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Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
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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
2-14b
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
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
2-14c
2
Scalp, Face, Nose, and Ears
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-15a
DISPOSITION
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
2-15b
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
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
2-15c
2
Scalp, Face, Nose, and Ears
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-16a
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
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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