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Finding as many clues as possible might be the only way to diagnose amelanotic melanoma It would be a rare lesion that is 100% featureless Most have vessels that can be identified with minimal pressure or the use of ultrasound or hand sanitizer gel Polarizing light is better than nonpolarizing for visualizing blood vessels
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Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
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3-107a
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No intervention Follow-up Histopathologic diagnosis
CASE 107
HISTORY
You were e-mailed this case for your dermoscopic evaluation No clinical image was sent It was a firm papule on the right shin of a 22-year-old woman She was not aware of its presence 1 Brown globules identify a melanocytic lesion 2 Fine peripheral pigment network and a central white patch diagnose a dermatofibroma 3 The central white patch is composed of homogeneous bony-white color and reticular depigmentation 4 The globular-like structures are created by the reticular depigmentation over a background of dark brown color 5 Reticular depigmentation is diagnostic of a dermatofibroma
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: 2,3,4
Discussion:
DERMOSCOPIC CRITERIA
Regular pigment network (black boxes) Central white patch Homogeneous bony-white color (stars) Reticular depigmentation (white boxes) Globular-like structures (yellow arrows)
A clinical image is not needed to help make the diagnosis The history and dermoscopic criteria are sufficient This is not the classic central white patch that is made up of centrally-located, homogeneous, bony-white color, characteristic of a dermatofibroma Reticular depigmentation (negative or white network) is made up of sharply in-focus honeycomb-like or reticular bony-white line segments The thickness, extent of the line segments, and intensity of the color varies from lesion to lesion Not uncommonly, reticular depigmentation makes up the central white patch of a dermatofibroma The fine, thin peripheral pigment network is one of the major criteria to diagnose dermatofibromas This is the exception to the rule that pigment network diagnoses a melanoctyic lesion Dermatofibromas are not melanocytic, and pigment network helps make their diagnosis The supposedly well-developed brown globules are not what they appear to be They are created by reticular depigmentation over a background of homogeneous dark brown color The novice dermoscopist could be easily led astray and consider them to be the brown globules of a melanocytic lesion
PEARL
Beware! While not the case here, reticular depigmentation/white network might be the only clue that a pigmented lesion is a melanoma!
3-107b
3
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RISK
Low Intermediate High
DIAGNOSIS
Nevus Seborrheic keratosis Basal cell carcinoma Vascular Dermatofibroma Squamous cell carcinoma Melanoma Other
3-108a
DISPOSITION
No intervention Follow-up Histopathologic diagnosis
CASE 108
HISTORY
At a routine follow-up skin examination, this small pigmented lesion was found on the shin of a 30-year-old woman 1 There is not a good clinico dermoscopic correlation because the lesion looks low risk based on ABCD clinical criteria, yet with dermoscopy it looks suspicious 2 Globules identify a melanocytic lesion 3 A large irregular dark blotch and reticular depigmentation diagnose a dermatofibroma 4 A large irregular dark blotch, irregular dots and globules, and reticular depigmentation suggest this is a melanoma 5 Sequential digital monitoring is indicated for this gray zone slightly suspicious pigmented skin lesion
3-108b
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
ANSWERS
DISPOSITION
No intervention Follow-up Histopathologic diagnosis Answers: 1,2,4
Discussion:
DERMOSCOPIC CRITERIA
Asymmetry of color and structure Multicomponent global pattern (1,2,3,4) Irregular brown dots and globules (circles) Irregular dark brown blotch (yellow arrows) Reticular depigmentation (yellow boxes) Hypopigmentation (stars)
This is a melanoma- incognito aka false negative clinical melanoma that would be missed if it were not examined with dermoscopy It lacks the ABCD clinical criteria and looks low risk Irregular brown globules identify a melanocytic lesion Some of the melanoma-specific criteria are well-developed and include: Asymmetry of color and structure Multicomponent global pattern with four different areas A large irregular dark blotch Reticular depigmentation There are poorly defined irregular dots and globules and hypopigmentation both of which are of minor diagnostic significance Section 4 could be an area of regression Reticular depigmentation (negative/white network) is an important clue that a lesion might be melanoma Reticular depigmentation can be found in: Banal nevi Dermatofibromas Dysplastic nevi Melanoma Spitz nevi
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