Published on February 19, 2014
TUTORIAL PRESENTATION DERMOSCOPY : PIGMENT v/s VASCULAR BY Dr. D R DHAKED
INTRODUCTION • Also k/a dermatoscopy, epiluminescence microscopy [ELM], incident light microscopy, skin surface microscopy • Non invasive diagnostic technique for in vivo observation of pigmented skin lesions, • Provides a horizontal view of the lesion, • Permits recognition of morphologic structures not visible by naked eye • Magnification ranges from 6x to 40x. • Widely used dermatoscope has a 10-fold magnification
Technical Procedures and Equipment • Lesions are inspected using a hand-held dermatoscope, a stereomicroscope, a camera, or a digital imaging system • Lens is paired with a bright halogen beam • Immersion fluid (mineral oil, alcohol or water) placed on lesion eliminates surface reflection and renders cornified layer translucent, • Allows better visualization of pigmented structures within epidermis, dermoepidermal junction and superficial dermis. • Size and shape of vessels of superficial vascular plexus can be easily appreciated • Examination of vessels is of particular interest in diagnosis of nonpigmented lesions,
• In diagnosing melanoma, dermoscopy has been reported to allow 10-27% higher sensitivity than clinical diagnosis by the naked eye [Mayer 1997]. Dermaphot Dermatoscope Videodermatoscope Stereomicroscope
Understanding of different dermoscopic features is important to formulate a diagnosis
Pattern analysis i) Pattern recognition:- Skin lesion can be placed in to one of nine groups • Reticular pattern – – – – Defined by a pigment network. Typical pigment networks are seen in acquired melanocytic naevi and some lentigo. A fine peripheral network is seen in dermatofibroma. An atypical pigment network has a high specificity for melanoma • Globular pattern – Presence of numerous, variously sized, round to oval structures with various shades of brown and gray-black coloration. – Indicative of junctional proliferation of melanocytes – Seen in acquired melanocytic naevi in young people • Homogenous pattern – A diffuse area of colour in the absence of a pigment network or other distinctive local features. – May seen in melanocytic lesions or blue naevi and seborrhoeic keratoses • Multicomponent – Combination of features such as globular reticular or reticular homogenous, – Combination of three or more patterns within a lesion (multicomponent) can be suggestive of melanoma
• Cobblestone – Closely aggregated, large somewhat angulated globules resembling a cobblestone. – Result from large dermal nests of melanoctyes found in dermal naevi • Parallel pattern – – Indicative of acral lesions. – A parallel-like fingerprint pattern can be seen in solar lentigo • Starburst pattern – Pigmented streaks in a radial arrangement at edge of a pigmented skin lesion. – Indicative of spitzoid lesions including pigmented spindle cell naevus of Reed, and spitzoid melanoma • Lacuna – Several to numerous, smooth-bordered, round to oval, variously sized structures. – Morphologic hallmark is their striking reddish, blue-purplish or black coloration. – Indicative of angioma • Unspecific – Relatively featureless lesions that cannot be categorised by any of the above. – This pattern can represent a subtle melanoma
Typical globular pattern in a Clark nevus, compound type Typical reticular pattern in a Clark nevus Dermatofibroma with reticular pattern in anular distribution Atypical reticular pattern in a melanoma in situ
Typical cobblestone pattern in a papillomatous dermal Typical homogeneous nevus (Unna nevus) pattern in a blue nevus Brownish-gray homogeneous pattern in a blue nevus Brownish-gray homogeneous pattern in a dermal nevus Lacunar pattern in an angiokeratoma Lacunar pattern in an angioma
Typical starburst pattern in a Reed nevus Parallelfurrow pattern, in an acral nevus Multicomponent pattern in a congenital speckled nevus (nevus spilus) Multicomponent pattern in a malignant melanoma lattice-like pattern, in an acral nevus
ii) Pattern comparison • Patients with multiple acquired melanocytic naevi will often have lesions showing a similar dermoscopic pattern • Any lesion found to have a different dermoscopic pattern, should be treated with suspicion. • Patients age should be taken into consideration as the dermoscopic morphology of acquired melanocytic naevi change as patients get older • Globular in teenage years • Reticular in 30-40 year olds • Homogenous in the over 50’s
Colour • Pigmentation of lesion is evaluated in terms of colour(s): black, dark brown, tan, grey, steel blue, purple, white, yellow and red. • Understanding colour is important as it helps determine the level of melanin in the skin: – Black - superficial epidermis – Brown - epidermis – Grey - papillary dermis – Blue - reticular dermis • Greater the number of colours more likely the lesion is to be malignant. • But not true in case amelanotic / hypomelanotic melanoma
Black: Black: epidermal melanin thrombus Grey: upper dermal melanophages Blue: deep dermal melanin White: regression White: or scarring keratin Dark brown: Tan: junctional melanin junctional melanin Purple: vascularity or bleeding Yellow: keratin Red: vascularity or bleeding Multiple colours : melanoma
Symmetry • • • • • • • • • • Clinically, evaluated in terms of shape. Symmetry of shape suggests a benign lesion, Asymmetry suggests melanoma By dermoscopy, symmetry is evaluated in terms of pigment pattern (colour and/or structure). Symmetrical pigment pattern is typical of benign skin lesions. Complete asymmetry, lesion may be malignant or atypical naevi. Uniform pigment also called ‘homogeneous’ (benign), Irregular pattern called ‘heterogenous’ (atypical or malignant). The degree of symmetry / asymmetry is quite subjective, It must be considered in combination with all other dermoscopic and non-dermoscopic features to help formulate a diagnosis
Homogeneous, symmetrical lesion Symmetrical shape & structure Asymmetrical shape & pattern (atypical naevus) Homogeneous structure with asymmetrical shape Symmetrical shape, asymmetrical pattern (melanoma)
Lesion specific features (local features) • Melanocytic lesions are made up of three types of structure: – Pigment network – Amorphous structureless areas (blotches) – Dots and globules • Benign lesions tend to have only one or two of these structural patterns in a symmetrical distribution. • Malignant lesions tend to have areas of network, amorphous structures and scattered globules in an atypical distribution
Pigment network • Formed by melanocytes or melanin in basal keratinocytes. • Dense pigment rings (the grid) are due to projections of rete pegs or ridges. • Paler ‘holes’ are due to projections of dermal papillae. • A typical pigment network is characterised by a light to dark-brown pigmented, regularly meshed and narrowly spaced network • Distributed more or less regularly throughout lesion • Usually thinning out at the periphery. • Seen in some typical and atypical benign melanocytic lesions.
Ink-spot lentigo Junctional naevus Junctional naevus Starburst pattern Lentigo simplex Solar lentigo Solar lentigo Junctional naevus Compound naevus Atypical naevus Compound naevus Interrupted network Atypical naevus Annular network Typical or Regular pigment network Atypical naevus Spoke-wheel network
Atypical or irregular pigment network • Characterised by a black, brown, or grey, irregularly meshed network, • Distributed more or less irregularly throughout the lesion • Usually ending abruptly at the periphery. • Streaks, brownish-black linear structures of variable thickness, not clearly combined with pigment network lines, • Branched streaks are seen in dysplastic naevi and some melanomas. • Radial streaming or parallel linear extensions at edge of lesion often represent radial growth phase of melanoma. • Pseudopods are bulbous projections at edge of lesion due to junctional nests of abnormal melanocytes in invasive melanoma • Thick lines (broadened network) are characteristic of melanoma, and are accompanied by irregular holes.
Dysplastic naevus Dysplastic naevus Recurrence after excision Melanoma Melanoma Melanoma Atypical lentiginous hyperplasia Melanoma Irregular pigment network: red arrows point to branched streaks, black arrows to broadened network, asterisk to streaming, thin arrow to pseudopods
Pseudonetwork: facial skin • Term ‘pseudonetwork’ is used when annular pigmentation is seen around hair follicles on facial skin. • On face, it may be difficult to differentiate benign naevi, lentigo, solar keratoses, lichenoid keratosis and early lentigo maligna. Solar lentigo Solar lentigo Solar keratosis Lichenoid keratosis
Negative network • White reticular pattern due to elongated rete pegs. • Characteristic of melanoma but also sometimes seen in Spitz naevi and some dysplastic naevi. • It may resemble the pattern seen in scars on lower leg (atrophie blanche). • It should not be confused with pale colour separating globules of a benign naevus. Melanoma Melanoma Green arrows point to negative network Atrophie blanche Benign naevus
Dermoscopy of palmo-plantar melanocytic lesions • ‘Parallel pattern’ refers to network seen within most melanocytic naevi on palmar and plantar surfaces. • Parallel furrow pattern: pigmented furrows • Lattice pattern: pigmented furrows and lines crossing these • Fibrillar/filamentous pattern: delicate pigmentation crossing the skin markings • Parallel ridge pattern: pigmented ridges (white dots represent sweat duct openings), highly specific for melanoma in volar sites. • There is no obvious parallel pattern in homogenous-type naevi on volar sites.
Dermoscopy of palmo-plantar melanocytic lesions Parallel furrow pattern Lattice pattern Lattice pattern Fibrillar pattern Mixed pattern Fibrillar pattern Dysplastic naevus Fibrillar pattern Parallel ridge pattern Melanoma
Amorphous areas (blotches) • Diffuse pigmentation without specific structural features • Brown blotches may be due to pigment in basal layer or papillary dermis and arise when rete ridges are flattened out. • Homogeneous blue pigmentation is seen in blue naevus. • Diffuse amorphous areas – Solar lentigo, Benign naevus, Blue naevus • Irregular blotches are sometimes only dermoscopic feature of melanoma. Blue-white veil • An irregular, confluent, grey-blue to white-blue diffuse pigmentation • Caused by an acanthotic epidermis with focal hypergranulosis above sheets of heavily pigmented melanocytes in upper dermis • Has high specificity for melanoma
Solar lentigo Diffuse amorphous areas Benign naevus Benign naevus Blue naevus Irregular amorphous areas Dysplastic naevus Melanoma Melanoma Melanoma Also has irregular network
Dots and globules • Sharply circumscribed, usually round or oval, variously sized brown, black or blue-grey structures. • Colour determines their site: – black dots are due to free melanin in the stratum corneum, – brown globules are due to junctional nests of melanocytes, – blue or grey dots are due to melanophages in dermis. • Benign lesions tend to have central black dots and globules. • Dots associated with a pigment network may be due to pigment on ridges (superimposed on network grid) or papillae (in the holes). • Circumferential brown globules are seen in enlarging dysplastic naevi. • Diffuse blue/grey dots in absence of a pigment network are characteristic of lichenoid keratosis. • Clusters of tiny brown dots are characteristic of melanoma.
Dots and globules in benign lesions Central dots Scattered dots Central globules Uniform globules Dermal naevus Cobblestone pattern Compound naevus Peripheral globules Atypical naevus Eccentric globules Dysplastic naevus Diffuse blue/grey dots Lichenoid keratosis
Dots and globules in melanoma: yellow arrows Black dots Brown dots Grey dots Peripheral dots Dots in basal cell carcinoma: yellow arrows Dots may be seen in pigmented basal cell carcinoma and rarely in seborrhoeic keratoses.
Dermoscopic structures of nonmelanocytic lesions • Some specific dermoscopic structures are helpful in diagnosis of non-melanocytic lesions. • These include: – Leaf-like areas – Blue ovoid masses – Milia-like cysts – Fissures and comedo-like openings
Leaf-like areas • Leaf-like areas are grey, brown or blue shiny, discrete bulbous structures unassociated with a pigment network (structureless). • They are seen on edges of pigmented basal cell carcinoma, • Some may not appear very like a leaf, in which case they are better known as ‘structureless areas’. • Moth-eaten edges of solar lentigos also sometimes appear leaf-like. Leaf-like areas: BCC Leaf-like areas: BCC Structureless areas: BCC Leaf-like areas: solar lentigo
• • • • • Blue ovoid masses Are large discrete pigmented round, oval or bullet-shaped blue structures Characteristic of basal cell carcinoma. When the structure has radial projections, they are called ‘spokewheel areas’. They are often found within leaf-like or structureless areas. Blue blotches that are sometimes seen in melanoma are irregular, less well defined and appear out of focus. Blue ovoid masses: BCC Spoke-wheel areas: BCC Blue blotches: melanoma
Milia-like cysts • Round white or yellow lesions due to intraepidermal keratin. • Characteristically found within a seborrhoeic keratosis. • May arise within dermal melanocytic naevi, BCC and melanoma. Seborrhoeic keratosis Seborrhoeic keratosis Compound naevus Pigmented BCC
Fissures and comedo-like openings • Brown-yellowish or brown-black, roundish to oval or even irregularly shaped, sharply circumscribed structures • Comedo-like openings are sometimes called ‘crypts’. • Little craters and tend to be dark brown, like irregular globules. • Often associated with fissures (clefts). • Characteristic of seborrhoeic keratoses, • May be found in dermal naevi. • Rarely, in melanoma Comedo-like openings: seborrhoeic keratosis Fissures: seborrhoeic keratosis Cysts & crypts: seborrhoeic keratosis Comedo-like openings: compound naevus
Cerebriform structure • Seborrhoeic keratosis may have a cerebriform or brain-like pattern. • Pattern is composed of fissures and ridges mimicking the gyri and sulci of the brain. • Useful sign in the absence of comedo-like openings or milia-like cysts. Fissures/comedo-like openings Enhanced by tanning cream
Fingerprint-like structures • Descriptive term for tan or dark-brown, fine parallel cordlike structures • Characteristically seen in seborrhoeic keratoses and solar lentigo. • Wider cords are called ‘fat fingers’. • Fat fingers are also rarely seen in melanoma. Fingerprint-like structures Fingerprint-like structures Fat fingers Crypts in elevated centre of lesion Fat fingers
The border of skin lesions • Clinical characteristic of an irregular edge is often seen in melanoma, but is quite common in benign lesions too • Border can fade out (often seen in atypical naevi) or be sharply demarcated in a small segment (typical of melanoma). • Sharp cut-off may also occur all the way around in a regular or irregular pattern. • ‘Moth-eaten’ edge, seen as concave areas at edge of a lesion. • Seen in ephilis and some flat seborrhoeic keratoses and lentigos Fading border benign naevus Localised sharp Sharp cut-off all cut-off: melanoma round: melanoma Moth-eaten edge: ephilis
Crystalline structures • Shiny, bright white, parallel or orthoganol or disordered linear streaks or short lines. • Seen by contact or non-contact polarised dermoscopy. • Are due to excessive collagen • May be seen in dermatofibroma, scar, basal cell carcinoma with fibroplasia, squamous cell carcinoma, Spitz naevi and melanoma. Dermatofibroma Pigmented basal cell carcinoma Superficial basal cell carcinoma Melanoma
Vascular structures and pattern • Vascular structures show up better in hypopigmented or nonpigmented lesions, or in lighter areas of pigmented tumors. • Most important chromophore in nonpigmented cutaneous tumors is hemoglobin
Dermoscopic morphologic features of vessels according to their location in the skin • Predominant vascular pattern also depends on volume of tumor and its proliferation pattern. • Nodular component of tumors, develop through neovascularization phenomena • Give rise to blood vessels with varying degrees of aberrant morphology.
Vessels in normal skin; note dotted vessels corresponding to papillary dermal vessels and network of vessels corresponding to upper dermal plexus
Diagnostic procedure for a hypopigmented lesion.
Vessel distribution patterns / Architectural Arrangement
Vascular patterns seen in melanocytic lesions.
Vascular patterns seen in melanocytic lesions, clear-cell acanthoma, and basal cell carcinoma.
Intradermal melanocytic nevus with comma vessels scattered throughout the lesion. A, Spitz nevus with dotted lesions distributed uniformly through the lesion. B, Spitz nevus with a greater variety of vascular patterns against a characteristic pink background. A, Dysplastic nevus with predominant irregular linear vessels. B, Dysplastic nevus with dotted and comma vessels against a brownish background
A, Superﬁcial spreading melanoma showing marked vascular polymorphism in the thick portion of the tumor. B, Detail of a milky-red globule containing vessels Dotted vessels in the typical string of pearls arrangement seen in clear-cell acanthoma. Bright red arborizing telangiectasias in sharp focus; a typical ﬁnding in basal cell carcinoma
Vascular patterns in keratinizing tumors
Vascular patterns in keratinizing tumors, sebaceous hyperplasia / molluscum contagiosum, and dermatoﬁbroma
Hairpin vessels in seborrheic keratosis. Bowen disease, glomerular vessels in a clustered distribution Crown vessels in a typical sebaceous hyperplasia lesion.
Crown vessels in 2 molluscum contagiosum lesions. Dotted vessels in a dermatoﬁbroma.
Vascular patterns in vascular lesions and Kaposi sarcoma.
Rainbow pattern in Kaposi sarcoma. Reddish-whitish areas, peripheral collarette, and rail lines in a pyogenic granuloma. Oval lacunae characteristic of angioma serpiginosum
Vascular patterns in inﬂammatory lesions.
Vascular patterns in infectious lesions.
Dotted vessels combined with a scaling surface Dilated vessels in a string-like distribution in in a typical psoriatic plaque. the center of a scar.
Diagnostic algorithm according to predominant vascular pattern.
Diagnosis Global Patterns Melanoma Clark nevus Specific Local Features Additional Local Features Confounding Features Multicomponent, Atypical pigment network, reticular, globular, irregular dots/globules, parallel-ridge, unspecific irregular streaks, bluewhitish veil, irregular pigmentation, regression structures, dotted or linear irregular vessels Hypopigmented areas, hairpin vessels, red globules Homogeneous or starburst pattern; typical pigment network, regular dots/globules, regular streaks, milialike cysts Reticular, globular, homogeneous Regular streaks, regression structures Multicomponent pattern; atypical pigment network, irregular dots/globules, irregular streaks, irregular pigmentation, dotted vessels Comedo-like openings, milia-like cysts Multicomponent pattern; irregular pigmentation Typical pigment network, regular dots/globules, regular diffuse or localized pigmentation, hypopigmented areas Unna and Miescher Globular, cobblestone, Regular dots/globules, nevi reticular, homogeneous, exophytic papillary unspecific structures, typical pseudonetwork, comma vessels
Diagnosis Global Patterns Specific Local Features Additional Local Features Confounding Features Reed and Spitz nevi Starburst, globular, multicomponent Regular streaks, regular Dotted vessels, typical diffuse pigmentation, pigment network reticular blue-whitish veil, regular dots/globules Reticular pattern; atypical pigment network, irregular dots/globules, irregular streaks, irregular pigmentation Recurrent nevus Multicomponent, homogeneous, unspecific Irregular pigmentation, Atypical pigment irregular streaks, white network, irregular areas dots/globules All local features mentioned in this row are commonly found in melanoma Blue nevus Homogeneous Regular diffuse pigmentation Hypopigmented areas Irregular diffuse pigmentation, arborizing vessels Congenital nevus Multicomponent, cobblestone, globular, reticular Regular dots/globules, typical pigment network, localized multifocal hypopigmentation, regular pigmentation Milia-like cysts, comedo- Localized irregular like openings, exophytic pigmentation, papillary structures regression structures
Diagnosis Global Patterns Specific Local Features Additional Local Features Confounding Features Combined nevus Multicomponent, Typical pigment Hypopigmented areas, homogeneous, globular, network, regular exophytic papillary reticular dots/globules, localized structures regular pigmentation Atypical pigment network, localized or diffuse irregular pigmentation Lentigo Reticular Typical pigment network Milia-like cysts, regular or pseudonetwork, dots/globules regular diffuse pigmentation Atypical pigment network, irregular pigmentation Vascular lesions Lacunar, globular, homogeneous Red lacunas, diffuse or localized structureless reddish-black to reddish-blue pigmentation Parallel pattern, regular Multicomponent dots/globules, whitish- pattern; irregular yellowish keratotic areas dots/globules, whitish veil
Diagnosis Global Patterns Specific Local Features Additional Local Features Confounding Features Labial and genital melanosis Unspecific, parallel Regular diffuse pigmentation, typical pigment network Atypical pigment network, irregular pigmentation Basal cell carcinoma Unspecific, multicomponent, globular Leaf-like areas, irregular Milia-like cysts, hairpin blue-gray dots/globules, vessels arborizing vessels Seborrheic keratosis Unspecific, globular, Milia-like cysts, comedo- Typical pigment reticular, homogeneous like openings, exophytic network, papillary structures, hypopigmented areas, regular diffuse dotted vessels, gyri and pigmentation, hairpin sulci, whitish-yellowish vessels horn masses Dermatofibra Reticular, unspecific, multicomponent Annular pigment network, central white patch Regular streaks Irregular gray-bluish pigmentation Multicomponent pattern; irregular pigmentation, regression structures, irregular dots/globules Localized pigmentation Irregular white areas or crusting, regular dots/globules, erythema
ABCD rule of dermoscopy (Modified according to Stolz 1994) Criterion Description Score Asymmetry In 0, 1, or 2 axes; assess not only contour, but also colors 0-2 and structures X 1.3 Border Abrupt ending of pigment pattern at the periphery in 0-8 0-8 segments X 0.1 Color Presence of up to six colors 1-6 (white, red, light-brown, 1-6 dark-brown, blue-gray, black) X 0.5 Differential structures Presence of network, structureless or homogeneous areas, streaks, dots, and globules X 0.5 1-5 Weight factor Total Dermoscopy Score (TDS) Interpretation <4.75 Benign melanocytic lesion 4.8-5.45 Suspicious lesion; close follow-up or excision recommended >5.45 Lesion highly suspicious for melanoma
Menzies scoring method To make a diagnosis of melanoma, 2 negative aspects (negative features) must be absent from the lesion and 1 or 2 positive aspects (from 1 of the 9 positive features) must be present.
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