Tag Archives: dermatology

Dermatologic Ultrasound: Skin Deep Knowledge

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According to the recent European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound,1 dermatologic ultrasound is the application of ultrasound to the diagnosis of skin and appendages (hair and nails) diseases, as well as their healthy state, and cosmetic alterations.

This application was born as a necessity to answer challenges in dermatology that could not be addressed with superficial exploration methods such as clinical inspection, wood lamp, or dermoscopy, which mainly offer 2D views of the skin. The possibility of adding a third dimension (depth) and even a 4th one (with Doppler or dynamic explorations) with ultrasound makes dermatologic ultrasound a new way to go from guessing what’s happening below the surface to “seeing” what is really happening.

Ultrasound follow-up of intralesional glucantime injection in a cutaneous leishmaniasis. a) Clinical before treatment, b) B-mode before treatment, c) Color Doppler before treatment, d) Clinical after 3 injections, d) B-mode after 3 injections, d) Color Doppler after 3 injections.

During my years of clinical practice incorporating ultrasound in dermatology, I have heard some questions that always seem to arise in meetings. These are some of them:

What are the technical requirements for quality dermatologic ultrasound?

Although equipment with 70 MHz can be helpful to elucidate very concrete aspects of skin pathology, most questions and clinical situations in dermatology can be addressed today with high-quality conventional equipment above 15 MHz with color Doppler.

Apart from high-quality equipment, having a deep knowledge of dermatology, basic ultrasound, and its physical principles is the key to performing appropriate explorations in dermatologic ultrasound.

Which are the main fields of dermatologic ultrasound?

The fields at the forefront of dermatologic ultrasound are skin oncology, inflammatory skin diseases, and cosmetic dermatology.

How can dermatologic ultrasound help us dermatologist in skin oncology?

Skin cancer is the most frequent cancer in the human body. Most malignant skin tumor prognosis and treatment rely on depth and structural invasion, therefore, dermatologic ultrasound is an essential tool compared with MRI or CT in these kinds of evaluations, mainly because of its higher resolution and availability.

Is dermatologic ultrasound helpful in inflammatory skin diseases?

Deep inflammatory skin diseases such as hidradenitis suppurativa and morphea and sclerosing diseases usually do not have clear superficial expression. Dermatologic ultrasound is a key tool for in-depth evaluation of the inflammatory state of these diseases and is a guide for treatment and follow-up.

What are the main applications of dermatologic ultrasound in cosmetic dermatology?

Detection of dermal fillers and the complications and adverse reactions of these medical devices is essential in the management of a responsible cosmetic dermatology practice. Dermatologic ultrasound can also be an excellent tool for skin aging evaluation and anti-aging treatment evaluation.

Who is the AIUM and how can I learn Dermatologic Ultrasound from the AIUM?

The American Institute of Ultrasound in Medicine (AIUM) is the only scientific society that hosts a very active Dermatologic Ultrasound Community, which was funded in 2015 by Ximena Wortsman together with Orlando Catalano (present vice-chair of the community), Fernando Alfageme (present chair of the community and author of this post), and Claudia Gonzalez (secretary).

This community and their members are very active in AIUM meetings, hosting several scientific and didactic sessions, and has also produced some reference papers in dermatologic ultrasound.

The AIUM has hosted several sessions and workshops in AIUM meetings in the last 5 years with the collaboration of the dermatologic ultrasound community, although a need for structured teaching and learning is still necessary for those who are interested in this subspecialty.

Dermatology is an amazing application for ultrasound and it will be key in the near future for high quality, personalized skin medicine to foster the best, responsible care for our patients.


Fernando Alfageme, MD, is a Dermatologist and Chair of the Dermatologic Ultrasound Community (AIUM) as well as Codirector of the Ultrasound Learning Centre (Dermatology) at EFSUMB.

Reference

Alfageme F, Wortsman X, Catalano O, et al. European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Position Statement on Dermatologic Ultrasound. Ultraschall Med. 2020 May 7. Online ahead of print. doi: 10.1055/a-1161-8872.

How I Became Involved in Dermatologic Ultrasound

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There are certain moments in time when your gut tells you that your life is about to change. It happened to me in 1999.

I was on a training visit to the Musculoskeletal Ultrasound Section of the Department of Diagnostic Radiology at the Henry Ford Hospital in Detroit when Dr WortsmanI saw a “hockey stick” probe. Instinctively, I decided to use it on my fingernails. The images I saw on the screen were so fantastic that I ran to the library to see if there were any papers or publications that focused on ultrasound of the nail.

Surprisingly, I discovered a few Italian and Danish dermatologists who were working with smaller types of high frequency ultrasound devices on experimental settings. Wanting to learn more, I wrote to them. I was thrilled when Professor Gregor Jemec responded and agreed to collaborate.

However, getting an ultrasound machine for a dermatology project proved to be more difficult. It took almost 2 years before an ultrasound machine was installed and available for me to use while I was at the Department of Dermatology at Bispejerg Hospital in Copenhagen.

After securing the machine, I had the opportunity to scan dermatologic patients on a daily basis and I realized the great potential this imaging modality had within dermatology.

Once I returned to Chile, I really got to work. I studied the sonographic patterns, began to correlate the ultrasound images with the clinical and histologic findings, and started to publish the results.

That also proved difficult at first because radiology journals felt the content was better suited for dermatology journals and dermatology journals recommended radiology journals since the content involved imaging. Probably these journals had a difficult time even finding someone to review this material.

It was during this rough beginning that I reached out to my uncle Jacobo. I was telling him how difficult publishing could be and he simply reiterated President Truman’s famous quote, “If you can’t take the heat, get out of the kitchen.”

That just made me more committed. I created an educational website and continued to practice, learn, research, and write. In 2010, the Journal of the American Academy of Dermatology published our paper that analyzed more than 4,000 dermatologic ultrasound cases with histologic correlation. In 2013, our book Dermatologic Ultrasound with Clinical and Histologic Correlations was published.

Since that time, a lot has changed. I used to hear radiologists and dermatologists comment that they had never heard of dermatologic ultrasound. Now, the use of ultrasound in dermatology is expanding rapidly with colleagues from around the world using this tool to diagnose common dermatologic conditions earlier and more precisely.

For me, the dermatologic ultrasound journey mirrored my family’s immigration journey. We both left something familiar and ended up in a distant land. While the journey has not been easy, the results have been more than worthwhile.

But our work continues. Now, one of our challenges is how to share what we have learned to inspire and train a new generation of dermatologic ultrasound professionals. As a specialty, we are excited by AIUM’s support through the development of a dermatologic ultrasound interest group. Here we will share information, research, and resources. Please join us!

Why did you becoming interested in ultrasound? Have you participated in your AIUM Community? What struggles have you overcome in your career? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Ximena Wortsman, MD, Radiologist, Chair of Dermatologic Ultrasound AIUM Interest Group, Senior Member of AIUM, Department of Radiology and Department of Dermatology, Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Clinica Servet, Faculty of Medicine, University of Chile, Santiago, Chile.