A Dermatologist's Diary: A Week of Dermoscopy Cases

Monday: The Critical Choice Between Polarized vs Non Polarized Dermoscopy

My week began with a patient who presented with a dark, irregular mole on his upper back. At first glance, it appeared concerning - asymmetrical with varying shades of brown. I reached for my dermatoscope, but then faced the crucial decision that often determines diagnostic accuracy: should I use polarized or non-polarized dermoscopy? This particular case perfectly illustrated why understanding the difference between these two modalities is essential in daily practice.

I started with non-polarized dermoscopy, which requires direct contact with the skin using interface fluid. This method revealed beautiful, clear images of the pigment network and allowed me to examine the superficial epidermal structures without surface glare. The mole showed what appeared to be an atypical pigment network with irregular dots, which initially raised my suspicion. However, when I switched to polarized dermoscopy without contact, I witnessed an entirely different set of features. The polarized light penetrated deeper, revealing blue-white structures and crystalline patterns that weren't visible with non-polarized examination. This comprehensive view provided by comparing both techniques gave me the confidence to identify this as a benign Reed nevus rather than a melanoma, saving the patient from an unnecessary biopsy.

The choice between polarized vs non polarized dermoscopy isn't merely technical preference - it's about accessing complementary information. Non-polarized dermoscopy excels at showing superficial epidermal structures and colors, while polarized dermoscopy reveals deeper dermal features and different morphological patterns. Having both capabilities in my clinic has become indispensable for accurate diagnosis, especially with pigmented lesions where the distinction between benign and malignant can be subtle.

Tuesday: Confirming Diagnosis Through Seborrheic Keratosis Dermoscopy Vessels

Tuesday brought a familiar face to my clinic - a patient in her sixties concerned about a new waxy, stuck-on appearing lesion on her chest. The clinical presentation strongly suggested seborrheic keratosis, but given its recent appearance and the patient's anxiety, I wanted to provide definitive reassurance through dermoscopic confirmation.

As I applied the dermatoscope with mineral oil, the classic features of seborrheic keratosis revealed themselves beautifully. The most telling signs were the specific vascular patterns that I've come to recognize instantly. The seborrheic keratosis dermoscopy vessels appeared as multiple hairpin vessels surrounded by a whitish halo, along with some comma vessels and milia-like cysts. These vascular structures, combined with the characteristic brain-like appearance and fingerprint-like patterns, confirmed the diagnosis beyond any doubt.

What's particularly fascinating about seborrheic keratosis dermoscopy vessels is how they differ from the vascular patterns seen in malignant lesions. While melanomas often display atypical, polymorphic vessels with irregular distribution, the vessels in seborrheic keratosis tend to be more regular and organized. Being able to show these features to my patient and explain how they confirm the benign nature of her lesion transformed her anxiety into understanding. She left the clinic not just with a diagnosis, but with education about what to look for in future skin growths.

Wednesday: Navigating a Challenging Lesion by Switching Dermoscopy Modes

Midweek presented one of those diagnostically challenging cases that test a dermatologist's skills. The patient had a lesion on his forearm that displayed features of both a dermatofibroma and a basal cell carcinoma. The surface showed central whitish scarring, but there were also some fine telangiectasias that raised concern. This was precisely the situation where my ability to switch between different dermoscopy modes became invaluable.

I began with polarized dermoscopy without contact, which immediately revealed the characteristic peripheral pigment network and central white patch typical of dermatofibroma. However, when I switched to non-polarized mode with interface fluid, I noticed subtle arborizing vessels that made me reconsider. The polarized vs non polarized dermoscopy comparison provided conflicting information, requiring careful analysis of which features were most significant.

To gather additional clues, I reached for my portable Woods Lamp, which revealed no fluorescence - ruling out certain fungal infections but not particularly helpful for this specific differential diagnosis. Returning to dermoscopy, I focused on the vessel morphology and distribution. The vessels, while somewhat arborizing, lacked the classic features of basal cell carcinoma when examined closely. The combination of examination techniques, particularly the ability to switch between dermoscopy modes, eventually led me to diagnose this as an atypical dermatofibroma with unusual vascular features. This case reinforced how different technologies provide complementary information, and how the skilled integration of multiple examination methods leads to accurate diagnosis.

Thursday: Demystifying Dermoscopy for Patients

Thursdays in my practice are often dedicated to patient education, and this week was particularly rewarding. I had scheduled a session with a patient who had multiple atypical moles and significant anxiety about skin cancer. She brought a list of questions about what all the colors and structures in her skin actually mean.

I began by showing her a benign mole under the dermatoscope, explaining how the uniform pigment network and symmetrical structure indicate regularity. Then I demonstrated what we look for in concerning lesions - the irregular dots, globules, and blotches that might suggest abnormality. The portable Woods Lamp proved especially helpful for showing how different skin conditions react to ultraviolet light, making abstract concepts more tangible.

When we examined one of her seborrheic keratoses, I pointed out the characteristic seborrheic keratosis dermoscopy vessels and explained how these differ from the vessels we might see in skin cancers. I also demonstrated the difference between polarized vs non polarized dermoscopy, showing her how each method reveals different layers and features of her skin. Her transformation from fearful patient to educated self-advocate was remarkable. By the end of our session, she understood not just what we look for, but why certain features matter more than others in determining whether a lesion is benign or requires further attention.

Friday: Reflections on How Technology Has Transformed Dermatology Practice

As Friday arrives, I find myself reflecting on how dramatically dermatology has evolved with the integration of technologies like dermoscopy. When I first started practicing, diagnosis relied heavily on clinical experience and visual inspection alone. The addition of tools like the portable Woods Lamp was helpful for specific conditions, but it was the widespread adoption of dermoscopy that truly revolutionized our field.

The ability to recognize specific patterns like seborrheic keratosis dermoscopy vessels has significantly reduced unnecessary biopsies while increasing our detection of early melanomas. Understanding when to use polarized vs non polarized dermoscopy has become second nature, much like a cardiologist knowing which EKG lead provides the most information for a particular arrhythmia. The portable Woods Lamp remains valuable for detecting pigmentary changes and certain infections, but it's the dermatoscope that has become the stethoscope of dermatology.

What's most rewarding is seeing how these technologies have improved patient outcomes. Earlier detection means less invasive treatments and better survival rates for skin cancers. More accurate diagnosis of benign lesions means fewer unnecessary procedures and reduced patient anxiety. The educational component - being able to show patients what we see and explain why we're confident in our diagnosis - has transformed the patient-doctor relationship. As I look ahead to next week's cases, I'm grateful to practice in an era where technology and clinical expertise combine to provide the best possible care for every patient who walks through our doors.