Non-melanocytic Lesions Non-melanocytic Patterns F088...Non-melanocytic Lesions •Seborrheic keratoses ... • Yellowish keratotic plugs in follicular ostia. ... white halos (purple

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Non-melanocytic Patterns

Michelle Tarbox, MD

Assistant Professor of Dermatology and Dermatopathology Texas Tech University Health Sciences Center

2018

Non-melanocytic Lesions

• Seborrheic keratoses• Acanthotic• Macular

• Vascular lesions• Angiomas• Angiokeratomas• Lymphangiomas

• Dermatofibromas• Conventional • Cellular

• Basal cell carcinoma• Pigmented and non-pigmented

• Actinic keratoses• Pigmented actinic keratoses

• Squamous cell carcinomas

• Merkel cell carcinoma

• Bugs• Cutaneous infections• Cutaneous infestations

• BONUS cases!

I have no conflicts of interest to disclose

Except that I LOVE dermoscopy

Non-Melanocytic Lesion Dermoscopy

• Problem: Often No Pigment!

• Solution: Use your clues!• Vascular structures• Chrysalis structures• Texture• Structureless areas• Scale

Comma-like - IDN Dotted -Spitz Linear irregular - AMM

Hairpin – SK, SCC, KA Glomerular - SCCIS Arborizing - BCC

Crown vessels – Seb H Strawberry pattern - AK

Milky red areas/globules – Thick AMM

J Am Acad Dermatol - 01-SEP-2010;

63(3)Vascular morphology

A regularB in a stringC clusteredD radialE irregularly branchedF irregular

J Am Acad Dermatol - 01-SEP-2010; 63(3)

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Seborrheic Keratosis

• Multiple milia like cysts

• Irregular crypts / comedo-like openings

• Fissures/ridges

• Fingerprint-like structures

Milia-like cysts = pseudo-horn cysts

(black arrows)

Comedo-like openings = comedostructures

(red arrows)

Personal Collection

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Multiple milia like cysts

Irregular crypts and comedo like openings

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Fissures and Ridges • Wedge shaped clefts in the epidermis

• AKA gyri and sulci, fat fingers, or cerebriform pattern

• Can also be seen in melanocytic nevi with congenital patterns, and epidermal nevi

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Fissures/ridgesPersonal Collection

Congenital type nevus with Fissures/ridges Personal Collection

Fissures/ridgesPersonal Collection

Personal Collection, patient granted special permission to show

tattoo

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Fingerprint – Like Structures

• Tiny ridges running in parallel

• Typically seen in flat seborrheic keratoses or solar lentigo

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Multiple milia like cysts

Hemangioma• Red-blue homogeneous color

• Red-blue lacunes

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• Multiple red to bluish-black lacunae

• Blue-white veil: no diagnostic significance• Red-blue lacunae, no pigment network • Hyperkeratosis over thrombosed vessels

Angiokeratoma

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Dermatofibroma• Central scar like pallor

• Surrounding delicate pigment network

• Chrysalis structures

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Cellular Dermatofibroma• Nodule with central scar like pallor

• Surrounding delicate pigment network

• Chrysalis structures / central erosion/focal ulceration

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BROWN BROWN

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Chrysalis Structures • AKA Crystalline structures or shiny white streaks (SWS)

• Only seen with polarized dermoscopy

• Most commonly seen in basal cell carcinoma and invasive melanomas, may be seen in dermatofibromas and scars

• In melanomas may reflect increased tumor thickness and regression

BCC Invasive Melanoma Aneurysmal DF


BCC

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BCC


Speaking of BCC Basal Cell Carcinoma

• Absent pigment network and:

• Ulceration

• Arborizing (tree-like) vessels

• Large blue gray ovoid nests

• Multiple blue gray globules

• Maple leaf areas

• Spoke wheel areas

Ulceration

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Ulceration Seen in pigmented and non-pigmented basal cell carcinoma

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Arborizing vessels

Personal Collection BCC

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Amelanotic Melanoma vs BCC

Personal Collection JAAD Vol 53, Issue 6, March 2007, Pages 508–513

Large Blue-Gray Ovoid Nests • Well circumscribed, confluent, pigmented ovoid areas

• Larger than globules

• Not connected to larger tumor body

• Represent large nests of pigmented BCC

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Large Blue-Gray Ovoid Nests

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Multiple Blue-Gray Globules

• Round, well circumscribed structures

• Smaller nests of pigmented basal cells

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Maple leaf areas

Spoke-wheelareas

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Maple Leaf Areas

• Nests of pigmented epithelial nodules of basal cell carcinoma

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Spoke-Wheel Areas• Well circumscribed brown to gray-blue-brown radial projections meeting at a

darker central hub

• Nests of basal cell carcinoma radiating from a follicular epithelium

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Non pigmented Actinic Keratoses

• Pink-red pseudo-network surrounding follicles

• White-to-yellow surface scale

• Fine wavy vessels surrounding hair follicles

• Yellowish keratotic plugs in follicular ostia


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Actinic keratosis

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“Strawberry-like” pattern

composed of reddish

pseudo network around

whitish keratin filled hair

follicles

Pigmented actinic keratosis

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Pigmented actinic keratosis

Squamous Cell Carcinoma in Situ • Glomeruloid blood vessels

• Focal heme crust

• Scale

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Lobules composed of central whitish yellow keratin surrounded by polymorphous vesselsDotted (yellow arrow), arborizing (blue arrow), glomerular (black circle), and linear irregular (red arrow) vessels on a yellowish white background in addition to perivascular white halos (black circle). Focal areas of ulceration (blue star) and blood spots (green star) were also noted.

A. Tülin Güleç

Dermoscopic features of squamous cell carcinoma of the tongue: It looks similar to cutaneous squamous cell carcinoma

Journal of the American Academy of Dermatology, Volume 75, Issue 2, 2016, e53–e54

http://dx.doi.org/10.1016/j.jaad.2016.01.030


Fig 2. Squamous cell carcinoma of the lip. Dermoscopy revealed central whitish yellow keratin surrounded by polymorphous vessels, namely, dotted (yellow arrow), arborizing (blue arrow), coiled (black circle), and hairpin (red arrow) vessels on a yellowish white background in addition to perivascular white halos (purple circle) and white structureless areas (black arrow) that correlated to aggregated mass of highly keratinized malignant squamous cells. Focal areas of surface scale (blue star) and blood spots (green star) were also noted.

A. Tülin Güleç

Diagnosing squamous cell carcinoma of the lip using dermoscopy

Journal of the American Academy of Dermatology, Volume 76, Issue 2, Supplement 1, 2017, S82–S83


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Merkel Cell Carcinoma

Fig 6. Combined squamous/Merkel cell carcinoma, case 5. A, Erythematous nodule on the upper aspect of chest with adherent scale; background dermatoheliosis with atrophy and wrinkling, along with a nearby actinic keratosis (upper left corner). B, Dermoscopy with milky red areas centrally (small top arrow) and large-diameter arborizing vessels at the periphery (larger lower arrows).

Andrea Luísa Suárez, Peter Louis, Jasmine Kitts, Klaus Busam, Patricia L. Myskowski, Richard J. Wong, Chih-Shan Jason Chen, Philip Spencer, Mario Lacouture, Melissa P. Pulitzer

Clinical and dermoscopic features of combined cutaneous squamous cell carcinoma

(SCC)/neuroendocrine [Merkel cell] carcinoma (MCC)

Journal of the American Academy of Dermatology, Volume 73, Issue 6, 2015, 968–975


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Scabies • Triangle indicating the head of

the mite

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Thank you! Michelle Tarbox, MD

Assistant Professor of Dermatology

Texas Tech University Health Sciences Center

[email protected]

Fun Benign things . . .

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Clear cell acanthoma •String of pearls vessels

•Glycogen rich keratinocytes

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Porokeratosis• White tract structure =cornoid lamella

• Central white area, red dots, globules and lines

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Sebaceous Hyperplasia

• Aggregated white-yellow nodules ~ cumulous cloud

• Crown vessels (radial wreath-like) • Banching vessels that extend towards the center of the lesion without crossing it



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Nevus Sebaceous

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Accessory Nipple

• Central white area

• Central streak

• Faint pigmented network at the periphery


Xanthogranuloma

•Orange-yellow background coloration with clouds of xanthomatous deposits

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BONUS Cases


Documents

Non-melanocytic Lesions Non-melanocytic Patterns F088...Non-melanocytic Lesions •Seborrheic keratoses ... • Yellowish keratotic plugs in follicular ostia. ... white halos (purple