Unrehearsed impromptu video with a goal to clarify the relationship between biomechanical faults affecting melanocytic lesions on the plantar skin of the feet

FOOT DERMOSCOPY- This video was not rehearsed. It was an impromptu recording made with me holding a cell phone camera. My goal was to clarify the relationship between biomechanical faults affecting melanocytic lesions on the plantar skin of the feet. I reviewed an axis of motion located on the transverse and frontal planes and clarified that the most motion occurs on the sagittal plane. I followed by emphasizing the sagittal plane compensation of a flexible plantarflexed first ray generally not resulting in a melanocytic lesion with a fibrillar pattern. The point is that anatomic location on the weight bearing portions of the foot alone is not the only factor in determining if a melanocytic lesion is a fibrillar pattern. Biomechanical faults too must be evaluated.
This is why dermoscopy and biomechanical exams must be tied together in the presence of melanocytic lesions on the plantar skin of the foot.
The plantar skin of the foot is your dermatoglyphic areas with ridges and furrows. I believe a better name for the furrows is flat skin.

Any time an unrehearsed spontaneous video is done sometimes points are left out. For example one has to first understand how to on a static exam determine if a plantarflexed ray is flexible. One could first hold the rearfoot in neutral some say so that the talar head is neither bulging medially or laterally and then maximally pronate the longitudinal axis of the midfoot by applying upwards pressure sub 5th metatarsal head and finally to check the range of motion of the first ray in the sagittal plane. If there is more motion available plantar to the level of the other lesser metatarsals one might just be dealing with a flexible plantarflexed ray. Then one should continue the examination by looking inside the shoe and to check for the weight distribution on the insole. If there is no depression sub first metatarsal head one can suspect a plantarflexed first ray. Because there is relative pronation of the rearfoot that occurs when the flexible plantar first ray compensates there might be a depression in the insert sub 2nd 3rd and 4th metatarsal heads. ( This occurs because relative rearfoot pronation results in hypermobility of the first ray.) In podiatric biomechanical exams one must take into consideration not only the static exam but the resulting effects on shoe gear, callous distribution, gait analysis. Finally on gait analysis one could check to see if there is relative pronation of the rearfoot that occurs if the calcaneus is pronating during the gait cycle when it should be supinating. These biomechanical concepts I learned during lectures at NYCPM approximately 1982. All my teachers in the orthopedics dept at NYCPM were very intelligent, caring and wonderful. I wich to thank every teacher I had. I am continuing to learn more every day. Furthermore, I believe that Root had an excellent textbook on biomechanics.
A lattice pattern does go over the ridges in an approximately perpendicular direction but the fibrillar pattern goes across the ridges at a diagonal pattern other than perpendicular.

If after a podiatric biomechanical gait analysis, static exam, examining the depression in the shoe gear if a flexible plantarflexed first ray is the final deformity, and if a melanocytic nevus is present with a fibrillar pattern sub first ray, in my opinion should be biopsied. The reasoning is that the flexible plantarflexed ray would not lead to enough shearing forces capable to result it the diagonal distribution of pigment across the ridges.

I wish to thank Derm Foot, the biomechanical lectures at NYCPM during 1982 and to all my teachers who I am so grateful for.

Basics about Foot Dermatology and using a Dermatoscope

A nonpolarized dermatoscope with a fluid medium allows a podiatrist to see soft tissue structures beneath the skin beneath the epidermis.

A polarized dermatoscope allows a podiatrist to see even into the papillary dermis.

I learned these concepts from the Derm Foot Lecture for which I am hoping more podiatrists will consider attending.

There are certain terms such as Wallace’s line, Dermatoglyphics, and

other terms that can readily be searched for online. There is a comprehensive text called Atlas of Dermoscopy that I will refer to later in this blog.

What is dermatoglyphics?

Please go online and look up the word Dermatoglyphics. You probably will conclude the plantar aspect of the feet have dermatoglyphics or ridges present. I like to refer to the plantar skin that consists of skin without ridges and skin with ridges.

The article in Podiatry Today regarding Acral Lentiginous Melanoma referred to the plantar skin  I believe as consisting of ridges and furrows.

Parallel furrow pattern, Lattice pattern and Fibrillar pattern

The following is a brief explanation of concepts I learned at the Derm Foot Seminar:

Parallel furrow pattern is no pigment crosses over the ridges.

Lattice pattern some pigment crosses over the ridges in basically a perpendicular direction

Fibrillar pattern is pigment crosses over the ridges diagonally.

If any of the patterns are irregular and not consistent then one should consider taking a biopsy. I did not learn about an irregular lattic pattern and I am guessing that it does exist. MY ONE REQUEST IS IF ANYONE EVER SEEN AN IRREGULAR LATTICE PATTERN PLEASE COMMENT ON THIS.

What is Wallace’s line?

This is discussed in many online sites. I think of a fingerprint on the hand or a foot print. Fingerprints have ridges which follow a certain pattern. The plantar ( or acral ) surfaces of the feet have ridges.

Please go online and look up the word Dermatoglyphics. You probably will conclude the plantar aspect of the feet have dermatoglyphics or ridges present.

At a certain level on the foot the dermatoglyphics begin to stop. This is called Wallace’s Line. This I learned at the Derm Foot Seminar. This is one reason why I am advocating that podiatrists go to the Derm Foot Seminar and the they consider purchasing the Atlas of Dermoscopy mentioned earlier.

Proximal to Wallace’s line one can  the 3 point check list that emphasizes if a lesion is asymmetric, has an atypical network, or has blue white structures. Dermoscopy the Essentials explains this quite clearly.

The Dermlight 4 has a strong polarization and pigment boost and a toggling function that in my opinion has state of the art in acquiring clear images.

What about the image below?

There are polls in this blog. Please do not attempt to answer the polls until you read the Atlas of Dermoscopy, or other references. These polls can be very confusing and are not meant to be used as a teaching tool for those who are not very familiar with dermatoscopes. 20140111_1906311

What kind of image is this?

There are polls in this blog. Please do not attempt to answer the polls until you read the Atlas of Dermoscopy, or other references. These polls can be very confusing and are not meant to be used as a teaching tool for those who are not very familiar with dermatoscopes.

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Pigment boost vs highly polarized image without pigment boot

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Above is a dermlite 4 with pigment boost using the toggle function with the nonpolarized mode. What is wrong with the above picture?

I found this on the internet “we reasoned that dermoscopy can benefit the pathologist examining excised specimens in identifying areas that were of concern to the clinician and in the decision regarding how to section the lesion and where to focus the histopathologic analysis.”

I finally found a dermatopathologist that is interested in reviewing the images that I will send him. Perhaps I can convince him to provide a secure upload site. In the meantime anytime an image cd goes out it must be encrypted by me. I use winzip. The problem is that once the win zip creates the zip file the recipient dermatopathologist must have some sort of zip software to unlock the encrypted images. Yet I found that if I use a win zip self extractor software I can send the images out without having the pathologist install any winzip software on his computer. Then again if this idea of sending dermatoscopic images is to occur on a wide scale basis the dermatopathologist should have a secure upload site.

IF DERMATOSCOPES ARE READILY AVAILABLE WHY DEPRIVE THE DERMATOPATHOLOGIST OF THE OPPORTUNITY TO TAKE SUCH INFORMATION AND USE IT IN THE FINAL PATHOLOGY REPORT? In this day and age patients should benefit from the future of dermatoscopes.

Now that I am using a Dermlite 4 dermatoscope with a pigment boost:

I am intending to go to different hospitals to lecture podiatry residents on the basics of dermatoscopes and incorporating them into biomechanical cases as well as podiatric medical examinations.

I also want to contact the specialty certifying board to let them know my opinions that the certifying exam needs more questions regarding dermoscopy.

Malpractice carriers from a risk management point of view will likely embrace the idea of podiatrists including dermatoscopes in their podiatric exams.

After studying dermoscopy I have learned a lot and still am learning more everyday.

After using the Derm Lite 4 dermatoscope I am quite pleased to have the opportunity to have such a clear image due to its intense polarization and thus ability to see such deeper structures.

 

 

 

Every podiatry clinic should have dermatoscopes. In this day and age with the availability of dermatoscopes why deprive any patient of an exam with a dermatoscope so as to attempt to make the most informed decision as to whether a lesion does or does not need to be biopsied.

Ideally hospitals should use dermatoscopes before biopsy and send their skin specimens to a dermatopathologist. JAMA dermatology Dec 2007 says it is time for  ex vivo dermoscopy dematopathologists to learn dermoscopy

The point of the article I feel that is important is:

“we reasoned that dermoscopy can benefit the pathologist examining excised specimens in identifying areas that were of concern to the clinician and in the decision regarding how to section the lesion and where to focus the histopathologic analysis.”

Thus my conclusion is that if podiatry residents would use dermoscopy and know which areas to biopsy and then send the specimen to a dermatopathologist instead of a generalized pathologist then the dermatoscopic data could help the dermatopathologist into how to section the lesion and to analyze the histopathology.

Diagnosing foot melanoma saves lives.

I have podiatrust in the goals of having most if not every podiatric teaching clinic having access to a dermatoscope with adequate polarization.

By the way Steve McClaine MD and Ashfaq Marghoob MD were some of the authors of that article.

One caveat, I learned at the Derm Foot lecture that once one is around Wallaces line the line separating the dermatoglyphic skin from non glaberous skin the apperance of structures such as globules, networks appear. I encourage everyone to purchase the textbook Atlas of Dermoscopy by Dr. Mahoob who is one of the authors. One other caveat, I learned at the derm foot seminar that in Black skin the appearance of pigment in the ridges occur in benign nevi.

Hospitals that advertise they are giving high quality care should purchase dermatoscopes to be used in podiatry clinics because it is a public health concern if dangerous lesions are not biopsied such as an ameleanotic melanoma. Such a lesion just might have been detected by using a dermatoscope. Please understand that at the Derm Foot Lecture this was only an introduction to dermoscopy that focused on the dermatoglyphic structures below Wallaces line, nails, and some of the foot and leg. The problem is that there is so much more to learn regarding pattern analysis etc…. There are other texts regarding dermoscopy. I do not agree with everything I read in every text yet this is a great starting point.

Another caveat, there are other structures such as aborizing blood vessel that were not discussed at the derm foot lecture that are best seen under polarized light. This was a concept I saw in the Atlas of Dermoscopy a publication I am recommending to everyone. Back in 1983 in dermatology we discussed about basil cell carcinoma and such lesion with its pearly white borders, and telangectasias present. Imagine having a strong polarized dermatoscope back then in the early 1980’s. Well today is just like the 1980’s because podiatry clinics fail to embrace this state of the art instrumentation. Imagine a strong polarization with a pigment boost from a dermalite DL4 on an ameleanotic melanoma. This lesion which is so often missed and not biopsied especially in podiatry clinics without such instrumentation. The most advanced dermatoscopes in the hands of an educated  podiatric residents or an attending can save lives.