Alex Verdieck, MD Richard Usatine, MD **Photographs removed from original presentation for copyright protection

10x magnification lens Enables user to better visualize and recognize the pattern of a lesion Polarized view  pigment/lesion characteristics without light reflection Non polarized view  Uses a fluid interface: etoh,u/s gel and contact  Visualizes surface structures better, glands etc

 nevi vs. melanoma  Identification of SK/dermatofibroma/hemangioma  Basal cell carcinoma

 Improved diagnosis  Reassurance for provider/patient  Decide whether lesion is worrisome enough to warrant biopsy without referral  Provide surveillance of a lesion

PROSCONS  Like technology  Like their apps  Learn more about the nature of skin lesions  Appreciate having the tools that increase their knowledge  Need time to develop skills  Multiple training sessions

 One color  One pattern  Regular pigment distribution

 Asymmetry of lesion  Atypical pigment network  Blue grey structures  2/3 or 3/3 excise

SYMMETRIC ASYMMETRIC  One side almost a mirror image of the other  2 sides appear different

TYPICAL PIGMENT NETWORKATYPICAL PIGMENT NETWORK  Pigment network stops and starts  Irregularly spaced lines  Thickened, irregular lines  Pigment pattern occurs throughout nevus  May be darker in middle, lighter in periphery  Lines of pigment are similar sized

 White, grey or blue coloring within mole  Signifies thickening of the epidermis and/or regression of pigmented cells

 SK  Stuck on appearance  Milia  Comedo-like openings  Cerebroform /brain like appearance  Melanoma  Flush with skin or above surface  Atypical pigment distribution/ color  +/- Blue white structures

 Sebaceous hyperplasia  2-5mm typical size  Yellow-red appearance  Vessels radiation from center  Central depression  BCC  Nodule of varying size  Reddish appearance  Branching vessels

 Crust  Pigment or no pigment  Structure-less areas  Blue grey blobs  Leaf-like structures

NON PIGMENTED BCCPIGMENTED BCC  No pigment  Branching vessels  Crust  No discernable pattern  Leaf like structures  Blue grey blobs  Branching vessels  Crust

 Pink, red or brown coloring concentrated in periphery  Central white patch “chrysalis”

VENOUS LAKEANGIOMA Blue purple or black color 2-10 mm Homogenous coloring  Pink, red, blue or purple color  1-3 mm,  +/- fibrous septations  lacunae

NEVUSMELANOMA  Parallel ridge ✓ ✗ ✗  Parallel furrow  Lattice like “string or pearls”  Fibrillar

NORMAL HISTOLOGY - NEVUSABNORMAL - MELANOMA  Melanocytes group regularly below the furrows and predominantly rise up within them  Melanocytes are are not regularly grouped and predominantly end up in the larger ridges  Varying color

 Purchased $270 scope and $60 book  Internet resources  AAFP article, Usatine et al  Practice  Atlas

 Cc: abnormal mole  CPX  Teaching

 Dermoscope  Book/Atlas  Website resources  Interest in training

 Define objectives  Limited dermoscopy vs everything  Which PGY level?  Identify faculty  Identify resources

 Introduce to residents  One on one training  Lectures focusing on short points (melanoma 3pt checklist, basal cell identification, etc.)  practice in clinic “the pt. has this skin thing..”  Commit to ddx, review characteristics

 Identify teachers/super users  Faculty development  Brush up on biopsy skills and standards of care/TX for skin cancer

 1 dermoscope basics  2 terminology  Dot/streak/globule  3 nevus  4 nevus vs melanoma  5 non-pigmented lesions  dermatofibroma  6 BCC  7 seborrheic keratosis  8 hematologic lesions  angioma vs lake  9 acral skin  nevus vs melanoma  10 nails  line/melanoma/blood

 Materials:  Dermoscope $ x how many clinic sites  Dermoscope for super-user  Camera attachments  Books $  Atlas $  Internet resources $0

 Pocket $  Polarized/non polarized $  Camera /phone attachment $30- $$$$$$

PROCONS  Better diagnosis  More biopsies?  Less referrals?  It’s really fun  Initial cost $500-$1000/site  Time commitment to learn  Can’t bill for dermoscopy  Less biopsies?

 – online curriculum    Atlas of Dermoscopy, Marghoob  Dermoscopy the Essentials, Soyer  Dermoscopy for the Family Physician  – video curriculum

 Remember the history of lesion is important  Path report is the final diagnosis. When in doubt biopsy, refer or provide surveillance  Brush up on biopsy skills and standard of care for cancerous lesions  Beware of residents using/diagnosing with very little knowledge

 two-step-algorithm/id ?mt=8

1. Decide if melanocytic or non-melanocytic -go though the 7 levels of characteristics of known lesions to identify what it is 2. Melanocytic lesions -determine risk and whether to biopsy