One of These Things Is Not Like the Others

One of these things is not like the others,
One of these things just doesn't belong,
Can you tell which thing is not like the others
By the time I finish my song?  (Words and Music by Joe Raposo and Jon Stone, Sesame Street)

The current public health message to patients is to look for the ABCD's of melanoma. But how many people do you think can actually remember what that mnemonic stands for?

The ugly duckling sign of melanoma was first described in 1998 by Dr. Jean-Jacques Grob of the University of Marsielle in Provence, France. It holds that nevi on a given individual tend to resemble each other, said Dr. Ashfaq A. Marghoob, at today's meeting at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation. Most individuals harbor nevi that resemble each other like brothers. And when a lesion breaks that common mould, it becomes an ugly duckling.

According to Dr. Marghoob, a dermatologist at Memorial Sloan-Kettering Cancer Center, New York, advising patients and even clinicians to look for the ugly duckling is a much easier and more effective way to detect melanoma.

To test his theory, Dr. Marghoob and coinvestigators assembled a portfolio of digital photographs of the backs of 12 patients at high risk for melanoma. Each of the patients had at least eight dysplastic nevi on their back.

In five patients, one of the skin lesions was a melanoma which was removed and histologically confirmed after the pictures were taken

The lesion raters consisted of 13 general dermatologists, 8 dermatologists with special expertise in pigmented lesions, 5 nurses, and 8 secretaries and other nonclinical hospital staff. They were asked if any of the 145 nevi differed from the others on the patients' backs.

All five melanomas but only 3 of 140 benign nevi were identified as ugly duckling lesions by at least two-thirds of the raters. The sensitivity of the ugly duckling sign--that is, the percentage of melanomas identified as "different"--was 100% for the experts, 89% for the general dermatologists, 88% for the nurses, and 85% for the nonclinicians. For the overall group, the sensitivity of the ugly duckling sign was 90% (Arch. Dermatol. 2008;144:58-64).

In a more recent study (albeit not a randomized, controlled, or even multi-centered clinical study), Dr. Marghoob asked his 12-year-old son, which one of these things is not like the other? His son was able to correctly identify the ugly duckling every time in over 30 slides.

If it's so easy, even a child can do it, Dr. Marghoob must have good reason to argue that the ugly duckling sign of melanoma should be part of the public health message. And it might just be a message well worth passing on to your patients.

This was just one of the great presentations of the first day of the Hawaii dermatology seminar. Dr. Stephen Dusza, Dr. James M. Grichnik, and Dr. Jedd D. Wolchok also presented their latest findings in melanoma research.

Stories from these presenters and many more throughout the seminar will be posted on the homepage of Skin & Allergy News Digital Network. And you may just want to consider checking this CME meeting out next year. Escaping the cold and getting CME credit at the same time, who could ask for anything more?

The Waikoloa sunshine is calling my name. (I'll be under an umbrella, of course!)

Amy Pfeiffer
Managing Editor

sknews@elsevier.com
_{Image courtesy pasma via Flickr Creative Commons}