Alex Anne Brown, PA-C

Alex Anne Brown, PA-C To request a skin exam with me, click https://nextpatient.co/p/2921/30289/appointments

How many more lives can you save?
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Dermoscopy allows for more accurate diagnosis of sub-clinical melanoma and non-melanoma skin cancers.

Happy Friday, everyone! Figured I’d ask here first 😊 I’m looking for co-authors to assist with research articles and tex...
10/06/2023

Happy Friday, everyone! Figured I’d ask here first 😊 I’m looking for co-authors to assist with research articles and textbook chapters. Hoping to get everything published in 2024. If you’re interested, comment below or DM me 🫶🏻

How often are you overlooking aggressive melanomas? The scalp is a crucial part of a skin exam and must be examined in e...
09/22/2023

How often are you overlooking aggressive melanomas? The scalp is a crucial part of a skin exam and must be examined in every patient.

Scalp melanomas have the highest mortality rates (compared to melanomas on other body sites). These lesions are tricky because they can manifest dermoscopic features of both facial and body melanomas.

Shown here is a 0.2mm melanoma in a 50 yo male with prior history of non-melanoma skin cancer. This lesion was biopsied due to regression structures (gray granularity) and a bland but atypical network.

Please don’t overlook this area on your patients 😳

Where’s the melanoma? 🚩 Shown here is an evolving melanoma in-situ in a 67 yo with no prior history. Even the small lesi...
09/19/2023

Where’s the melanoma? 🚩

Shown here is an evolving melanoma in-situ in a 67 yo with no prior history.

Even the small lesions deserve dermoscopy! What questions do you have?

I’ve missed you all! Im finally started to feel better after a several month hiatus. Thank you to everyone who has checked on me 💕

Comment what you would like to see more of on my account. All suggestions welcome 🙂 In the meantime, what structures do ...
06/14/2023

Comment what you would like to see more of on my account. All suggestions welcome 🙂

In the meantime, what structures do you see here?

Where’s the invasive melanoma? ☠️If you see polymorphous vasculature and shiny white structures, think melanoma! 🚩Shown ...
02/07/2023

Where’s the invasive melanoma? ☠️

If you see polymorphous vasculature and shiny white structures, think melanoma! 🚩

Shown here is a 0.4mm BD, vertical, T1a melanoma in a 70 yo M with no prior history

How often do you skip over the ears during your skin exam? Hopefully never 🚩🚩Shown here is a 0.75mm (at least) BD. Lesio...
02/01/2023

How often do you skip over the ears during your skin exam? Hopefully never 🚩🚩

Shown here is a 0.75mm (at least) BD. Lesion was present at the base. Final thickness TBD

There are 4 stages in the progression of facial melanomas. It often starts as grey dots that accumulate around the hair follicle until they form angulated lines and rhomboidal structures. Late stage melanoma on the face will show homogenous brown areas that obliterate the hair follicles

How do you differentiate a regressing SK from a regressing melanoma? Regression that starts in the center and expands ou...
01/18/2023

How do you differentiate a regressing SK from a regressing melanoma?

Regression that starts in the center and expands outwards is more concerning for melanoma 🚩

When a lentigo/SK involutes, it usually regresses from the outer edge towards the center (centripetally). You can usually see remnants of these benign lesions at the opposite edge.

As a reminder, there are 2 types of regression structures: scar-like depigmentation (fibrosis) and granularity (melanin). Both structures are shown in this example. Granularity is accentuated with non-polarized dermoscopy (3rd photo)

Melanoma in-situ in a 49 yo male with no prior history of skin cancer

Where is the melanoma? 🚩Dermoscopic examination of ALL skin lesions is the only way to identify melanoma that clinically...
01/09/2023

Where is the melanoma? 🚩

Dermoscopic examination of ALL skin lesions is the only way to identify melanoma that clinically appears benign

One of the most common dermoscopic presentations of melanoma in-situ (MIS) is a flat, reticular lesion with subtle atypical network as in this example

Shown here is a MIS in a 66 yo F with history of non-melanoma skin cancer.

Look closely and catch them early ✔️

Don’t overlook melanomas on your high risk patients. On chronically sun-damaged skin, these melanomas can be subtle 😅 Me...
01/06/2023

Don’t overlook melanomas on your high risk patients. On chronically sun-damaged skin, these melanomas can be subtle 😅

Melanomas on sun-damaged skin will often manifest one of the following features:
• Patchy peripheral islands of pigment or structureless areas
• Grey dots/granularity (regression)
• Angulated lines (see Nov 8 post for example)

Shown here is a 0.3 mm BD melanoma in a 68 yo F with no prior history

Please don’t treat melanoma with liquid nitrogen 🥴 If you don’t use dermoscopy prior to LN2, you could be inappropriatel...
01/01/2023

Please don’t treat melanoma with liquid nitrogen 🥴 If you don’t use dermoscopy prior to LN2, you could be inappropriately freezing a melanoma

I’ve seen it too many times to count

Shown here is a 0.2mm BD T1a melanoma in a 65 yo F with no prior history

It is impossible to differentiate a benign lentigo from subtle lentigo maligna without dermoscopyTo make matters more di...
12/19/2022

It is impossible to differentiate a benign lentigo from subtle lentigo maligna without dermoscopy

To make matters more difficult, lentigo maligna dermoscopic criteria cannot be seen in its earliest stages (which is exactly when you want to find them). My favorite method for these tricky lesions is the Inverse Approach

To use this method, look for criteria that rule-in a benign lesion of pigmented AK, seborrheic keratosis (SK), or solar lentigo (SL) rather than looking for lentigo maligna criteria.

For pigmented AKs, look for scales, white and wide follicular openings/rosettes, or erythema. For SK/SL, look for reticular or parallel lines, sharp demarcation, and other classic SK criteria (milia-like cysts, comedone openings, etc.).

One of these features has to be PREVALENT throughout the entire lesion

Shown here is a melanoma in-situ on chronically sun-damaged skin

Lallas A, Lallas K, Tschandl P, Kittler H, Apalla Z, Longo C, Argenziano G. The dermoscopic inverse approach significantly improves the accuracy of human readers for lentigo maligna diagnosis. J Am Acad Dermatol. 2021 Feb;84(2):381-389. doi: 10.1016/j.jaad.2020.06.085. Epub 2020 Jun 24. PMID: 32592885

Beware of the subtle melanomas ☠️Clinically, this lesion looks similar to the numerous lentigines and macular SKs seen o...
12/14/2022

Beware of the subtle melanomas ☠️

Clinically, this lesion looks similar to the numerous lentigines and macular SKs seen on her shoulders. The clue is in the dermatoscope

In melanoma, dots and globules vary in size, shape, and color. You can often find them focally at the periphery of the lesion. If network is present, it is usually atypical which further reinforces the need for a biopsy

Shown here is a 0.3mm BD, t1a melanoma in a 60 year old with no prior history

When you see vessels in a melanocytic lesion, watch out. You might be looking at a melanoma. Vessels in melanoma corresp...
12/07/2022

When you see vessels in a melanocytic lesion, watch out. You might be looking at a melanoma. Vessels in melanoma correspond to dermal invasion

The vessel morphology often depends on the degree of invasion. In thin melanomas, we often see dotted vessels at the center of the lesion. Thicker, more invasive melanomas will usually develop a polymorphous vascular pattern with larger caliber vessels

Shown here is a 0.2 mm T1a melanoma in a 66 yo female

This biopsy was reviewed by 5 different dermatopathologists 😅 Final diagnosis was 0.2mm melanoma arising in a nevusThe m...
12/05/2022

This biopsy was reviewed by 5 different dermatopathologists 😅

Final diagnosis was 0.2mm melanoma arising in a nevus

The most common features seen in melanoma arising in nevi are negative network, globules, and streaks (which we don’t see really here). So that’s when we look for other melanoma-specific structures

Dermoscopic presentation shows atypical network (obvious network on left and blurry delicate network on right). Maybe some early streaking starting on the left but not formed enough to call it streaking. Additionally you can see early formation of a peripheral tan structureless area

Superficial spreading melanoma is the most common type to arise in a pre-existing nevus. This explains the peripheral tan structureless area which corresponds to flattening of DE junction

One side of the lesion is a lentiginous compound nevus while the other side showed 0.2 mm melanoma

When you see grey follicular pigmentation, watch out. Lentigo maligna needs to be on your differential 🚩🚩Partially pigme...
11/30/2022

When you see grey follicular pigmentation, watch out. Lentigo maligna needs to be on your differential 🚩🚩

Partially pigmented follicular openings are an early clue to help differentiate lentigo maligna from a benign lentigo. Often this follicular pigmentation has a grey hue compared to the brown follicular pigmentation seen in lentigines.

Initial biopsy showed atypical melanocytic neoplasm but dermoscopically I was concerned for melanoma. After excision, pathology proved melanoma in-situ with clear margins ✔️

Trust your ~gut~ dermatoscope

Have you missed this game? 😅Where’s the melanoma? When a patient has severe background actinic damage and hundreds of BC...
11/29/2022

Have you missed this game? 😅Where’s the melanoma? When a patient has severe background actinic damage and hundreds of BCCs, it’s easy for your eyes to track from pink spot to pink spot during a skin exam. This can cause you to overlook the subtle pigmented lesions.

Slow down! Your patients deserve a good exam. Shown here is a melanoma (0.2mm BD) with atypical dots/globules and atypical network

Where’s the invasive melanoma? ☠️Angulated lines are sometimes the only feature seen in melanoma on sun-damaged skin 🚩🚩🚩...
11/08/2022

Where’s the invasive melanoma? ☠️

Angulated lines are sometimes the only feature seen in melanoma on sun-damaged skin 🚩🚩🚩 They consist of grey to brown lines that connect at angles before coalescing to form polygons

Shown here is a 0.4mm BD, Clark II, vertical, t1a invasive melanoma

Not all melanomas are clinically asymmetric 🚩 If you limit your dermoscopic exam to just asymmetric lesions or clinical ...
11/02/2022

Not all melanomas are clinically asymmetric 🚩 If you limit your dermoscopic exam to just asymmetric lesions or clinical outliers, you will overlook a melanoma.

Shown here is a 0.5 mm BD, Clark III, vertical, T1a invasive melanoma on a 49 yo female.

Shiny white lines and atypical vasculature are high-risk features seen in this lesion. These features correspond to stromal induction and neoangiogenesis which is why we often see them in thicker, invasive melanomas.

This one was a needle in a haystack 🪡

The first dermoscopic photo was taken in a prone position. The second dermoscopic photo was taken while standing which accentuates vasculature. The third was taken with non-polarized light to demonstrate how the shiny white lines disappear.

Where’s the melanoma? 🫠This evolving melanoma shows a subtle example of scar-like depigmentation which is one of the two...
10/28/2022

Where’s the melanoma? 🫠

This evolving melanoma shows a subtle example of scar-like depigmentation which is one of the two well-known regression structures that can be seen in melanoma.

Oftentimes, scar-like regression looks like a chunk was taken out of the lesion. It is usually a bone-white color that’s lighter than surrounding skin (though these subtle differences don’t always photograph well). Histopathologically, this corresponds to dermal fibrosis.

On chronically sun-damaged skin, dermoscopic features of melanoma can be subtle. Shown here is a melanoma in-situ with s...
10/25/2022

On chronically sun-damaged skin, dermoscopic features of melanoma can be subtle.

Shown here is a melanoma in-situ with subtle dermoscopic findings. It’s important to evaluate lesions in context with the age of patient, skin type, and amount of background actinic damage. Clinically, this was an outlier lesion on sun-damaged skin.

Swipe to see dermoscopic structures ⏩

Where’s the melanoma? 😱 Shown here is an evolving melanoma in-situ with atypical network, foci of grey color, and multip...
10/14/2022

Where’s the melanoma? 😱

Shown here is an evolving melanoma in-situ with atypical network, foci of grey color, and multiple small hyperpigmented areas.

I’m interested to hear what size excisional margins other countries use for melanoma in-situ. This lesion will be excised with 5-7mm margins.

The most sensitive feature for lentigo maligna is the presence of grey color under dermoscopy. Melanoma on chronically s...
10/07/2022

The most sensitive feature for lentigo maligna is the presence of grey color under dermoscopy.

Melanoma on chronically sun-damaged skin often manifests features other than the classic melanoma-specific structures.
▫️Patchy peripheral pigment islands are islands of pigment located at the periphery of the lesion and are usually associated with areas of central hypopigmentation. These “islands” can be reticular network or just structureless brown areas
▫️You could also see tan structureless areas with grey speckles of granularity
▫️Lastly, melanoma on sun-damaged skin often manifests one of my favorite structures, angulated lines!

This example shows patchy peripheral pigment islands (both reticular and structureless) with disorganized areas of hypopigmentation. The color also has a grey hue which is always a clue for lentigo maligna.

Have you ever used a Wood’s lamp for lentigo maligna? 🔦🔮 A Wood’s light is an essential part of the exam as it often sho...
10/06/2022

Have you ever used a Wood’s lamp for lentigo maligna? 🔦🔮 A Wood’s light is an essential part of the exam as it often shows that the melanoma is more extensive than it appears to the naked eye.

I often use a Wood’s lamp to delineate surgical margins, monitor scars for melanoma recurrence, and to plan scouting biopsies.

Shown here is a melanoma in-situ with several key structures that can be seen in melanomas on the face.

Don’t delay the diagnosis of melanoma because you’re afraid to biopsy the face. Shown here is a 0.4mm invasive melanoma ...
10/04/2022

Don’t delay the diagnosis of melanoma because you’re afraid to biopsy the face. Shown here is a 0.4mm invasive melanoma in a 45 yo male with no prior history of skin cancer.

If you can’t confidently say that a lesion is benign, melanoma needs to be on your differential. This lesion has no predominant features that support the diagnosis of a benign nevus, seb keratosis, lentigo, or pigmented AK.

Additionally a few follicular openings had❗️grey ❗️pigmentation. If this were a lentigo, we would expect follicular pigmentation to be the same color brown as the rest of the lesion.

What’s your approach to facial lesions?

Peripheral globules indicate that the lesion is in the radial growth phase. Melanomas in the radial growth phase can als...
09/13/2022

Peripheral globules indicate that the lesion is in the radial growth phase. Melanomas in the radial growth phase can also manifest this same feature❗️

So how do we differentiate benign from malignant?

Peripheral globules are only normal when the center consists of a benign reticular network, homogenous brown color, or diffuse globular center.

In this example, the center of the lesion looks like 💩💩💩 This is not a normal network. Biopsy showed severely dysplastic nevus

In melanomas, dots are irregularly distributed and are often found focally at the periphery of the lesion. Shown here is...
09/07/2022

In melanomas, dots are irregularly distributed and are often found focally at the periphery of the lesion.

Shown here is a melanoma in-situ with different size/shaped dots at the periphery. The network is considered atypical because there is more than one type (thicker, dark network and a thin, delicate network)

There are only 3 acceptable patterns for dots in melanocytic lesions:
• centrally located with typical peripheral network
• overlying typical network lines
• inside the hole of a typical network

What’s the diagnosis? Hint: not a skin cancer and not a tattoo! 😊                                                       ...
09/02/2022

What’s the diagnosis? Hint: not a skin cancer and not a tattoo! 😊

If you’re interested in finding early melanomas, come join me for a lecture on dermoscopy! I’ll review melanoma-specific...
08/31/2022

If you’re interested in finding early melanomas, come join me for a lecture on dermoscopy! I’ll review melanoma-specific dermoscopy structures and the inverse approach for early identification of lentigo maligna🔬

“Oh that’s been there my entire life” Biopsy confirmed melanoma in-situ. What structures do you see here?
08/30/2022

“Oh that’s been there my entire life”

Biopsy confirmed melanoma in-situ. What structures do you see here?

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Bradenton, FL

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