Contents

Preface

1 Introduction to Dermoscopy

Introduction to Dermoscopy

Device comparisons I

Device comparisons II

Device comparisons III

Device maintenance tips

Normal skin

Photodamaged skin I

Photodamaged skin II

Pigment depth and colour

The dermoscopic alphabet

2 Melanocytic Lesions

Melanocytic criteria

Pigmented network

Atypical pigmented network

Cobblestone morphology

Pigmented globules

Dermal naevi

Blue naevi

Combined naevi

Halo naevus

Recurrent naevus

Pink Spitz naevus

Pigmented Spitz naevus

Naevus morphology

Naevus morphology – Age

Naevus morphology – Phototype

Naevi – Pigment distribution

Naevus morphology – cases I

Naevus morphology – cases 2

Multicomponent morphology

3 Melanoma

Seven features of melanoma

Melanoma in situ

Thin invasive melanoma

Intermediate-thickness melanoma

Thick invasive melanoma

Hyperpigmented melanoma: brown

Hyperpigmented melanoma: black

Multicoloured melanoma

Hypopigmented melanoma

Superficial spreading malignant melanoma

Nodular melanoma: pigmented

Nodular melanoma: hypopigmented

Featureless melanoma

Small melanoma

Eccentric pigmented melanoma

Cutaneous melanoma metastases

Negative network

Regression in melanoma

Melanoma cases

Algorithms

Algorithms – limitations

4 Non-melanocytic Lesions

Seborrhoeic keratoses

Milia-like cysts

Comedo-like openings

Cerebriform pattern

Fingerprint structures and moth-eaten border

Benign lichenoid keratosis

Ink-spot lentigo

Solar lentigo

Clear cell acanthoma

Comedones

Porokeratosis

Haemangiomas

Angiokeratomas

Lymphangiomas

Subcorneal haematoma: homogeneous pattern

Subcorneal haematoma: parallel pattern

Sebaceous hyperplasia

Dermatofibroma: typical

Dermatofibroma: non-typical

Actinic keratosis

Bowen’s disease

Squamous cell carcinoma/keratoacanthoma

Basal cell carcinoma

Superficial BCC: clinical

Superficial BCC: dermoscopy

Nodular BCC: clinical

Nodular BCC: dermoscopy

Morphoeic BCC

Pigmented BCC – I

Pigmented BCC – II

Vessels in skin tumours

Exogenous pigmentation

Radiotherapy scars

5 Special Sites

Acral melanocytic lesions

Acral naevi

Acral melanoma – parallel pattern

Acral melanoma – non-parallel pattern

Acral melanoma – late diagnosis

Lentigo maligna

Lentigo maligna cases I

Lentigo maligna cases II

Melanonychia

Nail unit melanoma – early

Nail unit melanoma – late

Erythronychia

Nail unit squamous cell carcinoma

Nail unit infection

Subungual haematoma

Scalp BCC

Scalp melanoma

Scalp seborrhoeic keratoses

Scalp naevus sebaceous

Mucosal melanosis

Androgenetic alopecia

Alopecia areata

Trichotillomania and pickers nodule

Lymphocytic scarring alopecia: lichen plano pilaris

Neutrophilic scarring alopecia: tufted folliculitis

End-stage scarring: pseudopelade

Miscellaneous hair conditions

Scarring alopecia – Discoid lupus erythematosus

6 General Dermatology

Scabies

Head lice

Viral wart – verruca vulgaris

Molluscum contagiosum

Tungiasis

Psoriasis/eczema

Lichen planus

Blood vessel inflammation

Inflammatory conditions: cutaneous mastocytosis

Granulomatous inflammation

Nail fold capillary dilatation

Xanthogranuloma

7 Case Scenarios I

Case Scenarios II

8 Reference Points

Key points

Dermoscopy and skin lesion management

Teledermoscopy

9 Image Gallery

Image Gallery

Index

This edition first published 2012, © 2012 by Jonathan Bowling

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

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Library of Congress Cataloging-in-Publication Data

Bowling, Jonathan.
Diagnostic dermoscopy : the illustrated guide / Jonathan Bowling.
p. ; cm.
Includes bibliographical references and index.

ISBN-13: 978-1-4051-9855-4 (pbk. : alk. paper)
ISBN-10: 1-4051-9855-9 (pbk. : alk. paper) 1. Skin–Microscopy–Atlases. 2. Skin–Diseases–Diagnosis–Atlases. I. Title.
[DNLM: 1. Dermoscopy–Atlases. 2. Skin Diseases–diagnosis–Atlases. WR 17]
RL105.B69 2011
616.5′075–dc23

2011028325

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781444329841; Wiley Online Library 9781444329834; ePub 9781444329858

This book is dedicated to Annabel, Daisy, Ted, Tabitha and Poppy. Two were there at the start, more arrived in the middle, and all were present and happy for the end of the book.

Preface

Skin is a dynamic canvas upon which life paints its picture. Each individual has a unique ‘picture’ reflecting his or her age, skin phototype and UV exposure, as well as genetic and acquired influences. However, unlike a canvas hanging on the wall, this ‘picture’ is not static; it is biologically active and therefore changes and evolves through life.

Benign naevi dominate childhood and adulthood; however, this dominance is gradually replaced by seborrhoeic keratoses, which become more numerous later in life. Additionally, the accompanying increase in vascular lesions and potential for skin malignancy through life makes for a complex ‘picture’, rich in colours, shapes and textures.

To interpret the ‘picture’ accurately, one must understand not only the macro, the shape, size, colour and age of the canvas, but the micro, the brushstrokes used to create the detail in these patterns and colours. This micro detail is often obscured by light reflecting off the skin surface, which may explain why many different lesions look similar. By using dermoscopy, we can overcome this optical challenge, revealing the diagnostic detail within lesions – this is diagnostic dermoscopy.

Two important concepts are helpful in increasing diagnostic accuracy:

1. Tumours grow – they do not appear. We should therefore look for the diagnostic detail present in all lesions to find the small tumours.

2. Tumours evolve – they are not static. We should therefore accept that the detail seen may be influenced by many external and internal factors.

Increasing our understanding of the variety of ways in which tumours present will increase our diagnostic accuracy. This book therefore aims to illustrate the many ways in which different tumours present, complete with the diagnostic dermoscopic features to aid diagnosis.

Whenever possible, examples are shown for lesions that vary for size, shape, anatomical site, skin phototype and, when feasible, evolution with time. Hopefully, the diagnostic detail illustrated in this book will lead to improved skin lesion diagnosis and earlier diagnosis of skin cancer.

Since the introduction of dermoscopy into clinical practice in the 1990s, our understanding of this diagnostic technique has increased exponentially. Credit should be given to the dermoscopy pioneers, who reshaped the diagnostic world through research, education and innovation. Their endeavours have proven that dermoscopy is without doubt the gold standard in clinical diagnosis, a diagnostic technique practised in over 100 countries worldwide.

However, it is very important to remember that dermoscopy should not be practised in isolation. A clinical diagnosis is the summation of information gained from:

1. Clinical history

2. Clinical examination

3. Dermoscopic examination.

Diagnosis is in the detail; therefore, it is essential to combine all clinical skills and not use any in isolation. This book only provides information on one component of skin lesion diagnosis. We also know that tumours, especially melanoma, may take time to develop dermoscopic features, and may even mimic benign lesions. Additionally, in established tumours many dermoscopic features may be absent. Therefore, this book is aimed as a guide to be used in the clinical arena, to augment clinical decision-making and not to replace clinical judgement.

Jonathan Bowling