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January 4, 2018 / molehunter

Odd looking mole on shoulder

BY THE WAY a little reminder for 2018. This blog is a free educational resource aimed at doctors and nurses world wide who are using dermoscopy to  diagnose skin lesions. Obviously the general public can see it, and I take that into account as I write. However, it is aimed at medical professionals. All patients have given their consent for their images to be used in education and I am careful to avoid posting identifying features. If anyone has a mole that is changing, or looks weird in any way, you should see a suitably qualified doctor for diagnosis. I don’t offer a tele-consultation service, and if I did I’d have to get suitable indemnity cover and charge people for opinions. I have no intention of doing that-this blog is PURELY FOR EDUCATION.

Please bear this in mind. Happy New Year!

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A middle aged white person presented with this 8mm diameter changing mole on the shoulder.

melanoma 1.9 shoulder (1)

At a glance, we don’t like it. It violates the ugly duckling rule and the ABCD rule. Dermoscopy is hardly necessary, although at this distance it could still just about be an atypical or traumatised benign lesion.

melanoma 1.9 shoulder (2)

Any doubts are now removed, and the only decision to make is how quickly can we get this where it belongs, into a jar of formalin on the way to the histopathologist.

let us consider several diagnostic algorithms.

(A) chaos and clues. Is it chaotic? Yes. There are multiple colours and structures arranged in a disorderly way. Is it a seborrhoeic keratosis? I see no evidence for this. Therefore under the ‘chaos and clues’ algorithm, this will be excised.

Are there any clues? I can see some fragments of disrupted network around 11 and 4 o’clock, pointing to a melanocytic lesion. There are also brown dots and globules which  point to a melanocytic lesion. This leads us neatly into …

(B) the two step algorithm. 

step 1-is it melanocytic? Yes, because of the network and globules mentioned above.

step 2-could it be a melanoma? Yes, because the network, globules and other features are arranged very disorderly.

The two step algorithm is of limited use, but like a tin opener, sometimes it is the perfect tool and you don’t need any other.

(C) the seven point check list

I’m not going to copy the 7 points out, click on the link for a better experience, but they include irregular network, irregular dots and globules, irregular streaks, and irregular pigmentation-all of which we see here. As I as saying to a patient in clinic today, if I was limited to just one word to describe melanoma, the word would be irregular.

So the score is 4 out of 7 of the seven point check list. The original form of this algorithm is a points system, but professor Argenziano, who originated the system, now says that is any one of the seven features are present in a strong, positive form, that is enough to justify excision.

PS the other 3 points are atypical vessels, blue-white veil, and regression structures.

SO, we used 3 different algorithms, and they all gave the same answer. Harald Kittler, whose work I admire, says that he experienced dermoscopist learns and uses all algorithms and then adapts his or her own algorithm. As i see it, algorithms are like tools, or fishing flies, in a box. If carefully chosen, they are all good, but in different situations one will be better than the others. The art is knowing when. Experience comes with viewing and thinking about many cases, which is why I post cases here.

This proved to be a melanoma of medium thickness. Shame it wasn’t removed earlier.

 

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December 9, 2017 / molehunter

Dermoscopy course price reduction

Bookings for our 2018 integrated skin lesion recognition and dermoscopy course are going well, the course is getting on for half booked.  However, as I only recently announced it via the British Association of Dermatologists newsletter, to be fair to  those who will have just heard though this route i extended the early bird discount period to 31st December. Also, I inadvertently posted last year’s top price of £250, so I will honour that. So, if you are a doctor who was about to book at the advertised price of £280, provided you book and pay by New Year’s Eve, you just saved £50 due to my generosity and a typo! I suggest you spend the difference on the excellent text book ‘Dermoscopy, The Essentials’ by Peter H Soyer and friends.

Picture1

December 6, 2017 / molehunter

Dark mark under fingernail

Working in a skin cancer screening clinic, I see a lot of worried people. I am so glad to be able to reassure the majority that they don’t have a skin cancer. At least once a month I see someone with a dark mark underneath a fingernail or toenail.

Melanoma can affect the fingers and toes, but usually pigmentation under the nail is due to blood, regardless of whether the person remembers trauma. The most minimal knock can cause a microscopic droplet of blood to leak under the nail and spread out like a drop of ink between two microscope slides.

Here is a case which presented in a person of darker skin.

nail (2)

This plain view looks a bit worrying as the pigmentation appears black and is continuous with the proximal nail fold, also it’s wider at the base (which is what melanomas can look like) and there appears to be some pigment in the surrounding skin. However, this is a dark skinned person, so pigment change is less sinister, often due to inflammation. Lets look through a dermoscope.

nail (1)

I am immediately reassured, as this looks like blood, not melanin. a decision was made to photograph and review.

This is that the nail looked like 8 weeks later.

nail 3 and 4 (1)

And here is the dermoscopy.

nail 3 and 4 (2)

The pigment has almost all gone, and what we can see is just small linear streaks of blood. There is some ridging in the nail, most likely all due to some forgotten trauma. The patient was spared a painful nail bed biopsy.

I will post a few more images of nails in due course. I don’t have any images of melanoma affecting fingers and toes, they are not common, I have only seen a couple that I remember and was unable to photograph them. For every nail bed melanoma I have seen, I see at least 30 cases of blood under the nail. Dermoscopy is of great value in confirming this diagnosis, if you know what to look for.

For medical learners (for whom this blog is mainly intended although it’s open to the general public) there are some very good pictures of nail melanoma to be found on line. Eric Ehrsam’s blog is good (click on  the link) and YouTube videos by Professor Luc Thomas of Lyon, France. Luc is the acknowledged top expert on dermoscopy of the nail unit and his videos are excellent, here’s a link to one of them (warning, includes images of a nail bed biopsy, not a very nice procedure although sometimes necessary).

 

 

 

November 18, 2017 / molehunter

A nasty nodule

As I was teaching some medical students this week, most of the time when you see a melanoma, you immediately think ‘YECH! that needs to be in a jar-fast!’ This is an example. Just take one look at it-dermoscopy is not necessary.

3.7 melanoma 7 mitoses 1302196 (2)

Everything about this skin tumour is wrong. Let’s apply the ABCDE rule.

A-asymmetrical

B-border irregular

C-colour mixed-in particular there is pink, brown, black and blue

D-diameter you can’t tell on this projection but it was over 1cm.

E-for ERYTHEMA. I know that’s non standard, but the more melanomas I see, the more I am worried about pinkness.

But before all that there is the ‘one glance’ test, the ugly duckling sign. This is a mole you would hopefully, stop a stranger in the supermarket and beg them to get checked.

Anyway, here’s the dermoscopy.

3.7 melanoma 7 mitoses 1302196 (1)

NB the little pepper grain dots everywhere are an artefact, some form of external dirt.

To be honest, the dermoscopy doesn’t add very much, and it certainly doesn’t change our clinical decision. We can see, faintly, some linear-irregular vessels in the pink nodule, a blue-white veil becomes apparent just above and left of centre, and the off-centred black and brown area looks more irregular than we saw on naked eye. But who cares-we already decided it needed excision at one glance. But it’s always worth dermoscopy just to build up your knowledge base of dermoscopic signs of melanoma.

Histology confirmed a nodular melanoma, to nobody’s surprise. A dangerous tumour over 3mm thick that may end this poor person’s life, what a pity it wasn’t caught earlier.

learning point beware the new pink lump, or ‘perilous pink papule’. If this pink nodule had appeared on its own, without the other deeper colours, it would still have been 100% melanoma, just harder to diagnose.

 

 

June 15, 2017 / molehunter

draft patient skin cancer information leaflet page 1

draft skin cancer patient leaflet page 1 Just trying to post this here to see what it looks like. Anyone feel free to comment-this is an ongoing project.

 

June 7, 2017 / molehunter

PDF of June 7th presentation for GPs at RSH

This PDF is for the benefit of the doctors who attended the short presentation at the Royal South Hants’ department of dermatology on Wednesday 8th June. Hayes June 2017 short introduction to dermoscopy

Good hunting!

June 3, 2017 / molehunter

Integrated skin lesion recognition and dermoscopy course dates 9th March and 8th June 2018

Following our 7th successful year of running this course we have now fixed the dates for 2018. Same venue and format, just every increasing experience and more new images and cases. We have had to increase prices by around 10%, first increase since 2014, due to our rising expenses but still believe this to be the best value dermoscopy course in the UK, if not Europe! Booking is now open, reduced priced for bookings before 31st December 2017 and for nurses.

 

ATTENTION I have decided to extend the early bird discount to 31st December. Also, after incorrectly posting the main price as £250 on a national web site, I have owned this honest mistake on my part by reducing the price from £280 to £250. 9th December 2017.

 

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Integrated skin lesion recognition & dermoscopy course

Two Friday afternoons 9th March and 8th  June 2018

An interactive course suitable for all health professionals who have to evaluate suspicious moles. Ideal for GPs, dermatology and plastic surgical trainees, elderly care and occupational health doctors, specialist and practice nurses. No prior knowledge of dermoscopy is assumed. We believe this to be the best value UK dermoscopy course, combining expert presentations, a virtual textbook including all presentations on memory drive and 12 weeks of on -line case discussions.

South Coast Dermoscopy Associates

Dr Stephen Hayes, Associate Specialist in Dermatology, Southampton

Dr Catriona Henderson, Dermatologist, Southampton

Dr Birgit Pees, Dermatologist, Southampton

Between us we have been practicing, studying and teaching dermoscopy for a combined total of well over 50 years and attended numerous international conferences and courses. Over the last 2 years SH has taught dermoscopy in Jersey, Belfast, Kilkenny (with number 1 UK dermoscopy expert Jonathan Bowling), Birmingham, London, St Andrews and various other UK destinations. On 26th April 2017 the South Coast Dermoscopy team taught the first dermoscopy course for dermatology trainees at Willan House in London, HQ of the British Association of Dermatologists.

 

NB the above 3 speakers are intended and expected to be presenting, but may be varied due to circumstances beyond our control.

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9th March and 8th June 2018 Holiday Inn, Fareham, Hampshire + e-learning

Friday afternoons 13.30-17.00                 Hot lunch in restaurant from 12.30 + coffee included

Dermoscopy (dermatoscopy, surface skin microscopy) is an internationally validated technique which is increasingly seen as essential in the evaluation of pigmented and other skin lesions.  Peer review evidence from meta analysis (1) confirms that dermoscopy outperforms naked eye examination of pigmented skin lesions.

A one day dermoscopy course for GPs was shown in a prospective randomised trial to reduce avoidable referrals while missing far fewer skin cancers, only 6 compared with 25 for the control group (2) .

Since we began this annual course in 2011 the skin cancer problem has got steadily worse. Despite steadily  increasing numbers of urgent skin cancer referrals, dangerous skin cancers are still being missed. Missed melanoma as well as the potential tragedy for each patient continues to be the number one reason for doctors in dermatology being sued. Doctors who have done our course have fed back to us that they have picked up melanomas they would otherwise have missed, while reducing their overall referral rates.  This is in line with international published research which shows that GPs’ performance is significantly increased by one day of dermoscopy training. (1)

Our course is designed and delivered by an experienced former GPSI (SH, currently working as a specialty doctor in lesion recognition) and 2 senior skin cancer specialists. Learners should gain excellent skin lesion diagnostic skills, enabling them to safely reassure and advise the great majority of patients worried about harmless lesions and refer questionable lesions to the right person first time.

The course ran successfully each year from 2011 to 2016 with high levels of satisfaction from over 300 participants so far. We have improved the course following feedback. Approval is sought for 7 hours CME.  The 3 teachers attended the 3 day world dermoscopy congress in Vienna in April 2015 and have incorporated up to date evidence based insights from this global event into our teaching. We are booked to attend the 5th world congress in Thessaloniki in June 2018.

Our course begins by stressing the natural history of common and important skin lesions, basics of history taking, inspection and palpation of lesions before going on to what dermoscopy can add.

FREE VIRTUAL TEXTBOOK. learners receive an 8GB memory drive containing all presentations, 100 image based case discussions, PowerPoint presentations of virtual clinics which go through the essentials of skin lesion recognition and demonstrations of how to use various diagnostic algorithms. Some videos will also be included. This amounts to a virtual text book of dermoscopy to enable learning re-enforcement. You can work through it at your leisure and claim additional learning credits.

ON LINE CASE DISCUSSIONS. Participants will join a private Google email group for on line case discussions. Plain and dermoscopic lesion images will be emailed out 2 or 3 times a week for interactive discussion guided by Dr Hayes. Learners can raise any difficulties or questions and even post their own lesion images for discussion. We expect to do at least 30 case discussions, covering all kinds of skin lesion which occur in UK practice. Please, no nhs.net addresses as the security blocks images. Hotmail and  Gmail are suitable free alternatives that work well.

SESSION 2 will recapitulate the whole course including a reprise of the case discussions plus difficult cases and any particular learner issues that come up in the case discussions.

Curriculum

  • Natural history and basic rules of recognition of benign and malignant skin lesions. What to do before you pick up the dermoscope e.g. history, inspection, palpation.
  • Benign naevi. Natural history and development, various types, flat and raised moles. How to make a safe and positive diagnosis of benignity. Various network and globular patterns, vessels that point to benignity. Red flags and question marks
  • Seborrhoeic keratoses. Recognising their wide range of appearances. Dermoscopic features which allow a safe diagnosis. Traumatised warts-the sheep in wolf’s clothing-
  • Haemangiomas, recognising their dermoscopic features.
  • Melanomas-the range of presentations. Red flag features not to miss. Key dermoscopic features including abnormal networks, streaks, globules, blue grey veil, regression structures. Hypopigmented and amelanotic melanomas, ‘featureless’ melanomas, the deadly and deceitful pink nodule.
  • Basal cell cancers, vessels, pigmented structures, micro ulcers and other features.
  • Miscellaneous skin lesions including Bowen’s disease, dermatofibromas, scabies etc.
  • Diagnostic algorithms including 2 step, 3 point, 7 point, heuristic method, pattern analysis and an introduction to the new descriptive dermoscopic terminology of Harald Kittler.
  • Mole mapping and skin monitoring for high risk patients e.g. the dysplastic mole syndrome.
  • All presentations plus other material will be included on the memory drive. We decided to trust you on this as we believe it will be a better learning experience, but must ask you to respect our copyright on this material. We don’t mind you using the presentations for bona fide, in-house professional education with colleagues at your place of work, but you must not publish, copy, distribute or use any part of them in any other way.

 

We believe the above is a balanced and comprehensive curriculum which addresses all the important Primary Care issues about skin cancer triage, diagnosis and referral, but if other issues are raised by learners they can be addressed due to the nature of this course which runs on line over 12 weeks.

For all enquiries contact Dr Stephen Hayes at stevehayes272@gmail.com

Learners may also be interested in my blog at www.dermoscopy.wordpress.com where case discussions, links to other on line learning resources and details about the course may be found.

COST £220 for doctors, £150 for nurses if booked by 1st December 2017, £280/£170 thereafter.

Refund on application less £30 admin fee if requested before 10th February 2018, none thereafter. Discretionary deferment (minus £30 admin fee) to the 2019 course for bereavement, injury etc occurring after the above cancellation period.  People who cannot make one or other of the Friday sessions and declare this at the time of booking will receive £25 discount.

payment by BACS  30-90-85, 21513968 or cheque to South Coast Dermoscopy Associates,

96 Winchester Street,

Botley,

Hampshire SO30 2AA.

 

Dr Stephen Hayes                                              South Coast Dermoscopy Associates

 

(1) as in the meta-analysis by Vestergaard et al (British Journal of Dermatology. 2008; 159:35-48.)

(2) http://www.ncbi.nlm.nih.gov/pubmed/16622262).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION FORM  please type or write clearly and post or email to stevehayes272@gmail.com

 

Dear Dr Stephen Hayes

I wish to apply for a place on the South Coast Dermoscopy Associates skin lesion and dermoscopy course 2018. I have read, understood and accept the above terms. In particular, I will not make any use whatever of the images and other learning material in the memory drive or discussion group other than as permitted above.

Name

Address

Email address

GMC/CNG number

If you are a nurse please state your place of work and employer

Position (e.g. GP, specialist, specialist registrar, specialist nurse, APN, practice nurse etc.)

please tick one box. If applying for more than one person, please print multiple copies.

Doctor, early booker discount pre 31.12.17 £220
Nurse  as above £150
Doctor, post 1.12.17 £250
Nurse as above £170

 

 

To reduce costs, a receipt will be sent by email only and no reminders will be sent.

for directions see http://www.holidayinn.com/hotels/us/en/fareham/soafa/hoteldetail

Please note, the venue is 15 minutes by taxi from Southampton Airport, which is well served with flights from Dublin, Belfast, Paris, Amsterdam, Glasgow, Edinburgh, Manchester and several other major European cities.