DERM2019 Day 4: Contact Dermatitis, Dermoscopy Bootcamp, and More

The last day of DERM2019 included a dermoscopy session and several other key presentations from Jennifer Stein, David Cohen, and Gilly Munavalli. Here’s a brief recap from some of those talks!

Dermoscopy Bootcamp Presented by Jennifer Stein

Recap by Jayme M. Heim MSN, FNP-BC, West Michigan Dermatology

Dermoscopy is a noninvasive technique which enables a provider to help differentiate skin structures at a deeper level. This is important because it increases diagnostic accuracy and decreases the need for biopsies. However, this is just a diagnostic tool; it is not intended to replace your clinical judgement.

Knowing basic patterns when examining the skin will save the patient the need for biopsy. Examining the pigment network is the first step. The types of questions you need to keep in mind are as follows: What does the network look like? Is it a reticular pattern and consistent throughout? Does the lesion have a globular or a structureless network? Next, you will need to decide if the lesion is benign or malignant based on the overall pattern.

When viewing a melanoma with the aid of a dermatoscope, you should look for certain warning signs. These warning signs are: streaking, blue/white veil, peppering, angulated lines, white shiny perpendicular lines, and anything you cannot identify. If a lesion is brown and pink, you need to stop and think since this type of lesion is highly suspicious of melanoma.  If a lesion has two different sides, examine both sides. The content within the lesion will always be more important than the contour. If a pattern is not clearly malignant, but not clearly benign, it is safer to assume it may be a melanoma.

Non-melanocytic areas that can be distinctively identified on dermoscopy include pigmented basal cell carcinoma, angioma, seborrheic keratosis / solar lentigo, lichen plantus like keratosis and dermatofibroma. Look for the following features in a basal cell carcinoma: arborizing vessels, maple leaf like structures, blue/grey globules, spoke wheel areas, and large ovoid nests. Pigmented basal cell carcinoma’s are usually distinctive, but can mimic multiple melanoma.

Angioma’s can be very concerning to patients, especially if the engorged blood is dark. Look for the “maroon lagoons” when identifying an angioma.

Seborrheic keratosis and solar keratosis can be found in two common forms: a comedone like opening where millia like cysts are seen with sharp demarcation and a cerebriform pattern. Solar lentigo’s can morph into a seborrheic keratosis.

Lichen plantus like keratosis is also referred to a lichoid keratosis or benign lichenoid keratosis. When in their inflammatory stage, they are puffy, pink, and itchy. Afterward, a pigment change will remain on the skin.

Dermatofibroma’s will have a white, shiny center because of the collagen present in the lesion. This lesion is firm and on dermoscopy exam can be dotted / serpentine vessels.

Lentigo maligna is often seen in older patients. Lentigo maligna can be identified with one or more of the following four dermascopic features: grey dots, asymmetric follicular openings, rhomboidal structures, and homogenous areas. Lentigo maligna tracks down the hair follicle. This can only be seen during a dermoscopic exam.

Hands and feet can be difficult areas to discern. Lesions in these areas can represent melanoma, acral nevi, or acral congenital nevi. Benign lesions will have parallel furrows, appear lattice-like, and have fibrillar. Malignant lesions will have parallel ridges. Use of the BRAAFF Algorithm tool can be useful in guiding your clinical decision making.

Knowing how to evaluate lesions in clinical practice is important, but the bottom line is don’t be a hero; if you are not sure, then biopsy. The biopsy will lead to a definitive diagnosis.

Current Trends Contact Dermatitis Presentation from David Cohen

Recap by Leigh Ann Pansch, NP

There was a sobering silence during Dr. Cohen’s presentation on Contact Dermatitis. He presented data suggesting atopic dermatitis has a best friend forever and it’s allergic contact dermatitis. When your patients don’t quite respond to treatment the way you would expect, repeatedly improve and immediately flare again, have involvement of rash on the eyelids, face and dorsal hands we should be thinking patch test!

Formaldehyde was the 2015 allergen of the year and yet continues to be found in many cosmetics. Inside the body, aspartame (maybe that sugar-free product is not such a good idea) becomes methanol and degrades further into formaldehyde. We all need to be familiar with “slime dermatitis” too! Methylisothiazolinone (MCI) is found in commercial paints and school glue. You could’ve heard a pen drop when Dr. Cohen declared that MCI can cause rash in the few years after exposure. Nearly 1 in 20 people report fragrance sensitivity. Remember to address fragrances when directing skincare recommendations to the atopic patient. Don’t forget essential oils! Those naturally-occurring plant derivatives may be the cause of your persistent rash. Consider contact allergy to rubber allergens for health professionals. In 2017, we were introduced to nonionic surfactants (Alkyl Glucoside) as allergen(s) of the year. These plant derivatives come from palm or coconut oil and is found in many OTC cleansers, emollients, deodorants, and sunscreens. Consider allergy to propylene glycol with persistent rash involving the face, eyelids and other body locations which encounter pre-moistened wipes. Dr. Cohen asked us to, “Remain seated and hold your applause for the” new term regarding the 2019 “non-allergen” of the year “parabenoia!” Though parabens are found in many personal care products, true allergy to them is still rare. Animal testing revealed paraben derivatives may have a weak estrogen effect. Though they seem to be benign (in terms of contact dermatitis) preservatives, there is growing public concern for their presumed carcinogenic effects; a claim that has yet to be established by research. What an outstanding update on this topic! We all need to be vigilant to watch trends in personal care items, especially cautious of rubber allergens, preservatives, and fragrance.

DERM2020

DERM2020 will be held Thursday, August 6, 2020 through Sunday, August 9, 2020 at teh Encore Las Vegas, Nevada.

The meeting is offering a Registration Discount for All DERM2019 NP/PA Attendees! until September 1, 2019. Use Discount Code OnsiteDERM2019 for $50 Early Bird Registration. Visit www.DermNPPA.org to Register Now!