Non-Melanocytic Pattern Dermoscopy I have no conflicts of interest to disclose Except that I LOVE dermoscopy Michelle Tarbox, MD Assistant Professor of Dermatology and Dermatopathology Texas Tech University Health Sciences Center 2019 1 2 Non-Melanocytic Lesion Dermoscopy Often also non-pigmented Problem: No Pigment! Solution: Use your clues! Vascular structures Chrysalis structures Texture Structureless areas Scale Ulceration Vascular morphology J Am Acad Dermatol - 01-SEP-2010; 63(3) Comma-like - IDN Dotted -Spitz Linear irregular - AMM Hairpin SK, SCC, KA Glomerular - SCCIS Arborizing - BCC 3 4 Crown vessels Seb H Strawberry pattern - AK Milky red areas/globules Thick AMM A regular B in a string C clustered D radial E irregularly branched F irregular A. Dots (melanoma) B. Clods (lacunes) (hemangioma) C. Lines straight (ulcerated BCC) D. Lines looped (hairpin vessels)(scc) E. Lines curved (comma vessels) (dermal nevus) F. Lines serpentine (linear irregular vessels (BCC) G. Lines helical (corkscrew vessels) (SCCIS) H. Lines coiled (glomerular vessels) (SCCIS 5 6 J Am Acad Dermatol - 01-SEP-2010; 63(3) Rosendahl, Cliff et al. Dermatology Practical & Conceptual4.1 (2014): 59 66. PMC. Web. 9 Sept. 2018. 1
A. Random (non-specific) (SCCIS) B. Clustered (SCCIS) C. Serpiginous (string of pearls) (CCA) D. Linear (SCCIS) E. Centered (seborrheic keratosis) F. Radial (starburst) (SCC) G. Reticular (sun-damaged skin) Non-Melanocytic Lesions Benign Lesions Seborrheic keratoses Clear cell acanthoma Vascular lesions Angiomas Angiokeratomas Dermatofibromas Conventional Cellular Malignant Lesions Basal cell carcinoma Actinic keratoses Squamous cell carcinomas Merkel cell carcinoma H. Branched (arborizing) (BCC) Rosendahl, Cliff et al. Dermatology Practical & Conceptual4.1 (2014): 59 66. PMC. Web. 9 Sept. 2018. 7 8, patient granted special permission to show tattoo 9 10 Milia-like cysts = pseudo-horn cysts (black arrows) Comedo-like openings = comedo structures (red arrows) Multiple milia like cysts 11 12 2
13 14 Irregular crypts and comedo like openings Fissures and Ridges Wedge shaped clefts in the epidermis AKA gyri and sulci, fat fingers, or cerebriform pattern Can also be seen in melanocytic nevi with congenital patterns, and epidermal nevi 15 16 17 18 3
Fissures/ridges 19 20 Fissures/ridges 21 22 Congenital type nevus with Fissures/ridges 23 24 4
25 26 27 28 29 30 5
31 32 33 34 Clear cell acanthoma String of pearls vessels Glycogen rich keratinocytes 35 36 6
Hemangioma Red-blue homogeneous color Red-blue lacunes 37 38 39 40 Angiokeratoma Multiple red to bluish-black well defined lacunae Blue-white veil: no diagnostic significance Red-blue lacunae, no pigment network Hyperkeratosis over thrombosed vessels Acral pseudolymphomatous angiokeratoma of children with rainbow pattern: A mimicker of Kaposi sarcoma Pinos León, Víctor Hugo et al. Journal of the American Academy of Dermatology, Volume 76, Issue 2, S25 - S27 41 42 7
43 44 45 46 Multinucleate Cell Angiohistiocytoma Multinucleated cells in the superficial dermis with an angular outline (detailed in lower right corner, Hematoxylin & eosin, X100). Proliferation of small dilated vessels, slight interstitial infiltrate of spindle or dendritic perivascular cells, mostly lymphohistiocytic 47 48 Rato M, Monteiro AF, Parente J, Aranha J. Case for diagnosis. Multinucleated cell angiohistiocytoma. Anais Brasileiros de Dermatologia. 2018;93(2):291-293. 8
Dermatofibroma Central scar like pallor Surrounding delicate pigment network Chrysalis structures Diffuse reddish areas (attributed to the dilated vessels), whitish patches (associated with thickening of the collagen) and isolated peripheral areas with a fine reticulated appearance 49 50 Cellular Dermatofibroma Nodule with central scar like pallor Surrounding delicate pigment network Chrysalis structures / central erosion/focal ulceration BROWN BROWN 51 52 53 54 9
Ulceration without a clear history of trauma should lead to a biopsy Serum leaking from ulcerated areas may trap fibers of clothing or loose hair Adherent fiber ~ dermoscopic clue to ulceration 55 56 57 58 59 60 10
Ulceration Ulceration Seen in pigmented and non-pigmented basal cell carcinoma 61 62 Arborizing vessels 64 65 66 67 11
Large Blue-Gray Ovoid Nests Well circumscribed, confluent, pigmented ovoid areas Larger than globules Not connected to larger tumor body Represent large nests of pigmented BCC Large Blue-Gray Ovoid Nests 68 69 Benign intradermal vs Basal cell carcinoma Multiple Blue-Gray Globules Round, well circumscribed structures Smaller nests of pigmented basal cells 70 71 Multiple Blue-Gray Globules 72 73 12
Maple Leaf Areas Nests of pigmented epithelial nodules of basal cell carcinoma Spoke-wheel areas Maple leaf areas 74 75 Spoke-Wheel Areas Well circumscribed brown to gray-blue-brown radial projections meeting at a darker central hub Nests of basal cell carcinoma radiating from a follicular epithelium 76 77 Chrysalis Structures AKA Crystalline structures or shiny white streaks (SWS) Only seen with polarized dermoscopy Most commonly seen in basal cell carcinoma and invasive melanomas, may be seen in dermatofibromas and scars In melanomas may reflect increased tumor thickness and regression 78 79 BCC Invasive Melanoma Aneurysmal DF 13
BCC BCC 80 81 BCC 82 83 Fibroepithelioma of Pinkus Chrysalis structures on Dermoscopy Dermatol Pract Concept 2013;4(1):9 Non pigmented Actinic Keratoses Pink-red pseudo-network surrounding follicles White-to-yellow surface scale Fine wavy vessels surrounding hair follicles Yellowish keratotic plugs in follicular ostia Strawberry-like pattern composed of reddish pseudo network around whitish keratin filled hair follicles 84 85 Actinic keratosis 14
Pigmented actinic keratosis 86 87 Pigmented actinic keratosis Squamous Cell Carcinoma in Situ Glomeruloid blood vessels Focal heme crust Scale 88 89 90 91 15
92 93 94 95 96 97 16
Dermoscopic features of squamous cell carcinoma of the tongue: It looks similar to cutaneous squamous cell carcinoma Lobules composed of central whitish yellow keratin Polymorphous vessels dotted (yellow arrow) Arborizing (blue arrow), glomerular (black circle), and linear irregular (red arrow) vessels on a yellowish white background Journal of the American Academy of Dermatology, Volume 75, Issue 2, 2016, e53 e54 98 99 100 101 Diagnosing squamous cell carcinoma of the lip using dermoscopy Central whitish yellow keratin surrounded by polymorphous vessels Dotted (yellow arrow), arborizing (blue arrow), coiled (black circle), and hairpin (red arrow) White structureless areas (black arrow) ->nmass of highly keratinized malignant squamous cells Thin white cylinder with a hair shaft emerging from the center of it This finding is produced by highly keratinized malignant squamous cells invading hair follicles. Journal of the American Academy of Dermatology, Volume 76, Issue 2, Supplement 1, 2017, S82 S83 [Copyright: 2014 Rosendahl et al.] Dermatol Pract Concept 2013;4(1):9 102 103 17
Merkel Cell Carcinoma 104 105 106 107 108 109 18
Clinical and dermoscopic features of combined cutaneous squamous cell carcinoma (SCC)/neuroendocrine [Merkel cell] carcinoma (MCC) Combined squamous/merkel cell carcinoma, A. Erythematous nodule with adherent scale; background dermatoheliosis with atrophy and wrinkling, B. Dermoscopy with milky red areas centrally (small top arrow) and large-diameter arborizing vessels at the periphery (larger lower arrows) Journal of the American Academy of Dermatology, Volume 73, Issue 6, 2015, 968 975 110 111 The most likely diagnosis is: A. Stasis dermatitis B. Actinic keratosis C. Porokeratosis D. Clear cell acanthoma E. Squamous cell carcinoma in situ 112 113 The most likely diagnosis is: A. Stasis dermatitis B. Actinic keratosis C. Porokeratosis D. Clear cell acanthoma E. Squamous cell carcinoma in situ 114 115 19
Dermoscopic findings Glomeruloid blood vessels Focal heme crust Scale 116 117 Diagnosis: Squamous Cell Carcinoma In Situ The most likely diagnosis is: A. Actinic keratosis B. Inflamed seborrheic keratosis C. Atypical nevus D. Clear cell acanthoma E. Basal cell carcinoma 118 119 The most likely diagnosis is: A. Actinic keratosis B. Inflamed seborrheic keratosis C. Atypical nevus D. Clear cell acanthoma E. Basal cell carcinoma 120 121 20
Dermoscopic features String of pearls blood vessels Diagnosis: Clear cell acanthoma 122 123 The most likely diagnosis is: A. Basal cell carcionoma B. Inflamed seborrheic keratosis C. Amelanotic melanoma D. Merkel cell carcinoma E. Squamous cell carcinoma 124 125 The most likely diagnosis is: A. Basal cell carcionoma B. Inflamed seborrheic keratosis C. Amelanotic melanoma D. Merkel cell carcinoma E. Squamous cell carcinoma 126 127 21
The most likely diagnosis is: A. Nodular melanoma B. Inflamed seborrheic keratosis C. Atypical nevus D. Angiokeratoma E. Pigmented basal cell carcinoma 128 129 130 131 The most likely diagnosis is: A. Nodular melanoma B. Inflamed seborrheic keratosis C. Atypical nevus D. Angiokeratoma E. Pigmented basal cell carcinoma 132 133 22
Dermoscopic features Asymmetric Blue grey ovoid nests Arborizing telangiectasias Chrysalis structures Epidermal ulceration Diagnosis: Pigmented basal cell carcinoma Thank you! Michelle Tarbox, MD Assistant Professor of Dermatology Texas Tech University Health Sciences Center Michelle.Tarbox@ttuhsc.edu 134 135 Scabies Triangle indicating the head of the mite 136 137 138 139 23
140 141 142 143 Fun Benign things... 144 145 24
146 147 Porokeratosis White tract structure =cornoid lamella Central white area, red dots, globules and lines 148 149 150 151 25
152 153 Sebaceous Hyperplasia Aggregated white-yellow nodules ~ cumulous cloud Crown vessels (radial wreath-like) Banching vessels that extend towards the center of the lesion without crossing it 154 155 156 157 26
Nevus Sebaceous 158 159 Accessory Nipple Central white area Central streak Faint pigmented network at the periphery 160 161 Xanthogranuloma Orange-yellow background coloration with clouds of xanthomatous deposits 162 163 27
164 165 166 167 Thank you! Michelle Tarbox, MD Assistant Professor of Dermatology Texas Tech University Health Sciences Center Michelle.Tarbox@ttuhsc.edu 168 28