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Dermoscopy is useful for skin cancer screening, but a detailed approach is required that integrates this tool into a rational clinical work flow. To investigate clinician perceptions and behavior in approaching patients with skin tumors, a survey was launched by electronic mail through the International Dermoscopy Society. After 4 months, the responses were analyzed and significant findings calculated. Considering the current approach of study participants in examining patients for skin cancer, an up-to-date system of triage is presented in this review, which aims to promote an improved diagnostic accuracy and more timely management of skin malignancy.

Fig 1. Hypertrophic lupus erythematosus. A, Clinical image of extensive verrucous plaques on the right postauricular area, pinna, and cheek. B, Discoid lesion on the left cheek, demonstrating a scaly peripheral edge and central whitish-pink atrophic area. C, Polarized contact dermoscopic view of the scaly anterior edge of the discoid plaque pictured in (B) showing numerous white-to-yellow hyperkeratotic follicles, confluent scaly areas, whitish perifollicular haloes, blurred reddish vascular areas (arrows), and linear vessels. D, Central atrophic area of the same lesion revealing homogeneous white-to-pinkish areas with dotted (circle), hairpin (rectangle), and linear vessels (arrow). The dermoscopic features depicted in (C) suggest active DLE, whereas the features in (D) are consistent with advanced DLE.

The famous tale of Sleeping Beauty is believed to have originated from centuries-old European folklore. The earliest known written version appeared in the French work Le Roman de Perceforest (circa 1330-1344), followed by the Italian rendition Sun, Moon, and Talia by Basile (1634), Perrault’s The Sleeping Beauty in the Wood (1697), and the Grimm brothers’ Little Briar Rose (1812). A common theme of the various versions is that an infant girl is cursed to prick her finger on a wooden spindle (or flax) years later, causing her to become stuporose or to die. This raises the question: could this peculiar scenario be based on an actual medical condition?

Metaphoric or analogical terminology is common in clinical dermatology, dermoscopy and dermatopathology. Metaphoric language in dermatology has been criticized for a perceived lack of clear definition and specificity, and non-metaphoric (descriptive) terms and diagnostic algorithms have attempted to be constructed. Metaphors are pervasive in human language and appear to be deeply rooted in our conceptual frameworks. The utility of metaphors in dermoscopy is discussed, with particular reference to research in the cognitive sciences. Introduction: Metaphoric language in dermatology, dermoscopy and dermatopathology Metaphor is a complex subject in language and cognitive science. It is a linguistic and conceptual tool commonly used in science and the arts and has been defined as “understanding and experiencing one kind of thing in terms of another” [1]. Metaphors are a special form of analogy or association, and aim to help the learner comprehend and communicate new or unfamiliar (“target”) information based on known or familiar (“source”) knowledge. Lakoff and Johnson propose that our abstract thoughts are largely metaphoric, and that metaphoric language is secondary to this [1]. In their view “metaphoric thought is unavoidable, ubiquitous, and mostly unconscious,” having developed automatically in childhood as we learn to function in our everyday world [1]. Consequently, they regard metaphor as a natural and unavoidable aspect of human language. Metaphors are widely used in the dermatology lexicon, developed to aid recognition and description of clinical, dermoscopic, and dermatopathologic criteria. Examples include the prefix “lichen” in lichen planus, “bamboo” hair, “guttate” psoriasis, “arborizing” telangiectasias, “saw tooth” pattern, and so on. Besides explicit metaphoric terminology, covert metaphoric concepts are also common. The “disease as an enemy” metaphor is one example, wherein the dermatologist uses various diagnostic or therapeutic “armamentaria” to “fight” or “combat” the disorder [2]. However, metaphors have received criticism in the dermatologic literature in recent years. Notably, Ackerman says [3]: “. . . cliches are ubiquitous in dermatology and pathology in general and in dermatopathology in particular, the realm of inflammatory skin diseases being no exception. . . . Images like ‘corps ronds and grains’ . . . , ‘dilapidated brick wall’ . . . , ‘tombstone pattern’ . . . , ‘festooning’ . . . , ‘flame figures’ . . . , ‘ground-glass cytoplasm’ . . . , and ‘saw tooth pattern’ . . . may be picturesque, but none of them lend themselves to definition meaningfully by those who mouth them . . . Moreover, not a single one of those whimsical mental pictures has specificity.” [3] In sum, Ackerman regards these metaphors as lacking clear definition and specificity. Similarly, Kittler criticizes metaphors in traditional dermoscopy [4]: “The images invoked by metaphoric terms and opaque expressions result inevitably in failure to conjure the very same construct in the brain of any two individuals. Examples: ‘Leaf-like areas,’ ‘fingerprint-like structures,’ ‘fat fingers,’ ‘radial streaming,’ ‘moth-eaten border,’ ‘blue gray veil,’ and ‘honeycomb-like pattern.’ Those images impede repeatable diagnosis by dermatoscopy and prevent rational communication between dermatoscopists.” Moreover, Alendar et al [5] write, under the heading “No need for metaphoric language,” that “The current language of dermatoscopy consists mainly of metaphoric terms that are badly defined. This language is extremely confusing and discourages students to learn the technique profoundly.” The above viewpoints present metaphors as being non-scientific, lacking clear definition and specificity. Metaphor is thus regarded as a hindrance to understanding and communication in dermatology, dermatopathology and dermoscopy.

Skin A IR M Fund Conf CLINICAL PRESENTATION An 86-year-old man with skin phototype I/II presented with multiple flat, scaly, nonpigmented actinic keratoses (AKs) on the face and scalp (Fig 1, A). A clinically inconspicuous 2-mm scaly pink papule was also noted on the left nasal sidewall (Fig 1, A, inset). The second patient, a 74-year-old man with skin phototype II/III presented with numerous flat, scaly, pigmented facial AKs (Fig 1, B).

Patients with a high total nevus count (TNC) merit a total-body examination, but a simple strategy to identify these high-risk individuals is essentially missing. The aim of this study was to investigate the correlation between the number of melanocytic nevi on both arms and the TNC, and to evaluate patient variables that may have an effect on this association. In this multicenter, cross-sectional study, 2175 patients were examined and the mean number of arm nevi in relation to TNC was calculated. A mean value of fewer than 10 arm nevi was found in patients with TNC lower than 51 and a mean value of greater than 19 arm nevi was scored in patients with TNC greater than 50. These values remained unchanged after adjustment for various patient variables. In relation to TNC greater than 50, the presence of 20 or more arm nevi had specificity and negative predictive values of 95.2 and 89.6%, respectively. The sensitivity was 65.5% in patients younger than 50 years of age and 37.5% in the older age group. The number of arm nevi was significantly higher in individuals with a history of melanoma and in those with a melanoma detected during the study period. The presence of 20 or more nevi on the arms is an independent predictor of a high TNC and risk of melanoma. This sign thus represents a simple and rapid screening tool for either the primary care physician or the dermatologist to help identify high-risk patients.

From th Re U Fund Conf CLINICAL PRESENTATION A 75-year-old woman, with Fitzpatrick skin phototype I/II and a history of nonmelanoma skin cancer presented with a scaly, fissured, erythematous, fairly well demarcated patch involving the periungual skin of the left index finger (Fig 1). The lesion had persisted for[1 year despite the use of antibiotic and corticosteroid ointments. The patient was immunocompetent, an exsmoker, with no reported history of arsenic ingestion, trauma, burns, or ionizing radiation to the site.

A 62-year-old man with Fitzpatrick skin phototype I presented with partially pigmented macules on the cheek and temple (Fig 1, A and B). The second patient, a 63-year-old man with Fitzpatrick skin phototype III, presented with pigmented macules on the left and right cheeks (Fig 1, C and D).

Dermoscopy (dermatoscopy or surface microscopy) is an ancillary dermatologic tool that in experienced hands can improve the accuracy of diagnosis of a variety of benign and malignant pigmented skin tumors. The early and more accurate diagnosis of nonpigmented, or pink, tumors can also be assisted by dermoscopy. This review focuses on the dermoscopic diagnosis of pink lesions, with emphasis on blood vessel morphology and pattern. A 3-step algorithm is presented, which facilitates the timely and more accurate diagnosis of pink tumors and subsequently guides the management for such lesions.

Skin cancer is the most common malignancy in humans, thus representing a major health concern. Because of the increasing attention to skin cancer prevention, there has been a growing workload for dermatology clinics, with patients referred from primary care requiring assessment of suspicious skin tumors. This places a strain on limited specialist resources and can create a paradoxical situation wherein an early diagnosis becomes increasingly difficult for those patients who actually do suffer from skin cancer. The aim of these recommendations is to propose an updated, rational system of triage, involving improved accuracy of diagnosis and more timely management of skin cancer by both general practitioners and dermatologists.