First topic: I don’t know what I would do without my Dermlite 4 dermatoscope. Second topic: Please check out the Rhett Foundation’s website.

I bought 2 other brands of dermatoscopes and found the Dermlite 4 was the best so far. It has the highest degree of polarization I know of, with plastic ice caps to prevent spread of infection, and has a pigment boost. It also has the ability to toggle between polarized and nonpolarized modes, the largest viewing field I know of, attaches to my Samsung phone and certain iPhones.

I was finally successful in having a podiatric pathology report sent back to me with a copy of the dermatoscopic image taken from my Dermlite 4. This sets a new standard in podiatric pathology reporting which I believe is the future gold standard. Now that I have it, I don’t know what I would do without my Dermlite 4 dermatoscope.
Once one decides on a dermatoscope, this can be a lifetime investment. Only after deciding what features one wants in terms of degree of polarization, etc…. then I believe it is best to shop around for the best price. I am guessing if one attends a convention where dermoscopy is taught there just might be discounts available.

Please check out this website http://rhettfoundation.org/
I am grateful to the Rhett Foundation.

Do podiatrists treat warts without dermoscopy?

Sometimes patients refuse to excise their warts and opt for chemical treatment. Dermoscopy can provide information about the halo surrounding blood vessels. I thought it would make sense that if the white halo present surrounding the hairpin shaped vessels in seborrheic keratosis, then similarly in a wart that same white color would be present in any halo surrounding vessels.

I believe this pinkish or reddened color could also be due to trauma. If one is faced with the possibility of trauma or malignancy, perhaps it is better to be cautious and to biopsy the area. It might be helpful if the following information is sent with the biopsy specimen to a dermatopathologist:

1. any history of trauma to the lesion,

2. any history of skin cancer,

3. any family history of skin cancer

4. a dermatocopic image of non contact polarized dermocopy and non polarized dermoscopy. The non polarized dermoscopy might show  a blue white veil, any milea cysts. The non contact polarized dermoscopy would best emphasize the vascular structures and the color of any surrounding halo as well as the shape and distribution of vascular structures. If the dermatopathologist is not familiar with dermoscopy perhaps the laboratory might have the availability of a consultant that is.

Is there an obviously benign foot lesion without dermoscopy?

How can a lesion “obviously” be benign without dermoscopy? For example a lesion might have the charateristics of milia-like cysts, and comedo-like openings we all think is a seborrheic keratosis. Yet only through dermoscopy can one under polarized light see that the vascular structures might not have a white halo around hairpin vessels. What if under nonpolarized dermoscopy a blue white veil is seen in what you thought was a seborrehic keratosis? If such a blue-white veil is asymmetrically placed and has a dark blue color I would be concerned.

All a podiatrist really needs is to spend 2 hours at the dermfoot lecture with Dr. Marghoob. They may not be trained to diagnose specific structures yet they will be taught some basic screening method as to when to biopsy and when not to.

Dermatopathological vs Dermatoscopic images

In order for anyone to study dermatoscopy it is helpful to understand (dermatopathology) pictures about the histological structures on slides.

This is important because depending on if a vertical image or a horizontal image was taken, very different structures can appear quite similar.

For example a vertical image of a pathology slide of adipocytes without nuclei can so closely resemble a horizontal polarized dermatoscopic image of dermatofibromas without a peripheral network.)

I purchased called Essential Dermatopathology that has online access for the entire text as well as on online image bank.

I still feel the comprehensive textbook about Dermatopathology by Raymond Barnhill that I purchased is more detailed in different ways.

My question is what dermatopatholgy texts do other podiatrists use?

The Halo Nevus pathology report with a low lymphatic infiltrate got me to question future dermatopathology reports.

I never said I was a good artist. Yet when I give a lecture I want everyone to understand the concept of melanocytes traveling from the basal layer to the stratum corneum.

Second concept: there are Rete Ridges that are sometimes affiliated with flat skin and other rete ridges affiliated with a ridge. This is sometimes not the case in situations such as any dermatologic condition that might obliterate viewing the dermal epidermal junction. What about a Halo Nevus where the lymphocytic infiltrate is so thick that one cannot tell the melanocytes in the papillary dermis.

Once a pathologist diagnosed a Halo Nevus in the foot. I never heard of a Halo Nevus being present in the foot. I began to question this and I had my Dermatopathology Text by Raymond Barnhill. A Halo Nevus has a great deal of lymphocytes yet the picture on the report showed very little lymphocytic infiltrate. Thus I began to question dermatopathology reports.

Then again chances are it could be a Halo Nevus in the late stages with a decreased lymphocytic infiltrate.

Why not consider getting different opinions from different dermatopathologists?
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Pseudopods

What is the gold standard for being able to detect pseudopods? Pseudopods can indicate precancerous problems. What if the histological sectioning of a specimen misses the presence of pseudopods?

One gets training and experience by reading texts, going to courses. At the MSK cancer institute the 2nd lecture given in a 2 day intensive lecture series on intermediate dermoscopy lectures contained the following information given by Ralph Braun MD from the Dept of Dermatology in Switzerland:

Pseudo-pods were shown as histologic findings on a histology slide. One of the 2 dermoscopy texts I am curently reading show pseudo-pods on a slide.

Most dermatopathologists do not mention about the presence of pseudopods because the pathology labs either do not have access to dermatoscopic images and or they do not use such images in sectioning such specimens.

If a pathology lab actually used such dermatopathologic images and sectioned them propperly and found irregularly distributed pseudo-pods this just might save lives. Dermoscopy just might save lives.

Even if a podiatrist does not understand the full interpretation of dermatoscopic images if a pathology lab sending a dermatoscopic image on an encrypted disk where the dermatopathologist knows the password would allow the dermatopathologist to better interpret such findings.

A pseudopod a histological finding when a specimen is sent with a dermatoscopic image is only one example of this situation as to why pathology labs should encourage podiatrists to use dermatoscopes.

The argument may be made that it is a podiatrists responsibility to interpret a dermatoscopic image properly. Perhaps a similar argument may be made that if a pathology lab receive a dermatoscopic image the dermatopathologist has the responsibility to “properly” section the specimen so as to properly report a picture of the histological finding of a pseudopod.

As far as students disagreeing with their professors, why not also consider disagreeing with your dermatopathologist by going to dermatopathological textbooks and considering the accuracy of a report given by a dermatopathologist. I learned at the intermediate lecture series at MSK to question a pathologist report and to not always accept the report if one does not understand the histological structures.

One detailed dermatopathologic textbook I bought was the third edition of Dermatopathology edited by Raymond Barnhill.

1. Dermoscopy is a huge topic and contains a lot of volume.

2. There are several issues that are mixed into this subject matter.

3. Foreign verbiage is needed anytime a new topic is brought up.

4. Even if pseudopods are not a cellular level parameter, their distribution as seen on a dermatoscopic image contributes valuable additional information. This better enables the dermatopathologist to make a more accurate diagnosis.

5. If a podiatrist is not experienced at interpreting strutures, they still may be performing biopsies of dermatologic lesions. Once a decision is made to biopsy, this is an opportunity for even inexperienced podiatrists to send dermatoscopic pictures to an experienced dermatopathologist with the biopsy specimens. Such additional information can ultimately lead to a more accurate dermatopathology report.

 

 

Dermatofibroma has different patterns

5I just had an interesting dermoscopy case.

I was thinking that I was dealing with a fibroetithelioma of Pinkus because of a white network. However there were no vascular structures. Thus I began to instead think of a Dermatofibroma.

I learned at Derm Foot seminar that the dermatofibroma had a peripheral network and central scaring. I believe that Sloan Kettering had a much more intensive dermoscopy seminar. For example I learned there were so many different patterns for a dermatofibroma. I just obtained  an image of what I believe to be the multiple white scar-like patch throughout which is only present 4.8 percent of the time.

If any other podiatrists have dermatoscopic images of dermatofibromas what patterns did you find?