Dermoscopy: Recognizing Top Five Common In- Office Diagnoses

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

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

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

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

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

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

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

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

Network Patterns

Colors Yellow Black Epidermis Brown Dermis Blue Red

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

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

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

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

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

Case 1

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

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

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/

Diagram showing dermoscopic features of seborrheic keratosis [Marghoob]

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

http://www.ijdvl.com/viewimage.asp?img=ijdvl_2011_77_1_16_74966_f7.jpg Case 2

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

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

Superficial Basal Cell Carcinoma

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

Arborizing Telengiectasia Ulceration Large Blue-Gray Ovoid Nests

NonPigmented Basal Cell Carcinomas Arborizing Telangiectasia Shallow Erosions Shiny White Areas

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

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

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

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

Case 4

Dermatofibroma

Hemangioma Benign proliferations of blood vessels

Lacunae in Hemangioma

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

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

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

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

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

Question 3 Atypical dots and globules Asymmetry of color and/or 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

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, 2 nd 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