigmented Network Seen with both polarized and non-polarized dermoscopy Reverse of a pigmented network Negative Pigmented Network: Represents large tumor nests with elongated, thin rete ridges Light areas represent the grid Dark areas represent the holes Negative pigmented network Congenital nevus superficial type Negative pigment network Melanoma Ulceration raw or nonhealing +/- crust Diffuse & symmetrical negative pigment network Focal & asymmetrical negative pigment network 25

26 Dermoscopy Bridges Clinical with Histology Histology Clinical Rogers T, Marino ML, Dusza SW, Bajaj S, Usatine RP, Marchetti MA, Marghoob AA. A Clinical Aid for Detecting Skin Cancer: The Triage Amalgamated Dermoscopic Algorithm (TADA).J Am Board Fam Med. 2016;29(6): Dermoscopy Thank You For Your Attention 26