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

2. 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

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

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

5. 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

7.  One color  One pattern  Regular pigment distribution

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

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

10. 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

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

12.  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

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

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

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

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

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

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

20. 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

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

22.  Cc: abnormal mole  CPX  Teaching

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

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

25.  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

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

27.  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

28.  Materials:  Dermoscope $200-800 x how many clinic sites  Dermoscope for super-user  Camera attachments  Books $50-100  Atlas $150-300  Internet resources $0

29.  Pocket $250-400  Polarized/non polarized $500-1000  Camera /phone attachment $30- $$$$$$

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?

31.  www.dermoscopy.org – online curriculum www.dermoscopy.org  www.dermnetnz.org  www.dermoscopyatlas.com  Atlas of Dermoscopy, Marghoob  Dermoscopy the Essentials, Soyer  Dermoscopy for the Family Physician http://www.aafp.org/afp/2013/1001/p441.html http://www.aafp.org/afp/2013/1001/p441.html  www.dermoscopymadesimple.blogspot.com – video curriculum www.dermoscopymadesimple.blogspot.com

32.  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

34.  https://itunes.apple.com/us/app/dermoscopy- two-step-algorithm/id731753300?mt=8

35. 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