dermoscopy for acd - gplearning |...
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Dermoscopy
Australasian College of DermatologistsG.P Training Module
Synonyms
DermoscopyDermatoscopyEpiluminescence microscopySkin surface microscopyIncident light microscopyOil immersion microscopyIn vivo cutaneous surface microscopy
DefinitionNon-invasive in vivo technique10X magnification & bright illumination
Transparent mediumor
Polarised filter
…minimise skinsurface reflectance
Polarised filter
Dermoscopy
Allows visualisation of subsurfacestructures and colours not readily
observed with naked eye examination
Epidermis
Superficial dermis
Dermo-epidermal junction
Robert Johr M.D.
“Dermoscopy opens up a world of colour and structure that can’t be
seen with the naked eye”
Robert Johr M.D.
Dx = Benign junctional naevus
Uniform pigment networkFades at periphery
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Dx = Superficial spreading melanoma
Atypical pigment networkPseudopodsPeripheral black dotsBlue-grey veil
Brief history of dermoscopy1893 Diaskopie (Unna)1916 Binocular dermatoscope (Zeiss)1958 First portable dermoscope1989 First consensus meeting1991 First atlas (Kreusch)2001 Polarised light dermoscopy
*Almost 500 peer-reviewed publicationson dermoscopy in the last 5 years
Diagnostic algorithms
1987 Pattern Analysis (Pehamberger)1994 ABCD Method (Stolz)1996 Menzies Method1998 7 point checklist (Argenziano)2004 3 point checklist (Soyer)2007 C.A.S.H algorithm (Kopf)
Value of dermoscopy
Diagnostic aid for both:benign and malignant lesionspigmented and non-pigmented lesionsDiagnosis of early melanomaDifferentiation of melanoma from benign pigmented lesions e.g. naevi, seborrhoeic keratoses etcAcral skin & nail apparatus also
Value of dermoscopy
Improves diagnostic accuracy10-27% improvement in Dx of melanomaImproves benign to malignant ratioReduces need for biopsy
*Most valuable in diagnosing benign lesions that may otherwise require biopsy e.g. dark junctional naevi, angiomas, seborrhoeic keratoses
Value of dermoscopy
Improves clinical efficiencyBuilds clinical confidence Bridges clinical exam & pathologySpecialist and primary care setting
*Value is significantly influenced by observer experience
Menzies SW & Zalaudek I. Why perform dermoscopy? [editorial] Arch Dermatol 2006;142:1211-12
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Limitations of dermoscopyVery early melanoma‘Featureless’ melanomaAmelanotic melanomaNodular or primarily dermal lesionsExtremely dark lesions
Some formal training optimalLearning curve to overcomeHistopathology still gold standard
Digital dermoscopic monitoring enables detection of melanomas very early in their evolution before they have
developed typical clinical characteristics
Menzies SW et al. Arch Dermatol 2001;137:1583-9.Haenssle HA et al. J Invest Dermatol 2006;126:980-5.
Sequential monitoring
Novel uses
Inflammatory dermatoses e.g psoriasisInfections e.g scabiesNail fold vasculature e.g sclerodermaHair shaft disorders e.g monilethrixNail plate discolouration e.g. subungual haemorrhage
Dx = Chronic plaque psoriasis
Diffuse & regular dotted vessels
Dx = Scabies infestation
Delta or triangle Elements
Hand-held monocular instrument Similar to otoscopeL.E.D illuminationPolarised or non-polarised lightContact (wet) or non-contact (dry)Immersion fluid for contact dermoscopyCamera for documentationDigital-ELM (D-ELM) systems for archival
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Colours
Black Stratum corneumDark brown Superficial epidermisLight brown Deep epidermisGrey-blue Papillary dermisSteel blue Reticular dermisRed VasculatureWhite Depigmentation or scarYellow Hyperkeratosis or
sebaceous glands
Polarised light dermoscopyAdvantages
No immersion fluid necessary Non-contact (most DermLites)Quicker
Vascular structuresMilky-red areas
…seen more easilyDx = Nodular BCC
Arborising telangiectasia in sharp focusStructureless pink matrix
Dx = Hypomelanotic invasive SSM
Milky pink/red areasInverse networkAtypical vesselsFaint tan pigmentation
Polarised light dermoscopyDisadvantages
Blue-grey veilRegression structuresMilia-like cysts
…seen less easily
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Dx = Invasive SSM
Blue-grey veil
Benvenuto-Andrade C et al Arch Dermatol 2007;143:329-38.
Macro NPCD
PNCDPCD
Dysplastic naevus
Blue-grey veil
NPCD = non polarised contact dermoscopy e.g. Heine Delta-20PCD = polarised contact dermoscopy e.g. DermLite Fluid-IIPNCD = polarised non-contact dermoscopy e.g. DermLite Pro
Dx = Invasive SSM with regression
Blue-grey dots or peppering“Regression structures”
Benvenuto-Andrade C et al Arch Dermatol 2007;143:329-38.
Macro NPCD
PNCDPCD
Congenital naevus
Regressionstructures
Dx = Seborrhoeic keratosis
Milia-like cysts
Benvenuto-Andrade C et al Arch Dermatol 2007;143:329-38.
Macro NPCD
PNCDPCD
Seborrhoeic keratosis
Milial cystsComedo-like openings
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Which instrument?
Welch-Allyn Episcope™
Heine Delta-20®
Non-Polarised dermoscopy
Polarised dermoscopy
DermoGenius
DermLiteHeine Delta 20 + Nikon Coolpix 4500
DermLite Fluid II + Sony Cybershot DSC-W70
Cost
Handheld dermoscopes
$AUD 400.00 - 1900.00
Basic DermLites (polarised) cheapest
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Computerised image analysis
SolarScan (Polartechnics/C.S.I.R.O)MoleMax III (University of Vienna)Fotofinder
Digital dermoscopyMacroscopic imagingData storage and retrievalMonitoringDiagnostic support
SolarScan MoleMax-III
Computerised systems
Still require clinical judgement Still require dermoscopy skillsQuality of imaging not necessarily superior to handheld instruments
Which immersion fluid?
Oil e.g. olive, mineral, Nozoil*messy to apply and stain clothes
Alcohol or aqueous-based e.g. Codan*easier to apply, evaporate quickly
Gel e.g. KY gel, ultrasound gel*don’t run, preferable near eyes or onnail plates
Handling tips
1. Consider dry dermoscopy whenexamining a large number of lesions
2. Move to wet dermoscopy if uncertain3. Ensure good contact between the
glass plate and the skin surface4. Avoid excess pressure (compresses
and obscures vessels)
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Handling tips
5. Position the patient for comfortableexamination
6. The eye must be close to the lens7. Focus the lens where applicable8. Be liberal with immersion fluid
Dermoscopic terminologyPigment network
Typical = regular calibre lines & holes, fades atperipheryAtypical = non-uniform, ends abruptly, broadenedInverse = white lines, brown/red holesPseudonetwork = diffuse facial pigmentationinterrupted by follicular openings (unique tofacial skin)
Melanin in KC & MC outlining rete ridges
= Network lines
Epidermal supra-papillary plates
= Network holes
Dermoscopic terminologyPigment network1. typical2. atypical3. inverse4. pseudonetwork
1.
3. 4. 2.
Terminology cont’dDots <0.1mm, brown, black, blue or greyGlobules >0.1 mm, brown, black or redBlotches brown or black, structurelessPeppering fine blue-grey granules of melaninPseudopods peripheral finger-like projections
with bulbous endingsRadial streaming peripherally radiating linesBranched streaks alternate term for radial streaming
and or pseudopodsBlue-grey veil confluent bluish pigmentation with
overlying white ground-glass haze
Blue-grey veilBlue-grey veilBlue-white veil
‘Most significant dermoscopic finding of invasive melanoma’
51% sensitivity97% specificity
synonymous terms
Menzies SW et al. Melanoma Res 1996;6:55-62
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Compact orthokeratosis
Heavily pigmented melanocytes
Terminology cont’d
globules
peppering
dots
blotchesbranched streaks
radial streaming /
pseudopods
blue-grey veil
Terminology cont’dRegression structures scar-like depigmentation with
pepperingStructureless areas regions devoid of structuresCobblestone globules crowded polygonal globulesStarburst pattern symmetrical and radially
streaks Parallel patterns parallel pigmentation within
furrows or ridges on acral skin
Cobblestoneglobules
Regressionstructures
Terminology cont’d
Terminology cont’dStarburstpattern
Mulvehy J, Puig S et al Arch Dermatol 2004
Patterns on acral skinA. Parallel furrow B. Parallel furrow and
globulesC. Parallel furrow (thick)D. Parallel globulesE. LatticeF. LatticeG. Fibrillar or filamentousH. AtypicalI. HomogenousJ. GlobularK. ReticularL. Parallel Ridge
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Vascular terminology Lacunes large red-blue-black globular
structuresHairpin elongated and loopedDotted small pin sized vesselsComma comma or tadpole-shapedGlomerular highly convoluted resembling the
glomerular apparatus of the kidney
Argenziano et al. Arch Dermatol 2004
glomerular
lacunes hairpin
dotted
comma
Vessels (cont’d)
Vessels (cont’d)Coronal peripheral and wreath-likeCorkscrew irregular and thickly coiledArborizing branching, variable luminal diameter
Polymorphous multiple morphologies including comma, dotted, corkscrew,glomerular, linear irregular etc
corkscrew
arborizing
coronal
Vessels (cont’d)
a. Pigmented lesions
2 step algorithm
Pigmented lesion
Melanocytic Non-melanocytic
Benign Malignant ABCD rule7 point checklistMenzies method3 point checklist
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Step 1Classify as melanocytic or otherwise
Pigment network Pseudonetwork (facial skin)GlobulesStreaksHomogenous blue pigmentationParallel pattern (acral skin)
Uniform pigment networkFades at periphery
Dx = Benign junctional naevus
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Atypical pigment networkSymmetrically distributed black dots
Dx = Junctional naevus
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Dx = Dysplastic naevus
Atypical pigment networkBlack dots & blotches
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Dx = 0.7 mm Level II SSM
Inverse networkAtypical pigment networkMultiple coloursPeripheral brown dotsPseudopodsBlue-grey veil
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Image courtesy of Dr Greg Canning Image courtesy of Dr Ben CookDx = 0.8 mm Level III naevoid melanoma
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Eccentric inverse networkTypical pigment networkMulticomponent patternRegression structuresPolymorphic vessels
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Dx = Hypomelanotic invasive SSM
Inverse networkMilky pink areasAtypical vesselsFaint tan pigmentation
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern Dx = Hypomelanotic LIII 1.2mm SSM
Inverse networkMarginal typical pigment networkMulticomponentMultiple coloursAtypical vesselsHorn cysts
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Dx = Solar lentigo (facial)
PseudonetworkMoth eaten border
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Dx = Dermatofibroma
Lacy peripheral pigment networkCentral scar-like area
*Despite having a pigment network,dermatofibromas are non-melanocytic& are one exception to this rule*
Diffuse brown globulesSymmetry of structures
Dx = Benign compound naevus
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Dx = Evolving benign compound naevus
Peripheral brown globulesCentral reticular network
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Branched streaks/radial streamingBlue-grey veilMultiple coloursBlack blotches
Dx = Invasive SSM
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Dx = Invasive SSM
Branched streaks/radial streamingBlue-grey veilMultiple dotsScar-like depigmentationRegression structuresMultiple colours
Dx = Spitz naevus
Radially arranged streaks& pseudopodsStarburst pattern
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Diffuse homogenous blue pigmentation
Dx = Blue naevus
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Parallel furrow pattern
Dx = Benign acral naevus
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
Dx = Benign acral naevus
Parallel lattice pattern Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
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Parallel furrow pattern
Dx = Benign acral naevus
Fibrillar
Furrow
Lattice
Miyazaki JAAD 2005;53:230-6
A. Parallel furrow B. Parallel furrow and
globulesC. Parallel furrow (thick)D. Parallel globulesE. LatticeF. LatticeG. Fibrillar or filamentousH. AtypicalI. HomogenousJ. GlobularK. ReticularL. Parallel Ridge
Mulvehy J, Puig S et al Arch Dermatol 2004
Patterns on acral skin
RIDGE FURROW
melanoma benign naevus
Ridge pattern = consider melanomaLook for eccrine gland openings
Non-melanocytic lesionsdefying the 2 step rule
Network-like structuresSeborrhoeic keratosis, solar lentigo, dermatofibroma, accessory nipple
GlobulesSeborrhoeic keratosis, pigmented BCC dermatofibroma, talon noir (subcorneal haemorrhage)
StreaksSeborrheoic keratosis, pigmented BCC
Homogenous blueKaposi sarcoma, radiation tattoo, pigmented BCC
Scope et al. Dermatol Surg 2006;32:1398-406.
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If a lesion lacks positive melanocytic & non-melanocytic criteria, then by default it should
be deemed to be melanocytic.
In particular featureless melanoma should be considered.
melanocyticcriteria
non-melanocyticcriteria*
dermoscopic grey-zone?featureless melanoma*
Atypical/polymorphous vessels?faint tan pigmentHorn cystsBiopsy scar
Dx = Amelanotic lentigo maligna
2 step algorithm
Pigmented lesion
Melanocytic Non-melanocytic
Benign MalignantABCD rule
7 point checklistMenzies methodPattern analysis3 point checklist
Non-melanocytic
Melanocytic or not?
Argenziano et al JAAD 2003Argenziano G et al. J Am Acad Dermatol 2003;48:679-93.
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Seborrhoeic keratosis
fingerprinting
comedo-likeopenings hairpin vessels
milia-like cysts
Seborrhoeic keratosis
ridges and fissures (crypts) moth eaten & sharply
demarcated border
“fat fingers”network-like
structures
Fat fingersRidges and fissuresNetwork-like structuresComedo-like openings
Dx = Seborrhoeic keratosis
Fissures and cryptsFat fingersMilia-like cystsFingerprinting
Dx = Seborrhoeic keratosis
Comedo-like openingsAbsent networkAbrupt borderRidges and fissures
Dx =Seborrhoeic keratosis Braun RP et al. Arch Dermatol 2000;136:940-2
“The wobble sign”
Dermal naevuswobbles whilst
seb K won’t
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Solar lentigopseudonetwork
network-likestructures
finger-printing
moth eaten border
Moth eaten borderFingerprinting
Dx = solar lentigo
Moth eaten borderFingerprintingPseudonetwork
Dx = solar lentigo
Pigmented solar keratosis
Overlapping features with lentigo malignaLacks specific dermoscopic features
Pseudonetwork – broken upAnnular-granular structuresRhomboidal structures
Zalaudek I et al. JAAD 2005;53:1071-74
Moth eaten borderBroken up pseudonetworkSharp cut-off
Dx = pigmented solar keratosis
Benign lichenoid keratosis
peppering
finger-printing
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FingerprintingPeppering
Dx = benign lichenoid keratosis
Pigmented BCCblue-grey
ovoid nestsleaf-like structures
blue-grey globulesspoke-wheel areas
Leaf-like structuresArborising telangiectasiaBlue-grey ovoid nests
Dx = Pigmented BCC
Spoke wheel structuresNetwork-like structures
Dx = Pigmented BCC
Spoke wheel structuresNetwork-like structures
Dx = Pigmented BCC
arborisingtelangiectasia
ulceration
Pigmented BCC
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Arborising telangiectasiaBlue grey ovoid nest
Dx = Pigmented BCC
Arborising telangiectasiaUlceration
Dx = Basal cell carcinoma
Haemangioma
red-blue lacunes
Red & purple lacunes
Dx = Haemangioma
Red lacunes
Dx = Haemangioma
Dermatofibroma
delicate peripherallacy network
central scar
variable central dotted vessels
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Dx = Dermatofibroma
Lacy peripheral pigment networkCentral scar-like area Step 2
Once the lesions has been defined as melanocytic, classify as benign or malignant
Remember, if you can’t confidently identify the lesion as benign – some form of active intervention should be taken
2 step algorithm
Pigmented lesion
Melanocytic Non-melanocytic
Benign MalignantABCD rule
7 point checklistMenzies methodPattern analysis3 point checklist
Dermoscopy algorithms
1990 First Consensus meeting
22 unique patterns and structures8 variations on the pigment networkCumbersome to learnAlgorithms designed to help organise
Dermoscopy algorithmsPattern analysis (Pehamberger)
ABCD rule (Stolz)Menzies method7-point checklist (Argenziano)3-point checklist (Soyer)C.A.S.H algorithm (Kopf)
With experience, most will use their instinctbased on integrating all the features or ‘gestalt’
Superior diagnostic efficiency
Pattern Analysis
Melanocytic lesions are defined by colours and structures
Symmetrical distribution – benignBenign global patterns
Reticular, globular, cobblestone, starburst, homogenous, starburst or parallel
Melanoma local featuresDots, globules, blotches, radial streaming/pseudopods, regression structures, blue-grey veil, (polymorphic vessels)
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Benign lesions
Few coloursArchitectural orderSymmetry of patternHomogeneity
Benign naevus patterns
Benign naevi
Common melanocytic naevijunctional, compound & dermal
Blue naevus & combined naevusSpitz naevusCongenital naevusDysplastic naevus
Uniform pigment network
Dx =Benign junctional naevus
Uniform pigment networkMinor asymmetry of structures
Dx = Benign junctional naevus Dx = Benign compound naevus
Globular pattern
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Symmetry of structuresPeripheral reticular networkPatchy central brown globules
Dx = Benign compound naevus
Faint tan homogenous pigmentPeripheral comma-shaped vessels
Dx = Benign intradermal naevus
Homogenous blue pigment
Dx = Blue naevus
Regular pigment networkFocal homogenous blue blotch
Dx = Combined naevus
Starburst patternSymmetric peripheral globulesBlue-black colour
Dx = Spitz naevus
Symmetry of structuresCobblestone-globular pattern
Dx = Benign congenital naevus
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Dx = Benign congenital naevus
Cobblestone-globular patternSymmetry of structuresBlue-brown
Dx = Evolving benign compound naevus
Peripheral brown globulesCentral reticular network
Peripheral rim of globules
Sign of evolving naevi80% will show enlargement if followed
Not limited to Spitz naevi
Kittler H et al. Frequency and characteristics of enlargingcommon melanocytic naevi. JAAD 2000;136:316-20
Fibrillar
Furrow
Lattice
Miyazaki JAAD 2005;53:230-6
Acral naevi
Dysplastic naeviMay share clinical features (ABCD criteria) with melanomaRisk marker for melanomaFrequently large i.e. diameter 10mm+Very broad morphologic spectrumCytological and architectural atypia ranges from mild to severe Can be difficult to distinguish from early melanoma
Dysplastic naevi
5 commonest patternsDiffuse reticularPatchy reticularPeripheral reticular + central hypopigmentationPeripheral reticular + central hyperpigmentationPeripheral reticular + central globules
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At the more atypical end of the spectrumRegression structuresBroadened networkAbrupt network cut-offAsymmetric pigment pattern
Blue-grey veil, pseudopods, radial streaming usually absent
Dysplastic naevi
Dx = dysplastic naevus
Disordered networkRegression structuresCentral brown dots
Dx = dysplastic naevus
Patchy reticular network
Dx = dysplastic naevus
Peripheral reticular networkPatchy inverse networkPatchy hypopigmentationMultiple coloursArchitectural disorder
Melanoma
Melanoma
Multi-colouredArchitectural disorderAsymmetrical multi-component patterns
with 3+ structuresHeterogeneity
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ABCD Rule
Asymmetry2 axes (0-2) x 1.3Border sharpness (0-8) x 0.1Colours LB,DB,B,R,W,BG (1-6) x 0.5Dermoscopic structures (1-5) x 0.5(dots, globules, structureless, network, branched
streaks)
TDS <4.75 benign TDS >5.45 malignant
* ignores regression +vascular structures
* most tedious
Menzies methodNegative features (presence ≠ melanoma)
Symmetry of structuresSingle colour
Positive features (any 1 feature = suspicious)B-W veil Multiple colours (5-6)Streaks PseudopodsScar-like depigmentation Broadened networkDots - brown, black or blue-grey
7 point checklistMajor criteria
Atypical pigment networkBlue-white veilAtypical vascular pattern
Minor criteriaIrregular streaks BlotchesDots/globules Regression
Score of 3 or more = melanoma
3 point checklist
Asymmetry of structuresAtypical networkBlue-white structures
2 of 3 features…suspect malignancy
C.A.S.H. algorithm
Colour (LB, DB, black, red, white, blue)
Architectural disorder (none, mild, mod, marked)
Symmetry (symmetry in 2 axes, 1 axis, biaxial asymmetry)
Homo/heterogeneity (dots/globules, streaks, bwv,regression structures, single colour>10%, polymorphic vessels)
Total C.A.S.H. score (TCS) > 8 (melanoma)
1-60-30-20-7
Dx = Invasive Superficial spreading melanoma
Atypical pigment networkPseudopodsPeripheral black dotsBlue-grey veil
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Dx = In situ superficial spreading melanoma
Multi-component patternExtensive regressionRadial streamingBlue-grey veil
Multi-component patternRegression structuresBlue-white veilRadial streaming/pseudopodsScar-like depigmentation
Dx = Invasive superficial spreading melanoma
Dx = Invasive superficial spreading melanoma
Blue-white veilMulti-component patternRegression structuresPeripheral dots/globulesAtypical pigment network
Regression
Blue-white veil
Dx = 0.4 mm LII SSM
Blue-white veilMulti-component patternRegression structuresBranched streaksAtypical vessels
Image courtesy of Dr Cliff Rosendahl
Focally broadened networkRadial streamingArchitectural disorder
Dx = 0.35mm SSM Dx = 2.3 mm LIII amelanotic nodular melanoma
Polymorphic vessels (glomerular, hairpin & comma)Central pseudonetwork
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Is it benign?Remember…
Menzies two criteria for benignitySymmetry of patternSingle colour
3 point checklist allows one of…AsymmetryAtypical pigment networkBlue grey structures
Which lesions to examine?
Assess as many lesions as possibleAssess any changed lesionAssess any lesion causing concernAssess any distinct lesions (ugly duckling)Assess all clinically suspicious lesions
Bowling J et al. Dermoscopy key points. Dermatology 2007;214:3-5.
High risk patient with changed lesionArchitectural, shape or colour changePigmented lesion with extensive
regressionDermoscopically equivocal lesionsAmelanotic/hypomelanotic lesion with
atypical vessels or milky red globulesSpitzoid lesions
Which lesions to excise?
Bowling J et al. Dermoscopy key points. Dermatology 2007;214:3-5.
Which lesions to excise?
Atypical blue naevi Atypical dermatofibromasLesions lacking clinico-dermoscopic
correlationPresence of inverse network
Argenziano G et al. Dermoscopy features of melanoma incognitoJ Am Acad Dermatol 2007;56:508-13.
Special locationsFacelentigo malignamodified by pseudonetworkGlabrous skinacral lentiginous melanoma parallel ridge patternNailssubungal melanomadisruption of parallelism
Face
All pigmented lesions on the face will show a pseudonetwork which is due to follicular openings
A reticular net is not seen because the rete ridges are effaced
Lentigo maligna (in situ melanoma) has a set of unique dermoscopic features
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Lentigo maligna
rhomboidalstructuresasymmetric pigmented
follicular openings
pseudonetwork
annular-granular pattern
Dx = Lentigo maligna
PseudonetworkAnnular granular patternRhomboidal structures
Rhomboidal structures
Dx = Lentigo maligna
PseudonetworkAnnular granular patternFingerprintingBlack blotches
Dx = Lentigo maligna
PseudonetworkAsymmetric pigmented
follicular openings
APFO
Acral lentiginous melanoma
Parallel ridge pattern = probable melanomaRidges are broader than furrows
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Parallel ridge pattern
Dx =Acral lentiginous melanoma
Melanocytic CriteriaPigment networkPseudonetworkGlobulesStreaksHomogenous blueParallel pattern
‘Irregular dermoscopy pattern’Broad pigmented band made up of lines
of varying pigment, width and spacingLines may end abruptlyDisrupted parallelismSmall blood spots not uncommonNail dystrophy in advanced cases
Nail apparatus melanoma
Braun R et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol 2007;56:835-47
Nail apparatus melanoma
Micro-Hutchinson’s sign
‘Disruption of parallelism’
Braun R et al. Diagnosis and management of nail pigmentations. J Am Acad Dermatol 2007;56:835-47
Nail apparatus melanoma
‘Disruption of parallelism’
b. Non-pigmented lesions
Non-pigmented lesions
Dermal naevusNon-pigmented BCCBowen’s diseaseNon-pigmented solar keratosisSebaceous hyperplasiaHypomelanotic/amelanotic melanoma
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Dermal naevus
Comma vessels
Milial cystsTerminal hairs
Faint tan homogenous pigmentPeripheral comma-shaped vessels
Dx = Benign intradermal naevus
arborisingtelangiectasia
ulceration
Non-pigmented BCCshiny-pink
background
Dx = nodular basal cell carcinoma
Light pink backgroundArborising telangiectasia
Dx = nodular basal cell carcinoma
Light pink backgroundArborising telangiectasia Bowen’s disease (SCC in situ)
hyperkeratosis
glomerular & dottedvessels
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Dx = Bowen’s disease (SCC in situ)
Clustered glomerular vessels
Non-pigmented solar keratosis
Erythema (pink-red pseudonetwork)White-yellow hyperkeratosisYellow keratotic follicular plugs +/- halo Wavy perifollicular vessels
‘Strawberry appearance’ in 95% cases
Zalaudek I et al. Br J Dermatol 2006;155:951-6
Zalaudek I et al. Br J Dermatol 2006;155:951-6
Pink-red pseudonetwork
Yellowish follicular keratotic plugs
‘Strawberry appearance’
Sebaceous hyperplasia
coronal vesselsaggregated yellow
globules
Dx = Sebaceous hyperplasia
Aggregated central yellow globulesMarginal coronal vessels Hypomelanotic & amelanotic
melanomaGreat mimic with several variants
Nodular melanomaPseudo-inflammatory Regressed melanoma
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Dx = Amelanotic nodular melanomaDx = Dermatitis-like hypomelanotic melanoma
Hypomelanotic halo melanoma
Woods lamp
Dermoscopy
Variable pigment networkInverse networkMilky-red or pink veilDispersed atypical vasculaturee.g. linear irregular, dotted, hairpin & corkscrew Milky-red globulesRegression structures
Hypomelanotic melanomamarginal pigment network
inverse network
regression structures
milky pink veil
atypical vessels
Marginal pigment networkInverse networkRegression structuresMilky pink veil
Dx = 0.4 mm LII hypomelanotic melanoma
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Dx = 0.62 mm LII melanoma
Extensive regressionPeripheral brown globulesScattered atypical vessels Acknowledgements
Assorted images provided courtesy of…
Associate Professor John KellyDr Martin HaskettDr Ian McCollDr Cliff RosendahlDr Ben CookDr Greg CanningInteractive CD atlas of DermoscopyA. Marghoob, R. Braun & A. Kopf© 2006 Informa U.K. Ltd
Further ReadingMajor texts/atlasesHandbook of Dermoscopy [Mulvehy]Dermoscopy: The Essentials [Johr]An atlas of surface microscopy of pigmented skin lesions:Dermoscopy [Menzies]An atlas of dermoscopy [Marghoob]
Websiteshttp://www.dermoscopy.orghttp://www.emedicine.com/derm/topic557.htm