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October 19, 2021 / molehunter

Photographing your skin lesions can really help with diagnosis

This older white man had a large lump on his skin. It started to itch and bleed, so he went to see his GP, who was anxious enough to refer him on the skin cancer pathway.

He had taken a decent quality photo of it on his mobile phone.

patient mobile phone image of textbook seborrhoeic keratosis (or crusty wart)

This turned out to be a good idea, as by the time he reached my clinic, the lump had fallen off by itself!

It’s the same lesion, no doubt, but it’s nearly all gone.

Dermoscopy was employed to look for any clues, given that the patient’s own photo shows an obvious seborrhoeic keratosis (crusty wart).

The dermoscopy shows a mostly featureless pattern with a large number of grey dots and dashes (I call them charcoal flecks) which I have come to recognise as a characteristic feature of a resolving traumatised seborrhoeic keratosis. The grey dots and dashes represent thrombosed blood vessels. Another few weeks and they will likely disappear.

Crusty warts like this are very common as we get older, with many 70+ year olds having dozens, occasionally hundreds of them. They are related to age and genetics, not infectious and not pre-cancerous, although it is easy for an untrained person to think they look like a melanoma as they can fail the ABCD rule. They are ‘stuck on’ to the skin, living only in the epidermis (outer layer) and can be picked off when they are thin. We don’t usually treat them in the NHS as we don’t have the capacity, but if they are removed surgically in the private sector they are scraped off not cut out as there is no depth to them. And that is what often happens naturally.

This patient has obviously caught this wart on something, maybe turning over in bed, and sheared it off it’s base. What can be seen on the skin is the resolving trauma. There was no need for me to do a biopsy to prove the diagnosis as I have seen this appearance so often and as the previous photo showed such clear features of a seborrhoeic wart.

It’s really useful for people to photograph questionable skin lesions, as long as the focus and light are got right. I will have more to say about this later. Without this photo, a nervous dermatologist might have felt the need to do a biopsy. As it was, advice including when to recontact was given

October 15, 2021 / molehunter

GP melanoma work from Australia

This link should take you to a 12 minute presentation of some research into GP treatment of melanoma presented by my friend Professor Cliff Rosendahl. Share and enjoy!

https://echo360.net.au/media/4544a833-6ece-4ef9-ad0a-e5f6f8fed27b/public?fbclid=IwAR1LQGdjPmqay9m1gJyH-mLQMxIfl-U_JU7yw5yBdum_STv3rXTL0OaaFGQ

October 11, 2021 / molehunter

Dark skin lesion on leg was harmless

During Covid/Lockdown it has been more difficult for people worried about skin lesions to get to see a doctor, let alone one who is properly trained in skin lesion recognition (*).

This lesion was referred urgently by a practice nurse. It is a solitary, deeply pigmented lesion on an adult, white female leg, so there would be some reason for concern.

suspicious dark lesion on adult female leg

The obvious thing to do is look closer with a dermoscope.

haemangioma

There is one colour (mauve/purple) and one pattern (clods). So, no chaos (trivial degrees of asymmetry are irrelevant). It is a haemangioma, at a glance. Yes there is some whitish/blue out of focus fuzz-this is the fibrous stroma that contains the blood. the above image is on non-polarised dermoscopy. Below is the same lesion imaged with polarising dermoscopy (available at the press of a button on quality dermoscopes).

Haemangioma on polarising view

These shiny white structures represent collagen. Yes, shiny white streaks and clods/strands can be a clue to malignancy-they are seen in BCCs and melanomas. However, this is a clear cut haemangioma with no chaos-so, in this case, the polarising-specific shiny white structures are not clues to malignancy.

Dermoscopy, even with very limited training, can enable primary care health practitioners, including nurses, to triage out benign skin lesions, particularly warts and keratoses and haemangiomas. It’s an easy win.

(*) I have seen several papers proving that melanoma diagnosis has been delayed during Covid Lockdown, and am working on some data from my place of work which I hope to publish that shows the same. Digital teledermatoscopy could help with this.

abcd rule advanced dermoscopy amorphous centre dermoscopy asymmetrical black blotch basal cell cancer BCC benign intradermal naevus benign naevi benign naevus benign skin lesion blue grey structures blue grey veil brown globules chaos on dermoscopy clods dermoscopy dermoscopy course dermoscopy for beginners haemangioma harald kittler harmless mole Iris Zalaudek irregular dots and globules keratin lines reticular looped vesels looped vessels malignant melanoma dermoscopy dermatoscopy early detection saves lives course education Fareham melanoma reticular network SCC seborrhoeic keratosis seborrhoiec keratosis serpentine vessels shiny white streaks shiny white structures skin cancer skin cancer diagnosis squamous cell cancer sun damage sun damaged skin sun exposure suspicious moles ugly duckling wart

September 30, 2021 / molehunter

A second melanoma

A patient around retirement age presented with an obvious melanoma.

Obvious ‘ABCD’ melanoma-asymmetrical shape, irregular border, multiple colours, diameter well over 6mm.

A full skin check was carried out, and a second lesion of interest was discovered, underneath a fringe of hair. I often find skin cancers behind the ears and under fringes.

They had been aware of this but did not mention it to the doctor. The lesion fails ABCD, being irregular is shape, outline and colour and measuring over 6mm.

Dermoscopy shows chaos (asymmetry, multiple colours and structures) and several clues to melanoma. There are irregular dots and globules at around 10 o’clock, a blue-white featureless area just in from there, an irregular dark patch forming up at 4 o’clock, and a number of short brown lines, some angular.

Confirmed as a melanoma, 0.4mm.

LESSON people who have a skin cancer should ideally have a careful full skin check to see if they have another one. I have personally diagnosed about 200 people with melanomas and photographed as many as I could. I have 4 sets of photos of people who had 2 melanomas at first presentation, so about 1 in 50. With basal cell cancers, the figure would be much higher, with 3 or 4 cancers often present (especially in sun damaged elderly men who have had outdoor jobs). The most I have seen at one sitting was 12.

Find a skin cancer, see if you can find another. That’s before we even start on future/subsequent cancers.

September 20, 2021 / molehunter

Virtual International Skin Cancer Diagnostics and Dermoscopy day conference 22nd January 2022

This virtual (Zoom) refresher and update skin cancer diagnostics event is now fully confirmed and the details finalised.

Booking is now open.

It follows on from the very successful first event of this kind organised by the Primary Care Dermatology Society last January. The presenters are all my first choices and are well up in the ranks of the best in the world, representing 7 nations on 4 continents, with a huge weight of collective experience behind them. I have heard all of them present, some several times, and they are all first class communicators as well as experts in their field. In fact, they are so good that I even surrendered the course organiser’s privilege to give a presentation myself so that we could have one more of them! The emphasis is on early and accurate detection of melanoma and other skin cancers. The programme is below (a clearer version can be downloaded from the PCDS site at http://www.pcds.org.uk).

Cost is £75 (no discounts) and this includes 1 month view on demand, which should suit those for whom Saturday is a family/child care day or who might be skiing in late January. This day conference will be of great value to any doctor or nurse whose work involves evaluating skin lesions or doing skin checks, and particularly good for sharpening the skills of any who teach others skin lesion diagnostics. Some prior knowledge is assumed-it will be too advanced for complete beginners- but there is enough time to make a start and get up to speed by getting a book and using some of the resources on this site or linked to from it.

Four of the speakers (Cliff, Harald, Nisa and Beth) were to have presented at the conference I organised for Winchester in June 2020 which was sadly cancelled due to Covid. The others are all worthy of a place.

Cliff Rosendahl and Jeff Keir are expert skin cancer GPs who have taken the ‘routine skin check’ to a new level, as I saw working with them in their clinics when on sabbatical in Australia in the second last winter before Covid. They will show us how to pick up the tiniest melanomas and discuss all aspects of skin screening. I have seen them do it and they are masters. I am so glad they will be sharing their insights with delegates, al the more so since due to Covid/Lockdown, Cliff has been unable to get to Europe to teach as he usually does each year.

The brilliant Harald Kittler from Vienna will discuss the atypical/dysplastic naevus syndrome and what we should do about it. There is much confusion about this syndrome-Harald (who is qualified as a dermatohistopathologist as well as a dermatologist) has unravelled the mysteries of the ‘dysplastic naevus’ by years of meticulously observed sequential digital monitoring. His co-worker Philip Tschandl is well qualified to present an update of sequential digital monitoring for skin cancer-much of the leading work on this subject has come from the Vienna group. The morning concludes with Nisa Akay from Turkey giving an expert update and refresher on pigmented facial lesions.

Iris Zalaudek is a prolific publisher of dermoscopy research, a very popular speaker on the global stage for many years, and recent past President of the International Dermoscopy Society. She will take us on a tour of basal cell cancer variants, followed by current IDS President Aimilios Lallas who will discuss diagnosing difficult melanomas.

Beth Fernandes will show us some instructive cases from Brazil including some lesions in darker skin types, and after tea we will hear from my friend Diane Rolland about the extraordinary work of the Donna Annand Melanoma Charity on Jersey, which has done so much to educate both the public and local GPs.

Ben Esdaile from London, an experienced dermoscopist and teacher, will engage us with some interactive cases, and Prof Kittler will round the day off with an update on new and emerging technologies in skin lesion diagnostics, including the artificial intelligence diagnosis machines we keep hearing so much about. There will be Q&A sessions.

This international dermoscopy refresher and update will be of considerable value to dermatologists, plastic surgeons, GPs interested in dermatology, occupational health doctors, trainees, specialist skin cancer nurses and any clinician whose work involves evaluating skin lesions.

Dr Stephen Hayes

GMC number 2482404

Associate Specialist in Dermatology

University Hospital Southampton

UK board member of IDS

Executive Board member of IDS (Europe)

September 2021

on behalf of the Primary Care Dermatology Society (of Great Britain)