Anatomical vs biomechanical factors that need to be examined to determine if a fibrillar pattern is indeed benign

I learned from the Derm Foot Lecture from Dr. Marghoob in Maryland approx. 2006 that on the arch of the foot there is mainly a lattic type pattern, the weight bearing part of the foot there is the fibrillar pattern and in between there is a furrow pattern.  One can conclude that if one sees the fibrillar pattern on a non weight bearing area of the foot it needs to be biopsied. I learned from Dr. Marghoob’s lecture in Maryland approx. 2016 and the atlas of dermoscopy that shearing forces from weight bearing areas can cause a fibrillar pattern.

The examining the anatomic location of a lesion is only part of the information available. There is also biomechanical information available that I  believe should be also considered with the dermatoscopic results.

The problem is that it is not so simple understanding where the weight bearing areas of the feet are  unless a full biomechanical and gait analysis is performed to determine which parts of the foot are most susceptible to shearing forces.  THE ANATOMIC LOCATION ON THE FOOT IS NOT THE ONLY FACTOR IN DETERMINING THE SUSCEPTIBILITY TO SHEARING FORCES. THERE ARE BIOMECHANICAL FACTORS AS WELL FROM BIOMECHANICAL FAULTS DETERMINED BY ONES STATIC EXAM AND GAIT ANALYSIS. The following biomechanical example is not something mentioned at the seminar but what I learned at NYCPM back in 1982.

One example is a lesion on the plantar aspect of the first metatarsal head area. As we all know the compensation occurs on the frontal and saggital planes as a suponatory rock of the rearfoot and a lot of pressure is on the plantar aspect of the first metatarsal head thus a benign fibrillar pattern as seen on the dermoscopy exam.

Yet if the biomechanical fault is flexible the saggital plane compensation of the plantarflexed first ray is dorsiflexion and less pressure results under the first metatarsal ray and therefore a lattice type lesion instead of a fibrillar dermatoscopic pattern all other factors being constant.

Thus if one sees a benign fibrillar pattern one just might not worry so much if the plantarflexed first ray deformity is rigid vs be it a flexible deformity. If one finds a fibrillar pattern on the plantar aspect of a flexible plantarflexed first ray then one just might need to biopsy this lesion. This is one example why I feel that all biomechanical exams both static exams and weightbearing exams must include dermoscopy. Also all pedal dermoscopy exams of the feet must include biomechanical gait analysis as well as static exams of the lower extremities.

I wish to thank Dr. Marghoob for opening my eyes and getting me even more interested in dermoscopy. Again I believe that full biomechanical exams should also consider including the dermatoscopic examination of pedal lesions.

Biomechanical faults can affect the appearance of a dermatologic lesion. Dermatoscopy just might give more hidden information unseen by the naked eye.

Biomechanical faults may have resulted in changes in melanocytic lesions. Just as important at an x-ray is to examining one’s bones, the skin is a structure with changes that cannot be ignored in the static biomechanical exam. Dermatoscopes are needed to document that one is fully examining non osseous structures in the static part of a biomechanical exam.
It just might be useful information to fully appreciate the fully compensated, partially compensated,
non compensated biomechanical faults in the frontal, sagittal, and transverse planes and correlate such information with the results from
your dermatoscopic examination.

If it can be agreed that

1. The already required biomechanical exams in residency should include dermoscopy of melanocytic pedal lesions then

2. one might conclude that there is already an existing requirement to perform dermoscopy for melanocytic pedal lesions in residency as a part of such a required biomechanical exam. Reasoning is biomechanical faults of osseous and muscular structures alter pedal melanocytic patterns due to shearing forces. Biomechanical exams should include skin and its melanocytic lesions.

Perhaps every podiatric residency teaching program will begin to use dermatoscopes in the clinic. The particular brand used is not as important as the features present in a dermatoscope. To me a  dermatoscope I use should have adequate polarization and the ability to give a clear image so as to see the deep structures.

It may not be in the patients best interest to biopsy every foot lesion. The use of a dermatoscope is helpful in determining which lesions to biopsy. If a dermatoscopic exam performed by a podiatric resident in a clinic ultimately resulted in a decision to biopsy and to ultimately diagnose a foot melanoma the resulting referral to an oncologist could be life saving for the patient. If dermoscopy is taught in every podiatric residency clinic patients would likely benefit.

Just soon might be a requirement for such teaching programs to begin using such a diagnostic tool if needed to perform a comprehensive biomechanical exam in the presence of melanocytic nevi. In the past there have been cases where problems unrelated to foot melanoma such as heel pain  may have been treated and such a lesion was not even biopsied. My opinion to include dermoscopy in the “required” biomechanical exam in residency teaching programs just might help patient with melanocytic lesions. Once dermoscopy is performed then if a biopsy is needed then this can be helpful to patients in podiatric residency teaching programs. If dermoscopy is required by a podiatric residency program perhaps there is a greater possibility it will be taught.