dermoscopy pigment vs vascular
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TUTORIAL PRESENTATION
DERMOSCOPY :PIGMENT v/s VASCULAR
BY Dr. D R DHAKED
INTRODUCTION• Also k/a dermatoscopy, epiluminescence microscopy
[ELM], incident light microscopy, skin surface microscopy
• Non invasive diagnostic technique for in vivo observation of pigmented skin lesions,
• Provides a horizontal view of the lesion, • Permits recognition of morphologic structures not
visible by naked eye• Magnification ranges from 6x to 40x. • Widely used dermatoscope has a 10-fold
magnification
Technical Procedures and Equipment• Lesions are inspected using a hand-held dermatoscope, a
stereomicroscope, a camera, or a digital imaging system• Lens is paired with a bright halogen beam • Immersion fluid (mineral oil, alcohol or water) placed on
lesion eliminates surface reflection and renders cornified layer translucent,
• Allows better visualization of pigmented structures within epidermis, dermoepidermal junction and superficial dermis.
• Size and shape of vessels of superficial vascular plexus can be easily appreciated
• Examination of vessels is of particular interest in diagnosis of nonpigmented lesions,
• In diagnosing melanoma, dermoscopy has been reported to allow 10-27% higher sensitivity than clinical diagnosis by the naked eye [Mayer 1997].
Videodermatoscope
Stereomicroscope
Dermaphot Dermatoscope
Understanding of different dermoscopic features is important to formulate a diagnosis
Pattern analysis i) Pattern recognition:- Skin lesion can be placed in to one of nine groups• Reticular pattern -
– Defined by a pigment network. – Typical pigment networks are seen in acquired melanocytic naevi and some lentigo. – A fine peripheral network is seen in dermatofibroma. – An atypical pigment network has a high specificity for melanoma
• Globular pattern - – Presence of numerous, variously sized, round to oval structures with various shades of
brown and gray-black coloration. – Indicative of junctional proliferation of melanocytes – Seen in acquired melanocytic naevi in young people
• Homogenous pattern - – A diffuse area of colour in the absence of a pigment network or other distinctive local
features. – May seen in melanocytic lesions or blue naevi and seborrhoeic keratoses
• Multicomponent - – Combination of features such as globular reticular or reticular homogenous, – Combination of three or more patterns within a lesion (multicomponent) can be
suggestive of melanoma
• Cobblestone - – Closely aggregated, large somewhat angulated globules resembling a cobblestone. – Result from large dermal nests of melanoctyes found in dermal naevi
• Parallel pattern –– Indicative of acral lesions.– A parallel-like fingerprint pattern can be seen in solar lentigo
• Starburst pattern - – Pigmented streaks in a radial arrangement at edge of a pigmented skin lesion. – Indicative of spitzoid lesions including pigmented spindle cell naevus of Reed, and
spitzoid melanoma• Lacuna -
– Several to numerous, smooth-bordered, round to oval, variously sized structures. – Morphologic hallmark is their striking reddish, blue-purplish or black coloration. – Indicative of angioma
• Unspecific - – Relatively featureless lesions that cannot be categorised by any of the above. – This pattern can represent a subtle melanoma
Dermatofibroma with reticular pattern in anular distribution
Atypical reticular pattern in a melanoma in situ
Typical reticular pattern in a Clark nevus
Typical globular pattern in a Clark nevus, compound type
Typical cobblestone pattern in a papillomatous dermal nevus (Unna nevus)
Brownish-gray homogeneous pattern in a blue nevus
Brownish-gray homogeneous pattern in a dermal nevus
Typical homogeneous pattern in a blue nevus
Lacunar pattern in an angiokeratoma
Lacunar pattern in an angioma
Typical starburst pattern in a Reed nevus
Parallel-furrow pattern, in an acral nevus lattice-like pattern, in an acral nevus
Multicomponent pattern in a congenital speckled nevus (nevus spilus)
Multicomponent pattern in a malignant melanoma
ii) Pattern comparison• Patients with multiple acquired melanocytic naevi will
often have lesions showing a similar dermoscopic pattern
• Any lesion found to have a different dermoscopic pattern, should be treated with suspicion.
• Patients age should be taken into consideration as the dermoscopic morphology of acquired melanocytic naevi change as patients get older
• Globular in teenage years• Reticular in 30-40 year olds• Homogenous in the over 50’s
Colour
• Pigmentation of lesion is evaluated in terms of colour(s): black, dark brown, tan, grey, steel blue, purple, white, yellow and red.
• Understanding colour is important as it helps determine the level of melanin in the skin:– Black - superficial epidermis– Brown - epidermis– Grey - papillary dermis– Blue - reticular dermis
• Greater the number of colours more likely the lesion is to be malignant.
• But not true in case amelanotic / hypomelanotic melanoma
Black: epidermal melanin
Black: thrombus
Dark brown: junctional melanin
Tan: junctional melanin
Grey: upper dermal melanophages
Blue: deep dermal melanin
Purple: vascularity or bleeding
Red: vascularity or bleeding
White: regression or scarring
White: keratin
Yellow: keratin
Multiple colours : melanoma
Symmetry• Clinically, evaluated in terms of shape. • Symmetry of shape suggests a benign lesion, • Asymmetry suggests melanoma • By dermoscopy, symmetry is evaluated in terms of pigment
pattern (colour and/or structure). • Symmetrical pigment pattern is typical of benign skin lesions. • Complete asymmetry, lesion may be malignant or atypical naevi.• Uniform pigment also called ‘homogeneous’ (benign), • Irregular pattern called ‘heterogenous’ (atypical or malignant). • The degree of symmetry / asymmetry is quite subjective, • It must be considered in combination with all other dermoscopic
and non-dermoscopic features to help formulate a diagnosis
Homogeneous, symmetrical lesion
Symmetrical shape & structure
Homogeneous structure with asymmetrical shape
Asymmetrical shape & pattern (atypical naevus)
Symmetrical shape,
asymmetrical pattern (melanoma)
Lesion specific features (local features)• Melanocytic lesions are made up of three types
of structure:– Pigment network – Amorphous structureless areas (blotches) – Dots and globules
• Benign lesions tend to have only one or two of these structural patterns in a symmetrical distribution.
• Malignant lesions tend to have areas of network, amorphous structures and scattered globules in an atypical distribution
Pigment network
• Formed by melanocytes or melanin in basal keratinocytes. • Dense pigment rings (the grid) are due to projections of
rete pegs or ridges. • Paler ‘holes’ are due to projections of dermal papillae.• A typical pigment network is characterised by a light to
dark-brown pigmented, regularly meshed and narrowly spaced network
• Distributed more or less regularly throughout lesion • Usually thinning out at the periphery. • Seen in some typical and atypical benign melanocytic
lesions.
Typical or Regular pigment network
Ink-spot lentigo
Lentigo simplex
Solar lentigo
Solar lentigo
Junctional naevus
Junctional naevus
Compound naevus
Atypical naevus
Junctional naevus Starburst pattern
Compound naevus Interrupted network
Atypical naevus Annular network
Atypical naevus
Spoke-wheel network
Atypical or irregular pigment network• Characterised by a black, brown, or grey, irregularly meshed
network, • Distributed more or less irregularly throughout the lesion • Usually ending abruptly at the periphery. • Streaks, brownish-black linear structures of variable thickness, not
clearly combined with pigment network lines, • Branched streaks are seen in dysplastic naevi and some
melanomas.• Radial streaming or parallel linear extensions at edge of lesion
often represent radial growth phase of melanoma.• Pseudopods are bulbous projections at edge of lesion due to
junctional nests of abnormal melanocytes in invasive melanoma• Thick lines (broadened network) are characteristic of melanoma,
and are accompanied by irregular holes.
Irregular pigment network: red arrows point to branched streaks, black arrows to broadened network, asterisk to streaming, thin arrow to pseudopods
Dysplastic naevus
Dysplastic naevus
Recurrence after excision
Atypical lentiginous hyperplasia
Melanoma
Melanoma
Melanoma
Melanoma
Pseudonetwork: facial skin• Term ‘pseudonetwork’ is used when annular
pigmentation is seen around hair follicles on facial skin. • On face, it may be difficult to differentiate benign
naevi, lentigo, solar keratoses, lichenoid keratosis and early lentigo maligna.
Solar lentigo
Solar lentigo
Solar keratosis
Lichenoid keratosis
Negative network• White reticular pattern due to elongated rete pegs. • Characteristic of melanoma but also sometimes seen in
Spitz naevi and some dysplastic naevi. • It may resemble the pattern seen in scars on lower leg
(atrophie blanche). • It should not be confused with pale colour separating
globules of a benign naevus.
Melanoma
Melanoma Green arrows point to negative network
Atrophie blanche
Benign naevus
Dermoscopy of palmo-plantar melanocytic lesions
• ‘Parallel pattern’ refers to network seen within most melanocytic naevi on palmar and plantar surfaces.
• Parallel furrow pattern: pigmented furrows• Lattice pattern: pigmented furrows and lines crossing these• Fibrillar/filamentous pattern: delicate pigmentation crossing
the skin markings• Parallel ridge pattern: pigmented ridges (white dots represent
sweat duct openings), highly specific for melanoma in volar sites.
• There is no obvious parallel pattern in homogenous-type naevi on volar sites.
Parallel furrow pattern
Lattice pattern
Lattice pattern
Fibrillar pattern
Fibrillar pattern
Fibrillar pattern Dysplastic naevus
Mixed pattern
Parallel ridge pattern Melanoma
Dermoscopy of palmo-plantar melanocytic lesions
Amorphous areas (blotches) • Diffuse pigmentation without specific structural features• Brown blotches may be due to pigment in basal layer or
papillary dermis and arise when rete ridges are flattened out.• Homogeneous blue pigmentation is seen in blue naevus.• Diffuse amorphous areas
– Solar lentigo, Benign naevus, Blue naevus• Irregular blotches are sometimes only dermoscopic feature of
melanoma. Blue-white veil - • An irregular, confluent, grey-blue to white-blue diffuse
pigmentation • Caused by an acanthotic epidermis with focal hypergranulosis
above sheets of heavily pigmented melanocytes in upper dermis• Has high specificity for melanoma
Solar lentigo
Benign naevus
Benign naevus
Blue naevus
Dysplastic naevus
Melanoma
Melanoma
Melanoma Also has irregular network
Irregular amorphous areas
Diffuse amorphous areas
Dots and globules• Sharply circumscribed, usually round or oval, variously sized
brown, black or blue-grey structures. • Colour determines their site:
– black dots are due to free melanin in the stratum corneum, – brown globules are due to junctional nests of melanocytes, – blue or grey dots are due to melanophages in dermis.
• Benign lesions tend to have central black dots and globules.• Dots associated with a pigment network may be due to pigment
on ridges (superimposed on network grid) or papillae (in the holes).
• Circumferential brown globules are seen in enlarging dysplastic naevi.
• Diffuse blue/grey dots in absence of a pigment network are characteristic of lichenoid keratosis.
• Clusters of tiny brown dots are characteristic of melanoma.
Central dots
Central globules
Uniform globules Dermal naevus
Cobblestone pattern Compound naevus
Scattered dots
Peripheral globules Atypical naevus
Eccentric globules Dysplastic naevus
Diffuse blue/grey
dots Lichenoid keratosis
Dots and globules in benign lesions
Black dots
Brown dots
Grey dots
Peripheral dots
Dots and globules in melanoma: yellow arrows
Dots may be seen in pigmented basal cell carcinoma and rarely in seborrhoeic keratoses.
Dots in basal cell carcinoma: yellow arrows
Dermoscopic structures of non-melanocytic lesions
• Some specific dermoscopic structures are helpful in diagnosis of non-melanocytic lesions.
• These include:– Leaf-like areas– Blue ovoid masses– Milia-like cysts– Fissures and comedo-like openings
Leaf-like areas• Leaf-like areas are grey, brown or blue shiny, discrete bulbous
structures unassociated with a pigment network (structureless).
• They are seen on edges of pigmented basal cell carcinoma, • Some may not appear very like a leaf, in which case they are
better known as ‘structureless areas’. • Moth-eaten edges of solar lentigos also sometimes appear
leaf-like.
Leaf-like areas: BCC
Leaf-like areas: BCC
Structureless areas: BCC
Leaf-like areas:
solar lentigo
Blue ovoid masses• Are large discrete pigmented round, oval or bullet-shaped blue
structures • Characteristic of basal cell carcinoma. • When the structure has radial projections, they are called ‘spoke-
wheel areas’. • They are often found within leaf-like or structureless areas. • Blue blotches that are sometimes seen in melanoma are
irregular, less well defined and appear out of focus.
Blue ovoid masses: BCC
Spoke-wheel areas: BCC
Blue blotches:
melanoma
Milia-like cysts• Round white or yellow lesions due to intraepidermal
keratin. • Characteristically found within a seborrhoeic keratosis. • May arise within dermal melanocytic naevi, BCC and
melanoma.
Seborrhoeic keratosis
Seborrhoeic keratosis
Compound naevus
Pigmented BCC
Fissures and comedo-like openings• Brown-yellowish or brown-black, roundish to oval or even irregularly shaped,
sharply circumscribed structures• Comedo-like openings are sometimes called ‘crypts’. • Little craters and tend to be dark brown, like irregular globules. • Often associated with fissures (clefts).• Characteristic of seborrhoeic keratoses, • May be found in dermal naevi. • Rarely, in melanoma
Comedo-like openings: seborrhoeic keratosis
Fissures: seborrhoeic keratosis
Cysts & crypts: seborrhoeic keratosis
Comedo-like openings:
compound naevus
Cerebriform structure• Seborrhoeic keratosis may have a cerebriform or brain-like pattern. • Pattern is composed of fissures and ridges mimicking the gyri and
sulci of the brain.• Useful sign in the absence of comedo-like openings or milia-like
cysts.
Fissures/comedo-like openings Enhanced by tanning cream
Fingerprint-like structures• Descriptive term for tan or dark-brown, fine parallel cord-like
structures • Characteristically seen in seborrhoeic keratoses and solar
lentigo. • Wider cords are called ‘fat fingers’. • Fat fingers are also rarely seen in melanoma.
Fingerprint-like structures
Fingerprint-like structures Crypts in elevated centre of lesion
Fat fingers
Fat fingers
The border of skin lesions
• Clinical characteristic of an irregular edge is often seen in melanoma, but is quite common in benign lesions too
• Border can fade out (often seen in atypical naevi) or be sharply demarcated in a small segment (typical of melanoma).
• Sharp cut-off may also occur all the way around in a regular or irregular pattern.
• ‘Moth-eaten’ edge, seen as concave areas at edge of a lesion. • Seen in ephilis and some flat seborrhoeic keratoses and lentigos
Fading border benign naevus
Localised sharp cut-off: melanoma
Sharp cut-off all round: melanoma
Moth-eaten edge:
ephilis
Crystalline structures• Shiny, bright white, parallel or orthoganol or disordered
linear streaks or short lines. • Seen by contact or non-contact polarised dermoscopy. • Are due to excessive collagen • May be seen in dermatofibroma, scar, basal cell carcinoma
with fibroplasia, squamous cell carcinoma, Spitz naevi and melanoma.
Dermatofibroma
Pigmented basal cell carcinoma
Superficial basal cell carcinoma
Melanoma
Vascular structures and pattern
• Vascular structures show up better in hypopigmented or nonpigmented lesions, or in lighter areas of pigmented tumors.
• Most important chromophore in nonpigmented cutaneous tumors is hemoglobin
• Predominant vascular pattern also depends on volume of tumor and its proliferation pattern.
• Nodular component of tumors, develop through neovascularization phenomena
• Give rise to blood vessels with varying degrees of aberrant morphology.
Dermoscopic morphologic features of vessels according to their location in the skin
Vessels in normal skin; note dotted vessels corresponding to papillary dermal vessels and network of vessels corresponding to upper dermal plexus
Diagnostic procedure for a hypopigmented lesion.
Vessel morphology
Vessel distribution patterns / Architectural Arrangement
Vascular patterns seen in melanocytic lesions.
Vascular patterns seen in melanocytic lesions, clear-cell acanthoma, and basal cell carcinoma.
Intradermal melanocytic nevus with comma vessels scattered throughout the lesion.
A, Spitz nevus with dotted lesions distributed uniformly through the lesion. B, Spitz nevus with a greater variety of vascular patterns against a characteristic pink background.
A, Dysplastic nevus with predominant irregular linear vessels. B, Dysplastic nevus with dotted and comma vessels against a brownish background
A, Superficial spreading melanoma showing marked vascular polymorphism in the thick portion of the tumor. B, Detail of a milky-red globule containing vessels
Dotted vessels in the typical string of pearls arrangement seen in clear-cell acanthoma.
Bright red arborizing telangiectasias in sharp focus; a typical finding in basal cell carcinoma
Vascular patterns in keratinizing tumors
Vascular patterns in keratinizing tumors, sebaceous hyperplasia / molluscum contagiosum, and dermatofibroma
Hairpin vessels in seborrheic keratosis.
Crown vessels in a typical sebaceous hyperplasia lesion.
Bowen disease, glomerular vessels in a clustered distribution
Dotted vessels in a dermatofibroma.
Crown vessels in 2 molluscum contagiosum lesions.
Vascular patterns in vascular lesions and Kaposi sarcoma.
Rainbow pattern in Kaposi sarcoma.
Reddish-whitish areas, peripheral collarette, and rail lines in a pyogenic granuloma.
Oval lacunae characteristic of angioma serpiginosum
Vascular patterns in inflammatory lesions.
Vascular patterns in infectious lesions.
Dotted vessels combined with a scaling surface in a typical psoriatic plaque.
Dilated vessels in a string-like distribution in the center of a scar.
Diagnostic algorithm according to predominant vascular pattern.
Diagnosis Global Patterns Specific Local Features Additional Local Features
Confounding Features
Melanoma Multicomponent, reticular, globular, parallel-ridge, unspecific
Atypical pigment network, irregular dots/globules, irregular streaks, blue-whitish veil, irregular pigmentation, regression structures, dotted or linear irregular vessels
Hypopigmented areas, hairpin vessels, red globules
Homogeneous or starburst pattern; typical pigment network, regular dots/globules, regular streaks, milia-like cysts
Clark nevus Reticular, globular, homogeneous
Typical pigment network, regular dots/globules, regular diffuse or localized pigmentation, hypopigmented areas
Regular streaks, regression structures
Multicomponent pattern; atypical pigment network, irregular dots/globules, irregular streaks, irregular pigmentation, dotted vessels
Unna and Miescher nevi
Globular, cobblestone, reticular, homogeneous, unspecific
Regular dots/globules, exophytic papillary structures, typical pseudonetwork, comma vessels
Comedo-like openings, milia-like cysts
Multicomponent pattern; irregular pigmentation
Diagnosis Global Patterns Specific Local Features Additional Local Features
Confounding Features
Reed and Spitz nevi Starburst, globular, multicomponent
Regular streaks, regular diffuse pigmentation, reticular blue-whitish veil, regular dots/globules
Dotted vessels, typical pigment network
Reticular pattern; atypical pigment network, irregular dots/globules, irregular streaks, irregular pigmentation
Recurrent nevus Multicomponent, homogeneous, unspecific
Irregular pigmentation, irregular streaks, white areas
Atypical pigment network, irregular dots/globules
All local features mentioned in this row are commonly found in melanoma
Blue nevus Homogeneous Regular diffuse pigmentation
Hypopigmented areas Irregular diffuse pigmentation, arborizing vessels
Congenital nevus Multicomponent, cobblestone, globular, reticular
Regular dots/globules, typical pigment network, localized multifocal hypopigmentation, regular pigmentation
Milia-like cysts, comedo-like openings, exophytic papillary structures
Localized irregular pigmentation, regression structures
Diagnosis Global Patterns Specific Local Features Additional Local Features
Confounding Features
Combined nevus Multicomponent, homogeneous, globular, reticular
Typical pigment network, regular dots/globules, localized regular pigmentation
Hypopigmented areas, exophytic papillary structures
Atypical pigment network, localized or diffuse irregular pigmentation
Lentigo Reticular Typical pigment network or pseudonetwork, regular diffuse pigmentation
Milia-like cysts, regular dots/globules
Atypical pigment network, irregular pigmentation
Vascular lesions Lacunar, globular, homogeneous
Red lacunas, diffuse or localized structureless reddish-black to reddish-blue pigmentation
Parallel pattern, regular dots/globules, whitish-yellowish keratotic areas
Multicomponent pattern; irregular dots/globules, whitish veil
Diagnosis Global Patterns Specific Local Features Additional Local Features
Confounding Features
Labial and genital melanosis
Unspecific, parallel Regular diffuse pigmentation, typical pigment network
Regular streaks Atypical pigment network, irregular pigmentation
Basal cell carcinoma Unspecific, multicomponent, globular
Leaf-like areas, irregular blue-gray dots/globules, arborizing vessels
Milia-like cysts, hairpin vessels
Irregular gray-bluish pigmentation
Seborrheic keratosis Unspecific, globular, reticular, homogeneous
Milia-like cysts, comedo-like openings, exophytic papillary structures, regular diffuse pigmentation, hairpin vessels
Typical pigment network, hypopigmented areas, dotted vessels, gyri and sulci, whitish-yellowish horn masses
Multicomponent pattern; irregular pigmentation, regression structures, irregular dots/globules
Dermatofibra Reticular, unspecific, multicomponent
Annular pigment network, central white patch
Localized pigmentation or crusting, regular dots/globules, erythema
Irregular white areas
ABCD rule of dermoscopy (Modified according to Stolz 1994)Criterion Description Score Weight
factorAsymmetry In 0, 1, or 2 axes; assess not only contour, but also colors
and structures0-2 X 1.3
Border Abrupt ending of pigment pattern at the periphery in 0-8 segments
0-8 X 0.1
Color Presence of up to six colors 1-6 (white, red, light-brown, dark-brown, blue-gray, black)
1-6 X 0.5
Differential structures
Presence of network, structureless or homogeneous areas, streaks, dots, and globules
1-5 X 0.5
Total DermoscopyScore (TDS)
Interpretation
<4.75 Benign melanocytic lesion
4.8-5.45 Suspicious lesion; close follow-up or excision recommended
>5.45 Lesion highly suspicious for melanoma
Menzies scoring methodTo make a diagnosis of melanoma, 2 negative aspects (negative features) must be absent from the lesion and 1 or 2 positive aspects (from 1 of the 9 positive features) must be present.
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