4 курс / Дерматовенерология / Дерматоскопия (3)

light-brown reticular lines on dermatoscopy are a variant of dermatofibroma (3) with reticular lines only (5.4) and urticaria pigmentosa (4), a type of mastocytosis (5.5). When brown reticular lines are thick and not thin, one should first consider a Clark nevus or less often a superficial congenital nevus (5.6). A solar lentigo is very unlikely. A seborrheic keratosis may present with thick, brown, reticular lines, but in this case one nearly always sees reticular lines in combination with other characteristic features of seborrheic keratosis.

Black or at least very dark-brown reticular lines are a clue to the diagnosis of ink-spot lentigo (5.7). Additional

clues are abrupt ending of lines within the lesion and a sharply demarcated border. Normally no differential diagnosis needs to be considered. Very rarely a Reed nevus may demonstrate this pattern and color combination, but without the additional clues to “ink-spot lentigo”. For a lesion with only reticular lines but more than one color, one first should exclude a solar lentigo or seborrheic keratosis. This is done best by considering the clues to solar lentigo (well-demarcated, scalloped border) and seborrheic keratosis (white dots or clods, orange or yellow clods, well-demarcated border, circles, thick curved lines, vessels as loops or coils). Once a

solar lentigo or a seborrheic keratosis has been ruled out, three differential diagnoses should be considered: a) Clark nevus, b) “superficial” or “superficial and deep” congenital nevus, and c) in situ melanoma (5.8). One proceeds in the usual stepwise manner. The colors and their distribution are assessed before the final step, resolving the differential diagnosis using clues. For a pattern of reticular lines, only the colors light-brown, dark-brown, black and very rarely gray will be seen. In practice, there are only three ways that two colors combine in reticular lesions (in theory, of course, there is an infinite number of combinations). The first possibility

is central hyperpigmentation, i.e. light-brown reticular lines peripherally and dark-brown or even black lines in the center (5.9). This pattern is typical of a Clark nevus. All other diagnoses may be safely ruled out.

When dark-brown or black and light-brown areas are present alternately so that one obtains the impression of a speckled lesion, this type of color distribution is termed variegate. The differential diagnosis for a variegate reticular lesion is: Clark nevus, “superficial” or “superficial and deep” congenital nevus, or an in situ melanoma (5.10). While the distinction between a Clark nevus and a congenital nevus is purely of academic

interest, the differentiation between these and an in situ melanoma is of course very significant, and is based on the presence or absence of the clues to melanoma outlined in chapter 3. Only 5 of the 9 clues to melanoma are seen in reticular pattern lesions: a) gray dots, clods, circles or lines; b) radial lines or pseudopods seen only in some segments of the periphery; c) black dots or clods at the periphery d) thick reticular lines and e) angulated lines (polygons). When one of these clues is present, the diagnosis of melanoma should be seriously considered.

The third and last color combination seen in reticular pattern lesions is eccentric hyperpigmentation, i.e. the more heavily pigmented area is peripheral, not central. This color combination is found in both Clark nevi and in situ melanomas (5.11), but only rarely in congenital nevi. As in the case of variegate pigmentation, the differential diagnosis is resolved by assessing the lesion for clues to melanoma. When no clue to melanoma is present, a Clark nevus is the most likely diagnosis. A common difficulty is how one should proceed when the overall assessment shows a symmetrical pattern and

color combination, but a clue to melanoma is present, e.g. gray dots. This is a situation where experts will make better decisions than beginners, as the strength of the clue must be weighed against one’s level of certainty that the lesion is in fact symmetrical. As a general principle, symmetry of pattern and color should be given greater weight than the clue; in short, “pattern trumps clues”. Nevertheless, some of these lesions must be submitted for histopathology to confidently exclude malignancy. A clue should also be weighed differently depending on the number of lesions with similar features in the same patient. For example, some patients have multiple reticular lesions with gray dots or gray lines. In this context, gray structures have a lower weight as a clue to malignancy. This “comparative approach” (5) helps to increase specificity (to reduce the number of excisions of

nevi). If, on the other hand, there is only a single reticular lesion with gray structures the clue should be given more weight. This helps to increase sensitivity (to detect more melanomas). The management of patients with multiple nevi will be discussed in more detail in chapter 9.

Branched lines

Branched lines and reticular lines are closely related and often occur together. Sometimes they are difficult to distinguish, in which case one should analyze according to the much more common reticular pattern. There are, however, lesions that are exclusively composed of branched lines. In practice, these lesions are either black or brown, and they are all benign. Lesions that have only brown branched lines are either a Clark nevus or a “superficial” or “superficial and deep” congenital

nevus. The branched lines are probably columns of melanocytes at the base of rete ridges, which appear as nests in the vertical plane of the histopathological specimen. Black (or very dark-brown) branched lines indicate an “ink-spot” lentigo. Here again the pigmentation is at the base of the rete ridges but it is in basal keratinocytes, not in melanocytes as in Clark nevus or in superficial congenital nevus.

Angulated lines

Angulated lines are the hallmark of flat melanomas on skin with chronic sun damage, on both facial and non-facial skin (6, 7) (5.12). They often appear in conjunction with another pattern, most often with the reticular pattern on non-facial skin and with circles on facial skin. On non-facial skin, a pattern of angulated

lines is one of the most specific clues to the diagnosis of melanoma. On facial skin, however, angulated lines are also seen in pigmented actinic keratoses (8, 9). Most melanomas with angulated lines are in situ (not invasive). The lines are usually brown or gray. Many melanomas with angulated lines also have gray dots, but usually too few to be called a pattern. Close inspection of angulated lines may show them to be formed by densely packed gray dots.

Parallel lines

The pattern of parallel lines is the typical pigment pattern of acral skin. Parallel lines may be arranged in one of three ways; on the ridges (ridge pattern), in the furrows (furrow pattern), or crossing ridges and furrows (crossing pattern). Acral lesions that only show

a furrow pattern or a crossing pattern, and without any of the clues to melanoma, may be safely considered to be benign (10). These are either classical acral nevi or small “superficial” or “superficial and deep” congenital nevi (5.13).

Assessment of a lesion showing the ridge pattern proceeds in the normal stepwise fashion by evaluating color. If it is brown, in situ melanoma must be considered. Occasionally, acral nevi may also have a ridge pattern; the same is true for acral lentigines or melanotic macules related to the person’s ethnic origin or found as part of rare diseases such as the Laugier-Hunziker syndrome (11). However, a biopsy is usually required to confirm such a benign diagnosis.

Black, red or purple parallel lines on the ridges indicate either hemorrhage or exogenous pigmentation (5.14

bottom right). Satellite clods are a strong clue to the diagnosis of hemorrhage. As both hemorrhage and exogenous pigmentation are found in the stratum corneum (i.e. superficially) one can remove the pigmentation by careful paring with a scalpel. This is, of course, not possible with a melanocytic lesion.

Radial lines

As radial lines always occur in combination with another pattern, they are discussed in the section dedicated to lesions with more than one pattern.

Curved lines

Curved lines usually occur in combination with other patterns. However, some solar lentigines or seborrheic keratoses may have only curved lines (5.15). In these

cases one often finds clues like a curved, sharply demarcated border, or a few circles, to support the diagnosis of solar lentigo or seborrheic keratosis.

5.1.2 Pseudopods

Like radial lines, pseudopods occur only in combination with other patterns and are also discussed in the section dedicated to lesions with more than one pattern.

5.1.3 Circles

Just as the pattern of parallel lines is the pattern of acral skin, the pattern of circles is the pattern of facial skin. In contrast to parallel lines, the pattern of circles is not unusual at other locations on the body. On the face,

circles are formed by melanin pigment arranged either around the openings of the crater-like infundibula or in infundibular epithelium. The center of the infundibulum appears hypopigmented. If infundibula contain keratinized material rather than a hair-shaft, (which is not unusual) the hypopigmented center is seen as yellow or orange clods. Facial circles, especially when they are broad and confluent, are often seen on close inspection to be small dots arranged as circles around the openings of the infundibula. On facial skin it is crucial to differentiate between a pattern of circles (or dots arranged as circles) formed by pigment, and gaps in other patterns created by the infundibula, as this is of great diagnostic significance. This is most commonly

an issue with the pattern of dots and the structureless pattern (5.16).

Circles (or dots arranged as circles) may be brown or gray (5.17). Brown circles not associated with hair follicles are usually signs of solar lentigo or flat seborrheic keratosis. Brown circles associated with hair follicles can also be seen in solar lentigo and flat seborrheic keratosis. Occasionally, brown circles are present in

facial melanoma in situ but usually there is also another clue present. Gray circles on facial lesions indicate melanoma in situ. Gray dots arranged in circles, even when the gray color is only present in some parts of the lesion, give rise to the differential diagnosis of lichen planus-like keratosis, pigmented actinic keratosis and in situ melanoma. Clues that favor pigmented actinic keratosis (in addition to the non-dermatoscopic clue of

palpable roughness) are white circles, scale, and 4-white dots in a square (the latter visible only with polarized dermatoscopy). In lichen planus-like keratosis one can usually see remnants of a solar lentigo. The differential diagnosis of facial lesions with grey circles can be challenging (8) and is discussed further in chapter 8. In figure 5.18 we show a potpourri of facial lesions with circles or dots arranged as circles.

A biopsy is often needed to diagnose facial lesions with gray circles, as dermatoscopy cannot always differentiate between melanoma in situ, lichen planus-like keratosis and pigmented actinic keratosis. Confocal laser scanning microscopy may prove useful in this special case.

The pattern of circles is not confined to facial skin. On the trunk or the extremities, the pattern of thin brown circles has the same differential diagnoses as thin reticular lines, i.e. the pattern of circles may be a variant of the reticular pattern. In both cases there is melanin hyperpigmentation in the basal keratinocytes. In the reticular pattern, the rete ridges are narrow so that the lines touch each other, thus creating the impression of a network pattern. In a pattern of circles, however, the rete ridges are broad so that the lines arranged as circles around the papillae do not touch each other and on dermatoscopy one sees discrete circles (5.19). For both brown circles and brown reticular lines, the differential diagnosis includes a junctional Clark nevus and a solar lentigo. Dermatofibroma is an additional diagnosis for the pattern of circles (5.20). Rarely, a dermatofibroma may consist of just one pattern, i.e. thin brown circles.

5.1.4 Clods

After reticular lines, the pattern of clods is the second most common. Proceeding according to the method, color is assessed next.

One color predominates

When a lesion consists exclusively of clods, the color of the clods determines the diagnosis (5.21). When white and/or yellow clods predominate, seborrheic keratosis is the most common diagnosis. Dilated infundibula and inclusion cysts (“milia”) filled with keratin are clearly seen as yellow or white clods (5.22). It is important to remember that the white clods of seborrheic keratosis may not be accurately appreciated when using polarized dermatoscopy, only becoming clearly visible when a non-polarized instrument is used (12).

White and/or yellow clods are also found in cases of sebaceous gland hyperplasia. These clods are located centrally and are all of similar size and shape. Radial vessels, which do not cross the center of the lesion, are a strong clue to sebaceous gland hyperplasia. The central clods are subtle and easily overlooked if one is distracted by the more obvious peripheral vessels. The color of clods in a seborrheic keratosis depends on the quantity of the melanin mixed with keratin and may range from white or yellow to orange, brown or black. While orange clods are a sign of seborrheic keratosis, one should include basal cell carcinoma in the differential diagnosis because orange clods may also be due to ulceration (serum crust). Whereas multiple orange clods are seen in seborrheic keratosis