Dermoscopy of Malignant Skin Tumours: What's New?

Dermoscopy represents a new and effective tool that assists dermatologists in improving the accuracy of clinical diagnosis in onco-dermatology. The aim of this article is to provide an overview of the latest and important dermoscopic progress and observations in this ever-evolving field of dermatology.

Dermatoscopy of facial actinic keratosis, intraepidermal carcinoma, and invasive squamous cell carcinoma: a progression model.

BACKGROUND: Little is known about the dermoscopic features of keratinocyte skin cancer. OBJECTIVE: We sought to determine the dermoscopic features of facial actinic keratosis (AK), intraepidermal carcinoma (IEC), moderately to poorly differentiated invasive squamous cell carcinoma (SCC), and well-differentiated SCC of the keratoacanthoma type. METHODS: This was a retrospective analysis of dermoscopic images of histopathologically diagnosed keratinocyte skin cancer. RESULTS: A total of 243 (70 AK, 71 IEC, 78 SCC, and 24 keratoacanthomas) tumors of the face from 243 patients (mean age: 71.1 years; range: 44-94 years) were analyzed. The majority of patients had a fair skin type, history of melanoma or nonmelanoma skin cancer, and multiple AK. A red pseudonetwork was significantly associated with AK (P < .001), whereas dotted/glomerular vessels, diffuse yellow opaque scales, and microerosions were significantly more prevalent among IEC (P < .001). Hairpin vessels, linear-irregular vessels, targetoid hair follicles, white structureless areas, a central mass of keratin, and ulceration were significantly associated with invasive SCC (P < .001 for all criteria). Similar patterns as in SCC were observed among keratoacanthomas. LIMITATIONS: The retrospective design of our study and the lack of assessment of sensitivity and specificity of the dermoscopic criteria are limitations. CONCLUSIONS: Based on our findings we propose a progression model of facial AK developing into IEC and invasive SCC.

Total body skin examination for skin cancer screening in patients with focused symptoms.

BACKGROUND: The value of total body skin examination (TBSE) for skin cancer screening is controversial. OBJECTIVE: We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE. METHODS: In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE. RESULTS: We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas. LIMITATIONS: The impact of TBSE on skin cancer mortality was not evaluated. CONCLUSIONS: TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.

How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part I. Melanocytic skin tumors.

Dermoscopy is a noninvasive tool that can be helpful in the diagnosis of nonpigmented skin tumors. This is because dermoscopy permits the visualization of key vascular structures that are usually not visible to the naked eye. Much work has concentrated on the identification of specific morphologic types of vessels that allow a classification into melanocytic versus nonmelanocytic and benign versus malignant nonpigmented skin tumors. Among a broad spectrum of different types of vascular patterns, six main morphologies can be identified. These are comma-like, dotted, linear-irregular, hairpin, glomerular, and arborizing vessels. With some exceptions, comma, dotted, and linear irregular vessels are associated with melanocytic tumors, while the latter three vascular types are generally indicative of keratinocytic tumors. Aside from vascular morphology, the architectural arrangement of vessels within the tumor and the presence of additional dermoscopic clues are equally important for the diagnosis. This article provides a general overview of the dermoscopic evaluation of nonpigmented skin tumors and is divided into two parts. Part I discusses the dermoscopic vascular patterns of benign and malignant melanocytic skin tumors. Part II discusses the dermoscopic vascular patterns of benign and malignant nonmelanocytic nonpigmented skin tumors. In each part, additional special management guidelines for melanocytic and nonmelanocytic nonpigmented skin tumors, respectively, will be discussed.

How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors.

Nonmelanoma skin cancer refers to a broad class of tumors, including actinic keratosis, basal cell carcinoma, and squamous cell carcinoma, and as a group these are the most frequent cancers occurring in light skinned humans. In contrast to the rarity of amelanotic melanoma, nonmelanoma skin cancer commonly lacks pigmentation. Although these tumors rarely cause death related to metastases, they commonly destroy underlying tissues and should be removed at the earliest possible stage. Dermoscopy improves the clinical diagnosis of nonpigmented skin tumors by allowing the visualization of specific vascular structures that are usually not visible to the naked eye. Dermoscopic vascular patterns of several nonmelanocytic nonpigmented skin tumors, such as sebaceous hyperplasia, seborrheic keratosis, clear cell acanthoma, Bowen disease, or nodular cystic basal cell carcinoma are highly specific, allowing a ready diagnosis in most cases. Others, such as actinic keratosis, pyogenic granuloma, or uncommon adnexal tumors, may be difficult to differentiate even with the aid of dermoscopy. For this reason, general guidelines have been established to assist in making the most appropriate management decision. In the second part of this review of dermoscopic vascular structures of nonpigmented skin tumors, the dermoscopic patterns associated with benign and malignant nonmelanocytic skin tumors and recommendations for the management of these tumors will be discussed.

Entodermoscopy: a new tool for diagnosing skin infections and infestations.

BACKGROUND: There is upcoming evidence that dermoscopy facilitates the in vivo diagnosis of skin infections and infestations. As such, dermoscopy connects the research fields of dermatologists and entomologists, opening a new research field of 'entodermoscopy'. OBJECTIVE: To provide an overview on the current applications of entodermoscopy. METHODS: Systematic review of the English- and German-language literature by searches of Medline, Medscape and abstracts of the 1st World Congress of the International Dermoscopy Society. RESULTS: Dermoscopic patterns have been described for viral warts, molluscum contagiosum, scabies, pediculosis, tinea nigra, tungiasis, cutaneous larva migrans, ticks and reactions to spider leg spines. Besides the diagnostic role of dermoscopy, there is increasing evidence that it can also assist in the monitoring of treatment efficacy for some of these conditions. CONCLUSION: Although most of the current available literature is based on single observations and small case studies rather than controlled trials, an increasing interest in this field can be observed.

Never perform laser treatment of skin tumors with clinical "EFG" criteria.

Laser treatment is a common procedure for the treatment of cosmetically troubling skin lesions but has the limitation that histopathologic diagnosis is usually not obtained prior to treatment. Laser treatment of melanomas with benign clinical features may delay or make more difficult the correct diagnosis of such tumors. A helpful tool to identify clinically innocent appearing melanomas is the "EFG" rule, summarizing the common clinical features as "elevated, firm skin lesions showing continuous growth". We report a 42-year-old woman who presented with a recurrent and metastatic melanoma after laser treatment of a tumor which was apparently clinically innocent and highlight the clinical features of such benign-looking melanomas.

Dermoscopy patterns of fibroepithelioma of pinkus.

BACKGROUND: Fibroepithelioma of Pinkus (FeP) is a rare variant of basal cell carcinoma that may clinically mimic a number of benign skin tumors. While the dermoscopic features of basal cell carcinoma have been studied extensively, little is known about the dermoscopic features of FeP. OBSERVATIONS: Retrospective evaluation of clinical records and digital clinical dermoscopic images of 10 histopathologically proved FePs (6 nonpigmented and 4 pigmented) was performed. Clinically, no FeP was correctly identified and, in half of all patients, a clinical differential diagnosis of purely benign skin lesions was made. Dermoscopy enabled the correct diagnosis in 9 of 10 FePs, based on the presence of fine arborizing vessels, either alone or associated with dotted vessels, and white streaks (in 100%, 70%, and 90% of lesions, respectively). In the 4 pigmented FePs, a structureless gray-brown area of pigmentation and variable numbers of gray-blue dots were observed, in addition. CONCLUSIONS: Dermoscopy is helpful in diagnosing FeP and in differentiating this variant of basal cell carcinoma from other benign skin tumors commonly included in the clinical differential diagnosis. This presumes, however, that dermoscopy is used as a first-line examination for all skin lesions, not only for those that are clinically suspect.

"Tape dermatoscopy": constructing a low-cost dermatoscope using a mobile phone, immersion fluid and transparent adhesive tape.

IMPORTANCE: Medical professionals and indeed the general public have an increasing interest in the acquisition of dermatoscopic images of suspect or ambiguous skin lesions. To this end, good dermatoscopic image quality and low costs are important considerations. OBSERVATIONS: Images of seven lesions (seborrheic keratosis, melanoma in-situ, blue and dermal nevus, basal cell carcinoma and two squamous cell carcinomas) were taken. A novel technique of "tape dermatoscopy" involved: Using immersion fluid (i.e., water, olive oil, disinfectant spray) placed on the flat or slightly elevated lesion;Covering the lesion with transparent adhesive tape with lateral tension;Using ambient indoor or outdoor lighting for illumination (rather than flash photography);Positioning a photographic device at an angle of approximately 45° from the side of the lesion to avoid light reflection;Recording a focused image with a mobile phone or digital camera at a distance of approximately 25-30 cm from the lesion; andEnlarging the image on the screen of the device. Essential dermatoscopic features enabling a correct diagnosis were visible in 6 of the 7 lesions. 'Tape dermatoscopy" images of the lesions were compared to standard dermatoscopy (using a Fotofinder handyscope® in combination with a mobile phone). The latter confirmed the dermatoscopic features in six of seven lesions. CONCLUSIONS AND RELEVANCE: "Tape dermatoscopy" images can be recorded by medical personnel and even the general public without a dermatoscope. However, the limitations of this method are that images may be unfocused, exophytic tumors may be difficult to assess, excess pressure on tumoral blood vessels may lead to compression artefact, dermatoscopic features that are only visible under polarized light are unable to be detected (particularly "crystalline" or "chrysalis" structures) and tumors in certain anatomic locations may be difficult to assess (e.g., edges of nose, ears [demonstrated in one case], nails). Comparative prospective studies are necessary in order to test reproducibility of these preliminary findings, to establish special indications for the technique, and to develop guidelines for its effective use.

Twenty nevi on the arms: a simple rule to identify patients younger than 50 years of age at higher risk for melanoma.

Patients with a high total nevus count (TNC) merit a total-body examination, but a simple strategy to identify these high-risk individuals is essentially missing. The aim of this study was to investigate the correlation between the number of melanocytic nevi on both arms and the TNC, and to evaluate patient variables that may have an effect on this association. In this multicenter, cross-sectional study, 2175 patients were examined and the mean number of arm nevi in relation to TNC was calculated. A mean value of fewer than 10 arm nevi was found in patients with TNC lower than 51 and a mean value of greater than 19 arm nevi was scored in patients with TNC greater than 50. These values remained unchanged after adjustment for various patient variables. In relation to TNC greater than 50, the presence of 20 or more arm nevi had specificity and negative predictive values of 95.2 and 89.6%, respectively. The sensitivity was 65.5% in patients younger than 50 years of age and 37.5% in the older age group. The number of arm nevi was significantly higher in individuals with a history of melanoma and in those with a melanoma detected during the study period. The presence of 20 or more nevi on the arms is an independent predictor of a high TNC and risk of melanoma. This sign thus represents a simple and rapid screening tool for either the primary care physician or the dermatologist to help identify high-risk patients.

Pink lesions.

Dermoscopy (dermatoscopy or surface microscopy) is an ancillary dermatologic tool that in experienced hands can improve the accuracy of diagnosis of a variety of benign and malignant pigmented skin tumors. The early and more accurate diagnosis of nonpigmented, or pink, tumors can also be assisted by dermoscopy. This review focuses on the dermoscopic diagnosis of pink lesions, with emphasis on blood vessel morphology and pattern. A 3-step algorithm is presented, which facilitates the timely and more accurate diagnosis of pink tumors and subsequently guides the management for such lesions.

A clinico-dermoscopic approach for skin cancer screening: recommendations involving a survey of the International Dermoscopy Society.

Dermoscopy is useful for skin cancer screening, but a detailed approach is required that integrates this tool into a rational clinical work flow. To investigate clinician perceptions and behavior in approaching patients with skin tumors, a survey was launched by electronic mail through the International Dermoscopy Society. After 4 months, the responses were analyzed and significant findings calculated. Considering the current approach of study participants in examining patients for skin cancer, an up-to-date system of triage is presented in this review, which aims to promote an improved diagnostic accuracy and more timely management of skin malignancy.

Improving triage and management of patients with skin cancer: challenges and considerations for the future.

Skin cancer is the most common malignancy in humans, thus representing a major health concern. Because of the increasing attention to skin cancer prevention, there has been a growing workload for dermatology clinics, with patients referred from primary care requiring assessment of suspicious skin tumors. This places a strain on limited specialist resources and can create a paradoxical situation wherein an early diagnosis becomes increasingly difficult for those patients who actually do suffer from skin cancer. The aim of these recommendations is to propose an updated, rational system of triage, involving improved accuracy of diagnosis and more timely management of skin cancer by both general practitioners and dermatologists.