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March 2, 2018 / molehunter

A solitary dark mole on the back

Melanoma often occurs on the back, due to sun exposure. Sometimes it may grow for longer before being noticed than, say, on the arm or neck. People should check their backs, and each others’ backs. Or be like me, get a photo of your back as a reference-a mole that is new or changing is easier to detect if you have a photo.

Here’s a mole on someone’s back. There was doubt about how long it had been there for, but it was felt to be new and changing.

case 1 (A)

We worry about a single mole that stands out, the term ‘ugly duckling’ is used, although technically that refers to one out of several moles that stands out. On this view, the mole deserves further evaluation, although it could still be OK. Especially if it has been there for many years without changing (like I said, photography helps establish this.)

Dermoscopy.

case 1 (B)

Wrong. Too many colours, too many structures, lack of symmetry. I see irregular network, dots and globules, irregular black blotches, and a blue-white featureless area. More than enough to justify excision whichever algorithm the dermoscopist is using.

This was a thin, hopefully curable, melanoma.

Beware the ugly duckling, watch your back.

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February 24, 2018 / molehunter

A new, firm and growing pink lump on a middle aged woman’s leg

I always teach that there are four steps to doing skin lesion recognition properly. Step one is for the learner to stock their brain with correct information about the natural history of common and important skin lesions. (*) The web makes it easier to do this than it has ever been before, and is why I blog here. If the doctor or nurse has mastered step one, the description at the top of this post will have grabbed their attention and they will be anxious before even seeing the spot, lump or mole.

(2)

Here we are, a pink lump on the front of a middle aged woman’s shin. What could it be? It has to be something. It looks around 8-10mm and is irregular. Will dermoscopy give us any additional information? Let’s have a look.

(1)

I can see a pink background (no news there) many shiny white structures of various shapes and sizes, and with care some irregular blood vessels. The overall appearance is chaotic, and there are clues to amelanotic melanoma. Also, (diagnosis of exclusion) there are no features pointing to any other kind of skin lesion (e.g. wart, haemangioma, benign naevus, BCC etc).

This was excised as fast as possible. I was sorry but not surprised that it was a nodular non-pigmented (amelanotic) melanoma. In fact, a text book case.

A distinguished dermatologist once told me that I should not waste my time teaching dermoscopy to GPs, ‘You should tell them about the dangers of the new, firm, growing pink nodule instead.’ he said. We had this conversation a few times, and I said ‘I’m going to take half of your advice.’

The new, firm, growing pink nodule (especially in sun exposed locations in older white patients) is a RED FLAG warning sign. non-pigmented melanomas are very dangerous as they don’t look like the ‘typical’ black and other colours mole we are expecting to see, and also as they are biologically more aggressive for genetic reasons I won’t go into here.

Seven times beware the perilous pink papule. Patients can die, doctors can get sued, because you should have known.

 

(*) step 2, listen to the patient’s description of the lesion’s development, step 3 is to examine it, step 4 is dermoscopy. Then put it all together to make a rational decision above all answering the question-is this lesion safe, or not.

February 17, 2018 / molehunter

International dermoscopy day conference 28th November 2018

Advance notice:

‘International dermoscopy update and refresher day conference, Wednesday 28th November 2018’

This day refresher and update day conference presented by South Coast Dermoscopy is designed for Dermatologists, GPwSIs, and all clinicians using dermoscopy to evaluate skin lesions. We are delighted to welcome guest teacher Professor Luc Thomas from Lyons, France. Prof Thomas is a board member of the International Dermoscopy Society and the acknowledged world expert on nail unit tumour dermoscopy.

The programme will include dermoscopy of hypomelanotic and other difficult melanomas, the nail unit, diagnostic algorithms, pattern analysis, vessels, mole mapping and monitoring, descriptive (Kittlerian) terminology, insights and highlights from the 5th world dermoscopy congress (June 2018, Greece) and many new cases for interactive discussion.

Early bird price of £220 if booked by 1st June, thereafter £250. Hot lunch in seated restaurant, vegetarian options. Detailed programme to be published after world congress in June-we are all going to the congress in Thessaloniki and expect to gain insights form the world’s top experts on dermoscopy which we will feed back to delegates on this course. 6 hours CPD applied for.  Location Fareham, Hampshire. Details and application form from stevehayes272@gmail.com .

This day conference is not for beginners, but should be of benefit to any clinician who is regularly using dermoscopy and would like to refresh and top up their knowledge and understanding. As well as appealing to dermatologists, it is designed for doctors and specialist skin cancer nurses who have already participated in our annual Integrated Skin Lesion Recognition and Dermoscopy course which we have presented annually at Fareham since 2011. We will present mostly new cases that learners will not have seen before, Professor Thomas’s cases will all be new to us. I believe this is the first time he has presented at a dermoscopy conference in Britain.

If this international dermoscopy conference is a success, as we hope, we plan to repeat it annually or biannually with a different overseas guest speaker each time. Booking is not yet open but interest may be declared, if interested please keep the day free. Further announcements including a timetable and booking form will appear here.

The Holiday Inn, Fareham, is half way between Portsmouth and Southampton, 20 minutes by taxi from Southampton Parkway airport and station (frequent direct trains from London Waterloo) and convenient for the M27.

February 13, 2018 / molehunter

Dodgy dark mole on the trunk

This mole isn’t very large, but it stands out and may have changed recently. It’s OK by the ABCD rule as it looks oval, smooth and just one colour.

Dermoscopy changes everything.

2CA220B2-A3B5-4A50-89FB-F60EBDC0F887Multiple colours and structures = chaos. What clues?

there are peripheral streaks and globules (arguably pseudopods) from 6 to 9 o’clock, clues to melanoma. There is also a fuzzy blue-white haze, or blue white veil, on the right, a strong clue to melanoma. Also shiny white structures in the body of the lesion ( formerly called the chrysalis sign, a term best avoided). These also are a clue to melanoma. I’d bet my favourite guitar (a lovely cherry red maple flamed 2013 Les Paul) this is a melanoma.

The diagnosis of melanoma was confirmed, it was thin so hopefully this patient would be one of the 85% of all melanoma patients who are cured . Nearly 100% are cured by early detection and surgery.

Look again at the mole on the plain view, doesn’t look that impressive, does it? Dermoscopy works, and should be readily available by a trained person (ideally the person’s GP) who is worried about a new or changing mole.

PS this dermoscopy image was posted previously, but without the plain view.

February 10, 2018 / molehunter

Dots and globules on dermoscopy

I was in Essex last Wednesday teaching on a Primary Care Dermatology Society (www.pcds.org.uk) with long term friend and colleague Dr Stephen Kownacki. The PCDS runs Dermoscopy For Beginners day courses for GPs around the country, we had some 50 local GPs at this meeting, run in conjunction with the regional Royal College of GPs. I enjoyed myself and we had good feedback. (*)

As ever, I mentioned to the learners that there is a fantastic, and free, learning resource of dermoscopy videos on YouTube by board members of the International Dermoscopy Society. I have just been watching one by Ashfaq Marghoob, probably the top US dermoscopy doctor. I recommend it, and all the other IDS videos, to all dermoscopy learners.

(*) The PCDS also runs advanced dermoscopy courses for improvers and experts twice a year in London and Manchester. recommended for those who have been on an introductory course and are experienced and want to improve their skills.

February 6, 2018 / molehunter

black mark under finger nail-could it be melanoma skin cancer?

Following up my recent post about blood under a toenail, here are 2 sequential pictures showing blood growing out.

review nail

For every melanoma of the nail unit I see, I reckon I see about 30 or 40 cases of blood under the nail. This is the case regardless of people remembering an injury or not.

If there is a black or brown line going down the length of the nail, especially if it is slowly widening, and if the pigment spreads out into the skin, or the nail is being destroyed, definitely seek advice. But as these 2 pictures taken about 6 weeks apart show, blood under the nail gradually grows out and breaks up.

This is quite basic, but evidently a lot of people don’t know it, as I keep seeing blood under the nail referred urgently as suspected melanoma.

February 5, 2018 / molehunter

Bad information on moles and melanoma

I get a regular Google update on melanoma related news, this morning I found this article from Essex (the county where I was born). https://www.essexlive.news/news/uk-world-news/model-who-uses-sunbeds-twice-1161049

A 20 year old model, Ella Ravenscroft, with a history of sun bed use was worried that 4 of her moles had changed. She has now had 4 moles cut out. I assume we would have been told if any of them were malignant, so I’m sure they were all harmless. Was it really necessary for them to be cut out?

essex girl

 

The young lady said, and I quote, ‘I realised if I didn’t have them taken off I could end up with skin cancer’. This amounts to an assertion that these moles were known to be pre-malignant. No evidence is provided to support this statement, and I am concerned that it may lead to needless fear. I am seeing patients in my NHS clinic who have become terrified witless about trivial moles after something they have seen on line.

According to the latest research, which I have blogged about before here, there is probably no such thing as an identifiable ‘pre-malignant mole’.  So, with respect to Miss Ravenscroft, she appears to have picked up a populist idea which is scientifically established to be wrong. The idea that funny looking moles need to be cut out to stop them developing into cancer is mistaken, and can lead to needless fear and surgical scars.

From the photo she has shared, it looks like the 2 moles removed from Ella’s abdomen (replaced with a scar) were round and even in colour. I must be careful how I put this, and am not in a position to comment on the clinical judgment of whoever advised surgery, but the following facts are very well established:-

1) melanoma in 20 year olds is quite rare, even if they have used sun beds.

2) dermoscopy by a trained user can almost always give reassurance that a mole is harmless, avoiding the need for excision biopsy.

3) doubtful flat moles can usually be safely managed by photography and monitoring.

I am also concerned at the advice in the article that itching is a major sign of skin cancer. It is not. I am saying that from the position of an experienced NHS skin cancer doctor who has learned from the best international teachers and sees several hundred new cases of skin cancer every year. Hardly any skin cancers present with itch, hardly anything that presents with itch is a skin cancer. Change in shape, size and colour are much better guides-also bear in mind that 80% of melanomas come out of clear skin, only 20% from pre-existing naevi.

Fair play to the young lady for sharing her experience and warning again the dangers of sun beds. But it sounds as if, just possibly, dermoscopy and mole mapping might have allowed her to avoid some surgical scars. I don’t mean to cause offence or ridicule, but what is know is known, and this story, or at least the way it has been reported, appears to carry some misleading messages which I feel as a skin cancer diagnostician and educator a professional obligation to respond to.

There are 2 reasons I teach dermoscopy for skin lesion recognition, 1) earlier detection of skin cancers, and 2) to avoid the surgical removal of harmless moles.