White Structureless Areas Research Articles

Dermoscopy is a new diagnostic tool in diagnosis of common hypopigmented macular disease: A descriptive study.

One of the most frequent complaints in dermatology clinics is the eruption of hypopigmented patchy skin lesions. The aim of the study was to investigate the utility of dermoscopy in common hypopigmented macular diseases. Patients with the followings diseases were examined by dermoscopy: vitiligo, pityriasis alba, nevus depigmentosus, achromic pityriasis versicolor, idiopathic guttate hypomelanosis, and extragenital guttate lichen sclerosus.This study showed that these hypopigmented macular diseases might display specific dermoscopic features. In vitiligo, the mean dermoscopic features were the presence of a diffuse white glow with perifollicular pigment, perilesional hyperpigmentation, leukotrichia and the pigmentary network. In idiopathic guttate hypomelanosis, the characteristic features were the presence of multiple, shiny, scaly macules with welland ill-defined edges borders that coalesced into polycyclic macules. For nevus depigmentosus, the mean features were hypopigmented patches with irregular border with a faint reticular network. For pityriasis alba, the fairly ill-demarcated hypopigmented macules with fine scales were the mean feature. In lichen sclerosus, there were white structureless areas, perilesional erythematous halo, follicular plugging and white chrysalis like structures. Dermoscopy of achromic pityriasis versicolor showed a fairly demarcated white area with fine scales localized in the skin creases.

Clinical and dermoscopic spectrum of discoid lupus erythematosus: novel observations from lips and oral mucosa.

Under dermoscopy, discoid lupus erythematosus (DLE) exhibits specific findings. Commonly DLE lesions affect sun-exposed sites, especially the face. However, most of the dermoscopic reports come from scalp DLE. To our knowledge, the dermoscopic pattern for mucosal and labial DLE has not been previously reported. This study included 20 patients with histopathologically confirmed DLE lesions. Full history taking was obtained with photo documentation of lesions including the sites involved, the number of lesions per site, and the total number of lesions affecting every patient. Finally, a dermoscopic examination was performed. Almost 85% of patients had only cutaneous DLE lesions, while 15% showed both cutaneous and mucosal lesions. Follicular keratotic plugging (56.1%) and scales (52.6%) were the most frequently detected dermoscopic criteria. A significant correlation was found between lesion's age and the following dermoscopic criteria: (early lesions: follicular keratotic plugs and perifollicular white halos; while late lesions: telangiectasia and white structureless areas). Furthermore, telangiectasia, white structureless areas, and ulceration were found in dermoscopy of mucosal DLE. Also, telangiectasia, brown pigment spots, scales, white structureless areas, bleeding spots, and erosions were detected in dermoscopy of labial DLE. Moreover, labial storiform telangiectasia was seen under dermoscopy in patients with associated SLE. Dermoscopy is a valuable tool for diagnosing DLE at different sites and in differentiating between the early and end-stage lesions. Herein, we reported the first dermoscopic view for DLE affecting the lips and oral mucosa. Labial storiform telangiectasia could be a dermoscopic sign of coexisting SLE.

Correlations between histopathologic and dermoscopic findings in Korean actinic keratosis.

Skin biopsy for AK diagnosis is usually performed on only a limited part of the whole lesion. Therefore, a clinical diagnosis is important. According to a study, there is no significant correlation between histopathological and clinical classification system. We examined the correlation between microscopic information and dermoscopic findings to deduce if dermoscopic information reflects histopathologic grade severity. Forty seven patients with histologically confirmed AK were enrolled and positive ratio of red pseudonetwork, rosette, red background and targetoid signs, white-to-yellow scale, white structureless area, and pigmentation from dermoscopic findings were investigated. Furthermore, viable epidermal thickness, vessel lumen dimensions, existence and thickness of ortho- and parakeratosis, degree of sola elastosis, flag sign existence, and Roewert-Huber classification were measured as histologic findings. Red background did not show a significant correlation with vascular dimension or viable epidermal thickness. When targetoid sign was present, vascular dimension was significantly larger but showed no correlation with viable epidermal thickness, parakeratosis or orthokeratosis. Solar elastosis level was significantly higher when white-to-yellow scale was present. According to Spearman's correlation analysis, ortho/parakeratotic thickness showed correlations with each other. The negative correlation between viable epidermal thickness and vascular dimension was also shown. Roewert-Huber histologic AK classification showed no correlation with any factors we checked. Factors considered to be characteristic features of AK in dermoscopy seemed unassociated with histologic AK classification and additional research is needed to determine degree of dysplasia of AK lesions using dermoscopy.

Dermoscopy features of atypical fibroxanthoma: A multicenter study of the International Dermoscopy Society

Little is known about the dermoscopic features of atypical fibroxanthoma. This was a case-control study. Atypical fibroxanthoma lesions were compared with a control group with non-melanoma skin cancer. Altogether 40 atypical fibroxanthoma were collected. Most developed in men (93%), appearing mainly as nodular (63%), amelanotic (93%) and ulcerated (78%) lesions. Most lesions were located on the scalp (55%) and the ears (13%). Dermoscopically, most atypical fibroxanthoma displayed red (83%) and white (70%) structureless areas and irregular linear vessels (43%). A series of features achieved statistical significance when comparing atypical fibroxanthoma with non-melanoma skin cancer. The presence of red and white structureless areas and white lines, and the absence of yellowish-white opaque scales, hairpin vessels and arborising vessels were predictive of atypical fibroxanthoma in univariate analysis. However, when squamous cell carcinoma was excluded from the analysis, none of the criteria achieved statistical significance. When basal cell carcinoma was excluded, three variables achieved statistical significance in predicting atypical fibroxanthoma: red, structureless areas, the absence of opaque yellowish-white scales and absence of white circles. Atypical fibroxanthomas seem to be barely distinguishable from basal cell carcinoma dermoscopically, but they are more easily distinguishable from a well to moderately differentiated squamous cell carcinoma. A histopathological examination is needed for the final diagnosis.

Dermoscopy of Cutaneous Mastocytoma.

An 8-year-old boy presented with an episodically pruritic, dome-shaped, yellowish to skin-colored papule measuring approximately 6 mm × 5 mm on the right upper chest from the past 6 months [Figure 1]. Stroking the lesion with a blunt object produced a faint perilesional erythema without whealing. The lesion was completely excised, and hematoxylin-eosin analysis revealed diffuse dermal mononuclear cell infiltrate extending into and widening the dermal papillae [Figure 2a]. The cells stained positively with toluidine blue with metachromatic intracellular granules [Figure 2b]. The clinical and histological features were consistent with solitary cutaneous mastocytoma. Dermoscopy under polarized mode revealed a central whitish structureless area with a few reddish spots surrounded by reticulate brownish pigmentary networks on a yellowish background. The periphery of the lesion was formed by a reticulate hyperpigmented rim [Figure 3].Figure 1: A 6 mm × 5 mm yellowish smooth dome shaped papule on the right upper chestFigure 2: Photomicrograph showing diffuse mononuclear cell infiltrate involving the dermis extending into and expanding the dermal papillae [a, H and E, Original magnification x40]. The cells stained positively with toluidine blue with metachromatic (pink) intracellular granules [b, Toluidine blue, Original magnification x40]Figure 3: Non-contact dermoscopy under polarized mode using DermLite™ DL3 demonstrated a central white structureless area with a few red dots surrounded by reticulate brownish pigmentary network on a yellowish background (black circles), and a marginal reticulate hyperpigmented rim (yellow arrows pointing). [Original magnification x10]Cutaneous mastocytoma usually occurs as a solitary lesion commonly involving the trunk, neck, and extremities of children. The onset is generally within the first few months of birth but late onset lesions are not infrequent. Typical lesions are yellowish-brown, smooth dome-shaped papules or nodules which may urticate on stroking (Darier's sign). Although a pathognomonic feature, the Darier's sign is seen only in half of the cases.[1] Vano-Galvan et al. delineated four predominant dermoscopic features in cutaneous lesions of mastocytosis which included light brown blot, pigment network (attributable to dermal mast cell infiltrate and basal layer hypermelanization), and yellow-orange blot (attributed to dense papillary and reticular dermal mast cell infiltrate). Among these, the yellow-orange blot was consistently associated with mastocytoma.[2] In our case, the brown reticulate network on a background of yellowish hue was seen indicative of dense dermal mast cell infiltrate with increased melanization of the overlying basal layer of the epidermis, as evident in Figure 2a. The central pale yellow to whitish structureless area is caused by the accumulation of serosanguineous fluid produced due to excoriation of the epidermis in the centre of the lesion [Figure 1] because of scratching. The linear vessels and red spots in the centre correspond to dilated vessels seen prominently due to excoriation of the epidermis. Differential diagnoses for such lesions in children include juvenile xanthogranuloma and papular or tuberous xanthomata. Juvenile xanthogranuloma is a close clinical differential diagnosis for mastocytoma. Dermoscopically as well, it exhibits yellow-orange blots, however, the color contrasts typically give a “setting sun” appearance. Additional features include fine interrupted brownish lines and peripheral vascular patterns.[3] Hence, dermoscopy is a useful investigative tool not only to support the clinical findings of cutaneous mastocytoma but also to differentiate from closer differentials such as juvenile xanthogranuloma. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Dermoscopic and reflectance confocal microscopy features of cutaneous squamous cell carcinoma

Squamous cell carcinoma (SCC) of the skin is a highly prevalent neoplasm. The management and the prognosis of this tumour are dependent on its invasiveness and its grade of differentiation. To evaluate whether specific dermoscopic and reflectance confocal microscopy (RCM) criteria can predict the diagnosis of invasive SCC vs. in situ SCC and poorly differentiated compared with well- and moderately differentiated SCC. Dermoscopic and RCM images of SCC were retrospectively evaluated for the presence of predefined criteria. Among 143 SCCs, 121 cases had a complete set of images and thus were included in the study set. The head and neck area was the most frequently involved body site (74/121; 61.1%) followed by extremities (36/121, 29.7%) and trunk (11/121, 9.1%). Seventy tumours were in situ (57.8%), while 51 were invasive (42.1%), of these 11 were poorly differentiated (21.5%), 16 were moderately differentiated (31.3%), and 24 were well differentiated (47.0%). Chi-squared analysis demonstrated that invasive SCCs were characterized by polymorphic vessels, erosion/ulceration, architectural disarrangement, speckled nucleated cells in the dermis, irregularly dilated vessels and absence of hyperkeratosis. Buttonhole vessels, white structureless areas and dotted or glomerular vessels were significantly associated with in situ lesions. Poorly differentiated SCCs were typified by red areas, erosion/ulceration and architectural disarrangement. Well- or moderately differentiated SCCs were associated with white areas and speckled nucleated cells in the epidermis. Clinical, dermoscopic and RCM images provide useful information that should be integrated in order to achieve the optimal therapeutic management for the patient.

Basosquamous carcinoma: Dermoscopic clues to diagnosis

Basosquamous carcinoma (BSC) is a rare skin cancer which has areas of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) and a transition zone between them. However, dermoscopic features of BSC are not well described in the published work, except one study. The aim of the present study was to better identify and clarify the dermoscopic findings of BSC in the largest group of patients in the published work and to describe its dermoscopic features according to histopathologically BCC-dominant, SCC-dominant and intermediate categories. Dermoscopic features of 36 histopathologically proven BSC and their dermatopathological correlates were retrospectively analyzed. Dermoscopic features were evaluated by pattern analysis. Keratin mass (91.7%) was the most common dermoscopic feature. Surface scaling (77.8%), ulceration (69.4%), white structureless areas (69.4%), white clods (66.7%) and blood spots on keratin mass (66.7%) were the other frequent findings. Polymorphous vascular pattern consisting of various combinations of branched, serpentine, straight, coiled or looped vessels were detected in 61% of the lesions. BSC has BCC-dominant vascular features together with otherwise SCC-dominant morphology, the common pattern seen in BSC lesions being BCC-dominant polymorphous or monomorphous vasculature, together with dermoscopic findings of keratinization. White circles, known to be a valuable clue to SCC and keratoacanthoma, were present at the same magnitude in BSC in our study. The observed histological correlation of eosinophilic keratin overlying the epithelium which lined follicular infundibulae in these tumors, provides a plausible new perspective on dermoscopic white circles.

TOPICAL STEROID INDUCED FACIAL ROSACEIFORM DERMATITIS.

Abuse of topical steroids on the face for long periods of time is a condition that needs time to cure and also methods to better observe the clinical features and for the follow-up after the cessation of steroids. To investigate which are the most prominent dermoscopic features of the Topical Steroid Induced Facial Rosaceiform Dermatitis(TSIFRD). All 40 patients showed telangiectasias (100%) and dermoscopic polygonal vessels. 80% of the patients had dermoscopic features for Demodex Folliculorum, 80% had visible and dermoscopic pustules, 75 % had visible erythema on the face and by dermoscopy they all had red diffuse areas. The atrophy was clinically visible at 4 patients (Fig. 1a) as a severe skin thinning, but dermoscopy revealed also atrophic areas at another 4 as white structureless areas between vessels (Fig. 1b). The patients with dermoscopic atrophy were using 2 mometasone furoat, 6 clobetasol propionate - one of them in the periocular area developed a very strong clinically atrophy and also glaucoma but the cortisole levels were normal. Dermoscopy is a tool for early detection of the infraclinical signs of TSIFRD by dermoscopic features: polygonal vessels, telangiectasias, scales, depressible erythema, pustules, Demodex plugs and tails, atrophy.

Dermoscopic characteristics of nodular squamous cell carcinoma and keratoacanthoma.

Background:Nodular squamous cell carcinoma (SCC) and keratoacanthoma (KA) may mimic a variety of other benign and malignant non-pigmented nodules.Objectives:To analyze the dermoscopic characteristics of nodular SCC and KA.Patients/Methods:Retrospective analysis of 50 nodular SCCs and 8 KAs collected from a tertiary dermatology referral center and a private dermatology practice in Melbourne, Australia, between 1 September 2009 and 1 October 2012. All lesions were nodules; defined as firm, elevated, round, palpable tumors with a diameter of 5 mm or more. Clinical and dermoscopic images were evaluated by two examiners in consensus.Results:Signs of keratinization were frequently observed and included keratin crust/scale (90% of SCCs, 100% of KAs), central keratin mass (32% of SCCs, 88% of KAs), white structureless areas (66% of SCCs, 50% of KAs), white circles (32% of SCCs, 38% of KAs) and white keratin pearls (14% of SCCs, 12% of KAs). Hemorrhage was present in 72% of SCCs and 88% of KAs and preferentially occurred centrally and in areas of keratinization. For nodular SCCs and KAs, we observed glomerular vessels (42% and 25% respectively), linear irregular vessels (36% and 25% respectively), atypical vessels (30% and 38% respectively) and hairpin vessels (30% and 25% respectively).Conclusions:Hemorrhage, keratinization and vascular features (glomerular, hairpin and linear irregular morphologies) are useful in diagnosing both nodular SCC and KA. Further research on the comparative dermoscopic characteristics of a range of amelanotic nodules is important in order to improve diagnosis of these clinically challenging tumors.

Prediction without Pigment: a decision algorithm for non-pigmented skin malignancy

While there are several published comprehensive stepwise algorithmic methods for diagnosing pigmented skin malignancy, only limited material has been published for the stepwise assessment of non-pigmented lesions. We present a method based on pattern analysis, with a stepwise assessment, first, for ulceration, second, for white clues (defined as white lines, or in the case of a raised lesion any of the keratin clues: dermatoscopic white circles, dermatoscopic white structureless areas or surface keratin), and third, if no ulceration or white clues are present, proceed to vessel pattern analysis.This is a novel method, and apart from the assessment of white clues in raised lesions, it has not been formally tested. The priority of keratin clues in raised lesions over vessel pattern analysis has, however, been verified.It is conceded that this method is less specific than methods which have clues of pigmented structures, and accepting these limitations, Prediction without Pigment is a decision algorithm intended to guide the clinician in the decision as to whether to perform a biopsy rather than consistently leading to a specific diagnosis. Reaching a more specific diagnosis at the end of our flowchart can be achieved by weighing of clues both clinical and dermatoscopic, and that ability can be expected to improve with both knowledge and experience, but no diagnostic method, including this one, can be 100% sensitive in diagnosing malignancy, in particular, melanoma. Taking these limitations into account, any non-pigmented lesion, regardless of pattern analysis, which is raised and firm (nodular) and for which a confident, specific benign diagnosis cannot be made, should be excised to exclude the nodular variant of amelanotic melanoma.

Dermoscopy of basosquamous carcinoma

Basosquamous carcinoma (BSC) is a rare and potentially aggressive tumour, characterized by clinical and pathological features of both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). It is reported to have a nonspecific clinical presentation, which makes naked-eye diagnosis a challenge. To describe the dermoscopic patterns of BSC, which may facilitate early diagnosis and accurate management. This was a retrospective evaluation of clinical and dermoscopic images of histopathologically proven BSC, collected from skin cancer centres in Australia (Perth), Greece (Thessaloniki) and Italy (Naples, Reggio Emilia). Twenty-two tumours were included in the study. Our analysis revealed that the dermoscopic pattern of BSC comprises BCC-related criteria, as well as features that are known to characterize invasive SCC. The most frequently detected criteria were: unfocused (peripheral) arborizing vessels (73%), keratin masses (73%), white structureless areas (73%), superficial scale (68%), ulceration or blood crusts (68%), white structures (64%), blue-grey blotches (59%) and blood spots in keratin masses (55%). Notably, all but one of the tumours exhibited at least one BCC-related plus one SCC-related dermoscopic feature. BSC appears to have overlapping dermoscopic features of BCC and invasive SCC, and detection of at least one dermoscopic criterion of both BCC and SCC should raise suspicion for the tumour. Appreciation of the dermoscopic patterns of BSC might assist in the timely and accurate diagnosis and subsequent optimal management of this unusual and potentially metastatic skin tumour.

Dermoscopic Features of Basal Cell Carcinomas: Differences in Appearance Under Non-Polarized and Polarized Light

Basal cell carcinomas (BCCs) can be diagnosed using different dermoscopic modalities. To evaluate dermoscopic features of BCCs using nonpolarized and polarized dermoscopy to highlight similarities and differences between dermoscopic modalities. Retrospective study of 149 BCCs under nonpolarized dermoscopy (NPD), polarized contact dermoscopy (PCD), and polarized noncontact dermoscopy (PNCD). Images were evaluated for a range of dermoscopic colors, structures, and vessels. Features were compared according to histopathologic subtype. The most common dermoscopic structures in BCCs across all modalities included globules (50.3-51.0%), dots (49.7-50.3%), white structureless areas (63.1-74.5%), structureless gray-brown areas (24.2-24.8%), and ulcerations (28.2%). The most frequently observed vasculature included arborizing vessels (18.8-38.3%), short fine telangiectasias (SFTs) (73.8-82.6%), and vascular blush (41.6-83.2%). Structures with higher levels of agreement across modalities included pigmented structures and ulcerations. Lower levels of agreement existed between contact and noncontact modalities for certain vascular features. White shiny structures, which include shiny white lines (chrysalis and crystalline structures) (0-69.1%), shiny white areas (0-25.5%), and rosettes (0-11.4%), exhibited no agreement between NPD and polarized modalities. This study highlights differences in dermoscopic features of BCCs under three dermoscopic modalities. Shiny white lines (chrysalis and crystalline structures) and shiny white areas may be used as additional criteria to diagnose BCCs.

Dermatoscopy of facial actinic keratosis, intraepidermal carcinoma, and invasive squamous cell carcinoma: A progression model

Little is known about the dermoscopic features of keratinocyte skin cancer. We sought to determine the dermoscopic features of facial actinic keratosis (AK), intraepidermal carcinoma (IEC), moderately to poorly differentiated invasive squamous cell carcinoma (SCC), and well-differentiated SCC of the keratoacanthoma type. This was a retrospective analysis of dermoscopic images of histopathologically diagnosed keratinocyte skin cancer. A total of 243 (70 AK, 71 IEC, 78 SCC, and 24 keratoacanthomas) tumors of the face from 243 patients (mean age: 71.1 years; range: 44-94 years) were analyzed. The majority of patients had a fair skin type, history of melanoma or nonmelanoma skin cancer, and multiple AK. Ared pseudonetwork was significantly associated with AK (P < .001), whereas dotted/glomerular vessels, diffuse yellow opaque scales, and microerosions were significantly more prevalent among IEC (P < .001). Hairpin vessels, linear-irregular vessels, targetoid hair follicles, white structureless areas, a central mass of keratin, and ulceration were significantly associated with invasive SCC (P < .001 for all criteria). Similar patterns as in SCC were observed among keratoacanthomas. The retrospective design of our study and the lack of assessment of sensitivity and specificity of the dermoscopic criteria are limitations. Based on our findings we propose a progression model of facial AK developing into IEC and invasive SCC.

Dermoscopy of Lymphomatoid Papulosis

L YMPHOMATOID PAPULOSIS (LYP) IS CHARACterized by papular, papulonecrotic, and/or nodular skin lesions at different stages of development, predominantly on the trunk and limbs. We prospectively evaluated 8 patients using dermoscopy and histopathologic correlations. The aim of this pilot study was to define dermoscopic criteria associated with the different stages of the disease (erythematous papule, ulcerated and/or necrotic papule, and cicatricial lesion). The dermoscopic pattern was similar in all patients and varied with the different stages of the disease. The initial inflammatory papular lesion (Figure 1A) showed essentially a vascular pattern of tortuous irregular vessels radiating from the center to the periphery of the lesion (Figure 1B). A white structureless area was seen around the vessels (Figure 1B, inset). On histopathologic evaluation, dilated vessels were observed on the upper dermis (Figure 1C and D, arrow) among the tumoral dense infiltrate of large CD30 cells (for type A LyP). Intravascular thrombosis was noted on the small vessels, usually at the beginning of the ischemic process (Figure 1E, arrow). On more mature lesions (hyperkeratotic papules), a whitish structureless area was seen at the center of the papule (Figure 2A). The vessel pattern was still observed, but it spared the middle of the lesion (Figure 2B). This central pattern was correlated with the onset of a hyperkeratosis on histologic samples and the onset of fibrinoid necrosis (Figure 2C, arrow) associated with intravascular thrombosis on the upper dermis. In the third stage, the necrotic ulceration replaced the whitish structureless area (Figure 3A). We observed centrally a brown-gray structureless area corresponding to the fibrinocruoric material; the vessel pattern was strictly limited to the extreme periphery of the lesion (Figure 3B). On histopathologic analysis (Figure 3C), a crust was seen on the center of the lesion, while the tumoral infiltrate and vessels were only seen deeper and at the periphery. Finally, in the cicatricial phase (Figure 4A), we observed no more residual vessel pattern; only a browngray structureless mark suggesting postinflammatory pigmentation persisted (Figure 4B). Histopathologically, findings corresponded to the dermal fibrosis noted in scarring LyP but without residual tumoral infiltrate (Figure 4C). As LyP lesions mature, their histopathologic changes can be well correlated with morphologic features seen on dermoscopy.