Regressive scalp lesions: Dermoscopic and confocal clues Alice Mota Buc¸ard, MD,a Juliana Marques-da-Costa, MD,b Giuseppe Argenziano, MD,c Elvira Moscarella, MD,c Francesca Specchio, MD,d and Caterina Longo, MD, PhDc Rio de Janeiro, Brazil; and Reggio Emilia and Rome, Italy
CLINICAL PRESENTATION Four patients presented with suspicious pigmented scalp lesions with unknown history. All patients were men, aged 80 (Fig 1, A), 77 (Fig 1, B), 77 (Fig 1, C ), and 79 (Fig 1, D) years. Clinically, the lesions were flat and typified by brown-gray color.
Fig 1. Clinical images show flat-pigmented lesions with brown-gray color located on the scalp in patients age 80 (A), 77 (B and C) and 79 (D) years.
From the Hospital Federal de Ipanema, Servic¸o de Medicina Interna e Setor de Dermatologia,a and Hospital Naval Marcilio Dias, Servic¸o de Dermatologia,b Rio de Janeiro; Dermatology and Skin Cancer Unit, Arcispedale S Maria Nuova-IRCCS,c Reggio Emilia, and Dermatology Unit, University of Tor Vergata,d Rome, Italy. Publication of this article was supported by 3Gen. Funding sources: None. Conflicts of interest: None declared.
Reprint requests: Caterina Longo, MD, PhD, Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Viale Risorgimento, 80, 42100 Reggio Emilia, Italy. E-mail: longo. [email protected]. J Am Acad Dermatol 2015;72:S27-9. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.04.061
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DERMOSCOPIC APPEARANCE Lesions A and B (Fig 2) showed a granular pattern composed by sharply outlined blue-gray dots. Lesion C (Fig 2) showed blurred, blue-gray granules unevenly distributed and sometimes arranged in an annular-granular pattern around the follicular openings. Similarly, lesion D (Fig 2) revealed illdefined grayish granules intermingled with whitish areas. On top, a small brownish eroded papule with milia-like cysts was also visible.
Fig 2. Dermoscopic images. Lesions A and B (histologically lichenoid keratoses) are typified by a blurry granular pattern with sharply outlined blue-gray dots. Lesions C and D (histologically melanomas) show thick and fuzzy granules haphazardly distributed and grossly arranged around the follicular openings in a rudimentary annular-granular pattern. A small colliding seborrheic keratosis can be seen in lesion D (circle).
CONFOCAL MICROSCOPY APPEARANCE Confocally, lesions A and B (Fig 3) showed epidermal bulbous projections and plump bright cells (melanophages) suggestive of lichenoid keratosis. Conversely, lesions C and D were typified by a melanocytic proliferation of pagetoid cells (Fig 3, C ) and junctional nesting (Fig 3, D). Histopathologic examination confirmed the diagnosis of lichenoid keratosis for lesions A and B and of melanoma in situ for lesions C and D.
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Fig 3. Confocal microscopy images (500 3 500 m). A, Lichenoid keratoses. Epidermal bulbous projections (arrows) and plump bright cells (circle). B, Lichenoid keratoses. Bright epidermal projections (arrows). C, Melanoma. Pagetoid cells scattered in the epidermis. D, Melanoma. Junctional nesting of atypical melanocytes (arrows) and melanophages (circle).
KEY MESSAGE
Although blue-gray granules are the hallmark of lichenoid keratoses,1 when they appear blurred, confluent, or associated with white scarlike areas, the diagnosis of melanoma cannot be excluded and a biopsy is needed promptly. Confocal microscopy may add valuable information by revealing features suggestive of the epithelial or melanocytic nature of the proliferation.2-4
REFERENCES 1. Zaballos P, Martı E, Cuellar F, Puig S, Malvehy J. Dermoscopy of lichenoid regressing seborrheic keratosis. Arch Dermatol 2006;142:410. 2. Moscarella E, Zalaudek I, Pellacani G, Eibenschutz L, Catricala C, Amantea A, et al. Lichenoid keratosis-like melanomas. J Am Acad Dermatol 2011;65:e85-7. 3. Longo C, Scope A, Lallas A, Zalaudek I, Moscarella E, Gardini S, et al. Blue lesions. Dermatol Clin 2013;31:637-47. 4. Ramirez-Fort MK, Al Jalbout S, Kittler H, Pellacani G. Lichenoid keratosis: non-invasive imaging in the setting of diagnostic uncertainty. Dermatol Pract Concept 2013;3:63-5.
CLINICAL PRESENTATION Four patients presented with suspicious pigmented scalp lesions with unknown history. All patients were men, aged 80 (Fig 1, A), 77 (Fig 1, B), 77 (Fig 1, C ), and 79 (Fig 1, D) years. Clinically, the lesions were flat and typified by brown-gray color.
Fig 1. Clinical images show flat-pigmented lesions with brown-gray color located on the scalp in patients age 80 (A), 77 (B and C) and 79 (D) years.
From the Hospital Federal de Ipanema, Servic¸o de Medicina Interna e Setor de Dermatologia,a and Hospital Naval Marcilio Dias, Servic¸o de Dermatologia,b Rio de Janeiro; Dermatology and Skin Cancer Unit, Arcispedale S Maria Nuova-IRCCS,c Reggio Emilia, and Dermatology Unit, University of Tor Vergata,d Rome, Italy. Publication of this article was supported by 3Gen. Funding sources: None. Conflicts of interest: None declared.
Reprint requests: Caterina Longo, MD, PhD, Dermatology and Skin Cancer Unit, Arcispedale Santa Maria Nuova-IRCCS, Viale Risorgimento, 80, 42100 Reggio Emilia, Italy. E-mail: longo. [email protected]. J Am Acad Dermatol 2015;72:S27-9. 0190-9622/$36.00 ª 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.04.061
S27
S28 Buc¸ard et al
J AM ACAD DERMATOL
JANUARY 2015
DERMOSCOPIC APPEARANCE Lesions A and B (Fig 2) showed a granular pattern composed by sharply outlined blue-gray dots. Lesion C (Fig 2) showed blurred, blue-gray granules unevenly distributed and sometimes arranged in an annular-granular pattern around the follicular openings. Similarly, lesion D (Fig 2) revealed illdefined grayish granules intermingled with whitish areas. On top, a small brownish eroded papule with milia-like cysts was also visible.
Fig 2. Dermoscopic images. Lesions A and B (histologically lichenoid keratoses) are typified by a blurry granular pattern with sharply outlined blue-gray dots. Lesions C and D (histologically melanomas) show thick and fuzzy granules haphazardly distributed and grossly arranged around the follicular openings in a rudimentary annular-granular pattern. A small colliding seborrheic keratosis can be seen in lesion D (circle).
CONFOCAL MICROSCOPY APPEARANCE Confocally, lesions A and B (Fig 3) showed epidermal bulbous projections and plump bright cells (melanophages) suggestive of lichenoid keratosis. Conversely, lesions C and D were typified by a melanocytic proliferation of pagetoid cells (Fig 3, C ) and junctional nesting (Fig 3, D). Histopathologic examination confirmed the diagnosis of lichenoid keratosis for lesions A and B and of melanoma in situ for lesions C and D.
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Fig 3. Confocal microscopy images (500 3 500 m). A, Lichenoid keratoses. Epidermal bulbous projections (arrows) and plump bright cells (circle). B, Lichenoid keratoses. Bright epidermal projections (arrows). C, Melanoma. Pagetoid cells scattered in the epidermis. D, Melanoma. Junctional nesting of atypical melanocytes (arrows) and melanophages (circle).
KEY MESSAGE
Although blue-gray granules are the hallmark of lichenoid keratoses,1 when they appear blurred, confluent, or associated with white scarlike areas, the diagnosis of melanoma cannot be excluded and a biopsy is needed promptly. Confocal microscopy may add valuable information by revealing features suggestive of the epithelial or melanocytic nature of the proliferation.2-4
REFERENCES 1. Zaballos P, Martı E, Cuellar F, Puig S, Malvehy J. Dermoscopy of lichenoid regressing seborrheic keratosis. Arch Dermatol 2006;142:410. 2. Moscarella E, Zalaudek I, Pellacani G, Eibenschutz L, Catricala C, Amantea A, et al. Lichenoid keratosis-like melanomas. J Am Acad Dermatol 2011;65:e85-7. 3. Longo C, Scope A, Lallas A, Zalaudek I, Moscarella E, Gardini S, et al. Blue lesions. Dermatol Clin 2013;31:637-47. 4. Ramirez-Fort MK, Al Jalbout S, Kittler H, Pellacani G. Lichenoid keratosis: non-invasive imaging in the setting of diagnostic uncertainty. Dermatol Pract Concept 2013;3:63-5.
