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Inter-observer agreement is not always good even among experienced dermoscopists Some might not think there are spoke-wheel structures in this lesion We identified the spoke-wheel structures immediately, and based on that made the correct dermoscopic diagnosis before the lesion was removed With knowledge and imagination, there is no telling where dermoscopy will take you!
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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 105
HISTORY
White color developed around several nevi on a 19-year-old woman 1 Globules identify a melanocytic lesion 2 This could represent the fissure and ridge pattern of a halo seborrheic keratosis 3 Asymmetry of color and structure, irregular dots and globules, and regression diagnose a melanoma 4 This could be a halo nevus with a benign cobblestone global pattern 5 A wide diameter halo around a melanocytic lesion is diagnostic of melanoma
3-105b
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
Cobblestone global pattern Regular dots and globules (boxes) Regression (stars)
Brown globules identify a melanocytic lesion Large angulated globules with a few dots make up the cobblestone global pattern The fissure and ridge pattern of a seborrheic keratosis is in the differential diagnosis of a cobblestone global pattern This is a halo nevus with an unusually wide halo The size of a white halo has no diagnostic significance and does not diagnose melanoma Rarely, you may see halo seborrheic keratosis
PEARLS
Sequential digital clinical and dermoscopic monitoring is a cutting-edge way to follow this patient Halo nevi usually disappear over a variable period of time The wobble sign created by pressure from instrumentation directly on a lesion and side-to-side movement can be used to differentiate a seborrheic keratosis from a melanocytic nevus A seborrheic keratosis is usually fixed to the skin and is immobile a negative wobble sign An elevated nevus usually moves easily from side-to-side a positive wobble sign
3-105c
3
Trunk and Extremities
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-106a
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
CASE 106
HISTORY
This lesion was found on the knee of an 82-year-old man There could be a history of trauma while working in his yard However, the patient was not sure 1 Clinically and dermoscopically this is consistent with an abrasion and topical antibiotics should be recommended 2 If you miss the focus of brown globules, the homogeneous brown color suggests this red nodule could be a melanocytic lesion 3 Different shades of pink color are a red flag for concern 4 Pinpoint vessels and milky-red globules suggest this could be an amelanotic melanoma 5 This feature-poor lesion does not have well-developed melanoma-specific criteria
3-106
DERMOSCOPY: AN ILLUSTRATED SELF-ASSESSMENT GUIDE
RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
4 3-106c
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
ANSWERS
Answers: 2,3,4,5
Discussion:
DERMOSCOPIC CRITERIA
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular brown dots and globules (black box) Homogeneous brown color (yellow arrows) Different shades of pink color Milky-red globules (black arrows) Pinpoint vessels (yellow boxes) Ulceration (white box) Hypopigmentation (stars)
Clinically, but not dermoscopically, an infectious process is in the differential diagnosis Dermoscopic criteria for infectious lesions have not been well studied A focus of irregular brown globules identifies a melanocytic lesion If the globules are not identified, this could be considered to be melanocytic by default The focus of homogeneous brown color suggests the lesion could be melanocytic Amelanotic melanoma, devoid of the typical well-developed, melanomaspecific criteria seen in pigmented melanomas, often have foci of homogeneous brown pigmentation at the periphery Different shades of pink color are an important yet nonspecific clue that this lesion is an amelanotic melanoma These can be seen in melanocytic, nonmelanocytic, benign, malignant, or inflammatory pink lesions Foci of milky-red globules in a background of pink color are another important clue that this could be an amelanotic melanoma The pinpoint vessels could be considered milky-red globules The differentiation is a minor point because both types of vessels indicate the lesion might be high risk Hypopigmentation is created by the pressure of the camera In most pink lesions pink blanches away with adequate pressure The small ulceration has no diagnostic significance
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