Disclosure Statement: Dermoscopy STFM 2016 Richard P. Usatine, MD, FAAFP Professor, Family and Community Medicine Professor, Dermatology and Cutaneous Surgery Medical Director, Clinic University of Texas Health Science Center, San Antonio Co-President, Usatine Media medical app development company Author, 9 medical books including: Dermatologic and Cosmetic Procedures in Office Practice. Elsevier, Inc., Philadelphia. 2012. The Color Atlas of Family Medicine. 2 nd Edition. McGraw-Hill, New York, 2013 The Color Atlas of Pediatrics, McGraw-Hill, New York, 2014 Cutaneous Cryosurgery. 4 th Edition. Taylor and Francis, London, 2014 The Color Atlas of Internal Medicine, McGraw-Hill, New York, 2015 Some Dermatoscopes More dermatoscopes Thanks to Dr. Ash Marghoob Dermoscopy Video http://www.jfponline.com/specialtyfocus/musculoskeletal/article/ dermoscopy/ d2e15a5faac52d3dd2b43bd35147cb3d.ht ml?ooct=jfp-related 6 minutes For his mentorship in dermoscopy and the use of some of the slides in this presentation. 1
Light Source Source Polarizer is required Light Detector Detector Cross- Polarizing filter Only light undergoing multiple scattering events will result in sufficient change in angle of polarization (deeper, birefringence). Epidermis How can dermoscopy help? Helps differentiate benign from malignant lesions Miss less melanomas (sensitivity) Biopsy less benign lesions (specificity) Penetrating Light Superficial Light Surface Glare Dermis Improves malignant to benign biopsy ratio (accuracy) SK BCC Evidence The sensitivity of detecting melanoma went from 70% to 83% with the use of dermoscopy based on a meta-analysis of 13 studies. The specificity improved from 75% to 86%. 1 The sensitivity for melanoma diagnosis by primary care physicians using dermoscopy increased from 56% to 76%. 2 Primary care physicians using dermoscopy improved their triage of skin lesions suggestive of skin cancer by 25%. 3 Amelanotic melanoma 1. Bafounta ML, et al. Is dermoscopy (epiluminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evaluation of diagnostic tests. Arch Dermatol. Oct 2001;137(10):1343-1350. 2. Westerhoff K, et al. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol. 2000 Nov;143(5): 1016-20. 3. Argenziano G, et al. Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol. 2006 Apr 20;24(12):1877-82 Parallel pattern (volar skin = palms/soles) Benign furrows - ridges How dermoscopy helps 2
Dermoscopic features of melanoma Record your dermoscopy Attach your dermatoscope to your phone or a camera Photograph every lesion that you biopsy clinical and dermoscopic Download your photos to your computer When your path report comes back, look at your photos with the confirmed diagnosis Learning process Tips for storage and retrieval Label your photos with the name of the diagnosis so you can find them by dx in future Picasa is a free program from Google that is easy to search Don t put patient names or MRN s on files to avoid the HIPAA police Find your photos by date Use your image to accelerate your learning and provide images for consultations/referrals This all leads to improved learning and patient care. Features to look for in a dermatoscope Polarized and non-polarized in one package Attaches to your smartphone Second best attaches to a camera conveniently Charges easily Affordable Dermatoscopes DermLite: DL1, DL2, DL3, DL4 Attach to iphones/ipods/ipads and Androids Canfield Veos: iphone/ipod only Handiscope: iphone/ipod only Heine-Delta scopes attach to cameras with special hardware Welch Allyn scopes don t attach to anything and are not polarized Free for all Apple and Android devices Includes: Two step algorithm Useful Charts 50 Unknown cases Many images 3
Two-step diagnostic procedure Two Step Algorithm Benign DF, SK, CCA hemangioma Malignant BCC, SCC Nevus vs : Is the lesion a melanocytic tumor? Step 2 Nevus (Reassure) Suspicious (Bx or STMM) (Biopsy) Two-step diagnostic procedure 1. Network Pigment network Negative network Polygonal lines tumors have: 1. Network (with two exceptions), aggregated globules, streaks, homogeneous blue pigment In addition: 2. On volar skin (palms & soles) parallel pattern 3. On face - Pseudo-network pattern Pigment network Nevus 4
Exception I: Dermatofibroma Pattern trumps structure Fine network surrounding a scar like area Exception 2: Pattern trumps structure Solar lentigo: network with fingerprinting, fine interrupted lines & moth eaten border Ink spot lentigo: uniform black network 1b. Negative network with negative network 1c. Polygonal lines Polygonal lines indicates that the lesion is melanocytic. 2. Aggregated globules 2. Globules Aggregated Peripheral rim 5
3. Streaks Blue nevus 4. Homogeneous blue pigmentation 4. Homogeneous blue pigmentation Parallel pattern Palms/Soles & Nails = parallel pattern (acral) Facial = pseudo-network pattern 6
Two-step diagnostic procedure Is the lesion a melanocytic tumor? If it has one of these features, then Step 2 Nevus (Reassure) Suspicious (Bx or STMM) (Biopsy) Two-step diagnostic procedure Delicate network 1. Dermatofibroma Central scar-like/crystalline Benign DF, SK, CCA hemangioma Malignant BCC, SCC Order of dx. 1. DF 2. BCC 3. SCC 4. SK 5. Hemangioma 6. Clear cell acanthoma Ring-like globules Vessels / blush in center 2. BCC Positive features (At least one present): Large grey-blue ovoid nests Multiple grey-blue globules Leaf-like areas Brown to gray-blue discrete bulbous blobs Leaf-like pattern Leaflike areas Spoke wheel areas Arborizing tree-like telangiectasia Ulceration 7
Arborizing vessels In-focus, red, branching vessels Hairpin vessels usually with a white halo 3. SCC Focally scaly/keratotic and rough Glomerular vessels focally present at periphery Keratin pearls & white circles Rosettes (strawberry pattern) Brown dots/globules aligned in a linear fashion at the periphery PD NB: Pigmented AK can also have structures seen in LMM! 4. SK Milia-like cyst 5. Vascular lesions hemangiomas and angiokeratomas Comedo-like opening Fissures & ridges Fingerprint-like Fat fingers Hairpin vessels Moth-eaten borders Lacunae separated by septae This is a: 1. lesion 2. melanocytic lesion 8
This is a: 1. lesion 2. melanocytic lesion This is a: 1. lesion 2. melanocytic lesion This is a: 1. lesion 2. melanocytic lesion Step 2: Nevus vs. Nevus Suspicious Step 2 (Reassure) (Bx or STMM) (Biopsy) 9
The Beauty and the Beast sign 1 2 3 4 5* Benign nevi tend to adhere to one of ten recurrent patterns (finite #). These patterns all fit the definition of beauty, demonstrating symmetry of pattern, structure, and color. The most common benign patterns are: 6* 7 8 9 10* ü Deviate from global benign patterns ü Have at least one of the melanoma specific features listed below MM SPECIFIC STRUCTURE / FEATURE SENSITIVITY (highest reported) specific structures SPECIFICITY (highest reported) ODDS RATIO (highest reported) Atypical network 77% 89% 9.0 Streaks 23% 99% 5.8 Negative network 22% 95% 2.0 Chrysalis (Crystalline) 5% 99% 9.7 Atypical dots & globules 88% 97% 4.8 Atypical blotch 38% 88% 4.1 BWV 51% 99% 13 Regression structures 46% 94% 8.0 Atypical vessels 63% 96% 12.5 Peripheral brown structureless areas 63% 96% 28 Obieta MP, Braun RP, Scope A, Rabinovitz H, Marghoob AA. Dermoscopy of superficial spreading melanoma. G Ital Dermatol Venereol. 2009;144:51-60. 1 Does this lesion manifest one of the 10 benign nevus patterns? 1) yes 2) no 10
Does this lesion manifest any MM specific structures? 1) yes 2) no Peripheral network Central hypopigmented and structureless area 2 Nevus Does this lesion manifest one of the 10 benign nevus patterns? 1) yes 2) no Does this lesion manifest any MM specific structures? 1) yes 2) no 11
Milky red area Atypical globules Atypical network 3 Does this lesion manifest one of the 10 benign nevus patterns? 1) yes 2) no Does this lesion manifest any MM specific structures? 1) yes 2) no 12
Young woman with pruritic eruption Arrowhead Jet plane Triangle on top of circle Dermoscopy Resources Scabies mite Free dermoscopy app - Dermoscopy: Two Step Algorithm. Available on itunes and for Android www.usatinemedia.com. Authors: Marghoob AA, Usatine RP, Jaimes N. Dermoscopy. Website from Italy that includes a free dermoscopy tutorial http://www.dermoscopy.org/ International Dermoscopy Society, http://www.dermoscopy-ids.org/ Marghoob A, Usatine R. Dermoscopy. In: Usatine R, Pfenninger J, Stulberg D, Small R, eds. Dermatologic and Cosmetic Procedures in Office Practice. Philadelphia, PA: Elsevier; 2012. Marghoob AA, Usatine RP, Jaimes N. Dermoscopy. In: Usatine R, Smith M, Mayeaux EJ, Chumley H. Color Atlas of Family Medicine,2nd Edition. New York, NY: McGraw-Hill; 2013 Marghoob AA, Usatine RP, Jaimes N. Dermoscopy for the family physician. Am Fam Physician. 2013 Oct 1;88(7):441-50. Dermoscopy Courses American Dermoscopy Meeting is held yearly in the summer in a national park: http://www.americandermoscopy.com/ Great Smokey Mountains, August 11-13, 2016 Questions? AFP 2013 American Academy of Family Physicians (AAFP) yearly fall FMX offers dermoscopy workshops: Orlando, FL Sept 20-24, 2016 Memorial Sloan-Kettering Cancer Center holds a yearly dermoscopy workshop each fall in New York City: Manhattan October 14-15, 2016 13