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Figure 1-9 Seborrheic Keratosis Sharp borders (red arrows), milia-like
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cysts (black arrows), and pseudofollicular openings (boxes) characterize this seborrheic keratosis
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Figure 1-11 Seborrheic Keratosis An especially well-formed hairpin
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vessel (box) in a seborrheic keratosis
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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 Flat or slightly raised brown seborrheic keratoses Well-demarcated, concave borders that are felt to resemble a moth-eaten garment The majority of seborrheic keratoses have sharp, well-demarcated borders Not always indicative of melanoma in a pigmented lesion (Figure 1-9)
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SHARP DEMARCATION
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 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 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 1-12 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
Blue Red White
ULCERATION
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 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
SPOKE-WHEEL STRUCTURES
PIGMENTATION
Figure 1-13 Basal Cell Carcinoma Arborizing vessels (black arrows) and
ulceration (yellow arrows) characterize this nonpigmented basal cell carcinoma
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
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 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 1-15 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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