MAUI, HAWAII – Dermatologists in the know view dermoscopy as a powerful tool to increase diagnostic accuracy in evaluating pigmented lesions; less well appreciated is dermoscopy’s value in building patient trust in the physician, according to Dr. Steven Q. Wang.
"With the dermoscope, people feel like you’re providing a much more detailed exam," observed Dr. Wang, director of dermatologic surgery and dermatology at Memorial Sloan-Kettering Cancer Center’s Basking Ridge, N.J., campus.
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Dr. Steven Q. Wang
"We are a tertiary referral center. We have lots of patients come in who are high risk, with a personal or family history of melanoma and numerous nevi. I always ask why they have transferred their care. The common answer I hear is they feel their dermatologist was not giving them a detailed examination," he said at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.
Dr. Wang said he makes a point of giving every patient a full-body clinical examination, including looking between the toes. And he views every single lesion with his dermoscope, up close and personal, scope to skin.
"The dermoscope makes it easier to spot the outlier lesions, the ugly ducklings. And we’re all so busy in the office, running from room to room – dermoscopy helps me slow down my mind and really look," he explained.
It doesn’t take all that long, either. In a classic multicenter study, 1,328 patients with one or more melanocytic or nonmelanocytic skin lesions were randomized to receive a complete skin examination with or without dermoscopy. The median time for a complete skin examination alone was 70 seconds; with dermoscopy it rose to 142 seconds (Arch. Dermatol. 2008;144:509-13).
"You double the time required, but it’s still only a little over 2 minutes. Yet you’ve changed the patient’s perception," Dr. Wang said.
A digital dermoscope is basically a handheld microscope that permits detailed visualization of structures in the deep epidermis and superficial dermis not visible to the naked eye. There’s a learning curve involved. Dermatologists who pick up a dermoscope and try to use it without formal training have worse diagnostic accuracy than with clinical examination, while experienced dermoscopists have significantly greater diagnostic accuracy than can be achieved with clinical exam alone (Lancet Oncol. 2002;3:159-65).
Dr. Wang said that because patients have more trust in their dermatologist when they feel they are receiving a thorough skin examination including dermoscopy, they are more likely to be adherent to scheduled follow-up evaluations. And that, in turn, spells improved long-term outcomes in patients at elevated risk for melanoma.
This point was already brought home forcefully for him nearly a decade ago, he said, when he and his coinvestigators reported their experience with long-term follow-up of 258 patients at high risk for melanoma. The monitoring strategy consisted of annual total body photography, total skin examination, and dermoscopy. The cumulative 10-year incidence of melanoma was 14% in the 160 patients with classic atypical mole syndrome and 10% in the other 98 high-risk patients. Impressively, all of the melanomas were either in situ or less than 1 mm thick. There were no metastases and no melanoma-related deaths (J. Am. Acad. Dermatol. 2004;50:15-20).
Although dermoscopy is used primarily in examining pigmented skin lesions, it has other applications. For example, in performing Mohs surgery for basal cell carcinomas, Dr. Wang has found dermoscopy to be of assistance in a couple of ways: In patients with ill-defined tumor borders on clinical examination, dermoscopy can define the tumor borders presurgically, thereby reducing the number of Mohs surgical stages required; and when a patient returns for Mohs surgery 6 weeks after skin biopsy and the biopsy site has healed so completely it can’t be found with the naked eye, the dermoscope can identify the site by visualizing subtle scars and telangiectasias.
In general dermatology, Dr. Wang said he turns to dermoscopy as an aid in diagnosing connective tissue diseases, including dermatomyositis, scleroderma, and lupus. He applies ultrasound gel to the proximal nail fold and examines the site using the dermoscope. A finding of dilated blood vessels stands out as a helpful diagnostic clue.
In addition, Dr. Wang said he has utilized the dermoscope in diagnosing scabies by spotting the mites and their trails, in detecting the telltale Wickham striae of lichen planus, and in diagnosing other dermatologic disorders.
Dr. Wang reported having no relevant financial conflicts.
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