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Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
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3-23a
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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
3-23b
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
ANSWERS
Answers: 1,2,5
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
Discussion:
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)
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
3-23c
3
Trunk and Extremities
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-24a
DISPOSITION
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
3-24b
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
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)
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
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