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Once this lesion was determined to be melanocytic, it looked more malignant than benign The most atypical dermoscopic features could be associated with a benign lesion
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Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
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DISPOSITION
No intervention Follow-up Histopathologic diagnosis
CASE 73
HISTORY
An 84-year-old man with a history of multiple skin cancers had this lesion on his back 1 A milky-red area, irregular brown globules, polymorphous vessels, and milia-like cysts characterize this melanoma 2 Multiple milia-like cysts, pigmented pseudofollicular openings, and hairpin vessels diagnose a seborrheic keratosis 3 This could be a collision tumor: a seborrheic keratosis and amelanotic melanoma 4 The bluish-white color is not diagnostic of a melanoma and could be seen in a seborrheic keratosis 5 Multiple milia-like cysts and multiple pigmented pseudofollicular openings help differentiate a seborrheic keratosis from a melanocytic lesion that can have a few of these criteria
3-73b
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
1 2 3
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
ANSWERS
Answers: 2,3,4,5
Discussion:
DERMOSCOPIC CRITERIA
Asymmetry of color and structure Multicomponent global pattern (1,2,3) Milia-like cysts (circles) Pigmented pseudofollicular openings (arrows) Hairpin vessels (black box) Milky-red area (yellow box) Bluish-white color (stars)
Asymmetry of color and structure and a multicomponent global pattern are commonly seen in seborrheic keratosis and are a nonspecific finding of little significance if there are criteria that definitively diagnose a seborrheic keratosis Multiple milia-like cysts and pigmented pseudofollicular openings make the diagnosis The milia-like cysts look like stars in the sky This seborrheic keratosis is heavily pigmented, which is the norm The milky-red/pink area has a differential diagnosis Collision tumor: Seborrheic keratosis and amelanotic melanoma Seborrheic keratosis and basal cell carcinoma Seborrheic keratosis and eccrine porocarcinoma Focus of irritation One has to use their imagination to diagnose the hairpin vessels Polymorphous vessels (eg, linear, corkscrew) are in the differential diagnosis
PEARLS
Classic seborrheic keratosis without areas of potentially high risk pathology are routinely seen Collision tumors commonly have seborrheic keratosis as one component Beware! Melanomas are commonly mistaken for seborrheic keratosis
3-73c
3
Trunk and Extremities
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-74a
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
CASE 74
HISTORY
A 34-year-old woman noticed a change in a nevus on her arm, which she had for many years 1 Pigment network and brown globules identify a melanocytic lesion 2 There is symmetry of color and structure, a globular global pattern, regular pigment network, and comma-shaped vessels 3 Milky-red/pink color and pinpoint vessels are a red flag for concern 4 Foci of the globular global pattern suggest that this melanoma arose in a pre-existing nevus 5 Grayish homogeneous color without peppering suggests that there is regression in this melanoma
3-74b
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
Low Intermediate High
3 2 1
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3 3-74c
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
ANSWERS
Answers: 1,3,4,5
DERMOSCOPIC CRITERIA
Discussion:
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular pigment network (black boxes) Irregular purplish blotch (white arrows) Cobblestone-like globules (red boxes) Milky-red/pink color (stars) Pinpoint vessels (circles) Bluish-white color (yellow arrows) Gray homogeneous color and peppering (black arrows)
Clinically and dermoscopically this is clearly a high risk lesion There would not be a good clinico dermoscopic pathologic correlation if the pathologic report was not melanoma Remnants of the cobblestone global pattern indicate that the melanoma arose in a pre-existing nevus The differential diagnosis includes reticular depigmentation (white network/negative pigment network) The milky-red/pink color with pinpoint vessels are dramatic and the first clue one might notice that this is a high risk lesion If there s pink stop and think! There is a component of bluish-white color that can be a component of a milky-red area The milky-red/pink area has a differential diagnosis Neovascularization in a melanoma Amelanotic component of the pigmented melanoma The irregular purplish blotch is another melanoma-specific criterion that has no diagnostic significance The homogeneous grayish color with peppering represents foci of regression
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