Dermoscopy An Illustrated Self-Assessment Guide
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Dermoscopy An Illustrated Self-Assessment Guide Robert H. Johr, MD Clinical Professor of Dermatology and Associate Clinical Professor of Pediatrics Pigmented Lesion Clinic University of Miami School of Medicine Miami, Florida
Prof. Wilhelm Stolz, MD Director Clinic of Dermatology, Allergology and Environmental Medicine Hospital München Schwabing, and Professor of Dermatology, Faculty of Medicine Ludwig-Maximilians-Universität Munich Germany
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London Madrid Mexico City Singapore Sydney Toronto
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Contents Foreword Preface Acknowledgments
vii ix xi
Chapter 1
Dermoscopy from A to Z
01
Chapter 2
Scalp, Face, Nose, and Ears
27
Chapter 3
Trunk and Extremities
95
Chapter 4
Palms, Soles, Nails
325
Chapter 5
Genitalia
389
Index
419
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Foreword The new textbook, “Dermoscopy: An Illustrated SelfAssessment Guide” by Dr. Robert H. Johr and Prof. Wilhelm Stolz, is a welcome addition to the evolving world of dermoscopic knowledge. I have reviewed all of the images and the text and feel that the contributions are indeed unique. First of all, the exquisite nature of the photographic images deserves a comment. Also, the clarity of labeling for each image separates this text from all others I have seen. Specifically, all of the key features are isolated by means of circles, rectangles, asterisks, etc., and this clear demarcation has succeeded where many similar textbooks fail. Secondly, the questions, statements and the answer format draws the reader into the dialogue. You really cannot escape committing yourself to a diagnosis, or differential diagnosis, as you answer the questions and statements posed. I think these two unique aspects of the textbook serve the learning process in a very positive way. I should also add that I am an unabashed enthusiast of dermoscopy. Although I presently confine my clinical practice to pediatric dermatology, until 7 years ago, I saw adults on a daily basis and evaluated all of their pigmented lesions with dermoscopy. I have been committed to learning the technique for the last 14 years. Most of that learning curve has involved discussions and teaching by Dr. Robert Johr. Early on, we saw patients with complex pigmentary disorders such as xeroderma pigmentosum and evaluated numerous
lesions dermoscopically, helping to separate those lesions which deserved follow-up from those which deserved biopsy. To this day, I continue to use dermoscopy not only to evaluate pigmented lesions in children, but I also use it as an advanced “pocket magnifier”. Specifically, hair shaft disorders, scabies, questionable molluscum lesions, etc., are readily identified when separated out by means of dermoscopy. When I forget my dermascope or when I find it uncharged, I actually feel less qualified to evaluate my patients. I firmly believe that dermoscopy should be taught as an essential skill in every residency program and that all practitioners should strive to learn this technique. I certainly learned it when I was in my mid 50s, hence, a mature dog can learn new tricks. I am still surprised by the fact that virtually all children referred to me for evaluation of pigmented lesions have not been viewed with dermoscopy by their referring dermatologists. This needs to change. This technique adds a dimension which clearly makes us better diagnosticians and better dermatologists. The book by Drs, Johr and Stolz will help us in this effort. Ronald C. Hansen, MD Chief, Pediatric Dermatology Phoenix Children’s Hospital, Phoenix, Arizona Professor, Dermatology and Pediatrics University of Arizona College of Medicine, Tucson, Arizona
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Preface Dermoscopy is itself a language full of terms that have specific meanings and even connotations, depending on any given lesion being examined. As in any language, its vocabulary is a work in progress based in consensus among its “expert” speakers who are striving to create a system to communicate dermoscopic findings based on observational data. In order for there to be mutual comprehension among users of this powerful technique, the language of dermoscopy must be spoken properly. This is not an easy task since there is a significant learning curve to master the technique as well as its terminology. It takes study, practice, and dedication. Dermoscopy is the standard of care around the world and is becoming very popular in the United States. Dermatologists and other groups of physicians are realizing what a valuable tool it is. The goal of this book is to teach what we believe are the important general principals and specific points of dermoscopy and to allow for users to “self-assess” their knowledge and skills using the techniques taught here. In an era of information overload, we designed the book to be short, sweet, and to the point. We want it to be an easy, enjoyable, and practical read. Important principles are often repeated which is a good way for them to be remembered. We “keep it real” with 191 cases that any busy clinician may have the opportunity to see in general dermatology clinic on a daily basis. Great clinical and dermoscopic images with short histories are followed by five “true or false” statements. As in real life, then comes the decision making in check box form: what is the potential risk and what is the diagnosis? Finally, the disposition of the case; whether to effect no intervention, follow-up, or to make a histopathologic diagnosis? The concept of dermoscopic differential diagnosis is found throughout the book. In most cases, we do not get into the controversial issue of the best technique to make a histopathologic diagnosis. We leave that up to you. Turn the page, and the answers to the statements are given in a format that separates our book from the others. The dermoscopic images are presented again with an extensive description of the criteria in the lesion. It is essential to evaluate as much as possible before making a diagnosis. There are many circles, boxes, arrows, and stars to point out
the important features of each case. Our goal is to fully demonstrate the global features and local criteria of each lesion. This is another very important unique teaching point of our book. Each case has a discussion of all of its salient features. Not in long drawn out paragraphs, but in outline form. We realize that your time is valuable and want to make the learning and recall process as easy as possible. Series of cases are organized into groups. For example, there are lesions in which the major feature might be pigment network, dots and globules, regression, pink, blue or black color, or vascular structures. There are similar-looking clinical and/or dermoscopic images grouped together in specific body locations, such as brownish spots on an ear lobe or in the genital area. This simulates real-life encounters. One case often flows into the next and knowledge gained from the previous case is needed to solve the next case. Melanocytic, nonmelanocytic, benign, malignant, or inflammatory pathology from head to toe with 95 melanomas and their most important simulators. Each case ends with a series of dermoscopic and/or clinical pearls based on years of experience treating patients with skin cancer. The patients’ well-being trumps political correctness. The book is sprinkled with general principles and specific points that are controversial but strongly embedded in our core beliefs. This book was a coproduction between United States and Germany. The text was developed in Florida and most of the cases were seen in Munich. Being a competent diagnostician must include the tissue-sparing and potentially life-saving technique called dermoscopy. Each of us has a profound responsibility for the wellbeing of every patient that walks through the door. Always regard each patient as someone’s precious loved one as if they were your own! Robert H. Johr Boca Raton, Florida
Prof. Wilhelm Stolz Munich, Germany
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Acknowledgments I would like to thank James A. Ida, MD academic chief resident in the Department of Dermatology at Tufts Medical Center in Boston as well as a friend, for his excellent efforts as resident editor. James’s passion for language and grammatical style as well as keen interest in dermoscopy and in helping produce a superb text, made the tedious job of writing a book much more enjoyable. Thanks! I want to thank my wife of 38 years, Irma, for letting me be free in mind and spirit to spend the many hours it took to write this book. Her encouragement and willingness to listen to me when I thought or wrote something exciting was very helpful.
Dr. Robert H. Johr
First and foremost, I would like to express my deepest gratitude to my wife, Karola, who has lovingly shared my many dermoscopic and academic pursuits over the last two decades. For her tireless enthusiasm and skill with the beautiful color photography, a cornerstone of our text, I thank Mrs. Ulrike Brückl. Special thanks also go to our nurses, Mss. Carolin Mertens, Antje Angilotti, and Christa Meinhold, whose consistent passion and professionalism contributed greatly to our text. To the many physicians who supported me in my dermoscopy clinic and in the case preparations, most especially Drs. Brigitte Coras, Stefanie Guther, Anette Michael, Katrin Ramrath, Alexandra Tillmann, and Ulrike Weigert, I wish to extend my sincerest thanks. Finally, special thanks go to Mrs. Agnes Kaldewei, my long-time clinical and scientific assistant. Without her continuous and ever pleasant support, this text would not have been possible.
Dr. Wilhelm Stolz
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Dermoscopy An Illustrated Self-Assessment Guide
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Chapter 1
Dermoscopy from A to Z
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Chapter 1
SYNONYMS ■ ■ ■ ■ ■ ■ ■
Dermatoscopy Skin surface microscopy Epiluminescence microscopy (ELM) Digital dermoscopy/digital ELM Auflichtmikroskopie (German) Dermoscopia/Dermatoscopia (Spanish/Italian) Grammatically, dermatoscopy is correct English; however, dermoscopy is the term used by the International Dermoscopy Society (IDS), experienced dermoscopists, and is most commonly used in the literature. This might change in the future and dermatoscopy could become the term of choice again.
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Dermoscopy is an in vivo, noninvasive technique in which oil or fluid (eg, mineral oil, gels, alcohol, and water) is placed on the lesion ■ Fluid eliminates reflection of light from the surface of the skin allowing visualization of color and structure in the epidermis, dermo-epidermal junction, and papillary dermis ■ The color and structure visualized cannot be seen with the naked eye or with typical magnification that clinicians use ■ Polarizing light and digital instrumentation do not require fluid When using polarized light dermoscopy ■ Light from a polarized light source penetrates the stratum corneum with less scatter ■ A second polarizer screens out scattered surface light resulting in the physician seeing primarily light from the deeper structures ■ This removes the need for contact with the skin and the need for immersion fluids, resulting in faster examination times
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Helps to differentiate melanocytic from nonmelanocytic skin lesions Helps to differentiate benign from malignant skin lesions ■ With dermoscopy the diagnostician’s sensitivity to diagnose melanoma is 90% compared to 74% when the technique is not used ■ Dermoscopy improves the diagnosis of melanoma by 16% ■ The number of benign lesions excised for each melanoma found (malignant/benign ratio) is significantly decreased with dermoscopy Increases the diagnosis of early melanoma Increases the diagnosis of melanoma incognito (false negative melanoma)
Helps to avoid unnecessary surgery Helps to plan surgery Helps one to work better with their pathologist (asymmetrical high risk criteria, collision tumors, dermoscopic–pathologic correlation) Patient reassurance Allows for follow up of patients with multiple nevi digitally to find changes over time
There are pigmented skin lesions that are not high risk enough to warrant immediate histopathologic diagnosis, yet not so banal that there is no concern at all There are melanomas that do not appear to be high risk clinically or with dermoscopy They are only diagnosed after monitoring for dermoscopic changes over time when comparing baseline with subsequent digital images Short-term monitoring is performed every three or four months ■ Any change over time could be a melanoma and is an indication to make a histopathologic diagnosis Long-term monitoring is done at six month to yearly intervals ■ Important changes include asymmetrical enlargement, asymmetrical changes within the lesion without enlargement, the appearance of high risk criteria (eg, irregular pigment network, dots, globules, streaks, blotches, regression, polymorphous vessels), disappearance of well-developed local criteria, new colors Single or multiple suspicious pigmented skin lesions can be chosen for short- or long-term digital monitoring
THE TWO-STEP ALGORITHM ■
BENEFITS OF DERMOSCOPY ■
3
Dermoscopic Digital Monitoring
DEFINITION ■
Dermoscopy from A to Z
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The analysis of a suspicious skin lesion is a two-step process ■ Step one: determines if it is melanocytic or nonmelanocytic ■ Step two: if it has the criteria for a melanocytic lesion, the second step is to determine if it is low, intermediate, or high risk using the melanocytic algorithm of your choice Pattern analysis was the first melanocytic algorithm developed for this purpose and is most often used by experienced dermoscopists. Variations of pattern analysis (the simplified algorithms) have also been developed, including: ■ The ABCD rule of dermatoscopy (the second algorithm developed) (Table 1-1) ■ The seven-point checklist (Table 1-2) ■ Menzies method (eleven-point checklist) (Table 1-3) ■ The latest three-point checklist (Table 1-4)
4
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Table 1-1
ABCD RULE OF DERMATOSCOPY. IDENTIFY CRITERIA AND GIVE THEM POINTS TO DETERMINE THE TOTAL DERMATOSCOPY SCORE (TDS)
Table 1-3
DERMOSCOPIC CRITERION Negative Features Symmetry of pattern Presence of single color
DERMOSCOPIC CRITERION DEFINITION SCORE WEIGHT FACTOR Asymmetry in 0, 1, or 2 perpendicular axes; assess contour, colors and structures 0-2 Border abrupt ending of pigment pattern at periphery in 0-8 segments 0-8 Color presence of up to 6 colors (white, red, light-brown, dark-brown blue-gray, black) 1-6 Dermoscopic structures presence of network, structureless (homogeneous) areas, branched streaks, dots, and globules 1-5
Positive Features Blue-white veil Multiple brown dots Pseudopods (streaks) Radial streaming (streaks) Scar-like depigmentation Peripheral black dots/globules Multiple (5 or 6) colors Multiple blue/gray dots Broadened network
Formula for calculating total dermatoscopy score (TDS): (A score x 1.3) + (B score x 0.1) + (C score x 0.5) + (D score x 0.5) = TDS. Interpretation of total score: <4.75. Benign melanocytic lesion 4.75-5.45; suspect lesion (close follow-up or excision recommended); >5.45, lesion highly suspect for melanoma.
Melanocytic Lesion
Look for the criteria associated with a melanocytic lesion (Table 1-5). If one does not find them, the search is on for the criteria associated with seborrheic keratosis, basal cell carcinoma, dermatofibromas, vascular lesions, and others. ■ Not all of the possible criteria are needed to make a diagnosis ■ When there is an absence of criteria for a melanocytic lesion, seborrheic keratosis, basal cell carcinoma, dermatofibroma, or vascular lesion, you will have to deal with a melanocytic lesion by default ■ The “default category” is the last criterion used to diagnose a melanocytic lesion (Figure 1-1)
SEVEN-POINT CHECKLIST
DERMOSCOPIC CRITERION 1. 2. 3. 4. 5. 6. 7.
Atypical pigment network (major criteria) Blue-whitish veil Atypical vascular pattern Irregular streaks (minor criteria) Irregular dots/globules Irregular blotches Regression structure
For melanoma to be diagnosed both negative features must be absent and one or more of the 9 positive features must be present.
Criteria Defined
Step One: Identification of Criteria
Table 1-2
MENZIES SCORING METHOD. THE ELEVEN-POINT CHECKLIST
PIGMENT NETWORK/NETWORK ■ ■ ■
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On the trunk and extremities Shades of black or brown Honeycomb-like, reticular, web-like line segments (elongated and hyperpigmented rete ridges) with hypopigmented holes (dermal papilla) There are nonmelanoctyic lesions that can have a pigment network (ie, solar lentigo, seborrheic keratosis, dermatofibroma)
PSEUDONETWORK/PSEUDOPIGMENT NETWORK ■
Because the skin of the head and neck is thin and does not have well-developed rete ridges, one sees ■ Appendageal openings/adnexal structures (sebaceous glands, hair follicles) ■ Uniform, round white or yellowish structures
Table 1-4 SCORES 2 2 2 1 1 1 1
By simple addition of the individual scores a minimum total score of 3 is required for the diagnosis of melanoma, whereas a total score of less than 3 is indicative of nonmelanoma.
THREE-POINT CHECKLIST TO DIAGNOSE HIGH RISK LESIONS (MELANOMA, BASAL CELL CARCINOMA)
Asymmetry of color and/or structure Irregular pigment network Blue and / or white color 2 out 3, 3 out 3 → excise The three-point check list is based on simplified pattern analysis and is intended to be used by nonexpert dermoscopists as a screening technique. Its aim is to diagnose melanocytic and nonmelanoctyic potentially malignant pathology.
Chapter 1
Table 1-5
CRITERIA FOR VARIOUS LESIONS
CRITERIA FOR A MELANOCYTIC LESION Pigment network (trunk and extremities) Aggregated globules Homogeneous blue color of a blue nevus Parallel patterns on acral sites By default
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CRITERIA FOR A SEBORRHEIC KERATOSIS Milia-like cysts Pseudofollicular openings Fissures and ridges Fat fingers Fingerprint pattern Hairpin-shaped vessels Moth-eaten borders Sharp demarcation CRITERIA FOR A BASAL CELL CARCINOMA Absence of pigment network Arborizing blood vessels Pigmentation Ulceration Spoke-wheel structures
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Dermoscopy from A to Z
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When they penetrate areas of diffuse pigmentation, reticular-like structures are formed that are referred to as the pseudonetwork Monomorphous appendageal openings can often be seen on the skin of the face without any pigmentation They should not be confused with the milia-like cysts seen in seborrheic keratosis It is not always possible to make the differentiation Consequences could be misdiagnosing lentigo maligna for a seborrheic keratosis This criterion can also be seen with nonmelanocytic lesions (ie, solar lentigo, seborrheic keratosis) It is not 100% diagnostic of a melanocytic lesion
DOTS AND GLOBULES ■ ■
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CRITERIA FOR A DERMATOFIBROMA Central white patch Peripheral pigment network CRITERIA FOR A VASCULAR LESION Vascular spaces (lacunae )
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Roundish structures distinguished only by their relative sizes Dots (0.1mm) are smaller than globules (greater than 0.1mm) Black, brown, gray, or red ■ When black, they can represent melanin or atypical melanocytes in the epidermis ■ Regular brown dots and globules represent nests of melanocytes at the dermo-epidermal junction ■ Irregular brown dots and globules represent nests of atypical melanocytes at the dermo-epidermal junction ■ Fine grayish dots (“peppering”) represent free melanin and/or melanophages in the papillary dermis, which can be seen in regression areas along with other criteria or alone in benign pathology such as late stage lichen planus-like keratosis or posttraumatic ■ Reddish globules can be seen in melanoma (neovascularization) It is written and taught that globules identify a melanocytic lesion with no mention of the smaller dots. The reality is that both dots and globules define a melanocytic lesion (Figure 1-2)
Figure 1-1 Amelanotic Melanoma. This is a melanocytic lesion by default because there is an absence of criteria for a melanocytic lesion, seborrheic keratosis, basal cell carcinoma, dermatofibroma, or hemangioma. The blue-white color (arrow) is a clue that this might be a melanocytic lesion. There are pinpoint/dotted (yellow boxes) and irregular linear (black boxes) vessels plus a general milky-red background color. Note: This interdigital melanoma was mistakenly treated as a tinea for two years. (Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. May 2008-Vol 7-Issue 5. Fig 1b.)
Figure 1-2 Acquired Nevus. This is a melanoctic lesion because it has pigment network (black boxes) and globules (circles). There is a small hemangioma adjacent to the nevus (arrow).
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Figure 1-3 Blue Nevus. The classic homogenous blue color of a blue nevus.
Figure 1-4 Acral Nevus. This is a melanocytic lesion on acral skin with the benign parallel furrow pattern. Pigmentation is in the thin furrows (arrows) with globules (boxes) in the thicker ridges (stars).
HOMOGENEOUS BLUE PIGMENTATION ■
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Structureless blue color usually in the absence of local criteria such as pigment network, dots, or globules (Figure 1-3) Many variations of homogeneous blue color with or without the white color of scarring usually represent a blue nevus The history is important because there is a differential diagnosis which could include ■ A lesion as banal as a radiation tattoo ■ One more ominous such as nodular or cutaneous metastatic melanoma
PARALLEL PATTERNS/ACRAL PATTERNS/VOLAR SURFACES ON GLABROUS NON HAIR BEARING SKIN ■
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Furrows (also referred to as fissures) and ridges on the skin of the palms and soles ■ Dermatoglyphics are the skin markings that can form whorls, loops, and arches Can create parallel patterns
Thick fibrillar variant with thick oblique lines Thin filamentous variant with fine thin lines Pressure can change the lattice-like pattern into a fibrillar pattern Irregular thick and pigmented line segments could be seen in an acral melanoma ■ ■
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GLOBULAR PATTERN (BENIGN) ■
Brown globules without a parallel component
RETICULAR PATTERN (BENIGN) ■
A lesion with only pigment network
HOMOGENEOUS PATTERN (BENIGN) ■ ■
Brown homogeneous color Absence of local criteria (ie, pigment network, globules)
PARALLEL FURROW PATTERN (BENIGN PATTERN)
Single thin or thick brown parallel lines in the furrows of the skin (crista superficialis limitans) ■ Variations include two brown lines on both sides of the hypopigmented furrows with or without dots and globules ■ Single line of dots and globules along the furrows (single-dotted variant) Double line of dots and globules parallel to the hypopigmented furrows (double-dotted variant) (Figure 1-4) ■
LATTICE-LIKE PATTERN (BENIGN PATTERN) ■ ■
Brown parallel lines in the furrows Brown lines running perpendicular to the furrows forming a ladder-like picture (Figure 1-5)
FIBRILLAR PATTERN (BENIGN PATTERN) ■
Uniform brown lines that run in an oblique (///////) direction
Figure 1-5 Acral Nevus. Brown lines in the furrows (black arrows) and perpendicular to the furrows (yellow arrows) characterize the lattice-like pattern. Pressure on the foot can change this into the fibrillar pattern with fine oblique (/////) lines.
Chapter 1
Figure 1-6 Acral Melanoma. The parallel ridge pattern diagnoses this acral melanoma with pigmentation in the thicker ridges (black arrows). The thin white lines are the furrows (yellow arrows).
Dermoscopy from A to Z
7
Figure 1-8 Acquired Nevus. There is an increased incidence of acral melanoma in darker skinned races. This nevus on the palm of an AfricanAmerican was without change and demonstrates the benign parallel ridge pattern. Pigmentation is seen in the ridges of the nevus (yellow arrows) and in the ridges of the entire palm (white arrows).
PARALLEL RIDGE PATTERN (IN SITU AND EARLY INVASIVE ACRAL MELANOMA) ■
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Pigmentation is in the thicker ridges of the skin (crista profunda intermedia) (Figure 1-6) Sometimes there are monomorphous round white structures in the ridges that represent the acrosyringia of the sweat ducts that are said to look like a “string of pearls” ■ They are an important clue to help identify the ridges ■ They are never found in the furrows, always in the ridges Parallel ridge pattern is not 100% diagnostic for melanoma and can also be created by blood (black heel, talon noir) (Figure 1-7)
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Parallel ridge pattern can be found on normal skin in darker skinned races (Figure 1-8)
DIFFUSE VARIEGATE PATTERN (MELANOMA) ■ ■
Pigmented blotches Black, brown, or gray
MULTICOMPONENT PATTERN (MELANOMA) ■ ■
Filled with regular and irregular criteria Multiple colors plus areas with several acral patterns (parallel furrow, lattice-like, fibrillar)
NONSPECIFIC PATTERN (MELANOMA) ■
If one cannot determine any of the above benign or malignant patterns; this represents a red flag for concern
PEARLS ■ ■
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There can be exceptions to every dermoscopic rule The history and clinical appearance of the lesion are important and should not be ignored If a pigmented lesion on the palms or soles is rapidly changing yet has a typical benign pattern, it still could be melanoma A supposedly benign acral pattern with irregularity to the components could be high risk The presence of blood at acral sites (palms, soles, nails) may or may not be associated with melanoma Look carefully for other important criteria If in doubt, cut it out!
Seborrheic Keratosis MILIA-LIKE CYSTS Figure 1-7 Acral Hemorrhage. The parallel ridge pattern created by
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Variously sized white or yellow structures Small or large, single or multiple
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
They can appear opaque or bright like “stars in the sky” (epidermal horn cysts) Melanocytic lesions can have a few milia-like cysts
PSEUDOFOLLICULAR OPENINGS/COMEDO-LIKE OPENINGS ■ ■ ■
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Sharply demarcated roundish structures Pigmented or nonpigmented Shape and size can vary, not only within a single lesion, but from lesion to lesion in an individual patient (Figure 1-9) Large keratin-filled irregularly-shaped openings are called crypts When pigmented, they can be brownish-yellow or even dark brown and black (keratin-filled invaginations of the epidermis) Pigmented pseudofollicular openings can be hard to differentiate from the pigmented dots and globules of a melanocytic lesion A few pseudofollicular openings can be found in melanocytic lesions
Figure 1-10 Seborrheic Keratosis. A striking brain-like pattern created by pigmented fissures (yellow arrows) and light ridges (black arrows). Many of the ridges look like “fat fingers.”
FISSURES AND RIDGES ■
Fissures (sulci) and ridges (gyri) seen in papillomatous seborrheic keratosis can create several patterns ■ Cerebriform or brain-like in which they resemble a sagittal section through the cerebral cortex ■ Mountain-like with variously sized or uniformly roundish structures representing mountains (ridges) and fine pigmented lines representing valleys (fissures) ■ Possible to confuse the mountain and valley pattern with the cobblestone pattern of a melanocytic lesion ■ Pigmented fissures should not be confused with the pigment network of a melanocytic lesion ■ Hypo- and hyperpigmented ridges can be digit-like (straight, kinked, circular, or branched) and are referred to as “fat fingers”
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All of these patterns are commonly seen in this ubiquitous benign skin lesion (Figure 1-10)
FINGERPRINT PATTERN ■
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Brown fine/thin parallel line segments that resemble fingerprints Differ from the pigment network where the line segments are honeycomb-like or reticular Fingerprint pattern can be seen in flat seborrheic keratosis or in solar lentigines Some authors believe that solar lentigines are flat seborrheic keratosis
HAIRPIN VESSELS ■
Elongated vessels (capillary loops) resembling hairpins (Figure 1-11)
Figure 1-9 Seborrheic Keratosis. Sharp borders (red arrows), milia-like cysts (black arrows), and pseudofollicular openings (boxes) characterize this seborrheic keratosis.
Figure 1-11 Seborrheic Keratosis. An especially well-formed hairpin vessel (box) in a seborrheic keratosis.
Chapter 1
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Dermoscopy from A to Z
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May or may not be surrounded by hypopigmented halos Light halo indicates a keratinizing tumor and may be found in keratoacanthomas Irregular and thick hairpin vessels can be seen in melanoma
MOTH-EATEN BORDERS ■ ■
Flat or slightly raised brown seborrheic keratoses Well-demarcated, concave borders that are felt to resemble a “moth-eaten” garment
SHARP DEMARCATION ■
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The majority of seborrheic keratoses have sharp, well-demarcated borders Not always indicative of melanoma in a pigmented lesion (Figure 1-9)
Basal Cell Carcinoma ABSENCE OF THE CRITERIA SEEN IN A MELANOCYTIC LESION ■ ■
Specifically, absence of a pigment network Pigmented dots and/or globules found in some basal cell carcinomas ■ Raises the issue of dermoscopic differential diagnosis of individual criterion
Figure 1-12 Basal Cell Carcinoma. This pigmented basal cell carcinoma has classic arborizing vessels (black arrows), linear vessels (yellow box), gray blotches (black boxes), blue globules (yellow arrows), and fine gray dots (circles). The three different presentations of pigmentation point out to how variable this criterion can be. (Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. Sep 2007-Vol 6-Issue 9. Fig 2b.)
ARBORIZING VESSELS ■
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One of the most sensitive and specific vascular structures seen with dermoscopy ■ Red tree-like branching telangiectatic blood vessels ■ In focus vessels because they are on the surface of the lesion ■ Out-of-focus arborizing vessels should raise a red flag for concern that the lesion might be a melanoma ■ Can be thick or thin ■ Most often there are different caliber vessels in a single lesion Can also be found in ■ Benign nevi ■ Recurrent nevi ■ Sebaceous gland hyperplasia ■ Scars ■ On sun-damaged skin ■ Melanoma
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Blue Red White
ULCERATION ■
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Single or multiple areas, where there is loss of epidermis with oozing blood or congealed blood and crusts (Figure 1-13) There should be no recent history of trauma
SPOKE-WHEEL STRUCTURES ■
To date, spoke-wheel structures are the only criterion with dermoscopy, which are 100% diagnostic ■ Can be found in up to 10% of basal cell carcinomas ■ May or may not be associated with the other criteria used to make the diagnosis
PIGMENTATION ■
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Basal cell carcinoma may or may not contain pigment (pigmented nests or island of basal cell carcinoma in the dermis) that can range from ■ Fine dots to large leaf-like structures (bulbous extensions forming a leaf-like pattern) ■ Not necessary to try to determine if “leaf-like” structures (maple leaf-like areas) are present since in reality this is a difficult task ■ Blue-gray ovoid nets ■ Multiple blue-gray globules Colors that can be seen (Figure 1-12) ■ Black ■ Brown ■ Gray
Figure 1-13 Basal Cell Carcinoma. Arborizing vessels (black arrows) and ulceration (yellow arrows) characterize this nonpigmented basal cell carcinoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Well-defined pigmented radial projections meeting at a darker central globule/central axle/hub Complete or incomplete variations of this structure can be seen and one often has to use their imagination to make the identification Finding spoke-wheel structures might be the only clue to the correct diagnosis
PEARLS ■
A nonhealing area in an adult that bleeds spontaneously is a basal cell carcinoma until proven otherwise
Dermatofibroma CENTRAL WHITE PATCH ■
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Most typical presentation of this criterion is ■ Centrally located ■ Scar-like ■ Bony or milky-white ■ Homogeneous area (scarring in this fibrohistiocytic tumor) Several variations such as white network-like structures (white network, negative pigment network, reticular depigmentation), which can also be seen in Spitz nevi and melanoma Telangiectatic vessels with different shapes can also be found anywhere in the lesion Not all dermatofibromas have a central white patch The clinically firm feel and “dimple” sign should be used to help make the diagnosis
Figure 1-15 Atypical Dermatofibroma. Regressive melanoma is in the dermoscopic differential diagnoses of this atypical dermatofibroma. There is asymmetry of color and structure, the multicomponent global pattern, irregular pigment network (box), irregular globules (red arrows), and irregular blotches (yellow arrows). This warrants a histopathologic diagnosis.
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PIGMENT NETWORK ■
Dermatofibromas are one of the nonmelanocytic lesions that can have a pigment network; solar lentigines are another ■ In most cases, a fine peripheral pigment network with thin brown lines is seen ■ Ring-like structures that are a variation of a hyperpigmented network (Figure 1-14) ■ Not all dermatofibromas have a pigment network
Figure 1-14 Dermatofibroma. A classic central white patch (black arrow) and pigment network (black boxes) characterize this dermatofibroma. In this instance, ring-like structures (white arrows) make up the pigment network.
Atypical dermatofibromas with the following features are melanoma mimics that warrant a histopathologic diagnosis ■ Irregular pigment network ■ Irregular dots/globules/blotches ■ Pink color ■ Irregular regression-like white color ■ Polymorphous (different shapes) vascular structures (Figure 1-15)
Vascular Lesions LACUNAE/LAGOONS/SACCULES ■
Sharply demarcated bright red to bluish round or oval structures (dialated vascular spaces in the dermis) (Figure 1-16)
Figure 1-16 Hemangioma. Well-demarcated dark red lacunae (arrows) and blue-white color (stars) representing fibrous septa characterize this classic hemangioma.
Chapter 1
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Figure 1-17 Cutaneous Metastatic Melanoma. This is one of many generalized cutaneous metastatic lesions in a 27-year-old white male with a history of a 7mm melanoma on his back. There are well-demarcated lacunae-like areas (arrows) and atypical vessels (boxes). A collision lesion, hemangioma, and amelanotic melanoma are in the dermoscopic differential diagnosis.
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Step Two: Analysis of a Melanocytic Lesion Pattern Analysis Defined ■ Identify as many criteria in the lesion as possible and see if they fit into the known patterns associated with the variants of ■ Melanocytic Nevi ■ Congenital ■ Acquired ■ Recurrent ■ Halo ■ Combined ■ Blue ■ Dysplastic ■ Spitz
Melanoma ■ In situ ■ Superficial spreading ■ Nodular ■ Amelanotic ■ Lentigo maligna/Lentigo maligna melanoma ■ Nail apparatus ■ Acral ■ Mucosal Even though pattern analysis is considered a melanocytic algorithm, the same principles are used to diagnose all of the lesions that can be identified with the technique ■ Melanocytic ■ Nonmelanocytic ■ Benign ■ Malignant ■ Inflammatory
Step 1
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Pattern Analysis Method ■
Different shades of red and blue colors can be seen in a single hemangioma ■ Lacunae should not be mistaken for the milky-red color seen in pigmented and amelanotic melanoma, which can have “out-of-focus” reddish globular-like structures ■ Black homogeneous structureless areas represent thrombosis ■ Significant scale or dryness (hyperkeratosis) can be seen in angiokeratomas Patchy white color or bluish-white color (fibrous septa) are commonly seen in hemangiomas ■ It should not be mistaken for the scar-like white color of regression or the blue color that can be found in melanomas Cutaneous metastatic melanoma and hemagioma-like melanoma can be indistinguishable from a hemangioma ■ A history of a previous melanoma will help make the diagnosis (Figure 1-17)
Dermoscopy from A to Z
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Determine symmetry or asymmetry of color and/or structure using the mirror image technique ■ Contour of the lesion is not important with this algorithm ■ The lesion is bisected by two lines that are placed 90° to each other ■ One does not physically place lines over the lesion. The lines are visually imagined ■ The lines should be placed to create as much symmetry as possible ■ Are the color and/or the structure on the left half of the lesion a mirror image of the right half Repeat the analysis for the upper and lower half of the lesion Perfect symmetry of color and/or structure is not often found in nature, and interobserver agreement may not be good with this assessment even among experienced dermoscopists Symmetry or asymmetry can also be determined along any axis through the center of the lesion (Menzies method) Significant asymmetry of color and/or structure is a very important clue that you might be dealing with high risk pathology Raise a red flag for concern and proceed with focused attention to what else you might find
Step 2 ■ ■
Determine the global/overall pattern of the lesion The predominant criteria seen throughout the lesion could be ■ Reticular ■ Globular ■ Cobblestone ■ Homogeneous ■ Parallel
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Starburst Multicomponent ■ Nonspecific There can be combinations of criteria in a single lesion such as reticular and homogeneous or reticular and globular ■ The “reticular homogeneous pattern” or “reticular globular pattern” ■
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Step 3 ■
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Identify the local criteria in the lesion ■ Pigment network ■ Dots and globules ■ Streaks (also called pseudopods and radial streaming) ■ Blotches ■ Blue-white veil ■ Regression ■ Colors ■ Vascular structures
Global Patterns Reticular ■
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Determine if the criteria seen are ■ Regular or irregular ■ Good or bad ■ Low or high risk Melanoma-specific criteria are defined as criteria that can be seen in benign and malignant lesions but are more specific for high risk pathology such as ■ Dysplastic nevi ■ Spitzoid lesions ■ Melanoma All of the high risk criteria can be seen in benign pathology, and one should never tell patients that they have melanoma 100%
Table 1-6
Pigment network filling most of the lesion
Globular ■
Dots and globules filling most of the lesion
Cobblestone ■
Step 4 ■
Due to the different characteristics of the skin in these locations the criteria are different on ■ Trunk and extremities ■ Face, nose, and ears ■ Palms, soles, nail apparatus, and mucosa Thinner skin on the face, nose, ears versus the trunk and extremities, and thicker skin on the palms and soles with fissures and ridges The criteria found on the face, nose, ears, palms, soles, nails and mucosa are referred to as site-specific criteria (Table 1-6)
Larger angulated globules resembling street cobblestones filling most of the lesion (Figure 1-18)
Homogeneous ■
Diffuse pigmentation in the absence of local criteria such as pigment network, dots, and globules
Starburst (Spitzoid) ■
Streaks and/or dots and globules at the periphery of the lesion
Multicomponent ■ ■
Three or more different areas within a lesion Each zone can be composed of a single criterion or multiple criteria
Nonspecific ■
None of the above global patterns can be identified
MELANOMA-SPECIFIC CRITERIA IN DIFFERENT BODY REGIONS
TRUNK AND EXTREMITITES
FACE, NOSE, AND EARS
PALM AND SOLES
NAIL APPARATUS
GLOBAL CRITERIA Asymmetry of color and/ or structure Multicomponent pattern Nonspecific pattern LOCAL CRITERIA Irregular pigment network Irregular dots and globules Irregular streaks (pseudopods/ radial streaming) Irregular blotches Blue-white color Regression 5 or 6 colors Polymorphous vascular pattern
Asymmetrical pigmentation around follicular openings Annular- granular structures Rhomboid structures Circle within a circle Dark homogeneous areas Absence of the fingerprint pattern
Parallel ridge pattern Diffuse variegate pigmentation Multicomponent pattern Nonspecific pattern
Diffuse irregular pigmentation Irregular pigmented bands/melanonychia striata Loss of parallelism of pigmented bands Hutchinson and micro-Hutchinson sign
Chapter 1
Dermoscopy from A to Z
13
Regular Streaks ■ ■
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Figure 1-18 Acquired Nevus. Small dots and globules (boxes) and larger angulated globules (arrows) characterize this benign nevus. The mountain and valley pattern seen in seborrheic keratosis is in the dermoscopic differential diagnosis. A positive wobble sign in which the soft nevus moves from side to side with movement of instrumentation versus a stiff immoveable seborrheic keratosis helps to make the differentiation.
Black or brown linear projections of pigment Can be free standing or associated with a pigment network or dark blotches At all points along the periphery of the lesion Pseudopods and radial streaming are similar structures dermoscopically and histopathologically (aggregates of tumor cells running parallel to the epidermis that can be seen in Spitz nevi or represent the radial growth phase of melanoma), which are difficult to differentiate from each another To simplify the identification, the term “streaks” is now used by many but not all experienced dermoscopists to encompass all variations of this criterion The shape of the linear projections does not determine if they are regular or irregular, rather their distribution at the periphery of the lesion
Irregular Streaks ■ ■ ■
Black or brown linear projections Irregularly distributed at the periphery of a lesion Some but not all points at the periphery, “foci of streaks”
Regular Blotches ■
Local Criteria Regular Pigment Network ■ ■
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Various shades of brown Honeycomb-like (web-like, reticular) line segments (elongated hyperpigmented rete ridges) Uniform color, thickness, and holes (dermal papilla)
Irregular Pigment Network ■ ■
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Shades of black or brown Line segments that are thickened, branched, and broken up (enlarged, fused rete ridges) There may be a diffuse distribution or foci of irregular pigment network
Regular Dots and Globules ■
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Brown roundish structures ■ Usually clustered ■ Dots (0.1mm) are smaller than globules (greater than 0.1mm) ■ Size, shape, and color are similar with an even distribution in the lesion (nest of melanocytes at the dermoepidermo junction) Dots and/or globules only found at the periphery can be seen in dysplastic, Spitz, or actively changing nevi Actively changing means if followed digitally the nevus will invariably enlarge over time Peripheral dots and globules are usually seen in younger patients with benign pathology Beware of this pattern in an adult
Irregular Dots and Globules ■
Black, brown, gray, or red roundish structures ■ Different sizes, shapes, and shades of color ■ Usually but not always asymmetrically located in the lesion
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Dark shades of black, brown or gray Structureless (ie, absence of network, dots, or globules) areas of color Bigger than dots and globules Uniform shape and color symmetrically located in the lesion (aggregates of melanin in the epidermis and/or dermis)
Irregular Blotches ■
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Dark shades of black, brown or gray structureless areas of color Irregular in size and shape asymmetrically located in the lesion
Blue-White Veil ■ ■
Irregular, structureless area of confluent blue color Overlying whitish ground glass appearance ■ Orthokeratosis ■ Acanthosis ■ Hypergranulosis ■ Can represent heavily pigmented tumor cells in the dermis
Regression ■ ■
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Bony or milky-white scar-like depigmentation (fibrosis) With or without gray pepper-like granules (free melanin and/or melanophages in the dermis) The white color should be lighter than the surrounding skin ■ The bony-white color should be differentiated from tan hypopigmentation commonly found in melanocytic lesions ■ Blue color can also be seen in areas of regression Regression by itself is an independently potentially high risk criterion The more the regression seen, the greater the chance the lesion is a melanoma
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Blue-White Color ■
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It is not always possible to identify classic regression or blue-white veil Blue and/or white colors of any intensity, shape or distribution A red flag for concern should be raised that the lesion could be a melanoma
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Hypopigmentation ■
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Commonly seen featureless areas of light brown color in all types of melanocytic lesions both benign and malignant Inexperienced dermoscopists can have trouble differentiating hypopigmentation from the bony-white color seen with true regression
Colors Seen with Dermoscopy ■
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Eumelanin’s location in the skin will determine the colors one sees with dermoscopy In a flat or slightly raised lesion, black indicates that melanin is superficially located in the epidermis Black is not always an ominous color but can be seen in benign pathology as well as in invasive melanoma Light and dark brown indicates pigment is at the dermoepidermal junction Gray in the papillary dermis represents free melanin and/or melanophages (“peppering”) As the pigment gets into the deeper dermis it looks blue (the Tyndall effect) Red and/or pink colors can be created by inflammation or neovascularization Sebaceous material and hyperkeratosis can look yellow The more colors seen, the greater the chance that one is dealing with high risk pathology (Figures 1-19, 1-20, 1-21)
Figure 1-20 Melanoma. This is a melanocytic lesion because there are globules (circle). There is asymmetry of color and structure (+) plus the multicomponent global pattern (1,2,3). Local criteria include: irregular dots and globules (circle), blue-white color (stars), and peppering (boxes). The classic blue-white veil is not seen. More than five colors including red are another melanoma-specific criterion. (Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. Sep 2007- Vol 6-Issue 9. Fig 3b.)
Atypical Vascular Pattern/Polymorphous Vascular Pattern ■
Vessels that can be seen in melanoma are nonspecific; they can also be commonly found in other lesions, including ■ Benign ■ Malignant ■ Inflammatory
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Figure 1-19 Melanoma. This is a melanocytic lesion because there is a pigment network (red arrows) and globules (circles). There is asymmetry of color and structure (+) plus the multicomponent global pattern (1,2,3,4). Local criteria include: irregular pigment network (red arrows), irregular dots and globules (circles), irregular dark blotches (black arrows), and blue-white color (stars). The classic blue-white veil is not seen. Peppering (yellow box) and gray blotches (yellow arrows) are part of the regression. More than five colors are seen including red. (Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. May 2008-Vol 7-Issue 5. Fig 4b.)
Figure 1-21 Melanoma. This is a melanocytic lesion because there are globules (circles). There is an atypical starburst (Spitzoid) global pattern with foci of streaks at the periphery (boxes). Local criteria include: irregular dots and globules (circles), irregular streaks (boxes), and regression. The white and gray colors (yellow arrows) make up the regression. The black arrows point out where there are no streaks. Five colors including red round off the melanoma-specific criteria.
Chapter 1
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When identified, they should raise a red flag for concern including ■ Dotted/pinpoint ■ Irregular linear ■ Irregular torturous/corkscrew (irregular, thick, coiled) ■ Irregular hairpin (irregular and thick hairpin-shaped) ■ Glomerular One must focus their attention to make out the shapes of these small vessels
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Minimal pressure with polarizing instrumentation and the use of ultrasound gel, hand cleaning gel or other fluid is the best technique to visualize small vessels
Milky-Red Areas ■
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Localized or diffuse (amelanotic melanoma) pinkish-white color With or without reddish and/or bluish out-of-focus/ fuzzy globular structures (neovasculariztion) Not to be confused with the in focus lacunae seen in hemangiomas Diffuse or clustered fine coiled vessels that can be seen in ■ Bowen disease (Figure 1-22) ■ Melanoma ■ Pink lichen planus-like keratosis ■ Stasis and nonspecific dermatitis ■ Psoriasis
Asymmetrical Pigmentation Around Follicular Openings ■ ■
Seen only on the face, nose, and ears (“site-specific”) Irregular brown color outlining parts of the round follicular openings
The color does not completely encircle the openings (early proliferation of atypical melanocytes) A melanoma-specific criterion, used to diagnose lentigo maligna or lentigo maligna melanoma Seen only on the face, nose, and ears (“site-specific”) Brown or gray fine dots that surround follicular openings (melanophages and/or atypical melanocytes) This criterion and asymmetrical follicular pigmentation can be seen in ■ Lentigo maligna, lentigo maligna melanoma ■ Pigmented actinic keratosis ■ Posttraumatic ■ Late-stage lichen planus-like keratosis (Figures 1-23, 1-24) ■ Melasma
Rhomboid Structures ■ ■ ■
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Glomerular Vessels ■
15
Annular-Granular Pattern/Structures
PEARL ■
Dermoscopy from A to Z
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Seen only on the face, nose, and ears (“site-specific”) Rhomboid is a parallelogram with unequal angles and sides Black, brown, or gray thickening around the follicular openings In reality true rhomboids are not regularly formed Any pigmented thickening around follicular openings is worrisome A melanoma-specific criterion used to diagnose lentigo maligna or lentigo maligna melanoma
Dark Homogeneous Areas ■ ■ ■ ■
On the face, nose, and ears Irregular in size and shape Black or brown homogeneous blotches of color Complete occlusion and disappearance of follicular openings due to invasive melanoma (lentigo maligna melanoma)
Figure 1-23 Lichen Planus-like Keratosis. Remnants of a fingerprint Figure 1-22 Bowen Disease. Typical glomerular vessels (black box) and large dotted vessels (yellow box) help diagnose this nonspecific pink scaly patch. (Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. May 2008-Vol 7-Issue 5. Fig 2b.)
pattern (yellow boxes) of a flat seborrheic keratosis or solar lentigo and the gray annular-granular pattern (black boxes) around follicular openings (arrows) are the clues that this is not lentigo maligna. The gray dots represent melanophages and free melanin in the papillary dermis, not atypical melanocytes. A sub-set of lichen planus-like keratosis is thought to represent an immunologic event against flat seborrheic keratosis of solar lentigines.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Figure 1-24 Lentigo Maligna (ear lobe). This case demonstrates varia-
Figure 1-25 Acrolentiginous/Acral Melanoma/Nail-Apparatus
tions of the classic criteria. The lesion is suspicious clinically but has a differential diagnosis that includes a seborrheic keratosis. The dermoscopic criteria for a seborrheic keratosis are not present. There is asymmetry of color and structure, asymmetrical pigmentation (black arrows) around follicular openings (red arrows), annular-granular structures (circles), and irregular dark blotches (boxes). One should have a mental checklist of the melanoma-specific criteria for this diagnosis because they are not always easy to find and identify.
Melanoma. The pigmented bands are not uniform in color and thickness (black arrows). Broken up line segments (box) represent loss of parallelism. There is also Hutchinson sign (yellow arrows).
Micro-Hutchinson Sign: Hutchinson Sign ■
PEARLS ■
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Actinic keratosis and actinic/solar lentigines can be associated with lentigo maligna/lentigo maligna melanoma Use the areas where the high risk/melanoma-specific criteria are to perform an incisional biopsy, or the malignant diagnosis could be missed If you think the lesion is lentigo maligna yet the pathology report does not make the diagnosis, seek another histopathologic opinion or biopsy another area of the lesion
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Nonmelanocytic Nail-Apparatus Bands ■
Benign Pigmented Nail Bands (Melanonychia Striata) ■
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Single or multiple nail involvement with brown longitudinal parallel lines Uniform color, spacing, and thickness A single band in a lighter skinned person with these findings is still worrisome
Malignant Pigmented Nail Bands (Atypical Melanonychia Striata) ■
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Loss of parallelism (broken-up line segments) with brown, black, or gray parallel lines that demonstrate different shades of color, irregular spacing, and thickness (Figure 1-25) High risk dermoscopic criteria at this location in adults are usually not associated with high risk pathology when seen in children ■ Disfiguring nail-matrix biopsies can usually be avoided in children Any rapidly changing scenario warrants a histopathologic diagnosis no matter how old or young the patient Digital monitoring is helpful to monitor pigmentation in the nail apparatus to document stability or change over time
Pigmentation of the cuticle that can only be seen clearly with dermoscopy (micro-Hutchinson sign) Pigmentation of the cuticle easily seen without dermoscopy (Hutchinson sign) ■ Both are often associated with nail-apparatus melanoma yet not diagnostic (pseudo-Hutchinson sign) Uniform grayish bands can be seen with ■ Lentigo ■ Post-inflammatory ■ Post-traumatic ■ Drug-induced pigmentation multiple nails involved ■ Darker skinned races multiple nails involved
Nail-Apparatus Blood/Subungual Hematoma ■
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The color of blood seen in the nail apparatus depends on how long the blood has been there (breakdown of heme) ■ Fresh blood looks red or purple/violaceous ■ Older blood can look yellowish brown or black A well-demarcated homogeneous area with parallel lines at the distal edge and/or globule-like blood spots/pebbles (Figure 1-26) Digital dermoscopy is helpful to follow nail-apparatus blood that should slowly move distally over several months
PEARLS ■ ■
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Presence of blood in a nail does not rule out melanoma Search carefully for high risk criteria that might also be present Finding the Hutchinson sign and the parallel ridge pattern on the surrounding skin adjacent to the nail can help make the diagnosis of nail apparatus melanoma
Chapter 1
Dermoscopy from A to Z
17
Figure 1-26 Sub-ungual Hemantoma. Different colors plus blood pebbles (boxes) characterize this post-traumatic lesion. The white color (star) is secondary to trauma not regression. The brown (red arrows) and purple blotches (white arrows) result from the breakdown of blood/heme. No melanoma-specific criteria are seen.
Figure 1-27 Congenital Melanocytic Nevus. Terminal hairs with perifollicular hypopigmentation (boxes), irregular pigment network (circles), and regular dots (arrows) characterize this small banal congenital melanocytic nevus.
Longitudinal Erythronychia
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An inconsistent finding in single or multiple finger nails Single or multiple longitudinal pinkish blanching bands of variable thickness (normal vasculature) Multiple nail involvement is a benign sign Single nail involvement can be seen in amelanotic nailapparatus melanoma, Bowen disease and onychomatricoma Associated with inflammatory skin diseases (ie, lichen planus, Darier’s disease)
Common Dermoscopic Patterns Congenital Nevi ■ ■
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Diffuse homogeneous brown color Patchy or diffuse pigment network (target network may or may not be seen as network holes each with a small centrally located brown dot or pinpoint vessel) Globular and/or cobblestone pattern (target globules may or may not be seen as globules with a smaller centrally located brown dot or vessel) Islands of normal skin and islands of criteria such as pigment network, dots and globules Multicomponent pattern with three or more distinct areas of criteria Dark coarse terminal hairs (hypertrichosis) with or without surrounding hypopigmentation (perifollicular hypopigmentation) (Figure 1-27) Milia-like cysts and pseudofollicular openings, most often found in seborrhic keratosis, can be seen
Acquired Nevi ■ ■ ■ ■
Light/dark brown or pink color Regular pigment network Lacks sharp demarcation at the borders Globular or cobblestone pattern (the most common pattern seen in children)
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Symmetry of color and structure Comma-shaped blood vessels Hypopigmentation Milia-like cysts and pseudofollicular openings can be seen Pink nevi can be featureless (an absence of local criteria) or feature-poor (a few poorly developed local criteria) ■ A solitary flat pink lesion, with different shades of pink color, is more worrisome than multiple soft and compressible pink lesions
PEARL ■
Dermoscopy might not be helpful to diagnose pink macules and papules, which can be melanocytic, nonmelanocytic, benign, malignant, or inflammatory (Figure 1-28)
Blue Nevi ■
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Blue, blue-gray, or blue-black homogeneous color (Figure 1-3) Variable number of subtle blue globular-like structures may or may not be present Regression with white or gray areas commonly seen Radiation tattoo, nodular and cutaneous metastatic melanoma are in the dermoscopic differential diagnosis The history is essential to make the diagnosis
Combined Nevi ■
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Light or dark brown homogeneous color +/− other local criteria (regular nevus) and a blue blotch (blue nevus) with a “fried egg” clinical appearance Diffuse brown homogeneous color with a blue border Diffuse blue homogeneous color with brown border Variable combinations of blue and brown colors
Recurrent Nevi/Pseudomelanoma ■ ■
Sharp border Irregular pigment network; irregular streaks
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Figure 1-28 Pink Lichen Planus-like Keratosis. This small papule was
Figure 1-30 Dysplastic Nevus. There are foci of irregular dots and glob-
only found after a complete skin examination. There are different shades of pink color, pinpoint (boxes), and comma-shaped vessels (yellow arrows) plus a milky-red area (black arrow). (Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. Sep 2007- Vol 6-Issue 9. Fig 4b.)
ules (boxes), irregular dark blotches (black arrows), and multifocal hypopigmentation (red arrows).
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Irregular dots and globules White scar-like areas with linear and/or arborizing vessels Any combination of criteria can be seen Pigmentation centrally located within the scar ■ If the pigmentation goes beyond the borders of the scar, raise a red flag for concern that the lesion might be a melanoma ■ A history of previous surgery and histopathology is important to help rule out melanoma ■ If possible, review the pathology from the lesion that was excised (Figure 1-29)
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Dysplastic Nevi ■
ABCDE clinical lesions can be indistinguishable from melanoma and look banal or high risk with dermoscopy
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E for evolving/changing might be the only clue that a lesion is high risk (ie, dysplastic nevus, melanoma) Asymmetry of color and structure A multicomponent global pattern Irregular pigment network Irregular dots and globules Irregular blotches Multifocal hypopigmentation (Figure 1-30) Regression, blue-white color/blue-white veil, atypical vessels, and streaks are not usually seen Atypical pattern similar to superficial spreading melanoma Patients with multiple dysplastic nevi clinically, usually do not have many that look very atypical with dermoscopy Pink dysplastic nevi can be feature-poor or featureless with low or high-grade histopathology
PEARLS ■ ■
“Anything pink, stop and think!” Look for the clinical and/or dermoscopic “ugly duckling” to consider for biopsy or digital follow-up
Spitz Nevi
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Figure 1-29 Recurrent Nevus. Asymmetry of color and structure (+), the multicomponent global pattern (1,2,3) irregular globules (boxes), irregular dark blotch (yellow arrow), brown color (white arrows), scar tissue (stars) with linear vessels (black arrows) characterize this recurrent nevus.
There are six patterns seen in Spitz nevi ■ Starburst ■ Globular ■ Homogeneous ■ Pink ■ Black pigment network ■ Atypical Spitzoid is the term used when any of the different six patterns is seen Starburst is the most common pattern (Figure 1-31) ■ Streaks and/or dots and globules at the periphery ■ Light/dark brown, black, or blue color centrally ■ Regular or irregular pattern depends on the location of the streaks
Chapter 1
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Dermoscopy from A to Z
19
A Spitzoid melanoma histopathologically does not always have a Spitzoid dermoscopic features
In Situ Melanoma (Trunk and Extremities) ■ ■
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Figure 1-31 Spitz Nevus. A central regular dark blotch (stars) plus globules (black arrows) and a few streaks (red arrows) at all points along the periphery characterize this classic symmetrical starburst/Spitzoid pattern.
Lentigo Maligna/Lentigo Maligna Melanoma (Face, Nose, Ears) ■ ■ ■
Regular starburst pattern has symmetrical streaks and/or dots and globules around the lesion ■ Irregular starburst pattern has foci of streaks and/or dots and globules at the periphery ■ Beware! Symmetrical and asymmetrical starburst patterns can be seen in melanoma Globular is the second most common Spitzoid pattern ■ Filled with regular or irregular dots and/or globules ■ Blue color seen centrally is a clue that the lesion might be a Spitz nevus Homogeneous pattern ■ Featureless brown color Pink pattern ■ Featureless pink papule ■ Can have small vessels Black network pattern ■ The lesion is composed totally of a prominent black pigment network ■ Ink-spot lentigo and melanoma are in the differential diagnosis Atypical pattern ■ This can have any combination of melanoma-specific criteria ■ The histopathologic diagnosis is usually a surprise White pigment network/white network/negative pigment network/reticular depigmentation can be seen within the lesion ■ This is an important clue that the lesion is Spitzoid ■ Can also be seen in dermatofibromas and in melanoma ■
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PEARLS ■
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Most but not all Spitzoid patterns require a histopathologic diagnosis especially in adults The pink variant could actually be amelanotic melanoma A melanoma with a Spitzoid pattern dermoscopically is not always Spitzoid histopathologically
Can be associated with a dysplastic nevus or develop de novo May or may not demonstrate the clinical ABCD clinical criteria Flat or slightly raised lesion Asymmetry of color and structure Multicomponent global pattern Black and/or dark brown irregular pigment network Irregular dots and globules Irregular dark blotches Regression and/or hypopigmentation Lacks the criteria associated with deeper melanomas (pink, red, or blue color, atypical vessels) (Figure 1-32)
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Asymmetrical follicular pigmentation Annular-granular structures Rhomboid structures Circle within a circle ■ Gray color and/or gray granules (atypical melanocytes) surrounding the periphery of follicular units with the presence of a centrally located hair shaft Absence of the fingerprint pattern With invasion (lentigo maligna melanoma) one sees irregular black blotches with or without the disappearance/ destruction of follicular openings Melanoma-specific criteria as seen in other locations with more advanced disease
Superficial Spreading Melanoma ■ ■
Starts in an existing nevus or de novo Demonstrates the clinical ABCD criteria
3 1
2 3
Figure 1-32 In Situ Melanoma. This is a melanocytic lesion because there is a pigment network (black box) and globules (circles). There is asymmetry of color and structures (+), the multicomponent global pattern (1,2,3), irregular pigment network (black box), irregular dots and globules (circles), and reticular depigmentation (white box). The hypopigmentation (black stars) should not be confused with regression. There is diffuse erythema (red stars) and only three other colors. (Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. May 2008-Vol 7-Issue 5. Fig 3b.)
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Contains a variable number of the melanoma-specific criteria found on the trunk and extremities (Figures 1-19, 1-20, 1-21)
Nodular Melanoma ■ ■ ■ ■
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Starts in an existing nevus or de novo May or may not be fast growing Pigmented, hypomelanotic, or amelanotic Can be mistaken for benign nevus or squamous cell carcinoma Usually lacks the clinical ABCD criteria Due to the absence of the radial growth phase there is a scarcity of local criteria (pigment network, globules, streaks) Remnants of local criteria may or may not be present at the periphery of the lesion Large intense irregular dark blotches Multiple deeper skin colors seen such as blue, white, pink, milky-red Atypical vessels
PEARLS ■
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The clinical appearance of a lesion (flat, palpable or nodular, presence or absence of the ABCD criteria) plus the colors and structures seen with dermoscopy can help estimate if you are dealing with a thin, intermediate or thick melanoma Flat melanomas are usually in situ or early invasive,with black and brown colors plus well-developed local criteria Thick melanomas tend to be elevated or nodular and can have a paucity or absence of local criteria such as pigment network, plus blue-white veil/color, multiple colors, and the atypical vascular pattern
Amelanotic Melanoma ■ ■ ■
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Flat, palpable, or nodular Hypopigmented, pink or red May or may not have the melanoma-specific criteria typically seen in pigmented melanomas Different shades of pink color and polymorphous vascular pattern Milky-red areas are important clues to the correct diagnosis Pediatric patients have a high proportion of amelanotic melanomas Amelanotic melanoma should always be in the differential diagnosis of a pyogenic granuloma (Figure 1-33)
Figure 1-33 Amelanotic Melanoma (face). This is a melanocytic lesion because it has globules (boxes). Histopathologically it was an amelanotic melanoma even though brown color is seen with dermoscopy. There is an absence of melanoma-specific criteria found on the face with different shades of pink and brown color plus ulceration (yellow arrows). Follicular openings (black arrows) should not be confused with the milia-like cysts of a seborrheic keratosis.
Featureless Melanoma ■
Melanoma Incognito/False Negative Melanoma ■
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Dermoscopy might not be as helpful to make the diagnosis as the history of a melanoma being previously excised Single or multiple Pigmented or nonpigmented All different sizes, shapes, and colors can be seen in each patient with or without atypical vessels Any combination of criteria can be seen Benign patterns such as a hemangioma-like cutaneous metastatic melanoma (Figure 1-17)
Feature-poor Melanoma ■
Melanoma with subtle nondiagnostic criteria (Figure 1-33)
Clinically and/or dermoscopically the lesion does not look like melanoma With dermoscopy there can be obvious or subtle clues to make the diagnosis Clues to help make the diagnosis ■ History of dermoscopic change over time ■ A Spitzoid pattern in a lesion that does not look Spitzoid clinically ■ Areas of regression as the major high risk criterion ■ Polymorphous vessels in a pink lesion The “little red riding hood sign” is when the lesion looks clinically benign from a distance but not when seen close up with dermoscopy
PEARL ■
Cutaneous Metastatic Melanoma ■
Melanoma without dermoscopic criteria at all
Dermoscopy should not only be used on clinically suspicious lesions if one wants to diagnose melanoma incognito
Nail-Apparatus Melanoma ■ ■ ■
■ ■ ■ ■ ■
Amelanotic diffuse reddish color/amelanotic tumor nodule Longitudinal erythronychia in a single nail Diffuse melanonychia with different shades of black, brown, or gray color Irregular pigmented bands (Figure 1-25) A single uniform band does not rule out melanoma Irregular dots and globules Blood identified in 25% of lesions Variable amounts of nail-plate destruction with advanced disease
Chapter 1
■ ■
+/− Hutchinson sign The parallel ridge pattern can be seen on the adjacent skin
Ink-spot Lentigo ■ ■ ■ ■
Black macule or macules on sun-exposed areas Prominent thick black pigment network Usually a very easy clinical and dermoscopic diagnosis Melanoma could be in the clinical and dermoscopic differential diagnosis ■ Look for melanoma-specific criteria (ie, blue-white color, irregular blotches) that should not be present in an ink-spot lentigo
Solar Lentigo/Actinic Lentigo ■ ■ ■ ■
Macules and/or patches Different shades of homogeneous brown color Sharply demarcated moth-eaten concave borders Fingerprint pattern with straight and/or wavy linear line segments
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Nonpigmented actinic keratosis ■ Scaly surface ■ Pinkish-red pseudopigment network Pigmented actinic keratosis ■ Mimicks lentigo maligna ■ Asymmetrical follicular pigmentation ■ Annular-granular structures ■ Rhomboid structures
PEARL ■
Multiple scaly lesions favor the diagnosis of actinic keratosis over lentigo maligna. Both can have pigmented and nonpigmented variants.
21
PEARL ■
The yellowish clinical appearance and globules are the main features used to differentiate sebaceous gland hyperplasia from basal cell carcinoma.
Collision Tumor ■
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Actinic Keratosis ■
Dermoscopy from A to Z
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Lesion with the dermoscopic criteria for two different pathologies ■ One can find a triple collision lesion with three different pathologies Collision tumors are commonly seen Diagnostic criteria can be side by side or one can be seen within the other Examples include ■ Seborrheic keratosis, basal cell carcinoma ■ Seborrheic keratosis, in situ or invasive squamous cell carcinoma ■ Seborrheic keratosis, amelanotic or pigmented melanoma ■ Seborrheic keratosis, eccrine porocarcinoma ■ Basal cell carcinoma, seborrheic keratosis, clear cell acanthoma Any combination is possible (Figure 1-34)
Other Diagnoses Made with Dermoscopy Scabies ■ Burrows appear as discrete yellowish scaly linear areas ■ Mites can be seen as a small triangle/gray delta structure that corresponds to the front section of the body with its mouth/biting apparatus and legs ■ Higher magnification and oil/fluid increases the visibility of the mite, stool, and eggs
Bowen Disease (In Situ Squamous Cell Carcinoma) ■ ■ ■
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Pink or reddish scaly macules, papules, patches, plaques Pinpoint and/or glomerular vessels Clusters or diffuse distribution of vessels throughout the lesion With or without foci of pigmentation
Keratoacanthoma ■
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A rapidly growing reddish scaly nodule of short duration on sun exposed areas Centrally located yellowish keratinous material Peripheral whitish background Hairpin vessels with or/without a white halo at the periphery
Sebaceous Gland Hyperplasia ■ ■ ■
Delled yellow papules seen clinically Multiple grouped white or yellow globules Small caliber basal cell carcinoma-like vessels ■ The vessels have been termed crown or wreath-like vessels ■ Supposedly never to reach the center of the lesion ■ This is a misnomer because in reality the vessels rarely meet this criterion and can be found anywhere in the lesion
Figure 1-34 Collison Tumor—Squamous Cell Carcinoma and Seborrheic Keratosis. A rapidly growing nodule (arrows) representing a squamous cell carcinoma and the mountain and valley pattern of a seborrheic keratosis (box) characterizes this lesion. The cobblestone pattern of a nevus is in the dermoscopic differential diagnosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
Pediculosis Capitis ■ Direct visualization of the parasite and nits ■ It is possible to see if the nits are full (vital nits) or empty, which helps determine the success or failure of treatment Pediculosis Pubis ■ It is possible to easily see the parasite attached to adjacent pubic hairs or hairs at other sites Lichen Planus ■ Peppering ■ Brown blotches ■ White reticular areas (Wickham striae) ■ Negative pigment network/white pigment network/reticular depigmentation is in the dermoscopic differential diagnosis of Wickham striae Warts ■ Red and/or black dots (thrombosed capillaries) ■ With or without a white halo Psoriasis ■ Red scaly plaque or plaques ■ Diffuse distribution of pinpoint and/or glomerular vessels identical to Bowen disease ■ Distribution of lesions will help differentiate Psoriasis from Bowen disease ■ Both can have single or multiple lesions
Scleroderma Pattern ■ The triad of ■ Rarefied capillaries (less than 6 loops per mm) ■ Thin loops ■ Megacapillaries ■ Pearly shining sclerosis “cotton balls” Dermatomyositis ■ Mega, twisted, branched loops, microhemorrhage Lupus Erythematosus ■ Considerable variation of loops, branching, twisted, megacapillaries, microhemorrhage Trichoscopy ■ The use of dermoscopy to evaluate scalp skin and hair follicles ■ Structures that can be visualized include ■ Hair shafts ■ Hair-follicle openings ■ Perifollicular epidermis ■ Cutaneous microvasculature ■ Higher magnifications (20-70 fold) with digital systems and fluid (70% ethanol) are preferred ■ Hand-held instrumentation with lower magnification and other fluids such as emersion oil or gels can also be used Genetic Hair-Shaft Abnormalities Monilethrix
Nail Folds ■ Normal capillary loops are hairpin-shaped and run parallel to the axis of the nail ■ The main value of nail fold dermoscopy is the early diagnosis of scleroderma before there are positive clinical and serologic findings (Figure 1-35)
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Multiple constrictions of the hair shaft alternating with elliptical nodosities that look like a “pearl necklace” A high tendency to fracture, which gives hair a stubblelike appearance Hair shafts bend regularly in multiple places and curving in different directions “regularly bended ribbon sign”
Figure 1-35 Nail Fold Capillaries in Cutaneous Lupus. Uniform hairpin-shaped capillary loops are replaced with large (mega) irregularly-shaped capillary loops that still have a hairpin shape. The surrounding skin is atrophic with diffuse telangietatic vessels.
Chapter 1
Netherton Syndrome ■
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Trichorrhexis invaginata/bamboo hair/golf tee type characterized by invagination of the distal portion of the hair shaft into its proximal portion forming a ball-in-cup appearance Diagnosis can easily be made without the need for hair sampling and microscopic examination
Pili Annulati ■
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ANDROGENIC ALOPECIA
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Terminal to vellus hair ratio can be calculated without skin biopsies Increased percentage of thin hairs Decreased average hair diameter Predominance of hair-follicle units with single hairs Hyperkeratotic plugs Perifollicular pigmentation
ALOPECIA AREATA
Alternating light and dark bands are seen clinically ■ Light bands represent cavities within the cortex ■ Cavities appear as whitish areas within a darker hair shaft ■ The opposite is true with light microscopy
Acquired Hair Diseases ■
Dermoscopy from A to Z
Variable hair-shaft diameter Digital systems allow the precise measurement and monitoring of hair-shaft thickness Identify and count vellus hairs (thin hairs less than 0.03mm in width)
Regularly distributed hyperkeratotic plugs in hair follicles (yellow dots) Cadaverized hairs (black dots) Dystrophic hairs Micro-exclamation point hairs Fibrosis with white dots in long-standing cases
CICATRICIAL ALOPECIA ■
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Scarring alopecia of different etiologies looks the same with fibrosis of follicular ostia visible as white dots With more advanced disease, the dots coalesce to form bony white areas without visible ostia
QUESTIONS 1. Which criteria can be used to diagnose a melanocytic lesion? a. Milia-like cysts and pigmented pseudofollicular openings. b. Arborizing vessels, ulceration, and pigmentation. c. A central white patch plus fine peripheral pigment network. d. Lacunae and black homogenous blotches. e. Pigment network, brown globules, homogeneous blue color, or parallel patterns.
3. Which criteria can be used to diagnose a seborrheic keratosis? a. Milky-red areas, irregular streaks, and pigmented pseudofollicular openings. b. Streaks, irregular blotches, and regression. c. Fissures, ridges, sharp border demarcation, milialike cysts, pseudofollicular openings, fat fingers, and hairpin vessels. d. Rhomboid structures and/or circle within a circle. e. Diffuse brown color, glomerular vessels, and milia-like cysts.
2. Diagnosing a melanocytic lesion by default means? a. There are high risk criteria at the periphery of the lesion that are hard to identify. b. There are criteria for a seborrheic keratosis or basal cell carcinoma associated with pigment network and brown globules. c. There is an absence of criteria to diagnose a melanocytic lesion, seborrheic keratosis, dermatofibroma, pyogenic granuloma, or ink-spot lentigo, therefore the lesion should be considered melanocytic. d. There is an absence of criteria to diagnose a melanocytic lesion, seborrheic keratosis, basal cell carcinoma, dermatofibroma, or hemangioma, therefore the lesion should be considered melanocytic. e. None of the above.
4. Which criteria can be used to diagnose a basal cell carcinoma? a. Pigment network and arborizing vessels. b. Arborizing and pinpoint vessels plus multifocal hypopigmentation. c. The absence of a pigment network, arborizing vessels, pigmentation, ulceration, and spoke-wheel structures. d. Glomerular vessels, ulceration, and blue ovoid nests of pigmentation. e. Islands of black blotches, arborizing vessels, and moth-eaten borders.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
5. Vascular lesions can contain the following criteria: a. Out of focus lacunae-like globules. b. A variable number of red, sharply demarcated vascular spaces called lacunae and fibrous septae. c. Ten to twenty major and minor lacunae and thromboses. d. A minimal of two well-developed glomerular vessels. e. Fibrous septae, peppering, and blue dark lacunae.
6. Dermatofibromas can be associated with the following criteria: a. Pigment network, arborizing vessels, and central white patch. b. A central white patch that is never located at the periphery. c. A central white patch and peripheral pigment network. d. A complete absence of blood vessels and a few milia-like cysts. e. Multifocal hypopigmentation, arborizing vessels, and a central bluish-white veil.
7. Melanoma-specific criteria on the trunk and extremities can contain the following combination of criteria: a. Asymmetry of color and structure, a cobblestone global pattern, and regular globules or blotches. b. A multicomponent global pattern, symmetry of color and structure, regular network, regular globules, and regression. c. Polymorphous vessels, arborizing vessels, two colors, and regular streaks. d. Irregular pigment network, irregular globules, irregular blotches, and regression. e. Rhomboid structures and the parallel ridge pattern.
8. Dysplastic nevi typically have the following combination of criteria: a. Symmetry of color and structure and no melanomaspecific criteria. b. Asymmetry of color and structure, irregular pigment network, regular blotches, and regular streaks. c. Multifocal regression, peppering, regular pigment network, regular dots, and globules. d. Pinpoint, arborizing, and glomerular vessels plus several melanoma-specific criteria. e. Asymmetry of color and structure plus several melanoma-specific criteria.
9. Which of the following statements is true about Spitz nevi? a. They can have ten different patterns. b. A Spitzoid lesion only refers to the starburst or pink patterns. c. Melanoma is not in the differential diagnosis of regular starburst pattern. d. In an adult, most Spitzoid lesions do not need to be excised. e. Symmetrical and asymmetrical starburst patterns can be seen in melanoma.
10. Which of the following statements best describes the criteria seen in superficial spreading melanomas? a. Criteria associated with a benign nevus are never seen. b. They contain several well-developed melanomaspecific criteria such as symmetry of color and structure and one prominent color. c. Usually they have several well-developed melanomaspecific criteria such as asymmetry of color and structure, multicomponent global pattern, regular network, regular globules, and regular streaks. d. They contain a variable number of melanomaspecific criteria such as asymmetry of color and structure, multicomponent global pattern, irregular local criteria, five or six colors, and polymorphous vessels. e. Are usually feature-poor or featureless.
ANSWERS 1. E. Criteria to diagnose a melanocytic lesion include any variation of pigment network (regular and/or irregular), multiple brown dots and/or globules, homogeneous blue color of a blue nevus, and parallel patterns seen on acral skin. The default category is the last way to diagnose
a melanocytic lesion. Milia-like cysts and pseudofollicular openings can be seen in melanocytic lesions but are not primary criteria to make the diagnosis. Answers a, b, c and d diagnose a seborrheic keratosis, basal cell carcinoma, dermatofibroma, and hemangioma.
Chapter 1
2. D. Diagnosing a melanocytic lesion by default means that one does not see criteria for a melanocytic lesion, seborrheic keratosis, basal cell carcinoma, dermatofibroma, or hemangeoma. Default is an absence of criteria. One has to memorize all of the criteria from each specific potential diagnosis to be able to diagnose a melanocytic lesion by default. Dermoscopy cannot be mastered by osmosis. It is essential to study and practice the technique routinely in ones daily practice. Ink-spot lentigo and pyogenic granuloma are not in this algorithm. 3. C. All of the criteria used to diagnose seborrheic kerotosis are commonly seen in daily practice. Melanomaspecific criteria can also be seen in atypical seborrheic keratosis. Beware of seborrheic keratosis—like melanomas. Milky-red areas, irregular streaks, regression, rhomboid structures, and circle within a circle are all melanomaspecific criteria that are more sensitive and specific for melanoma but could be found in seborrheic keratosis. Glomerular vessels are a primary criterion to diagnose Bowen disease and are not seen in seborrheic keratosis. 4. C. Basal cell carcinomas are usually a clinical diagnosis and dermoscopy is used to confirm ones clinical impression. Dermoscopy gives one an on the spot second opinion. By definition, if one sees pigment network the lesion could not be a basal cell carcinoma. A sub-set of melanomas can be difficult to differentiate from basal cell carcinoma with pigmentation and arborizing vessels. Pinpoint and glomerular vessels could be seen but they would be out shadowed by arborizing vessels. If not, one could be dealing with a basal cell-like melanoma. Motheaten borders are seen in lentigines and flat seborrheic keratosis, never in basal cell carcinomas. 5. B. The hallmark of vascular lesions are lacunae, vascular spaces with well-demarcated sharp borders. There is no set number of lacunae needed to make the diagnoses. At times one has to use their imagination to decide if the margins fit the criteria for vascular spaces. Different shades of red, blue, and even black are typically seen. Black homogeneous color usually represents thombosis. Major and minor lacunae do not exist. Fibrous whitish septa and/or bluishwhite color are routinely seen in typical hemangiomas. At times it is not possible to differentiate lacunae and red color of a hemangioma from the milky-red areas that can contain out-of-focus reddish globules seen in melanoma. 6. C. Dermatofibromas are ubiquitous benign tumors and in most cases dermoscopy is not needed to make the diagnosis. A central white patch and pigment network, the primary criteria to make the diagnosis, may or may not be present. It might not be possible to differentiate an atypical dermatofibroma from a melanoma if melanoma-specific
Dermoscopy from A to Z
25
criteria are identified. There are innumerable ways that the central white patch can appear, and in many cases it is not centrally located. Telectangietatic vessels with polymorphous shapes are commonly seen but basal cell carcinoma-like arborizing vessels would make the diagnosis of a dermatofibroma unlikely.
7. D. Irregularity is the name of the game if criteria are to be considered melanoma-specific. Melanoma-specific criteria can be seen in both benign and malignant pathology but are more sensitive and specific for melanoma. There is not a single melanoma-specific criterion that is pathognomonic for melanoma. One should learn their definitions, and study as many classic textbook examples as possible. Rhomboid structures help diagnose melanoma on the face and the parallel ridge pattern can be seen in acral melanomas. 8. E. Dysplastic nevi are ubiquitous in the light-skinned population and can be indistinguishable clinically and dermoscopically from melanoma. They usually look more benign than malignant with dermoscopy; however, there are melanomas that do not have well-developed melanoma-specific criteria. Vessels of any kind are not typically seen except in pink feature-poor dysplastic nevi. They can have a variable number of melanoma-specific criteria (eg, irregular pigment network, irregular dots, and/or globules, irregular blotches) that are not as well developed as those seen in melanoma. Streaks, regression, and many colors are not usually seen and should raise a red flag for concern that the lesion might be a melanoma. 9. E. Spitzoid lesions are always a red flag for concern. Even symmetrical patterns can be seen in melanoma. There are only six patterns (starburst, globular, homogeneous, pink, black network, and atypical). One often has to use their imagination to diagnose a Spitzoid lesion. Since symmetrical and asymmetrical Spitzoid patterns can be found in melanoma, they should all be excised in children as well as in adults. A dermatopathologist that specializes in melanocytic lesions is good, while one that has expertise in Spitzoid lesions is ideal. Even experienced dermatopathologists have trouble differentiating atypical Spitzoid lesions from melanoma, and atypical Spitzoid lesions have the potential to metastasize because in reality they are melanomas. 10. D. Superficial spreading melanoma can have it all as far as the spectrum of melanoma-specific criteria goes. The criteria can be well developed or difficult to identify. Criteria associated with benign melanocytic lesions can also be seen. The more the high risk criteria identified in the lesion, the greater the chance that one is dealing with a melanoma. Nodular and amelanotic melanoma are more likely to be feature-poor or featureless.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
SUGGESTED READINGS Altamura D, Avramidis M, Menzies SW. Assessment of the optimal interval for and sensitivity of short-term sequential digital dermoscopy monitoring for the diagnosis of melanoma. Arch Dermatol. 2008; 144(4):502-506. Argenziano G, Zalaudek I, Johr RH et al. Dermoscopy features of melanoma incognito: indications for biopsy. J Am Acad Dermatol. 2007; 56(3):508-513. Argenziano G, Soyer HP, Chimenti S et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the internet. J Am Acad Dermatol. 2003; 48:679-693. Argenziano G, Zalundek I et al. Vascular structures in skin tumors: a dermoscopy study. Arch Dermatol. 2004; 140:1485-1489. Bowling J, Agenziano G et al. Dermoscopy key points: recommendations from the International Dermoscopy Society. Dermatol. 2007; 214:3-5. Cari P, DeGiorgi V, Crocetti E et al. Improvement of the malignant/benign ratio in excised melanocytic lesions in the dermoscopy era: a retrospective study 1997-2001. Br J Dermatol. 2004; 150(4):687-692. Johr RH, Soyer HP, Argenziano G. Dermoscopy: The Essentials. Edinburgh: Mosby; 2004.
Johr RH. Pink lesions. Clin Dermatol. 2002; 20:289-296. Kittler H, Guitera P, Riedl E et al. Identification of clinically featureless incipient melanoma using sequential dermoscopy imaging. Arch Dermatol. 2006; 142(9):1113-1119. Malvehy J, Puig S, Braun R, Marghoob A, Kopf AW. Handbook of Dermoscopy. London (UK): Taylor and Francis; 2006. Malvehy J, Puis S et al. Dermoscopy report: proposal for standardization. Results of a consensus meeting of the International Dermoscopy Society. J Am Acad Dermatol. 2007; 57:84-95. Marghoob AA, Braun PR, Kopf AW eds. Atlas of Dermoscopy. London (UK): Taylor and Francis; 2005 Menzies S, Zalaudek I. Why perform dermoscopy? The evidence for its role in the routine management of pigmented skin lesions. Arch Dermatol. 2006; 142(9):1211-1212. Stolz W, Braun–Falco O et al. Color Atlas of Dermatoscopy. 2nd ed. Berlin: Blackwell Publishing; 2002. Vestergaard ME, Macaskill P et al. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol. 2008; 159:669-676.
Chapter 2
Scalp, Face, Nose, and Ears
.
General Instructions: You will find a list of True/False statements following each case history. Select any statements, which you believe to be true. There may be one, more than one or no true statements for any given case. Choose the correct risk, diagnosis and disposition for each case. Then, turn the page to find a detailed discussion and pearls for each case.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-1a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-1b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 1 HISTORY An 85-year-old man noticed the significant darkening of a long time facial lesion. 1. Clinically and dermoscopically this could be lentigo maligna. 2. Multiple milia-like cysts and pseudofollicular openings diagnose a seborrheic keratosis. 3. It is not always possible to differentiate follicular openings from pseudofollicular openings and milia-like cysts. 4. The dark blotch with the bluish tinge is always high risk. 5. The dark blotch has histopathologic correlates that include atypical melanocytes.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ ✔ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
2-1c
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,3,5
Discussion: ■
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DERMOSCOPIC CRITERIA ■ ■
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Follicular openings (boxes) Pigmented pseudofollicular openings (yellow arrows) Milia-like cysts (black arrows) Hyperpigmentation (white arrows) Moth-eaten borders (red arrows)
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Multiple milia-like cysts and pseudofollicular openings characterize this seborrheic keratosis. Both criteria can also be found in benign nevi and melanoma. Dark colors (hyperpigmentation) are commonly found in seborrheic keratosis. Concave “moth-eaten” borders are one criterion seen in flat seborrheic keratosis and solar lentigines. Blue and/or white color in any intensity should raise a red flag for concern. Bluish color is not always high risk. In a flat lesion subtle blue and/or white color usually is low risk In a raised lesion intense blue and/or white color is potentially high risk.
PEARLS ■
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It is essential to differentiate the pseudofollicular openings and milia-like cysts of a seborrheic keratosis from the follicular openings seen in lentigo maligna or lentigo maligna melanoma. One should not stop and diagnose a seborrheic keratosis if milia-like cysts and pseudofollicular openings are identified before examining the entire lesion. High risk criteria pointing to the correct diagnosis might be found elsewhere and then they would be missed.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-2a-2
2-2a-1
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-2b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 2 HISTORY The mother of this 7-year-old female is concerned about a blue spot on her daughter’s face. She wants it treated immediately because the patient’s uncle was recently diagnosed with a melanoma. The lesion has been present for two years and is not changing. 1. Historically, clinically, and dermoscopically this clearly falls within the range of a blue nevus. 2. This could be a combined nevus. 3. This polychromatic lesion with white, blue, and shades of brown color indicates that it is high risk. 4. Different shades of blue, brown, black, and white can be seen in blue nevi. 5. The multiple follicular openings seen here are as expected on the face.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-2c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
Answers: 1,2,4,5
Discussion: ■
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DERMOSCOPIC CRITERIA ■ ■ ■
Follicular openings (circles) Brown color (arrows) Bluish-white color
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This blue nevus has a dermoscopic differential diagnosis that includes a combined nevus. In most cases blue nevi are easy to diagnose. The classic blue nevus is characterized by homogenous featureless blue color with well-demarcated borders. Hypopigmentation often scar-like is commonly seen. Globular-like structures can be seen in blue nevi. Combined nevi contain two different cell populations. ■ Blue nevi and compound nevi make up most combined nevi. Combined nevi can contain various shades and distributions of blue and brown colors. “Black” blue nevi are created by the black lamella (pigmented parakeratosis). ■ The black lamella looks like a jet black homogeneous blotch with a glazed appearance. Tape stripping can remove the black lamella, which is a positive clinical sign pointing toward low risk pathology. ■ The same holds true in whatever lesions that have a black lamella (ie, junctional nevus). Polychromatic blue nevi should raise a red flag for concern. ■ The concept of “raising a red flag for concern” means that there is a clue or clues that a lesion might be high risk. Proceed with focused attention with the complete analysis of the lesion.
PEARLS ■ ■
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The history is essential to help make the correct diagnosis of a blue nevus. Melanoma and cutaneous metastatic melanoma can be identical clinically and dermoscopically with a blue nevus. A “blue” nevus developing in an adult should always raise a red flag for concern. To allay the anxiety of the parents that this could be a melanoma, a punch excision of the lesion was performed which confirmed that this was in fact a benign blue nevus.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
2-3a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-3b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 3 HISTORY This young patient was referred to you for a second opinion because their dermatologist recommended excision of this “fried egg” appearing nevus. It was never examined with dermoscopy and the referring pediatric dermatologist thought that dermoscopic examination would be beneficial to help avoid surgery on the child’s face. 1. “Fried egg” appearing nevi are always at high risk, histopathologically, and, therefore, dermoscopic evaluation is not indicated. 2. In this age group “fried egg” appearing nevi are usually not high risk and dermoscopy can help to prove this. 3. Regular dots, globules, and a regular blotch characterize this combined nevus. 4. The dark blotch in an adult should raise a red flag for concern. 5. Sequential digital clinical and dermoscopic monitoring is an alternative to skin biopsy or excision.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-3c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ❑ No intervention ✔ Follow-up ❑ ❑ Histopathologic diagnosis
ANSWERS Answers: 2,3,4,5
Discussion: ■ “Fried egg” appearing nevi should be evaluated with dermoscopy before
DERMOSCOPIC CRITERIA: ■
■ ■
Regular dots and globules (circles) Islands of normal skin (arrows) Regular bluish-brown blotch (star)
■ ■
■ ■
■
■
more invasive procedures are performed. In this age group the chances of high risk pathology are extremely low. This congenital combined nevus has two cell populations: a blue nevus (the bluish-brown blotch) and compound nevus. Combined nevi do not always have a “fried egg” appearance. If found in a teenager or an adult, the bluish-brown blotch is potentially at more high risk. The bluish-brown blotch has a differential diagnosis that includes melanocytic atypia or melanoma. Islands of normal skin and islands of criteria are one of the patterns commonly seen in congenital melanocytic nevi.
PEARLS ■
■
Sequential digital monitoring and confident reassurance to the parents that an excision is not needed would be the optimal cutting-edge approach to handle this case. Whatever global patterns and local criteria are identified, one has to decide if they are regular or irregular, good or bad, low or high risk.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-4a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-4b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 4 HISTORY A 76-year-old man came for a consultation of a slowly enlarging growth on his nose that started one year ago. 1. Milia-like cysts and pigmented pseudofollicular openings diagnose this pigmented seborrheic keratosis. 2. Irregular globules and blotches, polymorphous vessels, and regression characterize this melanoma. 3. The absence of pigment network, arborizing vessels, plus pigmentation diagnoses this basal cell carcinoma. 4. This pattern of pigmentation and vessels can be found in a basal cell carcinoma or melanoma. 5. Leaf-like structures are present throughout this lesion.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-4c
❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 3,4
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■ ■
■
■
■
■
Arborizing vessels (red arrows) Irregular grayish-white blotches (black arrows) Follicular openings inside the lesion (yellow arrows) Follicular openings outside the lesions (yellow boxes) Pseudofollicular openings (white arrows) Bony-white color (stars)
■
■
■
■
■
■
An experienced dermoscopist can easily make the diagnosis. A less-experienced dermoscopist should evaluate all of the criteria found in the lesion with full knowledge of their definitions. Melanoma is in the differential diagnosis because of the irregular blackishgray blotches and diffuse bony- white color (regression). White color is commonly found in basal cell carcinomas and does not represent true regression. Pinpoint; irregular linear and other irregularly-shaped telangectatic vessels (polymorphous vascular pattern) are absent. The dermoscopic differential diagnosis of the large pseudofollicular opening includes ulceration. Ulceration is much more commonly found in basal cell carcinoma than in melanoma. Arborizing vessels are not found in seborrheic keratosis.
PEARLS ■
■ ■
■
■
There are innumerable shapes and sizes of pigmentation that can be found in basal cell carcinomas. One has to only determine if pigment is present or absent. Adjectives (ie, ovoid, leaf-like) describing the shape of pigmentation are not needed. The irregular grayish-black blotch at the superior pole fits the definition of a “leaf-like” structure, yet it has no resemblance to a leaf. This is an inaccurate concept that is written and taught, which should be abandoned.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-5a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-5b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
(Reprinted, with permission, from Stolz W, Braun-Falco O, Bilek P et al. (2002) Color Atlas of Dermatoscopy. Second Edition. Blackwell Publishing, Oxford.)
CASE 5 HISTORY This previously long-standing asymptomatic lesion suddenly became raised and tender, but only for a few days. The patient’s primary care physician was concerned about the sudden change and thought it was a skin cancer. 1. 2. 3. 4.
This is the classic clinical and dermoscopic picture of an inflamed molluscum contagiosum. This collision tumor consists of a squamous and basal cell carcinoma. Arborizing vessels and regression characterize this melanoma. Arborizing “basal cell-like” vessels and whitish-yellow globules characterize this typical sebaceous gland hyperplasia. 5. Basal cell carcinoma is in the clinical and dermoscopic differential diagnosis of sebaceous gland hyperplasia.
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38
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-5c
❑ ❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
ANSWERS Answers: 4,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
Basal cell-like vessels (black arrows) Sebaceous globules (yellow arrows) Follicular openings (red arrows)
■
■
■ ■
■
This is a classic clinical and dermoscopic sebaceous gland hyperplasia. The yellowish-white globules would not be seen in a basal cell carcinoma. By definition “crown” or “wreath-like” vessels said to characterize sebaceous gland hyperplasia surround and penetrate the lesion, but never reach the center. It is not necessary to adhere to this strict definition because it is rarely found in typical lesions. “Crown” or “wreath-like” vessels are poor terms that should be abandoned. Basal cell-like vessels in any distribution plus sebaceous globules make the diagnosis. Molluscum contagiosum typically presents with a clear papule that has a central dell. ■ Irregular whitish globules filling a lesion and peripheral linear vessels along the border have been reported.
PEARLS ■
■
The dramatic and worrisome short-lived change was created by an isolated pimple that coincidentally developed under the long-standing sebaceous gland hyperplasia. In general, it is not always necessary to rush into making a histopathologic diagnosis in a changing lesion when the change is of a short duration and the etiology of the change not clear.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-6a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-6b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 6 HISTORY A 64-year-old ski enthusiast with a history of many sunburns presented with a nonhealing lesion on his nose. 1. 2. 3. 4. 5.
This featureless lesion is of no concern. This feature-poor lesion does not have enough criteria to diagnose a basal cell carcinoma. Foci of asymmetrical follicular pigmentation are an important clue that this is a melanoma. Milia-like cysts, pink and gray color diagnose this irritated seborrheic keratosis. This feature poor melanoma has asymmetry of color and structure, asymmetrical follicular pigmentation, pink and gray color, polymorphous vessels, and ulceration.
39
40
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ❑ ✔ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-6c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 2,3,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■ ■
■ ■ ■ ■
Asymmetry of color and structure Follicular openings (arrows) Asymmetrical follicular pigmentation (boxes) Diffuse pinkish color Grayish-white color (black stars) Polymorphous vessels (circle) Ulceration (yellow star)
■
■
■
This lesion is feature-poor not featureless. Feature-poor means that the important criteria are present but not welldeveloped and easy to identify. Clinically one suspects a basal cell carcinoma but the ulceration is not enough to make that diagnosis. Asymmetrical follicular pigmentation is the most specific criteria to diagnose a melanoma. The polymorphous vessels (ie, pinpoint, linear) could easily be missed if too much pressure is applied with instrumentation.
PEARLS ■ ■ ■
■
Pink color should always be a red flag for concern in any lesion. “If there’s pink, stop and think.” If one has to spend too much time thinking about what is going on, it is time to make a histopathologic diagnosis. This diagnosis was a big surprise!
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-7a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-7b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 7 HISTORY A 39-year-old woman was concerned about a strange-looking spot on her face that did not wash off with soap. 1. 2. 3. 4. 5.
This is a typical make-up tattoo that should be treated with a laser. This could only be a melanocytic lesion because it has a pigment network. Lentigines and dermafibromous are nonmelanocytic lesions that can have a pigment network. Branched streaks and irregular globules diagnose this in situ melanoma. The black stellate macule seen clinically and thickened, branched black pigment network diagnose this classic ink-spot lentigo.
41
42
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
2-7c
❑ ❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑
ANSWERS Answers: 3,5
Discussion: ■ ■
■
DERMOSCOPIC CRITERIA ■
■
Thick, branched pigment network (arrows) Regular dots (circle)
■
■ ■
The diagnosis of an ink-spot lentigo can usually be made clinically. Look for high risk criteria so that you do not miss an ink-spot lentigo-like melanoma. The criteria seen here are not the ones used to diagnose in situ melanoma on the face (ie, asymmetrical follicular pigmentation, annular-granular structures, rhomboid structures, circle within a circle). Follicular openings that one expects to find on the face are not found in every patient. The dot-like structures represent remnants of the pigment network. Not all skin lesions with a pigment network are melanocytic (ie, lentigo, dermatofibroma).
PEARLS ■ ■
■
Ink-spot lentigines can be associated with a history of excessive sun exposure. A complete skin examination should be performed to look for more high risk pathology (ie, skin cancer). Complete skin examinations should be performed on all patients at the time one deems appropriate.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-8a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-8b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 8 HISTORY A 45-year-old man noticed the appearance of a new spot on his face that was getting darker. 1. Clinically and dermoscopically this could be an ink-spot lentigo. 2. The absence of a thick black branched pigment network should raise a red flag for concern that his might not be an ink-spot lentigo. 3. The irregular black blotch, irregular globules, and foci of blue-white color characterize this in situ melanoma. 4. This is too small to be a melanoma; therefore the high risk dermoscopic picture should be ignored. 5. The isolated pseudofollicular opening, milia-like cysts, and sharp demarcation diagnose this small seborrheic keratosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-8c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,2,3
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
Irregular black blotch (white star) Follicular openings (red arrows) Pseudofollicular opening (white arrow) Irregular dots (white circles) Blue-white color (black arrows)
■
■ ■
■
The history and dermoscopic picture are worrisome. An ink-spot lentigo might look like this dermoscopically. However, without the prominent pigment network it falls out of the range of a classic lesion. One has to create a dermoscopic differential diagnosis for the round white structures (ie, milia-like cysts vs follicular openings). Milia-like cysts and pseudofollicular openings can be seen in melanoma. This entire picture warrants a histopathologic diagnosis even if it is in a cosmetically sensitive area. Melanomas can start as a speck and remain less than 6mm for long periods of time.
PEARLS ■
■
■
■
Destructive therapy without a positive histopathologic diagnosis could be disastrous. If after destructive therapy without a previous histopathologic diagnosis a lesion like this recurs, a histopathologic diagnosis should now be made posthaste. “Melanoma incognito” aka false negative melanoma can mimic benign or other malignant lesions. “Melanoma incognito” can clinically and/or dermoscopically mimic seborrheic keratosis, vascular lesions, basal cell carcinoma combined, recurrent, Spitz, blue and dysplastic nevi, actinic keratosis, or solar lentigines.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
2-9a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-9b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 9 HISTORY There is only a two-month-history of this asymptomatic pigmented skin lesion on the ear of a 30-year-old man. 1. 2. 3. 4.
This is a melanocytic lesion because there are multiple brown globules. This is the typical dermoscopic appearance of a secondarily infected wound. This is an atypical Spitzoid global pattern because there are foci of irregular streaks. Asymmetry of color and structure, irregular globules, irregular streaks, an irregular black blotch plus regression characterizes this melanoma. 5. An atypical Spitzoid pattern seen with dermoscopy does not always correlate with a “Spitzoid” melanoma histopathologically.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-9c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,3,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■ ■
■
Asymmetry of color and structure Irregular dots and globules (circles) Irregular streaks (black arrows) Irregular black blotch (white star, white arrows) Regression (black star)
■
■
■
■ ■
A regular/good/low risk Spitzoid pattern, aka “Starburst” pattern, can have streaks and/or dots and globules at most points along the periphery of the lesion. An atypical Spitzoid pattern can have foci of streaks and/or dots and globules at some points along the periphery of the lesion. There are only streaks connected to the irregular black blotch which fits the definition of irregular streaks. Inter-observer agreement among experienced dermoscopists is not always good and another clinician might not agree that this is an atypical Spitzoid global pattern. The grayish-white regression area fills half of the lesion. “Spitzoid” dermoscopic patterns are not always Spitzoid histopathologically.
PEARLS ■ ■
■
■
■ ■
Even regular Spitzoid patterns can be seen in melanoma. All lesions with this pattern of criteria should be removed no matter how old or young the patient. There would not be a good dermoscopic–pathologic correlation if the histopathologic report was that of a benign lesion. Speak with your pathologist about the asymmetrical dermoscopic appearance of the criteria. A reevaluation of the specimen might be indicated. Do not hesitate to ask for another histopathologic opinion with a pigmented-lesion expert if there is not a good dermoscopic–pathologic correlation.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-10a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-10b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 10 HISTORY During a routine total body skin examination, this pigmented skin lesion was found on the scalp of an 83-year-old woman. 1. 2. 3. 4.
The clinical and dermoscopic differential diagnosis includes a seborrheic keratosis. The clinical and dermoscopic differential diagnosis includes an ulcerated basal cell carcinoma. The clinical and dermoscopic differential diagnosis includes invasive melanoma. The dermoscopic differential diagnosis of the irregular brown color includes irregular blotch vs ulceration. 5. The absence of arborizing vessels rules out a basal cell carcinoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑ 1 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
1
2-10c
❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,3,4
Discussion:
DISPOSITION
■
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular dots and globules (white boxes) Irregular grayish-black blotches (yellow arrows) Ulceration (white arrows) Regression (yellow stars)
■ ■ ■
■
■ ■
■
■
Strict analysis of the criteria favors the diagnosis of a melanoma. ■ Globules identify a melanocytic lesion: ■ Basal cell carcinomas can have pigmented globular-like structures that cannot be differentiated from the dots and globules of a melanocytic lesion. ■ Asymmetry of color and structure ■ Multicomponent global pattern ■ Irregular dots and globules ■ Irregular blotches ■ Regression Basal cell carcinomas do not always have arborizing vessels. Basal cell carcinomas do not always have pigment. Some of the grayish-black blotches fit the definition of “leaf like” structure, yet none look like any type of leaf! Spoke-wheel structures, which are not seen here, might be the only clue to diagnose a basal cell carcinoma. It is not always possible to be 100% sure of global patterns and local criteria. One has to be able to create a dermoscopic differential diagnosis for global patterns and local criteria. The multicomponent global pattern (three or more different areas within a lesion) is not diagnostic of melanoma. The multicomponent global pattern can be seen in melanocytic, nonmelanocytic, benign, and malignant lesions.
PEARLS ■
■
■
■
In this case, dermoscopy has been clinically helpful. Clearly this is not a seborrheic keratosis that needs no intervention. Even though one cannot be sure if this is a basal cell carcinoma or melanoma, we know that a histopathologic diagnosis is indicated. It is essential to be familiar with all of the classic examples of global patterns and local criteria. One will need that knowledge to be able to create a dermoscopic differential diagnosis when the occasion arises. Regularly one has to think in terms of dermoscopic differential diagnosis.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-11a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-11b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 11 HISTORY While washing this seven-year-old girl’s hair, her mother found this asymptomatic spot on her scalp. 1. 2. 3. 4. 5.
More than 50% of this lesion demonstrates regressive changes pathognomonic of a melanoma. There are no clues to differentiate hypopigmentation from regression in this lesion. Gray color and foci of “peppering” are the criteria to diagnose the regression in this lesion. The more regression in a lesion, the greater the chance it is a melanoma. Irregular dots and globules, irregular blotches, plus regression characterize this dysplastic nevus.
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50
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-11c
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ❑ ✔ Histopathologic diagnosis
ANSWERS Answers: 3,4,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■ ■ ■ ■
Irregular dots and globules (boxes) Irregular blotches (black arrows) Regression (star) Gray color (white arrows) Peppering (circles)
■
■
■ ■ ■ ■
■
Regression is not diagnostic of melanoma. Regression-like areas can be seen in melanocytic, nonmelanocytic, benign, and malignant lesions. The more regression, the greater the chance of high risk pathology (ie, dysplastic nevi, melanoma). It is not possible to differentiate this severely dysplastic nevus from a melanoma using dermoscopy. One might not be able to differentiate hypopigmentation from true regression. The white color of regression should be lighter than the surrounding skin. Gray color indicates that melanin is in the papillary dermis. The fine granules of “peppering” represent free melanin and/or melanophages in the papillary dermis. Gray color and “peppering” are found in regression not in hypopigmentation.
PEARLS ■ ■ ■
■
■
■ ■
The identification of regression is a red flag for concern. Proceed with focused attention and look for other high risk criteria. In this age group, and in this location, one would expect to find a globular pattern with regular dots and globules. There is not a good clinico-dermoscopic correlation—another red flag for concern. Not all scalp nevi in children need to be excised, especially if they have a banal clinical and dermoscopic appearance. The scalp is a common location to find dyspalstic nevi in children. It is essential to include the scalp in a complete skin examination.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-12a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-12b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 12 HISTORY A first-year-dermatology resident found this small pigmented lesion after a complete skin examination in a pediatric dermatology clinic. The parents had not been aware of it. 1. 2. 3. 4.
Regular dots and globules characterize this classic cobblestone pattern. Irregular dots and globules are one important feature of this dysplastic nevus. The multifocal hypopigmentation seen here is a site-specific criterion just found in the scalp. Asymmetry of color and structure, irregular dots and globules, and hypopigmentation characterize this dysplastic nevus. 5. Asymmetry of color and structure, irregular dots and globules, regression, and a milky-red area characterize this dysplastic nevus.
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52
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2-12c
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
Asymmetry of color and structure Irregular dots and globules (circles) Regression/whitish gray color (white arrows) Milky-red area/pink color (box)
■
■ ■
■
■ ■
As in Case 11, there is not a good clinico-dermoscopic correlation here A red flag for concern. One would expect to see the globular or cobblestone global pattern with regular dots and globules or larger, angulated globlules. Dots and globules with different sizes and shapes, scattered throughout the lesion are considered irregular by definition. The grayish-white area of regression is widespread. Multifocal hypopigmentations, not found here, would be one criterion commonly found in dysplastic nevi. There are no site-specific criteria found only on the scalp that are not found elsewhere on the body. The milky-red area does not contain out-of-focus, globular-like structures. In this case, the milky-red area is nonspecific and is not indicative of melanoma.
PEARLS ■ ■ ■
■
■
Do not be surprised to find nevi in the scalp of children. Do not be surprised to find atypical dermoscopic criteria in this location. In this case if the pathology report was not at least a dysplastic nevus, there would not be a good dermoscopic–pathologic correlation. When one does not have a good dermoscopic–pathologic correlation, speak with your pathologist. When one does not have a good dermoscopic–pathologic correlation, consider getting a pigmented-lesion expert pathologist’s opinion.
Chapter 2
Scalp, Face, Nose, and Ears
RISK
2-13a
❑ Low ❑ Intermediate ❑ High
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-13b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 13 HISTORY A 78-year-old female had a basal cell carcinoma excised 8 years ago from her scalp. There is now a new lesion adjacent to the surgery scar. 1. 2. 3. 4. 5.
This recurrent basal cell carcinoma is filled with typical arborizing vessels. This melanoma is filled with pinpoint and cork screw vessels. This lesion is filled with hairpin vessels. Hairpin vessels and gray color characterize this irritated seborrheic keratosis. At times, it may be challenging to accurately categorize small vessels but an attempt always helps.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
2-13c
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 3,4,5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■ ■ ■ ■
Classic hairpin vessels (black boxes) Nonperfect-shaped hairpin vessels (yellow boxes) Pinpoint vessels (circles) Linear vessels (red boxes) Gray color (black arrows) Brown color (yellow arrows)
■ ■
■ ■
Clinically, but not dermoscopically, this appears to be a basal cell carcinoma. Arborizing vessels are not seen anywhere. Basal cell carcinomas do not always have classic arborizing vessels. This lesion is filled with classic and not-so-classic hairpin vessels. There are no thick, irregular hairpin-shaped vessels that can be found in melanoma. The grayish color is the clue that there is inflammation. The brown color and pinpoint vessels have no diagnostic significance.
PEARLS ■ ■
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■
A recurrent basal cell carcinoma after so many years would be unusual. A new primary basal cell carcinoma may happen to arise coincidentally in the same area. None of the specific shape designations given to vessels are pathonomonic of any specific pathology. Inter-observer agreement on the exact shape of blood vessels within a given lesion might vary with the personal experience of the individual. Polarizing instrumentation, ultrasound gel/hand cleaning gel, and minimal pressure should be applied to better visualize small vessels.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-14a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-14b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 14 HISTORY A mother was worried about an enlarging growth by the right ear of her six-year-old child. 1. Clinically and dermoscopically this could be an amelanotic melanoma. 2. Clinically and dermoscopically this could be a Spitz nevus. 3. Different shades of pink color and polymorphous vessels are diagnostic of this amelanotic melanoma. 4. One can see pinpoint, linear, and hairpin vessels. 5. A vascular pattern in a pink lesion is one of the sub-types of Spitz nevi.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-14c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,2,4,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■ ■ ■ ■ ■ ■
Different shades of pink color White color Linear vessels (black arrows) Pinpoint vessels (boxes) Hairpin vessel (yellow arrow) Milia-like cyst (circle)
■
■ ■ ■ ■ ■
Amelanotic melanoma is a common subtype in this age group. Different shades of pink color and centrally-located vessels are commonly found in amelanotic melanoma, yet are not diagnostic. There are six dermoscopic patterns seen in Spitz nevi: starburst, globular, homogeneous, reticular/black pigment network, vascular, and atypical. All of the patterns can be seen in children. This lesion demonstrates the vascular pattern. Absence of pigment and vessels creates the pink color. The milia-like cyst has no diagnostic significance. Structures identical to milia-like cysts can represent mucoid degeneration and can be seen in melanomas.
PEARLS ■ ■ ■
Dermoscopy is more sensitive and specific to diagnose pigmented lesions. Classic patterns and their variations are commonly found in Spitz nevi. Pink lesions in any age group should raise a red flag for concern.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
2-15a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-15b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 15 HISTORY An 80-year-old female with a history of recurrent lentigo maligna on the right side of her face developed a new blue papule by her left ear. 1. This could be a de novo melanoma characterized by irregular blotches, blue-white color, and regression. 2. This could be a heavily pigmented basal cell carcinoma without arborizing vessels and ulceration. 3. Commonly, basal cell carcinomas have such extensive pigmentation. 4. Uncommonly, basal cell carcinomas have such extensive pigmentation. 5. Without arborizing vessels and spoke-wheel structures, one cannot diagnose a basal cell carcinoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-15c
❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,2,4
Discussion: ■
DERMOSCOPIC CRITERIA ■ ■ ■
Ulceration (yellow arrows) Bluish-white color (stars) Purplish color (red arrows)
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
With strict adherence to the definitions of the dermoscopic criteria, it is not possible to differentiate a basal cell carcinoma from melanoma. The bluish-white color has a dermoscopic differential diagnosis. Found in basal cell carcinomas and melanomas. Islands of pigmented basal cell carcinoma cells. Deep dermal heavily pigmented atypical melanocytes. The irregular dark color has a dermoscopic differential diagnosis. Ulceration vs irregular blotches. Blotches representing heavily pigmented atypical melanocytes. The reddish color represents vascularization. Most basal cell carcinomas are not so heavily pigmented. The minority of basal cell carcinomas (10 %) have spoke-wheel structures. Basal cell carcinomas do not always have arborizing vessels.
PEARLS ■ ■ ■
In general it is not always possible to be 100% sure of a given diagnosis. Be prepared to create a dermoscopic differential diagnosis. Err on the side of the most aggressive pathology when planning your surgical approach.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-16a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-16b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
y
CASE 16 HISTORY A barber found this lesion on the scalp of a 61-year-old man. 1. Compared to Case 15, this basal cell carcinoma is easier to diagnose because there are classic arborizing vessels. 2. A bluish-white veil and irregular blotches plus corkscrew vessels characterize this melanoma. 3. Arborizing vessels are always thick and branch at 90° angles. 4. Typically the arborizing vessels seen in basal cell carcinomas are in-focus because they are located on the surface of the lesion. 5. In or out-of-focus arborizing vessels can also be found in melanomas.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-16c
❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION
ANSWERS
❑ No intervention ❑ Follow-up ❑ ✔ Histopathologic diagnosis
Answers: 1,4,5
DERMOSCOPIC CRITERIA ■ ■ ■ ■
Arborizing vessels (black arrows) Ulceration (yellow arrows) Bluish-white color (stars) Brown color (white arrows)
Discussion: ■
■
■ ■ ■
■ ■ ■
■ ■ ■
There are no criteria to diagnose a melanocytic lesion (ie, pigment network, globules), unless one considers the default category. ■ The foci of ovoid brown color are not a criterion that can be used to diagnose a melanocytic lesion. Arborizing vessels plus ulceration are the two major criteria to help make the diagnosis. Thick and thin bored arborizing vessels are classic. The vessels are very thin in this lesion. Arborizing vessels can also be found in melanomas but much less frequently than in basal cell carcinomas. Out-of-focus vessels should raise a red flag for concern. Out-of-focus arborizing vessels favor a diagnosis of melanoma. It is not necessary to use a protractor to determine the angles of branching vessels. Angles are not of diagnostic significance. The “classic” bluish-white veil is not present. Blue and white colors are commonly found in basal cell carcinomas.
PEARLS ■
■
The stool quaic test can be used to differentiate an ulceration with blood from an irregular melanocytic blotch, which would not contain heme. At any location on the body, do not hesitate to cut off some hair to get a better view.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-17a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-17b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 17 HISTORY This 88-year-old woman has a biopsy proven basal cell carcinoma under a dark plaque. Clinically, both lesions seem to be connected. 1. 2. 3. 4.
Leaf-like structures fill the pigmented component of this basal cell carcinoma. Asymmetrically pigmented follicular openings are plentiful. A few rhomboid structures can be identified. Irregular blotches with and without follicular openings indicate dermal invasion in this melanoma. 5. Extensive regression characterizes this heavily pigmented basal cell carcinoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2-17c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 2,3,4
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
■
■
Follicular openings (yellow arrows) Asymmetrical follicular pigmentation (black arrows) Rhomboid structures (yellow box) Irregular blotch with follicular openings (black box) Irregular blotch without follicular openings (stars) Irregular dots and globules (yellow circles) Areas of regression (white arrows) Polymorphous vessels (red circles)
■
■
■
■
■
■
Clinically and dermoscopically, this is an obvious invasive melanoma. The first step in the progression of melanoma on the face is represented by asymmetrical follicular pigmentation. ■ The follicular openings should not be confused with milia-like cysts seen in seborrheic keratosis. The next step in the progression of melanoma on the face is the formation of rhomboid structures. True “rhomboid” forms (parallelogram with unequal angles and sides) are not necessary. Any pigmented thickening that surrounds follicular openings should be considered “rhomboid” structures. The irregular black blotch with follicular openings is the first sign of dermal invasion. The irregular black blotch without follicular openings represents complete obliteration of follicular openings indicating further dermal invasion. By definition, this is a collision tumor, representing a basal cell carcinoma and melanoma.
PEARLS ■ ■ ■
One does not need dermoscopy to realize that this is high risk pathology. The diagnosis of melanoma on the face is not always this easy. Dermoscopy is essential to help make the diagnosis in most cases of early lentigo maligna, which offers the patients their best chance for survivial.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-18a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-18b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 18 HISTORY Over the past few months this asymptomatic pigmented skin lesion on a 74-year-old man has been increasing in size and getting darker. 1. Milia-like cysts and pseudofollicular openings characterize this seborrheic keratosis. 2. The irregular blotch and areas of regression are important clues that this could be a melanoma. 3. The multicomponent global pattern, asymmetry of color and structure, irregular dots and globules, and an irregular blotch plus regression characterize this melanoma. 4. Multiple follicular openings are not identifiable. 5. Based on the history, clinical, and dermoscopic appearance, sequential digital dermoscopic monitoring is indicated rather than a biopsy.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK 1
❑ Low ❑ Intermediate ✔ High ❑
3 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-18c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 2,3,4
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular dots and globules (circles) Irregular black blotch (yellow arrows) Regression (white arrows) Peppering (box) Follicular openings (black arrows)
■
■ ■ ■
■
The history, clinical, and dermoscopic picture are worrisome. There are no criteria to diagnose a seborrheic keratosis. The irregular black blotch could be seen in a heavily pigmented seborrheic keratosis. The typical site-specific and melanoma-specific criteria from the face are not seen. ■ Asymmetrical follicular pigmentation ■ Annular-granular structures ■ Rhomboid structures ■ Circle within a circle The regression area is not seen clinically. The regression area consists of blue and white colors plus peppering. One can expect to see multiple follicular openings on the face which are not seen here. Follicular openings can be found outside of the lesion on normal skin.
PEARLS ■
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■
A large dark pigmented lesion on the face should always raise a red flag for concern. A large facial lesion could be a congenital melanocytic nevus, solar lentigo, or melanoma. The absence of criteria that favor low risk pathology (ie, fingerprint pattern) should raise a red flag for concern. If the expected site-specific criteria are absent, use the pattern analysis algorithm for the trunk and extremities or an algorithm of your choice to evaluate the lesion.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
2-19a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-19b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 19 HISTORY A total body skin examination was performed on this 70-year-old man at his first visit with a new dermatologist. The patient was not aware of the lesion on his right ear lobe that the dermatologist found. 1. This is a classic pigmented seborrheic keratosis that does not need dermoscopic evaluation. 2. In order not to miss melanoma incognito, aka false negative melanomas, one should routinely examine lesions that do not look atypical clinically. 3. Asymmetry of color and structure, irregular dots, globules and blotches, asymmetrical follicular pigmentation and regression characterize this melanoma. 4. Symmetry of color and structure, regular dots and globules, and blotches characterize this small congenital melanocytic nevus. 5. The dramatic asymmetric follicular pigmentation should raise a red flag for concern.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-19c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION
ANSWERS
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Answers: 2,3,5
Discussion: ■
■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
■
Asymmetry of color and structure Follicular openings (white arrows) Asymmetrical follicular pigmentation (black arrows) Asymmetrical follicular pigmentation units (white boxes) Irregular dots and globules (circles) Irregular dark blotches (black boxes) Regression (stars)
■ ■
■
■
■ ■
The clinical differential diagnosis includes a seborrheic keratosis or melanoma. This would be an unusual location for both pathologies. The fingerprint pattern, milia-like cysts, and pseudofollicular openings used to diagnose a seborrheic keratosis are absent. The asymmetrical follicular pigmentation units are dramatic. One should not confuse the follicular openings with milia-like cysts of a seborrheic keratosis. One infers that there is regression based on the clinical appearance of the lesion. The regression areas are not well developed because the color is not whiter than the surrounding skin. Gray color and “peppering” are absent. Criteria can be present yet do not always fit into the exact definitions given to them.
PEARLS ■
■ ■
■
On the face, nose, and ears, it is not always easy to identify the high risk criteria. It is essential to learn the definitions of the site-specific criteria. It is essential to have a color atlas of dermoscopy images, in your mind, of the important criteria. Focus your attention and make a careful search for the melanoma-specific criteria.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-20a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-20b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 20 HISTORY A 74-year-old man has this spot on his face, which has not changed for many years. 1. “Moth-eaten” convex borders and pseudopigment network, aka pseudonetwork, characterize this solar lentigo. 2. “Moth-eaten” concave borders, pseudonetwork, remnants of a fingerprint pattern, and homogenous color characterize this solar lentigo. 3. The pigment network and pseudonetwork are both created by elongated hyperpigmented rete ridges. 4. The pseudonetwork is found only on the face, nose, and ears, and diagnoses melanocytic lesions. 5. The pseudonetwork can be seen in melanocytic and nonmelanocytic lesions.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-20c
❑ ❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
ANSWERS Answers: 2,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■ ■
■ ■ ■
Sharp border demarcation Concave “moth-eaten” borders (black arrows) Pseudonetwork (boxes) Homogeneous color (stars) Remnants of the fingerprint pattern (white arrows)
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The criteria to diagnose melanoma are not seen. Typically, solar lentigines have sharp borders. Typically, solar lentigines have concave borders, said to resemble a moth-eaten garment, known as “moth-eaten borders.” The pigment network found on the trunk and extremities is created by elongated hyperpigmented rete ridges and is not usually seen on the face, nose, or ears. Follicular and other appendageal openings that penetrate areas of pigmentation create the pseudonetwork. The terms pseudonetwork and pseudopigment network are used interchangeably. The fingerprint pattern made up of fine, light brown, parallel line segments resembling finger prints differs from the honeycomb-like line segments of the pigment network. Well developed or fragments of the fingerprint pattern are commonly seen. ■ In this case the fragments of the fingerprint pattern are very difficult to see and could be easily overlooked.
PEARLS ■
■
■
Despite common teaching, there is no evidence to substantiate that the pseudonetwork is a primary criterion to diagnose melanocytic lesions. The pseudonetwork is site-specific and can be seen in melanocytic and nonmelanocytic lesions. One has to identify other criteria to make a diagnosis once the pseudonetwork is identified.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-21a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-21b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 21 HISTORY The pigmented skin lesion on the face of this 8-year-old boy was scheduled for excision by a plastic surgeon, under general anesthesia, after the patient was referred by a pediatric dermatologist. The dermatologist thought that it looked atypical clinically and there was a history of change. The lesion was never examined with dermoscopy. 1. Asymmetry of color and structure, irregular dots and globules characterizes this dysplastic nevus. 2. Nodular melanoma is in the clinical and dermoscopic differential diagnosis. 3. Minimal asymmetry of color and structure, foci of pseudopigment network, and heavy pigmentation characterize this small congenital melanocytic nevus. 4. Asymmetry of color and structure are commonly seen in congenital melanocytic nevi. 5. A history of change in a nevus is not always high risk, especially in a child.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-21c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
ANSWERS Answers: 3,4,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
Asymmetry of color and structure Appendageal openings (arrows) Pseudopigment network complex (homogeneous color and appendageal openings) Regular dots and globules (boxes)
■
■ ■ ■
Clinically and dermoscopically this is not high risk. Asymmetry of color and structure are commonly found in congenital melanocytic nevi of all sizes. Other experienced dermoscopists might not agree that there is asymmetry of color and structure. The pseudopigment network is easy to identify and expected in this location. The terms appendageal and follicular openings can be used interchangeably. At first blush, this lesion is similar to Case 18 however, there are no welldeveloped melanoma-specific criteria.
PEARLS ■ ■ ■
The majority of pigmented skin lesions in children are not high risk. Unnecessary surgery can be avoided in most children if dermoscopy is used. No child should ever have a pigmented skin lesion biopsied or removed before it is examined with dermoscopy.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-22a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-22b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 22 HISTORY A 65-year-old man was referred by another dermatologist to evaluate this lesion with dermoscopy to determine if it should be biopsied. This history of the lesion is not known by the patient. 1. Clinically and dermoscopically a solar lentigo and in situ melanoma are in the differential diagnosis. 2. There are no high risk dermoscopic features in this solar lentigo. 3. The linear tracks and globules diagnose a melanoma. 4. Linear tracks and linear globules can be seen in benign and malignant pathology. 5. The “peppering” seen in this lesion indicates that there is a component of trauma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High 1
4
DIAGNOSIS
2
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
2-22c
❑ ❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑
ANSWERS Answers: 1,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular linear globules (yellow box) Irregular linear lines aka train tracks (arrows) Irregular thick network (black box) Peppering (white box)
■ ■
■ ■
■
Most solar lentigines on the lips have a banal dermoscopic appearance (ie, homogeneous brown color, fine parallel lines). It is not always possible to differentiate a solar lentigo from in situ melanoma clinically and with dermoscopy. In such situations a biopsy is indicated. Several distinct patterns of criteria can be seen on the lips and in genital mucosa (nonglabrous skin): ■ Regular or irregular linear globules ■ Parallel lines of globules sometimes creating a “fingerprint” pattern ■ Single thin or thick lines ■ Two parallel lines the “train track” pattern ■ Multiple parallel line segments another “fingerprint” pattern ■ Thin or thick network-like structures “Peppering” indicates trauma unless other high risk criteria are seen. Asymmetry of color and structure, a multicomponent global pattern, and irregular criteria should raise a red flag for concern. Blue-white color, dark irregular blotches, ulceration, and polymorphous vessels not identified here can be seen in invasive melanoma.
PEARLS ■
■
■
■
In this location surgery can be avoided in most cases after a banal picture is seen with dermoscopy. Avoiding surgery and the formation of potentially raised scars that can be very annoying to the patient, is an important benefit of dermoscopy. In gray-zone lesions sequential digital clinical and dermoscopic monitoring can be used. The most atypical dermoscopic area should be used for an incisional biopsy.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-23a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-23b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 23 HISTORY This 57-year-old man’s main complaint was a slowly enlarging spot on his nose. 1. Arborizing telangiectases must always be present to diagnose a basal cell carcinoma on the nose. 2. The vessels in this lesion fall within the range of vessels that can be seen in basal cell carcinomas. 3. Blue, black, gray, brown, red, and white colors can be seen in basal cell carcinomas. 4. Asymmetry of color and structure, multiple colors, dots and globules, plus telangiectatic vessels characterize this pigmented basal cell carcinoma. 5. Pigment network, ovoid nets of blue pigment, ulceration, spoke-wheel structures, plus arborizing vessels are the criteria used to diagnose basal cell carcinomas.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION 2-23c
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 2,3,4
DERMOSCOPIC CRITERIA ■
■
■ ■ ■
■
Asymmetry of color and structure Nonarborizing telangiectatic “basal cell–like” vessels (black arrows) Blue globules (yellow arrows) Brown dots and globules (circle) Multiple colors—brown, blue, white Appendageal openings (red arrows)
Discussion: ■ ■
■
■
■
■ ■
Classic thick and thin arborizing vessels are not always found. On occasion, pinpoint, hairpin, linear, kinked, and other shaped telangiectatic vessels can be seen with or without arborizing vessels. The classic description of pigmentation that can be found in basal cell carcinomas includes: large gray-blue ovoid nests, gray-blue dots and globules, and leaf-like structures. Be aware that there are innumerable variations of size and shape of the pigmentation found in basal cell carcinomas. The absence of a pigment network helps to differentiate this from a melanoma. Pigment network is not seen in basal cell carcinomas. In order to diagnose a basal cell carcinoma there must not be a pigment network.
PEARLS ■
■
■
■
It is important to learn the definitions of the types of pigment that can be found in basal cell carcinomas. It is not essential to perfectly fit pigmentation into the specifically defined shapes and colors. If one follows the definition of how leaf-like structures should look, one will realize that they never look like any type of leaf! The concept of leaf-like structures is a misnomer that should be abandoned.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-24a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-24b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 24 HISTORY A 71-year-old man’s barber found this asymptomatic lesion on his scalp. 1. Multiple brown globules categorize this as a melanocytic lesion. 2. The multicomponent global pattern and asymmetry of color and structure are significant red flags for concern. 3. Irregular dots and globules and a large irregular black blotch are more reason for concern. 4. The blue-white and gray colors of regression points in the direction of a melanoma. 5. Even though streaks and polymorphous vessels are absent, this still could be a melanoma.
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RISK ❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ❑ ✔ Histopathologic diagnosis
2 3 4
2-24c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■ ■
■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3,4) Irregular dots and globules (circles) Irregular black blotch (stars) Regression (arrows)
■ ■
■
It is essential to include the scalp in a total body skin examination. Criteria used to diagnose benign pathology are not seen (ie, cobblestone pattern, milia-like cysts, brain-like pattern). Superficial spreading and nodular melanoma are typically found on the scalp. One should have a systematic check list of criteria that need to be identified. Go over the checklist with each lesion: ■ Step 1: Is the lesion melanocytic or nonmelanocytic? If the lesion is melanocytic: ■ Step 2: To determine if it is low, intermediate, or high risk using the algorithm of your choice. If using pattern analysis: ■ Step 3: What is the global pattern? ■ Step 4: Is there symmetry or asymmetry of color and structure? ■ Step 5: Identify the local criteria and determine if they are regular or irregular, good or bad, low or high risk. ■ Step 6: Put everything together and make a dermoscopic diagnosis. Do not make a dermoscopic diagnosis before identifying all of the criteria in a lesion.
PEARLS ■ ■
■
Bright light is essential for a good scalp examination. The entire scalp should be carefully checked when doing a complete skin examination. The sooner the checklists are memorized, the sooner one is on their way to becoming a well-organized dermoscopist.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
2-25a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-25b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 25 HISTORY A 77-year-old man was not aware of the pigmented lesion on his ear. 1. There are multiple asymmetrically pigmented follicular openings. 2. There are foci of rhomboid structures. 3. The irregular black blotches with and without follicular openings indicates dermal invasion of this lentigo maligna melanoma. 4. The irregular black blotches without follicular openings represents the “black lamella” indicating this pigmented lesion is benign. 5. If one has good eyesight and can perform a biopsy, dermoscopy is not helpful to diagnose lentigo maligna and its variants.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2-25c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
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■
Asymmetry of color and structure Follicular openings (red arrows) Asymmetrical follicular pigmentation (black arrows) Irregular black blotch with follicular openings (white arrows) Irregular black blotch without follicular openings (yellow arrows) Rhomboid structures (white boxes)
■
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■ ■ ■ ■
Clinically, but not dermoscopically, this could be a seborrheic keratosis or melanoma. There are no dermoscopic criteria to diagnose a seborrheic keratosis (ie, milia-like cysts, pseudofollicular openings, fingerprint pattern). The “black lamella” could look like this—a black homogenous blotch with a glazed look. The “black lamella” created by pigmented parakeratosis is not seen in melanoma. Tape stripping often removes the “black lamella.” Tape stripping will not remove the irregular black blotch in this melanoma. By now the diagnosis should be relatively easy. There are many faces of melanoma and the diagnosis will not always be so easy.
PEARLS ■
■
■
One should memorize the criteria that are needed to diagnose lentigo maligna and lentigo maligna melanoma. One should have images of the classic examples of the high risk criteria cemented in their minds. Focus ones attention to make the diagnosis.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-26a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-26b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 26 HISTORY A 76-year-old man has several gray scaly spots on his face that are sensitive to touch. 1. The clinical impression of a melanoma with regression is supported by the dermoscopic picture. 2. The gray pseudonetwork seen here is created by confluent annular-granular structures. 3. Annular-granular structures can be seen in pigmented actinic keratosis, lichen-planus keratosis, and lentigo maligna. 4. Annular-granular structures are the only criterion that is 100% diagnostic of lentigo maligna. 5. Multiple scaly lesions favor a diagnosis of pigmented actinic keratosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-26c
❑ ❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 2,3,5
Discussion: ■
DERMOSCOPIC CRITERIA ■ ■
■ ■
Follicular openings (arrows) Annular-granular structures (circles) Gray pseudonetwork (box) Brown color (star)
■
■ ■ ■
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Annular-granular structures are created by fine gray or brown dots that surround follicular openings. When gray they can represent melanophages and/or free melanin or atypical melanocytes. Annular-granular structures can be localized or diffuse. Confluent annular-granular structure creates the gray pseudonetwork. The differential diagnosis in this case includes: pigmented actinic keratosis, lichen planus keratosis, and lentigo maligna. Clinical sensitivity often expressed by patients favors the diagnosis of pigmented actinic keratosis. Diffuse “peppering” and remnants of an actinic/solar lentigo or flat seborrheic keratosis (fingerprint pattern) are characteristic of a chronic long standing lichen planus-like keratosis.
PEARLS ■
■
■ ■
Pigmented actinic keratosis and solar lentigines can be associated with lentigo maligna. Look for other criteria associated with lentigo maligna before making a final diagnosis of a pigmented actinic keratosis. Use the most atypical area for an incisional biopsy. A rough scaly pigmented area is a clue that a lesion with this dermoscopic picture is a pigmented actinic keratosis.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-27a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-27b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 27 HISTORY A 68-year-old man has an asymptomatic spot on his nose that was discovered by his wife. 1. 2. 3. 4. 5.
This barely visible tan macule does not warrant dermoscopic examination. Multiple milia-like cysts and pseudofollicular openings diagnose a seborrheic keratosis. Asymmetry of color and structure are a red flag for concern. Asymmetrical follicular pigmentation is another red flag for concern. For cosmetic reasons this lesion could be treated with liquid nitrogen without a biopsy.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-27c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 3,4
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■
Asymmetry of color and structure Different shades of brown and gray color Follicular openings (black circles) Asymmetrical follicular pigmentation (boxes) Irregular globules (yellow circle) Poorly defined border (black arrows)
■ ■
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■
■ ■ ■
Compared with all of the cases with the same diagnosis, the dermoscopic picture is not dramatic. One should not confuse the follicular openings with milia-like cysts of a seborrheic keratosis. The overall picture is that of an irregular pseudonetwork. A uniform pseudonetwork would be made up of light brown homogeneous color studded with monomorphous round follicular openings. There would not be asymmetrical follicular pigmentation. One must focus attention to find the asymmetrically pigmented follicular openings. Use the area with asymmetrically pigmented follicular openings if an incisional biopsy is performed. The criteria for a solar lentigo (fingerprint pattern) are absent. Poorly defined borders seen here do not favor a solar lentigo. Sharp concave “moth-eaten” border favors a solar lentigo.
PEARLS ■ ■
■
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■
Banal appearing pigmentation can represent lentigo maligna. Dermoscopy should not only be used to examine atypically pigmented skin lesions in order not to miss melanoma incognito. In this clinical scenario, an important clue is the absence of the fingerprint pattern. Immediately one should think this could be lentigo maligna and carefully search for the diagnostic criteria. This case points out the benefits of dermoscopy to diagnose early lentigo maligna. Use a Woods light to determine the extent of the pigmentation.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-28a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-28b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 28 HISTORY A 36-year-old woman has this brown spot on her face for a few years. It is asymptomatic and there is no history of change. 1. Different shades of brown and gray colors plus asymmetry of color and structure are a red flag for concern. 2. The uniform pseudonetwork rules out lentigo maligna. 3. There are only two asymmetrically pigmented follicular openings. 4. The light areas have a differential diagnosis that includes hypopigmentation, areas of inflammation, or regression. 5. Well developed “moth-eaten” borders and fingerprint structures diagnose a solar lentigo.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-28c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,3,4
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
■
Asymmetry of color and structure Different shades of brown and gray color Follicular openings (yellow boxes) Asymmetrical follicular pigmentation (black boxes) Irregular dots and globules (circles) Multifocal hypopigmentation (stars) Moth-eaten borders (arrows)
■
■
■ ■ ■
The dermoscopic picture is not perfectly banal appearing. A uniform pseudonetwork is not seen. One cannot determine if there are classic “moth-eaten” borders and sharp demarcation. There are only two asymmetrically pigmented follicular openings (a clue that this could be lentigo maligna) that even experienced dermoscopist might not see. The hypopigmented areas have a grayish tinge, which suggests that there is inflammation. True regression is not seen. Well-formed site-specific melanoma- specific criteria are absent. The irregular dots and globules are a minor criterion that has no diagnostic significance.
PEARLS ■
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■
Sequential short-term (3 months) digital clinical and dermoscopic monitoring would be one alternative to a biopsy in this cosmetically important area. One must be as knowledgeable as possible with difficult cases like this, in order to form a meaningful differential diagnosis. Look carefully for high risk criteria before making a benign dermoscopic diagnosis. Only subtle dermoscopic clues helped us diagnose this melanoma incognito in the form of lentigo maligna!
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-29a
DISPOSITION ❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 29 HISTORY A less-experienced colleague e-mails you this image and wants to know if you think a biopsy is indicated. A history and clinical image were not supplied. 1. 2. 3. 4. 5.
There are annular-granular structures. There is asymmetry of color and structure. There is asymmetrical follicular pigmentation. The borders are poorly defined. The differential diagnosis includes a pigmented actinic keratosis vs lentigo maligna.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2-29b
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
Asymmetry of color and structure Different shades of tan and gray colors Follicular openings (black arrows) Asymmetrical follicular pigmentation (boxes) Annular-granular structures (circles) “Moth-eaten” borders (red arrows)
■
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■
The striking dermoscopic findings are the annular-granular structures and asymmetrical follicular pigmentation. Once again there is an irregular pseudonetwork indicating the lesion is on the face. The annular-granular structures and asymmetrical follicular pigmentation are together in this lesion and are enough criteria to diagnose lentigo maligna. Interobserver agreement might be in conflict regarding the presence or absence of “moth-eaten” borders. Your advice to your colleague would include the differential diagnosis: pigmented actinic keratosis vs lentigo maligna. Your colleague should biopsy the area with annular-granular structures and asymmetrical follicular pigmentation.
PEARLS ■
■ ■
■
With knowledge and experience one can come up with a diagnosis, differential diagnosis, and plan without a history or clinical image just based on the dermoscopic picture. Make sure that your pathologist is a pigmented lesion expert. The histopathology of an actinic keratosis could be confused with lentigo maligna. If one thinks the lesion is a lentigo maligna but the biopsy reports an actinic keratosis biopsy another area.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-30a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-30b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 30 HISTORY Two dermatologists saw this lesion and said it was nothing to worry about. They did not examine it with dermoscopy. 1. 2. 3. 4. 5.
The roundish white structures could be milia-like cysts. The roundish white structures could be follicular openings. “Moth-eaten” borders diagnose a solar lentigo. Irregular dots and globules are a red flag for concern. Foci of asymmetrical follicular pigmentation are present.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Lentigo Maligna Solar Lentigo
ANSWERS Answers: 1,2,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
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■
■
Asymmetry of color and structure Different shades of brown color Follicular openings (black arrows) Annular-granular structures (circle) Asymmetrical follicular pigmentation (boxes) “Moth-eaten” borders (red arrows)
2-30c
DIAGNOSIS
■
■
■
■
■ ■ ■
A large solitary lesion on the face with different shades of brown color are the first red flags for concern. ■ Now is the time to focus one’s attention and look for high risk criteria associated with lentigo maligna. The differential diagnosis of the round structures includes follicular openings versus milia-like cysts. The entire picture is that of an irregular pseudonetwork filled with follicular openings. With foci of criteria associated with lentigo maligna, the “moth-eaten” borders are not enough to diagnose a large solar lentigo. Knowing that there is an association between solar lentigo and lentigo maligna was important in this case. Two biopsies were performed for academic reasons. The right side without any high risk criteria diagnosed a solar lentigo. The left side diagnosed lentigo maligna. ■ The biopsy was performed in the darker area where asymmetrical follicular pigmentation and annular-granular structures were seen with dermoscopy.
PEARLS ■
■
If one cannot differentiate a seborrheic keratosis from a melanocytic lesion based on the dermoscopy, look and palpate the lesion to help make the differentiation. Putting as much of the clinical picture together as possible is the best way to make the correct diagnosis.
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
2-31a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-31b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 31 HISTORY A 55-year-old man thought that a lesion on his forehead was getting darker. 1. Pseudofollicular openings, peppering, and remnants of the fingerprint pattern characterize this irritated seborrheic keratosis. 2. The gray pseudonetwork diagnoses a pigmented actinic keratosis. 3. Multiple circles within a circle are a red flag for concern and diagnose lentigo maligna. 4. Asymmetrical follicular pigmentation could be confused with circle within a circle structures. 5. Multiple milia-like cysts are enough to diagnose a seborrheic keratosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2-31c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 3,4
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■ ■
■
■
■ ■ ■
Asymmetry of color and structure Different shades of brown and gray color Hair shafts (black arrows) Follicular pigmentation (yellow arrows) Circle within a circle units (black boxes) Asymmetrical follicular pigmentation (white box) Fingerprint pattern (red box) Peppering (yellow box) Gray color (stars)
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At first blush, the striking asymmetry of color and structure and different shades of brown and gray color should be a red flag for concern. Annular-granular structures (atypical melanocytes) vs peppering (melanophages and/or free melanin) seen throughout the lesion is the differential diagnosis for the gray color—another red flag for concern Circle within a circle is a poorly studied unique structure composed of a central hair shaft and gray pigmentation (atypical melanocytes and/or peppering) that surround the hair shaft. ■ More work needs to be done to study this criterion to better delineate the histopathologic correlation. The differential diagnosis for the circle within a circle would be asymmetrical follicular pigmentation, pseudofollicular openings, and milia-like cysts. The central hair shaft differentiates the circle within a circle from follicular openings with pigmentation. A focus of well-developed fingerprint pattern (parallel line segments) makes the dermoscopic association of lentigo maligna and solar lentigo.
PEARLS ■
■ ■
■ ■ ■
The German philosopher Johann Wolfgang Goethe once wrote “One cannot see what one does not know.” (In German of course!) The concept of circle within a circle is not well known. Circle within a circle might be the only criterion seen to diagnose lentigo maligna. Mastering dermoscopy by “osmosis” cannot be done. Put in the time to learn as much dermoscopy as possible. The learning curve is steep!
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
2-32a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
2-32b1
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 32 HISTORY These two lesions were found on the forehead of a 70-year-old man with a history of actinic keratosis, basal, and squamous cell carcinoma.
LESION 1 1. Globules diagnose a melanocytic lesion. 2. Irregular pigmented pseudofollicular openings and milia-like cysts diagnose a seborrheic keratosis. 3. On close inspection there is significant asymmetry of color and structure. 4. The blue-white color and irregular dark blotches are a red flag for concern. 5. This could not be a melanoma because the typical site-specific and melanoma-specific criteria are not seen.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
2-32b2
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,3,4
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
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■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) vs Irregular cobblestone global pattern (irregular, large angulated globules) Irregular dots and globules (circles) Irregular blotches (star and yellow arrows) Blue-white color (white arrows) Asymmetrical follicular pigmentation (red arrows)
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At first blush this looks more like a seborrheic keratosis than melanoma. The irregular dots and globules could be confused with pigmented pseudofollicular openings characteristic of a seborrheic keratosis. A melanoma on the face with a cobblestone-like pattern is very unusual. ■ There are no well-developed site-specific and melanoma-specific criteria to diagnose this in situ melanoma. The bizarre-shaped blotches (yellow arrows) favor the diagnosis of irregular pseudofollicular openings of a seborrheic keratosis. The bluish-white color and large dark blotch could be found in a seborrheic keratosis. This difficult case could lead to a misdiagnosis of a seborrheic keratosis with the initiation of inappropriate destructive therapy before making a histopathologic diagnosis.
PEARLS ■
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■
This lesion points out the need for a differential diagnosis for global patterns, local criteria, and the potential diagnosis. If destructive therapy in a lesion like this is not successful, it is better to make a histopathologic diagnosis as soon as possible rather than carrying out additional blind destructive therapies. Dermoscopy is not a perfect technique. Don’t expect it to be!
Chapter 2
Scalp, Face, Nose, and Ears
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-32c1
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
LESION 2 1. 2. 3. 4.
The classic pseudonetwork diagnoses a solar lentigo. Ulceration and pigmentation characterize this basal cell carcinoma. Different shades of pink and brown are a red flag for concern. Several asymmetrically pigmented follicular openings are an important clue that this could be another melanoma. 5. This could be a feature-poor melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-32c2
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 3,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■ ■
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■ ■
Different shades of pink and brown color Regression (stars) Asymmetrical follicular pigmentation (yellow boxes) Irregular dots and globules (blaick box) Scale (red arrows) Ulceration (black arrows)
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■ ■
The pink color is the first clue of potentially high risk pathology. ■ “If there’s pink, stop and think !” Two completely different, melanomas in the same patient appearing side by side, is extremely unusual. Complete clinical and histopathologic separation rules out a single melanoma. The lesion is feature-poor because there are not well-defined high risk criteria. ■ This feature-poor pink lesion turned out to be an early invasive melanoma! The asymmetrically pigmented follicular openings could be missed even by the most experienced dermoscopist. Different shades of brown and especially pink color are clues to the seriousness of this lesion. The irregular dots and globules are a clue that the lesion is melanocytic. The ulceration was created by trauma.
PEARLS ■
■ ■
Even the most experienced dermoscopists routinely have difficult cases in which dermoscopy is inconclusive. It is a fact of life that everyone misses or misdiagnoses melanoma. Dermoscopists have a much better chance to avoid this unpleasant situation.
Chapter 3
Trunk and Extremities
General Instructions: You will find a list of True/False statements following each case history. Select any statements, which you believe to be true. There may be one, more than one or no true statements for any given case. Choose the correct risk, diagnosis and disposition for each case. Then, turn the page to find a detailed discussion and pearls for each case.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS 3-1a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-1b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 1 HISTORY A 32-year-old man has many small banal appearing nevi on his trunk and extremities. A nevus on his left arm looked different than the others. 1. 2. 3. 4. 5.
This is a melanocytic lesion because there is a pigment network. It has a reticular global pattern. There is symmetry of color and structure. A uniform, regular pigment network fills most of the lesion. Multifocal hypopigmentation and irregular pigment network diagnose a moderately dysplastic nevus.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-1c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION
ANSWERS
✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
Answers: 1,2,3,4
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
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■
Regular pigment network (black boxes) Irregular pigment network (white boxes) Multifocal hypopigmentation (black arrows)
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■
■
Melanoma is in the clinical differential diagnosis because there are slightly irregular borders, several dark colors, and it is an “ugly duckling.” One will not see the entire picture until the lesion is examined with dermoscopy. It could have looked much worse! The “ugly duckling” is a pigmented skin lesion that clinically and/or dermoscopically is different from the other lesions on a patient. An “ugly duckling” lesion is a red flag for concern; however, it is not always high risk. The dermoscopic picture seen here should give one reassurance that this is not a melanoma. By definition this is the reticular global pattern because the lesion is made up of pigment network. There are foci of irregular pigment network with broadened, branched, and broken up line segments. Irregular pigment network is not always associated with high risk pathology. Multifocal hypopigmentation and irregular pigment network can be found in dysplastic nevi. The hypopigmentaion could represent normal skin that commonly is found in melanocytic nevi. There are no well-developed melanoma-specific criteria, aka high risk criteria.
PEARLS ■ ■
■
■
If in doubt cut it out. With experience one will become less and less concerned with this entire clinical scenario. Digital clinical and dermoscopic monitoring for changes over time is a cutting-edge way to handle this case. An experienced dermoscopist would find this lesion perfectly banal appearing.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-2a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-2b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 2 HISTORY This asymptomatic pigmented skin lesion was found by a dermatologist while performing total body skin examination. 1. Compared to Case 1, the global dermoscopic picture is more worrisome. 2. There is definite asymmetry of color and structure. 3. Asymmetry of color and structure, irregular blotches, and foci of regression characterize this in situ melanoma. 4. This could be a dysplastic nevus characterized by asymmetry of color and structure, irregular pigment network, and multifocal hypopigmentation. 5. Skin markings traversing the lesion are creating the linear hypopigmentation.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-2c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
ANSWERS Answers: 1,2,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
Asymmetry of color and structure (+) Irregular pigment network (black boxes) Multifocal hypopigmentation (black arrows)
■ ■
■ ■
■ ■
Compared to Case 1 the global/overall dermoscopic picture is more worrisome. The irregular pigment network is more widespread than in Case 1. Linear hypopigmentation is commonly seen and is created by the normal skin markings that traverse the lesion. The bony-white color of regression is not seen. A banal acquired nevus and mildly dysplastic nevus are in this differential diagnosis. Melanoma is not in the clinical and dermoscopic differential diagnosis. Multiple similar appearing nevi are less worrisome than a single lesion that looks like this.
PEARLS ■
■
For the novice dermoscopist, digital clinical and dermoscopic monitoring for changes over time would be a cutting-edge way to handle this case. An experienced dermosopist might find this lesion perfectly banal appearing and find no need for follow-up.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-3a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-3b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 3 HISTORY The daughter of this 52-year-old woman noticed an “irregular mole” on her mother’s back. 1. Pigment network and globules identify a melanocytic lesion. 2. There is significant asymmetry of color and structure. 3. A regular pigment network, regular dots and globules plus regular dark blotches diagnose a congenital melanocytic nevus. 4. Asymmetry of color and structure, irregular dots and globules, irregular dark blotches, plus the suggestion of regression diagnose a melanoma. 5. One can tell by the colors and structures that this is not a deep melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2 2 3
3
3-3c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
1
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,2,4,5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
Asymmetry of color and structure (+) Multicomponent global pattern (1, 2, 3) Regular pigment network (black boxes) Irregular dots and globules (circles) Irregular dark blotches (black arrows) Regression (stars)
■
■ ■ ■
■ ■
■
Compared to Cases 1 and 2 the dermoscopic picture is worse. There are no irregular dark blotches in Cases 1 and 2. The presence of irregular dark blotches is a major red flag for concern. The asymmetry of color and structure, and irregular dark blotches but not the irregular dots and globules are the main high risk features in this lesion. It is debatable if true regression is present. The grayish color favors regression vs. hypopigmentation. The global pattern could also be described as reticular-homogeneous with foci of pigment network and homogeneous featureless dark color. In situ melanoma and a dysplastic nevus are in the differential diagnosis. In a flat or slightly raised lesion, the presence of local criteria (ie, pigment network, dots and globules) and light plus dark brown plus gray colors are all clues that this will not be a deep melanoma. These are all superficially located criteria. ■ Black color represents pigment in the epidermis. ■ In a nodular lesion, black color can be seen in deeply invasive melanoma ■ Light and dark brown color represents pigment at the dermal-epidermal junction. ■ Gray represents pigment in the papillary dermis. As a melanoma gets more invasive, local criteria tend to be less prominent and one see colors associated with a deeper location in the dermis (ie, blue, steel blue, pink, red).
PEARLS ■ ■
Clinically and dermoscopically, one can diagnose an in situ melanoma. With this information in hand, one can plan an excision with a 5mm border that would be adequate for an in situ melanoma, thereby getting the job done with one rather than typical two surgical procedures needed for most melanomas.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-4a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-4b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 4 HISTORY Two lesions catch your eye as potential melanomas when examining this patient. 1. 2. 3. 4. 5.
Pigment network and globules identify a melanocytic lesion. There is asymmetry of color and structure and the multicomponent global pattern. The pigment network, globules, and dark blotches are irregular. Regression fills the lower half of the lesion. Blue and/or white color represents another high risk criterion.
103
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
2 1
DIAGNOSIS 4
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
3-4c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■ ■ ■
Asymmetry of color and structure (+) Multicomponent global pattern (1, 2, 3, 4) Irregular pigment network (boxes) Irregular dots and globules (circles) Irregular dark blotches (white arrows) Blue-white color (stars) Regression (black arrows) Multiple colors
■
■
■
■
Step 1 is to determine if the lesion is melanocytic or nonmelanocytic. If melanocytic, Step 2 is to determine if it is high risk (ie, dysplastic nevus or melanoma). Pattern analysis: ■ What is the global pattern? ■ Is there symmetry or asymmetry of color and structure? ■ Identify all of the local criteria. ■ Are the local criteria regular or irregular? ■ Put everything together and make a dermoscopic diagnosis. This invasive melanoma has foci with overlapping of criteria (ie, irregular pigment network and irregular dark blotches, regression and remnants of fine pigment network, bluish-white color over brown color). Bluish-white color but not the classic “bluish-white veil” is present → a high risk criterion. The irregular dark blotches could be considered hyperpigmentation.
PEARL ■
If one wants to be thorough with the analysis of each lesion: ■ Memorize a checklist of things to look for. ■ Go over the checklist with every lesion. ■ Analyze all of the criteria in a lesion before making a diagnosis.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
3-5a1
3-5a2
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-5b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 5 HISTORY This was the other suspicious lesion found on back of the patient from the last case. 1. 2. 3. 4. 5.
Clinically but not dermoscopically this could be diagnosed as a seborrheic keratosis. Gray dots and globules diagnose a melanocytic lesion. Brown dots and globules diagnose a melanocytic lesion. Pinkish-white color and peppering characterize the area of regression. There are foci of polymorphous vessels; however, they are hard to differentiate from the peppering.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK 1
❑ Low ❑ Intermediate ✔ High ❑
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
ANSWERS Answers: 1,3,4,5
Discussion: ■
■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■ ■ ■
Asymmetry of color and structure (+) Multicomponent global pattern (1, 2, 3) Irregular brown dots and globules (black boxes) Regression (stars) Peppering (red boxes) Polymorphous vessels (circles) Hyperkeratosis (arrows)
3
3-5c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
■
■
■ ■
Brown, not gray, dots and globules are one criterion used to diagnose a melanocytic lesion. There are no criteria to suggest that this is a seborrheic keratosis. Regression fills most of the lesion. The gray dots and globules “peppering” plus the pinkish-white color make up the area of regression. Asymmetry of color and structure plus the multicomponent global pattern are easy to identify if one knows how they are defined. Foci of pinpoint and linear vessels (aka the polymorphous vascular pattern) are hard to differentiate from the peppering. ■ Gray color favors peppering vs. red color favoring pinpoint vessels. ■ Inter-observer agreement even among expert dermoscopists might differ on the best name for all of the small dots. ■ This brings up the concept of dermoscopic differential diagnosis. ■ Peppering with foci of vessels vs pure peppering without vessels. The hyperkeratosis has no significance. Putting everything together one could not diagnose anything other than a regressive melanoma.
PEARLS ■
■
■ ■ ■
One is obligated to examine most of the pigmented skin lesions in a patient with so many lesions. A good plan with such a difficult case is to have the patient return another day for a re-examination. Final conclusions should not be made hastily. This patient would benefit from total body photography. This patient would benefit from mapping out her nevi dermoscopically for sequential monitoring to look for significant changes over time.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-6a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-6b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 6 HISTORY This clinically banal looking nevus was found on the back of a 7-year-old girl. 1. 2. 3. 4. 5.
There isn’t a good clinico-dermoscopic correlation. Brown peripheral globules identify a melanocytic lesion. The asymmetry of color and structure is a red flag for concern. There are foci of markedly irregular pigment network. Asymmetry of color and structure, irregular pigment network, irregular dots and globules, multifocal hypopigmentation, and diffuse erythema characterize this dysplastic nevus.
107
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
1
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
3-6c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
Asymmetry of color and structure (+) Multicomponent global pattern (1, 2, 3) Irregular pigment network (boxes) Irregular dots and globules (circles) Multifocal hypopigmentation (stars) Diffuse erythema
■
■
■
■
■
■ ■
■
■
In this age group, a nevus that looks like this clinically should have a globular or cobblestone pattern with dermoscopy. Since it does not look so, there is not a good clinico-dermoscopic correlation → a red flag for concern. When there is not a good clinico-dermoscopic correlation, one should proceed with caution and look for high risk criteria. Peripheral dots and globules are routinely found in children and indicate an actively changing nevus. The peripheral dots and globules that can be seen in Spitz nevi would be more numerous. Sequential monitoring of a nevus with peripheral dots and globules will show that it enlarges over time. The pigment network is markedly irregular. ■ Foci are asymmetrically located. ■ They are irregularly pigmented, broken-up, branched and thickened. Diffuse erythema is commonly found in dysplastic nevi. Pressure with instrumentation blanched away the erythema revealing multifocal hypopigmentation. Multifocal hypopigmenation, not to be confused with regression, is commonly found in dysplastic nevi. This lesion is more benign than malignant looking with a typical pattern seen in dysplastic nevi.
PEARL ■
In order not to miss incognito lesions (ie, lesions that look banal clinically but not dermoscopically) such as dysplastic nevi, Spitz nevi, and melanoma: ■ Routinely examine with dermoscopy both banal and atypical appearing skin lesions.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-7a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-7b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 7 HISTORY This lesion was found on the hairy chest of a 56-year-old man. 1. 2. 3. 4.
Clinically and dermoscopically this is a typical benign appearing nevus spilus. Clinically and dermoscopically this could be a benign agminated nevus. Pigment network and globules identifies a melanocytic lesion. Irregular pigment network, irregular dots and globules, hyperpigmentation and areas of regression are the main features of this melanoma. 5. Islands of normal skin plus foci of regular pigment network and regular blotches characterize this benign congenital melanocytic nevus.
109
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-7c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 3, 4
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
Asymmetry of color and structure Irregular pigment network (boxes) Irregular dots and globules (circles) Irregular brown pigmentation (hyperpigmentation) Multifocal hypopigmentation (white arrows) Regression (stars)
■
■
■
The tan lentiginous background characteristic of a nevus spilus is not seen. Agminated nevi consisting of multiple grouped similar pigmented lesions remain in the clinical and dermoscopic differential diagnosis. ■ Agminated nevi have been reported in association with congenital, acquired, blue, and Spitz nevi. The prominent irregular pigment network and areas of regression are the main diagnostic features of this early invasive melanoma. The areas of regression are not whiter than the surrounding skin and do not contain “peppering.” ■ Criteria do not always conform to exact definitions. ■ Clinically regression is clearly apparent. The irregular dots and globules and hyperpigmentation are more high risk criteria that help make the diagnosis.
PEARLS ■ ■
■
■
■
Dysplastic nevi and melanoma can rarely develop in a nevus spilus. As a general rule, everything that one evaluates with dermoscopy should be categorized as being regular or irregular, good or bad, low or high risk. ■ There are no exceptions to this rule. It is essential to study images with the classic examples of all the important dermoscopic principles. Routinely one encounters variations of the classic morphology of global patterns and local criteria. Do not hesitate to cut away some hair if you need to get a clearer look in a hairy area.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-8a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-8b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 8 HISTORY A 70-year-old woman was concerned about this changing lesion on her left shin. 1. Historically and clinically, more so than dermoscopically, this is suspicious for a melanoma. 2. There are no dramatic high risk dermoscopic criteria. 3. The asymmetry of color and structure and a focus of an irregular pigment network are not high risk criteria. 4. Asymmetry of color and structure, irregular pigment network, and multifocal hypopigmentation are diagnostic of this dysplastic nevus. 5. Different shades of brown color are a red flag for concern.
111
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-8c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■ ■
■
Asymmetry of color and structures (+) Irregular pigment network (boxes) Irregular globules (circle) Multifocal hypopigmentation (stars) Different shades of brown color
■ ■ ■
■
This is a gray zone lesion that looks more benign than malignant. The history of change is very important. The clinical appearance is more worrisome than the overall dermoscopic picture. There are no dramatic melanoma- specific criteria. Clinically and dermoscopically this looks more like a dysplastic nevus. Different shades of brown are a red flag for concern. ■ Different shades of any color are a red flag for concern. Do not confuse areas of hypopigmentation with the bony-white color of regression.
PEARLS ■ ■
■ ■
The most experienced clinician could miss this in situ melanoma. Sequential clinical and dermoscopic monitoring can be used with gray zone lesions. Short-term monitoring → check again for changes in 3 to 4 months. Long-term monitoring → check again for changes in 6 months to a year.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
3-9a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-9b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 9 HISTORY A 64-year-old woman had a pigmented lesion on her left lower leg for several years that recently began to get bigger. 1. Pigment network and brown globules diagnose a melanocytic lesion. 2. There is significant asymmetry of color and structure as well as the multicomponent global pattern. 3. There is an irregular pigment network and irregular brown not red dots and globules. 4. The nodular component of this melanoma is amelanotic. 5. In a nodular lesion suspicious for melanoma, sequential digital monitoring is contraindicated.
113
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
1
RISK ❑ Low ❑ Intermediate ❑ ✔ High
2 1
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2
DISPOSITION
3
3-9c
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
DERMOSCOPIC CRITERIA ■
■
■
■
■
■ ■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Regular pigment network (yellow box) Irregular pigment network (black boxes) Irregular brown dots and globules (circles) Milky-red area (arrows) Amelanotic nodule (stars)
ANSWERS Answers: 1,2,3,4,5
Discussion: ■
■ ■
■
■
Compared with Case 8, melanoma-specific criteria are much easier to identify. This invasive melanoma is not mistakable for a benign lesion. Ask your pathologist to examine additional sections and reevaluate this case, if a benign lesion is reported. ■ Consider the opinion of a dermato-pathologist with special expertise in pigmented skin lesions if this is not reported to be a melanoma. ■ There should always be a good dermoscopic-pathologic correlation! This pinkish-white area has a dermoscopic differential diagnosis that includes regression or the amelanotic component of the melanoma. The milky-red area represents neovascularization.
PEARLS ■
■
■
A nodular lesion suggestive of a melanoma should be fully excised posthaste, allowing for pathologic examination of the entire lesion as well as tumor staging. Sequential monitoring is contraindicated in a nodular lesion that could be a melanoma. Even a short delay in making the diagnosis of a nodular melanoma could worsen the patient’s prognosis.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-10a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-10b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 10 HISTORY This asymptomatic lesion on a 24-year-old man was discovered by the patient who wanted to know what it was. 1. 2. 3. 4. 5.
This is a nodular amelanotic melanoma arising in a nevus. Milky-red areas and markedly atypical pigment network characterize this melanoma. This is a typical benign collision tumor consisting of a melanocytic nevus and hemangioma. Dermoscopy in general is not helpful to diagnose collision tumors. Benign and malignant pathology in any combination is possible in collision tumors.
115
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-10c
✔ ❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 3,5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■ ■
Regular pigment network (boxes) Homogeneous red color (stars) Lacunae (circles)
■
■ ■
■ ■
Collision tumors consist of two distinct pathologies within the same lesion. Collision tumors are commonly encountered. The most common tumors found in collision are: seborrheic keratoses, melanocytic nevi, hemangiomas, basal cell carcinomas, in situ and invasive squamous cell carcinomas, in situ, invasive amelanotic or pigmented melanoma. Triple collision tumors exist yet are not common (eg, basal cell carcinoma, seborrheic keratosis and clear cell acanthoma). Any combination is possible. Even though the pigment network is thickened and branched, it is uniform throughout → it is not considered an irregular pigment network. The lacuanae are visible but not well developed. Milky-red areas are in the differential diagnosis and consist of pinkish-white homogeneous color that can contain red and/or blue globular-like structures. ■ Hemanagiomas typically have sharp in focus vascular spaces. ■ Homogeneous red color along with lacunae can be seen. ■ Milky-red areas typically have out-of-focus/blurry globular-like structures. ■ At times this distinction cannot be made.
PEARLS ■
■
As a general rule, identify the criteria in a collision tumor and determine if they are regular or irregular just as you would do with a noncollision tumor. If there is any suggestion of high risk pathology → make a histopathologic diagnosis ASAP.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-11a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-11b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 11 HISTORY This lesion was found on the arm of a 52-year-old man. 1. This is a benign halo nevus characterized by a cobblestone pattern and surrounding white halo. 2. This is a benign halo hemangioma characterized by well-dermarcated lacunae and hypopigmentation. 3. The brown color of the lacunae-like structures is a clue that this might be a melanocytic lesion. 4. Clinically and dermoscopically, this could be a melanoma with halo nevus-like regression. 5. Brown, blue, gray, and white colors plus irregular vessels are clues that this is a melanoma.
117
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
1
❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS
2
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
1
ANSWERS Answers: 3,4,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■ ■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular brown globules (white boxes) Regression (stars) Gray color (black arrows) Irregular blue blotch (yellow box) Irregular vessels (red arrows)
1
3-11c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
■
■ ■
■
■ ■
A halo nevus is in the clinical and dermoscopic differential diagnosis. With an eccentrically located lesion and several high risk dermoscopic criteria, an invasive melanoma with halo nevus-like regression is a more likely diagnosis. The differential diagnosis of the tumor includes an irregular cobblestone pattern of a melanocytic nevus or lacunae-like vascular structures of a hemangioma. The brown color rules out a vascular lesion. Halo phenomenon can occur around melanocytic and nonmelanocytic lesions: ■ Congenital, acquired, dysplastic, blue, Spitz nevi, and melanoma. ■ Seborrheic keratosis, neurofibroma, basal cell carcinoma. ■ But not around hemangiomas. ■ a Vscular lesions typically have white color but within the lesion (fibrous septae). Cutaneous metastatic melanoma could have this dermoscopic picture with lacunae-like structures. Bony– white, blue, and gray color make up the area of regression. The fine gray granules (“peppering”) that can be seen in regression are not identified.
PEARLS ■ ■
■
■
A halo nevus-like lesion in an adult is melanoma until proven otherwise. Halo nevi can be found in children and in most cases are not high risk lesions. Halo phenomenon in a patient with a history of melanoma can be a clue that the patient has metastatic melanoma. One should search for irregular criteria before diagnosing a benign halo nevus.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-12a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-12b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 12 HISTORY This isolated lesion was thought to be high risk by the referring general practitioner, and was located on the back of a 34-year-old woman. 1. Milky-red areas and a blue-white veil characterize this nodular-melanoma. 2. Well-dermarcated vascular spaces, fibrous septa, and the absence of criteria seen in a melanocytic lesion characterize this classic hemangioma. 3. By definition, hemangiomas must have tightly spaced lacunae. 4. Bright red, violaceous, blue, and black colors can be found in hemangiomas. 5. Pyogenic granulomas can have similar lacunae-like structures and a white peripheral border.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-12c
❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,4
Discussion: ■ ■
■
DERMOSCOPIC CRITERIA ■ ■ ■
Lacunae (boxes) Fibrous septa (white arrows) Fibrous border (black arrows)
■
■ ■
■ ■
■
■
■ ■ ■
Clinically and dermoscopically this is a classic hemangioma. There are no criteria for a melanocytic → there should be no criteria for a melanocytic lesion. The main criteria are lacunae (aka saccules, lagoons). Lacunae → sharply demarcated, vary in size and distribution round to oval structures. Lacunae can be tightly packed or loosely distributed throughout the lesion. The color is determined by the location of vascular spaces in the dermis. ■ Bright red (cherry/senile hemangiomas) the vascular spaces are high up in the papillary dermis. ■ The deeper the vascular spaces, the darker the color (ie, darker shades of red, violaceous, blue). ■ Black color indicates thrombosis. Individual hemangiomas can have single or multiple colors. Bluish-white or white fibrous septa are commonly seen and should not be confused with the bluish-white or bony- white color found in melanomas. Milky-red areas in melanomas can have lacunae-like structures but the borders are not sharply demarcated. Pyogenic granulomas can have septa-like white lines in the lesion and at the periphery but lack lacunae. Angiokeratomas are hemangioma-like with varying amounts of scale or crust. Lymphangiomas have clear vascular-like spaces. Lymph-hemangiomas have a combination of clear and red vascular spaces.
PEARLS ■
■
It is essential to determine if the vascular spaces have sharp well-demarcated borders. It is essential to look for the criteria associated with melanocytic lesions (eg, melanoma).
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-13a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-13b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 13 HISTORY This is from the abdomen of a 19-year-old patient, and has been getting “scabby” over a 3-month period. 1. This nodular melanoma is characterized by an irregular black blotch, ulceration, and amelanotic milky-red areas. 2. A hemorrhagic crust, remnants of lacunae, and peripheral erythema characterize this thrombosed hemangioma. 3. This could be a partially thrombosed angiokeratoma. 4. A hemorrhagic crust is never found in nodular melanoma. 5. Black color in a vascular lesion represents thrombosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-13c
❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,3,5
Discussion: ■ ■
■
DERMOSCOPIC CRITERIA ■
■ ■
Hemorrhagic crust (aka thrombosis) (stars) Lacunae (white arrows) Peripheral erythema (black arrows)
■
■
■ ■
■
This is a worrisome gray zone lesion that could be a nodular melanoma. The lacunae and homogenous reddish color represent what is left of the hemangioma. Milky-red areas are in the differential diagnosis of the hemangioma component. The peripheral erythema could represent the amelanotic component of a nodular melanoma. The criteria seen here, point out the need for one to create a dermoscopic differential diagnosis. A pyogenic granuloma would not have such a large hemorrhagic crust. A thrombosed angiokeratoma could look like this especially since there are areas of yellow color that represents hyperkeratosis. Melanoma can have ulceration and crust formation.
PEARLS ■
■
■
If one has to spend abundant time thinking about what is going on, it is time to make a histopathologic diagnosis especially if nodular melanoma is in the differential diagnosis. A positive stool guaiac test might help differentiate the hemorrhagic crust (guaiac )+from a nonulcerated black blotch in a melanoma (guaiac −) The often dramatic jet-black color in thrombosed vascular lesions is as black as ever can be seen when using-dermoscopy, with the exception of the black lamella.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-14a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-14b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 14 HISTORY You were consulted because it was felt that this 16-year-old girl has a melanoma. 1. Pigment network and globules diagnose a melanocytic lesion. 2. The dark round structures could be irregular globules or thrombosed lacunae. 3. The reddish oval structures could represent lacunae of a hemangioma or the poorly defined globules seen in milky-red areas. 4. This melanoma is characterized by asymmetry of color and structure, a multicomponent global pattern, irregular pigment network, irregular globules, and a blue-white veil. 5. This thrombosed hemangioma is characterized by lacunae, thrombosed lacunae, and the bluish-white color created by hyperkeratosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
3 1 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2 3
3-14c
❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑
DISPOSITION
ANSWERS
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Answers: 2,3,5
Discussion: ■ ■
■
DERMOSCOPIC CRITERIA ■
■
■ ■ ■
■
■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Lacunae (black boxes) Thrombosed lacunae (arrows) Milky-red globular-like structures (white boxes) Network-like structures (yellow box) Bluish-white color (stars)
■
■
■ ■
■ ■
As in Case 13, the dermoscopic picture is not clear. The global pattern and local criteria have a differential diagnosis → vascular vs melanocytic. Several well-demarcated lacunae are an important clue that this is a vascular lesion. The presence of the lacunae suggests that the black round structures could be thrombosed lacunae rather than irregular globules of a melanocytic lesion. The milky-red globular-like structures are still lacunae→ lacunae do not always have sharp borders. The histopathologic correlate of the network-like structure is not known. Clinically, the lesion is dry and scaly → this creates the blue color seen by dermoscopy. Blue and/or white color is not always high risk and has a differential diagnosis. A multicomponent global pattern with three or more different areas within a lesion is not diagnostic of a melanoma and can be seen in benign and malignant pathologies (ie, congenital and dysplastic nevi or basal cell carcinomas).
PEARLS ■ ■
■
One cannot see what one does not know. Study hard to better serve your patients whose lives can depend on your correct dermoscopic diagnosis. There is a significant learning curve to become a competent dermoscopist.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-15a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-15b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 15 HISTORY A 63-year-old man has a growing lesion on his chest. 1. Pigment network and globules identify this melanocytic lesion. 2. There is asymmetry of color and structure plus a multicomponent global pattern. 3. There are foci of irregular pigment network, irregular dots and globules, irregular streaks, irregular pigmentation, and blue-white color. 4. Regression, milky-red areas, and polymorphous vessels are important high risk criteria that are not seen. 5. The differential diagnosis includes a dysplastic nevus or melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑ 1
3
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2
3-15c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION
ANSWERS
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Answers: 1,2,3,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■ ■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Irregular pigment network (black boxes) Irregular dots and globules (circles) Irregular streaks (yellow box) Irregular brown pigmentation Bluish-white color (stars)
■
■
■
The order of the questions is the order in which one should evaluate each lesion. ■ Step 1 → Is the lesion melanocytic or not? ■ Step 2 → Is there symmetry or asymmetry of color and/or structure? ■ Step 3 → What is the global pattern? ■ Step 4 → Find all of the local criteria (pigment network, dots and globules, streaks, blotches, regression, colors, vessels). ■ Step 5 → Determine if the local criteria are regular or irregular. ■ Step 6 → Double check to make sure you have not missed anything. ■ Step 7 → Could there be a dermoscopic differential diagnosis for the global pattern or any of the local criteria? ■ Step 8 → Put the entire clinical scenario together and make a diagnosis. ■ Step 9 → What is the best disposition for the lesion? The foci of irregular streaks are not that easy to identify in this invasive melanoma. One could consider the foci of irregular pigment network foci or irregular streaks. Different shades of brown and/or any other colors are a high risk criterion.
PEARLS ■ ■
Memorize all of the features one should look for in each case. Do not make a final diagnosis before you find and analyze all of the features in a lesion.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-16a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-16b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 16 HISTORY A 48-year-old man has a nonchanging brownish lesion in his left axilla for many years. 1. 2. 3. 4. 5.
Clinically but not dermoscopically this looks similar to the melanoma in Case 15. There are no criteria to diagnose a melanocytic lesion. There are no criteria to diagnose a basal cell carcinoma. Milia-like cysts and pigmented pseudofollicular openings characterize this seborrheic keratosis. Asymmetry of color and structures, a multicomponent global pattern, irregular globules, bluewhite veil, and regression characterize this melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-16c
DIAGNOSIS
ANSWERS Answers: 1,2,3,4
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■ ■ ■
■
■
DERMOSCOPIC CRITERIA ■ ■
■ ■
Milia-like cysts (black boxes) Pigmented pseudofollicular openings (arrows) Bluish-white colors (stars) Peppering (yellow box)
■
■ ■
■
■
■
■ ■
The history, if it is accurate, and clinical appearance are not high risk. The global dermoscopic appearance on the other hand is worrisome. Multiple milia-like cysts and pigmented pseudofollicular openings favor the diagnosis of a seborrheic keratosis. The differential diagnosis of the pigmented pseudofollicular openings includes irregular dots and globules of a melanocytic lesion. If one considers that this could be melanocytic then the asymmetry of color and structure, multicomponent global pattern, irregular dots and globules, blue-white and other colors are very worrisome. Milia-like cysts and pigmented pseudofollicular openings can be found in melanoma. Typically seborrheic keratosis can be heavily pigmented. The blue color in this benign lesion can be created by pigment deeper in the dermis similar to a blue nevus → the Tyndall effect. Peppering → gray color with fine gray dots indicates that there may be an inflammatory component (irritated seborrheic keratosis). The asymmetry of color and structure and multicomponent global pattern has no significance in nonmelanocytic lesions. A collision tumor, (eg, melanoma or nevus and a seborrheic keratosis), is in the differential diagnosis. This lesion should be very worrisome for the novice dermoscopist. One should always listen to the patient’s history. However, patient histories are not always reliable → in this case there was no history of change for many years.
PEARLS ■
■
■ ■ ■ ■
Commonly, pathology reports of melanomas have seborrheic keratosis as the primary diagnosis or seborrheic keratosis is in the differential diagnosis. Even the most experienced clinician could miss a seborrheic keratosis-like melanoma aka melanoma incognito → false negative melanoma. Atypical seborrheic keratosis can be impossible to differentiate from melanoma. Ask a more experienced dermosopist for their opinion with difficult cases. A consensus of minds is often the way to go with difficult cases. If in doubt, cut it out.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-17a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-17b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 17 HISTORY A 63-year-old man was in for a yearly skin examination, and this solitary pigmented lesion was found on his upper back. There is no other history. 1. 2. 3. 4. 5.
Pigment network identifies a melanocytic lesion. There is asymmetry of color and structure. There is a homogeneous reticular global pattern. The pigment network is irregular. The irregular pigmentation is a red flag for concern.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ✔ Follow-up ❑ ❑ Histopathologic diagnosis
3-17c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
Asymmetry of color and structure (+) Homogeneous—reticular global pattern Irregular pigment network (boxes) Irregular hyperpigmentation (stars) Background normal skin (arrows)
■
■ ■
■ ■ ■
■
One would expect to see this lesion filled with a regular pigment network → there is not a good clinico– dermoscopic correlation—a red flag for concern. Whatever the global pattern (eg, homogeneous—reticular; reticular—globular) one has to determine if the criteria are regular or irregular. By definition, the pigment network (reticular component of the global pattern) is irregular → thick, branched, broken up line segments. Irregular pigment network can be found in low risk nevi (eg, junctional nevi). The homogeneous darker color (homogeneous component of the global pattern) has a differential diagnosis that includes epidermal and/or dermal pigmentation with or without atypical melanocytes. The differential diagnosis of this lesion includes a nevus vs dysplastic nevus. Melanoma is not in the differential diagnosis. There would not be a good dermoscopic–pathologic correlation if this was thought to be a melanoma by the pathologist. Normal background skin is commonly found within a lesion and has no diagnostic significance → it must be differentiated from hypopigmentation or regression.
PEARLS ■
■
■ ■
Good communication with one’s pathologist is essential when there is not a good dermoscopic–pathologic correlation. A single lesion with this dermoscopic appearance is more worrisome than several lesions that look like this. For the novice dermoscopist → consider making histopathologic diagnosis. For the experienced dermoscopist → sequential digital monitoring.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-18a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 18 HISTORY A colleague e-mailed this image for your opinion of whether this could be a melanoma. It was located on the back of a 72-year-old man. 1. Pigment network identifies a melanocytic lesion. 2. Asymmetry of color and structure, a multicomponent global pattern, irregular pigment network, and irregular globules characterize this melanoma. 3. This is a classic fingerprint pattern often found in flat seborrheic keratosis. 4. A fingerprint pattern and nonpigmented pseudofollicular openings characterize this seborrheic keratosis. 5. Parallel line segments rather than honeycomb-like line segments differentiate the fingerprint pattern of a seborrheic keratosis from the pigment network of a melanocytic lesion.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-18b
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 3,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■ ■
■
Fingerprint pattern (boxes) Nonpigmented pseudofollicular openings (yellow arrows) Concave moth-eaten borders (black arrows)
■ ■
■
■ ■ ■ ■
This is a classic fingerprint pattern with brown parallel line segments that resemble the dermatoglyphics of the hand → fingerprints. ■ The differential diagnosis includes an early brain-like pattern also seen in seborrheic keratosis or an atypical pigment network. This pattern can be found in flat seborrheic keratosis or solar lentigines. There are multiple nonpigmented pseudofollicular openings that would not be seen in a solar lentigo. The nonpigmented pseudofollicular openings should not be confused with globules of a melanocytic lesion. The line segments of the fingerprint pattern can be seen throughout the lesion. There may only be remnants of a fingerprint pattern found in a lesion. There are no melanoma-specific criteria in this lesion. Once the definition of the fingerprint pattern is learned and one sees images of the pattern, it usually is easy to recognize.
PEARLS ■ ■
Caution! The fingerprint pattern can be associated with lentigo maligna. Look for high risk criteria throughout a lesion before diagnosing seborrheic keratosis or solar lentigo.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-19a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-19b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 19 HISTORY A 45-year-old man with signs of extensive sun damage has this pigmented skin lesion on his chest. 1. This could be a false negative dermoscopic melanoma because the clinical but not the dermoscopic appearance suggests a melanoma. 2. This is a solar lentigo with the fingerprint pattern and moth-eaten borders. 3. This is a melanocytic lesion because there is a pigment network. 4. Hypopigmentation filling the lesion rules out a melanoma. 5. Asymmetry of color and structure, a multicomponent global pattern, irregular pigment network, and regression characterize this invasive melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK 1
❑ Low ❑ Intermediate ✔ High ❑
2
2
2
DIAGNOSIS 1
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 3
3-19c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,3,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
Asymmetry of color and structure (+) The multicomponent global pattern (1,2,3) Regular pigment network (yellow boxes) Irregular pigment network (black boxes) Regression (stars)
■ ■
■ ■
■ ■ ■
The lesion looks worse clinically than dermoscopically. ■ It is not completely banal appearing dermoscopically. ■ It looks more benign than malignant dermoscopically. The clinical appearance overrides the dermoscopic picture. Regular pigment network with uniform line segments and holes (dermal papilla) can be contrasted with an irregular pigment network. The parallel lines of a fingerprint pattern are not seen. The areas of regression look more like hypopigmentation → they are inferred to be present because one sees regression clinically. ■ Hypopigmentation has no specific diagnostic significance. There are no dramatic melanoma- specific criteria. The differential diagnosis includes a dysplastic nevus or melanoma. This is a false negative dermoscopic melanoma.
PEARLS ■
■
■
■
■
When a lesion looks low risk clinically, a high risk dermoscopic appearance should not be ignored. When a lesion looks high risk clinically but not dermoscopically, the clinical appearance should not be ignored. In most cases, high risk looking lesions clinically will have a low risk dermoscopic appearance. With experience one will feel more comfortable handling all of these clinical scenarios. Gut feelings about the entire clinical scenario should never be ignored → if one has an uncomfortable feeling about a lesion it should probably be excised.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-20a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-20b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 20 HISTORY A 32-year-old man with a slowly growing pigmented lesion on his chest for many years is referred for your evaluation. 1. This medium sized congenital melanocytic nevus is characterized by regular pigment network, regular dots and globules, plus islands of normal skin. 2. The parallel fingerprint pattern helps to diagnose a traumatized flat seborrheic keratosis. 3. The clinical appearance, asymmetry of color and structure, regular pigment network, regular dots and globules, plus regression characterize this melanoma. 4. The clinical appearance, asymmetry of color and structure, a multicomponent global pattern, irregular pigment network, irregular dots and globules, plus regression characterize this invasive melanoma. 5. Clinically this could only be a melanoma and dermoscopic evaluation would not add useful information.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-20c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 4
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■ ■
■
■
■
Asymmetry of color and structure Multicomponent global pattern Irregular pigment network (black boxes) Fingerprint-like pigment network (yellow boxes) Irregular dots and globules (circles) Regression (arrows)
■ ■ ■
■
■
■
■
A medium-sized congenital melanocytic nevus and seborrheic keratosis are in the clinical, but not the dermoscopic differential diagnosis. It would be unlikely that a 32-year-old would have a solitary large seborrheic keratosis. There are no criteria to suggest this is a seborrheic keratosis. Congenital melanocytic nevi can have atypical dermoscopic features. Irregular criteria in a congenital melanocytic nevus should always raise a red flag for concern. The dramatic foci of parallel pigment network resembling the fingerprint pattern are only one criterion and not enough to diagnose a solar lentigo or seborrheic keratosis. All of the other melanoma-specific criteria must be taken into consideration. ■ Asymmetry of color and structure ■ Multicomponent global pattern ■ Irregular pigment network ■ Irregular dots and globules ■ Regression Dermoscopy adds essential information to confirm that this is a very high risk lesion. Dermoscopy rules out low risk pathology.
PEARLS ■ ■
One should use the areas with most atypical features for an incisional biopsy. Based on the clinical appearance and high risk dermoscopic criteria, one would be justified to completely excise this lesion without a preliminary biopsy even though it would create a big scar.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-21a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-21b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 21 HISTORY A 20-year-old woman was worried about a mole that was getting darker. 1. 2. 3. 4. 5.
Globules identify a melanocytic lesion. This could be the “mountain and valley” pattern of a seborrheic keratosis. This seborrheic keratosis is filled with pigmented pseudofollicular openings. Irregular dots and globules suggest that this is a changing dysplastic nevus or melanoma. This is the classic cobblestone global pattern of a banal nevus.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-21c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 1,2,5
Discussion: ■ ■ ■ ■
DERMOSCOPIC CRITERIA ■
■ ■
■
■
Symmetry of color and structure (+) Cobblestone global pattern Regular dots and globules (circles) Cobblestone globules (red arrows) Hypopigmented fissures (yellow arrows)
■
■
The history of a changing nevus is not always high risk. One expects nevi to change in children. Clinically and dermoscopically this is a banal lesion. This is the classic cobblestone global pattern: ■ Filled with large angulated brown globules resembling street cobblestones. ■ Smaller dots and globules can also be found. The clinical and dermoscopic differential diagnosis includes a seborrheic keratosis with a “mountain and valley” pattern. ■ Globules→ mountains ■ Fissures → valleys ■ There are no other criteria to diagnose a seborrheic keratosis → milia-like cysts, pseudofollicular openings, “fat fingers”, or hairpin vessels. An actively changing nevus typically has dots and globules only at the periphery of the lesion.
PEARLS ■
■
When the clinical and dermoscopic differential diagnosis is between a nevus and a seborrheic keratosis, look at and feel the lesion: ■ Soft and compressible→ nevus ■ Immovable dry and scaly → seborrheic keratosis A positive “wobble” sign (applying pressure with instrumentation [ie, Dermlite] and gentle side-to-side motion) helps diagnose a nevus → ■ A nevus will have a positive “wobble” sign with side-to-side movement of the lesion. ■ A seborrheic keratosis will have a negative “wobble” sign without any movement.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-22a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-22b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 22 HISTORY A 59-year-old woman with a history of melanoma returned for a routine skin examination. You notice that in general the color of her skin is unusual. 1. This is a classic example of cutaneous metastatic melanoma. 2. Globules identify a melanocytic lesion. 3. The jaundiced color of the lesion is a clue that the patient has metastatic melanoma to the liver. 4. The unusual color of the lesion is created by a self-tanner. 5. This is the cobblestone pattern of a benign nevus.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-22c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■ ■
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Cobblestone global pattern Symmetry of color and structure Cobblestone globules (black arrows) Fissures (yellow arrows) “Fat fingers” (white arrows)
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■ ■
Commonly, one encounters patients with a history of melanoma that still want to be tan. Patients that use self tanners can usually be easily recognized. Self tanners do affect what one sees with dermoscopy, although the changes are not significant. Once again as in Case 21 the differential diagnosis is between a nevus with a cobblestone pattern and a seborrheic keratosis with a “mountain and valley” pattern. Foci of small “fat fingers” favor a seborrheic keratosis. This case points out that “fat fingers” are not diagnostic of seborrheic keratosis and can be seen in melanocytic lesions.
PEARLS ■
■
Suggest to a patient that uses self-tanners that its use might adversely affect your dermoscopic examination. Try to get a feel if your patient has psychological issues related to the history of melanoma that might benefit from a psychological evaluation.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-23a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-23b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 23 HISTORY A 37-year-old pregnant woman developed multiple pigmented skin lesions during her 7th month of pregnancy. She was especially worried about this one. 1. 2. 3. 4. 5.
This could be the cobblestone pattern of a melanocytic nevus. This could be the fissure and ridge pattern of a seborrheic keratosis. Highly irregular hypopigmented globules and regression characterize this nodular melanoma. Without milia-like cysts one cannot diagnose a seborrheic keratosis. “Fat fingers,” nonpigmented pseudofollicular openings, fissures, crypts, and sharp border demarcation diagnose a seborrheic keratosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-23c
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 1,2,5
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
Discussion: ■ ■
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DERMOSCOPIC CRITERIA ■
■
■ ■ ■
■
Sharp border demarcation (red arrows) Nonpigmented pseudofollicular openings (yellow arrows) Fissures (white arrows) Crypts (stars) Ridges aka “fat fingers” (black arrows) Incipient seborrheic keratosis (blue arrow)
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This seborrheic keratosis is characterized by fissures and ridges. Several nonpigmented pseudofollicular openings should not be confused with globules of a melanocytic lesion. When the typical pseudofollicular openings expand into larger irregular keratin filled areas they are referred to as crypts. Crypts can be found in papillomatous nevi. Hypo or hyperpigmented ridges can be digit-like in shape and are referred to as “fat fingers.” ■ “Fat fingers” are commonly encountered. ■ “Fat fingers” can be straight, kinked, circular, or branched. ■ “Fat fingers” might be the only clue to diagnose a seborrheic keratosis. Seborrheic keratosis can be devoid of milia-like cysts. A melanocytic nevus could look exactly like this. Palpate the lesion to help differentiate: ■ A nevus will be soft and compressible while a seborrheic keratosis will be firm and not compressible. There is an independent small seborrheic keratosis seen clinically and with dermoscopy.
PEARLS ■
■
There are several misnomers in the dermoscopic language, which we think should not be used. ■ The “crown vessels” seen in sebaceous gland hyperplasia are defined as basal cell-like vessels at the border of the lesion that penetrate the lesion but never reach the center. Rarely will you see this distribution of vessels in typical sebaceous gland hyperplasia. ■ “Leaf-like” structures represent one type of pigmentation found in basal cell carcinomas that have finger-like projections said to look like a “maple leaf ” or be “leaf-like.” If one finds pigmentation in a basal cell carcinoma that fits this description it will never look like any type of a leaf. “Fat fingers” are not a misnomer because they are an excellent description of one morphologic variation of ridges.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-24a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-24b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 24 HISTORY On routine skin examination, this lesion was found on the back of a 28-year-old man. 1. Peripheral globules are seen clinically suggesting this could be a Spitz nevus. 2. This could be a dysplastic nevus characterized by irregular dots and globules and different shades of brown color. 3. Peripheral dots and globules indicate this could be an actively changing nevus. 4. Clinically and dermoscopically this could be a banal acquired nevus. 5. A symmetrical “Spitzoid” pattern may be found in melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-24c
DIAGNOSIS
ANSWERS Answers: 1,2,3,4,5
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■ ■ ■
■
DERMOSCOPIC CRITERIA ■
■ ■
■
Symmetry of color and structure (+) “Spitzoid” global pattern Irregular dots and globules (circles) Hypopigmentation (arrows)
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■ ■ ■ ■
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■
This is a melanocytic lesion because there are brown globules. These are irregular dots and globules because they are of different sizes and shapes. Globally this has a “Spitzoid” pattern because it resembles the “starburst” pattern. ■ There are peripheral globules without streaks. Any of the six dermoscopic pictures representing Spitz nevi are also referred to as being “Spitzoid.” ■ All “Spitzoid” lesions do not have a “starburst” pattern. ■ A symmetrical “Spitzoid” pattern is less worrisome than an irregular “Spitzoid” pattern. This is a symmetrical “Spitzoid” pattern because the dots and globules surround the entire lesion. The differential diagnosis includes: ■ Nevus ■ Spitz nevus (correct diagnosis) ■ Dysplastic nevus ■ Melanoma Even a symmetrical “Spitzoid” pattern could be found in melanoma. All “Spitzoid” lesions should be removed, especially in adults. When present, different shades of dark color are a red flag for concern. One should search carefully for other high risk criteria that might not be that easy to find. Peripheral dots and globules can be a clue of an actively changing nevus → it will enlarge over time. Inter-observer disagreement and decision-making in a lesion like this exist: ■ This is a perfectly banal appearing Spitz nevus. ■ This could be a symmetrical “Spitzoid” melanoma. ■ This is a banal lesion with peripheral globules that will change over time.
PEARLS ■
■
The history and clinical appearance of the lesion are very helpful to determine the disposition in this particular case. For the experienced dermoscopist, sequential digital follow-up is one alternative to excision.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-25a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-25b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 25 HISTORY A 45-year-old woman with a history of lentigo maligna on her face presented with this new pigmented skin lesion on her left anterior thigh. 1. Globules identify a melanocytic lesion. 2. There is significant asymmetry of color and structure plus a multicomponent global pattern. 3. Irregular pigment network, irregular globules, a focus of purplish-white color, and regression are all red flags for concern. 4. The lesion was excised and reported to be a dysplastic nevus which is a good dermoscopic– pathologic correlation. 5. Diagnosing this histopathologically as a dysplastic nevus is not a good dermoscopic– pathologic correlation.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
3-25c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,5
Discussion: ■
■
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
■
■ ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
■
■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Irregular pigment network (box) Irregular globules (circles) Different shades of homogeneous brown color Purplish-white color (black arrows) Regression (stars)
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■
This new, small pigmented skin lesion looks high risk clinically and with dermoscopy. The asymmetry of color and structure is striking and is an important red flag for concern → proceed with focused attention and look for other high risk criteria. The globules are also unusually large and asymmetrically located at the periphery, another red flag for concern. The focus of pigment network is unusually thick and irregular. The pigment network and irregular globules could be considered to be irregular streaks. ■ Whatever one decides these structures are, they are still atypical and high risk. The light color seen throughout has a differential diagnosis → hypopigmentation vs regression. Different shades of homogeneous brown color is another high risk criterion to put into the entire pattern analysis algorithm. The purplish -white color does not fit the description of a blue-white veil and could represent neovacularization. There would be no point to do an incisional biopsy on such a small lesion that clinically and dermoscopically could be a melanoma. A good dermoscopic– pathologic correlation: ■ The histopathologic diagnosis should correspond with your dermoscopic diagnosis. When there is not a good dermoscopic– pathologic correlation: ■ Speak with your pathologist. ■ Consider getting another dermato-pathologists opinion.
PEARLS ■ ■
■
There should always be a good dermoscopic– pathologic correlation. Having digital dermoscopic images of a potentially high risk lesion is the best way to go back and make sure that there is a good dermoscopic– pathologic correlation. Addendum: Initially the lesion was excised with clear margins. Based on a poor dermoscopic–pathologic correlation (histopathologic diagnosis was a dysplastic nevus), another histopathologic opinion was obtained with a pigmented lesion expert. The second opinion was that of an early invasive melanoma, which led to an appropriate re-excision. The patient is doing well 5 years post diagnosis.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-26a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-26b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 26 HISTORY A 47-year-old woman with a history of melanoma and multiple seborrheic keratosis developed this new lesion in the epigastric area. 1. 2. 3. 4.
Clinically and dermoscopically with “fat fingers” this looks like a seborrheic keratosis. Globules identify a melanocytic lesion. Large peripheral globules create a “Spitzoid” global pattern. Clinically and dermoscopically the lesion appears to be a seborrheic keratosis which is a good clinical– dermoscopic correlation. 5. A “Spitzoid” lesion in an adult is not a red flag for concern.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-26c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,3
Discussion: ■
■ ■
DERMOSCOPIC CRITERIA ■
■ ■ ■
Symmetry of color and structure (+) “Spitzoid” global pattern Irregular globules (arrows) Multifocal hypopigmentation (stars)
■
■
■
■
■ ■
This new lesion was less than 6 mm and looked like a seborrheic keratosis clinically. It was a surprise to see this dermoscopic picture. If it were not for the history that this was a new lesion, it might not have been examined with dermoscopy. To avoid missing high risk incognito lesions, one should routinely examine clinically banal appearing lesions. This was a clinically false negative high risk moderately dysplastaic nevus with atypical “Spitzoid” features histopathologically. This is an excellent example of a bad clinico-dermoscopic correlation → a red flag for concern. ■ The clinical and dermoscopic pictures do not match up well. Even though the globules are large, they do not look like “fat fingers.” ■ Inter-observer agreement even among expert dermoscopists is not always good. ■ Another dermoscopist might think that the globules do resemble “fat fingers.” Symmetry of color and structure can still be found in high risk pathology. The hypopigmentation has no significance and should not be confused with regression, which would be whiter.
PEARLS ■
■
■
It can be difficult for even an experienced dermato-pathologist to differentiate a benign “Spitzoid” lesion from a “Spitzoid” melanoma. Clarify with the dermato-pathologist if a benign “Spitzoid” lesion with atypical features is really not a melanoma. Several experienced dermato-pathologists might not be able to correctly diagnose a “Spitzoid” melanoma. ■ Consider sentinel node biopsy with atypical “Spitzoid” lesions if they have sufficient depth of invasion.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-27a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-27b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 27 HISTORY The pediatrician of this 5-year-old referred the patient for evaluation of a congenital melanocytic nevus that was getting bigger, and recently developed a few new dark spots. The patient’s mother was very worried. 1. Dots and globules identify a melanocytic lesion. 2. The dots and globules are more or less similar in size and shape, and symmetrically located throughout the lesion. 3. Asymmetry of color and structure, irregular dots and globules, and irregular blotches characterize this dysplastic congenital nevus. 4. Islands of normal skin and the globular pattern characterize this banal congenital nevus. 5. The presence of high risk criteria (eg, a multicomponent global pattern) in a congenital melanocytic nevus is always high risk.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-27c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS DISPOSITION
Answers: 1,2,4
❑ No intervention ✔ Follow-up ❑ ❑ Histopathologic diagnosis
Discussion: ■ ■
■ ■
DERMOSCOPIC CRITERIA ■
■ ■
■
■
■
■
Symmetry of color and structure Globular global pattern Regular dots and globules (circles) Hyperpigmented globules (black boxes) Islands of normal skin (black arrows) Perifollicular hypopigmentation (yellow boxes) Lanugo hairs (yellow arrows)
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■ ■
■
Clinically and dermoscopically this is a banal congenital melanocytic nevus. There is symmetry of color and structure → this pattern is seen throughout the entire lesion. There are uniform, regular dots and globules. Foci of darker color (hyperpigmentation) are routinely seen in congenital nevi and are not a sign of atypia. Islands of normal skin may or may not be found around hairs typically found in congenital nevi. ■ Perifolicular hypopigmentation Fine lanugo or thick dark terminal hairs are commonly but not always seen in congenital nevi. There are no high risk criteria in this lesion. High risk criteria (eg, irregular dark blotches or irregular bluish globules) would be a red flag for concern and a histopathologic diagnosis should be considered. It is expected that congenital melanocytic nevi will enlarge as this child grows.
PEARLS ■ ■
■
The management of congenital melanocytic nevi is controversial. Most authorities believe that they should either be excised or monitored to identify early changes of malignancy. Digital gross and digital dermoscopic imaging for sequential monitoring would be the cutting-edge way to follow any congenital melanocytic nevus → small, medium, or large. ■ Side-by-side comparisons of baseline and follow-up images could be made to look for important changes over time such as: ■ Asymmetrical enlargement ■ The presence of new high risk criteria ■ The presence of new colors ■ Regression ■ Disappearance of criteria
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-28a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-28b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 28 HISTORY Over the past 3 months this acquired pigmented skin lesion on the back of a 31-year-old woman got bigger. 1. A central white patch and peripheral pigment network characterize this dermatofibroma. 2. Regular pigment network, regular globules, and hypopigmentation characterize this small congenital nevus. 3. The irregular black blotch and regression are clues that this is a high risk lesion. 4. Regular pigment network, regular globules, symmetry of color and structure, plus a “Spitzoid” global pattern characterize this Spitz nevus. 5. Asymmetry of color and structure, a multicomponent global pattern, irregular pigment network, irregular dots and globules, an irregular black blotch and regression characterize this melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
1
❑ Low ❑ Intermediate ✔ High ❑ 2
3
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-28c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 3,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular pigment network (black boxes) Irregular dots and globules (circles) Irregular black blotch (yellow box) Regression (stars) “Peppering” (white boxes)
■ ■
■ ■
■
■
Clinically, one sees a persistent mark on the skin which is created by pressure from the instrumentation. This sign could mean: ■ This is an interesting case that many people looked at. ■ This is a difficult case that a novice dermoscopist spent a lot of time looking at. This is a melanocytic lesion because there is pigment network and globules. There are foci where the network and globules seem to be a unit → this is an unusual union. The area of regression is widespread and well developed. The lesion is more malignant then benign looking, and has a differential diagnosis → dysplastic nevus. The central patch of a dermatofibroma is not always centrally located but it is always bony– white, not gray, in color. This could not be a congenital nevus because it recently developed and the overall/global pattern would not be seen in a congenital lesion.
PEARL ■
If one needs too much time to figure it out, then it’s time to cut it out!
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-29a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-29b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 29 HISTORY A 50-year-old man was found to have this asymptomatic lesion on his left lower leg. 1. Pigment network and globules identify a melanocytic lesion. 2. Pigment network and central white patch diagnose a dermatofibroma. 3. The central white patch of this dermatofibroma is characterized by a negative pigment network (ie, white pigment network, reticular depigmentation) and homogenous white color. 4. Reticular depigmentation (white pigment network) can be found in dermatofibromas, Spitz nevi, and melanoma. 5. A white pigment network might be the only clue that a lesion is a melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-29c
❑ ❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,3,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
Regular pigment network (black boxes) Central white patch (black arrows) Reticular depigmentation (white boxes) Globular-like structures (yellow arrows) Pink color
■
■ ■
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■ ■
The pink color seen clinically and with dermoscopy represents diffuse erythema. Diffuse erythema and/or small vessels with different shapes (eg, pinpoint, linear, branched) are commonly found in dermatofibromas and are not high risk. Presence of a pigment network is not always diagnostic of a melanocytic lesion because it can also be seen in lentignes and dermatofibromas. The central patch of a dermatofibroma should be milky/bony–white. The central white patch in this lesion has two components: ■ Homogenous white color ■ Reticular white color→ reticular depigmentation, white network, negative pigment network, white pigment network. The globular-like structures are not true globules of a melanocytic lesion (ie, nests of melanocytes) but are created by the reticular depigmentation over a background of brown color. A reticulated central white patch is commonly found in dermatofibromas. A reticulated white pigment network can also be found in banal acquired nevi, Spitz nevi, and melanoma.
PEARLS ■
■
■
Typically, dermatofibromas have a characteristically firm feel on palpitation → use your fingers and touch the lesion in question. Look carefully for melanoma-specific criteria when there is a negative pigment network, so as not to miss a dermatofibroma-like melanoma. A reticulated white pigment network might be the only clue that a lesion is a melanoma.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-30a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-30b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 30 HISTORY A 38-year-old woman noticed a color change over a few week period in this pigmented lesion located on her left arm. 1. A central white patch and reticular depigmentation characterize this dermatofibroma. 2. An eccentric focus of reticular depigmentation is a clue that this night not be a dermatofibroma but a melanoma. 3. Globules identify a melanocytic lesion. 4. Asymmetry of color and structure, a multicomponent global pattern, multifocal hypopigmentation, and regular dots and globules characterize this mildly dysplastic nevus. 5. White and gray homogeneous colors plus “peppering” characterize the regression in this melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS 2
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
3-30c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 2,3,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular dots and globules (black boxes) Bony-white color of regression (black arrows) Gray homogeneous color of regression (yellow arrows) “ Peppering “ (yellow box) Reticular depigmentation (white arrows)
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■
This is a melanocytic lesion because there are brown globules. There is asymmetry of color and structure because: ■ The gray homogeneous color on the right side is not seen on the left side. ■ The gray homogeneous color seen in the lower half is not seen in the upper half. ■ Reticular depigmentation is mostly on the right side. ■ Dots and globules are just on the right side. The central white patch of a dermatofibroma is in the differential diagnosis of the bony-white color of regression. The white color should not be confused with hypopigmentation → It is too white. An absence of pigment network does not rule out a dermatofibroma → there are dermatofibromas without pigment network or central white patch. Homogenous gray color and the fine gray dots “peppering” are part of the regression. The large area of regression is much easier to see than the foci of reticular depigmentation.
PEARLS ■ ■
■ ■
Typically there is no history of change with dermatofibromas. The entire clinical scenario is important: ■ Personal and family history ■ History of the lesion ■ Clinical and dermoscopic features. Dermoscopy in a vacuum is not as helpful as knowing the whole story. Think differential diagnosis for local criteria and global patterns.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-31a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-31b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 31 HISTORY A 33-year-old woman recently noticed an irregularly shaped skin lesion on her left lower leg. There was no history of any changes. 1. Globules diagnose a melanocytic lesion. 2. Multifocal hypopigmentation, symmetry of color and structure, and regular dots and globules diagnose a benign nevus. 3. Clinically and dermoscopically, there is the suggestion of regression, a red flag for concern. 4. The absence of reticular depigmentation rules out a melanoma. 5. A multicomponent global pattern, asymmetry of color and structure, irregular dots and globules, regression and reticular depigmentation characterize this invasive melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2
3
ANSWERS Answers: 1,3,5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular dots and globules (circles) Regression (stars) Reticular depigmentation (boxes)
3-31c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
The reticular depigmentation is more widespread than in Case 30. Compared to Case 30 the regression is not bony-white. Multifocal hypopigmentation would be in the differential diagnosis of the areas of regression. ■ Gray color favors regression over hypopigmentation. ■ Hypopigmentation is light brown color and does not contain gray color. ■ Regression is observed clinically, which is a point in favor of regression over hypopigmentation.
PEARLS ■ ■
■
The important features could be missed if one is in a hurry. If there are clues that a lesion might be high risk, think to yourself slow down, focus your attention, and look carefully at the lesion. High risk criteria are not always easy to find (ie, reticular depigmentation) but might be the only clues to suggest the seriousness of a lesion.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-32a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-32b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 32 HISTORY A 63-year-old man had this lesion on his chest that has been getting bigger and darker over a 1 year period. 1. Clinically and dermoscopically, the eccentric pigmentation is diagnostic of a melanoma. 2. Peripheral pigment network and a black central white patch characterize a senile dermatofibroma. 3. The irregular pigment network and irregular black blotch are melanoma-specific criteria. 4. Symmetry of color and structure, regular pigment network, a regular black blotch, and regression characterize this melanoma. 5. Asymmetry of color and structure, a multicomponent global pattern, irregular pigment network, irregular black blotch, and hypopigmentation characterize this melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑ 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
1 3
3-32c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 3, 5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Irregular pigment network (boxes) Irregular black blotch (yellow arrows) Hypopigmentation (stars)
■
■
■
■
■
Pigment network identifies a melanocytic lesion. A black central white patch does not exist in dermatofibromas. To date senile dermatofibromas have not been reported. Eccentric criteria (eg, pigment network, dots and globules, blotches) are a red flag for concern. Eccentric criteria may or may not be high risk → melanoma-specific criteria. ■ One must determine if eccentric criteria are regular or irregular, low or high risk, good or bad. The black blotch is irregular because: ■ It is asymmetrically located. ■ There are different shades of dark color. ■ The borders are irregular. The pigment network is irregular because: ■ There are only a few foci of network. ■ The line segments are thick and branched. The hypopigmentation should not be confused with regression. ■ It is not bony-white ■ The hypopigmentation has no diagnostic significance.
PEARLS ■ ■
Eccentric criteria are a red flag for concern. Proceed with focused attention and analyze all of the criteria in the lesion.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-33a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-33b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 33 HISTORY A 24-year-old, fair-skinned, blue-eyed, red head with multiple banal appearing nevi was found to have this lesion on his abdomen. 1. 2. 3. 4. 5.
This is a melanocytic lesion by default. There is asymmetry of color and structure and a multicomponent global pattern. The differential diagnosis of the light area includes hypopigmentation or regression. The eccentrically located regular blue blotch is a red flag for concern. The dermoscopic differential diagnosis includes a banal nevus, combined nevus, or regressive melanoma.
161
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
1
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
4
3-33c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■ ■
DERMOSCOPIC CRITERIA ■
■
■ ■ ■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Regular blue blotch (box) Hypopigmentation (stars) Irregular dot and globular-like structures (circles) Irregular purplish-brown color Gray homogenous color (yellow arrows)
■ ■
■
■
■
Compared to Case 32, the entire picture is not so clear. This is a melanocytic lesion by default because there are no clear cut criteria for a melanocytic lesion, seborrheic keratosis, basal cell carcinoma, dermatofibroma, or vascular lesion. White color is always a red flag for concern. The white and gray colors favor regression over hypopigmentation. ■ Histopathologically, there was no regression found in this lesion. One cannot tell if there are true dots and globules or they are created by the irregularity of the dark color. The blue color is considered a blotch because it is larger than dots or globules. The blue blotch has a histopathologic differential diagnosis that includes: ■ The blue nevus component of a combined nevus ■ Melanocytic atypia ■ Malignant melanocytes
PEARLS ■
■
■
This case points out the need for one to be as knowledgeable as possible and the need to think in terms of dermoscopic and histopathologic differential diagnosis. Dermoscopic criteria are not always what they appear to be (eg, there is no regression in this lesion). Dermoscopy is not a perfect technique. Don’t expect it to be!
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-34a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-34b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 34 HISTORY A 17-year-old presented with multiple small congenital nevi. There was no history of change in any of the lesions. While examining all of the nevi with dermoscopy, this “ugly duckling” nevus with an irregular black blotch was found. Initially, the blotch was not seen clinically because it was very small. 1. This is a banal appearing congenital combined nevus. 2. Dermoscopically and clinically this is an “ugly duckling” lesion because it was the only nevus with a black blotch. 3. On close inspection, cobblestone-like globules are seen asymmetrically located in the lesion. 4. The irregular black blotch could represent transepidermal elimination of melanin, melanocytic atypia, or melanoma arising in a small congenital melanocytic nevus. 5. To avoid a large keloid with a complete excision, one could biopsy the black blotch to make the diagnosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
1
❑ Low ❑ Intermediate ✔ High ❑ 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
3-34c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,3,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
■
■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular black blotch (yellow arrows) Bluish-white color (yellow star) Hypopigmentation (black stars) Irregular cobblestone globules (white box) Irregular dots and globules (circles) Scale (yellow boxes)
■
■
■
■
■ ■
It was a surprise to find the black blotch in what appeared to be a banal small congenital melanocytic nevus. All of the other nevi had a classic cobblestone global pattern. ■ Uniform large angulated globules filling the lesion. Retrospectively, a black speck was seen clinically but only after it was found with dermoscopy. One should always try to examine clinically banal as well as atypical lesions no matter how many nevi a patient has. ■ Have the patient come back another time if there is not enough time to fully examine most if not all of the lesions. An irregular cobblestone pattern is in the differential diagnosis of the multicomponent global pattern. The irregular black blotch is a red flag for concern and the histopathologic correlates include: ■ Transepidermal elimination of melanin ■ Melanocytic atypia ■ Malignant melanocytes The black color rules out a combined nevus in which the color should be bluish. There is significant scaliness, which creates areas that look like reticular depigmentation. ■ A quick swipe with an alcohol prep will eliminate the scaliness to confirm that there is no reticular depigmentation.
PEARLS ■ ■ ■
■
Always eliminate dryness over a lesion to get a better dermoscopic view. Melanoma arising in a small satellite congenital melanocytic nevus is a rarity. Beauty is in the eye of the beholder. The “ugly duckling” is not always ugly especially to its mother. A clinical and/or dermoscopically “ugly duckling” lesion is always a red flag for concern but it is not always high risk.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-35a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-35b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 35 HISTORY A 55-year-old man developed a dark papule in a pre-existing pigmented skin lesion on his abdomen. 1. 2. 3. 4. 5.
Globules identify a melanocytic lesion. Milia-like cysts and pigmented pseudofollicular openings diagnose a seborrheic keratosis. The large blue ovoid nest of pigment is enough to diagnose a pigmented basal cell carcinoma. Different shades of brown color are clues that this could be a melanoma. If it were not for the history of change, this could be a combined nevus.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
1
❑ Low ❑ Intermediate ✔ High ❑
1
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 1
ANSWERS Answers: 1,4,5
Discussion: ■
■
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
■ ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular brown dots and globules (black circles) Irregular blue globules (white circle) Irregular bluish-white blotch (white arrows) Hypopigmentation (stars) Different shades of brown color Milia-like cysts (boxes)
3-35c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
■
■
■
■
■
The development of a dark papule, in a pre-existing melanocytic lesion, is melanoma until proven otherwise. The skin markings, seen clinically, do not favor a benign lesion. ■ Skin markings and hairs can be found in melanomas. The irregular brown dots and globules could be easily overlooked. The blotch is irregular because: ■ There is bluish-white color. ■ There is a focus of irregular blue dots and globules. ■ It is asymmetrically located within the lesion. The blue dots and globules could be created by nests of melanocytes deeper in the dermis or by irregularities in the homogeneity of the bluish-white blotch. Different shades of homogenous brown color are a red flag for concern. ■ Different shades of any homogeneous color should always be a red flag for concern. There are a few milia-like cysts. ■ To diagnose a seborrheic keratosis there should be multiple milia-like cysts plus other criteria. ■ The irregular brown dots and globules do not look like the pigmented pseudofollicular openings seen in seborrheic keratosis. The only resemblance this melanoma has to a pigmented basal cell carcinoma is the dark bluish-white blotch. ■ A pigmented basal cell carcinoma would not have diffuse brown homogenous color. ■ Arborizing vessels are not needed to diagnose a basal cell carcinoma. A combined nevus is in the dermoscopic but not in the historical or clinical differential diagnosis. The areas of hypopigmentation are not white enough to be considered regression.
PEARLS ■
■
■
One does not need dermoscopy to realize that this could be a melanoma. ■ Dermoscopy increases the diagnosis of melanoma by at least 16% when compared to skin examination without it. Dermoscopy is an enjoyable tool that allows one to see colors and structures not visible with the naked eye or with the typical magnification that clinicians use. Dermoscopy helps confirm with an on the spot second opinion clinical impressions of high risk pathology (eg, dysplastic, Spitz nevi, squamous and basal cell carcinoma, melanoma).
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-36a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-36b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 36 HISTORY This was the only pigmented lesion on the back of a 45-year-old man. The rest of his skin was devoid of melanocytic nevi, lentigines, hemangiomas, seborrheic, or actinic keratosis, typically found on people that live in Florida. 1. Globules identify a melanocytic lesion. 2. There is asymmetry of color and structure and a multicomponent global pattern. 3. There are irregular dots and globules, irregular streaks, irregular blackish-gray blotches, and blue-white color. 4. The dermoscopic differential diagnosis includes a dysplastic nevus and melanoma. 5. One could speculate that this will not be an in situ melanoma based on an evaluation of the entire dermoscopic picture.
167
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑ 1 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 4
3-36c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,5
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular dots and globules (circles) Irregular streaks (black arrows) Irregular blackish-gray blotches (white arrows) Irregular blue blotch (yellow arrow) Bluish-white color (stars)
■
■
■
■ ■
Clinically, the lesion is not as dramatic as the dermoscopic picture. ■ All of the important melanoma-specific criteria are easy to identify. One should go over the entire checklist of points that need to be evaluated: ■ Melanocytic vs nonmelanocytic. ■ Symmetry vs asymmetry of color and structure. ■ What is the global pattern? ■ Identify and evaluate all of the local criteria. ■ Make a dermoscopic diagnosis. There is blue and white color but not the blue-white veil. ■ Blue and/or white color in any form is a high risk criterion. One can tell by the multiple colors and paucity of local criteria that this is not an in situ melanoma. Clinically and dermoscopically this looks more like a superficial spreading rather than a nodular melanoma. ■ Histopathologically it was a nodular melanoma. ■ This is not a perfect dermoscopic-pathologic correlation even though it is still a melanoma. ■ One should confirm with the dermatopathologist that this is really a nodular melanoma. A dysplastic nevus would not have so much diversity of color and structure. Foci of streaks at the periphery not their shape determines that they are irregular. ■ Regular streaks would be found symmetrically around the lesion at the periphery. ■ As in this case, streaks can be an extension of the pigment network or come off a dark blotch (tumor body).
PEARLS ■ ■
A dramatic dermoscopic picture like this one can come as a surprise. When that happens, one must refrain from outbursts of surprise with statements such as “Oh my God” or “This looks very bad.” Patients don’t like that!
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-37a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-37b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 37 HISTORY The patient’s neighbor noticed this skin lesion on the upper thigh of a 42-year-old man. 1. A central white patch and blue blotch characterize this small dermatofibroma. 2. Multifocal hypopigmentation, regular dots and globules, and a regular blue blotch characterize this dysplastic nevus. 3. Several globules identify a melanocytic lesion. 4. The blue blotch in the context of a melanocytic lesion diagnoses this combined nevus. 5. Asymmetry of color and structure, a multicomponent global pattern, irregular globules, an irregular bluish-white blotch, regression, and pinpoint vessels characterize this nodular melanoma.
169
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2
3
3-37c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 3,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular brown globules (black boxes) Irregular bluish-white blotch (yellow arrows) White component of regression (stars) Gray component of regression (white arrows) Pinpoint vessels (yellow boxes)
■ ■
■ ■
As compared to Case 36, clinically and dermoscopically, this looks more like a nodular melanoma because there is: ■ A nodule not flat lesion ■ Paucity of local criteria ■ Pinpoint vessels The gray homogenous color favors regression over hypopigmentation. Purplish color differentiates the pinpoint vessels from dots and globules of a melanocytic lesion, which should be brown. ■ One cannot always tell the difference. A combined nevus would not have so much diversity of criteria. An atypical dermatofibroma could look like this. ■ Melanoma is in the differential diagnosis of atypical dermatofibromas. ■ Atypical dermatofibromas should be removed.
PEARLS ■
■
■
Any papule or nodule with even a suggestion that it could be a melanoma should be excised posthaste. Sequential digital monitoring is contraindicated in any lesion that could be a nodular melanoma. Any delay in making the diagnosis could affect the patient’s survival chances.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
3-38a
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-38b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 38 HISTORY The daughter of this 81-year-old man found this lesion on the arm of her father and brought it to the attention of his dermatologist. 1. 2. 3. 4. 5.
Dermoscopy is not needed to diagnose this melanoma. Globules identify a melanocytic lesion. There is significant asymmetry of color and structure and a multicomponent global pattern. The dots and globules are irregular. An irregular dark blotch, bluish-white color, and regression are other melanoma-specific criteria.
171
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
4
2
DIAGNOSIS
1
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 5 3-38c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
DISPOSITION
Discussion:
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
■
■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■ ■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4,5) Irregular dots and globules (circles) Irregular black blotch (yellow arrows) Regression (stars) Peppering (boxes) Bluish-white color (white arrows) Irregular blue blotch (black arrow)
■
■
■
■
■
It is not necessary to examine the entire lesion to diagnose this melanoma. ■ Examine the entire lesion before making a dermoscopic diagnosis. Asymmetry of color and structure. ■ The left and right sides are not mirror images of each other. ■ The lower and upper halves are not mirror images of each other. A multicomponent global pattern. ■ Three or more different areas within the lesion. ■ A single criterion or multiple criteria can make up each zone. Irregular dots and globules. ■ Different sizes and shapes ■ Asymmetrical location Irregular black blotch. ■ Irregular in size and shape ■ Asymmetrical location Regression. ■ Bony/milky-white color ■ Peppering → fine gray dots Bluish-white color. ■ This is not a blue-white veil → irregular homogenous blue color with an overlying ground glass appearance. ■ Blue and/or white color is any form is a high risk criterion. ■ The bluish-white color lies over the irregular black blotch. Irregular blue blotch. ■ Larger than a dot or globule ■ Irregular border ■ Asymmetrical location
PEARLS ■
■ ■ ■
Seeing examples of well-developed melanoma-specific criteria is essential if one has a chance to identify them when they are not so well developed. Look carefully for subtle criteria before determining that they are absent. All of the melanoma-specific (high risk) criteria can be found in benign lesions. No single criterion is pathognomonic of a melanoma.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-39a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-39b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 39 HISTORY A 27-year-old man moved from another city to Miami. He came in for a routine skin examination because he has a history of dysplastic nevi. This lesion on his very hairy chest was being followed in another pigmented lesion clinic with regular photography and not dermoscopy. There was no history of change. 1. 2. 3. 4.
One’s first impression is that this is a melanoma. The bluish-white veil clinches the melanoma diagnosis. The milky-red globules are diagnostic of a melanoma. The lesion was excised with a diagnosis of a dysplastic nevus. That is a good dermoscopic– pathologic correlation. 5. Asymmetry of color and structure, a homogenous global pattern, regular dots and globules, regular blotch, veil, and globular vessels characterize this melanoma.
173
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
1
RISK ❑ Low ❑ Intermediate ✔ High ❑
2 3
4
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
1
5
6
3-39c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
2
ANSWERS Answers: 1
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4,5,6) Irregular dots and globules (black circles) Bluish -white color (stars) Milky-red globules (red circle)
■
■
■
The dermoscopic picture is dramatic compared to the not so high risk looking clinical lesion. The histopathologic diagnosis of a dysplastic nevus was not a good dermoscopic-pathologic correlation. ■ Dermoscopically it looked like a melanoma but it was not a histopathologic melanoma. ■ When there is not a good dermoscopic–pathologic correlation, seek other dermatopathologists’ opinions. ■ This is a false positive dermoscopic melanoma. ■ In this case, none of the three dermatopathologists diagnosed a melanoma. There is blue and white color but not the blue-white veil as it is defined. ■ The bluish-white color is over poorly defined irregular dark color. Milky-red globules are not diagnostic of a melanoma but are a red flag for concern. ■ It is hard to tell if some of the globules are reddish or brown. The melanoma-specific criteria include: ■ Asymmetry of color and structure ■ Multicomponent global pattern ■ Irregular dots and globules ■ Bluish-white color ■ Milky-red globules ■ Multiple colors
PEARLS ■
■
■ ■
Never tell a patient that they have melanoma 100%. The worst clinical scenario including the dermoscopic picture might still be benign. With difficult cases, one can send digital dermoscopic images to expert dermoscopists for their opinion. ■ Take dermoscopy to a higher level by having equipment to take digital dermoscopic images. Do not hesitate to seek other dermatopathologists opinions with difficult cases. At times it is necessary to cut hair away to get a better clinical and dermoscopic look at a suspicious skin lesion.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-40a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-40b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 40 HISTORY A 55-year-old man came in for a skin examination only to make sure that he was okay. This lesion was found on the upper back. He was not aware of its presence. 1. Globules identify a melanocytic lesion. 2. There is asymmetry of color and structure and a multicomponent global pattern. 3. One sees foci of irregular pigment network, irregular dots and globules, an irregular brown blotch, regression, and bluish-white color. 4. The lesion was excised and reported to be a dysplastic nevus, which is not a good dermoscopic-pathologic correlation. 5. The arborizing vessels, surrounding the lesion, indicate that there is significant sun-damaged skin.
175
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑ 1
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2
3
3-40c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular pigment network (yellow arrows) Irregular dots and globules (circles) Irregular brown blotch (white arrow) Regression (stars) Bluish-white color (yellow box) Arborizing vessels (black arrows)
■
■
■
The dermoscopic diagnosis but not the histopathologic diagnosis was thought to be a melanoma. ■ That is not a good dermoscopic–pathologic correlation ■ It was sent for review to a national pigment lesion expert dermatopathologist who reported this was “definitely” not a melanoma. ■ With free margins and a benign pathology report, was the patient in the clear? ■ No, this is a false negative pathologic, but not dermoscopic melanoma. This case is the opposite of Case 39 in which the lesion was truly benign. Some of the melanoma-specific criteria are easy to see: ■ Asymmetry of color and structure ■ Multicomponent global pattern ■ Regression ■ Bluish-white color Some of the melanoma-specific criteria are not easy to see: ■ Irregular pigment network ■ Irregular dots and globules ■ Irregular brown blotch Arborizing vessels are not diagnostic of a basal cell carcinoma and can also be found in/on: ■ Nevi ■ Sebaceous gland hyperplasia ■ Scar tissue ■ Sun-damaged skin → individual mats or diffuse arborizing vessels ■ It is not always possible to differentiate a solitary mat of arborizing vessels from a basal cell carcinoma→ if in doubt, cut it out!
PEARLS ■
■
■ ■
Even the most experienced pigmented lesion expert dermatopathologists do not always get it right. A consensus of opinions might be better than a single opinion (eg, dermoscopists, dermatopathologists). Every one misses and/or misdiagnoses melanoma. It is a sad fact of life!
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-41a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-41b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 41 HISTORY The patient of Case 40 returned for a 6-month follow-up skin examination and some spots were seen in the melanoma excision site. 1. This is a typical combined nevus that coincidentally is near the melanoma excision site. 2. The brown, blue, and white colors could be seen in melanoma. 3. The history, clinical, and dermoscopic appearances of the new spots are consistent with cutaneous metastatic melanoma. 4. The brown and bluish-white colors are irregular. 5. Without the history and visible surgical scar, the dermoscopic differential diagnosis includes: a combined, blue, Spitz nevus, nodular, and cutaneous metastatic melanoma.
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RISK ❑ Low ❑ Intermediate ✔ High ❑
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-41c
DIAGNOSIS
ANSWERS Answers: 2,3,4,5
Discussion: ■
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
■
■
■
DERMOSCOPIC CRITERIA ■
■
■
Irregular bluish-white color (stars) Irregular brown color (white arrows) Surgical scar (black arrows)
■
■
The histopathology was said to be benign, however, the large blue and small brown spots made clear that the original diagnosis was not correct. → It was a melanoma! Cutaneous and lymph node metastasis might be the only way to diagnose melanoma in clinically and histopathologically equivocal cases. The histopathologic diagnosis of the bluish-brown area was consistent with nodular or cutaneous metastatic melanoma. ■ A sentinel lymph node biopsy was positive → metastatic melanoma. ■ The patient is disease free 6 years post diagnosis Without the history, the dermoscopic differential diagnosis includes: ■ Combined nevus ■ Spitz nevus ■ Blue nevus ■ Nodular melanoma ■ Cutaneous metastatic melanoma Dermoscopic features of cutaneous metastatic melanoma are not specific. ■ Pigmented ■ Nonpigmented → hypo or amelanotic (pink or reddish in color), ■ With or without polymorphous vessels → differently shaped small or larger telangiectatic vessels. The history of a past melanoma excision thick enough to metastasize is usually more helpful than the dermoscopic features to diagnose cutaneous metastatic melanoma.
PEARLS ■ ■
This case points out how treacherous melanoma can be. Luck might be as important as depth of invasion for patient survival. ■ The diagnosis of an in situ amelanotic melanoma in the scalp of a young man with a lot of hair → good luck. ■ A young man with an “irritated” mole who thinks it is caused by his belt, does nothing about it, and then dies at age 33 → bad luck.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-42a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-42b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 42 HISTORY This lesion was found in the posterior upper arm of a 42-year-old woman. 1. 2. 3. 4. 5.
Clinically and dermoscopically this could be a nodular melanoma. Clinically and dermoscopically this could be a blue nevus. Clinically and dermoscopically this could be cutaneous metastatic melanoma. This is the classic homogenous blue global pattern characteristic of a blue nevus. Irregular dots and globules plus different shades of blue and brown color are diagnostic of a nodular melanoma.
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RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-42c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
ANSWERS Answers: 1,2,3,4
Discussion: ■
DERMOSCOPIC CRITERIA ■ ■
■ ■
Homogenous global pattern Irregular bluish dots and globules (boxes) Milia-like cyst (circle) Homogeneous brown color (arrows)
■
■
■
■
■
This is a classic blue nevus with a homogeneous global pattern. Based on the history, there could be other diagnostic possibilities: ■ Rapidly growing nodule → nodular melanoma. ■ A history of a melanoma in the area → cutaneous metastatic melanoma. Typically, one finds a solitary blue papule or nodule that the patient knows has been present for years without any changes. There are different shades of blue, bluish-white, and some suggestion of brown color. ■ This combination of colors could also be found in a combined nevus. The irregular dots and globules (nests of melanocytes) are blue because they are deeper in the dermis (ie, the “Tyndall” effect). ■ They could also be created by irregularities of the bluish-white color over the background of diffuse blue color. The milia-like cyst has no diagnostic significance. ■ Milia-like cysts are not exclusively found in seborrheic keratosis. ■ Milia-like cysts can be found in melanocytic nevi and in melanomas.
PEARLS ■ ■
The history is essential to help diagnose a blue nevus. In general, the family and personal history plus the history and clinical appearance of a lesion will help one make a more accurate dermoscopic diagnosis.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-43a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 43 HISTORY This dermoscopic image was on the dermatology board examination without a history or clinical image. 1. Globules suggest that this could be a melanocytic lesion. 2. Ulceration, an ovoid blue nest of pigmentation, and a spoke-wheel structure suggest this could be a basal cell carcinoma. 3. Asymmetry of color and structure, a multicomponent global pattern, irregular brown globules, irregular streaks, an irregular bluish-black blotch, and regression suggest that this could be a melanoma. 4. Ulceration is present but does not help distinguish a basal cell carcinoma from a melanoma. 5. Spoke-wheel structures have not yet been reported in melanoma and are exclusively found in basal cell carcinomas.
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RISK ❑ Low ❑ Intermediate ✔ High ❑
1 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
4
3-43b
❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
■ ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular streak-like structures (black arrows) Irregular dot and globular-like structures (circles) Blue ovoid nest of pigmentation (white stars) Finger-like projections (yellow arrows) Ulceration (yellow box) Spoke-wheel structure (black box)
■
■
■
■ ■
This pigmented basal cell carcinoma can not be distinguished from melanoma. ■ There are no arborizing vessels. ■ Basal cell carcinomas can be without arborizing vessels. Multicomponent global pattern is not exclusively found in melanomas. Ulceration can be found in basal cell carcinomas and in melanomas. ■ Statistically, ulceration is found more often in basal cell carcinomas. ■ Ulceration in this case favors the diagnosis of a basal cell carcinoma. There are globular-like and streak-like structures, which means: ■ These structures resemble globules and streaks, respectively, but morphologically they are not true globules or streaks. ■ The histopathologic correlation of these criteria is not known in this case because it was not specifically looked for by the dermatopathologist. ■ They are variations of pigmentation seen in basal cell carcinomas. The blue ovoid nest of pigmentation has a differential diagnosis that includes an irregular dark blotch of a melanocytic lesion. ■ Finger-like projections coming off the blotch favor blue-ovoid basal cell nest. ■ The differential diagnosis includes irregular streaks of a melanocytic lesion. ■ This is also how “leaf-like” structures are said to look. ■ There is no resemblance to any type of leaf! ■ “Leaf-like” structures is a misnomer and the concept should be abandoned. The whitish color suggests regression. ■ White color can be found in basal cell carcinomas. The spoke-wheel structure has a central brown globule (“hub”) with a suggestion of linear structures radiating from the center (spokes). ■ Imagination may be needed to diagnose spoke-wheel structures. ■ Number of radial projections varies. ■ One or more spoke-wheels can be found in a basal cell carcinoma. ■ Spoke-wheel structures might be the only criterion to diagnose a basal cell carcinoma → no arborizing vessels, pigmentation, or ulceration. One cannot always differentiate melanoma from basal cell carcinoma. Dermoscopy shows → histopathologic diagnosis is indicated.
PEARLS ■
■
Use the potentially most high risk diagnosis to plan a surgical approach: ■ Biopsy a basal cell carcinoma ■ Excision of a potential melanoma This case points out the need to create a dermoscopic differential diagnosis.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-44a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-44b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 44 HISTORY This asymptomatic dark blue lesion was found on the thigh of an 85-year-old man. 1. 2. 3. 4.
Globules identify a melanocytic lesion. Multiple blue ovoid nests diagnose a basal cell carcinoma. Large, well-demarcated blue vascular spaces diagnose a hemangioma. Asymmetry of color and structure, a multicomponent global pattern, regular dots and globules, regular blotches and regression diagnose a nodular melanoma. 5. Areas with purplish color, suggest that this is a vascular lesion.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
1
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 3-44c
❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑
2
DISPOSITION ❑ ✔ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
ANSWERS Answers: 3,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Large blue vascular spaces (white stars) Purplish color (arrows) Whitish color (black stars) Globular-like structures (circles)
■ ■ ■
■
■
■
■
This vascular lesion points out that asymmetry of color and structure and a multicomponent global pattern are not diagnostic of a melanoma. Vascular lesions do not always have small lacunae. Vascular lesions can have large vascular spaces. The vascular spaces have a differential diagnosis that includes: ■ Ovoid nests of pigmentation → basal cell carcinoma ■ Irregular blotches → melanoma ■ Agminated (grouped in the same area) blue nevi The purplish color is a clue that this could be a vascular lesion. ■ Vascular lesions can have different shades of red, blue, and/or black colors (representing thrombosis). Vascular lesions typically have white color created by hyperkeratosis or by fibrous septa. The globular-like structures are artifacts created by oil placed over the lesion to eliminate the dryness. The less-experienced dermoscopist might consider this to be a melanoma. ■ If in doubt, cut it out!
PEARL ■
Always eliminate dryness when it exists to get a better dermoscopic view of a lesion. ■ A quick swipe with an alcohol prep gets the job done but does not last long and might need to be repeated. ■ Oil or gel (eg, ultrasound gel, hand washing gel) can be used if one wants to take digital dermoscopic images because it lasts much longer than alcohol to eliminate dryness and enhances digital image quality.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-45a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-45b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 45 HISTORY This was found on the left forearm arm of a 67-year-old woman. 1. 2. 3. 4. 5.
Globules identify a melanocytic lesion. There is asymmetry of color and structure and a multicomponent global pattern. There are irregular dots and globules, bluish-white color, and regression. A few milia-like cysts are not enough to diagnose a pigmented seborrheic keratosis. A focus of milky-red globules helps diagnose this melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
4
1 3
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ ❑ Histopathologic diagnosis
2 2
3-45c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■ ■ ■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■ ■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular dots and globules (circles) Bluish-white color (white arrows) Regression (stars) Milky-red area (yellow arrows) Normal skin markings (red arrows) Milia-like cysts (black arrows)
■ ■
■
■ ■
Melanoma arose in a nevus → area 2 of multicomponent global pattern. Shows the importance of a systematic analysis of a suspicious lesion. This is melanocytic because there are multiple globules. There is obvious asymmetry of color and structure. The global pattern is multicomponent because there are four distinct areas with different criteria. Local criteria include: ■ Irregular dots and globules ■ Bluish-white color → there is no “veil” ■ Areas of regression are questionably present ■ A small focus of milky-red area (neovascularization) Regression not easily seen with dermoscopy was present histopathologically. The skin markings have no diagnostic significance. ■ They crisscross the homogeneous brown color of the benign nevus component of the lesion.
PEARLS ■
■ ■
Memorizing a systematic plan of attack requires motivation to master the technique, dedication, and some hard work. Having a written cheat sheet of the important criteria may aid learning. Better communication between the dermoscopist and pathologist could lead to a more accurate histopathologic diagnosis. ■ Regression is seen with dermoscopy but not reported histopathologically. ■ Important criteria might be asymmetrically located in the lesion but not reported histopathologically → more cuts might be indicated.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-46a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-46b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 46 HISTORY A 36-year-old man was concerned about this darkening lesion on his right arm. 1. Clinically and dermoscopically, the blue and brown areas represent cutaneous metastatic melanoma. 2. This is the classic “starburst” global pattern of a Spitz nevus. 3. There are irregular streaks at the periphery. 4. There are regular streaks at the periphery. 5. The majority of the lesion is filled with a regular black blotch.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ ❑ Histopathologic diagnosis
3-46c
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■ ■
■ ■ ■ ■
“Starburst” global pattern Symmetry of color and structure Regular streaks (arrows) Regular black blotch (stars) Bluish-white color Nevus (box)
■
■
■
■
■ ■
■
This is a classic “starburst” global pattern: ■ Regular streaks ■ Homogeneous dark color ■ Bluish-white color The streaks are considered to be regular because they are located at most points along the periphery. Streaks are considered irregular when they are not located at most points along the periphery (ie, when there are only foci of streaks, they are considered irregular). ■ Location at the periphery, not the shape, determines if streaks are regular or irregular. Dots and globules at the periphery can be components of the “starburst” pattern → they are not present in this lesion. Any of the six dermoscopic patterns representing Spitz nevi are referred to as being “Spitzoid”: ■ Starburst ■ Globular ■ Homogeneous ■ Vascular (pink or reddish) ■ Black pigment network (reticular) ■ Nonspecific A regular “Spitzoid” pattern is less worrisome than an irregular “Spitzoid” pattern. Cutaneous metastatic melanomas could have a homogeneous dark blotch but not a symmetrical ring of streaks at the periphery. The brown color with a fine regular pigment network represents a nevus that has nothing to do with the Spitz nevus. ■ It is not uncommon to have different pathologies adjacent to each other (eg, seborrheic keratoses, nevi, and/or hemangiomas).
Chapter 3
■
A “black lamella” (ie, pigmented parakeratosis, histopathologically) is in the differential diagnosis of the black blotch. ■ It is a jet black thin appearing blotch with an overall shiny appearance → similar to the black color of a black widow spider. ■ Tape stripping can help to make the differentiation → specks from the “black lamella” can become stuck to the tape. ■ The “black lamella” does not always come off with tape stripping.
PEARLS ■ ■ ■
An acquired “Spitzoid” lesion in an adult is always a red flag for concern. Melanoma can have a symmetrical “Spitzoid” pattern. All “Spitzoid” lesions should be considered for excision, not only in adults, and regardless of the age of the patient.
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Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-47a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-47b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 47 HISTORY Friends of this 44-year-old man were concerned about this darkening lesion on the upper arm. 1. Similar to Case 46, this is a symmetrical “Spitzoid” or “starburst” global pattern. 2. This is an atypical “Spitzoid” pattern composed of irregular dots and globules at the periphery, an irregular black blotch, and bluish-white color. 3. The bluish-white color and irregular black blotch are melanoma-specific criteria. 4. “Spitzoid” melanomas always have a “Spitzoid” dermoscopic pattern. 5. One can have “Spitzoid” dermoscopic pattern without a “Spitzoid” histopathologic pattern.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-47c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ ❑ Histopathologic diagnosis
ANSWERS Answers: 2,3,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■
Irregular “Spitzoid” global pattern Asymmetry of color and structure (+) Irregular dots and globules (circles) Irregular black blotch (white stars) Bluish-white color (arrows) Peripheral erythema (black stars)
■
■
■
■
■
■
This is an irregular “Spitzoid” global pattern. ■ There is asymmetry of color and structure. ■ There are foci of irregular dots and globules at the periphery → some of the globules look like streaks. ■ There is bluish-white color typically found in “Spitz” nevi. ■ There is an irregular black blotch→ black color can also be found in “Spitz” nevi. Any combination of dots, globules, and/or streaks at the periphery plus light/dark brown, black, or blue color located within the lesion may be found in “Spitz” nevi. A negative or white pigment network (reticular depigmentation) is a clue that a lesion might be a “Spitz” nevus. One often has to stretch their imagination to diagnose a “Spitzoid” pattern. Experienced dermoscopists might not think this is a “Spitzoid” pattern. ■ It could be considered a multicomponent global pattern. The melanoma-specific criteria are striking and enough to make the diagnosis without further categorization as “Spitzoid.” ■ This was not a “Spitzoid” melanoma histopathologically. The peripheral erythema has no diagnostic significance in this case. ■ One can see a corona of erythema clinically around “Spitz” nevi. ■ In general, a corona of peripheral erythema seen clinically is a clue that the lesion might be a “Spitz” nevus.
PEARLS ■ ■
“Spitzoid” lesions are very commonly encountered. Any atypical “Spitzoid” dermoscopic and/or histopathologic diagnosis could actually be a melanoma.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-48a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-48b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
(Reprinted, with permission, from Stolz W, Braun-Falco O, Bilek P et al. (2002) Color Atlas of Dermatoscopy. Second Edition. Blackwell Publishing, Oxford.)
CASE 48 HISTORY Over a 6-month period, this black spot on the back of a 5-year-old girl has been getting bigger. 1. 2. 3. 4. 5.
Irregular streaks and black color characterize this de novo nodular melanoma. In general, this is a “Spitzoid” global pattern with the sub-category of a “starburst” pattern. Regular streaks are the major clue that this is a Spitz nevus. The black color is diagnostic of a thrombosed hemangioma. The homogenous black color could be created by a “black lamella.”
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-48c
DIAGNOSIS
ANSWERS Answers: 2,3,5
Discussion: ■
DISPOSITION
■
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑ ■
■
DERMOSCOPIC CRITERIA ■
■ ■ ■
Symmetry of color and structure “Starburst” global pattern Regular streaks (arrows) Regular black blotch (stars)
■
■
■
■
In this age group, acquired black papules are most likely a Spitz nevus, also called Reed nevi when dark. Nodular melanoma is in clinical but not dermoscopic differential. ■ This is a classic “starburst” global pattern. ■ Melanomas do not usually demonstrate so much symmetry. ■ The more the asymmetry of color and structure the greater chance the lesion is high risk (eg, dysplastic or atypical Spitz nevus, melanoma). Regular streaks (sometimes termed “pseudopods” and “radial streaming”) are finger-like projections along the periphery. Streaks represent variations of the same criterion with the same histopathologic correlates: ■ Intraepidermal or junctional confluent radial nest of melanocytes, which can be benign or malignant. ■ The radial growth phase of melanoma. Even though jet black color may be seen in thrombosed hemangiomas, hemangiomas do not show symmetrical streaks at the periphery. This lesion could have a “black lamella” created by pigmented parakeratoses. ■ Tape strip to see if fragments of pigmented “black lamella” adhere to tape. ■ Fragments of “black lamella” may or may not stick to the tape. Spitz nevi have been shown to be dynamic, changing patterns over time (eg, a globular pattern morphing into a “starburst” pattern). Even though this lesion demonstrates striking symmetry of color and structure, histopathologically it could still be an atypical “Spitzoid” lesion or melanoma. For this reason a histopathologic diagnosis should be made. ■ Atpyical “Spitzoid” lesions are not uncommonly found in children. ■ “Spitzoid” melanomas can be found in children.
PEARLS ■ ■
■
One of the major benefits of dermoscopy is patient reassurance. One should take the opportunity to alleviate the anxiety most parents would have in this situation by confidently making the diagnosis of a benign “Spitz” nevus. Parents should be informed of a very small chance this could be higher risk.
Chapter 3
Trunk and Extremities
RISK
3-49a
❑ Low ❑ Intermediate ❑ High
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-49b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 49 HISTORY A 45-year-old man was worried about a dark spot on his chest, which started to itch. 1. This is a melanocytic lesion because there are brown globules. 2. There is asymmetry of color and structure and a multicomponent global pattern. 3. This could be considered an atypical “Spitzoid” global pattern with irregular globules and bluish-white color. 4. Symmetry of color and structure, bluish-white color and regular globules rules out a melanoma. 5. Significant asymmetry of color and structure and several melanoma-specific local criteria suggest that this could be a dysplastic nevus or melanoma.
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RISK ❑ Low ❑ Intermediate ✔ High ❑ 1 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ ❑ Histopathologic diagnosis
DERMOSCOPIC CRITERIA ■
■
■
■
■
■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Irregular dots and globules (circles) Bluish-white color (white arrows) Different shades of brown color Hypopigmentation (black arrows)
3
3-49c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,3,5
Discussion: ■
■ ■
■ ■
■
■
■
The multicomponent global pattern could also be considered as atypical “Spitzoid.” ■ Bluish-white color ■ Irregular globules → globular “Spitzoid” pattern Both global patterns are high risk and a significant red flag for concern. This atypical “Spitzoid” lesion actually turned out to be a “Spitzoid” melanoma. ■ All atypical “Spitzoid” dermoscopic patterns are not histopathologically “Spitzoid” melanomas. Blue or bluish-white color is a clue that the lesion might be “Spitzoid.” There is a good clinico–dermoscopic correlation. ■ Both clinical and dermoscopic pictures are potentially high risk. There is a good dermoscopic-pathologic correlation. ■ The dermoscopy looks bad enough to be a melanoma. The hypopigmentation is light brown and should not be confused with the bony-white color of regression. This lesion is more malignant looking than benign but it is not definitively malignant. ■ Case 39 looks similar to this and turned out to be a dysplastic nevus. ■ Always consider a dermoscopic differential diagnosis.
PEARLS ■
■
■
Never tell a patient that they have melanoma 100% because you might be wrong. Your reputation in the community will suffer if that happens. Always be as positive with the patient as possible even if there is a chance that they have a melanoma. Put yourself in their shoes and be empathetic.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-50a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-50b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 50 HISTORY A 70-year-old Haitian man with Fitzpatrick skin type VI came in to treat some warts. After a total body skin examination, this pigmented skin lesion was found hidden on his right buttock under the waistband of his underwear. 1. Scaliness, pigmented pseudofollicular openings, and pseudostreaks are typical of pigmented seborrheic keratosis in darker-skinned races. 2. Globules identify a melanocytic lesion. 3. The global pattern could be multicomponent or “Spitzoid.” 4. Asymmetry of color and structure, irregular pigment network, irregular dots and globules, irregular streaks, bluish-white color, and regression put melanoma in the differential diagnosis. 5. An incisional biopsy was consistent with tumoral melanosis (TM) with no suggestion of melanoma. This is a good dermoscopic–pathologic correlation.
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RISK
1
❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
4
3
3-50c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
2
ANSWERS Answers: 2,3,4
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular pigment network (red boxes) Irregular dots and globules (white boxes) Irregular streaks (black arrows) Bluish-white color (red stars) Regression (black stars) Regular pigment network on normal skin (circle)
Discussion: ■
■
■
■
■ ■
■
This in situ melanoma was hidden under the waistband of this dark-skinned patient’s underwear. ■ Melanoma is most typically found at acral sites in darker-skinned individuals. Initial clinical and dermoscopic impression was seborrheic keratosis. ■ A significant number of melanomas have seborrheic keratosis as the primary diagnosis or is in the differential diagnosis on pathology request forms. ■ Irregular dots and globules thought to be pigmented pseudofollicular openings. ■ Streaks considered pseudostreaks of seborrheic keratosis. An Incisional biopsy consistent with tumoral melanosis with no sign of melanoma. ■ This was not a good dermoscopic–pathologic correlation. Tumoral melanosis (TM) is a rare histopathological finding: ■ A nodular or plaque-like accumulation of melanin-laden macrophages/melanophages in the dermis. ■ Immunohistochemical stains are important to confirm no melanocytes. ■ TM pigmented cells are negative for S-100 and HBM-45. ■ TM pigmented cells are positive for macrophage markers such as CD68. ■ Most biopsies are to rule out melanoma. ■ There can be a history of melanoma and TM is found in a satellite nodule or lymph node mass → metastatic melanoma. ■ TM may be the residual finding after partial or complete melanoma regression. ■ TM with complete regression should be considered a high risk melanoma. ■ A metastatic work-up is indicated. ■ Sentinel node biopsy and metastatic work-up negative in this case. Dramatic dermoscopy with well-developed melanoma-specific criteria. An atypical starburst “Spitzoid” global pattern is in the differential diagnosis since there is bluish-white color and irregular streaks. This was not a “Spitzoid” melanoma histopathologically.
PEARLS ■
■ ■
People of all skin types deserve total body skin examinations. ■ The incidence of melanoma is increasing in Latinos and African-Americans. ■ White Hispanics and African-Americans tend to have deeper melanomas and/ or metastatic melanoma at the time of diagnosis compared to Caucasians. Dermoscopy is beneficial in all skin types. Dermoscopic findings have been consistent in all skin types.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-51a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-51b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 51 HISTORY Eight years ago, a 48-year-old Latin female had a pigmented lesion on her left anterior thigh excised. Unfortunately, the lab report with the diagnosis was lost. Three years ago the lesion recurred in the same spot and has been getting progressively darker. The patient did not remember the name of the doctor who did the excision or the lab where the specimen was sent. 1. The lesion was excised with a histopathologic diagnosis of tumoral melanosis (TM). The margins were free and there was no evidence of melanoma. No further surgery or work-up is indicated. 2. Clinically and dermoscopically this should be considered a regressed melanoma even without histopathologic proof. 3. Widespread regression is diagnostic of melanoma. 4. The irregular black blotch with foci of bluish-white color is diagnostic of melanoma. 5. Reticular depigmentation is seen within and outside of the lesion and has no diagnostic significance.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
1
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2
3 3 3-51c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION
ANSWERS
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Answers: 2,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
■ ■ ■
Asymmetry of color and structure (+) Multicomponent global pattern (1, 2, 3) Irregular dots and globules (white boxes) Irregular black blotch (arrows) Bluish-white color (over the irregular black blotch) Regression (stars) Peppering (circles) Reticular depigmentation (red boxes)
■
■
■
Two cases of tumoral melanosis (TM), a rare diagnosis seen within a 2-week period is remarkable. ■ Perhaps TM is under diagnosed. With clinical and dermoscopic diagnosis of melanoma and histopathologic diagnosis of TM with regression, contact dermatopathology posthaste! ■ There was not a good dermoscopic-pathologic correlation. ■ The block was sent to a pigmented lesion expert for another histopathologic opinion which was the same diagnosis → TM, regression without evidence of melanoma consider melanoma to a depth of 1.8mm. ■ The original pathology report could not be obtained. ■ Sentinel node biopsy and a metastatic work-up were negative. There is a differential diagnosis for the irregular black blotch. ■ Atypical melanocytes → melanoma. ■ TM → melanophages and free melanin in the dermis-> melanoma? The black globules have a differential diagnosis. ■ Nests of melanocytes → melanoma. ■ Nests of melanophages → TM. The reticular depigmentation seen within and outside of the lesion represents normal skin markings and has no diagnostic significance. ■ High risk criteria (eg, arborizing vessels and reticular depigmentation) are significant only when seen within the lesion.
PEARLS ■
■
Consider excision at the time of the initial visit with any patient that might have a melanoma to avoid loss to follow-up. ■ Patients can be unreliable and wait long periods of time before having suspicious lesions, that turn out to be melanoma, removed! TM is not an easy diagnosis to make and a consensus of educated, experienced clinicians may be needed to decide the proper disposition.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-52a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-52b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 52 HISTORY This lesion was found on the calf of a 72-year-old man who plays tennis three times a week in Florida. 1. Globules identify a melanocytic lesion. 2. There is asymmetry of color and structure and a multicomponent global pattern. 3. There are regular dots, globules, streaks, blotches, and bluish- white color diagnosing a dysplastic nevus. 4. This could be a collision tumor. 5. The melanoma-specific criteria are more than enough to diagnose a melanoma.
201
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
2
1
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
3
3-52c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,2,4,5
DERMOSCOPIC CRITERIA ■
■
●
■ ■
■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular dots and globules (circles) Irregular streaks (arrows) Irregular black blotch (white stars) Bluish-white color (over the irregular black blotch) Regression (black stars) Peppering (red box)
Discussion: ■ ■
■
The clinical suspicion of a melanoma is confirmed with dermoscopy. There is a pigmented and amelanotic component to this melanoma. ■ A collision tumor is in the differential diagnosis. The melanoma-specific criteria are well developed: ■ Asymmetry of color and structure → no mirror images of criteria. ■ Multicomponent global pattern → each section has several criteria. ■ Irregular dots and globules → different sizes and shapes, asymmetrical location. ■ Irregular streaks → only in one spot. ■ Six colors. ■ Irregular black blotch with overlying bluish-white color → no “veil.” ■ Regression with peppering. ■ There is a differential diagnosis of the peppering. ■ “Pinpoint” vessels if they look red to you. ■ “Peppering” if they look gray. ■ Milky-red color in the lower half.
PEARLS ■ ■
This is a straightforward case. One can practice their memorized checklist of points that should be covered in every case for completeness.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-53a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-53b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 53 HISTORY This 40-year-old woman had a nevus adjacent to the areola on her left breast for years and was not aware of any changes, but admits that she does not usually check her skin. 1. 2. 3. 4.
This is a melanocytic lesion by default. The presence of a “black lamella” rules out a melanoma. The black blotch is very irregular and it is the most obvious high risk criterion present in the lesion. Remnants of a pigment network and homogenous light brown color are clues that this melanoma arose in a pre-existing nevus. 5. The clinical lesion and dermoscopic criteria suggest that this is an in situ or thin invasive melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
1
RISK ❑ Low ❑ Intermediate ✔ High ❑
2
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
3 3
3-53c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
2
3
ANSWERS Answers: 3,4,5
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■
■
■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular pigment network (black boxes) Irregular dots and globules (white boxes) Irregular streaks (black arrows) Irregular black blotch (white stars) Bluish-white color (yellow arrows) Regression (black stars)
■
■
■
■
Pigment network and globules are the criteria that diagnose this as a melanocytic lesion. → It is not melanocytic by default. ■ Consider a lesion to be melanocytic “by default” if there are no criteria to diagnose a melanocytic lesion, seborrheic keratosis, basal cell carcinoma, dermatofibroma, or vascular lesion. The irregular black blotch is not a “black lamella.” ■ A “black lamella” is a homogeneous black blotch with a shiny appearance. ■ The irregular black blotch is inhomogeneous → broken up. Some of the criteria are hard to see: ■ Pigment network is questionably present. ■ Focus of irregular streaks is questionably present. ■ Bluish-white color is very subtle and could be missed if one is in a hurry. ■ Regression is questionably present and could represent normal background skin color. ■ Dots and globules are easier to find scattered throughout the lesion. The irregular black blotch and asymmetry of color and structure are easy to see and these high risk criteria suggest this is a melanoma. Section 2 represents the melanoma arising in a dysplastic nevus in Section 3. ■ There are no criteria to suggest the nevus is dysplastic yet it turned out to be dysplastic histopathologically. ■ It was a feature-poor dysplastic nevus without high risk criteria. One can tell that this is not a deep melanoma by following indications: ■ Flat lesion clinically, not raised or nodular. ■ Black and brown color indicating the pathology/pigment is in the epidermis and/or the upper dermis. ■ An absence of criteria and colors of a deeper melanoma (eg, polymorphous vessels, prominent blue color). ■ The foci of bluish-white color are of no diagnostic significance in this lesion.
PEARLS ■
■
This case is easy to diagnose even for the novice provided they actively study and practice the technique. Dermoscopy cannot be learned by osmosis.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-54a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-54b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 54 HISTORY A 35-year-old woman reported that this small lesion on her abdomen got darker over a 3-month period. 1. While not obvious, the suggestion that there are globules identifies this as a melanocytic lesion. 2. Symmetry of color and structure and regular blotches diagnose a banal acquired nevus. 3. The blotches are not as dramatic as the ones in Case 53, yet they are still irregular and a red flag for concern. 4. The clinical and dermoscopic differential diagnosis includes a dysplastic nevus or in situ melanoma. 5. Subtle bluish-white color and erythema diagnose an in situ melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-54c
DIAGNOSIS
ANSWERS Answers: 1,3,4
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■
■
■
DERMOSCOPIC CRITERIA ■
■ ■
■
■
■
Asymmetry of color and structure Homogeneous global pattern Irregular dots and globules (boxes) Irregular black blotches (black arrows) Bluish-white color (overlying the irregular dark blotches) Hypopigmentation (stars)
■
■
■
■
This is a gray zone lesion in which the picture is not so clear. ■ The differential diagnosis includes a dysplastic nevus or in situ melanoma. Asymmetry of color and structure and irregular black blotches are the melanoma-specific criteria that are easy to see. ■ Melanoma-specific criteria are more sensitive and specific for melanoma, but could be found in benign lesions (eg, banal or dysplastic nevi). The global pattern is homogeneous: ■ Most of the lesion is filled with homogeneous color. ■ There are a few areas with local criteria (eg, dots and globules). ■ Could be a multicomponent global pattern with three distinct areas of criteria. In general, whatever global pattern one finds, it is still essential to determine if it is regular or irregular, good or bad, low or high risk. The irregular globules seen in one of the blotches might be created by inhomogeneity of the blotch and not true globules. The hypopigmented area has an erythematous component: ■ Pressure with instrumentation blanched away the erythema leaving residual hypopigmentation. ■ Erythema is commonly found in dysplastic nevi. The high risk criteria that raise a red flag for concern include: ■ Even though it is small, a clinical lesion with the ABCD features. ■ E for evolving/changing is very worrisome and should be added → ABCDE. ■ Asymmetry of color and structure. ■ Irregular black blotches. ■ Diffuse erythema ■ Bluish-white color.
PEARLS ■ ■ ■ ■
Well developed or not, melanoma-specific criteria should not be ignored. Subtle foci of melanoma-specific criteria may be only clue of high risk. Before making a benign diagnosis look for poorly developed high risk criteria. Small melanomas (less than 6 mm) can be diagnosed with attention to history, clinical appearance, and subtle melanoma-specific criteria.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-55a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-55b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 55 HISTORY The husband of this 57-year-old woman found this lesion on her back. 1. A central white patch and peripheral network diagnose a dermatofibroma. 2. A central bluish-white blotch and regular streaks diagnose a “Spitz” nevus. 3. A large crypt, milia-like cysts, and pigmented pseudofollicular openings diagnose a pigmented seborrheic keratosis. 4. There are no well-developed melanoma-specific criteria in this irritated congenital nevus. 5. Multifocal hypopigmentation, regular peripheral globules, and a regular blotch diagnose an actively changing nevus.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
2 3
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-55c
DIAGNOSIS
ANSWERS Answers: None are correct
Discussion:
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
■
■
■
■ ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■
■
■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular dots and globules (circles) Irregular streaks (black arrows) Irregular dark blotch (yellow arrows) Bluish-white color (overlying the irregular dark blotch) Regression (stars) Milia-like cysts (yellow boxes) Five colors
■
■
■ ■
■
Critics of dermoscopy might say that one does not need the technique to realize this could be a melanoma and they are correct in this case. There is no pigment network, and one might argue that the bluish-white color is a variation of the morphology of the white color seen in dermatofibromas. There are no crypts → large crater-like invaginations filled with yellowish keratin found in seborrheic keratosis and dermal nevi. There is bluish-white color superimposed on areas of the irregular dark blotch. The streaks are questionably present and irregular ■ Asymmetrically located at points along the periphery. With bluish-white color and irregular streaks this could be considered to be an irregular starburst “Spitzoid” global pattern. Differential of larger brown peripheral globules may be irregular streaks. ■ Inter-observer agreement among expert dermoscopists is not always ideal. ■ Some might consider the globules to be streaks. There is widespread regression The milia-like cysts have a differential diagnosis: ■ They are created by inhomogeneity of the whitish-colored regression. ■ True milia-like cysts → milia-like cysts can be found in melanomas. The main dermoscopic features that diagnose this melanoma include: ■ Asymmetry of color and structure ■ Multicomponent or irregular starburst “Spitzoid” global pattern ■ Irregular dark blotch ■ Irregular streaks ■ Bluish-white color → there is no “veil” ■ Multiple colors
PEARLS ■ ■
■
Dermoscopy is not needed to diagnose all high risk lesions. Meta-analysis has shown that dermoscopy improves the diagnosis of melanomas over clinical examination alone by as much as 16%. Though not required in this case, not using dermoscopy risks: ■ Missing melanomas ■ Unnecessary surgery (malignant to benign ratio for dermoscopists is much better than for nondermoscopists).
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-56a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-56b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 56 HISTORY This contentious 70-year-old man came in for some scaly spots on his face. He almost refused a total body skin examination that we routinely offer new patients. It was a surprise to find this lesion on his lower back. 1. 2. 3. 4.
Clinically and dermoscopically, this is highly suspicious for a melanoma. Pigment network and globules identify a melanocytic lesion. There are foci of irregular pigment network. It does not matter if one considers the global pattern to be homogeneous or multicomponent; it is still regular and low risk. 5. Asymmetry of color and structure, an irregular dark blotch and regression are major features of this lesion.
209
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
2 2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2 2
3
ANSWERS Answers: 1,2,3,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■
■ ■ ■
■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Irregular pigment network (boxes) Irregular dots and globules (circles) Irregular dark blotch (arrows) Regression (stars) Bluish-white and gray colors (within the regression) Multiple colors
3-56c
❑✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
■
■
■
■
The histopathologic diagnosis was a dysplastic nevus: ■ This was not a good clinico–dermoscopic–pathologic correlation. ■ There was a very strong feeling that this was an in situ melanoma. ■ A second histopathologic opinion by a pigmented lesion expert concurred with the diagnosis of a dysplastic nevus. ■ In situ melanoma arising in a nevus was in the differential diagnosis. There are well-developed melanoma-specific criteria: ■ Asymmetry of color and structure ■ Irregular pigment network ■ Regression ■ Composed of white, gray, and blue color. Regression was not seen clinically or histopathologically. ■ Hyperkeratosis and melanosis can cause bluish-white color → dermoscopic differential diagnosis in play. The irregular dark blotch is not well developed compared to the ones in Cases 51, 52, and 53. ■ It might not be considered a true blotch but hyperpigmentation. This is a false positive dermoscopic melanoma.
PEARLS ■ ■ ■
Dermoscopy helps one decide on a surgical approach. Many colleagues routinely shave off atypically pigmented skin lesions. When the suspicion for melanoma is high, we do not recommend a shave excision in which the chances of getting free margins are not as great as with a complete excision.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-57a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-57b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 57 HISTORY A 19-year-old woman noticed this pigmented lesion on her upper arm a month ago. 1. 2. 3. 4. 5.
Clinically and with a nonhomogeneous blue global pattern this could be a blue nevus. Clinically and with bluish-white color this could be a nodular melanoma. A few lacunae-like structures put a vascular lesion in the differential diagnosis. A paucity of local criteria suggests this is a heavily pigmented nodular melanoma. Clinically and dermoscopically this is suspicious for a nodular melanoma, however, one does not see nodular melanoma in this young age group.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-57c
❑ ❑ ❑ ❑ ❑ ❑ ❑✔ ❑
ANSWERS Answers: 1,2,3,4
Discussion: ■
DERMOSCOPIC CRITERIA ■ ■ ■ ■
■
Homogeneous global pattern Bluish-white color (stars) Reddish color (arrows) Irregular dots and globules (yellow boxes) Lacunae-like structures (white boxes)
■
■
■
■
■
Nodular melanoma can be the easiest diagnosis to make or miss. ■ Always maintain a high index of suspicion with a papule or nodule no matter what the history, clinical, and/or dermoscopic appearance is. Asymmetry of the shades of bluish-white color is a red flag for concern. ■ This is an inhomogeneous homogeneous global pattern. An absence or paucity of local criteria is often found in nodular melanoma. ■ Check the periphery for foci of local criteria. The histopathologic correlate of the reddish color is not known: ■ It could be erythema. ■ It is not the milky-red color that can be seen in melanoma. The suggestion of a few lacunae-like structures and blue color could be seen a vascular lesion. Nodular melanoma ■ Can be found in any age group, young and old alike. ■ Can develop overnight. ■ Grow rapidly or be present for a long time. ■ Be amelanotic, hypomelanotic, or heavily pigmented. ■ Patients may or may not be aware of changes in a long-standing lesion.
PEARLS ■
■ ■
Include nodular melanoma in your systematic checklist of points to think about in any nodular lesion. It could be one of the great masqueraders! Foci of local criteria are a red flag for concern in equivocal nodular lesions.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-58a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-58b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 58 HISTORY This black nodule was clearly an “ugly duckling” lesion found on the back of an 81-year-old man whose back was covered with typical brown seborrheic keratosis. 1. A sharply demarcated black nodule with very irregular black globules characterizes this nodular melanoma. 2. Sharp border demarcation, multiple milia-like cysts, and pigmented pseudofollicular openings characterize this classic seborrheic keratosis. 3. A black nodule with a paucity of local criteria help diagnose this nodular melanoma. 4. Diffuse bluish-white color favors the diagnosis of a melanoma. 5. There are no criteria to suggest that this is a melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-58c
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■ ■
■
Sharp border demarcation (black arrows) Milia-like cysts (boxes) Pigmented pseudofollicular openings (white arrows) Bluish-white color (yellow arrows)
■ ■
■
■
■
There are no criteria to diagnose a melanocytic lesion, basal cell carcinoma, dermatofibroma, vascular lesion, squamous cell carcinoma, or anything other than a classic seborrheic keratosis. Clinically this looks very similar to the nodular melanoma in Case 57, which points out the benefits of dermoscopic examination vs clinical examination alone. ■ This was an “ugly duckling” lesion clinically → a red flag for concern. ■ Nodular melanoma is clearly in the clinical differential diagnosis. ■ Nodular melanoma is clearly not in the dermoscopic differential diagnosis. Sharp border demarcation can be seen in seborrheic keratosis and melanoma. Multiple milia-like cysts and multiple-pigmented pseudofollicular openings are not typically found in melanoma. ■ A few milia-like cysts and pseudofollicular openings can be found in benign and malignant melanocytic lesions. One does not need to find the full constellation of criteria to diagnose seborrheic keratosis. The novice dermoscopist might have a difficult time deciding if there are irregular dots and globules or pigmented pseudofollicular openings. The subtle bluish-white and black color are commonly found in seborrheic keratosis and are not melanoma-specific criteria. ● Seborrheic keratosis can be heavily pigmented.
PEARLS ■
■
Clinical and/or dermoscopic “ugly duckling” lesions are not always high risk. ■ Just a red flag for concern that deserves your undivided attention. Beware! There are seborrehic keratosis-like melanomas → melanoma incognito. ■ Collision tumors consisting of seborrehic keratosis and melanoma are a common combination.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-59a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-59b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 59 HISTORY A 60-year-old man has this violaceous nodule on his back for many years. 1. 2. 3. 4. 5.
Milky-red areas and regression characterize this amelanotic nodular melanoma. The white stellate areas represent reticular depigmentation-(negative/white network). Homogeneous purple color, lacunae, and fibrous septa characterize this hemangioma. One cannot diagnose a vascular lesion because the color is too dark. At least 50% of a lesion should be filled with well-developed lacunae before one can diagnose a vascular lesion.
215
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ✔ Low ❑ ❑ Intermediate ❑ High
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ✔ No intervention ❑ ❑ Follow-up ❑ Histopathologic diagnosis
3-59c
❑ ❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 3
Discussion: ■
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DERMOSCOPIC CRITERIA ■
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Homogeneous purple colors (stars) Lacunae (boxes) Fibrous septa (arrows) ■
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Clinically but not dermoscopically melanoma is in the differential diagnosis. ■ This lesion looks clinically similar to Cases 57 and 58. The history favors of a benign lesion. ■ Patient’s histories are not always accurate but should always be listened to. This is not a melanocytic lesion by default because there are criteria for a vascular lesion: ■ Lacunae ■ Homogeneous purple color ■ Fibrous septa Lacunae are: ■ Not always well developed. ■ May be few in number or diffusely fill a lesion. ■ There is no set number required to diagnose a vascular lesion. Milky-red areas found in melanomas are pinkish-white not purplish in color, with or without out-of-focus reddish globule-like structures. Reticular depigmentation (white pigment network, negative pigment network) found in melanoma typically is thinner, whiter, and in sharper focus. Fibrous septa (white color) are typically found in vascular lesions. Any shade of red or purple color can be found in vascular lesions. ■ The deeper in the dermis that the vascular spaces are the darker the color will be.
PEARLS ■
■
In equivocal cases search for foci of melanoma specific-criteria before diagnosing a benign vascular lesion. If in doubt, cut it out because there are hemangioma-like melanomas and hemangioma-like cutaneous metastatic melanoma → melanoma incognito.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS 3-60a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-60b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 60 HISTORY A 47-year-old physician was very upset when he discovered this new lesion on his right lower abdomen. 1. 2. 3. 4. 5.
Globules identify a melanocytic lesion. The global pattern is “Spitzoid.” There are irregular dots and globules, irregular dark blotches, and reticular depigmentation. An atypical Spitz nevus and “Spitzoid” melanoma are in the differential diagnosis. It is not clear if there are globules or streaks at the periphery and does not matter because both are high risk.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
❑✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-60c
DIAGNOSIS
ANSWERS Answers: 1,2,3,4,5
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■
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DERMOSCOPIC CRITERIA ■
■ ■
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Asymmetry of color and structure “Spitzoid “ global pattern Irregular dots and globules (circles) Irregular dark blotches (white arrows) Reticular depigmentation/ white network (yellow arrows)
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Even though the lesion does not demonstrate the ABCD criteria and even before it is examined with dermoscopy one should be thinking this could be high risk. ■ A new black lesion in an adult. The global pattern is atypical starburst: ■ Asymmetry of color and structure. ■ Foci of dots, globules, and/or streaks at the periphery. ■ Centrally located reticular depigmentation (eg, negative pigment network). The globules are irregular by definition: ■ Different sizes and shapes ■ Asymmetrical location The dark blotches are irregular by definition: ■ Irregular outline ■ Asymmetrical location Morphology is a variation of classic reticular depigmentation: ■ It should be with thinner white lines and with more defined reticulation ■ At times one has to use their imagination to identify criteria that are not classic. Reticular depigmentation can be found in dermatofibromas, dysplastic nevi, Spitz nevi and melanomas and is not a differentiating criterion. There is not a good dermoscopic–pathologic correlation: ■ The dermoscopic pattern in this Spitz nevus is atypical and “Spitzoid” yet there was no mention of atypia histopathologically. ■ One should communicate with their dermatopathologist and make sure atypical histopathologic features were not missed. ■ Consider another histopathologic opinion with a “Spitzod” lesion expert → they are out there.
PEARLS ■ ■
■ ■
Some believe Spitz nevi are atypical histopathologically and not high risk. Histopathologic criteria that subcategorize Spitz nevi as atypical, potentially high risk→ melanoma. Ensure pathologist is aware of the criteria in an atypical “Spitzoid” lesion. Sending clinical and dermoscopic images to the pathologist improves communication and can motivate them to search for high risk features that could otherwise be missed.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-61a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-61b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 61 HISTORY This solitary lesion was found on the anterior thigh of a 53-year-old woman. 1. The clinical appearance and presence of multiple milia-like cysts diagnose a pigmented seborrheic keratosis. 2. Peripheral globules identify a melanocytic lesion. 3. Bluish-white color and an irregular black blotch filling most of the lesion are red flags for concern. 4. Milia-like cysts are usually white or yellow and not bluish-white. 5. It is hard to decide if this is a heavily pigmented seborrheic keratosis or a melanoma which is an indication to make a histopathologic diagnosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS
2
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
4 3
5 3-61c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 2,3,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
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Asymmetry of color and structure Multicomponent global pattern (1,2,3,4,5) Irregular black and brown dots and globules (circles) Irregular bluish-white dots (boxes) Irregular black blotch (arrows) Bluish-white homogeneous color (stars)
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The irregular black blotch filling most of the lesion is an immediate cause for concern. ■ Proceed with focused attention to completely analyze the lesion. With a potentially difficult and/or high risk lesion go directly into your organized checklist of features to look for. Step one → melanocytic vs nonmelanocytic ■ This is melanocytic because there are brown globules. Step two → Global features ■ Asymmetry of color and structure. ■ Multicomponent global pattern with four different areas of criteria. Step three → Local criteria ■ Poorly defined irregular black and brown dots and globules. ■ Irregular bluish-white dots and globules. ■ These are not milia-like cysts and probably represent hyperkeratosis (scale). ■ Irregular black blotch is filling most of the lesion. ■ Subtle foci of homogeneous bluish-white color → not a “veil.” Step four → Diagnosis and/or differential diagnosis ■ One cannot be sure if this is a heavily pigmented seborrheic keratosis or melanoma. Step five → Lesion disposition ■ Make a histopathologic diagnosis since melanoma is in the differential diagnosis.
PEARL ■
If one gets to the point of confusion, stop and think “If in doubt, cut it out.” Problem solved!
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-62a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-62b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 62 HISTORY A 74-year-old woman has this nodule on her sternum for two years. 1. This is a beautiful heart-shaped benign seborrheic keratosis with multiple milia-like cysts and large pigmented crypts. 2. A central white patch and hyperpigmentation characterize this dermatofibroma. 3. This is a melanocytic lesion by default. 4. Irregular black blotches and an absence of local criteria other than a few irregular vessels at the periphery help to diagnose a nodular melanoma. 5. The whitish color could be created by hyperkeratosis (scale) or regression.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
1
RISK ❑ Low ❑ Intermediate ✔ High ❑
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3
4
3-62c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 3,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
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■ ■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular dark blotches (arrows) Hyperkeratosis (scale) (stars) Whitish dots (white boxes) Polymorphous vessels (yellow boxes)
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An adorable heart-shaped lesion seen clinically is of no significance other than the fact that it is a black nodule. There is an absence of criteria to diagnose a melanocytic lesion, seborrheic keratosis, basal cell carcinoma, dermatofibroma, or hemangioma → melanocytic by default. Scaliness creates the whitish color. ■ Dry skin significantly diminishes what one can see with dermoscopy. ■ Mineral oil was used to eliminate the dryness → a glob of mineral oil covers 90% of the lesion. ■ The whitish dots are not milia-like cysts and are created by the dry scaly skin. Once a melanocytic lesion is diagnosed, the irregular dark blotches, absence of local criteria, and polymorphous vessels put nodular melanoma at the top of the diagnostic list. One has to look hard to identify the atypical vessels and for some they would be questionably present.
PEARLS ■ ■
It is essential to eliminate dry scaly skin to get a better dermoscopic view. With a vivid imagination interesting shapes can be see dermoscopically! ■ Hearts, Yorkies, and even invasive melanoma that looks like Mickey Mouse with two big ears. ■ An interesting observation that adds an aspect of frivolity to a very serious subject.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-63a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-63b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 63 HISTORY This solitary lesion was found on the back of a 40-year-old woman. 1. The irregular round to oval black structures could represent globules of a melanocytic lesion or pigmented pseudofollicular openings of a seborrheic keratosis. 2. The irregular black blotch could represent invasive melanoma or hyperpigmentation in a seborrheic keratosis. 3. The diffuse bluish-white color does not help to differentiate a melanoma from a seborrheic keratosis. 4. The sharp border demarcation does not help differentiate a melanoma from a seborrheic keratosis. 5. Multiple hairpin-shaped vessels suggest that this is a seborrheic keratosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
1
2
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 4
3-63c
❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Answers: 1,2,3,4,5
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
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Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Sharp border demarcation (black arrows) Pigmented pseudofollicular openings (yellow arrows) Nonpigmented pseudofollicular opening (white box) Irregular brown dots (yellow box) Irregular black blotch (white arrows) Bluish-white color (stars) Hairpin-shaped vessels (black boxes) Polymorphous vessels (red boxes)
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Asymmetry of color and structure and the multicomponent global pattern are not exclusively found in high risk melanocytic lesions. This case points out the need to think in terms of dermoscopic differential diagnosis. ■ Irregular dark globules of a melanocytic lesion vs pigmented pseudofollicular openings of a seborrheic keratosis. ■ The focus of small dots has no diagnostic significance. ■ Irregular black blotch of a melanoma vs hyperpigmentation of a seborrheic keratosis. ■ Bluish-white color is nonspecific and can be seen in seborrheic keratosis and in melanoma. ■ The absence of milia-like cysts does not rule out a seborrheic keratosis. ■ Polymorphous vessels with some hairpin shapes can be seen in melanoma and seborrheic keratosis. ■ One often has to use their imagination to see hairpin shapes. The hairpin-shaped vessels and nonpigmented pseudofollicular opening favors the diagnosis of a seborrheic keratosis. Pigmented pseudofollicular openings can have a three-dimensional appearance when seen in vivo that does not show up in digital dermoscopic images. For the experienced clinician, the diagnosis of an atypical seborrheic keratosis should be easier to make than by the novice dermoscopist. ■ A stuck on clinical appearance seen here is commonly found in seborrheic keratosis.
PEARLS ■
■
Beware! Melanomas can have a stuck on clinical appearance similar to seborrheic keratosis. A collision tumor, melanoma and seborrheic keratosis is in the differential diagnosis.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-64a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-64b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 64 HISTORY You spot this innocuous looking pink macule on the upper back of a 69-year-old man. 1. 2. 3. 4.
Globules identify a melanocytic lesion. Regression, polymorphous vessels, and irregular globules diagnose a regressive melanoma. A pink scaly macule with glomerular vessels diagnoses Bowen disease. An absence of pigment network, arborizing vessels, and pigmentation diagnose a pigmented basal cell carcinoma. 5. A pink lesion seen clinically is nonspecific and the vessels seen with dermoscopy can in many instances make a specific diagnosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS
2
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
3-64c
❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS DISPOSITION
Answers: 4,5
❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
Discussion: ■
■
DERMOSCOPIC CRITERIA ■
■
■ ■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Arborizing vessels (arrows) Brown dots and globules (black circles) Blue globule (red circle) Depigmentation (stars)
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This is a nonmelanocytic lesion with asymmetry of color and structure and a multicomponent global pattern. Pink macules and papules are nonspecific and can be melanocytic, nonmelanocytic, benign, malignant, or inflammatory. ■ Shiny semi-translucent clinical appearance suggests basal cell carcinoma. ■ Bowen disease (in situ squamous cell carcinoma) typically has: ■ Pinkish scaly macules, patches or plaques ■ Not shiny or semi-translucent ■ Contains diffuse or localized glomerular vessels → pinpoint or circular grouped telectangietatic vessels One sees classic arborizing vessels, both small and large bore, branching: ■ Sharply in focus due to surface location ■ Out-of-focus vessels are not on the surface of a lesion. ■ Out-of-focus arborizing vessels are a “red flag” and could be melanoma. Arborizing vessels are not exclusive to basal cell carcinoma. They can be in: ■ Melanoma ■ Sun-damaged skin ■ Scar tissue ■ Nevi ■ Sebaceous gland hyperplasia Nonarborizing vessels can also be seen in basal cell carcinomas. Pigmentation is commonly found in basal cell carcinomas. ■ The size, shape, and color are highly variable. ■ No specific pigmentation type is diagnostic of basal cell carcinoma. White color is commonly found in basal cell carcinomas and could be confused with the bony-white color of regression seen in melanomas.
PEARLS ■
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Always keep in mind that the “classic” clinical and/or dermoscopic basal cell carcinoma could be a melanoma. Be vigilant and always maintain a high-melanoma index of suspicion.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-65a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-65b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 65 HISTORY This suspicious lesion was found by an internist on the chest of an 80-year-old man. 1. 2. 3. 4. 5.
Milky-red areas, pinpoint and arborizing vessels characterize this amelanotic melanoma. The white area has arborizing vessels and ulceration diagnosing a basal cell carcinoma. The brown area has globules and pigment network diagnosing a nevus. This could be a collision tumor or a melanoma arising in a nevus. A basal cell carcinoma and nevus are never seen in combination in collision tumors.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3-65c
❑ ❑ ✔ ❑ ❑ ❑ ❑ ❑ ❑
ANSWERS Answers: 2,3,4
Discussion: ■
■
DERMOSCOPIC CRITERIA ■ ■
■ ■
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Arborizing vessels (arrows) Polymorphous vessels (red boxes) Ulceration (black box) Irregular brown globules (circle) Regular fine pigment network (yellow box)
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Strict dermoscopic evaluation diagnoses a collision tumor or melanoma arising in a nevus. There are classic arborizing vessels and a small ulceration that diagnoses a basal cell carcinoma. ■ Melanoma could also have similar appearing arborizing vessels and ulceration. The diffuse bony-white color could be seen in a basal cell or melanoma and is not a differentiating criterion. The irregular brown globules and pigment network are not well developed and could be easily overlooked. Any combination of benign and/or malignant tumors is theoretically possible in collision tumors. ■ A basal cell carcinoma and nevus would not be unusual. There are foci of nonarborizing vessels (eg, polymorphous vessels). ■ Not uncommonly, small telectangietatic vessels with various shapes (eg, linear, comma-shaped, pinpoint) are also found in basal cell carcinomas along with arborizing vessels. There are no milky-red globules. ■ The globules are brown and not milky-red in color. ■ There is not a pinkish background surrounding the globules.
PEARL ■
Be aware of the concept of collision tumors so that they are in the differential diagnosis when the dermoscopic criteria present themselves.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-66a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-66b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 66 HISTORY This very small lesion was found on the posterior shoulder of a 45-year-old man. 1. There are classic arborizing vessels of a basal cell carcinoma. 2. The combination of arborizing vessels, white color, and pigment diagnose a pigmented basal cell carcinoma. 3. The large brown irregular blotch with a focus of bluish-white color is a clue that this might be a melanoma. 4. Pigment network seen outside of the lesion has no diagnostic significance. 5. In focus arborizing vessels are never seen in basal cell carcinomas.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1 2
DIAGNOSIS Benign Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
2
3
3-66c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,3,4
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■ ■ ■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular brown blotch (black arrows) Bluish-white color (circle) Arborizing vessels (red arrows) Regression (stars) Pigment network (boxes)
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Here it is, a melanoma that at first blush looks like a typical basal cell carcinoma that has: ■ Classic arborizing vessels ■ White color ■ Pigmentation One sees fine pigment network surrounding the lesion: ■ A normal skin finding when found outside of the lesion. ■ More commonly found in darker-skinned races. There are clues that this might be a melanoma: ■ Clinically it does not look like a basal cell carcinoma. ■ The large brown blotch with a focus of bluish-white color is not typically seen in basal cell carcinomas. The white color has a differential diagnosis: ■ Regression in a melanoma. ■ White color typically seen in basal cell carcinomas. In-focus classic arborizing vessels can also be found in melanomas. ■ Statistically they are much more commonly found in basal cell carcinomas.
PEARLS ■ ■ ■
Congratulate yourself if you diagnose a barely perceptable lesion like this. You have taken dermatology and dermoscopy to a higher level. Focus one’s attention on every patient at all times because patients’ lives are on the line any time of the day.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-67a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-67b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
(Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. Nov 2008-Vol 7- Issue 11. Fig 1.)
CASE 67 HISTORY This nodule on the back of a 63-year-old man was found by his wife while in the swimming pool. 1. Clinically and dermoscopically, this is a classic basal cell carcinoma. 2. Arborizing vessels, blue ovoid nests of pigment, and brown globules diagnose a basal cell carcinoma. 3. Brown globules identify a melanocytic lesion. 4. Well-developed melanoma-specific criteria suggest that this could be a melanoma. 5. There is a large area of milky-red color with a few milky-red globules.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
1
❑ Low ❑ Intermediate ✔ High ❑
2
2
3
DIAGNOSIS Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3
1 1
3-67c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 3,4,5
Discussion:
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
■
■
■
DERMOSCOPIC CRITERIA ■
■
■
■ ■ ■ ■
■ ■
Asymmetry of color and structure (+) Multicomponent global pattern (1,2,3) Irregular brown dots and globules (black boxes) Bluish-white color (blue stars) Regression (black stars) Peppering (yellow boxes) Polymorphous vessels (black arrows) Milky-red area (red arrows) Six colors
■
■
A dark nodule with a multicolor macular component is not what one would see clinically with a basal cell carcinoma. Brown globules identify a melanocytic lesion. ■ They are difficult to see. The lesion is filled with well-developed melanoma-specific criteria. ■ Asymmetry of color and structure ■ Polymorphous vessels ■ Multicomponent global pattern ■ Milky-red area ■ Regression with peppering ■ Six colors ■ Bluish-white color Some of the criteria have a differential diagnosis. ■ Bluish-white color of a melanoma vs blue ovoid nests of a basal cell carcinoma. ■ The blue color is not ovoid in shape, which goes against the diagnosis of a basal cell carcinoma. ■ Arborizing vessels of a basal cell carcinoma vs polymorphous vessels of a melanoma. ■ The vessels have very little branching, which goes against the diagnosis of a basal cell carcinoma. ■ The presence of other shapes (eg, pinpoint, linear) favors the diagnosis of a melanoma. There is a large milky-red area with a few out-of-focus reddish globules. ■ This favors the diagnosis of a melanoma. ■ Not typically seen in basal cell carcinomas. ■ This could easily be overlooked by the novice dermoscopist.
PEARLS ■
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At first blush, one might focus on the basal cell-like linear vessels and blue color, and diagnose a basal cell carcinoma. It is essential to examine all of the criteria in a lesion before making a dermoscopic diagnosis. When it is not possible to differentiate a basal cell carcinoma from a melanoma, consider the lesion to be a melanoma and arrange to make a histopathologic diagnosis posthaste!
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-68a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-68b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
(Reproduced, with permission, from Journal of Drugs in Dermatology. New Methods and Technologies. Nov 2008-Vol 7- Issue 11. Fig 2.)
CASE 68 HISTORY This case was e-mailed to you for your opinion. Is it a pigmented basal cell carcinoma or melanoma? 1. Clinically it looks like a melanoma. 2. Pigment network and globules identify a melanocytic lesion. 3. Asymmetry of color and structure and a multicomponent global pattern could be seen in both pathologies. 4. Lacks the arborizing vessels suggestive of a basal cell carcinoma. 5. The large irregular black blotch, white color with polymorphous vessels favors the diagnosis of a melanoma.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
3
1
DIAGNOSIS ❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
2
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 2
3 3-68c
3
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
ANSWERS Answers: 1,2,3,4,5
Discussion: ■
DERMOSCOPIC CRITERIA ■
■
■
■
■
■ ■
■ ■
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular pigment network (black boxes) Irregular black globules (yellow boxes) Irregular black blotches (yellow arrows) Regression (stars) Polymorphous vessels ■ Pinpoint (circles) ■ Linear (black arrows) Six colors Hyperkeratosis (white box)
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■
The lesion looks like a melanoma clinically: ■ Central dark blotch ■ ABCD criteria ■ Absence of the semi-translucency typically seen in basal cell carcinoma There are well-developed melanoma-specific criteria: ■ Asymmetry of color and structure ■ Multicomponent global pattern ■ Both could be seen in basal cell carcinoma or melanoma. ■ Irregular black globules ■ Polymorphous vessels ■ Irregular black blotches ■ Six colors ■ Regression The diffuse white color has a differential diagnosis: ■ Bony-white color of regression seen in melanoma ■ White color of a basal cell carcinoma Polymorphous vessels seen in the bony-white color favors the diagnosis of a melanoma. The absence of arborizing vessels goes against the diagnosis of a basal cell carcinoma.
PEARLS ■
■
■
Even experienced dermoscopists might confuse this with a pigmented basal cell carcinoma if one does not focus their attention and is in a hurry. Minimal pressure with instrumentation and use of a gel (ultrasound or hand sanitizer) applied to the skin will allow one to better visualize small telangiectatic vessels. Small vessels are better visualized with polarizing noncontact dermoscopy (dermlite 3GEN) when not using gel.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-69a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-69b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 69 HISTORY A 76-year-old man was seen by his dermatologist for a skin infection when this lesion was found on his posterior left upper arm. 1. Globules identify a melanocytic lesion. 2. Milky-red color and reticular depigmentation are clues that this is a melanoma. 3. A central white patch, peripheral pigment network, and arborizing vessels characterize this dermatofibroma. 4. Regression is seen clinically and dermoscopically. 5. The large area of regression is characterized by milky-red color, homogeneous gray color, and polymorphous vessels.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ❑ Intermediate ✔ High ❑
1
DIAGNOSIS
2
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑
3 3-69c
❑ ❑ ❑ ❑ ❑ ❑ ✔ ❑ ❑
ANSWERS Answers: 1,2,4,5
Discussion: ■
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DERMOSCOPIC CRITERIA ■
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Asymmetry of color and structure Multicomponent global pattern (1,2,3) Irregular brown dots and globules (black circles) Irregular streaks (black arrows) Reticular depigmentation (white boxes) Regression (stars) Polymorphous vessels (yellow boxes) Homogenous gray color and peppering (yellow circles) Arborizing vessels (red boxes)
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The brown globules are hard to see, nevertheless identify a melanocytic lesion. ■ This could also be considered a melanocytic lesion by default if one does not agree that there are brown globules. Reticular depigmentation (negative pigment network/white pigment network/white network) seems to blend in with stellate bony-white scar tissue in some areas. Milky-red/pink color fills most of the lesion. ■ Pink color in any form is always a red flag for concern. ■ However, pink color is not always associated with high risk pathology. Asymmetry of color and structure and the multicomponent global pattern are melanoma-specific criteria that can be seen in basal cell carcinoma and melanoma. One focus of irregular streaks is a melanoma-specific criterion but of little importance in the context of the other well-developed high risk criteria. The area of regression is made up of: ■ Bony-white color ■ Milky-red/pink color ■ Polymorphous vessels ■ Pinpoint ■ Linear ■ Homogenous gray color and peppering An atypical dermatofibroma is in the dermoscopic but not the clinical differential diagnosis. The arborizing vessels surrounding the lesion are a sign of chronic sun damage and have nothing to do with the lesion itself.
PEARLS ■ ■
It cannot be overemphasized: If there’s pink, stop and think! While not specific, pink color is an independent potentially high risk criterion.
Chapter 3
Trunk and Extremities
RISK ❑ Low ❑ Intermediate ❑ High
DIAGNOSIS
3-70a
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
DISPOSITION
3-70b
❑ No intervention ❑ Follow-up ❑ Histopathologic diagnosis
CASE 70 HISTORY A 64-year-old man was seen for his melanoma follow-up when this lesion was found on his back. 1. 2. 3. 4.
A central white patch and pigment network put a dermatofibroma in the differential diagnosis. Pigment network identifies a melanocytic lesion. An amelanotic nodule with a few pinpoint vessels puts melanoma in the differential diagnosis. Slightly irregular pigment network, a hypomelanotic central area, and diffuse erythema put an irritated nevus in the differential diagnosis. 5. Irregular pigment network and multifocal hypopigmentation put a dysplastic nevus in the differential diagnosis.
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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK ❑ Low ✔ Intermediate ❑ ❑ High
✔ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-70c
DIAGNOSIS
ANSWERS Answers: 1,2,3,4,5
Discussion: ■
DISPOSITION ❑ No intervention ❑ Follow-up ✔ Histopathologic diagnosis ❑ ■
DERMOSCOPIC CRITERIA ■
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Reticular-homogeneous global pattern Asymmetry of color and structure Irregular pigment network (boxes) Irregular dots (black circles) Hypopigmentation (black stars) Regression (white stars) Pinpoint vessels (red circles)
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Pigment network identifies a melanocytic lesion. ■ It could be considered regular or slightly irregular. ■ The brown dots are too small to be considered globules, which would be another criteria identifying a melanocytic lesion. ■ Dermatofibromas are nonmelanocytic lesions that can have a pigment network. The global pattern is reticular-homogeneous. ■ Reticular created by pigment network. ■ Homogeneous created by an amelanotic centrally located dermal nevus. Even though this lesion was found in an adult, this pattern is more commonly found on the scalp in children and is also referred to as: ■ Targetoid nevus ■ Reverse fried egg nevus ■ Fried egg nevus has a central dark area. ■ “ Crown on thorns” nevus (our preferred term). The differential diagnosis for the hypopigmented areas includes: ■ Regression ■ Hypopigmentation seen in a dermal nevus ■ Not uncommonly, dermal nevi have very little if any pigment. ■ Multifocal hypopigmentation commonly found in dysplastic nevi ■ A nodule of amelanotic melanoma The pinpoint vessels: ■ Are nonspecific and could be seen in regression or in a dermal nevus. ■ Might easily be missed since they are not well developed. Diffuse erythema is a nonspecific sign of inflammation that easily blanches away with pressure from instrumentation.
PEARLS ■
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The value of being able to create a dermoscopic differential diagnosis for global patterns and local criteria is highlighted in this case. “Crown of thorns” nevi are commonly found in the scalp of children and are usually benign. A “Crown of thorns” nevus in an adult is a red flag for concern. Whatever is seen
