DERMATOSCOPY

1. DERMATOSCOPE AND ITS APPLICATION IN
DERMATOLOGY
SWATHY LEKSHMI J L
4/12/2014

2. Non invasive diagnostic
tool which visualizes subtle
clinical patterns of skin
lesions and subsurface skin
structures not normally
visible to the naked eye

3. HISTORY
1636- Christophorus Kolhaus
1893- Unna
1920- Johann Saphier “Dermatoscopy”
1950- Goldman “Dermoscopy”

4. PRINCIPLE
Trans illumination and magnification
Visibility of subsurface structures improved by LINKAGE fluids
Immersion oil
Olive oil
Mineral oil
Water
Antiseptic solution
Glycerin
Liquid paraffin

5. BASIC DESIGN
Achromatic lens -10
Inbuilt illuminating system-
Halogen lamps
Power supply
Inbuilt photography system

6. TYPES
Instruments without image capturing facility
Image capturing facility
Analytical capability
Videodermatoscope:
Polarised or non polarised video probe that
transmits images to monitor

8. STEREOMICROSCOPE
Allows an accurate
binocular observation
with different
magnifications (X6-80).
The illumination system
includes a halogen lamp
(12 V/50W)

11. TECHNIQUE
Non contact/Contact technique
Noncontact avoid risk of nosocomial
infection
Poor resolution & illumination
Contact plates- Graduated/ non
graduated

12. WHAT IS DERMOSCOPY IS USED FOR?
EVALUATING PIGMENTED SKIN LESIONS
EVALUATING NONPIGMENTED SKIN LESIONS
ENTODERMOSCOPY
TRICHOSCOPY
ONYCHOSCOPY

13. COLOUR
• Epidermis appears white
• Melanin
• Upper epidermis- Black
• DEJ- Light to dark brown
• Papillary dermis- Slate blue
• Reticular dermis- Steel blue

14. • White shades- Regression
melanoma, halo nevus, lichenoid keratosis, scars
• Red shades- Increased vascularisation, bleeding

15. PRIMARY & SECONDARY GUIDE CRITERIA

16. PRIMARY CRITERIA
• Pigmented network lines and hypo pigmented holes
• Histologically- the length of rete ridges and to
distribution of melanin within keratinocytes of
epidermal rete ridges
• Hypo pigmented holes- supra papillary plates
PIGMENT NETWORK

17. MELANOCYTIC NAEVUS
• PN slightly pigmented
• Light brown network
• Thin lines and fade gradually at periphery
• Holes are regular and narrow

19. MELANOMA
• Thickened and
darkened
• Tree like branching at
periphery
• Ends abruptly
• Irregular holes

20. ATYPICAL NAEVI
• Areas of irregular and discrete PN
• Asymmetrically distributed

21. PSEUDOPIGMENT NETWORK
• Homogenous pigmentation interrupted by
hypopigmented hair follicles and sweat gland openings
• Uniform & symmetric in colour and pattern – Benign
• Nonuniform & asymmetric – Lentigo maligna

23. RADIAL STREAMING AND PSEUDOPODS
• Histologically- confluent junctional nests of atypical
melanocytes
• Linear extension of pigment at the periphery of
lesion
• Curved finger like projections, dark brown or black

24. MELANOMA

25. PIGMENTED GLOBULES
• Round or oval, dark brown or black >1 mm
• Histologically -nests of pigmented melanocytes at
the junction in papillary dermis
• Milky red globules- nests of melanoma cells with
increased vascularity

27. Cobble stone pattern- Benign melanocytic lesion
Dark or slate blue irregularly distributed- MM

28. SECONDARY CRITERIA
PIGMENTED DOTS
• Small round or irregularly shaped structures
• Black or dark brown
• Focal accumulations of free melanin or no. of highly
pigmented melanocytes in cornified layers of
epidermis

29. BENIGN
MELANOCYTIC
LESIONS
• Homogenous in
colour
• Regular in shape,
size and
distribution

30. MELANOMA OR
ATYPICAL LESION
• Dots occur at
periphery
• Irregular in
size, shape
and
distribution

31. BLUE- WHITE VEIL
• Ground glass area of
pigmentation
• Blue grey to white in
colour
• Compact orthokeratosis
and hypergranulosis
• Confluent nests of
heavily pigmented
melanocytes in dermis
• Melanoma and Spitz nevi

32. SPITZ NAEVUS – WHITISH BLUE VEIL

33. BLUE GREY AREAS
• Colouration varying
from grey-blue to deep
grey
• Melanin/ hemosiderin
within melanocytes
and melanophages
• Melanoma regression

34. STEEL BLUE AREAS
Structure less, grey-blue and homogenously diffuse
Blue nevi

35. DEPIGMENTATION
Fibroplasia,
telangiectasias
and loss of
melanin

36. INVASIVE MELANOMA

37. NEGATIVE PIGMENT NETWORK
• Lighter serpiginous lines making up
cords and darker areas resembling
elongated tubular or curved globular
like structures
• Thin elongated hypo pigmented rete
ridges accompanied by the presence
of large nests of heavily pigmented
melanocytic cells at dermal papillae
• Highly specific for melanoma

38. CHRYSALIS STRUCTURES
• Thick, short, bright, whitish
linear structures
• Orthogonally oriented
• Changes in composition
and orientation of collagen
• Melanoma, Spitz nevi,
Dermatofibroma ,BCC

39. NONSPECIFIC GUIDE CRITERIA

40. MILIA LIKE CYSTS
• Keratin filled cysts
• White-yellow
circular, 0.1- 1 mm

41. COMEDO LIKE OPENINGS
• Keratin filled within invaginations
of epidermis

42. RED- BLACK LAGOONS
• Small, well defined,
round or oval areas
• Thrombi within the
vascular spaces of
papillary dermis
• Hemangioma and
angiokeratoma

43. MAPLE LEAF- LIKE PIGMENTATION
Heavily pigmented
basaloid cells
BCC

44. VASCULAR PATTERNS
Kreusch& Koch
Thick arborizing vessels- Pigmented BCC
Corona vessels- Sebaceous hyperplasia
Comma shaped- Dermal nevi
Point vessels- Melanocytic trs, Superficial epithelial trs
Hairpin vessels- angiogenesis
Linear irregular vessels- Malignant melanoma

47. PIGMENTED SKIN LESIONS
• MELANOCYTIC LESIONS
• Melanoma
• Benign naevi
• Atypical naevus
• PIGMENTED BCC
• SEBORRHOEIC KERATOSIS
• VASCULAR LESIONS
• MISCELLANEOUS
• Dermatofibroma
• scc insitu

48. Benign Melanocytic
Vs
Malignant melanoma
Pattern analysis
ABCD rule
Menzies’ method
7 point checklist

49. PATTERN ANALYSIS
Step 1: Melanocytic or Non melanocytic
Step 2: Identify the melanocytic lesion by CASH

50. MELANOCYTIC NAEVI
• Few colours, regular design, symmetrical pattern
MALIGNANT MELANOMA
• Several colours, architectural disorder, asymmetry
heterogeneity

51. ABCD RULE
Asymmetry
Border
Colour
Different structural components

54. MENZIES METHOD

55. 7 POINT CHECKLIST

56. MOLE MAPPING
• To monitor atypical
melanocytic lesions
over time
• 3-6 monthly intervals
in multiple atypical
lesions

57. NON MELANOCYTIC LESIONS

58. PIGMENTED BCC
• Pink colour
• Absence of pigment
network
• Arborizing vessels

59. PIGMENTED BCC
Negative feature: Absence of
pigment network + At least one
Linear and arborizing telangiectasis
Leaf-like or structure less areas on
the periphery
Multiple blue gray nodule
Large blue gray ovoid nests
Focal ulceration
Spoke wheel areas

60. SEBORRHEIC KERATOSIS
• Multiple milia like cysts
• Comedo-like openings
• Hyperkeratosis/ fissures/
ridges
• Light brown finger like
structures
• Hairpin blood vessels
• Cerebriform apperance

61. SK with HK, Fissures, Ridges

62. SK- Cerebriform apperance

63. ACTINIC KERATOSIS
• Pink/ red pseudo network& erythema surrounding the
hair follicle
• White to yellow surface scales
• Linear or wavy vessels surrounding the hair follicle
• Hair follicle openings filled with yellowish keratotic
plugs

64. SEBACEOUS HYPERPLASIA
• Central follicular opening
&surrounding yellow
nodule
• Vessels may extend to the
centre of lesion
• Never arborizing

65. DERMATOFIBROMA
• Central white scar like
patch
• Peripheral delicate
network
• Absence of
melanocytic features

66. CLEAR CELL ACANTHOMA
• Homogenous, symmetrically or bunch like
arranged pinpoint like capillaries

67. VASCULAR LESIONS

68. PYOGENIC
GRANULOMA
• Reddish
homogenous areas
• White collarette
• Ulceration
• White rail lines
intersecting the
lesion

69. HEMANGIOMA
Red homogenous
area

70. KAPOSI’S SARCOMA
• Bluish-reddish
colouration
• Rainbow pattern- most
distinctive feature
• Scaly surface and small
brown globules

71. ENTOMODERMOSCOPY

72. LUPUS VULGARIS
• Orange- yellowish globules or areas
• Enhances the diagnosis

73. LEISHMANIASIS
Orange- yellowish globules or areas, linear vessels,
erythema, follicular plugging, hyperkeratosis,
central ulceration

74. SCABIES
• Jet with
contrail
apperance

75. PEDICULOSIS
• Ovoid brownish
structures
• Ovoid translucent
empty structures-
empty nits

76. COMMON WART
• Multiple densely packed
papillae with a central dot
or loop, surrounded by
whitish halo
• Small red to black dots
PLANTAR WART
• Prominent haemorrhage
within yellowish papilliform
surface

77. PLANE WART
Regularly distributed red dots, light brown to
yellow background
GENITAL WART
Mosaic pattern, finger like or knob
like pattern, nonspecific pattern

78. MOLLUSCUM CONTAGIOSUM
• Central pore or
umbilication
• White to yellow
amorphous structures
• Peripheral linear or
branching vessels (red
corona)

79. TICK BITES
• Legs protruding from the skin surface

80. RARE SKIN INFECTIONS
TUNGIASIS
Nodule with a central targetoid brownish ring, which in turn
surrounds a central, black, pore.
CUTANEOUS LARVA MIGRANS
Translucent brownish structure less areas in a segmental
arrangement, corresponding to the body of the larva

81. MYCOSES
TINEA NIGRA
Reticulated pattern , consisting of superficial fine, wispy,
light-brown strands or 'pigmented spicules’
ONYCHOMYCISIS
White to yellow streaks and homogeneous areas in the
distal nail plate.

82. TRICHOSCOPY

83. FINDINGS
• Vascular patterns
• Follicular& perifollicular signs
• Hair shaft characteristics

84. NORMAL SCALP
• Red loops
• Perifollicular pigment network
• Follicular unit- 2-4 terminal hair
1-2 vellus hair

85. SCALP PSORIASIS
Twisted red loops

86. SEBORRHOEIC DERMATITIS
Arborizing red lines

87. ALOPECIA AREATA
• Yellow dots
• Short vellus hairs
• Black hairs
• Tapering and
broken hairs

88. TRICHOTILLOMANIA
• Hairs broken at different levels
• Longitudinal splitting of hair shaft

89. ANDROGENETIC
ALOPECIA
• Variability in hair
shaft diameter >20%
• Peripilar signs
• Yellow dots

90. PRIMARY CICATRICIAL ALOPECIA
• Follicular ostia -
• Fibrous tract+

91. TELOGEN EFLUVIUM
• Yellow dots and short vellus hairs
• Upright regrowing hairs

92. TINEA CAPITIS
• Comma hairs
• Corkscrew hairs
• Zigzag hairs and interrupted (Morse code-
like) hairs

93. HAIR SHAT DISORDERS

95. MONILETHRIX : beading (nodes)
C
O
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E
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T
A
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96. T. invaginata : bamboo, matchstick
C
O
N
G
E
N
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T
A
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97. Pili torti : flattened with irregular twists
C
O
N
G
E
N
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T
A
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98. Wooly hair : crawling snake,short wave
C
O
N
G
E
N
I
T
A
L

99. T.Nodosa : white nodes,
brush-like ends
Acquired

100. Trichomycosis : yellow concretions
Acquired

101. ONYCHOSCOPY

102. • Examine the nail plate from above as well as end-on
• Pigment in the top of the nail plate - proximal matrix
• Pigment at the bottom of the nail plate - distal matrix or
nail bed.

103. Melanocytic naevus of the nail apparatus is
characterised by:
Regular parallel lines
Brown background
Granular inclusions

104. EPITHELIAL MELANIN
• Homogeneous longitudinal
thin grey lines
• Light brown to dark grey
background colour.

105. NAIL MATRIX MELANOMA
• Longitudinal brown to black parallel lines with irregular
colouration, spacing, or thickness
• Disruption of parallelism
• Brown background
• Hutchinson sign: pigmentation of cuticle
• Nail plate fissuring or destruction

107. Microscopic
Hutchinson’s
sign

108. Blood spots are well-circumscribed dots, globules or
blotches
Red, purple, blue, brown or black
SUBUNGUAL HAEMORRHAGE

109. NAILFOLD CAPILLOROSCOPIC INSTRUMENT

110. SD PATTERN
Irregular
extravasations
Dilated loops
Budding

111. Benefits
• Dermoscopy increases the sensitivity for the diagnosis of
melanoma without decreasing the specificity
• Dermoscopy reduces the number of unnecessary
biopsies.
• Dermoscopy allows digital surveillance and monitoring of
in patients with multiple atypical nevi.
• Dermoscopy is useful in the diagnosis and differentiation
of nonmelanocytic benign and malignant tumors

112. Limitations
• The diagnostic accuracy of dermoscopy- experience in the
interpretation of dermoscopy .
• May fail to recognize melanomas that lack specific dermoscopic
criteria (featureless melanomas) .
• Dermoscopy alone cannot establish the diagnosis of malignancy;
histopathologic examination remains the gold standard.

113. THANK YOU