Dermoscopic and confocal microscopy patterns of vulvar mucosal melanotic macules Angela Ferrari, MD,a Marina Agozzino, MD,a Marco Ardig o, MD,b Renato Covello, MD,c Vitaliano Silipo, MD,a d Elvira Moscarella, MD, Paola De Simone, MD,a and Caterina Catricala, MDa Rome and Reggio Emilia, Italy
CLINICAL PRESENTATION A 50-year-old woman presented with asymmetrical, flat, dark brown to greyish macules occurring on the vulvar mucosal area (Fig 1).
Fig 1. Asymmetrical, flat, dark brown to greyish macules on the vulvar mucosal area.
DERMOSCOPIC APPEARANCE The dermoscopic evaluation revealed a pattern composed of brown, linear parallel streaks that was visible at one side of the lesion (Fig 2, A). A ring-like pattern was also detected and was characterized by multiple round to oval, tan structures with hyperpigmented regular borders (Fig 2, A).
CONFOCAL REFLECTANCE MICROSCOPY Confocal reflectance microscopic examination was performed with the handled Vivascope 3000 (Caliber Imaging and Diagnostics, Inc, Rochester, NY). A regular honeycomb pattern was detected in the superficial layers. At the level of the epithelialechorion junction, cord-like structures were visible, and these were composed of tubular structures rimmed by monomorphic roundish cells that corresponded to the parallel pattern seen during the dermoscopic evaluation (Fig 2, A [maroon square] and B). In the area of the dermoscopic ring-like pattern, dermal papillae appeared rimmed by bright, monomorphic, roundish cells, corresponding to hyperpigmented keratinocytes (Fig 2, A [blue square] and C ). A few plump, bright cells corresponding to melanophages were seen within the dermal papillae (Fig 2, C ).
From the Departments of Oncologic Dermatologya and Dermatology,b Santa Maria and San Gallicano Dermatologic Institute, IRCCS, Rome; Department of Pathology,c Regina Elena National Cancer Institute, Rome; and the Dermatology and Skin Cancer Unit,d Arcispedale S. Maria Nuova, IRCCS, Reggio Emilia. Supported in part by the Italian Ministry of Health (grant RF-20102316524). Conflicts of interest: None declared.
Correspondence to: Elvira Moscarella, MD, Dermatology and Skin Cancer Unit, Arcispedale S. Maria Nuova, IRCCS, Viale Risorgimento, 80, 42100 Reggio Emilia, Italy. E-mail: elvira. [email protected]. J Am Acad Dermatol 2014;70:e81-2. 0190-9622/$36.00 ª 2013 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2013.10.038
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Fig 2. A, Dermoscopy, revealing a parallel pattern, composed of brown, linear parallel streaks, visible at one side of the lesion (maroon square). A ring-like pattern is also detected, characterized by multiple round to oval tan structures with a hyperpigmented regular border (blue square). B, RCM examination at the level of the epithelial-chorion junction. Cord-like structures are visible, composed of tubular structures rimmed by monomorphic roundish cells, and corresponding to the parallel pattern seen in dermoscopy. C, In the area of the dermoscopic ring-like pattern, dermal papillae appear rimmed by bright, monomorphic, roundish cells, corresponding to hyperpigmented keratinocytes. Few plump bright cells, corresponding to melanophages, are seen within dermal papillae (red arrows).
HISTOLOGIC DIAGNOSIS The histopathologic examination revealed benign mucosal melanosis.
KEY MESSAGE Vulvar mucosal melanotic macules clinically appear more frequently as multifocal flat lesions that may display a spectrum of dermoscopic patterns and need to be distinguished from vulvar melanoma. The parallel-like pattern and the ring-like pattern are strongly predictive of benign mucosal melanosis, and when detected in flat, brown macules of the mucosal areas they are typically benign.1 Confocal reflectance microscopy reveals microscopic details in vivo at a level of resolution close to conventional histology2 and with a high correspondence with dermoscopy.
REFERENCES 1. Ferrari A, Buccini P, Covello C, De Simone P, Silipo V, Mariani G, et al. The ring-like pattern n vulvar melanosis. A new dermoscopic clue diagnosis. Arch Dermatol 2008;144:1030-4. 2. Cinotti E, Perrot JL, Labeille B, Adegbidi H, Cambazard F. Reflectance confocal microscopy for the diagnosis of vulvar melanoma and melanosis: preliminary results. Dermatol Surg 2012;38:1962-7.
CLINICAL PRESENTATION A 50-year-old woman presented with asymmetrical, flat, dark brown to greyish macules occurring on the vulvar mucosal area (Fig 1).
Fig 1. Asymmetrical, flat, dark brown to greyish macules on the vulvar mucosal area.
DERMOSCOPIC APPEARANCE The dermoscopic evaluation revealed a pattern composed of brown, linear parallel streaks that was visible at one side of the lesion (Fig 2, A). A ring-like pattern was also detected and was characterized by multiple round to oval, tan structures with hyperpigmented regular borders (Fig 2, A).
CONFOCAL REFLECTANCE MICROSCOPY Confocal reflectance microscopic examination was performed with the handled Vivascope 3000 (Caliber Imaging and Diagnostics, Inc, Rochester, NY). A regular honeycomb pattern was detected in the superficial layers. At the level of the epithelialechorion junction, cord-like structures were visible, and these were composed of tubular structures rimmed by monomorphic roundish cells that corresponded to the parallel pattern seen during the dermoscopic evaluation (Fig 2, A [maroon square] and B). In the area of the dermoscopic ring-like pattern, dermal papillae appeared rimmed by bright, monomorphic, roundish cells, corresponding to hyperpigmented keratinocytes (Fig 2, A [blue square] and C ). A few plump, bright cells corresponding to melanophages were seen within the dermal papillae (Fig 2, C ).
From the Departments of Oncologic Dermatologya and Dermatology,b Santa Maria and San Gallicano Dermatologic Institute, IRCCS, Rome; Department of Pathology,c Regina Elena National Cancer Institute, Rome; and the Dermatology and Skin Cancer Unit,d Arcispedale S. Maria Nuova, IRCCS, Reggio Emilia. Supported in part by the Italian Ministry of Health (grant RF-20102316524). Conflicts of interest: None declared.
Correspondence to: Elvira Moscarella, MD, Dermatology and Skin Cancer Unit, Arcispedale S. Maria Nuova, IRCCS, Viale Risorgimento, 80, 42100 Reggio Emilia, Italy. E-mail: elvira. [email protected]. J Am Acad Dermatol 2014;70:e81-2. 0190-9622/$36.00 ª 2013 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2013.10.038
e81
e82 Ferrari et al
J AM ACAD DERMATOL
APRIL 2014
Fig 2. A, Dermoscopy, revealing a parallel pattern, composed of brown, linear parallel streaks, visible at one side of the lesion (maroon square). A ring-like pattern is also detected, characterized by multiple round to oval tan structures with a hyperpigmented regular border (blue square). B, RCM examination at the level of the epithelial-chorion junction. Cord-like structures are visible, composed of tubular structures rimmed by monomorphic roundish cells, and corresponding to the parallel pattern seen in dermoscopy. C, In the area of the dermoscopic ring-like pattern, dermal papillae appear rimmed by bright, monomorphic, roundish cells, corresponding to hyperpigmented keratinocytes. Few plump bright cells, corresponding to melanophages, are seen within dermal papillae (red arrows).
HISTOLOGIC DIAGNOSIS The histopathologic examination revealed benign mucosal melanosis.
KEY MESSAGE Vulvar mucosal melanotic macules clinically appear more frequently as multifocal flat lesions that may display a spectrum of dermoscopic patterns and need to be distinguished from vulvar melanoma. The parallel-like pattern and the ring-like pattern are strongly predictive of benign mucosal melanosis, and when detected in flat, brown macules of the mucosal areas they are typically benign.1 Confocal reflectance microscopy reveals microscopic details in vivo at a level of resolution close to conventional histology2 and with a high correspondence with dermoscopy.
REFERENCES 1. Ferrari A, Buccini P, Covello C, De Simone P, Silipo V, Mariani G, et al. The ring-like pattern n vulvar melanosis. A new dermoscopic clue diagnosis. Arch Dermatol 2008;144:1030-4. 2. Cinotti E, Perrot JL, Labeille B, Adegbidi H, Cambazard F. Reflectance confocal microscopy for the diagnosis of vulvar melanoma and melanosis: preliminary results. Dermatol Surg 2012;38:1962-7.
