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It is not always possible to identify classic regression or blue-white veil Blue and/or white colors of any intensity, shape or distribution A red flag for concern should be raised that the lesion could be a melanoma Commonly seen featureless areas of light brown color in all types of melanocytic lesions both benign and malignant Inexperienced dermoscopists can have trouble differentiating hypopigmentation from the bony-white color seen with true regression Eumelanin s location in the skin will determine the colors one sees with dermoscopy In a flat or slightly raised lesion, black indicates that melanin is superficially located in the epidermis Black is not always an ominous color but can be seen in benign pathology as well as in invasive melanoma Light and dark brown indicates pigment is at the dermoepidermal junction Gray in the papillary dermis represents free melanin and/or melanophages ( peppering ) As the pigment gets into the deeper dermis it looks blue (the Tyndall effect) Red and/or pink colors can be created by inflammation or neovascularization Sebaceous material and hyperkeratosis can look yellow The more colors seen, the greater the chance that one is dealing with high risk pathology (Figures 1-19, 1-20, 1-21)
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Colors Seen with Dermoscopy
Figure 1-20 Melanoma This is a melanocytic lesion because there are
globules (circle) There is asymmetry of color and structure (+) plus the multicomponent global pattern (1,2,3) Local criteria include: irregular dots and globules (circle), blue-white color (stars), and peppering (boxes) The classic blue-white veil is not seen More than five colors including red are another melanoma-specific criterion (Reproduced, with permission, from Journal of Drugs in Dermatology New Methods and Technologies Sep 2007- Vol 6-Issue 9 Fig 3b)
Atypical Vascular Pattern/Polymorphous Vascular Pattern
Vessels that can be seen in melanoma are nonspecific; they can also be commonly found in other lesions, including Benign Malignant Inflammatory
Figure 1-19 Melanoma This is a melanocytic lesion because there is a pigment network (red arrows) and globules (circles) There is asymmetry of color and structure (+) plus the multicomponent global pattern (1,2,3,4) Local criteria include: irregular pigment network (red arrows), irregular dots and globules (circles), irregular dark blotches (black arrows), and blue-white color (stars) The classic blue-white veil is not seen Peppering (yellow box) and gray blotches (yellow arrows) are part of the regression More than five colors are seen including red (Reproduced, with permission, from Journal of Drugs in Dermatology New Methods and Technologies May 2008-Vol 7-Issue 5 Fig 4b)
Figure 1-21 Melanoma This is a melanocytic lesion because there are
globules (circles) There is an atypical starburst (Spitzoid) global pattern with foci of streaks at the periphery (boxes) Local criteria include: irregular dots and globules (circles), irregular streaks (boxes), and regression The white and gray colors (yellow arrows) make up the regression The black arrows point out where there are no streaks Five colors including red round off the melanoma-specific criteria
1
Dermoscopy from A to Z
When identified, they should raise a red flag for concern including Dotted/pinpoint Irregular linear Irregular torturous/corkscrew (irregular, thick, coiled) Irregular hairpin (irregular and thick hairpin-shaped) Glomerular One must focus their attention to make out the shapes of these small vessels
The color does not completely encircle the openings (early proliferation of atypical melanocytes) A melanoma-specific criterion, used to diagnose lentigo maligna or lentigo maligna melanoma Seen only on the face, nose, and ears ( site-specific ) Brown or gray fine dots that surround follicular openings (melanophages and/or atypical melanocytes) This criterion and asymmetrical follicular pigmentation can be seen in Lentigo maligna, lentigo maligna melanoma Pigmented actinic keratosis Posttraumatic Late-stage lichen planus-like keratosis (Figures 1-23, 1-24) Melasma Seen only on the face, nose, and ears ( site-specific ) Rhomboid is a parallelogram with unequal angles and sides Black, brown, or gray thickening around the follicular openings In reality true rhomboids are not regularly formed Any pigmented thickening around follicular openings is worrisome A melanoma-specific criterion used to diagnose lentigo maligna or lentigo maligna melanoma On the face, nose, and ears Irregular in size and shape Black or brown homogeneous blotches of color Complete occlusion and disappearance of follicular openings due to invasive melanoma (lentigo maligna melanoma)
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