Dr Amanda Oakley Dermatologist Dept of Dermatology, Health Waikato Adjunct Associate Professor, Waikato Clinical Campus 14:00-16:00 WS #14: Dermoscopy Part 1
Skin Lesions and Dermatoscopy 16 August 2018 Christchurch GPCME Amanda Oakley Dermatologist, Dept of Dermatology, Health Waikato Adjunct Associate Professor, Waikato Clinical Campus Website Manager, DermNet New Zealand Specialist Dermatologist, Tristram Clinic Diagnosing Dermatologist, MoleMap NZ Director, New Zealand Teledermatology Tristram Clinic
Declaration of conflict of interest I diagnose for MoleMap NZ Thanks for many images I am Founder and Chief Editor of DermNet NZ Sponsored by PHARMA I have been on various advisory boards over the years but not relevant to this talk
This workshop Is not intended to make you an expert Expects you to take a history and to undertake total body skin examination 4
Content of workshop Course context Pre-test Introduction to dermatoscopy Clinical features of pigmented skin lesions Dermatoscopy of pigmented skin lesions Interactive exercises 5
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Melanoma Standards Standard 1.1 Patients are offered evidence-based information on risk factors, prevention and detection of melanoma early Avoid sunburn and adopt UV protection (physical methods complemented by sunscreen) Strongly discourage use of sunbeds Advise all adults, particularly those aged 50 and over to: Regularly examine their skin Get someone else to check areas difficult to see Seek advice from a doctor about suspicious lesions. Total lack of sun exposure not advisable without vitamin D supplementation
Risk factors are age, prior melanoma / skin cancer / sun damage, many/large moles But two-thirds melanoma in average-risk subjects Nearly all skin cancer relates to UVR exposure Protect skin from UVR (sun, indoor tanning beds) Behaviour, clothing, SPF 50+ sunscreen Teach self skin-examination If risk factors, annual full skin check If many moles, digital dermatoscopic surveillance 8
Strongest predictors of invasive melanoma in > 65 yr: 2.3 x risk than < 45 Men: 2.1 x risk than women Queenslanders Skin doesn't tan: 4.8 x risk than if tan deeply At age 21 with many moles: 4.4 x those with 0 If >21 lesions treated, 2.5 x higher risk than those who had none treated 9
Primary prevention Target: All ages Fair skinned people People who work outdoors People with existing sun damage 10
Vitamin D and sun exposure 11
Estimate patient s risk of melanoma / NMSC Risk factor widget on BPAC Stay alert to incidental skin lesions Melanoma + NMSC Carry out full skin check Determine what s normal for the patient (moles, freckles, seborrhoeic keratoses, angiomas) 12
Take a history Skin cancer, immune suppression (drugs, disease), strong family history of melanoma (2+ < 40 yrs) Examine face and hands for actinic keratoses, solar lentigines Examine all skin for mole number (> 100), pattern Large moles, small dark moles, odd-looking moles Large congenital melanocytic naevi If > 20 cm, send to specialist for assessment 13
Melanoma Standards Standard 4.1 Investigation, Diagnosis and Staging Patients have access to a clinician trained in: Early detection and diagnosis of melanoma, including the use of dermatoscopy Surgical skills to undertake excision and direct closure of in-situ or thin melanoma The triage and referral of patients with lesions of uncertain diagnosis, thicker melanoma and lesions on sites where surgery is difficult.
Today s workshop is an introduction to dermatoscopy; it takes practice to be good at it Digital dermatoscopy (images) enhances skill Aids referral + clinicopathological correlation Automated devices should not be relied upon Surgical skills also take training + practice If you are not doing lots of surgery, refer to someone who is 15
Other resources Please join MelNet www.melnet.org.nz/ DermNet NZ www.dermnetnz.org/cme/ Dermatoscopy Teledermatology for suspected skin cancers 16
Not always easy 17
Pre-test 10 images of pigmented skin lesions Decide if benign or malignant Select a diagnosis 10 seconds for each case 18
Lesion 1 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 19
Lesion 2 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 20
Lesion 3 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 21
Lesion 4 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 22
Lesion 5 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 23
Lesion 6 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 24
Lesion 7 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 25
Lesion 8 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 26
Lesion 9 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 27
Lesion 10 Benign or Malignant? a) Melanocytic naevus? b) Melanoma? c) Seborrhoeic keratosis? d) Basal cell carcinoma? 28
Introduction to dermatoscopy 29
This workshop is interactive Option A Option B 30
Who has their own dermatoscope? I have my own I don t have my own 31
What is dermatoscopy? = Dermatoscopy, epiluminescent microscopy Skin examination using: Magnification Good light Means to reduce surface reflection Contact fluid film Polarising filter Improves diagnostic accuracy in expert hands Confirmed by numerous clinical trials 32
Why magnify? 34
Why reduce surface reflection? No polarisation Polarisation 36
Dermatoscopes 37
This workshop is interactive Option 1 Option 2 Option 3??? 38
Option 4 None of the options are true: I don t know Not applicable 39
My dermatoscope is: Polarised Unpolarised A? B? Both? 40
My dermatoscope is: Contact Non-contact A? B? Both? 41
I have photodermatoscopy: Yes No A? B? Both? 42
Which dermatoscope? Depends on budget, interest, digital imaging Choices: Polarised, unpolarised or both Contact or non-contact Ability to attach to a camera Lens size and quality Portability Charger: AC, USB, dock 43
Non-contact devices Speedy review of entire skin surface Polarised view
Contact devices Add fluid Better quality Best for imaging Polarised and non-polarised options 46
Polarised vs unpolarised Both have liquid interface and lens in contact with the skin
How to use non-contact dermatoscope Takes practice to focus on skin lesions Allows a quick review of many lesions 50
How to use contact dermatoscope Tedious but higher quality Apply fluid to lesion Clean lens between lesions Clean lens between cases 51
Photography = digital dermatoscopy Camera Adapter(s) Suitable dermatoscope Archiving system Software suitable for sharing images 53
Why take photos? Clinical purposes The record Referral: required for HSCan melanoma referrals Clinicopathological correlation Education Yours Someone else s Research, publication 54
Smartphone + device Handyscope, Veos HD1, HD2 For iphone 4, 5, 6 Dermlite DL1, DL2, DL3 For iphone 4, 5, 6, 6+, 6s; ipod Touch; ipad 3, 4, air, mini; Galaxy S3, S4, S5 S6 Heine ic1 For iphone 5, 6 DermLite Hüd For smartphones 55
www.dermengine.com 56
DermEngine software 57
Dermatoscopy training requires: Experience in skin history / examination Elementary course e.g., today s Reference books, articles, online resources A dermatoscope immediately to hand A camera to record lesions of interest Continued practice 58
Training in dermatoscopy Online modules: http://www.dermnetnz.org/doctors/ Apps Textbooks International Diploma of Dermatoscopy http://www.medunigraz.at/dermatoscopy/ MMed (Skin Cancer) Program, U of Queensland www.skincancermasters.com Healthcert Skin Cancer Certificate Courses www.skincancercourses.com.au Skin Cancer College Australasia Certificatehttp://www.skincancercollege.org/education-events/rangecourses/ 59
itunes App Store 60
Virtual Dermatoscope 61
When to use dermatoscopy All the time! Pigmented and non-pigmented lesions Benign, malignant and of uncertain significance Inflammatory dermatoses Psoriasis, eczema, lichen planus, lupus Infestations Head lice, scabies 62
Which of these has scabies? A? B? Both?
Which of these has scabies? A? B? Both?
Dermatoscopy of burrow
Skin examination 66
I d like a skin check Take a history Assess risk factors for skin cancer Identify lesion(s) of concern To patient, significant other, health professional Onset, duration, behaviour Effect of previous treatment 67
Risk factors for melanoma/nmsc Age, esp. >50 years Previous melanoma Previous keratinocytic skin cancer (BCC, SCC) Many moles Large moles Familial melanoma (2+ young, close relatives) Sunburns (melanoma, BCC) Chronic exposure to UV (AKs, SCCs) 68
Skin examination Good light & magnification Whole body Lesion location, distribution, morphology Size Shape Surface Structure Colour Ugly duckling? Dermlite Lumio & Lumio S 69
Photograph the lesion Anatomic Close-up 70
Take dermatoscopy images Clean lenses, dry carefully Apply fluid to lesion surface Spacer plate out, in contact with lesion, focus & capture 71
Dermatoscopy images Polarised Unpolarised 72
Dermatoscopy images Polarised Unpolarised 73
Still not sure? Excise with 2-mm margin 74 Histopathology: seborrhoeic keratosis
Pigmented skin lesions Melanocytic Naevus + melanomas Epithelial Seborrhoeic keratosis + BCC / SCC Vascular Angioma + haemorrhage Other Dermatofibroma 75
Benign lesions Rarely need excision. Exceptions: If malignancy cannot be excluded Significant symptoms Cosmetic reasons Benign lesions show symmetry: Single or multiple patterns Assess structure, colour and border (not shape) 76
So, which benign lesions: Should be referred? Excised as a precaution? Followed up? Ignored? It isn t always easy! 77
High Suspicion of Cancer HSCan (melanoma) Ministry of Health idea Initially for triage Later will be for referral 78
Which has red flag A? A? B? Both? 79
Red flag A : asymmetry Speckled lentiginous naevus Melanoma in situ 80
Which has red flag B? A? B? Both? 81
Red flag B : border Melanoma in situ Benign melanocytic naevus 82
Which has red flag C? A? B? Both? 83
Red flag C : colour Nodular melanoma 2.5 mm Melanoma in situ 84
Which has red flag D A? B? Both? 85
Red flag D : different SS melanoma 2.5 mm Seborrhoeic keratosis 86
Red flag D : different SS melanoma 3 mm Seborrhoeic keatosis 87
Which has red flag E? A? B? Both? 88
Which has red flag E 2014-2015 2012-2015 A? B? Both? 89
Evolving: lesion A Seborrhoeic keratosis 2014 Seborrhoeic keratosis 2015 90
Evolving: lesion B Benign naevus 2012 Benign naevus 2015 91
Evolving: lesion B Benign naevus 2012 Benign naevus 2017 92
Evolving lesion 2010 2011: melanoma in situ 93
Evolving lesion 2010: monitored 2011: melanoma in situ 94
Dermatoscopy of benign lesions No Chaos Symmetry of structure Symmetry of colour Symmetry of border One pattern, 2 concentric/regular patterns or 3 concentric patterns 95
Dermatoscopy of malignant lesions Chaos Asymmetry of structure Asymmetry of colour Asymmetry of border abruptness More than one pattern + One of the following clues: 1. Eccentric structureless zones, any colour 2. Gray circles, lines, dots, clods 3. Black dots or clods at periphery 4. Focal pseudopods or radial lines at periphery 5. White lines 6. Thick reticular lines 7. Polymorphous vessels 8. Parallel lines on the ridges (acral lesions only) 9. Large polygons 96
Chaos & Clues poster See Melnet website Provided by A/Prof Cliff Rosendahl http://www.melnet.org.nz/resources/tools-for-skin-lesion-diagnosis 97
Modified pattern analysis Descriptive dermatoscopy 98
Dermoscopic pattern analysis Skin lesions are made up of structures: lines, dots/clods & structureless zones of varying colours... Structures forming neat patterns = naevi Structures disordered / chaotic = cancer 99
Patterns of lines 100
Clods Cobblestone pattern Globular or brown clod pattern 102
Patterns of dots Grey Red 103
Structureless patterns Brown (1 component) Skin coloured (2 components) 104
Complex patterns in naevi Structureless in structureless Structureless in dot/clods 105
Complex patterns in naevi Concentric patterns Repeating pattern 106
Disordered pattern in melanoma 107
Melanocytic lesions Naevi Melanoma 108
Melanocytic naevi Benign proliferation of melanocytes Naevocellular naevus Forming nests, chords, strands Congenital, tardive or acquired Histological classification (Ackerman) Congenital (superficial, superficial and deep), blue, combined, dermal / Unna / Miescher, halo / Sutton, recurrent, Clark, Spitz, Reed Junctional, compound, dermal 109
Junctional naevus: histology 110
Junctional naevus: dermatoscopy Sometimes a central area of dermal naevus is seen 111
Compound naevus: histology 112
Compound naevus: dermatoscopy 113
Dermal naevus: histology 114
Dermal naevus: dermatoscopy 115
Melanocytic naevi Congenital naevus Giant >40cm, large >20cm, medium >1.5cm, small Various clinical types Tardive naevus Appears in childhood/adolescence and evolves Similar pathological features to congenital naevus Acquired naevus Later onset, more superficial Follow immunosuppression or sun exposure 116
Which lesion is congenital? A? B? Both? 117
Both are true congenital naevi Large, distinctive lesions Present at birth A medium-sized >1.5 cm & <20 cm B giant-sized >40 cm
Which lesion is congenital? A? B? Both? 119
A is congenital True congenital naevus Childhood-onset tardive naevus Terminal hair indicates lesion was present at birth or during childhood (developmental) 120
Childhood-onset or tardive naevi Onset prior to puberty Sun has minor role A is common mole B is annular or eclipse naevus often found in scalp
Blue naevus Often deep blue May be grey, skin-coloured, brown Dermal spindle-shaped dendritic melanocytes 122
Blue naevus: histology 123
Blue naevus: dermatoscopy 124
Which is blue naevus? A? B? Both? 125
Dermatoscopy Angioma Blue naevus Clods pattern (lacunar) Structureless pattern (homogeneous) 126
Papillomatous dermal naevus (Unna) Often on trunk Soft, protruding mole Skin-coloured, brown, black Develops from flat naevus 127
Non-papillomatous dermal naevus: (Miescher) Dome-shaped nodule on face Skin coloured to dark brown May have terminal hair Histology: dermal melanocytes 128
Which is dermal naevus? A? B? Both? 129
Dermatoscopy of dermal naevi Unna naevus Miescher naevus Cobblestone pattern (clods) Structureless pattern (+ vv) 130
Acquired naevus = Clark naevus Trunk, prox. limbs Any colour (pink, brown, black) Round or oval Histology of larger lesions dysplastic Superficial, flatt(ish) 131
Naevus on face Look for holes Hair follicles Sweat ducts No pigment Pseudonetwork 132
Acral naevus (palm/sole) Ridges and furrows Pigment in furrows 133
Which is facial naevus? A? B? Both? 134
Dermatoscopy of special sites Facial naevus Acral naevus (plantar) Pseudoreticular: skin coloured clods Parallel lines (+ lattice-like) 135
Eccrine ducts 136
Signature naevi* People often have several of similar type More obvious in fair skinned people with many moles Typical for the individual Solid pink Solid brown Lentiginous Perifollicular hypopigmentation Eclipse Cockade *Bolognia 137
Patient with many naevi 138
Solid brown naevus Structureless, 1-2 colours 139
Solid pink naevus Regular vascular pattern 140
Lentiginous signature naevus Reticular, structureless centre 141
Perifollicular hypopigmentation Reticular, hypopigmented clods 142
Eclipse naevus 2 patterns (reticular + structureless) 143
Cockade naevus 3 patterns (reticular + structureless + clods) 144
Cockade means? A knot of ribbons worn on a hat A targetoid naevus A? B? Both? 146
Cockade Hungary Brazil Argentina France 147
Funny-looking naevi Atypical naevus Benign or melanoma! Atypical Spitz naevus Benign or melanoma! Dysplastic naevus Benign or melanoma! MELTUMP (Melanocytic tumour with uncertain malignant potential) Benign or melanoma! STUMP (Spitzoid tumour with uncertain malignant potential) Benign or melanoma! SAMPUS (superficial atypical melanocytic proliferation) Benign or melanoma! 148
Atypical naevus = uncertain biology 149
Atypical naevi: dermatoscopy 150
Which is benign? A? B? Both? 151
Dermatoscopy helps if uncertain Benign compound naevus Melanoma in situ B has greater asymmetry of structure or Chaos 153
Melanoma Malignant neoplasia arising from melanocytes In situ or invasive Sometimes, very difficult to diagnose Clinically, dermatoscopically, histologically Most important prognostic factor Breslow thickness 154
Melanoma Most lesions (?70%) de novo A few arise within naevi Congenital, tardive, acquired Diagnosed by appearance or behaviour Observed change In flat lesions, dermatoscopic change seen long before clinical change In nodular lesions, change often observed by patient 155
Observed change 2011 2012 156
Clinical subtypes of melanoma Lentigo maligna melanoma Lentiginous melanoma Superficial spreading melanoma Nodular melanoma Acral lentiginous melanoma Desmoplastic melanoma Mucosal melanoma Naevoid melanoma Animal melanoma Non-cutaneous melanoma 157
Clinical ABCD rule for melanoma Asymmetry of shape Border irregularity Colour variability Diameter >6 mm Evolving For lay people to detect melanoma Features may not apply to early melanoma or nodular melanoma 158
Clinical A(B)CD rule for melanoma Asymmetry of structure (Border irregularity) Colour variability Different 159
Ugly duckling sign 160
ABCD+. Which is melanoma? A? B? Both? 161
Dermatoscopy Congenital naevus Melanoma in situ Less disordered More disordered 162
Which is melanoma? A? B? Both? 163
Both reported as melanoma in situ 164
Blue colour suggests invasion 165
Clinicopathological correlation Check lab report against clinical images Is the pathology diagnosis consistent with your clinical diagnosis? If not, contact the pathologist This needs to be done promptly 166
Histology melanoma in situ Revised report: Invasive melanoma, 1.8 mm thickness 167
Pigmented non-melanocytic lesions Solar lentigo Seborrhoeic keratosis Keratinocytic cancer BCC, SCC 168
Solar lentigo Circumscribed light brown macule May develop into seborrhoeic keratoses In sun-damaged skin Melanin in basal keratinocytes Melanocytes normal or increased number Elongated rete ridges 169
Solar lentigo 170
Solar lentigo Sharp edge Structureless, yellowish 171
Solar lentigo Moth-eaten edge Subtle structures 172
Seborrhoeic keratoses Skin coloured, yellow, brown, black Smooth to verrucous Irregular structure Flat or thickened Very variable in appearance Stuck-on 173
Seborrhoeic keratoses 174
Seborrhoeic keratosis Stuck on, warty Orange clods, curved thick lines 175
Seborrhoeic keratosis Yellowish, greasy White clods 176
Seborrhoeic keratosis Yellowish, greasy White (& orange) clods 177
Seborrhoeic keratosis Thick curved lines 178
Which is solar lentigo? A? B? Both? 179
Pseudoreticular pattern in both Solar lentigo Melanocytic naevus Moth-eaten Roundish 180
Which is seborrhoeic keratosis? A? B? Both? 181
A is seborrhoeic keratosis Seborrhoeic keratosis Melanoma Easy! The seborrhoeic keratosis is scaly / warty 182
Which is seborrhoeic keratosis? A? B? Both? 183
B is seborrhoeic keratosis Dermal papillomatous naevus Seborrhoeic keratosis Discontinuous clods Interlinked clods + thick lines 184
Is precise diagnosis important? No if both are benign! Dermal papillomatous naevus Seborrhoeic keratosis 185
Does it wobble? Yes: melanocytic naevus No: seborrhoeic keratosis
Not always easy Seborrhoeic keratosis Melanoma Both can have have irregular and complex structures 187
Keratinocytic cancers Basal cell carcinoma Locally destructive On hair-bearing skin only Various types: Nodular Superficial Morphoeiform Fibroepithelial Infundibulocystic May be pigmented Actinic keratoses Rough white lesions on erythematous base May be pigmented SCC in situ Red scaly plaque May be pigmented Invasive SCC 188
Basal cell carcinoma Slow growing tumours on any site Locally destructive Early ulceration & bleeding May be pigmented Various subtypes: Nodulocystic Micronodular Morphoeic / sclerosing Ulcerative Superficial Basisquamous 189
Basal cell carcinoma 190
Dermatoscopy of basal cell carcinoma Irregular, bleeding, growing Irregular, bleeding, branched red lines 191
Dermatoscopy of Pink, shiny, enlarging basal cell carcinoma Peripheral dirty pigment, red branched lines 192
Actinic / solar keratosis Fluctuating small scaly plaques on areas chronically exposed to sunlight (face, hands) Tender, red or brown superficial lesions Variable adherent scale or horn Only on other sites when face and hands are badly affected Uncommon in darker skin types Uncommon in indoor workers 193
Actinic keratoses 194
Pigmented actinic keratosis Scaly irregular tender patch Strawberry + superficial network of broken-up lines 195
Strawberry Yellow dot within white circle with curved red lines 196
SCC in situ / intraepidermal ca One or more slowly-enlarging, red to brown, irregular plaques On any site May ulcerate or bleed Scale is prominent Bowen disease Often confused with eczema or psoriasis 197
SCC in situ All 4 of these were all found on the same patient s trunk and limbs 198
SCC is / IEC Irregular red scaly plaque Dotted blood vessels 199
SCC is / IEC Irregular red/brown scaly plaque Dotted blood vessels, may b in rows like the pigment 200
Invasive SCC Usually arise from actinic keratosis or IEC Fast-growing indurated, tender plaques or nodules Variable scale, horn and ulceration Variable differentiation: Keratoacanthoma Microinvasive disease Well differentiated Moderately well Undifferentiated Anaplastic 201
Invasive SCC 202
Squamous cell carcinoma Tender scaly growing nodule Central scale, white periphery 203
Squamous cell carcinoma Ulcerated tender growing nodule Central ulcer, white circles, white periphery 204
Which is BCC? A? B? Both? 205
Dermatoscopy Pigmented BCC 0.4 mm amelanotic melanoma Irregular peripheral pigment Small focus of pigment network 206
Which is BCC? A B A? B? Both? 207
Dermatoscopy Dermal naevus Nonpigmented basal cell carcinoma Structureless + terminal hairs Branched red lines + scale + ulcer 208
Which is BCC? A? B? Both? 209
Dermatoscopy Angioma Pigmented basal cell carcinoma Purple clods Irregular clods + dirty dishwater 210
Dirty dishwater 211
Dirty dishwater Irregular leaf-like clods and dots, grey-brown colour 212