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Common Applications of Dermatologic Sonography
The selected article for discussion is:
“Common Applications of Dermatologic Sonography” (Wortsman)
Questions for discussion:
- Dr. Wortsman states: “The assessment of objective information in dermatologic diseases seems to be a necessary field for further investigation that can save clinical time dedicated to complex scoring.” Do you foresee a significant impact of sonographic assessment on the use of dermatologic scoring systems?
- The author refers to cutaneous sonography as a “reliable adjunctive tool” for diagnosis and assessment of dermatologic diseases. How do you see the role of sonographic assessment evolving for dermatologists?
- The author states: “Sonography has been reported to be useful for diagnosing foreign bodies, which is a matter of utmost importance when dealing with radiolucent structures. Moreover, this imaging technique may guide percutaneous removal of these bodies.” Do you see a role for sonography in emergency settings as a “first” assessment of patients with foreign bodies retained in the skin?
Background and Study Design:
The author notes the importance of skin health to the psychological and social well-being of individuals. This review analyzes the growing use of sonography as an adjunctive tool in the diagnosis and management of dermatologic conditions to obtain critical information otherwise unavailable to the clinical naked eye.
Methods:
Reviewed cases were extracted from a national referral center that performs dermatologic sonographic examinations. The review analyzes the most common dermatologic applications of sonography, and some technical considerations for exam performance. All examinations were performed by the same radiologist, using gray scale and color Doppler sonography with spectral curve analysis of blood flow. Three-dimensional reconstructions were performed for highlighting the dimensions of cutaneous lesions.
Findings and Conclusions:
The author compares sonography with other imaging modalities:
1- Patient care considerations:
- Compared with CT, sonography lacks the secondary effects of radiation.
- Compared with MRI, sonography does not confine the patient in a reduced space.
- Dermatologic sonographic studies do not usually require the injection of a contrast medium, at least in baseline studies.
2- Diagnostic considerations:
- High penetration and high resolution imaging may be critical in some cutaneous entities, eg, skin cancer, in which tumor depth is important, and to assess cutaneous disease when thickness, echogenicity, and vascularity patterns vary depending on the phase of the disease. Sonography offers penetration and resolution advantages over other modalities:
- Compared with confocal microscopy and optical coherence tomography which provide high resolution/low penetration images, ultrasound with variable frequency transducers provides high penetration and resolution without loss of definition with depth changes.
- MRI and CT have limited resolution for discriminating epidermis and dermis, and low discrimination of cutaneous and ungula lesions < 3mm.
The author describes sonographic findings associated with inflammatory/infectious diseases, ungual lesions, exogenous components, and malignant skin conditions, noting: “A good correlation has been reported between sonography and histologic assessment for tumor thickness, and these findings could be particularly critical in melanoma, in which the thickness of the primary lesion can affect important decisions such as performance of sentinel node biopsy and the size of the incision. Sonography can also depict satellite, in-transit, and nodal metastases.”
Conclusions:
Sonography allows reasonable discrimination between lesional and nonlesional skin tissue, dermatologic and nondermatologic origins, hypovascular, and hypervascular lesions, and exogenous and endogenous components.
According to Dr. Wortsman, the sonographically-obtained information can allow modifications of decisions about treatment management, the site of incision at surgery, performance of a sentinel node study.
In addition, the author predicts that “the anatomic data provided by sonography may support a better cosmetic prognosis.”
Tags: dermatology, emergency, lesions, sonography, ultrasound, ungual
Views: 432
Replies to This Discussion
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Permalink Reply by Ximena Wortsman on -
Visual clinical scoring systems have greatly helped clinicians but they can be complex, subjective and poorly reproducible. In my experience, to include a non invasive imaging modality such as ultrasound to assess the degree of involvement and activity can considerably impact the way how dermatologists deal with common cutaneous diseases. Once the anatomical critical data, invisible to the naked eye, has been provided, the clinicians usually start to increasingly use the information delivered by the method.
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Permalink Reply by Ximena Wortsman on
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Nowadays, clinicians and patients demand more than ever anatomical information to get early treatments and better cosmetic results. The role and degree of participation of sonography in the field of dermatology probably will depend on the degree of interaction in each institution between the ultrasound imaging, dermatology and dermopathology units. Thus, a multispecialty approach can be a key factor to provide a solid base for working and continue growing in this area.
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Permalink Reply by Ximena Wortsman on
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Certainly, ultrasound should be the first choice imaging modality to deal with foreign bodies located in the skin. It can prove the existence, assess the exact axis and location, provide the measurements and guide the removal.
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Permalink Reply by Fernando Valenzuela on -
I am a dermatologist and I have had the opportunity to evaluate many patients with high-resolution ultrasound. This painless and safe tool has allowed me to modify some surgical approaches, like margins during dermatology surgery, as well as activity of cutaneous inflammatory diseases such as morphea and psoriasis, and it is extremely useful discovering the nature of "mysterious" skin lesions such fillers- caused dermatoses. Summarizing, cutaneous ultrasonography allows me to see "beyond sight"
Ximena Wortsman said:Nowadays, clinicians and patients demand more than ever anatomical information to get early treatments and better cosmetic results. The role and degree of participation of sonography in the field of dermatology probably will depend on the degree of interaction in each institution between the ultrasound imaging, dermatology and dermopathology units. Thus, a multispecialty approach can be a key factor to provide a solid base for working and continue growing in this area.
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Permalink Reply by Marco Alvarez on -
- Imaging based scoring systems aim to provide “objective” parameters that can help to both stage and monitor the response to a treatment or the activity of an specific pathology. I can foresee that DERMUS (Dermatological Ultrasound) will not be the exception. Radiologist and Sonographers will need to learn about Dermatology and Dermatologist will need to learn and understand the Ultrasound lingo. A lot of responsibility on both sides. At the end of the day, working as a team and applying objective Ultrasound Scoring systems will significantly help the patient and clinician.
Ximena Wortsman said:Visual clinical scoring systems have greatly helped clinicians but they can be complex, subjective and poorly reproducible. In my experience, to include a non invasive imaging modality such as ultrasound to assess the degree of involvement and activity can considerably impact the way how dermatologists deal with common cutaneous diseases. Once the anatomical critical data, invisible to the naked eye, has been provided, the clinicians usually start to increasingly use the information delivered by the method.
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Permalink Reply by Marco Alvarez on
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We will need to break free from the vicious cycle of “I do not order it because they do not provide it and I do not provide it because they do not order it”. During this “r”evolution Dermatology (and patient care) will only come out stronger once the learning curve has come to an stable point.
Ximena Wortsman said:Nowadays, clinicians and patients demand more than ever anatomical information to get early treatments and better cosmetic results. The role and degree of participation of sonography in the field of dermatology probably will depend on the degree of interaction in each institution between the ultrasound imaging, dermatology and dermopathology units. Thus, a multispecialty approach can be a key factor to provide a solid base for working and continue growing in this area.
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Permalink Reply by Marco Alvarez on
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Sometimes patients come to the E.R. and plain films are ordered to “rule out” a soft tissue foreign body –many times even if the suspected foreign body is know not to be radiopaque-. Ultrasound does not only provide excellent real time localization but can also leave a hook wire marker for the surgeon or even guide the removal procedure. I can definitively see the use of Ultrasound as a first assessment tool to rule out, mark and even remove soft tissue foreign bodies under real time guidance
Ximena Wortsman said:Certainly, ultrasound should be the first choice imaging modality to deal with foreign bodies located in the skin. It can prove the existence, assess the exact axis and location, provide the measurements and guide the removal.
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Permalink Reply by Dr MM Nurus shafi on -
Thanks all for valuable interactions in this apparently unknown territory. Amazed to see the vast frontiers of US.
Once I saw a FB ( sharp end of a date leaf ), in deltoid muscle.
Marco Alvarez said:Sometimes patients come to the E.R. and plain films are ordered to “rule out” a soft tissue foreign body –many times even if the suspected foreign body is know not to be radiopaque-. Ultrasound does not only provide excellent real time localization but can also leave a hook wire marker for the surgeon or even guide the removal procedure. I can definitively see the use of Ultrasound as a first assessment tool to rule out, mark and even remove soft tissue foreign bodies under real time guidance
Ximena Wortsman said:Certainly, ultrasound should be the first choice imaging modality to deal with foreign bodies located in the skin. It can prove the existence, assess the exact axis and location, provide the measurements and guide the removal.
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