TELEDERMATOLOGY READER REPORT1
History
Chief complaint: presenting for diagnosis of a lesion.
History of present illness: A 66-year-old man presents with a "growing brown spot" (primary lesion) on the abdomen (location) that he states has been growing quickly in the last 6 months (duration). Prior treatment: none. His primary symptom: none. Prior biopsy: none. He has no personal or family history of skin cancer or melanoma. Other significant laboratory/study findings: none.
Image Quality Assessment
Marginal satisfactory with suggestions for improvement.
TELEDERMATOLOGY IMAGING READER REPORT
A single image (Figure 1) was provided that shows an asymmetrical brown/pink/red lesion with irregular borders. It is recommended with melanocytic lesions that five images are taken including a size meter (ruler), with at least one from a greater distance (securing the site for reidentification if face-to-face evaluation is needed). Submitting multiple images minimizes errors in light reflection and pixilation (from camera to screen).
INTERPRETATION OF IMAGES
Lesion A
Findings
The presented lesion and history are most consistent with the diagnosis of a suspicious melanocytic process (e.g., dysplastic nevus or melanoma).
RECOMMENDATIONS
Skin Care and Treatment Recommendations
Present to dermatology for excisional biopsy and full skin evaluation for similar lesions. Given the rapid growth and pigment irregularity, this lesion would best be evaluated face-to-face by a trained dermatologic provider. Most pigmented lesions that meet criteria for a suspicious melanocytic process (see below) should be assessed by a consultant in dermatology, expeditiously.
RECOMMENDED FOLLOW-UP
Type of Visit
Refer to dermatology clinic for evaluation (face-to-face) and excisional biopsy.
(Type of visit: completing teledermatology provider picks one of the following: return to primary provider for treatment; refer to dermatology clinic for evaluation (face-to-face); or lesion is benign, recommend reassurance and follow-up as needed [PRN].)
CLINICAL PEARL
The best screening tool for both the patient and the provider are the ABCDE criteria of melanoma for a worrisome melanocytic lesion (mole): asymmetry, border, colors, diameter/duckling, and evolving. Asymmetry of the mole can be checked by putting an imaginary line through the center of the lesion in any axis to see if the halves are mirror images. Border irregularity refers to the edges of the mole being notched, ragged, or blurred (not well demarcated). Color variation within the mole must be considered. Melanoma often has a variety of the following shades: black, brown, reddish brown, pink, and white. The white can be a sign of regression. A mole with a diameter greater than 6 mm confers higher risk of it being a melanoma. In addition, in the "D" category is the "ugly Duckling rule." This comparative evaluation tool is based in analyzing both classic pigmented lesions and amelanotic or desmoplastic melanomas and finding the "ugly duckling" that does not match the rest of the background moles on the patient. The evolving or changing mole, per the patient's history, is the final worrisome feature (Swetter, 2014). If the lesion has two or more of these criteria, it increases the odds of the melanocytic lesion being a melanoma, and the patient needs a biopsy at a face-to-face visit.
REFERENCE