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March 18, 2017 / molehunter

PDF of PCDS Chesford Grange presentation

This is intended for the delegates at today’s Primary Care Dermatology Society spring meeting at Chesford Grange.

PDF FINAL EDIT chesford dermoscopy

March 16, 2017 / molehunter

Melanoacanthoma or black keratosis

Thanks to my friend Dr Neil Shrof for this case.




Very dark ugly duckling. Is it a nodular melanoma? No. Black seb k, also known as melanoacanthoma. Stuck on appearance and keratin pits. Harmless.





March 12, 2017 / molehunter

Pattern analysis of multi component melanoma on dermoscopy

The 2017 South Coast Dermoscopy skin lesion recognition and dermoscopy course has just started with a group of about 75 GPs, dermatology trainees, dermatologists, plastic surgeons, nurses and podiatrists assembling at The Holiday Inn Fareham last Friday.

This is the first case I sent out to our on line case discussion group. I like to put up some easy cases to start with. No plain view to hand. In fact I posted this here a few years back, but never mind, its a nice case.


This is an obvious melanoma, at one glance. Professor Peter Soyer calls this the heuristic method, after ‘Eureka!’ which means ‘I have it!’.  OK, but why is it a melanoma?

Any of the accepted diagnostic methods will get us there. Let’s start with the 2 step algorithm.

step 1: is it melanocytic?  There are brown globules (clods in the new terminology) particularly from 6 to 9 o’clock. Brown globules are a positive feature for melanocytic lesions. Can we see features of any non-melanocytic lesion (i.e. haemangioma, seborrhoeic keratosis, dermatofibroma etc)? No. So it is melanocytic by default and also on positive grounds (brown globules).

step 2; could it be a melanoma? Yes, because of gross asymmetry and multiple patterns and colours. Therefore excision.

The 3 step pathway. In this, we look for asymmetry, blue-white structures, and atypical network. Our lesion here shows the grossest of asymmetry, not so much of shape but of colour and patterns (which are both more important than geometry). We can see blue-white structures (also called blue white veil) and we can also see atypical network, in this case inverse network (the lacy white net-like structure at right and right of centre.) So again positive.

The 7 point check list of Argenziano.  Please click on the link for a discussion of this 7 point check list.  Again, positive. I can see gross asymmetry, irregular dots and globules, blue-white veil, pseudopods (basically a pseudopod is a blob of the end of a streak) an a few other structures.

Chaos and clues. This is chaotic as it has many structures and colours all mixed up. Step 2 of ‘chaos and clues’ is, having said ‘yes, chaos’ we look for clues, initially to ask the question ‘Is it a seborrheoic keratosis?’ Plainly not, the lesion lacks the fissured keratin, comedo like openings, milia like cysts, cerebriform appearance or looped vessels we expect to see in a seb k. When we look for melanoma clues, they are abundant (see above link to 7 point check list).

using SCOPE, our own mnemonic, we see no Symmetry, many COlours, many Patterns and odd things happening at the Edge.

The lesson being that whichever algorithm or scoring technique we use, this is a melanoma (as proved on histology, 3.5mm Breslow thickness). Professor Harald Kittler has said that experts learn all the algorithms and then invent their own. Sometimes one is better, sometimes another, sometimes a mixture.

Pattern analysis is defined as the simultaneous evaluation of all dermoscopic features of a lesion. The link takes you to a useful discussion on dermnetnz.

February 20, 2017 / molehunter

Selfies for melanoma detection

This sounds interesting.

A US based study using self photographes and Apple software is trying to see if this can be used to detect melanoma early. A paper in the British Journal of Dermatology by Peter Soyer et al showed that selfies of patient- identified suspicious moles with a cheap smartphone dermoscope was feasible.

In the end though, what really matters is people looking out for new and funny moles and easy access to a trained, capable dermoscopist. I am currently working on a presentation about mole monitoring and will post a summary here. Based on what I have been able to learn, there is a lot to be said for selfie mole mapping and 3 monthly review by a friend or relative, with easy access to an expert opinion in the event of a new or changing mole.

more later.


February 4, 2017 / molehunter

2 ugly moles on men’s backs

These 2 cases were seen on the same day and had similar stories-a suspicious mole noticed on a middle aged white man’s back. Both are ‘ugly ducklings’, that is to say your eye is drawn to them as the most outstanding mole on the person’s skin.


Are you worried about 1, 2 or both? Perhaps you may agree its not so easy to be sure.

Dermoscopy changes everything.


This is the dermoscopy of the first lesion. It shows an even reticular network, several shades of brown but no additional colours, an overall well balanced structure, and was flat on palpation. Diagnosis: benign junctional naevus which just happens to be the man’s largest naevus.  No concerns, advised to self photograph and report any significant change.

Lesion 2 is different.


Multiple colours, multiple structures= chaos. The main colour is light to medium brown, but there is also a black blotch to right of centre and a bluish structureless area. As far as structure is concerned, there are multiple dots and globules of varying sizes and irregular distribution. Diagnosis=probable superficial spreading melanoma. (histology awaited)

PS melanoma confirmed 0.45mm Breslow, should be cured.


Dermoscopy makes a difference to the diagnosis of a solitary questionable mole.


December 23, 2016 / molehunter

Checking your partner’s moles can save their life

New research shows the benefit of education about how to check someone’s skin for  abnormal moles can greatly increase the pick up rate of skin  ancers at an early, therefore more curable, stage. I have been convinced of this for years and try to always to educate my patients, using on line images of melanoma.

More needs to be done by health care providers and others to educate the public. Earlier diagnosis saves more lives than drugs like nivolumab and vemurafenib, and saves them cheaper.


November 30, 2016 / molehunter

Scary looking mole, but harmless

A middle aged white person presented with a story of a mole on an arm that had been changing and growing over 6 months. In the absence of a photograph, we have no objective way of being certain whether, and how much, a lesion has changed, so have to go on people’s stories. Here is the plain view.


And a close up


Not that worrying, but there is the history to consider and it is the largest mole. Dermoscopy.


Irregular globules can be seen, varying in size and mainly a greyish-blue in colour. Given the history of change, this was considered to be adequate grounds for excision.  Note also the pale circles associated with hair shafts, these are of no concern and are termed perifollicular hypopigmentation.

Histology was of a benign dermal naevus.

On reflection, did this mole really need excising? I showed the picture to colleagues, some said yes, others said that photography and monitoring would be acceptable. This is a debate that will continue-we must not miss melanomas but should avoid excising excessive numbers of benign lesions. Sharing images like this where histology has been obtained should perhaps over time help us to be more confident in deciding to monitor-but many experts say, if there is doubt about a changing/suspicious solitary lesion then remove the doubt by getting histology. I am sure we will get to know better as time goes on PROVIDED that we photograph lesions before surgery and then learn from the photos when the histology report comes back. And we all need to audit our ‘hit rate’.