Dermatoscopic criteria for age-related skin processes

Yana Goncharova , Doctor of Medical Sciences, Professor (Ukraine - Qatar)

Innovations in diagnostics

Clinical manifestations of age-related skin changes are traditionally divided into two groups: mandatory clinical signs, which are observed in absolutely all people, and optional (minor) ones. The first group includes wrinkles (facial and senile), dry skin, atrophy, and ptosis. The second includes swelling and pastiness around the eyes, skin porosity, telangiectasia, rosacea, stellate angiomas, “ruby bodies”, hypertrichosis, hirsutism, hyperpigmentation, seborrheic keratomas, age spots, warts, xantellisms.

The clinical diagnosis of skin aging is not difficult, but in some cases it becomes necessary to assess the evolution of these changes, for example, to analyze the effectiveness of cosmetic anti-aging procedures. To diagnose the condition of the skin, there are various devices that allow you to assess the degree of hydration, turgor, relief condition, etc. As a rule, these are non-invasive organ-preserving research methods.

Visual examination, as the very first and simplest diagnostic method in dermatology, is invaluable, and to make it more informative, it can be supported by examination with a magnifying glass, vitroscopy, dermatoscopy, and ultrasound. Visual diagnostics is directly related to the possibility of archiving and storing skin images, which allows for dynamic assessment and makes it more accessible to consult the patient with other specialists and a council. Digital photography has been successfully used for this purpose.

Thanks to scientific developments and the introduction of innovative technologies into practice, new non-invasive high-resolution methods for studying the structure of skin and other tissues have appeared in the last decade. These include dermatoscopy, digital photography, optical coherence tomography, high-frequency ultrasound scanning, nuclear magnetic resonance, multiphoton microscopy, confocal laser scanning microscopy.

Dermatoscopy capabilities

Dermatoscopy is a method of optical examination of the skin that dates back to 1663, when Johan Kolhaus first used a microscope to examine the blood vessels of the nail bed. Two centuries later, in 1879, the German surgeon Carl Hueter applied the idea of his predecessor to a detailed study of the blood capillaries of the lower lip. A year earlier, Ernst Abbe and Carl Friedrich Zeiss proposed the method of oil immersion microscopy, which in 1893 was transformed into skin microscopy by Paul Gerson Unna, who established that the upper layers of the epidermis prevent the penetration of light into the dermis. Water-soluble oil was used to diffuse light through the superficial layers of the skin and image structures of the epidermis and upper dermis.

In 1987, a group of scientists led by Hubert Pehamberger presented the first differential diagnostic algorithm (pattern analysis), based on the study of dermoscopic signs of benign and malignant pigmented skin tumors. To conduct a dermoscopic examination, a stereomicroscope was used, which made it possible to obtain a three-dimensional image of all structural elements of pigmented skin tumors with a magnification of 6 to 40.

Since 1990, the widespread use of the dermatoscope has led to a real increase in the detection and clinical follow-up of early forms of cutaneous melanoma

In the process of research, the main and additional dermoscopic signs of pigmented skin tumors were identified, which were compared with the data of morphological studies of the surgical material. This algorithm allows for differential diagnosis of melanocytic and non-melanocytic, as well as malignant and benign pigmented skin tumors based on characteristic structural elements that are detected during dermatoscopy and correspond to a certain morphological structure.

A group of scientists led by Otto Braun-Falco invented a hand-held dermatoscope, which expanded scientific research and introduced dermatoscopy into everyday clinical practice. Since 1990, the widespread use of the dermatoscope has led to a real increase in the detection and clinical follow-up of early forms of cutaneous melanoma. From 1994 to the present, in oncodermatological practice, the ABCD clinical rule, proposed by Robert J. Friedman in 1985, has been used to diagnose melanoma. The ABCD rule includes the assessment of pigment formation of the skin according to four parameters: A - asymmetry of the pigment spot, B - unevenness of the borders, C – uneven coloring, D – diameter more than 6 mm. The presence of three or more signs indicates a malignant tumor. Similar to the ABCD clinical rule, a dermoscopic index has been proposed to identify potentially dangerous melanocytic neoplasms.

Dermatoscopy is a valuable auxiliary method that allows you to differentiate the formation of a melanocytic nature (pigmented nevus or “mole”) from actinic keratomas, seborrheic keratomas and other pigmentations of non-melanocytic origin (photo 1, 2). This area of application of dermatoscopy has been quite well studied. Often, dermatoscopy helps to diagnose other optional signs of skin aging, such as basal cell carcinomas, xanthomas, and vascular formations.

Photo 1

Photo 2

The idea of using dermatoscopy to evaluate the effectiveness of anti-aging cosmetic procedures, based on the analysis of the main signs of aging, is a new direction in dermatocosmetology

Use of dermatoscopy in the assessment of aging

The idea of using dermatoscopy to evaluate the effectiveness of anti-aging cosmetic procedures, based on the analysis of the main signs of aging, is a new direction in dermatocosmetology.

The condition of facial wrinkles can be assessed by the severity of the epidermal crease (photo 3).

Photo 3

The appearance of senile wrinkles is associated with sagging skin, therefore such wrinkles are smaller and look like a mesh, the severity of which is clearly visible during dermoscopic examination. Both facial and senile wrinkles are better visualized without pressing the dermatoscope on the skin being examined, since the pressure of the dermatoscope on the tissue will smooth out the relief. Dry skin is assessed by the severity of peeling. Superficial dried and keratinized epidermocyte cells are better visible with “dry” dermatoscopy without the use of contact gel (photo 4).

Photo 4

One of the components of age-related skin atrophy is a decrease in the number of layers of the epidermis. The degree of atrophy of the epidermis during dermatoscopy is assessed indirectly by how well the underlying capillaries of the papillary dermis are visible.

By conducting a dermoscopic examination, you can also evaluate the severity of heliodermatitis, which dermoscopically has the appearance of unevenly colored skin with alternating hyperpigmentation, hypopigmentation, up to achromia and erythema (photo 5).

Photo 5

As you know, the appearance of the so-called changes with age. pores or mouths of sebaceous follicles. Their condition is largely due to hormonal changes. During menopause, the pores expand, but at the same time they become empty and look like enlarged gaping openings of the follicles. The severity of the pores can also be assessed by dermatoscopy (photo 6). In the same way, with dermatoscopy we can assess the presence and severity of comedones.

Photo 6

To assess the evolution in the process of cosmetic treatment or dermoscopic diagnosis of skin aging, it is important to perform dermatoscopy each time on the same place, i.e. on a standard area

As a result, the following dermoscopic signs of skin aging can be identified: facial wrinkles, senile wrinkles, dry skin, atrophy, uneven coloring, pores, comedones.

Skin Aging Index

Photo 7 shows dermatoscopy of normal skin of a 25-year-old patient. There is no peeling, normal pore diameter, no pigment spots or telangiectasia, microrelief is not expressed.

Photo 7

Such a dermoscopic picture can be taken as a standard or, according to our proposed scale of age-related changes (see Table 1), corresponds to 0 points.

Table 1. Dermatoscopic assessment with calculation of the skin aging index

To assess the evolution in the process of cosmetic treatment or dermoscopic diagnosis of skin aging, it is important to perform dermatoscopy each time in the same place, i.e. in a standard area. Taking into account the features and differences of the skin in different areas of the face, we selected three areas - the central part of the forehead (between the eyebrows), the periorbital area (the “crow’s feet” area), and the area in the middle of the cheek (fossa canina projection). The choice of zones can be arbitrary, the main thing is that the dermatoscopy zone coincides for each study in the same patient.

For comparison, photo 8 shows pronounced pores of different diameters, closed comedones (3 points), slight focal hyperpigmentation (1 point), multiple telangiectasia (3 points). We proposed a skin aging index (SAI), according to which in the case shown in photo 8, the SAI is equal to 7 points. The value of the ISC with minimal signs of aging is 0-2 points, with moderate signs of aging - 2 - 8 points, with pronounced signs of aging - 8-15 points. The value of this index is in assessing evolutionary changes, for example, before and after chemical peels using trichloroacetic acid or other invasive procedures.

Photo 8

Thus, dermatoscopy of age-related skin changes is a valuable and promising method for additional diagnosis and assessment of the effectiveness of invasive cosmetic procedures.

First published: KOSMETIK international journal, No. 2/2011