Dermatoscopes lead the way in the future for skin cancer detection

Richard Usatine, MD, FAAFP

Richard Usatine, MD, FAAFP

Technology is paving the way to more-efficient skin cancer diagnoses in the office setting.

Richard Usatine, MD, FAAFP, reviewed the latest diagnosis and treatment options available for basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma during his "Skin Cancer Update: For the Family Physician” CME session Friday morning at FMX.

"Dermoscopy really is the cutting-edge way to diagnose skin cancers and diagnose them early. The evidence is clear, if you use a dermatoscope, your sensitivity and your specificity for diagnosing skin cancer will go up,” said Usatine, professor of family medicine and professor of dermatology and cutaneous surgery, University of Texas Health Sciences Center, San Antonio.

Dermoscopy helps differentiate benign and malignant lesions, meaning fewer missed melanomas and fewer biopsies of benign lesions.

"In the future, I think all family physicians will have dermatoscopes, and they will be using them to see into the skin,” Usatine said.

Usatine reviewed the characteristics of the major BCC types, including nodular, superficial, and schlerosing/infiltrating.

A shave biopsy is the fastest and most effective way of diagnosing a BCC, Usatine said. However, he suggested a punch biopsy may be considered if the lesion is atrophic and hard to shave or if a deeper, more aggressive lesion is suspected. "Over 90 percent of the time, my diagnosis for BCC is with a shave or saucerization. If it is flat, I just take the blade, bend it and saucerize underneath it,” he said. Treatment options for BCC include electrodessication and curettage, cryotherapy with 3 to 5 mm margins, excision with 3 to 5 mm margins, and Mohs surgery. Treatment with Imiquimod or 5-fluorouracil is appropriate for superficial BCC, and hedgehog inhibitors (Vismodegib and Sonidegib) may be used for locally advanced or metastatic BCC, although they are all extremely expensive, he noted. Mohs surgery, though, is the treatment of choice for BCCs with poorly defined margins.

"I would recommend—if you have an aggressive cancer on the face or on the nose—that you send someone to a Mohs surgeon, even if they have to drive an hour down the road,” he said.

More rare and usually found on sun-exposed areas, SCC's found on the lips or mouth, on the ear, or arising from a burn are at increased risk for metastasis. Usatine said excision with a 4 to 6 mm margin, or Mohs for the worst ones, are usually indicated as treatment options, although SCC in situ can be handled with curettage and desiccation after a shave biopsy or cryotherapy.

"Once you've had a patient with one of these skin cancers, they need to be monitored for life,” said Usatine, who suggested that patients be checked every six months for new cancers.

Usatine also reviewed the types of melanomas and National Comprehensive Cancer Network guidelines, which indicate deep-shave biopsy is preferable to superficial- shave or punch biopsy for the diagnosis of thin and intermediate-depth (<2 mm) melanomas.

"Almost all of my melanoma biopsies are done with saucerization, and that is what my dermatology colleagues do, too,” he said.

Surgical literature supports the practice of saucerization, (scoop or deep-shave biopsy). Usatine said the research indicates it leads to accurate diagnosis and staging 97 percent of the time.