Questions and Answers

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During lecture you mentioned orienting the excision in the way of lymphatic drainage – can you explain that?

What is your advice for immersion fluids in a busy clinic? Do you use alcohol spray? Swabs?

Will we be learning about dermoscopic best practices in patients with darker skin colors?

How does one distinguish between normal telangiectasia vs serpentine or arborizing vessels?

Are blue gray dots/ globules/ nests only in pigmented BCC? 

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?

How does one distinguish between normal telangiectasia vs serpentine or arborizing 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?

Can you see in regular BCC? Are they only in pigmented BCC or are they seen in non pigmented BCC too?

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. 

I have always heard the excision is placed in relaxed skin tension lines… is that the same orientation of lymphatic drainage?

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? 

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. 

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)… 

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?

What are some reliable features to distinguish scars, old and new; traumatized lesions; from neoplasms and malignancies?

Will there be more information about the benefits/ when to use polarized light?

Why do string of pearls once? Is there a pathological correlation? 

What is the difference between “pseudonetwork” that you would see on the face and angulated lines/rhomboid structures that is a melanoma specific structure?

Would Harold still do Mohs for LM if the special melanocyte stains are not available for the mohs surgeon? 

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.

Are the rushed permanent sections of slow mohs done same day with a pathologist or over the course of days?

For pink nevi, what are the criteria for biopsying –  if vessels are polymorphous, then biopsy and if uniform, then follow? 

Are there dermascopic features for traumatized nevi?  How can you say traumatized if it resembles mm? 

What percent of ocular mm are bap mutation?  What percentage of patients with ocular mm get Cutaneous mm if bap pos/neg? 

How do you know if a mole is changed due to previous (now healed) trauma? 

What do the structureless tan areas in a pigmented lesion correlate wtih histologically?

What about the rosettes in AK? What is the histopathologic correlate of the rosettes?

Please differentiate Scc from Psoriasis from eczema vascular pattern.

Will you be showing images of keloids 

Will you be showing images of halo nevi under Dermoscopy? 

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.

I have always used non-contact dermoscopy, and I would like to know more details about how to do contact dermoscopy:

What immersion liquids are better to use?

How to apply the immersion liquid? 

Can any of those immersion liquids damage the dermatoscope?

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.

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)?

Does NB-UVB phototherapy increses de risk for melanoma?

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? 

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?

In non red head individuals that want a tan without actually tanning, it is safe. 

For someone like you, taking melanotan vs tanning would carry theoretically the same risk to developing melanoma? 

Why would intralesional c/s not limit the body’s immune system to get rid of the lesion?

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?  

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. 

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?  

I just wondered if you ever excised without biopsy other than melanoma. 

Could you please comment on the atypical/ dysplastic nevus syndrome management in primary care.

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? 

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?  

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? 

Will it actually benefit the pt by making the final excision smaller, after allowing healing of the initial excision?

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?

Do you use something like hair-removal tape?

Imiquimod adjunct or treatment?

Is there a good paper to used as reference?

I know some of my community derms use it sometimes for treatment, sometimes for adjunct after excision. I am not clear on the indications.

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

Should I be requesting a new scope?

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

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

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?

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?

Questions?

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