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?
Alex Anne Brown, PA-C
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- Alex Anne Brown, PA-C
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How many mo
(7)
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
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
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
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 ✔️
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
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
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
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
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
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
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
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
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
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.
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.
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 ⏩
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.
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.
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.
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?
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
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
09/02/2022
What’s the diagnosis? Hint: not a skin cancer and not a tattoo! 😊
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🔬
08/30/2022
“Oh that’s been there my entire life”
Biopsy confirmed melanoma in-situ. What structures do you see here?
08/26/2022
Two melanomas in the same week manifesting this unique circular structure. My previous post showed an evolving melanoma in-situ with a solitary pigmented circle on the periphery of the lesion. In this example, biopsy showed invasive melanoma (0.2mm Breslow) with a similar structure. This case was discussed with Dr. Marghoob who presented the idea that these structures could be pigmented ostial openings.
(A more scientific term than “weird eyeball” as described on my instagram story 😂)
08/22/2022
Multiple small hyperpigmented areas of irregular shape - a clue for melanoma in-situ.
These are irregularly shaped and they don’t correspond to any other dermoscopic structure.
(These aren’t dots because they are irregularly shaped, not round)
Dr. Lallas explained that these structures correspond to the initial phase of upward migration of melanoma cells into the epidermis. That’s why they appear black in color.
Shown here is an atypical melanocytic neoplasm (AMN) with concern for evolving melanoma in-situ.
08/19/2022
Clinical, dermoscopic, and histologic correlation is important 🚩🚩🚩
Initial biopsy of this lesion showed benign lentigo.
Of course, the lesion was rebiopsied due to clinical and dermoscopic concern for melanoma.
Final biopsy confirmed lentigo maligna.
What features do you see under dermoscopy? 😬🤯😳
08/12/2022
“Sir, I’m sorry to say we biopsied your extra finger”
Biopsy showed traumatized supernumerary digit 🫠😅
08/11/2022
Where’s the melanoma? 😅🤯
Planning margins for excision in lesions like this can be tricky. Sometimes I change the contrast levels on my photos to accentuate certain structures when marking margins (see last photo).
Where do you think the margins are in this example? First or second dotted photo?
08/05/2022
How do you differentiate skin cancer from DSAP? You use dermoscopy.
This patient has widespread DSAP on upper and lower extremities. I examined all erythematous lesions and found this sneaky BCC.
My approach to these patients: examine all lesions, improve the DSAP with lovastatin/cholesterol cream, then repeat the skin exam.
Shown here is a superficial and nodular BCC
DSAP is disseminated superficial actinic porokeratosis
08/03/2022
What’s the diagnosis? 😍
07/25/2022
Where’s the melanoma?
If you see scar-like depigmentation in a melanocytic lesion, you must rule-out melanoma.
Regression structures consist of both scar-like depigmentation and granularity. Granularity can be considered benign in a nevus if it encompasses < 10% surface area. But scar-like depigmentation in a nevus is never normal 🚩🚩🚩
Shown here is a subtle melanoma in-situ
07/23/2022
Where’s the cancer?
Here’s a perfect example of a pigmented squamous cell in-situ ✅
What dermoscopic structures support the diagnosis?
07/20/2022
If you see both dotted and serpentine vessels in a melanocytic lesion, your ONLY differential diagnosis is melanoma.
Shown here is a 0.5mm, partially pigmented melanoma with dotted vessels, subtle serpentine vessels, and remnants of brown color at the periphery.
07/19/2022
Benign lentigo or melanoma?
The network shown here is atypical because there is more than one type. There are sections of delicate, brown network along with obvious gray-brown network fragments (pieces of broken network).
Another clue in this example is the focal presence of atypical dots. These dots are atypical because they occur focally and aren’t associated with a normal network.
Catch them early 💪🏼
Melanoma in-situ
07/17/2022
If you aren’t using dermoscopy, you don’t know what you’re missing (no pun intended 😅)
Dermoscopy allows us to find melanomas that would otherwise be overlooked. Just because a lesion is symmetric, uniform, and one shade of brown does not necessarily make it benign 🚩🚩🚩
Shown here is an atypical melanocytic neoplasm with concern for evolving melanoma in-situ. Interestingly, it is located near a wide local excision of a melanoma from a few months ago (one of my posts from March)
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