Diagnosis and Management of Acral Pigmented Lesions

BACKGROUND

Survival outcomes in acral lentiginous melanoma (ALM) are worse than for cutaneous melanoma. Diagnostic delays are believed to contribute to worse outcomes in ALM, including advanced-stage disease at initial presentation. Acral lentiginous melanoma, especially in its early stages, may be difficult to discern from benign pigmented acral lesions.

OBJECTIVE

The purpose of this article is to provide a comprehensive review of the diagnosis and management of acral pigmented lesions.

MATERIALS AND METHODS

A literature review was performed. The outcomes included were the clinical and dermoscopic features and the management frameworks and considerations for acquired and congenital melanocytic nevi, acral melanosis, nonmelanocytic pigmented lesions, and ALM.

RESULTS

Original research studies were primarily included. The use of dermoscopy, such as the 3-step algorithm and blotch (irregular), ridge pattern (parallel), asymmetry of structures, asymmetry of colors, furrow pattern (parallel), fibrillar pattern (BRAAFF) checklist, increases the diagnostic accuracy of acral pigmented lesions with high specificity and sensitivity. Short-term digital dermoscopic surveillance can be used to manage acral lesions, and histopathology should be collected when there is a concern for ALM.

CONCLUSION

The use of dermoscopy and an understanding of how to manage acral lesions may limit the number of biopsies performed on the acral skin, decrease the time to diagnosis, and facilitate early detection of ALM.

Early Detection and Prognostic Assessment of Cutaneous Melanoma: Consensus on Optimal Practice and the Role of Gene Expression Profile Testing

Importance

Therapy for advanced melanoma has transformed during the past decade, but early detection and prognostic assessment of cutaneous melanoma (CM) remain paramount goals. Best practices for screening and use of pigmented lesion evaluation tools and gene expression profile (GEP) testing in CM remain to be defined.

Objective

To provide consensus recommendations on optimal screening practices and prebiopsy diagnostic, postbiopsy diagnostic, and prognostic assessment of CM.

Evidence Review

Case scenarios were interrogated using a modified Delphi consensus method. Melanoma panelists (n = 60) were invited to vote on hypothetical scenarios via an emailed survey (n = 42), which was followed by a consensus conference (n = 51) that reviewed the literature and the rationale for survey answers. Panelists participated in a follow-up survey for final recommendations on the scenarios (n = 45).

Findings

The panelists reached consensus (≥70% agreement) in supporting a risk-stratified approach to melanoma screening in clinical settings and public screening events, screening personnel recommendations (self/partner, primary care provider, general dermatologist, and pigmented lesion expert), screening intervals, and acceptable appointment wait times. Participants also reached consensus that visual and dermoscopic examination are sufficient for evaluation and follow-up of melanocytic skin lesions deemed innocuous. The panelists reached consensus on interpreting reflectance confocal microscopy and some but not all results from epidermal tape stripping, but they did not reach consensus on use of certain pigmented lesion evaluation tools, such as electrical impedance spectroscopy. Regarding GEP scores, the panelists reached consensus that a low-risk prognostic GEP score should not outweigh concerning histologic features when selecting patients to undergo sentinel lymph node biopsy but did not reach consensus on imaging recommendations in the setting of a high-risk prognostic GEP score and low-risk histology and/or negative nodal status.

Conclusions and Relevance

For this consensus statement, panelists reached consensus on aspects of a risk-stratified approach to melanoma screening and follow-up as well as use of visual examination and dermoscopy. These findings support a practical approach to diagnosing and evaluating CM. Panelists did not reach consensus on a clearly defined role for GEP testing in clinical decision-making, citing the need for additional studies to establish the clinical use of existing GEP assays.

Expert Consensus Statement on Proficiency Standards for Dermoscopy Education in Primary Care

BACKGROUND

Primary care providers (PCPs) frequently address dermatologic concerns and perform skin examinations during clinical encounters. For PCPs who evaluate concerning skin lesions, dermoscopy (a noninvasive skin visualization technique) has been shown to increase the sensitivity for skin cancer diagnosis compared with unassisted clinical examinations. Because no formal consensus existed on the fundamental knowledge and skills that PCPs should have with respect to dermoscopy for skin cancer detection, the objective of this study was to develop an expert consensus statement on proficiency standards for PCPs learning or using dermoscopy.

METHODS

A 2-phase modified Delphi method was used to develop 2 proficiency standards. In the study's first phase, a focus group of PCPs and dermatologists generated a list of dermoscopic diagnoses and associated features. In the second phase, a larger panel evaluated the proposed list and determined whether each diagnosis was reflective of a foundational or intermediate proficiency or neither.

RESULTS

Of the 35 initial panelists, 5 PCPs were lost to follow-up or withdrew; 30 completed the fifth and last round. The final consensus-based list contained 39 dermoscopic diagnoses and associated features.

CONCLUSIONS

This consensus statement will inform the development of PCP-targeted dermoscopy training initiatives designed to support early cancer detection.

Acral Lentiginous Melanoma: A United States Multi-Center Substage Survival Analysis

Background

Acral lentiginous melanoma is associated with worse survival than other subtypes of melanoma. Understanding prognostic factors for survival and recurrence can help better inform follow-up care.

Objectives

To analyze the clinicopathologic features, melanoma-specific survival, and recurrence-free survival by substage in a large, multi-institutional cohort of primary acral lentiginous melanoma patients.

Methods

Retrospective review of the United States Melanoma Consortium database, a multi-center prospectively collected database of acral lentiginous melanoma patients treated between January 2000 and December 2017.

Results

Of the 433 primary acral lentiginous melanoma patients identified (median [range] age: 66 [8–97] years; 53% female, 83% white), 66% presented with stage 0–2 disease and the median time of follow-up for the 392 patients included in the survival analysis was 32.5 months (range: 0–259). The 5-year melanoma-specific survivals by stage were 0 = 100%, I = 93.8%, II = 76.2%, III = 63.4%, IIIA = 80.8%, and IV = 0%. Thicker Breslow depth ((HR) = 1.13; 95% CI = 1.05–1.21; P < .001)) and positive nodal status ((HR) = 1.79; 95% CI = 1.00–3.22; P = .050)) were independent prognostic factors for melanoma-specific survival. Breslow depth ((HR = 1.13; 95% CI = 1.07–1.20; P < .001), and positive nodal status (HR = 2.12; 95% CI = 1.38–3.80; P = .001) were also prognostic factors for recurrence-free survival.

Conclusion

In this cohort of patients, acral lentiginous melanoma was associated with poor outcomes even in early stage disease, consistent with prior reports. Stage IIB and IIC disease were associated with particularly low melanoma-specific and recurrence-free survival. This suggests that studies investigating adjuvant therapies in stage II patients may be especially valuable in acral lentiginous melanoma patients.

Dermoscopy Proficiency Expectations for US Dermatology Resident Physicians: Results of a Modified Delphi Survey of Pigmented Lesion Experts

Importance

Dermoscopy education in US dermatology residency programs varies widely, and there is currently no existing expert consensus identifying what is most important for resident physicians to know.

Objectives

To identify consensus-based learning constructs representing an appropriate foundational proficiency in dermoscopic image interpretation for dermatology resident physicians, including dermoscopic diagnoses, associated features, and representative teaching images. Defining these foundational proficiency learning constructs will facilitate further skill development in dermoscopic image interpretation to help residents achieve clinical proficiency.

Design, Setting, and Participants

A 2-phase modified Delphi surveying technique was used to identify resident learning constructs in 3 sequential sets of surveys-diagnoses, features, and images. Expert panelists were recruited through an email distributed to the 32 members of the Pigmented Lesion Subcommittee of the Melanoma Prevention Working Group. Twenty-six (81%) opted to participate. Surveys were distributed using RedCAP software.

Main Outcomes and Measures

Consensus on diagnoses, associated dermoscopic features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for US dermatology resident physicians.

Results

Twenty-six pigmented lesion and dermoscopy specialists completed 8 rounds of surveys, with 100% (26/26) response rate in all rounds. A final list of 32 diagnoses and 116 associated dermoscopic features was generated. Three hundred seventy-eight representative teaching images reached consensus with panelists.

Conclusions and Relevance

Consensus achieved in this modified Delphi process identified common dermoscopic diagnoses, associated features, and representative teaching images reflective of a foundational proficiency in dermoscopic image interpretation for dermatology residency training. This list of validated objectives provides a consensus-based foundation of key learning points in dermoscopy to help resident physicians achieve clinical proficiency in dermoscopic image interpretation.

Technological advances for the detection of melanoma: Advances in molecular techniques

The growth of molecular technologies analyzing skin cells and inherited genetic variations has the potential to address current gaps in both diagnostic accuracy and prognostication in patients with melanoma or in individuals who are at risk for developing melanoma. In the second article in this continuing medical education series, novel molecular technologies are reviewed. These have been developed as adjunct tools for melanoma management and include the Pigmented Lesion Assay, myPath Melanoma, and DecisionDx-Melanoma tests, and genetic testing in patients with a strong familial melanoma history. These tests are commercially available and marketed as ancillary tools for clinical decision-making, diagnosis, and prognosis. We review fundamental principles behind each test, discuss peer-reviewed literature assessing their performance, and highlight the utility and limitations of each assay. The goal of this article is to provide a comprehensive, evidence-based foundation for clinicians regarding the management of patients with difficult pigmented lesions.

Real-world outcomes of melanoma surveillance using the MoleMap NZ telemedicine platform

BACKGROUND

MoleMap NZ is a novel New Zealand-based store-and-forward telemedicine service to detect melanoma. It uses expert review of total body photography and close-up and dermoscopic images of skin lesions that are suspicious for malignancy.

OBJECTIVE

The purpose of this study was to assess the effectiveness of MoleMap NZ as a melanoma early detection program.

METHODS

We conducted a review of 2108 melanocytic lesions recommended for biopsy/excision by MoleMap NZ dermoscopists between January 2015 and December 2016.

RESULTS

Pathologic diagnoses were available for 1571 lesions. Of these, 1303 (83%) lesions were benign and 260 (17%) lesions were diagnosed as melanoma, for a melanoma-specific benign:malignant ratio of 5.0:1. The number needed to biopsy to obtain 1 melanoma was 6. Among melanomas with available tumor thickness data (n = 137), 92% were <0.8 mm (range in situ to 3.1 mm), with in situ melanomas comprising 74%.

LIMITATIONS

Only lesions recommended for excision were analyzed. Pathology results were available for 75% of these cases. Tumor thickness data were available for 53% of melanomas diagnosed.

CONCLUSIONS

This real-world study of MoleMap NZ, a community-based teledermoscopy program, suggests that it has the potential to increase patients' access to specialist expertise via telemedicine. Additional studies are needed to more accurately define its efficacy.

Calciphylaxis in Association with Alcoholic Cirrhosis and Hepatorenal Syndrome

A 45-year-old woman with cirrhosis secondary to alcohol abuse was transferred from an outside hospital for management of a painful cutaneous eruption, progressively worsening over 2 weeks. On examination, the patient was a middle-aged white woman lying in bed in no acute distress, with jaundice and a protuberant abdomen consistent with ascites. The patient was afebrile (98.2°F), heart rate of 79 beats per minute, blood pressure of 105/61 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 93% on room air. She had multiple large stellate lesions of retiform purpura with central hemorrhagic necrosis on both thighs, with surrounding induration (Figures 1 and 2). These purpuric plaques and perilesional skin were exquisitely painful to palpation.

Acquired Ichthyosis in the Setting of Active Pulmonary Tuberculosis

Acquired ichthyosis is an uncommon disorder of cornification. It characteristically presents as symmetric scaling of the skin on the trunk and extensor surfaces of the extremities. It is clinically and histologically similar to ichthyosis vulgaris; however, acquired ichthyosis develops later in life and has been associated with various malignancies, infections, medications, autoimmune diseases, metabolic disorders, and malnutrition. We describe a case of a 35-year-old woman with active pulmonary tuberculosis and a history of breast cancer who presented with a several-month history of a widespread, scaly, pruritic skin eruption. Physical examination revealed fine, scaly patches on the extremities with relative sparing of the flexures and larger, scaly, ichthyosiform patches on the chest and back. Skin biopsy revealed orthokeratotic hyperkeratosis and a diminished granular layer, consistent with a diagnosis of acquired ichthyosis. Further evaluation, including positron-emission tomography/computed tomography scan, revealed hypermetabolic infiltrates and cavitation in the lungs, consistent with active pulmonary tuberculosis; there was no evidence of new or recurrent malignancy. The patient was treated with antituberculosis drugs and topical ammonium lactate cream. With incident cases rarely reported in the literature, this case of new-onset ichthyosis in the setting of active pulmonary tuberculosis highlights the distinctive clinical and histologic features of acquired ichthyosis and emphasizes the relationship of acquired ichthyosis with underlying systemic disease, particularly infection.

Botulinum toxin for treatment of Raynaud phenomenon in CREST syndrome

Calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome is a form of a rare, clinical subtype of systemic sclerosis, known as limited systemic sclerosis. Limited systemic sclerosis, including CREST syndrome, manifests as fibrotic skin changes restricted to the hands and face, with vascular, musculoskeletal, and visceral involvement. We present a case of a 75-year-old woman with a longstanding history of CREST syndrome complicated by a digital ulceration and persistent pain associated with recalcitrant Raynaud phenomenon. After failing a number of first-line pharmacologic therapies such as diltiazem, sildenafil, and topical nitropaste, the patient was started on a trial of botulinum toxin for the left second digit, with 10 unit injections into both webspaces for a total of 20 units. Following injection, the patient reported no further baseline pain in the affected finger and an over fifty-percent improvement in discomfort with manipulation of the digit at a follow-up time of one week. The ulceration started healing within the following three weeks. This result was maintained at a follow-up time of six weeks.

Folliculotropic mycosis fungoides

Folliculotropic mycosis fungoides (MF) is a distinct subset of cutaneous T cell lymphoma (CTCL). The disease is typically marked by an aggressive course and is often recalcitrant to skin-direct therapy. We report a case of an 83-year-old woman with folliculotropic MF characterized by erythematous, scaly plaques on the forehead along with poliosis and alopecia of the right medial eyebrow.

Recurrent Palisaded Neutrophilic and Granulomatous Dermatitis in the Setting of Systemic Lupus Erythematosus

We present the case of a 66-year-old woman with a history of systemic lupus erythematosus, who presented with tender nodules on the forearms. The patient reported an 8-year history of pink bumps on the extensor surfaces of the forearms bilaterally that would arise episodically for a few weeks and subsequently resolve with no intervention. Her systemic lupus erythematosus was under good control with oral prednisone 10 mg daily, and the development of these lesions was not associated with concomitant flares of the systemic lupus erythematosus.

Severe Oral Mucositis: A Rare Adverse Event of Pembrolizumab

Treatment of malignancy with anti-programmed cell death 1 (PD-1) immune checkpoint inhibitors can cause mucocutaneous side effects resulting from T cell activation. Due to their recent development, the full side effect profile remains to be fully elucidated, however dermatologic adverse events are most common. The main oral toxicities of these immune checkpoint inhibitors include: xerostomia, dysgeusia, and lichenoid reactions. Oral mucositis occurs more rarely in the setting of PD-1 inhibition, and few other reports of a Grade 3 or higher, severe, stomatitis have been reported in the literature. We present a case of a 78-year-old woman with Grade 3 ulcerative oral mucositis that occurred 13 months after initiation of PD-1 inhibitor, pembrolizumab, for the treatment for lung adenocarcinoma. She was successfully treated with prednisone, and pembrolizumab was temporarily held by her oncologist. Physicians should be aware of the possibility of severe mucositis in the setting of PD-1 inhibitors, as well as the management. J Drugs Dermatol. 2018;17(7):807-809.

Eczematous reaction to IVIG for the treatment of dermatomyositis

The use of high-dose intravenous immunoglobulin (IVIG) is an accepted therapy for patients with refractory dermatomyositis. Cases of eczematous reactions to IVIG have been reported in the literature, but to our knowledge, none in patients being treated for dermatomyositis. We report on the cases of two female patients with refractory dermatomyositis who developed pruritic, scaly pink plaques after receiving high-dose IVIG. This diffuse eczematous skin reaction to high-dose IVIG is a rare adverse event that most often occurs days after administration of therapy. Practitioners should be aware of this entity because the eczematous eruption may be extensive and can commonly worsen with subsequent re-exposure to IVIG.

Mycoplasma pneumoniae, more than a lung disease

Mycoplasma pneumoniae-induced rash and mucositis (MIRM) is a recently described clinical entity and should be considered in children who present with oral (94% of patients), ocular (82% of patients), and urogenital lesions (63% of patients). MIRM was first described as a distinct clinical entity from Stevens Johnson syndrome/Toxic epidermal necrolysis (SJS)/(TEN) in 2015 [1]. As a new, uncommon diagnosis it frequently poses a diagnostic and therapeutic challenge for pediatricians and dermatologists. We report a case of MIRM in a previously healthy 15-year-old boy.

Pregnancy and Melanoma: Recommendations for Clinical Scenarios

Managing pregnant patients with a history of melanoma or with a melanoma diagnosis can be daunting and confusing for dermatologists. We present three clinical scenarios that raise questions about the safety of pregnancy in patients with a history of melanoma, skin biopsies during pregnancy, and excisions and sentinel lymph node biopsies during pregnancy. Our recommendations incorporate the most up-to-date clinical data to help guide clinicians when faced with pigmented lesions and melanoma in a pregnant patient.

Generalized eruptive syringomas

Eruptive syringoma is a rare variant of syringoma, benign neoplasms of the eccrine sweat ducts that appear on the face, neck, chest, and axillae of predominately Asian and African American women before or during puberty [1, 2]. Lesions appear as small skin-colored or slightly pigmented, flat-topped papules [2]. The condition can be cosmetically disfiguring and difficult to treat, especially in dark-skinned patients. The investigators report a 52-year old Guyanese woman who presented with widespread, chronic, non-pruritic and nontender, skin-colored papules that arose approximately 20 years earlier. A punch biopsy of affected skin was obtained and the histological diagnosis was eruptive syringoma. The patient pursued no further treatment, after discussion of costs and risks.

Acquired elastoma in a subungual location

Elastomas are connective tissue nevi or hamartomas. They may occur in isolation or can be associated with familial syndromes such as Buschke-Ollendorff syndrome. Elastomas typically present in childhood as small ivory papules or firm skin-colored nodules that can coalesce into larger yellow plaques. These lesions are typically distributed over the extremities, abdomen, and back. Herein, we report an unusual case of a renal transplant recipient who presented with an acquired subungual papule with associated koilonychia and distal nail plate dystrophy. Histopathologic findings were consistent with subungual elastoma.

Dermoscopic Findings of an Unusual Acral Nevus on the Hand of a Child

Distinguishing benign acral nevi from small early acral melanomas may be challenging in certain cases. Dermoscopy is a noninvasive imaging technique that can help clinicians better visualize deeper lesion structures and thus more easily differentiate benign nevi from melanoma. We report the case of a 13-year-old girl with a changing dark brown to black macule with a central papular component on the volar surface of the right third finger. Dermoscopy revealed asymmetrically distributed irregular black blotches on a bluish-black background. Histopathology revealed a traumatized compound melanocytic nevus. Certain melanocytic nevi, although histologically benign, may not conform to the limited selection of reassuring benign dermoscopic patterns. Nevi in children are often dynamic and have a high likelihood of dermoscopic change.

Pemphigus foliaceus exacerbated by radiation, in association with myasthenia gravis

Pemphigus foliaceus (PF) is a sporadic autoimmune blistering disease of unknown etiology. The production of immunoglobulin G4 antibodies against desmoglein-1 is responsible for the clinical manifestation of PF. We present a case of a woman with a recent diagnosis of myasthenia gravis (MG), who was also recently treated with radiation therapy for breast cancer. The clinical exam, supported by biopsy and direct immunofluorescence, were consistent with PF. We present this case to increase the awareness of the potential exacerbation or induction of PF with radiation, and of the association of PF and myasthenia gravis. Only five prior cases of radiation-exacerbated or radiation-induced PF have been reported in the literature to date. Furthermore, the co-existence of the autoimmune entities of myasthenia gravis and PF has been reported in the literature in only 9 cases and was also noted in this patient.

What Is the Evidence that Riboflavin Can Be Used for Migraine Prophylaxis?

Individuals with migraine often have recurrent, painful symptoms, and symptomatic treatments have detrimentalside effects and do not prevent further attacks. Studies indicate that riboflavin can be used to decrease headachefrequency and lessen the need for symptomatic treatment. Mitochondrial dysfunction may play a role in migrainepathogenesis by interfering with oxygen metabolism. Daily doses of riboflavin, vitamin B2, may improve mitochondrialfunction by increasing the reserve of brain mitochondrial energy, and there are minimal side effects with dailytreatment. However, there is a need for further randomized, double-blind controlled studies to determine the effectivedose. Although riboflavin may not fully eliminate migraine nor take effect for several months, riboflavin is apromising prophylactic agent with minimal adverse effects that may significantly reduce the frequency of migraine.

Growth-Curve Modeling of Nevi With a Peripheral Globular Pattern

Importance

Although nevi with a peripheral rim of globules (peripheral globular nevi [PGN]) observed with dermoscopy are associated with enlarging melanocytic nevi, their actual growth dynamics remain unknown. Because change is a sensitive but nonspecific marker for melanoma, beginning to understand the growth patterns of nevi may improve the ability of physicians to differentiate normal from abnormal growth and reduce unnecessary biopsies.

Objective

To study the growth dynamics and morphologic evolution of PGN on dermoscopy.

Design, Setting, and Participants

A total of 84 participants with 121 PGN from September 1, 1999, through May 1, 2013, were identified retrospectively. Cohorts were recruited from the Memorial Sloan Kettering Cancer Center; Melanoma Unit of the Hospital Clinic, University of Barcelona; and Study of Nevi in Children. All 3 cohorts underwent longitudinal monitoring with serial dermoscopic imaging of their PGN. Data analysis was performed from May 1, 2014, through April 1, 2015.

Main Outcomes and Measures

Establishment of the natural growth curve of PGN. The secondary aim was to establish the median time to growth cessation in those PGN for which the size eventually stabilized and/or had begun to decrease during the study period.

Results

The median duration of follow-up was 25.1 (range, 2.0-114.4) months. Most of the nevi (116 [95.9%]) enlarged at some point during sequential monitoring. The rate of increase in the surface area of PGN varied among cohorts and ranged from -0.47 to 2.26 mm2/mo (mean rate, 0.25 [95% CI, 0.14-0.36] mm2/mo). The median time to growth cessation in the 26 PGN that stabilized or decreased in size (21.5%) was 58.6 months. All lesions changed in a symmetric manner and 91 (75.2%) displayed a decrease in the density of peripheral globules over time.

Conclusions and Relevance

Nevi displaying a peripheral globular pattern enlarged symmetrically with apparent growth cessation occurring during a span of 4 to 5 years. Our results reiterate the important concept that not all growth is associated with malignancy.

TNF-inhibitor induced lupus in a patient treated with adalimumab for rheumatoid arthritis

Anti-tumor necrosis factor induced lupus (ATIL) is a rare side effect reported in patients treated with anti-tumor necrosis factor medications such as infliximab, etanercept and adalimumab. Of the three, this condition has been least commonly reported secondary to adalimumab. In this report, we present a case of ATIL in a patient treated for rheumatoid arthritis (RA) with adalimumab. This report will increase physician awareness of the warning signs, diagnostic options and potential complications of ATIL. In this patient, adalimumab was discontinued and treatment was started, leading to improvement in the patient's status.

One-year follow-up of dermoscopy education on the ability of medical students to detect skin cancer

BACKGROUND

Learning skin cancer detection skills is important, yet many medical schools lack a standardized skin cancer examination (SCE) curriculum.

OBJECTIVE

To determine medical students' skills in discriminating benign from malignant skin lesions on a 10-item image-based test one year after receiving a SCE intervention.

METHODS

Cohort 1 received SCE teaching only. Cohort 2 received SCE teaching with dermoscopy tutorial, and a dermatoscope. The same test was given to assess students post-intervention and one year later.

RESULTS

43% (n = 145) and 38% (n = 143) of cohorts 1 and 2, respectively, participated one year later. Both cohorts improved or maintained their scores to correctly classify all lesions from post-intervention to one-year follow-up. After one year, cohort 2 maintained higher scores for successful identification of both benign and malignant lesions as compared to cohort 1.

CONCLUSION

Medical students receiving a SCE intervention can improve their diagnostic skills after one year, especially with the aid of dermoscopy.

White shiny structures: dermoscopic features revealed under polarized light

BACKGROUND

White shiny structures, including white shiny lines, white shiny areas and rosettes, are features only observed under polarized dermoscopy (PD).

OBJECTIVE

To evaluate the prevalence of the varied morphologies of white shiny structures in melanoma, basal cell carcinoma (BCC), squamous cell carcinoma (SCC), actinic keratosis (AK) and lichen planus-like keratosis (LPLK).

METHODS

Retrospective study using dermoscopic images of biopsy-proven melanoma, BCC, SCC, AK and LPLK.

RESULTS

A total of 538 lesions were assessed under PD. One or more types of white shiny structures were observed in 38.7% of study lesions (208/538). BCCs were significantly more likely to display a combination of white shiny areas and white shiny lines (short lines and/or ill-defined strands) (31.9%; 61/191) than any other lesions (P<0.001). BCC were more likely than other lesions to have white shiny lines distributed without any organized pattern (P<0.001). Lines in melanoma were significantly more likely than other lesion types to be oriented orthogonally (P<0.001). When white shiny lines were present, melanomas were significantly more likely than other lesions to exhibit short discrete white lines (P<0.001). Rosettes were significantly more likely to be observed in actinic tumours than other lesions (P<0.001).

CONCLUSION

The presence of white shiny lines of any length accompanied by white shiny areas is most suggestive of a diagnosis of BCC (P<0.001). Melanomas are more likely to display short white shiny lines in an orthogonal distribution (P<0.001) and without white shiny areas. Actinic tumours are most likely to exhibit rosettes (P<0.001).

Detection of early basal cell carcinoma with dermoscopy in a patient with psoriasis

A 49-year-old man with a history of basal cell carcinoma and psoriasis presented for routine skin exam and psoriasis management. He had multiple erythematous, scaly patches and plaques, originally diagnosed as psoriasis. Noticeably, one erythematous patch had a focal erosion. Dermoscopy revealed arborizing vessels, an erosion, pink structureless areas, and short, fine telangiectasias (SFTs), suggestive of superficial basal cell carcinoma (sBCC). Dermoscopy of all other lesions was consistent with psoriasis, exhibiting dotted vessels on a faint erythematous background. In conclusion, sBCCs may be overlooked in patients with multiple psoriatic plaques. In this case, the lesions were all initially presumed to be psoriasis. After detecting an erosion, the clinician was prompted to inspect further with dermoscopy and biopsy. Suspicion of sBCC was confirmed after visualization of dermoscopic structures consistent with sBCC. We highlight this case to encourage the use of dermoscopy in these patients for prompt diagnosis of BCCs.