comedo-like openings (clods, brown or orange & circles) milia-like cysts (dots or clods, white) 1/29/18 Dotted vessels are also commonly seen in SCC

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1 Brown circles Dotted vessels are also commonly seen in SCC Step1 1. Nevus (unequivocal) 2. DF/IDN 3. BCC 4. SCC Network Patchy network Peripheral network & central hypopigmentation DF: network with central white blotch Arborizing / branched vessels DF: network with ring-like globules, shiny white streaks & pink hue Spoke wheel like Peripheral network & central hyperpigmentation IDN: comma/curved vessels, brown halo, brown pigmentation, globules Leaf like areas Peripheral network & central globules Blue gray ovoid nests Globular Multiple blue gray dots / globules Globular Cobblestone Shiny white blotches & strands Reticular Peripheral globules Ulceration Homogenous blue Homogenous brown Milia-like cyst Comedo-like opening Fissures & ridges (gyri & sulci) Fingerprint-like (jelly sign) SK Glomerular / coiled vessels White circles Brown circles Rosettes Brown dots radially arranged Yellow scale Strawberry pattern Hairpin vessels with Hairpin (looped) vessels 5. Seb K 6. Other Milia like cysts Angioma: Red lacunae Fingerprint like Comedo like openings Fissures/sulci Sebaceous hyperplasia: Angiokeratoma: Crown vessels Red / blue / black lacunae Moth eaten Sharp demarcation Gyri/ridges and Hairpin vessels border sulci/fissures with Step 2: Look for melanoma patterns & CCA: Vessels in serpiginous / string of pearls arrangement (Card 2&3) Moth-eaten borders milia-like cysts (dots or clods, white) round whitish or yellowish commonly seen in seborrheic keratosis can also be seen in congenital nevi & MM if pigmented, they resemble globules comedo-like openings (clods, brown or orange & circles) commonly seen in seborrheic keratosis also seen in papillomatous melanocytic nevi keratin-filled invaginations of the epidermis 1

2 1/29/18 seborrheic Keratosis multiple milia-like-cysts (3 or more) comedo-like openings (crypts) Milia cyst are more conspicuous under non-polarized light Milia cyst (superficial & small) are not usually visible with polarized dermoscopy Gyri & sulci (fissures & ridges) Confluent branching clefts Start is PD Milia cysts are more conspicuous under NPD Due to deep keratin filled invaginations of the epidermis Commonly seen in seborrheic keratosis 2

3 1/29/18 Fissures (sulci) & ridges (gyri) = cerebriform pattern Fingerprint like network Fingerprint-like Structures Seen in solar lentigines and early seborrheic keratosis Tiny ridges running in parallel & resembling fingerprints Sometimes it is difficult to differentiate lentigo/sk from melanocytic lesions. The ink test can help 3

4 Hairpin (looped) vessels with a white halo Looped vessels in papillary dermis Hairpin blood vessels with a White halo due to keratin Seborrheic keratosis Moth eaten borders Seen in solar lentigines and early SK Resembles a moth-eaten garment 4

5 Moth-eaten Border Jelly sign is associated with lentigo (experience) Jelly sign Exemplar Jelly sign It is discussed but yet to be published Moth eaten borders 5

6 Specific criterion for lentigo? Yes, based on experience needs formal study What do you see? comedo Blue white veil? globules B:M ratio in the hands of experienced dermoscopists is 5:1 (it is lesions like these that make up the bulk of the benign biopsies) Fat finger like Few milia cysts When dermoscopy morphology gives conflicting / mixed messages then R/O worst diagnosis. Specific must support interpretation of the global patter

7 Step1 1. Nevus (unequivocal) 2. DF/IDN 3. BCC 4. SCC Network Patchy network Peripheral network & central hypopigmentation DF: network with central white blotch Arborizing / branched vessels Glomerular / coiled vessels DF: network with ring-like globules, shiny white streaks & pink hue Spoke wheel like Peripheral network & central hyperpigmentation IDN: comma/curved vessels, brown halo, brown pigmentation, globules Leaf like areas Peripheral network & central globules Blue gray ovoid nests White circles Brown circles Rosettes Brown dots radially arranged Globular Multiple blue gray dots / globules Yellow scale Globular Cobblestone Shiny white blotches & strands Reticular Peripheral globules Strawberry pattern Ulceration Homogenous blue Hairpin vessels with Homogenous brown Vascular lesion Lacunae separated by BWV septae red maroon blue black clear 5. Seb K Milia like cysts Comedo like openings Fissures/sulci Fingerprint like Moth eaten border Sharp demarcation Gyri/ridges and sulci/fissures Hairpin vessels with 6. Other Angioma: Red lacunae Angiokeratoma: Red / blue / black lacunae Sebaceous hyperplasia: Crown vessels CCA: Vessels in serpiginous / string of pearls arrangement Step 2: Look for melanoma patterns & (Card 2&3) Lacunae (Clods, red) red, maroon, blue, black lagoons (clods) 7

8 Hemangioma Lacunae (saccules) Pearl: Caution if you see ill defined lacunae that are not separated by: Septae BWV -Well defined lacunae -Septae separating lacunae -Lacunae surrounded by BWV Thrombosed Angiomas Blackest of Black Angiokeratoma Thrombosed angioma 8

9 P1 thrombosed lacunae and blue-white veil P2 erythematous zone around lesion Ref: Zaballos P P3 focal bloody crusts Angiokeratoma Sebaceous Hyperplasia Morphology/Distribution/Arrangement Serpentine and arborizing vessels that are a bit out of focus and come from periphery and migrate towards the center of the lesion but do not cross the midline (crown/corona vessels). The center of the lesion has popcorn like appearance. 9

10 Clear cell acanthoma Morphology/Distribution/Arrangement Dotted or glomerular vessels distributed in a serpiginous pattern (string of pearls) Step1 1. Nevus (unequivocal) Network Patchy network Peripheral network Peripheral Peripheral network Globular & central network & central & central globules hypopigmentation hyperpigmentation Globular Reticular Homogenous Cobblestone Peripheral globules blue Homogenous brown 2. DF/IDN DF: network DF: network with ring-like with central globules, shiny white white blotch streaks & pink hue IDN: comma/curved vessels, brown halo, brown pigmentation, globules 3. BCC Arborizing / branched vessels Spoke wheel like Leaf like areas Blue gray ovoid nests Multiple blue gray Shiny white blotches & dots / globules strands Ulceration 4. SCC Glomerular / coiled vessels White circles Brown circles Rosettes Brown dots radially arranged Yellow scale Strawberry pattern Hairpin vessels with 5. Seb K Milia like cysts Comedo like openings Fissures/sulci Fingerprint like Moth eaten border Sharp demarcation Gyri/ridges and sulci/fissures Hairpin vessels with 6. Other Angioma: Red lacunae Angiokeratoma: Red / blue / black lacunae Sebaceous hyperplasia: Crown vessels CCA: Vessels in serpiginous / string of pearls arrangement Step 2: Look for melanoma patterns & (Card 2&3) 10