I don’t know what I would do without my Dermlite 4 dermatoscope.

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 has the ability to toggle between polarized and nonpolarized modes. It has the largest viewing field I know of. It attached to my Samsung phone and it attaches to 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.

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.

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?

Biomechanical faults affect melanocytic lesions but what about considering their affects on non melanocytic structures such as vascular tissues

These are questions and ideas I thought of myself. If shearing forces can affect the parallel furrow pattern why can’t similar forces affect other structures besides those seen in a melanocytic lesion? For example in a basil cell carcinoma why can’t shearing forces cause an arborizing vessel appearance to instead appear as polymorphous or dotted? Or why can’t the blue-white veil overlying raised area instead appear homogenous? Or why can’t a typical network appear atypical? Or why can’t a regular globular pattern appear irregular?

Why is a lattice pattern instead of a parallel furrow pattern present on the arch which clinically without a biomechanical analysis would appear non weightbearing? One cannot just look at the arch and assume it is non weight bearing.

The answer to this puzzle is that the biomechanical exam yields information unknown to only a dermatoscopic exam. There are different biomechanical faults in different planes be it your sagittal, transverse and frontal planes. Some of these faults occur on the rearfoot, some on the forefoot while some are uncompensated, partially compensated and fully compensated.

Key: After a complete biomechanical evaluation and fully checking the shoe gear and insoles, if there is a biomechanical deformity (with or without any degree of compensation) which results in biomechanical non weight bearing area with very limited shearing forces, plus a dermatoscopic exam with a fibrillar pattern then one must biopsy.

I thought of combining a gait analysis and static exam including shoe gear analysis and how such forces affect one’s dermatoscopic images. This topic is further discussed in the post below.

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 wish 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, Dr. Marghoob and the Atlas of Dermoscopy, the biomechanical lectures at NYCPM during 1982 and to all my teachers who I am so grateful for.

Why am I pleased with my dermlite 4 dermatoscope

Suppose there are characteristics of milia-like cysts in seborrheic keratosis.
or shiney white structures in basal cell carcinoma, this is all the more reason to use a dermlite 4 dermatoscope with its high polarization and ability to toggle from polarized to nonpolarized. I believe it is common knowlege that milia cysts do not show up well on polarized dermoscopy and shiney white structures do not show up well using non polarized dermoscopy.