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DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
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Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
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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
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
2-18c
2
Scalp, Face, Nose, and Ears
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-19a
DISPOSITION
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
2-19b
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: 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
2-19c
2
Scalp, Face, Nose, and Ears
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
2-20a
DISPOSITION
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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