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Questions & Answers

During lecture you mentioned orienting the excision in the way of lymphatic drainage – can you explain that?
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If a sentinel node biopsy is subsequently required then orienting the initial biopsy excision along lymphatic drainage will not compromise the SLN biopsy.


What is your advice for immersion fluids in a busy clinic? Do you use alcohol spray? Swabs?
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The wet surface and contact will provide with a clearer and sharper view. This is true also for polarized light. Anytime I want a good view of a lesion I will always use liquid and contact. I use a small spay bottle filled with isopropyl alcohol. Much easier and faster to spay alcohol on the skin then to open up a wipe and squeeze out the alcohol.

Furthermore, those wipes come in foil packets that a terrible for our environment since they do not degrade. In a busy clinic you would end up opening 100s of packs a day – lots of $ and time and environmentally damaging.


Will we be learning about dermoscopic best practices in patients with darker skin colors?
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There are no good studies on this topic! We need clinicians seeing darker skin type individuals to create an atlas of what lesions look like across skin types. In my experience all the rules we are discussing are the same irrespective of skin type but all pigmented structures are much darker. So, no one has yet created best practices around dark skin. Clearly an area that needs work.


How does one distinguish between normal telangiectasia vs serpentine or arborizing vessels?
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  1. The vessels in the lesion will look different to surrounding vessels.
  2. Vessels in a lesion are redder and sharply in focus. Those in normal skin are fuzzier.
  3. Red in tumor vessels are much redder as compared to surrounding vessels 

Are blue gray dots/ globules/ nests only in pigmented BCC? 
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Blue gray non- aggregated dots/globules are quite specific for bcc! Rarely seen in other lesions. Few rare exceptions exist including clonal variant of sk. Will discuss in the post test discussion session. 


It seems like the blood vessels seen in BCC are seen in Type 1-2 skin with a ruddy complexion or rosacea. Do they actually look different?
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  1. The vessels in the lesion will look different to surrounding vessels. The vessels also appear concentrated within the lesion. 
  2. Vessels in a lesion are redder and sharply in focus. Those in normal skin are fuzzier.
  3. Red in tumor vessels are much redder as compared to surrounding vessels 

How does one distinguish between normal telangiectasia vs serpentine or arborizing vessels?
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  1. The vessels in the lesion will look different to surrounding vessels.
  2. Vessels in a lesion are redder and sharply in focus. Those in normal skin are fuzzier.
  3. Red in tumor vessels are much redder as compared to surrounding vessels 

Is there any data that shows that these early “small white papule” BCCs advance/grow/invade if left untreated? In other words, is there value in identifying small/early lesions?
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Based on cross sectional studies the answer to that question is yes. These lesions are easy to treat with little to no downside. Allowing them to grow becomes problematic. However, no longitudinal studies exist to document the rate of growth of bcc. But this is true for melanoma as well. This all brings up the issue of potential over diagnosis. In other words, finding cancer that will not cause morbidity or contribute to the patient’s death. We simply do not know the answer yet but work is occurring in this field. Clearly dermoscopy is helping us to Identify earlier  and smaller lesions. My gut tells me this is a good thing but time will tell…


Can you see in regular BCC? Are they only in pigmented BCC or are they seen in non pigmented BCC too?
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Only seen in pigmented bcc. The presence of a blue or brown structure in a bcc defines the lesion as a pigmented bcc!


Do you have any advice for interpreting pink/red nevi in type 1/2 skin? I find these the toughest lesions clinically and end up biopsying 1-2 to find out “how atypical” they are under the microscope then try to only choose “ugly ducklings” moving forward. 
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The key is the vessel pattern and whether or not it’s an outlier. All other lesions I follow closely to determine their biological behavior.


I have always heard the excision is placed in relaxed skin tension lines… is that the same orientation of lymphatic drainage?
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Usually the relaxed lines and lymphatic drainage is in same directions but not always. If there is a discordance then direction of lymphatic drainage takes priority. 


Have all dermoscopy suggested diagnoses shown in  all conference presentations been confirmed by biopsy?  Meaning, do we know for sure that specifically the pre-cancerous and benign lesions are what they are presented to be? 
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At this meeting all lesions are either biopsy proven OR have been proven to be biologically indolent over at least one year of follow up.


Could you help me distinguish between the milky white area and white papule on the face of BCC (Dr. Rabinovitz used examples in his BCC talk), and the milky white of amelanotic melanoma?  It makes a difference, including how, at least, I would sample each: for BCCs, I commonly shave, while for melanomas, I punch so I have a depth.  
I recognize that every amelanotic melanoma I’ve seen are macular or only broadly raised (smooth plaque) without any white papule (but an amelanotic melanoma could occur where a benign white papule is nearby) while Dr. Rabinovitz spoke of a white papule in a milky white area.
This does not make me nervous, but curious on your perspective. I look at the whole patient, the background, and with dermoscopy can label accurately most benign flesh/white colored bumps on sun damaged skin. I see lots patients with severe sun damage with white facial papules and lots of baseline erythema. So I would like to know how to discriminate better – I wouldn’t biopsy all, nor would I ignore all. 
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Milky red looks similar in bcc and mm. However, to my eye the red in melanoma has a more bubble gum pink. The main difference is the vessel pattern within the area of red. In bcc arborizing and in mm polymorphous. Regarding white structures, in mm you see short white lines. In bcc it’s blotches of white.


How does one reliably distinguish between a pigmented actinic keratosis and an inflamed flat seborrheic keratosis on the face – couldn’t both have a scalloped border, scale (inflamed AK)… 
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Regarding pigmented Ak vs sk vs lmm can be real challenging. For such lesions I have the advantage of confocal. One thing is for sure, I would not freeze them. Either monitor or biopsy.


One of the presenters was discussing doing curretage and dessication after doing a shave excision biopsy on the face. Under what circumstances, why, and how do you perform curretage and dessication?
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Tough to answer since it depends on age of patient, size of lesion, location on face, subtype of bcc as well as a host of other factors such as immunosuppressive. In general, small bcc  in areas of the face that heal well with secondary intention do well with ed&c.


What are some reliable features to distinguish scars, old and new; traumatized lesions; from neoplasms and malignancies?
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Scars are flat lesions and if vessels are present they are oriented in same direction. In irritated lesions and malignancy you see disorganize distribution of polymorphous vessels. The most important is that scars have a white background with vessels and malignancy and irritated lesion have a pink background with vessels.


Will there be more information about the benefits/ when to use polarized light?
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Polarized light allows you to see vessels better and also allows you to see shiny white lines. These shiny white lines are not seen with non-polarized light. Polarized dermoscopy increases your sensitivity for detecting malignancy!


Why do string of pearls once? Is there a pathological correlation? 
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It has to do with the peculiar elongated rete ridge pattern associated with CCa. It results in a particular egg crate pattern and the vessels in the papillary dermis result in the string of pearls.


What is the difference between “pseudonetwork” that you would see on the face and angulated lines/rhomboid structures that is a melanoma specific structure?
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Pseudonetwork is composed of round circles and angulated likes creates polygonal structures (not round).


Would Harold still do Mohs for LM if the special melanocyte stains are not available for the mohs surgeon? 
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Without stains one cannot rely on Mohs!.


How do you diagnose metastatic bcc? Do pt usually have any systemic symptoms? When a pt comes in with 25 bcc how do I know if he has met bcc.
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Extremely rare. In my career I have seen only 5 cases. They present with symptoms or swelling or lymph node swelling. 


Are the rushed permanent sections of slow mohs done same day with a pathologist or over the course of days?
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Usually done overnight (not same day)


For pink nevi, what are the criteria for biopsying –  if vessels are polymorphous, then biopsy and if uniform, then follow? 
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If isolated
If outlier
If found on type 3 or higher skin types
If symptomatic
If change

These are the main reasons to biopsy.


Are there dermascopic features for traumatized nevi?  How can you say traumatized if it resembles mm? 
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You cannot. They need to be biopsied!


What percent of ocular mm are bap mutation?  What percentage of patients with ocular mm get Cutaneous mm if bap pos/neg? 
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This info has not yet been elucidated. Susana is collecting data to address this and hopes to have answers within next few years.  Regarding ocular mm, most are due to gnaq mutations. However in Germline bap deficient patients the ocular mm have same mutation and lack the gnaq mutation. Regarding cutaneous mm in pats with ocular mm: the ocular mm due to gnaq does not increase risk of cutaneous mm. Those with bap def ocular mm are at increased risk of cutaneous mm but we do not know the magnitude.


How do you know if a mole is changed due to previous (now healed) trauma? 
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Without dermoscopy the differential is between angioma to pigmented bcc to melanoma.


What do the structureless tan areas in a pigmented lesion correlate wtih histologically?
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Flattened de junction with pagetoid cells.


What about the rosettes in AK? What is the histopathologic correlate of the rosettes?
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Keratin filled Ostia / follicular openings.


Please differentiate Scc from Psoriasis from eczema vascular pattern.
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Scc – scale with focal glomerular vessels
Psoriasis – white scale with homogeneous distribution of dotted vessels – multiple lesions
Eczema – focal yellow to orange crusting with  dotted vessels


Will you be showing images of keloids 
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No. Skin cancer does not usually enter the differential for classic keloids.


Will you be showing images of halo nevi under Dermoscopy? 
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Halo nevi are homogeneous and globular nevi with white halo around each. I will try and address in lecture.


How do you diagnose metastatic bcc? Do pt usually have any systemic symptoms? When a pt comes in with 25 bcc how do I know if he has met bcc.
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Extremely rare. In my career I have seen only 5 cases. They present with symptoms or swelling or lymph node swelling.


I have always used non-contact dermoscopy, and I would like to know more details about how to do contact dermoscopy:
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Contact provides sharper and clearer image.


What immersion liquids are better to use?
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Isopropyl alcohol.


How to apply the immersion liquid? 
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I keep in small spray bottle and squirt it on the skin.


Can any of those immersion liquids damage the dermatoscope?
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Alcohol will not damage your scope.


How can I clean the immersion liquid off?  Alcohol dries off (I imagine that oil would be messy.  I also worry that I would scratch the lens of the dermatoscope if I wipe it frequently.) you will not scratch lens if you wipe the alcohol off with a gauss pad.
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For nail lesions I use ultrasound gel as immersion fluid. Just wipe of gel from lens with alcohol wipe before it dries.


Also, not related to non-contact dermoscopy: how can I best use the different color modes in a dermatoscope (or are they not too helpful)?
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I do not think the color boost adds anything


Does NB-UVB phototherapy increses de risk for melanoma?
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Yes.


Will we be seeing dermoscopic images of less common tumors such as Merkel Cell Carcinoma, atypical fibroxanthoma, DFSP, etc…  Or can these be found on dermoscopedia? 
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Nothing specific in any of those tumors except pink and atypical vessels.


I wonder if you have heard or have any experience with the “injectable” called Melanotan? I have had a few patients who use this in order to stimulate a tan without sun exposure. I wonder if this is safe?
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Stimulating the tanning pathway in someone who is wild type mc1r is fine. However, these individuals will not seek melanotan since they tan extremely easily. Patients with mc1r variants have higher concentrations of phenomelanin. Pheomelanin is a free radical and increases dna damage. By giving these individuals melanotan they may  increase their risk for melanoma!


In non red head individuals that want a tan without actually tanning, it is safe. 
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Red hair: NO! 


For someone like you, taking melanotan vs tanning would carry theoretically the same risk to developing melanoma? 
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I would stay away from melanotan! Too many unknowns. I would never give a patient a green light to use melanotan. Nor would I give the green light to tan with UV. Both are bad but acknowledge that the magnitude may differ. You are choosing between 2 evils and thus you are stuck between a rock and a hard place. I personally would keep my distance.


Why would intralesional c/s not limit the body’s immune system to get rid of the lesion?
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Because many ka are reactive process. The inflammation is driving the process. Stop the inflammation and the lesion regresses.


Our dermatopathologist will occasionally read a shave biopsy as “actinic keratosis with follicular involvement” which often raises concern for squamous cell carcinoma.  Our physician has discussed this with the pathologist but our general approach, especially if clinically suspicious, is to excise or perform Mohs surgery depending on site of biopsy.  Is this an appropriate approach?  Are we being overzealous by removing via Mohs or should we be treating conservatively via LN2?  
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In my opinion you are doing too much. Also, this is not an indication for Mohs and if you get audited it may cause you headaches. AK with follicular involvement should be treated as an AK with cryo or 5fu etc. Tomorrow there will be a lecture dedicated to aK management! 


We are mainly treated based on clinical presentation so not every case goes to Mohs but occasionally it is quite obvious that the diagnosis doesn’t match the clinical presentation.  Thank you again. 
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As long as it is well documented as to why you are deviating from standard practice then all is well.


We have been talking quite a bit about biopsy vs excision vs watching/waiting on multiple lesions.  I am wondering how often do you biopsy a lesion before excision vs how often do you excise without biopsy?  Are you only excising melanomas/suspicious for melanoma lesions and biopsying the rest before excising?  
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The latter. Excise the lesions highly suspicious for melanoma and biopsy the rest.


I just wondered if you ever excised without biopsy other than melanoma. 
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If I know that I have a small nodular bcc then I will excise so as to spare the patient any further procedures.


Could you please comment on the atypical/ dysplastic nevus syndrome management in primary care.
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In my opinion if you have a dns patient with 100s of atypical nevi and have no imaging technology to follow such patients then best to refer. As a gp it is important to know when to treat and when to refer.


If you are relatively sure you see a clear cell acanthoma- that is benign right?  Or do you biopsy?
I saw a pink symmetrical pap that looked like a string of pearl arrangement and I think the speaker said that was a spitz Nevus? 
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The clinical is different.
CCa has a collarette of scale and Spitz does not. Spitz usually will have negative network or shiny white lines and CCa will not.
If I see a classic CCa with colarette of scale and string of pearls vessels I will not biopsy.


I’m sure there are varying opinions, but I’m curious how the faculty manage biopsy proven moderate to severely atypical nevi with positive margins when the original intent by the clinician was complete removal of the lesion with their excision or saucerization.   From my path lab these come reported as having been reviewed at the intradepartmental dermatopathology conference. If clinically no residual lesion remains, are all reexcised?  Are only severe lesions reexcised?  Are they observed?  
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Basically mild to mod dn are not reexcised if intent was complete removal at time of biopsy. For severe dn most would reexcise.


If I do a partial excision of a suspicious lesion which then requires larger excision, is it reasonable for me to go ahead and do a partial elliptical, suture it, and allow 2-3 wk healing before the larger dermatology excision? 
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I would simply do an excisional biopsy from the get go.


Will it actually benefit the pt by making the final excision smaller, after allowing healing of the initial excision?
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No.


If I cryo a suspected AK, but it returns (ie, I was wrong and it was an SCC). How long before I would expect it to grow back?
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Not sure, but suspect it would grow back within months.


Do you use something like hair-removal tape?
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No.


Imiquimod adjunct or treatment?
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Treatment.


Is there a good paper to used as reference?
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Simply do a pubmed search and you will finds a lot of papers on this topic.


I know some of my community derms use it sometimes for treatment, sometimes for adjunct after excision. I am not clear on the indications.
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The only indication for treatment is for ak and superficial bcc. Everything is off label.


Finally, my very basic dermlite has no “contact” lens. How important is this feature?
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Very important.


Should I be requesting a new scope?
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Yes


I don’t have an LED magnifying glass, but I do have a headlamp and loupe, for general surveying—will this be sufficient?
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That is fine.


What causes the veil appearance on both benign and malignant skin lesions under Dermoscopy.
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Orthokeratosis.


For the once a week imiquimod treatment for AK prophylaxis are patients using 5% over the entire face for treatment? Using around 3 sachets at a time?
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Orthokeratosis.


For the once a week imiquimod treatment for AK prophylaxis are patients using 5% over the entire face for treatment? Using around 3 sachets at a time?
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You only need to use one pack. Wash face and apply on damp skin. One pack will be sufficient.


Questions?

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