“Dermoscopy Rocks” – The Supplemental Tool Can Open Your Eyes to Hidden Signs and Irregularities the Naked Eye Might Miss

The primary reason for using dermoscopy is to gather information you might miss due to limitations faced during the patient visit, noted John Burns, MPAS, PA-C, of the Vancouver Clinic, in a presentation titled Case Based Approach to the Basics of Dermoscopy. Burns ([pictured, right) was amongst the top faculty who delivered new and updated information on dermoscopy-related topics recently at the SDPA Annual Summer Conference in Chicago.  He provided some pearls of dermoscopy, including the following:

1. Dermoscopy is not meant to replace your clinical assessment, but rather supplement. Getting a dermoscopic view can help assure your suspicious about lesions that are concerning.
2. Dermoscopy is not perfect. Dermoscopy findings can be incongruous with the final diagnosis; however, do not get discouraged when the dermoscopic view does not match the pathologic findings or support a clear diagnosis.
3. Photograph, photograph, photograph. You can learn from what you see in a picture. Make sure you get patient consent prior to taking photographs and make sure to place them in the patient’s chart.
4. Dermoscopy is like any tool—practice makes perfect. There is a learning curve to dermoscopy, so the more you use it, the better you get.
5. You want maximum sensitivity and reasonable specificity.
6. Nothing is wrong with a seeking a second opinion or asking for more time to review photos/findings.

SPECIAL COVERAGE: SDPA Annual Summer Conference 2021, Chicago, July 22-25, 2021

Burns continued with an overview of the mechanics of dermoscopy, particularly how light interacts with the skin. Using side-by-side comparisons of the clinical versus dermoscopic view, he illustrated how the dermoscopy can improve the view of many features on the skin that can be easily missed with the naked eye. He explained how fluid (e.g., rubbing alcohol, hand sanitizer) applied to the skin prior to dermoscopic examination allows light to enter and help in visualization of the skin layers.

He showed side-by-side views using polarized and nonpolarized light, concluding that using a hybrid dermatoscope (i.e., a dermatoscope that can switch between polarizations) is ideal because it allows you to see “both worlds.” Next, Burns presented several case photos that clearly illustrated using the two-step algorithm identifying melanocytic and non-melanocytic features of lesions that can be seen using a dermatoscope. Step 1 was an intensive look at non-melanocytic features seen in dermoscopy.

Step 1—Non-melanocytic Features. The first series of case photos clearly demonstrated key features basal cell carcinoma—a non-melanocytic skin cancer. He reviewed the following features typically seen in BCC: “pink bubblegum stroma,” “translucent stroma,” and blood vessels that branch out like a tree, referred to as arborizing blood vessels. Other features of BCC dermoscopic findings include the presence of blue/gray dots and globules, concentric circles or “nests” of BCC, leaf-like areas and “spoke-wheel structures.” Acknowledging the colorful terms for these features, he told the audience, “Once you see these structures, you’ll never forget them!” Following BCC, he gave visual examples seen with dermoscopy for other non-melanocytic lesions, such as “classic” actinic keratosis, squamous cell carcinoma, solar lentigo, lichenoid keratosis, angiokeratoma, clear cell acanthoma, dermatofibroma, sebaceous hyperplasia, and porokeratosis.

Step 2—Melanocytic Features. One take-home message about melanocytic features was the importance of recognizing disruption of certain patterns, which is highly indicative of melanoma. For instance, atypical and negative networks are very characteristic of melanoma. Other tell-tale dermoscopic signs of melanocytic lesions include the following: irregular dots and globules, asymmetrical blotches, tan structureless areas, the “blue-white veil,” scar-like area, blue/gray “peppering,” shiny white structures, which Burns noted can be seen better with polarized light, red globules, polymorphous vessels, milky redness, hyperpigmented patchy areas, angulated lines, prominent skin markings, and streaks.

Next, Burns discussed when key features overlap and lead to uncertain diagnosis. For instance, a lesion that has benign patterns and just one melanocytic feature can be a challenge to diagnose. “These are the lesions we really struggle with,” Burns said.

Burns showed a series of patient cases with photos to bring home his message that “dermoscopy rocks.” The first case was a non-symmetrical lesion with irregular network and streaks. Under dermoscopy, attendees could clearly see malignancy in the lesion. “Early melanoma is where dermoscopy shines,” he said.

Lastly, he provided an overview of the “different flavors of melanoma,” explaining that, “you can’t have a rainbow without rain.” In conclusion, he encouraged dermatology providers to follow a small piece of advice: even if the dermoscopy is bland, don’t let “weird-looking” lesions go!”

Byline: Angela Saba, Managing Editor, Journal of Dermatology for Physician Assistants

Pictured: John Burns, MPAS, PA-C, delivering a presentation during the SDPA Annual Summer Conference 2021 in Chicago (July 22-25, 2021).

Posted: August 13, 2021