Eccrine porocarcinoma arising in a seborrheic keratosis evaluated with dermoscopy and treated with Mohs' technique.

Dermoscopic Findings of Clonal Seborrheic Keratosis and Pigmented Basal Cell Carcinoma in the Skin of Color Patients - A Comparison.

Tumor of follicular infundibulum–associated neoplasms

Skin cancers are often misdiagnosed or diagnosed late in skin of color (Fitzpatrick types 4-6) resulting in increased morbidity and mortality. Rare skin cancers such as Eccrine Porocarcinoma (EPC), which accounts for 0.005% to 0.01% of all epidermal skin neoplasms, are even less likely to be accurately diagnosed in skin of color. Eccrine Porocarcinoma is often misdiagnosed as Squamous cell carcinoma (SCC), Basal Cell Carcinoma (BCC), melanoma, and seborrheic keratosis. The paucity of case reports of EPC in skin of color adds to the challenge of achieving accurate, timely diagnosis and treatment in this patient population. The purpose of this research is to review case reports of EPC documented in skin of color, highlighting salient clinical and histopathological characteristics of EPC, and to describe an additional case of EPC in skin of color that was initially misdiagnosed as seborrheic keratosis. Our search combined “eccrine porocarcinoma” and one of the following terms: “ethnic skin”, “skin of color”, “black”, “dark skin”, “African American”, “Indian”, “Native American”, “Asian”, “Hispanic”, “Indigenous Peoples”, “Middle Eastern” —as these tend to correspond with Fitzpatrick IV – VI types. Google scholar, PubMed, and Ovid MedLine Databases were used to search for articles. Case reports ranging from 1994 to present day were included in analysis.

Background Seborrheic keratosis (SK) is the most common benign skin tumour to be misdiagnosed clinically as melanoma. SK may grow rapidly, is dark coloured with black areas and is accompanied with itching. Thus, it is difficult to distinguish it from malignant melanoma on clinical basis. Dermatoscope is a simple noninvasive tool useful for the early recognition of pigmented skin tumours, especially SK, melanoma and pigmented basal cell carcinoma, as it helps in differentiating each of them by specific criteria. In case a doubt about the diagnosis persists, biopsy is carried out for confirmation. Aim of the work The aim of the present study was to determine the role of dermatoscope in diagnosing and differentiating different types of SK, and its ability to detect suspicious lesions and confirm diagnosis by using histopathology. Patients and methods This study was carried out on 50 SK patients; out of them nine had suspicious lesions. All patients were subjected to dermatological, dermoscopic and histopathological examinations for suspicious lesions. Results In our study, the most common dermoscopic findings for different types of SK (stucco, dermatosis papulosa nigra, melanoacanthoma, flat type) were sharp demarcated border, comedo-like openings, milia-like cysts, moth-eaten borders and cribriform pattern. In addition, hairpin blood vessels and fat finger appeared in flat type SK. In our study, the dermoscopic criteria of suspicious lesions (n = 9, 18%) was diagnostic by 22.2% to tumour, as it showed structureless area and blue gray clods (n = 1, 11.1%); structureless area, yellow clods and blue gray clods (n = 1, 11.1%); and sharp demarcated borders, comedolike openings, moth-eaten borders, milia-like cysts and fissures and ridges (n = 7, 77.8%). Overall, 22.2% of the biopsied cases were basal cell carcinoma and 77.8% were SK. Conclusion SK must be taken seriously with close follow-up by using dermoscopy to detect any malignant changes.

Eccrine porocarcinoma (EPC) is a rare malignant skin tumor presumably arising from the intraepidermal ductal portion of the sweat gland. EPC occasionally mimics eccrine poroma (EP), seborrhea keratosis (SK), basal cell carcinoma (BCC), pyogenic granuloma (PG) and amelanotic melanoma with its clinical appearance as a pink nodule. Dermoscopy is an invaluable technique in diagnosing skin tumors. However, few cases of EPC have been reported using dermoscopic images, and their details were not well examined. Here, we present three histopathologically proven cases of EPC and summarize their dermoscopic findings together with five previously reported cases. None of the eight cases showed dermoscopic evidence indicative of SK (comedo-like openings, milia-like cysts, fissures and ridges, and hairpin vessels with white halo), BCC (blue-gray ovoid nests, multiple blue-gray globules, wheel-like structures, shiny white areas, leaf-like areas and arborizing vessels) or PG (reddish homogeneous area with collarette and white rail lines). A milky red area, which was suggestive of amelanotic melanoma, was not detectable in any cases. Seven cases exhibited a polymorphous vascular pattern mainly consisting of hairpin, linear-irregular and dotted vessels. A combination of round-to-oval pink-white structureless areas and white-to-pink halo was observed in five of eight cases, with one case showing the white-to-pink halo alone. Our investigation revealed that the dermoscopic characteristic of EP was also observed in discrete areas of EPC lesions. Thus, it is possible that the histopathological architecture of EPC contains portions of benign EP-like components. Awareness of this dermoscopic aspect of EPC may be helpful when diagnosing pink nodules.

Background:Seborrheic keratosis (SK) is the most common benign epidermal tumor of the skin. Even though SK has been well characterized clinically, dermoscopically, and histopathologically, data regarding clinical dermoscopic and histopathological correlation of different types of SK are inadequate.Aim:We carried out this study to establish any correlation between the clinical, dermoscopic, and histopathological appearance of SK and its variants.Methods:This was a descriptive study. Patients with SK were evaluated with respect to age, sex, family history of similar lesions, site of lesions, and symptoms associated with the lesions. Dermoscopy was performed in all cases. Biopsies were taken from the lesions and assessed for histopathology.Results:The most common age group affected by SK was 31–50 years (42%). A female preponderance of 76% was seen. Majority of our patients had a positive family history (62%), though Sun exposure was not seen to be a major factor. The most common clinical variant was common SK (CSK) (46%). The most common dermoscopic findings seen in CSK were comedo-like (CL) openings, fissures and ridges (FR), and milia-like (ML) cysts. Dermatosis papulosa nigra and pedunculated SK had characteristic FR and CL openings on dermoscopy. Stucco keratoses showed network-like (NL) structures and sharp demarcation. CL opening on dermoscopy corresponded to papillomatosis and pigmentation, ML cysts corresponded to horn cysts, FR corresponded to papillomatosis, and NL structures corresponded to an increase in basal layer pigmentation.Conclusions:This study emphasizes the use of dermoscopy in improving the diagnostic accuracy of SK. The correlation between the various histological and dermoscopic features is described.

Basal cell carcinoma (BCC) and seborrheic keratosis (SK) are representative pigmented skin tumors, and they are differentiated as non-melanocytic lesions in the two-step dermoscopy algorithm proposed by the Consensus Net Meeting on Dermoscopy. Because most BCC in Japanese patients are pigmented clinically, dermoscopy plays an important role in their differential diagnosis. The dermoscopic criteria for BCC include the lack of a pigment network and the presence of at least one positive feature for BCC, such as large blue-gray ovoid nests, multiple blue-gray globules, leaf-like areas, spoke wheel areas, arborizing vessels and ulceration. Whereas various dermoscopic features are seen in SK, comedo-like openings, milia-like cysts, and fissures and ridges are especially important features. It is necessary for clinicians to consider the pathological conditions causing the dermoscopic features of BCC and SK. In addition, the sensitivity and specificity of each feature should be taken into consideration to ensure an accurate dermoscopic diagnosis.

To the Editor: Seborrheic keratosis (SK) is one of the most common benign skin tumors in clinic. Due to the wide variation in its clinical features, however, and particularly when both its manifestations and dermoscopic findings of its lesion are atypical, it may be challenging to differentiate SK lesions from other benign or malignant skin tumors.[1,2] We here report a case of SK of an adenoid type that initially imitated pigmented basal cell carcinoma (BCC) upon dermoscopy. A 49-year-old female patient presented with a 2-year history of a single, slowly growing papule on her right arm with occasional itching. Physical examination revealed a 4 mm × 5 mm rough, slightly hard, oval brown papule with central erosion [Figure 1A]. Subsequent dermoscopy (CBS-908; CBS Inc., Wuhan, China) revealed an ulcer and hairpin vessels in the center of the lesion, with surrounding blue-gray globules and leaf-like areas at the edge [Figure 1B]. Most of the dermoscopic findings, especially the pigmented structures without pigment network, were consistent with a diagnosis of pigmented BCC.Figure 1: Clinical manifestation and dermoscopic and pathological findings in the study patient. (A) An oval brown papule with erosion in the center and measuring 4 mm × 5 mm was observed on her right arm. (B) Dermoscopy (polarized-light, original magnification ×50) revealed ulcer (asterisk) and central hairpin vessels (black arrow), brown keratin scales and surrounding blue-gray globules (white arrow), and leaf-like areas (circle) at the edge. (C) Strands of proliferating basaloid cells were found to extend from the epidermis and interweave in the dermis. No stratum corneum was detected in the middle of the lesion. Histopathology also revealed some pigment deposition and inflammatory cells infiltration in the superficial dermis (hematoxylin-eosin staining, original magnification ×40).Histopathologically, the lesion in our patient showed acanthosis and thin proliferating strands of basaloid cells arising from the epidermis and twisting in the dermis [Figure 1C]. The stratum corneum was missing in the middle of the lesion, whilst pseudohorn cysts were present in the epidermis. The epithelium showed hyperpigmentation and also some pigment deposition and inflammatory cells infiltration in the superficial dermis. Based on these findings, we made a final diagnosis of an adenoid type of SK, rather than a pigmented BCC. The dermoscopic features of an adenoid SK have not been previously reported, and the most typical dermoscopic findings of SK such as comedo-like openings, cerebriform pattern, and milia-like cysts were not clearly visible in our present case.[3] At the same time, the SK lesion in our current patient also showed no typical dermoscopic features of other epidermal hyperplastic tumors, such as Bowen's disease (ie, glomerular vessels and scaly surface) or keratoacanthoma (such as keratin crust, white circles, or dot vessels).[4] Notably, this patient has previously stated that the lesion was occasionally itchy, suggesting that the central erosion surface may have been caused by recent irregular scratching. Irritation or prior trauma may also render dermoscopic findings atypical that make it difficult to differentiate from other tumors.[5] In terms of dermoscopic details, it is noteworthy in the first instance that erosion occurred instead of ulceration in our present case, but that these two processes are not easily distinguishable under dermoscopy. Second, the hairpin vessels without white halo[5] were apparent in our present case instead of the arborizing vessels that are typical of pigmented BCC, and were therefore considered diagnostic clues for SK. Lastly, the hyperkeratosis on the edge of the lesion and epidermal hyperpigmentation, and the free pigment and melanophages in the dermal papilla, had initially been mistaken for leaf-like areas and for blue-gray globules that are characteristic of pigmented BCC nests, respectively. In conclusion, although dermoscopy is a valuable tool for diagnosing SK, the adenoid type of these lesions that have been scratched can mimic pigmented BCC under dermoscopy thus making dermoscopic findings atypical and accurate diagnosis more difficult. In such cases, therefore, it is important not to rely solely on dermoscopy but to utilize a combination of an auxiliary examination, medical history taking, and clinical characteristics to make a differential diagnosis, particularly when secondary injuries occur. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Conflicts of interest None.

The coexistence of more than one neoplasm in a single cutaneous specimen is relatively uncommon and has been defined as a collision or compound tumour (1, 2). Although some of these collision tumours may arise from the involvement of related cell types, most occur by chance (1). Melanocytic naevus has been reported as occurring associated with several different tumour types (1, 3). The association of a melanocytic naevus arising contiguously with or adjacent to seborrhoeic keratosis is, however, uncommon (1, 4–7). We report here a patient who presented with a pigmented macule that she had had for a long time, and which had recently increased in size and darkened. Histopathological examination showed a pigmented seborrhoeic keratosis that developed contigu-ously with a melanocytic naevus.CASE REPORTA 39-year-old woman had had a brown, asymptomatic cutaneous lesion on her back since childhood. She re-ported that the lesion had increased in size and became darker in the last year. Clinical examination disclosed an asymmetric, pigmented tumour measuring 13 mm in diameter on the right scapular region. The lesion exhibited 2 well-differentiated areas of pigmentation: one part was light brown in colour, 4 mm in diameter and the other was black, 9 mm in diameter, with fol-licular prominence (Fig. 1a). Dermoscopic evaluation of the whole lesion revealed a sharp demarcation, with pseudo-horn cysts, comedo-like openings and fissures in the bigger area. The other part of the tumour showed the presence of a pigmented network with small hy-popigmented areas. Clinical and dermoscopic findings suggested a collision tumour: seborrhoeic keratosis and melanocytic naevus. The lesion was surgically excised. Histopathological examination showed a symmetrical intradermal melanocytic proliferation composed of nests of melanocytes without atypia, consistent with a melanocytic intradermal naevus. Adjacent to the mela-nocytic naevus we observed a proliferation of pigmen-ted small basaloid cells with uniform appearance with hyperkeratosis, acanthosis and pseudohorn cysts (Fig. 1b). The latter features were consistent with pigmented seborrhoeic keratosis.DISCUSSIONThe combination of a melanocytic naevus with other tumours of epidermal or adnexal origin has often been described (1, 3). Common epidermoid cyst and melano-cytic nevus is the association reported most frequently (8). Melanocytic naevus has also been associated with a trichilemmal cyst(9), steatocystoma, hidrocystoma and dermoid cyst(8), syringoma(10), trichoepithelioma (3), trichoadenoma (11) and basal cell carcinoma (1). Despite the fact that melanocytic lesions and seborr-hoeic keratosis are among the skin lesions from which biopsies are more commonly taken, the association of a melanocytic naevus with a seborrhoeic keratosis is uncommon. Boyd & Rapini (1), in a retrospective study of 40,000 cutaneous biopsies, found 14 cases of melanocytic naevus juxtaposed with a seborrhoeic keratosis. Only another 4 cases of melanocytic naevus

To estimate the population-based incidence of first and multiple basal cell carcinomas (BCCs) throughout Europe. The registry practices of 4 population-based cancer registries that routinely register BCC incidence were evaluated for inclusion of first and subsequent histologically confirmed BCCs. Where multiple BCCs were not routinely registered, comparisons with hospital databases were made. Cancer registry databases from Finland, Malta, the Netherlands (Eindhoven), and Scotland were inspected for registry of first and multiple BCCs in recent years. Cross-checks with hospital and pathology databases were made to check for completeness. Age-standardized first BCC incidence rates varied between 77 (Malta) and 158 (Eindhoven) per 100 000 person-years. Generally, rates were higher in males than in females, and incidences increased steeply with increasing age. There were approximately 30% more patients with a BCC and 40% to 100% more BCC tumors diagnosed in a given calendar year than were routinely reported for patients with a first primary BCC. The difference between the number of first primary BCCs and the total number of BCCs in a calendar year was generally slightly higher for males than for females and increased substantially with increasing age. Currently, routinely reported first BCC incidence rates of the included countries should be multiplied by a factor of 1.3 for an estimate of total number of patients diagnosed as having a BCC in a given year.

Objective The aim of this study was to understand the role of specific markers of stem cells Oct-4 expression in the development of human epidermal non-melanoma cutaneous tumors.Methods The paraffin-embedded samples were retrieved from files of pathology department at our hospital,including 20 cases of skin squamous cell carcinomas (SCC),20 cases of basal cell carcinomas (BCC),20 cases of seborrhoeic keratosis (SK) and 20 cases of normal skin (from head,face,trunk,extremities).The expression of Oct-4 and PCNA were observed by immunohistochemical staining technique.Results Oct-4 protein was abnormally increased in SCC and BCC comparel to normal skin and SK ( P ＜0.05 ).However there were no significant difference of Oct-4 protein expression between SCC and BCC ( P ＞0.05).There were also no significantly different Oct-4 protein expression between Sk and the normal skin ( P ＞ 0.05 ),and no significantly different Oct-4 protein expression between SK and BCC( P ＞0.05 ).PCNA protein was abnormally increased in SCC and BCC compared to normal skin and SK ( P ＜0.01 ).There were significantly different PCNA protein expression between SCC and BCC( P ＜0.05).There were also significantly different PCNA protein expression between SK and the normal skin ( P ＜ 0.05 ).However there were no significant difference of PCNA protein expression between SK and BCC ( P ＞ 0.05 ).There were positive correlation between the expression intensity of Oct-4 and PCNA in SCC and BCC.Conclusions The abnormal expression of Oct-4 may have an important role in the development of BCC and SCC.Positive Oct-4 expression cells may be the tumor stem cell in SCC and BCC.There were positive correlation between the expression intensity of Oct-4 and PCNA in SCC and BCC.The over expression Oct-4 in BCC and SCC may play an important role in proliferation of tumor. Key words: Octamer transcription factors/metabolism; Carcinoma, squamous cell/metabolism/pathology; Carcinoma, basal cell/metabolism/pathology; Keratosis, seborrheic/metabolism/pathology

Basal cell carcinoma (BCC) is uncommon in individuals with skin of color. Multiple carcinomas in skin of color are rare, even in the setting of predisposing factors such as chronic immunosuppression, genetic predisposition, and chronic ultraviolet radiation exposure. Herein, we present a case of multiple pigmented BCCs, as a subtype of multiple non-syndromic BCC, in a Fitzpatrick skin type (FST) IV woman of South Asian descent. A 52-year-old immunocompetent woman from Bangladesh with FST IV and a history of type 2 diabetes, hypercholesterolemia, gastroesophageal reflux disease, and asthma presented for Mohs micrographic surgery of a biopsy-proven nodular BCC of the left lower eyelid (Figure 1a). Over the course of a year, she developed seven additional biopsy-confirmed BCCs of pigmented histologic subtype on both sun-exposed and sun-protective sites. The BCCs were located on the right scalp at the hairline (Figure 1b), left upper back (Figure 1c), right middle back (Figure 1d), lower back (Figure 1e), right thigh (Figure 1f), right temple (Figure 1g), and right lateral cheek (Figure 1h). Dermoscopy revealed spoke wheel and maple leaf structures. Basic serologies were within normal limits. Family history was unremarkable for skin cancer. There was no evidence of jaw cysts, plantar or palmar pits, skeletal abnormalities, or other stigmata of BCC-associated syndromes like basal cell nevus syndrome (BCNS), xeroderma pigmentosum, and Rombo syndrome. There was no history of visceral neoplasms, smoking, significant ionizing radiation, artificial UV, or occupational exposures.1 Wearing sun-protective clothing was reported, however, sunscreen use was denied. The patient immigrated to the United States from Bangladesh and frequently travels to her home country. Intermittent recreational ultraviolet exposure early in life may be a significant risk factor for BCC development, as BCC incidence is inversely related to latitude. Bangladesh is also known to have higher levels of arsenic in drinking water, which may have contributed to the development of multiple BCCs in our patient.1 The patient underwent six Mohs micrographic surgeries for the lesions on the lower eyelid, scalp, upper back, middle back, temple, and cheek, as well as two excisions for the lesions on the thigh and lower back. Daily sun protection and skin checks every 3 months were recommended. A referral to genetics for further workup of possible underlying genodermatoses was made but ultimately declined. The lack of genetic testing is a limitation of this report and reflects challenges contributing to the underrepresentation of foreign-born individuals in health research. Our patient offers a unique clinical presentation of non-syndromic, multiple-pigmented BCCs in an FST IV patient of South Asian descent. Reports of BCNS in the South Asian and Bangladeshi populations are exceedingly rare. In individuals with BCNS and darker skin types, the development of multiple BCCs is thought to be blunted compared to their White counterparts.2 Kulkarni et al. present a case of BCNS in a 25-year-old man of mixed African-American and White descent with FST IV and 11 biopsy-confirmed BCCs.3 In immunocompetent individuals with multiple BCCs, the most and least common histologic subtypes are nodular (60.5%) and pigmented (1.1%), respectively.3 Shoji et al. reported the first case of multiple pigmented basal cell carcinomas in an Asian, more specifically, in a Korean woman.4 Additionally, a case of non-syndromic, multiple-pigmented BCCs in a 74-year-old male with FST IV was reported in Spain.5 Our case adds to the limited literature of multiple pigmented BCCs as a subtype of multiple non-syndromic BCCs. The authors provided consent for the publication of all patient photographs and medical information at the time of article submission to the journal, stating that all patients permitted their photographs and medical information to be published in print and online and with the understanding that this information may be publicly available.

Making a definitive diagnosis of seborrheic keratosis (SK) can be challenging for the naked eye due to its wide variation in clinical features. Fortunately, however, most cases of SK exhibit the typical dermoscopic findings of fissures and ridges, hairpin vessels with white halo, comedo-like openings, and milia-like cysts, all of which are helpful to distinguish SK from melanoma, melanocytic nevus, squamous cell carcinoma, basal cell carcinoma (BCC) and other skin tumors. Histopathologically, these dermoscopic characteristics correspond to papillomatous surface of the epidermis, enlarged capillaries of the dermal papillae, pseudohorn cysts in the epidermis opened to the surface of the lesion and intraepidermal cysts, respectively. Clinicians should bear in mind that the clonal type of SK dermoscopically mimics melanoma and BCC by the presence of globule-like structures, while regressing SK exhibits a granular pattern that is similar to the peppering found in melanoma. Furthermore, milia-like cysts alone are insufficient for a conclusive diagnosis of SK because melanoma in rare cases displays cysts along with other SK-like dermoscopic findings.

A melanoacanthoma (MA) is a pigmented variant of seborrheic keratosis. Owing to the pigmentation, MAs may mimic the clinical appearance of malignant melanomas (MMs). However, the dermoscopic patterns of MAs and MA-like MMs have rarely been compared. To elucidate the clinical and dermoscopic differences between MAs and MA-like MMs. This study included 77 MA and 33 MA-like MM patients. We retrospectively reviewed the medical records, clinical findings, and dermoscopic findings of the two groups. Crypts and comedo-like openings (71.4%) in MAs and the blue-white veil (60.6%) in MMs were the most common dermoscopic findings. Crypts, comedo-like opening, milia-like cysts, fissures, and hairpin vessels appeared more frequently in MAs (P < .05). However, atypical pigment networks, blue-white veils, pseudopods and streaks, and atypical vessels were more common in MMs (P < .05). MAs often showed melanoma-specific dermoscopic findings, especially blue-white veils (22.1%). Furthermore, fissures (42.4%), crypts (21.2%), and comedo-like openings (15.2%) were observed in MMs, although they are typically benign patterns. Differences in dermoscopic patterns might provide important clues for the differential diagnosis of MA-like lesions. However, MAs such as MMs and true-benign MAs may overlap clinically in appearance and on dermoscopy. Several benign patterns were frequently observed in MMs (fissures, globular pattern, crypts, comedo-like openings, cerebriform appearance, and milia-like cysts), and several malignant patterns were observed in MAs (blue-white veil, pseudopod, and atypical pigment network). Importantly, if any of the melanoma-associated features or atypical vessels are present, the lesion should be biopsied to establish a diagnosis.

Malignant tumor occurring within seborrheic keratosis (SK), which is one of the most common benign cutaneous tumors, is extremely rare. We report a case of basal cell carcinoma (BCC) arising within SK. Additionally, this is the first study to describe the immunohistochemical characteristics of this type of carcinoma. An 89-year-old Japanese woman presented with a persistent scaly plaque in the right auricle of her ear. Histopathological study revealed a superficial type of BCC arising within SK. Immunohistochemical studies showed that cytokeratin 17 (CK17), CK19, SOX9 and p53 protein were expressed in BCC, but not in SK. BCC is considered to originate from the follicular germinative cells, and the outer root sheath may be the possible origin. SK is also thought to be a benign skin appendage neoplasm showing follicular differentiation, especially follicular infundibula. Therefore, previous reports speculated that there was a pathogenic relationship between SK and BCC, with respect to a common follicular origin. However, the immunohistochemical characteristics of this study suggest that BCC does not arise directly from SK, but instead, that SK is the nidus of the carcinoma, resulting in the abutment of SK with BCC. Furthermore, the results of the present case suggest that immunohistochemical surveillance of the expression of CK17, CK19 and SOX9 and p53 protein is useful in differentiating minute BCC from the non-neoplastic hair buds.