Dermoscopy in Basal Cell Carcinoma: An Updated Review

Dermoscopy is a noninvasive technique that has been demonstrated to improve diagnostic accuracy in basal cell carcinoma (BCC). The first dermoscopic model for the diagnosis of BCC, based mainly on the identification of pigmented structures, was described by Menzies et al., and since then dermoscopy has generated an abundance of literature useful to routine clinical practice. From a practical perspective, dermoscopic structures associated with BCC can be classified as pigmented, vascular, or nonpigmented/nonvascular. One of the most recent applications of dermoscopy in BCC is as an aid to predicting histologic subtype and essentially differentiating between superficial and nonsuperficial BCC. It can also, however, help raise suspicion of more aggressive variants with a higher risk of recurrence. A thorough dermoscopic examination during follow-up of patients with actinic damage or a history of multiple BCCs can facilitate the detection of very incipient lesions and significantly impact treatment and prognosis.

Dermoscopy of inverted follicular keratosis: study of 12 cases

BACKGROUND

Inverted follicular keratosis (IFK) is an uncommon benign tumour of the follicular infundibulum, which is often misdiagnosed clinically as other keratinizing tumours, and commonly diagnosed correctly by histopathology. There are few reports about the dermoscopic findings of this lesion.

AIM

To evaluate the dermoscopic features of IFK.

METHODS

The dermoscopic structures and patterns in digital dermoscopic images of 12 histopathologically confirmed cases of IFK collected from 5 hospitals in Spain were evaluated.

RESULTS

A keratoacanthoma (KA)-like pattern composed of central keratin surrounded by hairpin vessels in a radial arrangement was the most common pattern in IFK (58.3%). The second most common pattern was composed of a yellowish-white amorphous central area surrounded by vascular structures in a radial arrangement (33.3%). The remaining case showed a pattern composed of a yellowish-white amorphous central area with milky red globules. Vascular structures were present in all cases, with a monomorphic pattern in seven cases and a polymorphic pattern in five, mainly with radial arrangement. Arborizing vessels, linear irregular vessels, corkscrew vessels and milky red globules were present in some cases.

CONCLUSIONS

We describe the two main patterns of IFK. Lesions with a KA-like pattern are clinically and dermoscopically undistinguishable from KA and squamous cell carcinoma. Cases with a polymorphic vascular pattern could be confused with malignant tumours, including basal cell carcinoma and amelanotic melanoma.

Yellow and orange in cutaneous lesions: clinical and dermoscopic data

Colour of the lesions is clue for the clinical and dermoscopic diagnosis. Nevertheless, we have detected in the literature an uneven relevance of the colours as a diagnostic criterion. Thus, while red, brown and blue have taken important role in dermoscopic descriptions, other like yellow and orange have been given much less importance. This article reviews those lesions in which the yellow and orange colours have been considered constitutive or essential for diagnosis, and on the other hand it emphasizes the entities in which may appear these colours and are not well reflected in the literature. We believe that organize all this information will help us in a better understanding of these pathologies.

Dermoscopy of tumours arising in naevus sebaceous: a morphological study of 58 cases

BACKGROUND

Naevus sebaceous is a congenital hamartoma commonly associated with the development of secondary neoplasms. There are sparse data relating to the dermoscopy of tumours arising in naevus sebaceous.

OBJECTIVES

To evaluate the dermoscopic features of a large series of neoplasms arising in naevus sebaceous.

METHODS

Digital dermoscopic images of 58 histopathologically confirmed cases of secondary neoplasms arising in naevus sebaceous collected from 11 hospitals in Spain, France, Italy and Austria were evaluated for the presence of dermoscopic structures and patterns.

RESULTS

The most frequent tumours collected were: trichoblastoma (39.6%), basal cell carcinoma (20.7%) and syringocystadenoma papilliferum (15.6%). The most remarkable findings were: (i) the pattern composed of asymmetrical large blue-grey ovoid nests was more common in basal cell carcinomas than in trichoblastoma (58.3% vs. 4.3%; P < 0.001) and the pattern composed of a symmetrical total large blue-grey ovoid nest (a blue-grey homogeneous area which occupies the whole lesion) was more common in trichoblastoma (82.6% vs. 16.6%; P < 0.001); (ii) the most frequent pattern associated with syringocystadenoma papilliferum was a symmetric, erythematous lesion with exophytic papillary structures, ulceration and vessels (55.5%); (iii) the most common pattern associated with apocrine hidrocystomas was a total symmetric homogeneous area and arborizing telangiectasias (60%).

CONCLUSIONS

Benign adnexal tumours associated with naevus sebaceous are dermoscopic mimickers of basal cell carcinomas. A pigmented nodule arising in a naevus sebaceous with a total blue large ovoid nest on dermoscopy could be a trichoblastoma, basal cell carcinoma, hidrocystoma or hidradenoma. Dermoscopy can be a useful diagnostic tool which generates a more accurate preoperative diagnosis.

Blue-black rule: a simple dermoscopic clue to recognize pigmented nodular melanoma

BACKGROUND

Dermoscopy improves melanoma recognition, but most criteria were described in the context of superficial spreading melanoma.

OBJECTIVES

To test whether pigmented nodular melanoma could be recognized dermoscopically by the presence of a combination of blue and black colour within the lesion.

METHODS

Dermoscopic images of histopathologically diagnosed pigmented nodular tumours with no (or only minimal) flat component were evaluated for the presence of standard melanoma criteria and for the presence of a new feature named blue-black (BB) colour. Sensitivity, specificity, positive predictive value and negative predictive value were calculated for standard criteria and BB feature in relation to the diagnosis of melanoma and to diagnosis of malignancy.

RESULTS

Of 283 lesions, 160 were malignant, including 78 (27·6%) melanomas, and 123 were benign. The BB feature and the standard criteria had 78·2% and 43·6% sensitivity for melanoma, respectively, whereas a combined method based on the presence of either the BB feature or one (or more) of the standard criteria reached 84·6% sensitivity, with 80·5% specificity and 93·2% negative predictive value. Sensitivity values for malignant lesions were only 24·4%, 56·9% and 60% for standard criteria, BB feature and the combined method, respectively. However, the combined method gave 91·9% specificity and 90·6% positive predictive value for malignancy.

CONCLUSIONS

Using a method based on the BB feature or one of the standard melanoma criteria, only 9·4% of positive pigmented nodular lesions were found to be benign and only 6·8% of negative lesions were found to be melanoma histopathologically.

Dermoscopy of scalp tumours: a multi-centre study conducted by the international dermoscopy society

BACKGROUND

Little is known about the dermoscopic features of scalp tumours. Objective  To determine the dermoscopic features of scalp tumours.

METHODS

Retrospective analysis of dermoscopic images of histopathologically diagnosed scalp tumours from International Dermoscopy Society members.

RESULTS

A total of 323 tumours of the scalp from 315 patients (mean age: 52 years; range 3-88 years) were analysed. Scalp nevi were significantly associated with young age (<30 years) and exhibited a globular or network pattern with central or perifollicular hypopigmentation. Melanoma and non-melanoma skin cancer were associated with male gender, androgenetic alopecia, age >65 years and sun damage. Atypical network and regression were predictive for thin (≤1 mm) melanomas, whereas advanced melanomas (tumour thickness > 1 mm) revealed blue white veil, unspecific patterns and irregular black blotches or dots.

CONCLUSIONS

The data collected provide a new knowledge regarding the clinical and dermoscopy features of pigmented scalp tumours.

Dermoscopy of pyogenic granuloma: a morphological study

BACKGROUND

Pyogenic granuloma is a common, benign, vascular lesion of the skin and mucous membranes which is a simulator of amelanotic/hypomelanotic melanoma and other tumours.

OBJECTIVES

To determine the diagnostic significance of dermoscopic structures and patterns associated with pyogenic granulomas in a large series of cases.

METHODS

Digital dermoscopic images of histopathologically proven cases of 122 pyogenic granulomas and 140 other tumours (28 amelanotic melanomas, seven melanoma metastases, 22 basal cell carcinomas and 83 other tumours) were collected from university hospitals in Spain, Italy, Austria and Turkey. The frequency, sensitivity, specificity, positive predictive value, negative predictive value, intraobserver agreement and interobserver agreement of the dermoscopic structures and patterns associated with pyogenic granulomas were calculated.

RESULTS

Vascular structures were observed in 45% of pyogenic granulomas (sensitivity of 45·1% and specificity of 17·9%; both P < 0·001). Seven exclusive patterns were made up from the combination of the structures 'reddish homogeneous area' (RHA), 'white collarette' (WC), 'white rail lines' (WRL) and 'vascular structures' (VS). The pattern composed of RHA, WC and WRL showed the highest sensitivity (22·1%; P < 0·001) and a specificity of 100% (P < 0·001) for pyogenic granulomas. Two other patterns (RHA + WC and RHA + WC + WRL + VS) showed 100% specificity when compared with melanoma (P < 0·001 and P < 0·05, respectively).

CONCLUSIONS

Even though some dermoscopic patterns are useful in the recognition of pyogenic granulomas, dermoscopy is not a substitute for histology, mostly when vessels are present, as melanoma cannot be ruled out.

Dermoscopic features of melanomas associated with MC1R variants in Spanish CDKN2A mutation carriers

BACKGROUND

The presence of at least one MC1R gene variant is associated with a reduction in age at melanoma diagnosis in families with CDKN2A mutations.

OBJECTIVES

To describe dermoscopic features of early melanoma in CDKN2A gene mutation-positive Spanish individuals and to evaluate the possibility of a correlation between particular dermatoscopic pattern and MC1R gene variants.

METHODS

Patients in whom a melanoma was diagnosed during specific follow up of high-risk individuals carrying CDKN2A mutations (with familial or personal history of previous melanoma) were included in this study. The decision to remove such melanomas was taken on the basis of history, clinical and dermoscopic evaluations including total body photography and digital dermoscopy.

RESULTS

Of the nine patients included in this study, three were noncarriers of the red hair MC1R polymorphism, three patients had one red hair MC1R polymorphism and three patients had two red hair MC1R polymorphisms. On dermoscopic analysis of suspect melanocytic lesions we found that the mean +/- SD ABCD total dermoscopy score (TDS) was significantly higher in noncarriers of red hair MC1R polymorphisms than in carriers of two MC1R gene red hair variants (6.8 +/- 0.4 vs. 4.4 +/- 0.9; P = 0.014).

CONCLUSIONS

Early melanomas in patients with two MC1R red hair variants may be difficult to diagnose definitively by dermoscopy because, in our limited experience, they show fewer colours and structures and have a lower TDS. In such melanomas, subtle atypical vessels and other changes detected by digital image follow up may be useful to confirm the diagnosis of melanoma. An integrated approach including clinical history and dermoscopic data (also considering additional information, such as the presence of atypical vessels) should be utilized in evaluating these high-risk patients. Further studies are necessary to confirm our suggestion.

Dermoscopic pattern of intermediate stage in seborrhoeic keratosis regressing to lichenoid keratosis: report of 24 cases

BACKGROUND

Lichenoid keratosis (LK) is a well-described entity which has been proposed to represent an immunological or regressive response to pre-existing epidermal lesions such as solar lentigines or seborrhoeic keratoses.

OBJECTIVES

To evaluate the dermoscopic criteria of a series of cases of LK with remaining areas of seborrhoeic keratosis which were both dermoscopically and histologically diagnosed.

METHODS

Pigmented lesions with dermoscopic areas of seborrhoeic keratosis and LK in the same tumour were consecutively diagnosed and prospectively included in the study. All pigmented lesions were examined and registered using DermLite Foto equipment (3Gen, LLC, Dana Point, CA, U.S.A.), at 10-fold magnification, at the Dermatology Department of Hospital de Sant Pau i Santa Tecla (Tarragona, Spain), between 1 January 2003 and 31 December 2005.

RESULTS

In total, 24 cases of lesions with dermoscopic areas of seborrhoeic keratosis and LK were collected. In four lesions (17%), the clinical differential diagnosis without dermoscopy included malignant melanoma and in seven lesions (29%), basal cell carcinoma. The diagnosis of LK was clinically considered without dermoscopy in only six cases (25%). A granular pattern was observed to be distributed throughout the LK areas of the lesions. This pattern consisted of the presence of brownish-grey, bluish-grey or whitish-grey coarse granules that formed, in 11 cases (46%), globules and/or short lines. In one lesion, located on the face, these short lines produced annular or rhomboid structures as seen in lentigo maligna melanoma.

CONCLUSIONS

Dermoscopy is a useful tool which assists in the correct clinical recognition of LK, which may also potentially illuminate the pathogenesis of these tumours, showing the intermediate stage of regressing epidermal lesions in an LK.

Dermoscopic findings in pyogenic granuloma

BACKGROUND

To the best of our knowledge, no specific dermoscopic criteria have been described in the medical literature for the diagnosis of pyogenic granuloma.

OBJECTIVES

To evaluate the morphological findings of pyogenic granuloma under dermoscopic observation.

METHODS

Dermoscopic examination (using the DermLite Foto; 3Gen, LLC, Dana Point, CA, U.S.A.) of 13 patients with pyogenic granulomas was performed to evaluate specific dermoscopic criteria.

RESULTS

The most frequently occurring dermoscopic features were found to be: reddish homogeneous area (92%), white collarette (85%), "white rail" lines that intersect the lesion (31%) and ulceration (46%). The results of our study reveal that the absence of specific dermoscopic criteria for other skin tumours and a reddish homogeneous area surrounded by a white collarette are the most frequent dermoscopic pattern in pyogenic granulomas (85%).

CONCLUSIONS

Dermoscopy is a useful tool for improving the recognition of pyogenic granuloma.

Dermoscopic findings of haemosiderotic and aneurysmal dermatofibroma: report of six patients

BACKGROUND

The clinical diagnosis of dermatofibroma is commonly easy. However, the differentiation of dermatofibroma from other cutaneous tumours is difficult in some instances, primarily in atypical cases and rare variants. Haemosiderotic dermatofibroma is a variant composed of numerous small vessels, extravasated erythrocytes and intra- and extracellular haemosiderin deposits. Aneurysmal dermatofibroma is a variant composed of large, blood-filled spaces without endothelial lining. Some authors consider that haemosiderotic dermatofibroma is an early stage in the development of aneurysmal dermatofibroma. The clinical differential diagnosis of haemosiderotic or aneurysmal dermatofibroma must include melanoma and other melanocytic tumours, vascular neoplasms, adnexal tumours and nonspecific cysts. Dermoscopy improves the diagnostic accuracy in pigmented and nonpigmented skin lesions.

OBJECTIVES

To evaluate specific dermoscopic criteria.

METHODS

Dermoscopic examination (using the DermLite Foto; 3Gen, LLC, Dana Point, CA, U.S.A.) of six patients with haemosiderotic or aneurysmal dermatofibromas was performed to evaluate specific dermoscopic criteria.

RESULTS

A multicomponent pattern with a central bluish or reddish homogeneous area in combination with white structures and a peripheral delicate pigment network along with vascular structures was noted in five of six lesions.

CONCLUSIONS

This dermoscopic pattern yielded the diagnosis of haemosiderotic or aneurysmal dermatofibroma in most cases. However, this multicomponent pattern may present in some melanomas and although it is useful in determining a clinical diagnosis of aneurysmal dermatofibroma, it may not be specific to this entity.

Dermoscopy is useful for the recognition of benign-malignant compound tumours

The association of two different neoplasms in the same lesion is uncommon and has been reported as collision or compound tumours in the medical literature. In cases where a malignant neoplasm exists in association with a benign lesion it is important to make an accurate diagnosis in order to treat the lesions correctly. Dermoscopy is an in vivo, noninvasive technique that improves the clinical accuracy in diagnosing melanoma and other pigmented skin lesions. We describe the dermoscopic characteristics of various collision or compound tumours that were composed of benign and malignant neoplasms: two cases of seborrhoeic keratosis associated with basal cell carcinoma, two cases of melanocytic naevus and basal cell carcinoma and one case of dermatofibroma associated with basal cell carcinoma. We conclude that dermoscopy is a useful tool for improving the recognition of these kinds of tumours.