Applied Evidence

Dermoscopy in family medicine: A primer

J Fam Pract. 2018 December;67(12):E1-E11

References

1. Herschorn A. Dermoscopy for melanoma detection in family practice. Can Fam Physician. 2012;58:740-745.

2. Buckley D, McMonagle C. Melanoma in primary care. The role of the general practitioner. Ir J Med Sci. 2014;183:363-368.

3. Mayer JE, Swetter SM, Fu T, et al. Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part I Epidemiology, high-risk groups, clinical strategies, and diagnostic technology. J Am Acad Dermatol. 2014;71:599.e1-599.e12.

4. Mayer JE, Swetter SM, Fu T, et al. Screening, early detection, education, and trends for melanoma: current status (2007-2013) and future directions: Part II Screening, education, and future directions. J Am Acad Dermatol. 2014;71:611.e1-611.e10.

5. Morris JB, Alfonso SV, Hernandez N, et al. Use of and intentions to use dermoscopy among physicians in the United States. Dermatol Pract Concept. 2017;7:2.

6. Salerni G, Terán T, Alonso C, et al. The role of dermoscopy and digital dermoscopy follow-up in the clinical diagnosis of melanoma: clinical and dermoscopic features of 99 consecutive primary melanomas. Dermatol Pract Concept. 2014;4:39-46.

7. Vestergaard ME, Macaskill P, Holt PE, et al. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol. 2008;159:669-676.

8. Westerhoff K, McCarthy WH, Menzies SW. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol. 2000;143:1016-1020.

9. Menzies SW, Emery J, Staples M, et al. Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial. Br J Dermatol. 2009;161:1270-1277.

10. Kittler H. Dermatoscopy: introduction of a new algorithmic method based on pattern analysis for diagnosis of pigmented skin lesions. Dermatopathology: Practical & Conceptual. 2007;13:3.

11. Kittler H, Marghoob AA, Argenziano G, et al. Standardization of terminology in dermoscopy/dermatoscopy: results of the third consensus conference of the International Society of Dermoscopy. J Am Acad Dermatol. 2016;74:1093-1106.

12. Stolz W, Riemann A, Cognetta AB, et al. ABCD rule of dermoscopy: a new practical method for early recognition of malignant melanoma. Eur J Dermatol. 1994;4:521-527.

13. Pehamberger H, Steiner A, Wolff K. In vivo epiluminescence microscopy of pigmented skin lesions I Pattern analysis of pigmented skin lesions. J Am Acad Dermatol. 1987;17:571-583.

14. Menzies SW, Ingvar C, McCarthy WH. A sensitivity and specificity analysis of the surface microscopy features of invasive melanoma. Melanoma Res. 1996;6:55-62.

15. Argenziano G, Fabbrocini G, Carli P, et al. Epiluminescence microscopy for the diagnosis of doubtful melanocytic skin lesions. Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Arch Dermatol. 1998;134:1563-1570.

16. Henning JS, Dusza SW, Wang SQ, et al. The CASH (color, architecture, symmetry, and homogeneity) algorithm for dermoscopy. J Am Acad Dermatol. 2007;56:45-52.

17. Soyer HP, Argenziano G, Zalaudek I, et al. Three-point checklist of dermoscopy. A new screening method for early detection of melanoma. Dermatology. 2004;208:27-31.

18. Lallas A, Moscarella E, Longo C, et al. Likelihood of finding melanoma when removing a Spitzoid-looking lesion in patients aged 12 years or older. J Am Acad Dermatol. 2015;72:47-53.

19. Dupuy A, Dehen L, Bourrat E, et al. Accuracy of standard dermoscopy for diagnosing scabies. J Am Acad Dermatol. 2007;56:53-62.

Benign nonmelanocytic lesions

Dermatofibromas are benign symmetric lesions that feel firm and may dimple upon application of lateral pressure. They are fibrotic scar-like lesions that present with 1 or more of the following dermoscopic features (FIGURE 4):

peripheral pigment network, due to increased melanin in keratinocytes
homogeneous brown pigmented areas
central scar-like area
shiny white lines
vascular structures (ie, dotted, polymorphous vessels), usually seen within the scar-like area
ring-like globules, usually seen in the zone between the scar-like depigmentation and the peripheral network. They correspond to widened hyperpigmented rete ridges.

Seborrheic keratosis (SK) is a benign skin growth that often has a stuck-on appearance (FIGURE 5). Features often include:

multiple (>2) milia-like cysts
comedo-like openings
a network-like structure that corresponds to gyri and sulci and which in some cases can create a cerebriform pattern
fingerprint-like structures
moth-eaten borders
jelly sign. This consists of semicircular u-shaped structures that have a smudged appearance and are aligned in the same direction. The appearance resembles jelly as it is spread on a piece of bread.
hairpin (looped or twisted-looped) vessels surrounded by a white halo.

Other clues include a sharp demarcation and a negative wobble sign (which we’ll describe in a moment). The presence or absence of a wobble sign is determined by using a dermatoscope that touches the skin. Mild vertical pressure is applied to the lesion while moving the scope back and forth horizontally. If the lesion slides across the skin surface, the diagnosis of an epidermal keratinocytic tumor (ie, SK) is favored. If, on the other hand, the lesion wobbles (rolls back and forth), then the diagnosis of a neoplasm with a dermal component (ie, intradermal or compound nevus) is more likely.

Angiomas and angiokeratomas. Angiomas demonstrate lacunae that are often separated by septae (FIGURE 6). Lacunae can vary in size and color. They can be red, red-white, red-blue, maroon, blue, blue-black, or even black (when thrombosis is present).

Angiokeratomas (FIGURE 7) can reveal lacunae of varying colors including black, red, purple, and maroon. In addition, a blue-whitish veil, erythema, and hemorrhagic crusts can be present.

Continue to: Sebaceous hyperplasia...