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2/12/2018
1
Non-melanocytic Patterns
Michelle Tarbox, MD
Assistant Professor of Dermatology and Dermatopathology Texas Tech University Health Sciences Center
2018
Non-melanocytic Lesions
• Seborrheic keratoses• Acanthotic• Macular
• Vascular lesions• Angiomas• Angiokeratomas• Lymphangiomas
• Dermatofibromas• Conventional • Cellular
• Basal cell carcinoma• Pigmented and non-pigmented
• Actinic keratoses• Pigmented actinic keratoses
• Squamous cell carcinomas
• Merkel cell carcinoma
• Bugs• Cutaneous infections• Cutaneous infestations
• BONUS cases!
I have no conflicts of interest to disclose
Except that I LOVE dermoscopy
Non-Melanocytic Lesion Dermoscopy
• Problem: Often No Pigment!
• Solution: Use your clues!• Vascular structures• Chrysalis structures• Texture• Structureless areas• Scale
Comma-like - IDN Dotted -Spitz Linear irregular - AMM
Hairpin – SK, SCC, KA Glomerular - SCCIS Arborizing - BCC
Crown vessels – Seb H Strawberry pattern - AK
Milky red areas/globules – Thick AMM
J Am Acad Dermatol - 01-SEP-2010;
63(3)Vascular morphology
A regularB in a stringC clusteredD radialE irregularly branchedF irregular
J Am Acad Dermatol - 01-SEP-2010; 63(3)
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Seborrheic Keratosis
• Multiple milia like cysts
• Irregular crypts / comedo-like openings
• Fissures/ridges
• Fingerprint-like structures
Milia-like cysts = pseudo-horn cysts
(black arrows)
Comedo-like openings = comedostructures
(red arrows)
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Multiple milia like cysts
Irregular crypts and comedo like openings
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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
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Fissures/ridgesPersonal Collection
Congenital type nevus with Fissures/ridges Personal Collection
Fissures/ridgesPersonal Collection
Personal Collection, patient granted special permission to show
tattoo
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Fingerprint – Like Structures
• Tiny ridges running in parallel
• Typically seen in flat seborrheic keratoses or solar lentigo
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Multiple milia like cysts
Hemangioma• Red-blue homogeneous color
• Red-blue lacunes
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• Multiple red to bluish-black lacunae
• Blue-white veil: no diagnostic significance• Red-blue lacunae, no pigment network • Hyperkeratosis over thrombosed vessels
Angiokeratoma
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Dermatofibroma• Central scar like pallor
• Surrounding delicate pigment network
• Chrysalis structures
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Cellular Dermatofibroma• Nodule with central scar like pallor
• Surrounding delicate pigment network
• Chrysalis structures / central erosion/focal ulceration
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BROWN BROWN
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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
BCC Invasive Melanoma Aneurysmal DF
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BCC
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BCC
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Speaking of BCC Basal Cell Carcinoma
• Absent pigment network and:
• Ulceration
• Arborizing (tree-like) vessels
• Large blue gray ovoid nests
• Multiple blue gray globules
• Maple leaf areas
• Spoke wheel areas
Ulceration
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Ulceration Seen in pigmented and non-pigmented basal cell carcinoma
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Arborizing vessels
Personal Collection BCC
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Amelanotic Melanoma vs BCC
Personal Collection JAAD Vol 53, Issue 6, March 2007, Pages 508–513
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
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Large Blue-Gray Ovoid Nests
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Multiple Blue-Gray Globules
• Round, well circumscribed structures
• Smaller nests of pigmented basal cells
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Multiple Blue-Gray Globules
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Multiple Blue-Gray Globules
Maple leaf areas
Spoke-wheelareas
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Maple Leaf Areas
• Nests of pigmented epithelial nodules of basal cell carcinoma
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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
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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
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Actinic keratosis
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“Strawberry-like” pattern
composed of reddish
pseudo network around
whitish keratin filled hair
follicles
Pigmented actinic keratosis
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Pigmented actinic keratosis
Squamous Cell Carcinoma in Situ • Glomeruloid blood vessels
• Focal heme crust
• Scale
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Lobules composed of central whitish yellow keratin surrounded by polymorphous vesselsDotted (yellow arrow), arborizing (blue arrow), glomerular (black circle), and linear irregular (red arrow) vessels on a yellowish white background in addition to perivascular white halos (black circle). Focal areas of ulceration (blue star) and blood spots (green star) were also noted.
A. Tülin Güleç
Dermoscopic features of squamous cell carcinoma of the tongue: It looks similar to cutaneous squamous cell carcinoma
Journal of the American Academy of Dermatology, Volume 75, Issue 2, 2016, e53–e54
http://dx.doi.org/10.1016/j.jaad.2016.01.030
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Fig 2. Squamous cell carcinoma of the lip. Dermoscopy revealed central whitish yellow keratin surrounded by polymorphous vessels, namely, dotted (yellow arrow), arborizing (blue arrow), coiled (black circle), and hairpin (red arrow) vessels on a yellowish white background in addition to perivascular white halos (purple circle) and white structureless areas (black arrow) that correlated to aggregated mass of highly keratinized malignant squamous cells. Focal areas of surface scale (blue star) and blood spots (green star) were also noted.
A. Tülin Güleç
Diagnosing squamous cell carcinoma of the lip using dermoscopy
Journal of the American Academy of Dermatology, Volume 76, Issue 2, Supplement 1, 2017, S82–S83
http://dx.doi.org/10.1016/j.jaad.2016.10.026
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Merkel Cell Carcinoma
Fig 6. Combined squamous/Merkel cell carcinoma, case 5. A, Erythematous nodule on the upper aspect of chest with adherent scale; background dermatoheliosis with atrophy and wrinkling, along with a nearby actinic keratosis (upper left corner). B, Dermoscopy with milky red areas centrally (small top arrow) and large-diameter arborizing vessels at the periphery (larger lower arrows).
Andrea Luísa Suárez, Peter Louis, Jasmine Kitts, Klaus Busam, Patricia L. Myskowski, Richard J. Wong, Chih-Shan Jason Chen, Philip Spencer, Mario Lacouture, Melissa P. Pulitzer
Clinical and dermoscopic features of combined cutaneous squamous cell carcinoma
(SCC)/neuroendocrine [Merkel cell] carcinoma (MCC)
Journal of the American Academy of Dermatology, Volume 73, Issue 6, 2015, 968–975
http://dx.doi.org/10.1016/j.jaad.2015.08.041
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Scabies • Triangle indicating the head of
the mite
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Thank you! Michelle Tarbox, MD
Assistant Professor of Dermatology
Texas Tech University Health Sciences Center
Fun Benign things . . .
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Clear cell acanthoma •String of pearls vessels
•Glycogen rich keratinocytes
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Porokeratosis• White tract structure =cornoid lamella
• Central white area, red dots, globules and lines
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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
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Nevus Sebaceous
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Accessory Nipple
• Central white area
• Central streak
• Faint pigmented network at the periphery
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Xanthogranuloma
•Orange-yellow background coloration with clouds of xanthomatous deposits
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