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İlhan Erdil D, Koku Aksu AE, Turgut Erdemir VA, Erdil D, Leblebici C, Kara Polat A. Dermoscopic monitoring of pediatric melanocytic nevi regarding pattern and diameter changes. An Bras Dermatol 2024:S0365-0596(24)00138-7. [PMID: 39004596 DOI: 10.1016/j.abd.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/06/2023] [Accepted: 01/05/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Childhood and adolescence are dynamic period in terms of nevogenesis, and the development and growth of new melanocytic nevus are frequently observed. In this study, the aim was to examine the pattern and diameter changes seen in the follow-up of pediatric melanocytic nevus. OBJECTIVES To describe the pattern and diameter changes seen in the follow-up of pediatric melanocytic. METHODS Our study involved the assessment of 301 pediatric melanocytic nevi in 50 patients attended at the Dermatology Clinic of Istanbul Training and Research Hospital between January 2008 and 2022. The pediatric melanocytic nevi were diagnosed clinically and dermoscopically. Subsequently, we conducted video-dermoscopic monitoring of these nevi over a span of 3 months to 3 years. RESULTS 46% of our patients were female (n = 23), with a mean age of 11.5 years. While the pattern of nevi was globular in 40% patients, the rate of globular pattern decreased to 30% in the follow-up. The basal homogeneous nevus pattern was seen in 10% patients, but was detected in 13.9% in the follow-up. Peripheral globules were observed in 19.3% of the cases, but in the follow-up, 61.1% of the globules regressed completely. Nevus excision was indicated in only 11 of 301 nevi. STUDY LIMITATIONS Single-center study and a small of studies available on this subject. CONCLUSIONS Pediatric melanocytic nevi can show dynamic changes compared to nevi in adults. In this study, growth rates, dermoscopic features, and pattern changes seen in the follow-up of melanocytic nevi were evaluated. The globular pattern was observed most frequently. The presence of peripheral globules is frequently observed in pediatric melanocytic nevi with regression during the follow-up period.
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Affiliation(s)
- Dilara İlhan Erdil
- Department of Dermatology, University of Health Sciences, İstanbul Training and Research Hospital, İstanbul, Turkey.
| | - Ayşe Esra Koku Aksu
- Department of Dermatology, University of Health Sciences, İstanbul Training and Research Hospital, İstanbul, Turkey
| | | | - Duygu Erdil
- Department of Dermatology, University of Health Sciences, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Cem Leblebici
- Department of Pathology, University of Health Sciences, İstanbul Training and Research Hospital, İstanbul, Turkey
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2
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Briatico G, Brancaccio G, Scharf C, Moscarella E, Di Brizzi EV, Balato A, Argenziano G. Indications for and Contraindications to Digital Monitoring of Patients with Melanocytic Lesions. Dermatol Pract Concept 2024; 14:dpc.1403a200. [PMID: 39122551 PMCID: PMC11314790 DOI: 10.5826/dpc.1403a200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2024] [Indexed: 08/12/2024] Open
Affiliation(s)
- Giulia Briatico
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Gabriella Brancaccio
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Camila Scharf
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Elvira Moscarella
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Eugenia Veronica Di Brizzi
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Giuseppe Argenziano
- Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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Avcı C, Akın G, Lebe B, Şahin MT, Fetil E. Can we manage the melanocytic lesions with peripheral globules according to the grade of dysplasia? Australas J Dermatol 2024; 65:358-368. [PMID: 38572867 DOI: 10.1111/ajd.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND/OBJECTIVES Although excision of melanocytic nevi with high-grade dysplasia is recommended by the World Health Organization (WHO), clinical studies investigating the approach based on the grading dysplasia of melanocytic lesions with peripheral globules (PGs) are lacking. We investigated the grades of dysplasia and their distinguishable dermoscopic and clinical features to provide accurate data for managing these lesions. METHODS We retrospectively classified histologically confirmed melanocytic lesions with PGs according to the 2018 WHO Classification of Skin Tumours criteria in a university hospital in Turkey. Dermoscopic features, lesions, and patient characteristics were recorded. RESULTS Sixty-six lesions of 56 patients were included. After classification, 9.1% (n: 6) of lesions were melanomas, 39.4% (n: 26) were high-grade dysplastic nevi, and 50% (n: 33) were low-grade dysplastic nevi (n: 33, 50%). There was one nevus with no dysplasia (n: 1, 1.5%). Univariate analysis revealed that ≥31 years of age, irregular shape of peripheral globules, black colour, total colour count, and maximum diameter of the lesion were associated with high-grade dysplasia and melanoma. In the multivariate analyses, ≥31 years of age (OR = 3.80, 95% CI, 1.17-12.37), irregular shape of peripheral globules (OR = 3.90, 95% CI, 1.15-13.2), and total colour count (OR = 3.21, 95% CI, 1.2-8.5) were significant predictive factors for the lesions with high-grade dysplasia and melanomas. CONCLUSIONS To avoid the underdiagnosis of both melanomas and high-grade dysplastic nevi with PGs, the irregular shape of peripheral globules and multiple colours after the third decade may be useful in making an excision decision. The risk increases every 1-year increase in age. Excision is suggested for all melanocytic lesions with PGs for patients 60 years or older because of the high risk of melanoma and melanocytic nevus with high-grade dysplasia.
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Affiliation(s)
- Ceylan Avcı
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Gülfem Akın
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Banu Lebe
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Mustafa Turhan Şahin
- Department of Dermatology, Faculty of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - Emel Fetil
- Department of Dermatology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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Ilut PA, Camela E, Lallas K, Papageorgiou C, Manoli SM, Kyrgidis A, Liopyris K, Sgouros D, Apalla Z, Lallas A. The Natural Evolution of Nevi with Peripheral Globules. Dermatology 2023; 239:760-767. [PMID: 37279706 DOI: 10.1159/000531004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/02/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Peripheral globules (PG) in melanocytic lesions represent a concerning dermoscopic feature since they might be present in growing nevi and melanomas. Their natural evolution has not been fully elucidated, and an age-based management approach has been recommended. OBJECTIVES The aim of this study was to calculate the growth rate of lesions with PG and investigate possible association with age, sex, location, and the global dermoscopic pattern. METHODS We retrospectively selected the lesions of interest from a cohort of Caucasian patients who underwent sequential digital dermoscopy monitoring. Lesions with PG distributed at 75% or more of their circumference with available follow-up images or histopathologic report were included. The surface area was automatically calculated with the help of an incorporated tool used in the acquisition of the images. The images were also evaluated by independent investigators for the presence of pre-defined criteria. Growth-curve models were used to assess the growth rate. The outcome variable was the area of nevi in mm2, and scatterplots with Lowess curves were used to present the mean change of nevi during follow-up. RESULTS A total of 208 lesions from 98 patients with a median age of 36 years (range 15-75) were included. The median follow-up time was 18 months (range 4-48). The mean growth rate for all nevi was 0.16 mm2/month (95% CI, 0.14-0.18, p < 0.001), ranging from -0.29 to 0.61 mm2/month. The growth rate was higher in nevi with a homogeneous dermoscopic pattern (p < 0.001). The number of peripheral globules during follow-up varied from increasing to complete disappearance. None of the lesions developed any melanoma-specific structure at follow-up. CONCLUSION Nevi with PG grew at a mean rate of 0.16 mm2/month, and the growth rate was independent of age, gender, or anatomic location. Nevi with homogeneous pattern demonstrated the highest growth rate in our cohort. None of the monitored nevi with PG developed melanoma-specific criteria at follow-up.
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Affiliation(s)
- Paula Anca Ilut
- Department of Dermatology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Elisa Camela
- Dermatology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Konstantinos Lallas
- Department of Medical Oncology, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
| | - Chryssoula Papageorgiou
- Second Dermatology Department, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
| | - Sofia-Magdalini Manoli
- First Dermatology Department, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
| | - Athanassios Kyrgidis
- Department of Oral and Maxillofacial Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki "George Papanikolaou,", Thessaloniki, Greece
| | - Konstantinos Liopyris
- Department of Dermatology, University of Athens, Andreas Sygros Hospital for Cutaneous and Venereal Diseases, Athens, Greece
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dimitrios Sgouros
- Second Department of Dermatology and Venereology, ATTIKON General University Hospital, Medical School, National and Kapodistrian University, Athens, Greece
| | - Zoe Apalla
- Second Dermatology Department, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
| | - Aimilios Lallas
- First Dermatology Department, School of Medicine, Faculty of Health Sciences, Aristotle University, Thessaloniki, Greece
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Cappilli S, Ribero S, Cornacchia L, Catapano S, Del Regno L, Quattrini L, D'Amore A, Federico F, Broganelli P, Peris K, Di Stefani A. Melanocytic Lesions with Peripheral Globules: Proposal of an Integrated Management Algorithm. Dermatol Pract Concept 2023; 13:dpc.1301a10. [PMID: 36892354 PMCID: PMC9946096 DOI: 10.5826/dpc.1301a10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION A peripheral rim of globules represents a marker of the horizontal growth phase in nevi and is a common feature in children and adolescents. The observation of melanocytic lesions with peripheral globules (MLPGs) in adulthood deserves more attention, since melanoma may exhibit this feature, albeit rarely. Risk-stratified management recommendations considering a global clinical approach are still missing. OBJECTIVES To analyze current knowledge on MLPGs and propose an integrated management algorithm stratified for age groups. METHODS We conducted a narrative review of current published data on MLPGs, analyzing clinical dermoscopic and confocal distinguishing features of melanoma from benign nevi. RESULTS The risk of finding a melanoma when removing an MLPG increases with age, especially in people >55 years old, and is significantly higher in the extremities, head/neck and in case of a single asymmetrical lesion, ≥6 mm in diameter. Dermoscopic features associated with melanoma diagnosis include atypical peripheral globules, asymmetrical distribution, multiple rims as well as the reappearance of globules after prior loss. In addition, wide blue-grey regression areas, atypical networks, eccentric blotches, tan structureless peripheral areas and vascularization are atypical dermoscopic features. Confocal worrisome findings are represented by pagetoid cells within the epidermis, architectural disarrangement and atypical cells of the dermo-epidermal junction with irregular peripheral nests. CONCLUSION We proposed a multi-step age-stratified management algorithm integrating clinical, dermoscopic and confocal findings that may increase the early recognition of melanoma and avoid surgical excision of benign nevi.
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Affiliation(s)
- Simone Cappilli
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simone Ribero
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luigi Cornacchia
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Silvia Catapano
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura Del Regno
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Laura Quattrini
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandra D'Amore
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Federico
- Patologia, Dipartimento di Scienze della Vita e Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
| | - Paolo Broganelli
- Dermatology Clinic, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ketty Peris
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Di Stefani
- UOC di Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy.,Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
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Moraes AFA, Blumetti TCMP, Pinto C, Bertoli E, Rezze G, Marghoob AA, Braga JCT. Melanoma with peripheral globules: clinical and dermoscopic features. J Am Acad Dermatol 2022; 87:567-572. [PMID: 35487331 DOI: 10.1016/j.jaad.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Morphology and biology of nevi with peripheral globules are well known, while that of melanomas with peripheral globules remain unclear. OBJECTIVE Comparing the dermoscopic characteristics of nevi and melanomas with peripheral globules. METHODS A total of 401 melanocytic lesions with peripheral globules were included in this retrospective study. Dermoscopic patterns and structures, including those of the peripheral globules, were evaluated. A generalized estimating equation model with a binomial distribution dependent variable and logit link function was fitted to the dataset to identify features with the highest odds for differentiating melanoma from nevi. RESULTS Of the 401 lesions, 179 (44.64%) were excised, 41 (10.22%) of which were melanoma. Melanomas were most common in the lower extremities (P<0.01), with a disorganized pattern, whereas melanocytic nevi were most common on the trunk, with an organized pattern. The presence of blotches, atypical dots and globules, or atypical vessels was associated with melanomas (P<0.01). LIMITATIONS The retrospective design of the study may have caused an inclusion bias. CONCLUSION Melanocytic lesions displaying peripheral globules are at the greatest risk for melanoma if located on the lower extremity and if lesions reveal any of the following structures: blotch or atypical dots and globules or atypical vessels.
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Affiliation(s)
- Ana F A Moraes
- Department of Cutaneous Oncology, A.C. Camargo Cancer Center, São Paulo, SP, Brazil.
| | | | - Clovis Pinto
- Department of Anatomy Pathology, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Eduardo Bertoli
- Department of Cutaneous Oncology, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Gisele Rezze
- Dermatologist from Dermaimage Medical Associates, São Paulo, SP, Brazil
| | - Ashfaq A Marghoob
- Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Juliana C T Braga
- Department of Cutaneous Oncology, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
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[Translated article] SARS-CoV-2 Spike-like Pigmented Peripheral Structures: A Dermoscopic Finding in Dysplastic Nevi and Incipient Melanomas. ACTAS DERMO-SIFILIOGRAFICAS 2022. [PMCID: PMC8811704 DOI: 10.1016/j.ad.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Martin-Gorgojo A, Ramírez-Bellver JL, Ruiz-Rodríguez R, Pizarro Á. SARS-CoV-2 Spike-like Pigmented Peripheral Structures: A Dermoscopic Finding in Dysplastic Nevi and Incipient Melanomas. ACTAS DERMO-SIFILIOGRAFICAS 2021:S1578-2190(21)00306-1. [PMID: 34785818 PMCID: PMC8579716 DOI: 10.1016/j.adengl.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.ad.2021.07.015 . The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal
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Affiliation(s)
| | | | | | - Á Pizarro
- Clínica Dermatológica Internacional, Madrid, Spain
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9
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Massone C, Hofman-Wellenhof R, Chiodi S, Sola S. Dermoscopic Criteria, Histopathological Correlates and Genetic Findings of Thin Melanoma on Non-Volar Skin. Genes (Basel) 2021; 12:1288. [PMID: 34440462 PMCID: PMC8391530 DOI: 10.3390/genes12081288] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 11/23/2022] Open
Abstract
Dermoscopy is a non-invasive, in vivo technique that allows the visualization of subsurface skin structures in the epidermis, at the dermoepidermal junction, and in the upper dermis. Dermoscopy brought a new dimension in evaluating melanocytic skin neoplasms (MSN) also representing a link between clinical and pathologic examination of any MSN. However, histopathology remains the gold standard in diagnosing MSN. Dermoscopic-pathologic correlation enhances the level of quality of MSN diagnosis and increases the level of confidence of pathologists. Melanoma is one of the most genetically predisposed among all cancers in humans. The genetic landscape of melanoma has been described in the last years but is still a field in continuous evolution. Melanoma genetic markers play a role not only in melanoma susceptibility, initiation, and progression but also in prognosis and therapeutic decisions. Several studies described the dermoscopic specific criteria and predictors for melanoma and their histopathologic correlates, but only a few studies investigated the correlation among dermoscopy, pathology, and genetic of MSN. The aim of this work is to review the published data about dermoscopic features of melanoma, their histopathological correlates with regards also to genetic alterations. Particularly, this review will focus on low-CSD (cumulative sun damage) melanoma or superficial spreading melanoma, high-CSD melanoma, and nevus-associated melanoma.
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Affiliation(s)
| | | | | | - Simona Sola
- Surgical Pathology, Galliera Hospital, 16128 Genoa, Italy;
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10
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Martin-Gorgojo A, Luis Ramírez-Bellver J, Ruiz-Rodríguez R, Pizarro Á. [SARS-CoV-2 Spike-like Pigmented Peripheral Structures: A Dermoscopic Finding in Dysplastic Nevi and Incipient Melanomas]. ACTAS DERMO-SIFILIOGRAFICAS 2021; 113:72-73. [PMID: 34305145 PMCID: PMC8280368 DOI: 10.1016/j.ad.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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11
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Lazaridou E, Fotiadou C, Apalla Z. Melanocytic lesions with peripheral globules: still a pitfall in the differential diagnosis of melanoma. J Eur Acad Dermatol Venereol 2021; 35:1040. [PMID: 33885195 DOI: 10.1111/jdv.17239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
- E Lazaridou
- Second Department of Dermatology-Venereology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - C Fotiadou
- Second Department of Dermatology-Venereology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Z Apalla
- Second Department of Dermatology-Venereology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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