4 курс / Дерматовенерология / Дерматоскопия (3)

Dermatoscopy is a simple method that anyone can learn. However, many doctors still doubt that they can gain sufficient skill in dermatoscopy for it to be useful in their everyday clinical practice. One of the main reasons for this attitude is the discrepancy between the simplicity of the method and the difficulty of the jargon used by experts, which may be quite incomprehensible to the uninitiated. Such jargon rarely adds significant information to one’s observation but it does create an irksome barrier which makes dermatoscopy unnecessarily difficult to learn. One of the main concerns of this book is to remove this barrier from the path of learning.

The reason for writing this book was the clear need for a single source of concise, easily comprehensible, and consistent learning materials to teach the method of pattern analysis. Pattern analysis is a comprehensive and powerful diagnostic tool and has proved to be the method with the greatest diagnostic accuracy in the majority of studies. The method presented here is not a new invention, or even another new algorithm, but plain and simple pattern analysis. Its novelty is merely that inaccuracies and ambiguities have been consistently avoided, and prime importance has been given to clarity, logic, and consistency in both the language used to describe lesions and the method of using these descriptions to reach a diagnosis. I would not have undertaken this project without the encouragement and support of Dr. Elisabeth Riedl and Dr. A. Bernard Ackerman, who contributed to the development of the method by providing a large number of valuable ideas and concepts. Regrettably, Dr. Ackerman passed away suddenly in December 2008. He has left a void that cannot be filled. He was a magnificent teacher, full of spirit and verve, and possessed unique originality.

I also wish to thank those who generously provided the visual material and thus made it possible to write this book at all. As the majority of clinical photographs have been derived from the archives of the Department of Dermatology in Vienna, I am most grateful to the current Head of the Department, Univ. Prof. Dr. Hubert Pehamberger who, with no hesitation and with the greatest willingness, gave permission to use these images. I also thank his retired predecessors Univ. Prof. Dr. Klaus Wolff and Univ. Prof. Dr. Herbert Hönigsmann. Most of the clinical pictures were taken by Andreas Ebner, who is an extremely talented and patient photographer at

the Department of Dermatology in Vienna. I thank Univ. Prof. Dr. Michael Binder; he was my first teacher of dermatoscopy and generously provided his camera for taking many of the dermatoscopic pictures in this book. However, the photographs in this book are not derived from Vienna alone. Colleagues from all corners of the globe generously and selflessly provided photographs, include Giuseppe Argenziano, Ralph Braun, Ian McColl, Jean-Yves Gourhant, Maggie Oliviero, Harold Rabinovitz, Isil Kilinc Karaarslan, Iris Zalaudek, and of course the two co-authors Cliff Rosendahl and Alan Cameron. The English edition of this book could not have been produced without their help. Philipp Tschandl helped us to inspect and prepare the photographs, select references, and especially write the chapter on Inflammatory Skin Diseases. The excellent English draft of the German edition was produced by Sujata Wagner. I am indebted to her for her patience and accuracy. Finally, I wish to thank the staff of Facultas Verlag (publisher) for their support and cooperation. Specifically, Hani Aghakhani and Norbert Novak worked extensively in designing the book. Finally I must thank Dr. Sigrid Neulinger for her extreme patience in dealing with innumerable missed deadlines.

Preface to 2nd edition

The success of the first edition took us by surprise. It has been translated into seven languages. The second edition is not merely a reprint of the first. All chapters have been updated and new material added, incorporating suggestions of readers and correcting the (inevitable!) mistakes that were brought to our attention. Some chapters have been completely rewritten. We thank Jean-Yves Gourhant, Pedro Zaballos, Iris Zalaudek, Giuseppe Argenziano, Bengü Nisa Akay, and Bianca Carlos for providing us their images. We have worked hard on the 2nd edition and we hope that we exceeded your expectations.

Harald Kittler, Alan Cameron,

Cliff Rosendahl, Philipp Tschandl

Vienna, Austria and Brisbane, Australia,

September 2016

1.1 The Investigation Technique

Dermatoscopy is a simple and non-invasive investigation technique that enhances one’s naked eye perception of skin lesions by revealing significant additional morphological features, and thus facilitating, or making possible, the establishment of a diagnosis. The first use of an instrument with an inbuilt light source and the first use of the word ‘dermatoscopy’ to describe the technique appears to be in 1920, by the German dermatologist Johann Saphier (1) (1.1).

Saphier based his approach on previous reports published by Unna and Kromayer (1893), who described a technique of viewing skin lesions through a glass plate coupled to the skin by immersion oil (under the name ‘diascopy’). Like Unna and Kromayer, Saphier’s investigations were mainly focused on inflammatory skin diseases. At the time, the diagnosis of pigmented skin lesions was considered to be of little importance. The benefits of dermatoscopy for the diagnosis of pigmented lesions became recognized in the last third of the 20th century – specifically for the diagnosis of melanoma. During this renaissance dermatoscopy was given several other names such as epiluminescence microscopy. A more recent term frequently used in the Anglo-American literature is dermoscopy. However, these neologisms have contributed to the type of confusion that arises when different terms are used for one and the same entity. Saphier, who was first to describe an instrument with all the components of modern instruments, named it dermatoscopy. Therefore, this is the only term that will be used in this book.

From Saphier’s time through until the 1980s, dermatoscopy was performed using cumbersome stereomicroscopes. Today one uses a simple hand-held instrument consisting of a focusable magnifying lens, LED illumination, a transparent contact plate and possibly polarizing filters (1.2).

The use of a contact plate coupled to the skin with a transparent fluid is crucial to the function of the dermatoscope. When one examines lesions clinically (or with a dermatoscope without fluid), the majority of the light remitted to the observer’s eye is reflected back from the most superficial layer of the epidermis, the stratum corneum. This largely obscures details of

Figure 1.1a: Extract from Johann Saphier’s original paper titled “Dermatoskopie”, published in 1920 in the Journal “Archiv für Dermatologie und Syphilis“ (Archive for Dermatology and Syphilis).

Figure 1.1b: Binocular dermatoscope from Saphier’s times (around 1920).