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1 Dermoscopy Australasian College of Dermatologists G.P Training Module Synonyms Dermoscopy Dermatoscopy Epiluminescence microscopy Skin surface microscopy Incident light microscopy Oil immersion microscopy In vivo cutaneous surface microscopy Definition Non-invasive in vivo technique 10X magnification & bright illumination Transparent medium or Polarised filter …minimise skin surface reflectance Polarised filter Dermoscopy Allows visualisation of subsurface structures 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 network Fades at periphery

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Page 1: Dermoscopy for ACD - gplearning | Logingplearning.racgp.org.au/.../Module2/.../Dermoscopy_Presentation.pdf · G.P Training Module Synonyms Dermoscopy ... Acral skin & nail apparatus

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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