Dotted Vessels Research Articles

SnapshotDx Quiz: December 2018

SnapshotDx Quiz: December 2018

Differentiation of pityriasis rubra pilaris from plaque psoriasis by dermoscopy.

BackgroundDiagnosing and differentiating pityriasis rubra pilaris (PRP) from other disorders can be a challenging task. Although histopathology remains the gold standard, it may not be feasible at times, especially in children. Being noninvasive, dermoscopy can be of great diagnostic importance in such a scenario. Dermoscopy overcomes the refractive properties of stratum corneum by interface medium or cross-polarization enabling easier visualization of lesions.ObjectiveTo study the dermoscopic features of PRP and compare them with dermoscopic features of psoriasis.Patients and MethodsRetrospective observational analysis of dermoscopic characteristics of 28 patients with PRP (16) and psoriasis (12). Polarized dermoscopy at 10× magnification was performed and photographs were captured by Apple iPhone 7. The selection of dermoscopic variables was based on preexisting literature on the dermoscopic patterns of the 2 entities.ResultsThe most frequent dermoscopic criteria of PRP were the presence of a central hair (16/16; 100%), follicular plugs (11/16; 68.7%), and perifollicular yellow/orange halos (9/16; 56.2%). No vascular structures were seen in our cases of PRP. Psoriasis was characterized by regularly distributed dotted vessels (12/12; 100%) and white scales (8/12; 66.6%).ConclusionsRound-to-oval yellowish areas surrounding a central hair with or without follicular plugs represents the most frequent dermoscopic pattern of PRP.

The vascular morphology of melanoma is related to Breslow index: An in vivo study with dynamic optical coherence tomography.

Malignant melanoma is an aggressive skin cancer, which can lead to metastasis development. Vascularization enhancement is fundamental for tumor growth, worsening the prognosis. Dynamic optical coherence tomography (D-OCT) enables the in vivo evaluation of vascular patterns in skin lesions. In vivo evaluation of the melanoma vessel morphology by means of D-OCT and correlation with Breslow index. Retrospective analysis of histologically proven melanomas, evaluated by D-OCT at three different depths (150, 300 and 500μm), was performed. Vessels were classified according to morphology (dots, blobs, coiled, line, curved, serpiginous), distribution (regular, irregular) and the presence/type of branches. The data were correlated with Breslow thickness. A total of 127 melanomas were evaluated. Dotted vessels were recorded at all depths, and their irregular distribution was associated with lesions thicker than 1.0mm (from 75% to 91%), compared with thin ones (42%) at 150μm (P=0.031), and from 33% to 57% vs 18% at 300μm (P=0.021). Serpiginous and branching vessels with bulges were predominantly seen in melanomas thicker than 2mm at 150μm (from 14% to 27%, P<0.001) and 300μm of depth (from 36% to 54%, P<0.001). Background noise hampered vessel detection at 500μm. No correlation with dermoscopy/histology. Vascular pattern evaluation at 150 and 300μm provided data on tumor microvascular asset and its pattern of progression in accordance with Breslow thickness. Since vascular progression is theoretically linked with tumor aggressiveness, the study of vascular pattern related with melanoma metastatization capability is warranted.

Dermoscopic characterization of cutaneous lymphomas: a pilot survey.

While substantial dermoscopic analysis of melanocytic lesions has been performed, dermoscopic characterization of cutaneous lymphoid proliferations has been limited. Cutaneous lymphoma, particularly early mycosis fungoides (MF) and its variants, is often challenging to clinically and pathologically distinguish from inflammatory processes of the skin. This study aimed to survey the dermoscopic findings of cutaneous lymphomas and to discern whether any patterns might potentially serve as specific signatures. Fifteen patients with an established diagnosis of cutaneous lymphoma were prospectively recruited and seen in the university multidisciplinary cutaneous lymphoma program with MF, an MF- variant, CD30-positive lymphoproliferative disorder, or cutaneous B-cell lymphomas and were included in our study. Dermoscopic findings, histologic features, clinical characteristics, and demographic data were analyzed. Patch stage MF was characterized by interconnected white structureless patches encircling small fine linear vessels, yielding an overall trabeculated to fenestrated pattern under dermoscopy. Corresponding histopathologic findings for these patterns included epidermotropism, atypical pleomorphic cells, and lichenoid infiltrates. Folliculotropic mycosis fungoides (FMF) was characterized by folliculocentric erosions surrounded by dotted and fine linear vessels, loss of terminal follicles, comedo-like openings, and interconnected regular-appearing structureless patches. Corresponding histopathologic findings in these FMF cases were typical of FMF. Notably, these changes were not appreciated in lymphomatoid papulosis. Primary cutaneous follicle center B cell lymphoma showed crystalline structures and vascular pseudopods. Cutaneous lymphomas appear to demonstrate characteristic dermoscopic patterns, reflective of the specific lymphoma type and its corresponding histopathology, which have not been seen in inflammatory skin conditions, such as psoriasis and eczematous dermatitis.

Trichoscopy – a useful tool in the preliminary differential diagnosis of autoimmune bullous diseases

Scalp is a common location of autoimmune bullous diseases. Trichoscopy is a noninvasive method for diagnosing hair and scalp diseases. Data on trichoscopy in autoimmune bullous diseases are limited to the studies on pemphigus including a small number of patients. Trichoscopic characteristics of bullous pemphigoid and dermatitis herpetiformis were not reported to date. The aim of the study was to determine the value of trichoscopy in the differential diagnosis of pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, and dermatitis herpetiformis. Trichoscopy was used to evaluate scalp lesions in 68 patients (26 with pemphigus vulgaris, 17 with pemphigus foliaceus, 17 with bullous pemphigoid, and 8 with dermatitis herpetiformis). The working magnification was 20-fold and 70-fold. The most frequent trichoscopic feature of autoimmune bullous diseases was extravasations. They occurred in 76.9% of patients with pemphigus vulgaris, 70.6% of patients with pemphigus foliaceus, 76.5% of patients with bullous pemphigoid, and 100% of patients with dermatitis herpetiformis. Yellow hemorrhagic crusts occurred in, respectively, 73.1%, 70.6%, 64.7%, and 35.5% of the cases. Yellow diffuse scaling and tubular scaling occurred more frequently in pemphigus foliaceus (52.9% and 41.2%, respectively). Clustered dotted vessels were characteristic for dermatitis herpetiformis (5/8, 62.5%). Dotted vessels with whitish halo were a hallmark of pemphigus vulgaris. A trichoscopic algorithm for the differential diagnosis of autoimmune bullous diseases was developed. Autoimmune bullous diseases present characteristic trichoscopic patterns. Trichoscopy can be regarded as a rapid in-office preliminary diagnostic method in the differential diagnosis of these diseases.

Update on dermoscopy of Spitz/Reed naevi and management guidelines by the International Dermoscopy Society.

Spitzoid lesions represent a challenging and controversial group of tumours, in terms of clinical recognition, biological behaviour and management strategies. Although Spitz naevi are considered benign tumours, their clinical and dermoscopic morphological overlap with spitzoid melanoma renders the management of spitzoid lesions particularly difficult. The controversy deepens because of the existence of tumours that cannot be safely histopathologically diagnosed as naevi or melanomas (atypical Spitz tumours). The dual objective of the present study was to provide an updated classification on dermoscopy of Spitz naevi, and management recommendations of spitzoid-looking lesions based on a consensus among experts in the field. After a detailed search of the literature for eligible studies, a data synthesis was performed from 15 studies on dermoscopy of Spitz naevi. Dermoscopically, Spitz naevi are typified by three main patterns: starburst pattern (51%), a pattern of regularly distributed dotted vessels (19%) and globular pattern with reticular depigmentation (17%). A consensus-based algorithm for the management of spitzoid lesions is proposed. According to it, dermoscopically asymmetric lesions with spitzoid features (both flat/raised and nodular) should be excised to rule out melanoma. Dermoscopically symmetric spitzoid nodules should also be excised or closely monitored, irrespective of age, to rule out atypical Spitz tumours. Dermoscopically symmetric, flat spitzoid lesions should be managed according to the age of the patient. Finally, the histopathological diagnosis of atypical Spitz tumour should warrant wide excision but not a sentinel lymph-node biopsy.

Intraoperative dermoscopic features of onychomatricoma: a review of 10 cases.

Amelanotic nail tumours are difficult to diagnose. Dermoscopy is an accessible tool successfully used in diagnosis of amelanotic or melanotic skin tumours. We have previously shown the usefulness of dermoscopy in the preoperative diagnosis of onychomatricoma (OM). In this study, we completed this work by identifying additional intraoperative criteria to better establish the initial diagnosis of this tumour. Evaluation of intraoperative dermoscopy in a small series of OM cases in order to define relevant diagnostic criteria. In total, 10 patients with OM diagnosed in our centre were enrolled in the study. Six trained dermoscopists individually evaluated each criterion, then the data were compared and a consensus reached after discussion between the observers. For each criterion, we analysed its frequency and its interobserver accordance. We defined three architectural criteria (the 'Sagrada Familia' sign, digitations and the 'mirror sign'), and three vascular criteria (sagittal vessels, dotted vessels and irregular vessels). The Sagrada Familia sign, digitations and mirror sign were found in 100%, 90% and 70% of the cases, respectively, with high interobserver agreement. The vascular criteria were less regularly observed: sagittal, dotted and irregular vessels were respectively found in 80%, 70% and 50% of the OM cases, and were more difficult to assess, as shown by the lower interobserver agreement rates. Intraoperative dermoscopy of the nail matrix and bed offers useful information for the diagnosis and management of OM. Larger comparative studies should be performed to evaluate the true benefit of this approach.

Association between dermoscopic and reflectance confocal microscopy features of cutaneous melanoma with BRAF mutational status.

Melanomas harbouring common genetic mutations might share certain morphological features detectable with dermoscopy and reflectance confocal microscopy. BRAF mutational status is crucial for the management of metastatic melanoma. To correlate the dermoscopic characteristics of primary cutaneous melanomas with BRAF mutational status. Furthermore, a subset of tumours has also been analysed for the presence of possible confocal features that might be linked with BRAF status. Retrospectively acquired dermoscopic and confocal images of patients with melanoma in tertiary referral academic centres: Skin Cancer Unit in Reggio Emilia and at the Melanoma Unit in Barcelona. Kruskal-Wallis test, logistic regressions, univariate and multivariate analyses have been performed to find dermoscopic and confocal features significantly correlated with BRAF mutational status. Dermoscopically, the presence of irregular peripheral streaks and ulceration were positive predictors of BRAF-mutated melanomas with a statistically significance value, while dotted vessels were more represented in wild-type melanomas. None of the evaluated reflectance confocal microscopy features were correlated with genetic profiling. Ulceration and irregular peripheral streaks represent dermoscopic feature indicative for BRAF-mutated melanoma, while dotted vessels are suggestive for wild-type melanoma.

Dermoscopic hemorrhagic dots: an early predictor of response of psoriasis to biologic agents.

BackgroundBiologic agents are routinely used in the treatment of severe psoriasis. The evaluation of treatment response is mainly based on the physician’s global clinical assessment.ObjectiveTo investigate whether dermoscopy might enhance the assessment of response of psoriasis to treatment with biologic agents.MethodsPatients with severe psoriasis scheduled to receive a biologic agent were enrolled in the study. A target lesion from each patient was clinically and dermoscopically documented at baseline and after one, two and six months. The clinical response was evaluated by the recruiting clinicians at all visits, while dermoscopic images were evaluated by two independent investigators, blinded to the clinical information. Chi Square test was used for cross-tabulation comparisons, while odds ratios, 95% confidence intervals and p values were calculated using univariate logistic regression.ResultsOverall, there was a significant correlation between clinical response and vessel distribution at all time points: a regular vessel distribution correlated with no response, a clustered distribution with partial response, and the dermoscopic absence of vessels with complete response. The presence of dermoscopic hemorrhagic dots was a potent predictor of favorable clinical response at the subsequent visit at all time points. Among lesions initially clinically responding and later recurring, 87.5% displayed dermoscopic dotted vessels despite the macroscopic remission.ConclusionDermoscopy might be a useful additional tool for evaluating the response of psoriatic patients to biologic agents. Hemorrhagic dots represent an early predictor of clinical response, while the persistence or reappearance of dotted vessels might predict clinical persistence or recurrence, respectively.

Hypokératose acrale circonscrite (HAC) : utilité diagnostique de la dermoscopie

Circumscribed palmar hypokeratosis (CPH) is a rare skin disease, first described in 2002, associated with sudden localized reduction of the corneal layer. In most cases, it presents as an isolated rounded erythematous palmar lesion on the thenar eminence. We describe the dermoscopic semiology of CPH in 3 cases. Three patients between the ages of 59 and 72 presented very limited erythematous lesions suggestive of CPH. Dermoscopic examination of these lesions provided similar findings. Biopsy, which was performed in one patient, confirmed the diagnosis of CPH. Two dermoscopic elements of CPH are characteristic: (1) the sides of the lesion have a "stair step" or "geological strata" type of configuration, and the thickness of the different strata varies; (2) the centre of the lesion showed a homogeneous erythematous area with a vascular pattern composed of dotted vessels of the superficial dermis and sometime vascular loops. These dermoscopic aspects are characteristic and enable CPH to be differentiated from Bowen's disease or porokeratosis of Mibelli. In Bowen's disease, there is no stair step like aspect to the sides of lesions; further, the centre of the lesion shows glomerular vessels (coiled vessels) and/or globular vessels (small red clods). In porokeratosis, peripheral keratotic "white track" structures comprise a single pigmented channel or a double white line. There is no "stair step" or central vascular pattern. The dermoscopic semiology of CPH is highly characteristic and enables differentiation from Bowen's disease and porokeratosis.

Dermoscopy as a diagnostic aid for pruritic folliculitis of pregnancy

Pruritic folliculitis of pregnancy is a noninfective dermatosis of the gestation period characterized by multiple pruritic follicular papules and/or pustules which is not uncommonly mistaken for other similar skin disorders that may occur during pregnancy. In the present article we describe the usefulness of dermoscopy as a supportive diagnostic tool in a case of pruritic folliculitis of pregnancy. The main (always present) dermoscopic clue consisted of a vellus hair in the centre of each papule/pustule. Moreover, most papules showed a central yellowish-orange hue with some dotted vessels and irregular haemorrhagic spots. The detection of the aforementioned dermoscopic features might help distinguish pruritic folliculitis of pregnancy from its main differential diagnoses, mainly including microbial folliculitis, prurigo lesions, and the papular stage of pruritic urticarial papules and plaques of pregnancy, as they typically show different dermoscopic patterns. ( J Dermatol Case Rep . 2016; 10(1): 19-20)

Photoletter to the editor: Dermoscopy as a diagnostic aid for pruritic folliculitis of pregnancy.

Pruritic folliculitis of pregnancy is a noninfective dermatosis of the gestation period characterized by multiple pruritic follicular papules and/or pustules which is not uncommonly mistaken for other similar skin disorders that may occur during pregnancy. In the present article we describe the usefulness of dermoscopy as a supportive diagnostic tool in a case of pruritic folliculitis of pregnancy. The main (always present) dermoscopic clue consisted of a vellus hair in the centre of each papule/pustule. Moreover, most papules showed a central yellowish-orange hue with some dotted vessels and irregular haemorrhagic spots. The detection of the aforementioned dermoscopic features might help distinguish pruritic folliculitis of pregnancy from its main differential diagnoses, mainly including microbial folliculitis, prurigo lesions, and the papular stage of pruritic urticarial papules and plaques of pregnancy, as they typically show different dermoscopic patterns.

Dermoscopic features of conjunctival, mucosal, and nail pigmentations in a case of Laugier-Hunziker syndrome.

A 23-year-old man presented with multiple lip pigmentations. Longitudinal hyperpigmented streaks on his nails, as well as an ill-defined 2×3 mm pigmented spot on his right eye were noted (Figure 1). The family history was unremarkable. He was not taking any medication. Figure 1. Clinical view of labial (A), ungual (B) and conjunctival (H) pigmentations are shown. Dermoscopic findings included reticular lines (B), globules (C), and parallel lines (D) in the labial pigmentation; brown to gray longitudinal regular lines (F, G) in ... Colonoscopy and barium radiography of intestine were unremarkable. Complete blood count, complete metabolic panel, and urinalysis were within normal limits. The patient was diagnosed with Laugier-Hunziker syndrome (LHS). Dermoscopic examination of the lip pigmentations disclosed parallel lines, reticular lines and globules. The only recognized color was brown, which had a grayish hue in some parts of the lesion. A light brown colored homogeneous pattern was observed in the conjunctival pigmentation. The pigmented nail streaks showed brown-to-gray longitudinal regular lines (Figure 1). Histopathological examination of the labial pigmentation revealed basal keratinocyte pigmentation. No increase in the melanocyte count was identified with S100 and HMB45 immunohistochemical staining. Iron accumulation was not seen with specific Perls’ stain. The histopathological findings were compatible with the diagnosis of melanotic macule. Impression cytology examination of the conjunctival pigmentation revealed melanocytes with only a mild atypia suggesting a benign nature. The patient was processed to follow-up. LHS is a rare, acquired disease characterized by hyperpigmented macules of the lips and oral mucosa along with longitudinal melanonychia. Pigmentations in other mucosal surfaces may also exist. Although this syndrome is being regarded as benign, invasive mucosal melanoma has been reported in a case of LHS [1]. Parallel ridge pattern and irregular diffuse pigmentation in acral lesions; irregular lines on a brown background and micro-Hutchinson’s sign in nail apparatus lesions [2]; and the combination of blue, gray, or white color with structureless zones in mucosal lesions are the dermoscopic findings suggestive of melanoma [3]. Little data exists regarding the dermoscopic features of conjunctival pigmentations in the literature. Atypical pigment network, irregular dots and globules, regression structures, and a blue-white veil are the dermoscopic findings reported in a case of palpebral conjunctival melanoma [4]. Dermoscopic findings may differ from usual in some pigmentation syndromes including LHS. Parallel ridge pattern has been determined in benign acral pigmentations of several LHS cases [5–7]. Although nail pigmentations in LHS have been found to demonstrate similar dermoscopic findings with that seen in ethnic type and drug induced pigmentation, which are regular linear pigmentation lines on a grayish background, micro-Hutchinson’s sign have also been reported in benign nail pigmentations of some LHS cases [2,5,8]. Parallel furrow pattern, brown and blue-gray granular pigmentation along with linear and dotted vessels on whitish pink areas are the dermoscopic findings reported in labial pigmentations of LHS cases [5]. The only LHS case with labial melanoma in the literature exhibited blue-whitish veil on dermoscopic examination [1]. Dermoscopic findings in the present case were consistent with benign nature. The dermoscopic finding of a conjunctival pigmentation in LHS is being reported for the first time by the present study. The identification of dermoscopic features of this syndrome may simplify the management of LHS. Further reports are necessary to arrive at a conclusion.

Dermoscopic Features of Vulvar Lichen Sclerosus in the Setting of a Prospective Cohort of Patients: New Observations

Objective: Dermoscopic features of vulvar lichen sclerosus (VLS) were investigated in order to determine both vascular and non-vascular features of this disease. Materials and Methods: Dermoscopic images of 35 patients affected with histopathologically confirmed VLS were evaluated for the presence of predefined morphological criteria. Results: On dermoscopy, VLS lesions exhibited very sparse vessels, mainly linear, without a specific arrangement. Dotted vessels were observed mostly in the early stage of the disease. Patchy, structureless areas, whitish to white-yellowish to pink-whitish in colour over a diffuse whitish background, were a distinctive and constant dermoscopic feature. Grey-blue dots, usually with a characteristic peppered arrangement, corresponding to dermal melanophages, were also frequently seen. Comedo-like openings and scales were observed, as well as peculiar structures like ice slivers, not identified by histological examination. Conclusion: Our findings show that VLS exhibits characteristic dermoscopic patterns that can aid in its clinical diagnosis.

Clinical and dermoscopic features of atypical Spitz tumors: A multicenter, retrospective, case-control study

Few studies have described the clinical and dermoscopic features of atypical Spitz tumors. We sought to describe the clinical and dermoscopic features of a series of atypical Spitz tumors as compared with those of conventional Spitz nevi. This was a multicenter, retrospective, case-control study, analyzing the clinical and dermoscopic characteristics of 55 atypical Spitz tumors and 110 Spitz nevi that were excised and diagnosed histopathologically. The majority of atypical Spitz tumors presented clinically as a plaque or nodule, dermoscopically typified by a multicomponent or nonspecific pattern. A proportion of lesions (16.4%) exhibited the typical nonpigmented Spitzoid pattern of dotted vessels and white lines under dermoscopy. Nodularity, ulceration, linear vessels, polymorphic vessels, white lines, and blue-white veil were associated with atypical Spitz tumors by univariate analysis, but only nodularity and white lines remained significant after multivariate analysis. In contrast, a pigmented typical Spitzoid pattern was a potent predictor of Spitz nevi, associated with 6.5-fold increased probability. Differentiation from Spitzoid melanoma and other nonmelanocytic lesions was not investigated. Atypical Spitz tumors are polymorphic melanocytic proliferations with a nodular clinical appearance. Dermoscopically they demonstrate a multicomponent and nonspecific pattern. A typical nonpigmented Spitzoid pattern on dermoscopy (with dotted vessels and white lines) does not exclude atypical Spitz tumors.

DIAGNÓSTICO PELA DERMATOSCOPIA DE DOENÇA DE BOWEN EM PACIENTE HIV POSITIVO

A doença de Bowen é uma forma de carcinoma espinocelular intraepidérmico. Acontece em qualquer parte da pele, porém as áreas fotoexpostas são as mais prevalentes. Pode estar associado a imunossupressão.Paciente masculino, 46 anos, com diagnóstico de SIDA, último CD4 de 55 células. Relata aparecimento de lesão em abdome, de evolução de seis meses. Ao exame, placa numular, eritematosa, não descamativa em região de flanco direito. As hipóteses diagnósticas foram de ceratose seborréica irritada, eczema numular ou melanoma amelanótico. À dermatoscopia, observou-se agrupamentos de vasos glomerulares e escamas brancas. Deste modo, levantou-se a hipótese de se tratar de doença de Bowen. A histopatologia foi compatível com doença de Bowen. A dermatoscopia é uma técnica não invasiva, que permite a visualização morfológica de estruturas não observadas a olho nu. Na DB, caracteriza-se por presença de estruturas vasculares (vasos glomerulares ou pontilhados) e escamas na superfície. Neste caso, a dermatoscopia foi essencial para repensar a hipótese diagnóstica inicial da lesão. Mesmo na lesão não-pigmentada, a dermatoscopia vêm se mostrando uma arma importante no exame clínico do paciente.

Differentiation of pityriasis lichenoides chronica from guttate psoriasis by dermoscopy.

Clinical differentiation between pityriasis lichenoides chronica (PLC) and guttate psoriasis (GP) may sometimes be a difficult task, which often requires histological analysis to reach a definitive diagnosis. In this study, PLC and GP lesions were examined using dermoscopy, and the significance of specific dermoscopic findings was investigated in order to facilitate their differentiation and decrease the number of cases requiring biopsy. We found that the incidence of orange-yellowish structureless areas, focal dotted vessels and nondotted vessels was statistically significant in PLC, while the incidence of diffuse dotted vessels was statistically significant in GP.

An itching plaque

A 30-year-old woman presented to our hospital in Manacor, Mallorca, with a new lesion on the thorax that had appeared three to four months earlier, had gradually enlarged and was slightly itchy. The patient was otherwise healthy. Physical examination revealed a tender, brownish papule or plaque contacting the elastic band of the underwear under the right breast (Figure 1). The remaining physical exam showed no other relevant lesions. Dermoscopic examination showed an ill-defined redyellowish background with a small, pigmented, structureless area. Tiny, dotted and comma vessels were barely visible. Remarkable were numerous rounded or droplet-shaped, whitish structures spread all over the lesion (Figure 2). A 3 mm punch biopsy was obtained showing epidermal acanthosis and an intense superficial dermal inflammatory infiltrate. The infiltrate was composed by neutrophils, eosinophils and plasma cells, intermingled with bigger epithelioid cells, some of them containing tiny, round, basophilic structures in their cytoplasm (Figure 3). What is your diagnosis?

Videodermatoscopy of pearly penile papules. Case reports

Pearly penile papules are harmless dermatological condition characterized by small dome-shaped to filiform skin-colored papules located in one to several rows along the sulcus or corona of the glans penis. We describe six male patients with pearly penile papules whose diagnosis was assisted by means of videodermatoscopy. All lesions showed a characteristic whitish pink cobblestone appearance arranged in one or several rows. Each papule contained central dotted or commalike vessels and was surrounded by crescent-shaped whitish structures. Videodermatoscopy may assist the diagnosis of pearly penile papules and successfully differentiate them from genital warts and molluscum contagiosum.

A case of soft fibroma of the nipple with a cauliflower-like appearance.

Dear Editor: Soft fibroma (acrochordon, fibroepithelial polyp, or skin tag) is a common pedunculated skin neoplasm and usually appears as a furrowed papule, filiform lesion, or large bag-like protrusion. Soft fibromas primarily occur on the neck, axillae, and groin. However, it may present at unusual sites of the body such as the penis, urethra, and vulva. Moreover, a few reports on soft fibromas occurring on the breast and nipple have been published1. Herein, we report a rare and interesting case of a soft fibroma arising from the nipple, showing an unusual cauliflower-like appearance. A 51-year-old obese woman presented with a 25-year history of a painless pedunculated polyp originating from her right nipple. The lesion measured 2.4×2.3×1.4 cm and demonstrated a verrucous and cauliflower-like surface (Fig. 1A, B). Neither acanthosis nigricans nor epidermal nevus was observed on the adjacent skin. Dermoscopy revealed irregular epidermal projections and focal dotted vessels (Fig. 1C). Total surgical excision of the polyp, sparing the right nipple, was performed. Histopathological analysis showed papillomatosis, hyperkeratosis, and regular acanthosis of the epidermis with fibrocollagenous tissue in the dermis (Fig. 1D). On the basis of these findings, we diagnosed the lesion as a soft fibroma. Fig. 1 (A) A large solitary pedunculated polyp originating from the right nipple. (B) The polypoid lesion measuring 2.4×2.3×1.4 cm and demonstrating a cauliflower-like surface. (C) Dermoscopic findings showing irregular epidermal projections ... There have been only a few reports on soft fibromas of the nipple presenting with bullous formation or comprising a large elastic mass with a short pedicle2,3. Furthermore, there has been no report of a large and cauliflower-like soft fibroma of the nipple in the Korean literature. Because the clinical manifestations of soft fibroma of the nipple are nonspecific, histological examination is required for differential diagnosis, including pedunculated seborrheic keratosis, pleomorphic fibroma, nevoid hyperkeratosis of nipple and areola, and verruca vulgaris. In our case, the unusual clinical presentation of the cauliflower-like nipple tumor made the diagnosis of the lesion difficult. However, the histopathological findings provided important clues for making an accurate diagnosis. Thus, we have described a rare and interesting case of a cauliflower-like soft fibroma of the nipple.